Kristi, Again more problems, I hope you get this copy

"Understanding Communication Difficulties
 in Parkinson's Disease."

Overview of Parkinson's Disease

Parkinson's Disease (PD) is a progressive neurological condition effecting
approximately 25,000 people in Australia. For many years it has been
perceived as a disease of the elderly, however 2500 people under the age of
50 (some as young as 25) live with the condition. Although the cause of PD
is currently unknown, there is much that we do know about the illness.

Parkinson's Disease is a progressive degeneration, and subsequent death of
the brain cells (neurones) responsible for movement. These "movement cells"
produce a chemical messenger, dopamine, which is responsible for smooth
movements. As these cells die the amount of dopamine the body is capable of
producing substantially decreases, thus resulting in a disease which
manifests itself in many ways. Characteristically common symptoms such as
tremor (shaking), Bradykinesia (poverty and slowness of movement), Rigidity
(muscle stiffness) and Akinesia (freezing) may occur. However, these
symptoms are often combined with other symptoms that are equally as
challenging such as depression, lethargy, gait disorder and communication
difficulties.

Communication difficulties in Parkinson's Disease are very common and
varied. The following text will outline the components which affect
communication, the impact on the individual, and help that is available
(e.g. how, when and where).

Components which affect Communication

The first thing to be emphasised is that Parkinson's Disease is a condition,
which affects every individual differently. No two people experience the
disease or the disease process identically. The communication difficulties
identified may occur in one patient and not in another and they may occur in
varying combinations.

When communicating, it is estimated that words account for only 7 % of the
overall effect, whilst 38% of the message is conveyed via tone, intonation
and volume and a further 55% with body language and facial expressions.  To
communicate effectively we listen to the speed, volume and tone of others'
language and attempt to match it. When these skills start to decline our
communication system begins to break down and subsequently many social
problems may arise.

Respiration (Breathing)
Respiration forms the basis of all speech output, so any difficulties with
breathing will more than likely detrimentally affect speech. Approximately
50% of Parkinsonians have decreased lung function and capacity, as a result
of muscle stiffness and slowed muscle action. The result of this is that the
Parkinsonian may  'run out' of air before the end of the message, thus
producing quiet speech.



Phonantion (sounds)
One of the most common symptoms of PD is Bradykinesia (slowness or poverty
of movement). Bradykinesia affects all muscles, including those responsible
for speech, thus Parkinsonians often find it extremely difficult to initiate
speech, and once initiated it often sounds weak and strained. Parkinsonians
also often find it very difficult to increase, vary or control the volume of
their speech.
When phonation problems occur in conjunction with respiration problems the
result is weak, quiet, strained, monotonous speech.

Facial Musculature
For some Parkinsonians, a weakness develops in the muscles used in speech
(tongue, lips and jaw). This weakness is sometimes accompanied by a reduced
range of motion of the muscles responsible for speech, thus resulting in
articulation inaccuracies and errors.

Articulation
Difficulties with respiration and phonation can contribute to an impression
of inaccurate speech. This inaccuracy becomes most apparent when the
Parkinsonian attempts complicated sound combinations or long bursts of
continuous speech. Sounds such as 'p' and 'b', which require pressure (by
the lips) are affected by weak movements, thus resulting in sounds or words
being "run together".

Intelligibility/Prosody(e.g. intonation, tone, volume)
Intelligibility of speech may be influenced by speech rate; speech may be of
a variable rate, it may be excessively slow or very fast; or it may begin at
the normal rate, speeding up as the conversation progresses (festinates).
Speech may also be somewhat distorted by the reduction in emphasis or stress
between words in sentences. Speech often sounds monotonous and flat (e.g.
unable to distinguish between sarcasm and sadness), resulting in reduced
intelligibility.

Facial Expression
Displaying a masked facial expression is an extremely challenging
communication problem for Parkinsonians. This "masking" minimises a
Parkinsonian's outward display of emotion. Eye-blink is often reduced and
there may be freezing of facial postures. People may view Parkinsonians with
masked facial expressions as being hostile or unwelcoming, thus resulting in
them being treated as demented, confused, depressed or uninterested.

