Aphasia

Aphasia is the loss of language, not of intelligence. The part of the brain that handles words has been damaged: the person can no longer find the name of a thing, gets tangled in grammar, misses the sense of what is said to them, stumbles over reading and writing. And yet they are entirely themselves: they get the joke, know their family, remember their trade, make their own decisions. From the outside almost none of this shows, so people around them start speaking to them as if they had gone back to childhood. Aphasia usually arrives all at once, at the moment of a stroke, and from the first weeks it begins to retreat, sometimes completely.

What exactly breaks down in speech

Language does not sit in one block of the brain, so it does not break in one single way. One person hunts for words and speaks in effortful bursts, yet understands every word said to them and gets furious with their own mouth. Another speaks fluently, with normal rhythm and intonation, and still says nothing at all: words are swapped for similar-sounding or invented ones, and at first the speaker does not notice.

What you can see and hear:

• the word sits on the tip of the tongue and will not come, so the person describes the object instead of naming it;
• a neighbouring word slips out instead, close in meaning or in sound: "table" for "chair", "boat" for "coat";
• the sentence falls apart: small words and endings drop out and speech sounds telegraphic;
• the person hears what is said but cannot unpick it, especially in noise, on the phone, or when the speaker is quick;
• reading and writing suffer alongside speech: the letters are familiar, but the line will not come together;
• hardest of all are numbers, dates, the names of months and people's names.

Hearing has nothing to do with it, and raising your voice does not help. Time helps: the pause in which the person can assemble a sentence.

How it differs from slurred speech

These two are confused constantly, textbooks included. In dysarthria the tongue, lips and vocal cords obey poorly: speech is slurred and slowed, but the words chosen are the right ones and the person understands everything. Aphasia touches not the muscles but language itself, as a system of signs: the pronunciation can be perfectly clear while the sentence means nothing.

The difference is not academic. In dysarthria a way round remains: writing, typing, pointing, gesture. In aphasia those routes are damaged too, so sessions are built differently. A similar mix-up happens with apraxia of speech, where the person knows the word but cannot organise the movements to say it. Telling these apart is the speech and language therapist's job, and everything that follows depends on what they find.

Where the damage comes from

The underlying cause is always the same: injury to the language areas, usually in the left half of the brain. What differs is what injured them.

• Stroke. The commonest cause by far. Speech goes within seconds or minutes.
• Head injury. Also sudden, but with an obvious reason behind it.
• Brain tumour. Speech worsens over weeks and months, often alongside morning headaches or a first-ever seizure.
• Infection. Encephalitis or a brain abscess: language goes over a few days with fever, headache, drowsiness or odd behaviour. This is an emergency, and it is not rarely taken for a nervous breakdown.
• Seizures and their aftermath. After an epileptic seizure speech can be disturbed for hours and then return.
• Gradual loss. There is a separate form, primary progressive aphasia: words are lost over years while memory, orientation and personality stay intact for a long time. It gets blamed on tiredness or age, and years pass before the diagnosis.

Occasionally speech goes astray briefly for a reversible reason: low blood sugar, migraine with aura, poisoning, a severe infection in an older person. None of this can be told apart by eye; it gets sorted out in hospital.

Speech lost suddenly is an emergency

Call the emergency services at once (112 in Europe) if someone suddenly has:

• a drooping face, with one corner of the mouth pulled down;
• weakness in the arm or leg on one side, or numbness down one half of the body;
• speech that is slurred, jumbled or gone altogether, and they cannot follow questions;
• lost or doubled vision;
• abrupt dizziness and loss of balance.

Even if it all clears on its own ten minutes later, do not cancel the call: this can be the warning shot before a major stroke. Note the exact time the person was last speaking normally, because that is what the window for dissolving or removing the clot is counted from, and it is counted in hours. Do not drive them yourself: they may deteriorate on the way, and an ambulance crew starts treating on board.

How the cause is worked out

In the first days the priority is finding the cause: neurological examination, a brain scan, blood tests and, where needed, imaging of the blood vessels. Language is checked briefly with simple tasks: name these objects, repeat this sentence, follow a two-step instruction.

The detailed assessment is done by a speech and language therapist, and it exists not for the sake of a label but for a plan: what has held up better, understanding or speaking, writing or the spoken word, single words or sentences. Whatever is preserved becomes the foundation. The assessment is repeated, because the picture shifts noticeably over the first months.

What brings speech back

There is no pill for aphasia. What works is therapy: regular, started as early as possible and intensive enough, since short occasional visits deliver far less than a dense schedule.

• finding words with the help of pictures, categories, sound patterns or the first part of the word;
• rehearsing whole useful phrases, the ones the person needs every day;
• work on understanding, from simple requests to long, layered ones;
• reading and writing, including typing if the hand works less well;
• ways round the problem: gesture, drawing, photographs, cards, apps on a phone;
• group sessions, where speech is practised in real conversation rather than in an exercise.

Recovery moves fastest in the first months but does not stop there: people go on gaining ground years later, particularly if they keep working at it. Where the cause is progressive the aim changes: not to win back what has gone, but to learn ways of communicating in good time, while learning them is still easy.

Mood deserves a separate mention. Losing speech strikes at independence and often brings low mood and isolation: the person stops phoning, turns down company. This is treatable, and it should be raised with a doctor as plainly as the speech itself.

How to talk so it comes easier

• Use your ordinary voice. Shouting is pointless; hearing is fine.
• Short sentences, one question at a time, a pause afterwards. The pause may last longer than feels comfortable.
• Do not finish sentences for them unless asked. Give them the chance to get there.
• Frame questions so they can be answered with yes or no, or by choosing between two options.
• Write down key words, draw, point to objects and photographs. That is conversation, not defeat.
• Turn the television off and sit face to face: background noise and unseen lips take away half of what is understood.
• Speak to the person, not to whoever came with them, and speak to them as an adult.

Online consultation

In an online appointment a doctor can go through how and when the speech changed, what is hardest now and whether there are other neurological signs, explain which investigations make sense and in what order, and advise which specialist to see in person. They can also help make sense of reports already issued and plan the therapy. For relatives, the most practical part is covered: how to set up communication at home and what to avoid.

This material is for information only and does not replace medical advice.