Dysarthria (speech disorder)
Speech comes out of the breath, the vocal folds, the soft palate, the tongue and the lips all working together.
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Speech comes out of the breath, the vocal folds, the soft palate, the tongue and the lips all working together. Dysarthria is what happens when the thought is formed and the words are chosen but the muscles meant to produce them cannot cope: they have weakened, slowed down or lost their precision. To a listener it can look as though the person is struggling to find words, but that is not it. Understanding, reading, writing and the ability to reason are unaffected, and that is the first thing everyone around should know.
When minutes count
Call an ambulance at once (across European countries the single number 112 works) if speech has become slurred suddenly, especially alongside any of these:
- one side of the face has dropped, with the corner of the mouth or an eyelid sagging;
- the person cannot raise both arms and hold them up, and one drifts down;
- speech has become jumbled and incoherent, or they cannot understand what is said to them;
- weakness or numbness has come on suddenly in an arm or a leg;
- vision has gone abruptly, or there is double vision, dizziness or loss of balance.
That is what a stroke looks like. The earlier treatment starts the better it works, and lost time cannot be made up. Do not drive, and do not take the person to hospital yourself: the call handler will say what to do until the crew arrives. And even if it all passes off by itself within minutes, still make the call, because a brief episode often heralds a real stroke within days.
What dysarthria sounds like
The main feature is blurred pronunciation. It ranges from barely noticeable, so that the listener merely asks again more often, to so marked that only a relative used to the voice can follow it. From the particular way speech is disturbed a doctor can often tell which part of the nervous system is involved.
- speech slows and drags, and every word takes effort;
- or the opposite: it speeds up and crowds together towards the end of a phrase;
- the voice sounds nasal, with air escaping through the nose because the soft palate is not sealing;
- volume goes out of control, so speech is too quiet without the speaker noticing, or unexpectedly loud;
- the voice turns hoarse, strained and monotone, and loses expression;
- phrases shorten and break up, because there is not enough breath for a long sentence;
- dribbling appears, chewing becomes harder, and food sits in the cheek.
Tiredness, nerves and background noise make speech noticeably worse. That is not a sign that the illness is advancing but a property of dysarthria itself, and important conversations are best kept for the time of day when there is more energy.
How this differs from aphasia
The two are often confused, and they sometimes occur together, for instance after a stroke.
- Dysarthria is a failure of execution. The person knows exactly what they want to say and, handed a pen, will write it without a single error.
- Aphasia is a failure of language itself. Finding words, building a sentence and understanding other people all suffer, and with them reading and writing.
- Apraxia of speech is a failure of movement planning. The errors are inconsistent: the same word comes out right one time and wrong the next, and the person seems to grope for the position of the tongue.
- A voice disorder involves the vocal folds, so the voice is hoarse or gone altogether while the sounds themselves are shaped clearly.
The distinction is not academic: it determines what the speech therapist will work on and how to talk with the person at home.
Why the speech muscles weaken
Dysarthria is not a disease but a consequence, and it can arise at any age. Suddenly it is brought on by a stroke, a severe head injury, or infection or inflammation of the central nervous system. Gradually, by conditions that damage that system year after year:
- Parkinson's disease, in which speech becomes quiet and flat;
- multiple sclerosis;
- motor neurone disease, where speech and swallowing are sometimes the first things to go;
- tumours of the brainstem and cerebellum;
- damage to the cerebellum, which produces clipped speech, as though stamped out syllable by syllable;
- cerebral palsy and Down's syndrome, where the difficulty is present from early on.
Medicines can disturb speech too: anticonvulsants, tranquillisers, some antipsychotics and lithium all cause slurring as a side effect. What matters here is not to stop treatment on your own but to tell the doctor, because the dose can often be arranged differently.
