Chronic Aphasia: Life After Treatment

Chronic Aphasia: Life
After Treatment
Carrie-Anne Kirkland, Ms. Ed.
Doctoral Student
Outline of Presentation
1. Present general background on
stroke and aphasia
2. Discuss the effectiveness of therapy
methods for acute and chronic PWA
and their caregivers
3. Identify some unanswered questions
regarding the communication needs
of PWA and their caregivers
Statistics Cont’d
� Medical advances have made survival
from stroke more possible (Wineburgh &
Small, 2004)
� Stroke survivors live to an average age
of 79.6 years (Circulation, 2006)
Doctoral Committee Members
� Rosemary Lubinski, Ed.D.
� Kris Tjaden, Ph.D.
� Geralyn Timler, Ph.D.
Statistics
� Stroke: 3 rd leading cause of death in the
U.S. (Centers for Disease Control, 2008)
� ~700,000 people incur a new or recurrent
stroke each year (Circulation, 2006)
Statistics Cont’d
� At least 25% of all strokes result in
aphasia
(http://www.stroke.org/site/News2?page=NewsArticle&id=7121)
� ~1 million PWA in the U.S. (National Stroke
Association, 2008)
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Statistics Cont’d
� ~80,000 new aphasia cases each year
(National Stroke Association, 2008)
� Of new cases reported each year 40%
to 60% move from acute to chronic
stage (Meinzer, Streiftau, & Rockstroh, 2007) 0
Acute & Chronic
Aphasia Defined
� Acute aphasia: First 6 months to 1 year
post-stroke (Meinzer, Streiftau, & Rockstroh, 2007; Meinzer, et.
Al., 2005)
� Chronic aphasia: 6+ months (Eldar, 2000);
2+ years post-stroke (Lyon, 1998)
Therapy
Acute Stage
� Most rehabilitation occurs within the first 6
months to 1 year post stroke
� Medicare covers rehabilitation for up to
two months (Holland & Fridriksson, 2001)
� Other managed care organizations may
limit services even more (Helm-Estabrooks & Holland,
1998)
Stroke
Aphasia
Muscular
Dystrophy
Parkinson's
Alzheimer's
Disease
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
New Cases each Year
Current Cases in
Millions
Adapted from:
Holland, A., Fromm, D., DeRuyter, F., & Stein, M. (1996). Treatment Efficacy: Aphasia. Journal of Speech and
Hearing Research, 39: s27-s36.
Lyden, P. (1996). Magnitude of the problem of stroke and the significance of acute intervention. Proceedings of a National
Symposium on Rapid Identification and Treatment of Acute Stroke, Bethesda, MD.
http://www.wrongdiagnosis.com/d/duchennemd/prevalence.htm
http://www.cdc.gov/stroke/faqs.htm
Factors Affecting
Aphasia Therapy Today
� Changes in health care policy
� Insurance reimbursement
� Federal health care legislation
� Political climates
� Managed health care/private insurance
carriers
Hallowell & Chapey, (2008)
Therapy
Chronic Stage
� Restrictions from Medicare and managed care
do not typically afford therapy once a PWA
reaches the chronic stage
� Medicare typically used up within first 6 months
to 1 year
� Limited resources available to chronic PWA and
their caregivers
(Lyon, 1998 )
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Frederick L. Darley
� In 1972: The first to identify the need
for efficacy studies with language
therapy for aphasia
� Darley urged the profession to take a more
precise look at the efficacy of aphasia
therapy and opened the door for outcomes
research
(Wertz & Irwin, 2001)
Acute Stage
� 37 acute stage studies reviewed from 1904
to 2006
�32 reported improvement in response to
treatment
�4 reported no improvement
�1 reported both
Chronic Stage
� 32 chronic stage studies reviewed from
1969 to 2008
� 26 reported improvement in response to
treatment
� 5 reported no improvement
� 1 reported both
Clinical Outcomes
Research
� Encompasses all forms of methodologies
and evidence (Cherney & Robey, 2001)
� 69 studies from 1904 to 2008 are included
in acute and chronic aphasic tables
� Treatment methods investigated
Therapy
Acute Stage
1 year post stroke received the following
therapies:
� Relaxation training
� Schuell-Wepman-Darley
Multimodal Stimulation
