Speech and Language After a Stroke: A Simple Guide for Ontario Families
Written by Mariya Kika, M.H.Sc., Reg. CASLPO, Speech-Language Pathologist
October 20th is Aphasia Awareness Day. Learn more about it in this simple, plain-language guide.
Table of Contents
At dinner, your dad points at a spoon and calls it a fork, even though he has soup in front of him. During chit chat, your partner’s speech sounds thicker and slower since the stroke. Throughout the day, the person you’re caring for coughs every time they take a sup of water,
These differences may all start to appear after a stroke, but they do not all fall under the same term. They have different names and need different treatments and approaches. Having an understanding of what is what can help you make sense of what the team tells you and allows you to ask the right questions.
In plain language: A stroke can change how a person speaks, understands, reads, writes and swallows. Each change has its own name, such as aphasia, dysarthria or dysphagia, and each one is treated differently. A speech-language pathologist assesses which changes are present and builds therapy around the person's daily life.
How can a stroke affect speech and language?
A stroke happens when blood flow to part of the brain is blocked, or when a blood vessel in the brain bursts. Differences that occur will depend on the severity of the stroke and where in the brain it occurred. Other factors come into play as well, including age, pre-existing conditions, and more. Thus, two people can have very different presentations after a stroke, even when their strokes sound similar on paper.
The most common changes are outlined below. Many individuals often see multiple changes.
What is aphasia?
Aphasia is a language disorder. It can affect speaking, understanding, reading and writing. Canada's stroke guidelines report that about 21% to 38% of people have aphasia in the early period after a stroke.
Aphasia can look like:
Word-finding problems, such as getting stuck or saying a related word instead ("table" for "chair")
Speaking in short or automatic phrases is easier than longer sentences
Or, speaking in long, fluent sentences that don't quite make sense
Losing track when others talk quickly or several people talk at once
Difficulty reading a text message or writing a shopping list
Aphasia does not affect intelligence. Importantly, cognition may be affected separately by the stroke, but aphasia is not a reflection of intelligence. The person still has their knowledge, opinions and sense of humour. What's harder is getting from the thought to the word, or pulling meaning from the words that they hear.
To learn more about how aphasia affects speaking, understanding, reading, and writing, see Speech Therapy for Aphasia: How Can Adults Rebuild Communication After Stroke.
What causes slurred speech after a stroke?
Slurred speech after a stroke is not attributable to aphasia, which is a language disorder. Slurred speech is often characterized under dysarthria, which happens when the muscles used for speech are weak or poorly coordinated. That includes the lips, tongue, soft palate, vocal folds and the muscles that control breathing.
Speech may sound slurred, slow, quiet, rough or nasal. If dysarthria is not co-occurring with aphasia, then an individual may benefit from writing messages to support their speech and get their messages across.
What is apraxia of speech?
Apraxia of speech is another motor-speech difference that can occur after a stroke. Similarly to dysarthria, it does not affect language, although it may co-occur with expressive aphasia types. Apraxia refers to difficulties with planning the movements of speech. The muscles aren't weak, instead, the brain has trouble putting the instructions for each sound in the right order.
A person with apraxia may struggle to get a word started, or say it differently each time they try. Automatic phrases like "I don't know" sometimes come out easily, while a phrase they reach for on purpose won't come out the way they want.
What are the signs of swallowing problems after a stroke?
Coughing at meals, multiple swallows, and food that feels stuck are common signs of swallowing difficulties after a stroke. This is called dysphagia. Canada's stroke guidelines estimate that it affects between 19% and 65% of people in the early stage, depending on the stroke and how it's measured. Dysphagia can increase the risk of pneumonia, poor nutrition and dehydration, if not correctly managed.
Signs to watch for at meals:
Coughing or throat clearing while eating or drinking
Food that feels stuck, or food left pocketed in the cheek
Meals that take much longer than before
Difficulties with specific textures, such as dry food (i.e., cookies, nuts, toast)
Weight loss or repeated chest infections
If a speech-pathologist is part of the hospital team, it is important to clarify their discharge instructions, including what to do, what to avoid, and if a follow up appointment for a swallow imaging examination is recommended. This is typically referred to as a VFSS and occurs when the swallow is observed under X-ray.
Why can conversation feel different even when speech is clear?
Some people speak clearly after a stroke but have trouble with the thinking skills that conversation relies on. They may drift off topic, repeat themselves, miss a joke or a shift in tone, or struggle to follow a group conversation. These are called cognitive-communication changes, and families sometimes mistake them for a change in personality.
How does speech therapy after a stroke work in Ontario?
Speech therapy after a stroke usually begins in the hospital. As previously stated, the hospital-based SLP will assess the swallow if clinically indicated. They may also complete a communication screen to tailor recommendations. These may include recommendations for early access to therapy that is intensive and tailored to the person's needs, depending on the results of the screener.
Family involvement is encouraged and can be incredibly helpful to the patient. This can include advocacy, practicing supported conversation strategies, supporting changes in swallowing, and simply being there for the individual and giving them the space they need to communicate.
After discharge, some people continue through a public outpatient or home care program, and some see a private SLP if they are not deemed eligible for public services. Some may do both, depending on the waitlist for services. Private therapy typically starts with an assessment, then goals set with the person and family, practice built around real situations, and a gradual taper as those goals are met.
When should you get medical help right away?
A second stroke can happen. Call 9-1-1 right away for any new signs. Use FAST: Face, is it drooping? Arms, can you raise both? Speech, is it slurred or jumbled? Time to call 9-1-1.
About the author
Mariya Kika is a registered speech-language pathologist and the founder of Cognicare Speech Therapy, operating virtually across Ontario. She holds a Master of Health Science from the University of Toronto. She previously worked as the sole speech-language pathologist at Altum Health, part of Toronto's University Health Network, providing outpatient neurorehabilitation that centered return-to-work care. She is a member of the Canadian Concussion Network, Ontario Brain Injury Association, Toronto Brain Injury Association, and Canadian Telerehab Community of Practice.
For more on aphasia, see Stroke & Aphasia, Speech Disorders and this blog post Communicating with a Loved One Who has Aphasia.