Two rare causes deserve naming separately, because they are easy to miss and both respond to treatment. The first is myasthenia: speech is clear at the start of a conversation and fades as the person keeps talking, then recovers after a rest. It usually comes with double vision, a drooping eyelid and weakness that builds towards evening. The second is Wilson's disease, a disorder of copper handling that shows up in young people and, besides speech, brings tremor, clumsiness, changes in character and liver damage. Both are picked up by blood tests, and both are far more manageable the earlier they are found.
What makes the cause worth chasing quickly
See a doctor without delay if:
- speech is getting worse over weeks or months;
- choking, coughing while eating and drinking, or a sense of food sticking have appeared alongside it, since food may pass into the airway and cause pneumonia;
- speech is clearly worse by the end of the day and after talking for a while, with double vision or a drooping eyelid;
- a child has stopped speaking as well as they already could;
- morning headache, vomiting or unsteadiness on the feet have joined the speech problem;
- speech changed soon after a new medicine was started or a dose was altered.
An ambulance is needed for more than a sudden onset. Call one if breathing is becoming difficult, if the person cannot swallow their own saliva, or if a fever and breathlessness follow an episode of choking.
How it gets worked out
The appointment begins with talking and examining: the neurologist checks the muscles of the face, tongue and palate, then strength, reflexes and coordination, and assesses swallowing. How far the tests go depends on what is found. Usually it means an MRI scan of the brain, blood tests including antibodies where myasthenia is suspected, and a study of conduction through nerves and muscles. If there is choking, swallowing is examined separately, by X-ray or endoscopy.
Alongside this the speech therapist makes an assessment of their own: measuring how intelligible the speech is, working out which sounds are affected, and checking breath, voice and the movement of the articulators. That assessment becomes the baseline against which progress is later measured.
What a speech therapist can do
There is no magic exercise that gives speech back, but intelligibility can almost always be raised, sometimes strikingly. The plan depends on the cause and on whether recovery or increasing weakness lies ahead.
- exercises for lips, tongue and palate, working on strength, accuracy and range of movement;
- work on breath and vocal support so that phrases do not break off;
- slowing the rate, the simplest and most effective measure of all: slow speech is intelligible even with marked muscle weakness;
- deliberate, exaggerated articulation and breaking long words into parts;
- specific loudness training programmes, which work particularly well in Parkinson's disease;
- a voice amplifier where there is enough strength for sound but not for volume;
- an alphabet board, cards, or an app with synthesised speech on a phone or tablet.
With conditions that will progress, sessions shift towards additional ways of communicating, and these are best brought in early while speech is still there. If the voice may be lost in time, it is recorded: phrases and words banked in advance make it possible to speak later through a synthesiser that sounds like the person rather than like nobody.
How to make conversation easier
Half the outcome rests not with the person speaking but with the person listening.
For the speaker: switch off the television and cut out background noise where you can; sit facing the other person; get their attention before you begin the sentence; name the topic in a single word before developing the thought; take a breath before each sentence and speak in short runs; do not hesitate to help yourself out with gestures, writing or a phone; and pause when tired, because forcing the end of a sentence adds nothing to clarity.
For the listener: look at the speaker's face; let them finish and do not supply words unless asked; never nod when you have not understood, which is the most dispiriting thing of all; ask specifically, repeating back the part you did catch; offer yes-or-no answers when the conversation is going nowhere; and do not raise your voice, because the person is not deaf and hears you perfectly well.
Online consultation
Remotely it is straightforward to establish what you are dealing with and where to go next: the doctor listens to the speech, asks how it began and whether it varies through the day, and helps separate dysarthria from aphasia and from a voice disorder. We can look at whether the change is linked to your medicines; draw up the list of tests worth taking to a neurologist; discuss what to do about choking before that appointment and how to eat more safely; and pick out the measures that raise intelligibility from today, explaining how to prepare for speech therapy. Slurred speech of sudden onset is not assessed remotely: that is a reason to call an ambulance immediately.
This material is for information only and does not replace medical advice.
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