Language/Memory
"Freezing"  can, not only affect a persons facial expression and body
movements, but also affect a person's cognition. Parkinsonians often report
a difficulty in "changing tack" during a conversation and as a result are
often thinking of inputting into a conversation that has dramatically
changed focus during their "thinking time". Language and Memory problems
however, are not only restricted to this, difficulties understanding the
subtleties conveyed in different tones of voice (e.g. anger, shame,
excitement) are also common.




Overall Communication
The overall impression of someone displaying some of the aforementioned
characteristics (e.g. reduced facial expression and gestures) is someone who
appears humourless, emotionless and lacking strong feelings. This person may
often find it difficult communicating in a group situation and may often be
unintelligible in one-to-one situations.

Where can I get help/ Who do I contact?
Speech Pathologists have many useful strategies for dealing with
communication difficulties. Speech Pathologists can be accessed through your
local hospital, rehabilitation centre, Community Health Centre or Movement
Disorder Program.
Alternatively, Speech Pathology Australia can provide you with the names of
privately practicing speech pathologists by phoning (03) 9642 4899.

Carers can also seek help on communication and other difficulties associated
with PD by contacting the Brain Foundation of Victoria and asking about
their free carer education programs. Phone: (03) 98822203

Yooralla Equipment Services also have electronic  speech aids available.
Enquiries can be made by phoning (03) 93626111.

When to seek help
The best time to seek help is immediately following diagnosis.The
Parkinsonian may not feel that they need help at this stage, however they
can be alerted to the need for self-monitoring of their communication.
Help should be sought if there are any indications of any communication
difficulties- the earlier the better. The Speech Pathologist will advise on
the best way to maintain
communication and monitor performance.

 Strategies for assisting with communication difficulties.

For the Parkinsonian
? Reduce background noise so that less effort is needed to be heard (e.g.
turn down T.V. when having a conversation).
? Think loud and think shout!
? Exaggerate Pronunciation - pretend your listener cannot hear and has to
read your lips. Force your lips and jaw to work hard as you articulate
words. Face your listener as much as possible.
? Think carefully about what you are going to say before you say it
? Be aware of your breathing. Breathe in deeply before you speak and
forcefully push the breath out with the speech
? Concentrate on your rate of speech. Work on keeping it slow and even
? Concentrate on finishing the sound of each word  before starting the next.
? Remember that short, concise phrases are easier to understand than longer
ones.
? Talk for yourself, even if it takes longer.
? Clear your mouth of saliva regularly whilst talking..
? Most of all RELAX
? Encourage your family and friends to let you know when your voice drops.
?  Daily deep breathing and relaxation exercises are helpful for the head,
neck and shoulders.
? On the phone hold your head up straight and speak directly into the
mouthpiece.

For the carer
? Avoid talking to the Parkinsonian in groups or crowds. Extra effort to
speak clearly will be needed in a noisy environment as background noise
interferes with speech and the listener's attention.
? Reduce distracting noises and activities.
? Maintain a relaxed atmosphere for maximal communication.
? When using longer sentences, pause to give a listener time to understand.
? Use simple language- short words and sentences - if the person has
difficulty understanding
? Face the listener; it is easier to communicate when people give each other
full attention.
? Ask one question at a time
? Wait for a response each time you speak
? Ask the person to say one thing at a time
? If you are not sure how the person is reacting to something because of
reduced facial and body language ask them
? Try to appear calm. Your body language can help keep a confused person
calm
? Try lowering the pitch of your voice - lower pitch is easier to
understand. A high pitch voice can indicate that you are upset.
?  Smile and use physical displays of affection
? Use gestures when speaking - demonstrate an action, point, touch etc.

For more information contact Parkinson's Victoria, 20 Kingston Rd Cheltenham
3192 or Phone  03 95511122.

Please note that this information is not written by a speech pathologist and
is only designed to summarise the literature available. This information is
in no way meant to  replace or undermine the role of the speech pathologist
in treating communication impairment in PD.

Compiled by Jodie Davies, Client Services Officer for Parkinson's Victoria.

References

Kirsner, A. (1999). Resource Kit for Carers of People with Neurological
Conditions
or Acquired Brain Injury.
McLean, J., & Handy, C. (1998). Caring for Yourself and Parkinson's.
Morris, M., Iansek, R., & Kirkwood, B. (1995). Moving Ahead with Parkinson'
s.
Parkinson's Disease Society (Europe). Speech Therapy Information Pack.
Scott, S. (1998). The importance of communication. Parkinson's Australia
Magazine.