Visits Approach (SWDM)
� Melodic Intonation Variable
Therapy (MIT)
� Individual vs. Group
� Operant Therapy
� Group
� Oral Reading
� Language Oriented
Treatment (LOT)
� Conventional Therapy
� Computer Reading Therapy
(CRT)
� Constraint Induced Therapy
� Graphic Topic Setters
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Conclusions
Aphasia Tables
1. Speech and language therapies are
generally effective for individuals with
acute and chronic aphasia
2. Many therapy approaches not well
described
3. Lack of well designed studies
Chronic Care
� PWA and their family often left without
meaningful or functional communication
when formal therapy ends (Vickers & Hagge, 2007)
� Chronic PWA and their family still seek
assistance or information (Fink & Swartz, 2000)
Caregiver Studies
� 6 Studies reviewed from 2004 to 2007
� 4 reported improvements in response to
treatment
� 1 reported no improvement
� 1 reported both
Caregivers of PWA
� 4/5 families in the US experience a family
member that requires lifelong care due to a
stroke (National Stroke Association, 2005)
� Most long term care for chronic PWA in
the home is provided by a spouse or adult
children (Hallowell & Chapey, 2001)
What Do We Know?
Caregiver Intervention
� Family education, training, and support
programs used to complement traditional
aphasia therapy (Sorin-Peters, 2004)
� Limited number of studies targeting
therapy outcomes for caregivers (Watamori,
Kobayashi, & Osada, 2007)
Conclusions
Caregiver Table
Therapy that acknowledges the role of
the caregiver of the PWA generally has a
positive impact on quality of life and
communication for PWA and their
caregiver(s)
(van der Gaag, 2005, Sorin-Peters, 2004)
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Unanswered
Questions/
Future Research
3. What types of outcome measures
best document non-traditional
improvements in both PWAs and
caregivers: including quality of life,
stress, burden, depression, and other
psychosocial outcomes?
References
American Stroke Association (2005). Heart disease and stroke statistics
2005 update. Retrieved March 24, 2008, from
www.americanheart.org.
Barthel, G., Meinzer, M., Djundja, D., & Rockstroh, B. (2008).
Intensive language therapy in chronic aphasia: Which aspects
contribute most? Aphasiology, 22(4): 408-421.
Centers for Disease Control (1999, August), Achievements in public
health, 1900-1999. Morbididty and Morality Weekly Report, 48
(30).
Chapey, R. (Ed.) (2008). Language Intervention in Adult Aphasia. 5 th
Edition. Baltimore: Williams and Wilkins.
Cherney, L., & Robey, R. (2008). Aphasia treatment: Recovery,
prognosis, and clinical effectiveness. In R. Chapey (Ed.),
Language Intervention in Adult Aphasia (5 th ed.), (pp. 148-172).
Baltimore: Williams and Wilkins.
Clark, N., & Rakowski, W. (1983). Family caregivers of older
adults: Improving helping skills. The Gerentologist, 23(6), 637-
642.
1. Further research needs to focus on
well-defined therapy methods for
specific types of aphasics both at the
acute and chronic stages using higher
levels of evidence.
2. How can we help acute and chronic
PWAs and caregivers cope with
communication changes despite
degree of improvement?
4. What therapy techniques facilitate
communication in a variety of living
settings (home, skilled living, nursing
home)?
5. What is the cost effectiveness of
various therapy approaches for
PWAs and caregivers?
References
Darley, F. L. (1972). The efficacy of language rehabilitation in
aphasia. Journal of Speech and Hearing Disorders, 37, 3-21.
Fox, L., Poulsen, S., Bawden, K., & Packard, D. (2004). Critical
elements and outcomes of a residential family-based
intervention for aphasia caregivers. Apahsiology, 18(12), 1177-
1199.
Fink, R., & Schwartz, M. (2000). MossRehab Aphasia Center: A
collaborative model for long term rehabilitation. Topics in
Stroke Rehabilitation, 7(2), 32-43.
Frattali, C. (1998). Measuring Outcomes in Speech-Language Pathology.
New York: Thieme.
