We often take language and our ability to communicate for granted. For patients with aphasia, it is an extremely challenging and frustrating impairment. Aphasia is the loss of the ability to speak or comprehend written or spoken language.
 
There are three main forms of aphasia.

1. In Broca aphasia, or expressive aphasia, the patient possesses normal comprehension but exhibits slow, nonfluent speech and cannot express oneself. It is named for the Broca area of the brain that connects to the motor neurons of the mouth and larynx, and controls spoken language (Clark, 2022). Broca aphasia is often associated with damage to the left frontal lobe.
2. Wernicke aphasia, or receptive aphasia, is an impairment in which the patient has abnormal comprehension with fluent speech. This is named for the Wernicke area of the brain that receives information from the auditory cortex and then assigns word meanings (Clark, 2022). The patient cannot understand words and it is often associated with damage to the temporal lobe.
3. Global (mixed) aphasia is a combination of both receptive and expressive aphasia.

Causes of Aphasia (Clark, 2022)

The most common cause of aphasia is ischemic stroke. Other causes include hemorrhagic stroke, neoplasm, cerebral abscess, encephalitis or other central nervous system infections, and traumatic brain injury. Less common causes include multiple scelerosis and encelphalomyelitis. Transient aphasia can occur with transient cerebral ischemia (TIA), migraine, and seizures. Progressive aphasia may be a sign of neurodegenerative disease.

Language Assessment (Bickley et al, 2021)

Aphasia will first be detected as you assess your patient’s mental status. During your evaluation, pay close attention to their speech and language, including their expression, reception, and comprehension of words. As you talk to the patient, note the following characteristics of their speech.

• Quantitiy: Is the patient talkative or reticent? Does the patient speak spontaneously or respond only to direct questions?
• Rate and Volume: Is the patient’s speech fast, slow, loud, or soft?
• Articulation: Are the patient’s words clear?
• Fluency: Does the patient exhibit a normal flow and rate of speech and use words appropriately?
  • Are there hesitancies or gaps in the flow and rhythm of words?
  • Does the patient exhibit abnormal inflections (i.e., monotone)?
  • Is the patient using circumlocutions in which phrases or sentences are substituted from a word the patient can’t think of, such as “what you sit on” instead of “chair.”
  • Does the patient use paraphasias where words are not formed properly, are incorrect, or made up.

Evaluating for Aphasia (Bickley et al, 2021)

If the patient’s language is abnormal, or lacking meaning or fluency, evaluate the patient for impairments in vision, hearing, intelligence and education that could affect their responses. Then proceed through the following aphasia assessment:

• Word comprehension
  • Ask the patient to follow a one-step command, such as “Stick out your tongue.”
  • Then try a two-step command: “Point to your ear, then your foot.”
• Repetition
  • Ask the patient to repeat a phrase of one-syllable words such as: “No ifs, ands, or buts.”
• Naming
  • Ask the patient to name the parts of speech.
• Reading comprehension
  • Ask the patient to read a paragraph out loud.
• Writing
  • Ask the patient to write a sentence spontaneously.
  • If the patient can write a sentence correctly, they don’t have aphasia.

These questions will help determine which type of aphasia your patient may have. Note, all patients with a newly identified aphasia should undergo a structural brain scan such as magnetic resonance imaging (MRI) (Clark, 2022).

Nursing Considerations (Hinkle, 2021)

Employ the following communication strategies when caring for patients with aphasia.

• Face the patient and establish eye contact.
• Speak in a clear, slow manner, and with a normal tone of voice.
• Use short phrases, and pause to give the patient time to comprehend what is being said.
• Limit conversation to practical and concrete matters.
• Use gestures, pictures, objects, and writing.
• As the patient uses and handles an object, say what the object is to help the patient match the words with the object or action.
• Use the same words and gestures each time you give instructons or ask a question.
• Attempt to minimize loud noises and sounds. Too much background noise can distract the patient or make it difficult to understand the conversation.

References:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
 
Clark, D.G. (2022, June 7). Approach to the Patient with Aphasia. UpToDate.  https://www.uptodate.com/contents/approach-to-the-patient-with-aphasia
 
Hinkle, J. (2021). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15^th ed.). Wolters Kluwer Health.  https://wolterskluwer.vitalsource.com/books/9781975161057