By Angela Roberts-South, M.A., Ph.D. Candidate
The ability to communicate clearly is critical to maintaining existing relationships and to forging new ones. Parkinson’s disease (PD) can compromise this ability, and it is important for people with Parkinson’s and their care partners to know that there are strategies available that can help to improve their communication abilities.
Communication Challenges in Parkinson’s
Each person’s experience with Parkinson’s is unique, and this holds true for communication. Symptoms vary and can change as the disease progresses.
Language and Memory. Some people with PD experience changes in cognition and language, which make it difficult to think quickly, to manage multiple tasks, to find words or to understand complex sentences. These changes, even if subtle, can make it challenging for a person with Parkinson’s to follow a conversation. For example, I often hear people with PD say, “I know the word I want to say, but I just can’t find it.” A related problem can be the time it takes to formulate ideas. Together, these problems can create pauses in the conversation and cause others to become unsure about when it is their turn to speak. In a fastmoving group discussion, others may not wait, and the person with PD can find him- or herself getting left out. It may help to make others aware of these challenges, and to check in with the person with PD to see if they have anything to add.
Emotions and Gestures. People with PD can have difficulty recognizing both words and facial expressions that convey emotions. At the same time, they may speak with a ‘flatter’ voice and make fewer expressive facial expressions, meaning that their faces communicate less meaning to their listeners. The same goes for physical gestures. Body language adds emphasis to a speaker’s words, but in PD the speaker often has a compromised ability to make gestures. Together, these symptoms can affect how listeners interpret intended emotions such as humor, irony or sarcasm.
Speech and Voice. About 90 percent of people with PD will experience changes in their voices or their ability to make speech sounds at some stage of their lives. Most commonly, the voice becomes quieter. It can also develop a breathy or hoarse quality. These changes may make a person’s speech less precise and more difficult to understand, especially when speaking to partners who have hearing loss. Researchers believe that these symptoms are due to brain changes that make it difficult to follow internal cues, telling us how loud the voice should be or how much effort is required to produce clear speech. Then there is the matter of the speed at which people speak. Some individuals with PD may speak more slowly. Others — perhaps 10 percent — accelerate their speech so much that they stumble over sounds, and seem to be stuttering.
Walking and Talking. People with PD may find it difficult to communicate while walking or doing other tasks. Speech may become softer, and less clear when moving around. The problem may be exacerbated if the person also is trying to express complicated sentences. People may also experience more frequent and longer pauses in conversation. The reverse of this is also true. People with PD may change their walking pattern or have more challenges maintaining balance when they are trying to talk while walking.
Tips for Improving Communication
Certain strategies for improving communication work better for some people than for others, or may need to be adjusted at a different stage of Parkinson’s. The key to managing these problems is to remain flexible and to find a strategy that works for you. For all of these, the best results will come from working with a speech language pathologist (SLP).
Exercise the Voice. A well-studied technique for increasing vocal volume is the Lee Silverman Voice Treatment (LSVT®). It is an intensive voice exercise program that helps people with PD speak more loudly and clearly, and make facial expressions that are more emphatic. Therapy is conducted over the course of one month (four visits per week), under the direction of an SLP who is certified in the techniques. People with advanced PD, or with more severe cognitive changes, may face challenges in applying these techniques.
Speak Above the Crowd. For people who have difficulty making their voices louder, there are devices that optimize the natural tendency we all have to raise our voices above background noise. This natural tendency is called the Lombard effect. One device, called a SpeechVive®, is worn in the ear like a small hearing aid. When a person begins to speak too quietly, the device plays a background noise into the ear. The onset of this noise and the brain’s natural tendency (i.e., Lombard effect) results in the person with PD increasing their voice volume without having to think about doing so. Recently, a small study showed potential for a lasting benefit – the people who wore the device daily for eight weeks had a continued therapeutic effect even when not wearing it. An app for the iPhone called iParkinson’s works in a similar way although evidence on the therapeutic effect of this app is limited.
Pace Yourself. Reducing the rate of speech can be very challenging for individuals with PD. Concentrating on slowing down is typically not effective for more than a few words at a time. Sometimes, therapies that focus on voice and speech, such as LSVT, can help to reduce the rate. There are also devices that can record a person’s voice and play it back to them using an earpiece with a very subtle delay. This is called delayed auditory feedback. Another approach to slowing speech down is to use pacing therapy and/or pacing boards. Pacing board devices can be very simple, such as a series of cards with printed shapes or words on them that the person touches in sequence with every spoken word. This slows down the rate of speaking. There are smartphone and tablet apps that serve similar purposes.
Amplify with a Microphone. There are various amplifiers that may help, such as the personal amplifier, which requires the person with PD to wear a small microphone that picks up the voice, and a speaker that amplifies it. These devices range widely in size and in sound quality. They amplify the person’s voice to the same level for everyone. Some people may only need their voices amplified when they are talking on the telephone. There are telephones that amplify the voice to the person on the receiving end of the phone. Lastly, there are devices called wireless personal FM systems, borrowed from the hearing loss community, which can effectively amplify the voice with excellent sound quality. With this device, the person with PD wears a transmitter around the neck and a small microphone. Their conversation partner wears a receiver around the neck, equipped with an ear insert or tiny headphones. In situations where the person with PD needs to talk to more than one person at a time, each listener wears a receiver of their own and can set the amplification level that is comfortable for them. These devices are useful for conversations happening at longer distances (e.g., between rooms).
Think Outside the Voice. While rare in PD, there are times when a person’s speech becomes extremely unintelligible. In these cases, it might be best to use specialized devices that ‘speak’ for you. Devices range from low-tech alphabet boards to high-tech computerbased devices that become your ‘voice.’
Find an Approach That Works for You
There is no one-size-fits-all solution for improving communication in PD. The key is to be flexible, creative, and to shift or combine strategies as needed as the disease progresses and communication needs change. It is also important to remember that everyone involved in the conversation plays a role in its success, and in allowing people with PD to be heard. As such, successful therapy programs include not only the person with PD but also their communication partners.
Ms. Roberts-South works at Western University in Ontario, Canada. She first presented this topic as a PD ExpertBriefing, which is available at: www.pdf.org/parkinson_briefing_improvingcom.