Golper, L. & Brown, K. (2007). Applying evidence to clinical
practice. In R. Lubinski, L. Golper, & C. Frattali (Ed.),
Professional Issues in Speech-Language Pathology and Audiology (3 rd
ed.), (pp. 560-576). NY: Thomson Delmar Learning.
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References
Holland, A. & Fridriksson, J (2001). Aphasia management during
the early phases of recovery following stroke. American Journal
of Speech-Language Pathology, 10: 19-28.
Holland, A., Fromm, D., DeRuyter, F., & Stein, M. (1996).
Treatment Efficacy: Aphasia. Journal of Speech and Hearing
Research, 39: s27-s36.
Hallowell, B. & Chapey, R. (2008). Delivering language
intervention services to adults with neurogenic communication
disorders. In R. Chapey (Ed.), Language Intervention in Adult
Aphasia (5th ed.), (173-193). Baltimore: Williams and Wilkins.
LPAA Project Group (2000). Life participation approaches to
aphasia: A statement of values for the future. ASHA Leader,
3: 4-6.
References
Meinzer, M., Streiftau, S., & Rockstroh, B. (2007). Intensive
language training in the rehabilitation of chronic aphasia:
Efficient training by layperson. Journal of the International
Neuropsychological Society, 13: 846-853.
Meinzer, M., Djunja, D., Barthel, G., Elbert, T., & Rockstroh, B.
(2005). Long-term stability of improved language functions in
chronic aphasia after constraint-induced aphasia therapy.
Stroke, 36: 1462-1466.
Michallet, B., Le Dorze, G., & Getreault, S. (2001). The needs of
spouses caring for severely aphasic persons. Aphasiology, 15,
731-747.
National Stroke Association. (2008). Recovery After Stroke:
Thinking and Cognition. Available at www.stroke.org.
Rau, M. (1991) Impact on families. In R. Lubinski (Ed.), Dementia
and Communication (152-167). Philadelphia: B.C. Decker, Inc.
References
Watamori, T., Kobayashi, H., & Osada, H. (2007) Development of
a caregiver burden scale to assess feelings of burden in caregivers
of older adults with chronic aphasia. Gerontology, 12(2): 2-8.
Wertz, R. & Irwin, W. (2001). Darley and the efficacy of language
rehabilitation in aphasia. Aphasiology, 15(3): 231-247.
References
Lubinski, R. (2008). Aphasia treatment: Recovery, prognosis, and
clinical effectiveness. In R. Chapey (Ed.), Language Intervention
in Adult Aphasia (5 th ed.), (pp. 269-296). Baltimore: Williams
and Wilkins.
Lyden, P. (1996). Magnitude of the problem of stroke and the
significance of acute intervention. Proceedings of a National
Symposium on Rapid Identification and Treatment of Acute
Stroke, Bethesda, MD.
Lyon, J. (1992). Communication use and participation in life for
adults with aphasia in natural settings: The scope of the
problem. American Journal of Speech-Language Pathology, 1(3), 7-
14.
Lyon, J. (1998). Coping with Aphasia. Sand Diego, CA: Singular
Publishing Group Inc.
References
Simmons-Mackie, N. (2008). Aphasia treatment: Recovery,
prognosis, and clinical effectiveness. In R. Chapey (Ed.),
Language Intervention in Adult Aphasia (5 th ed.), (pp. 246-268).
Baltimore: Williams and Wilkins.
Sorin-Peters, R. (2004). The evaluation of a learner-centred training
programme for spouses of adults with chronic aphasia using
qualitative case study methodology. Aphasiology, 18(10): 951-975.
Steele, R., Aftonomos, L., & Munk, M. (2003). Evaluation and
treatment of aphasia among the elderly with stroke. Topics in
Geriatric Rehabilitation,19(2): 98-108.
Thom, T., et al. (2006). Heart disease and stroke statistics: 2006
update: A report from the American Heart Association statistics
committee and stroke statistics subcommittee: available at
http://www/lww.com/reprints
Vickers, C. & Hagge, D (2007). Therapy in long-term aphasia:
Today’s choices and future possibilities. Gerentology, 12(2): 16-26.
Questions?
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