Maintaining the art of conversation in Parkinson’s disease
Conversation has been described as ‘a vocal competition in which the one who is catching his breath is called the listener’ (Anon.). The competition is hardly fair for people with Parkinson’s disease (PD) who are inevitably relegated to the listening role by their hesitant, hypophonic speech.Relationships are forged from social interaction, but patients with PD are limited by the dual effects of poor verbal and non-verbal communication compounded by impairment of semantic processing affecting complex sentence comprehension [1].
Academic research can sometimes lose sight of the human context, and the literature on speech in PD has largely concentrated on detailed dissection and description of the various impairments in phonation, articulation, acoustic perception and timing, which characterise PD speech [2–4].
In contrast, the article by Miller et al. is notable for examining communication from the perspective of the impact on the individual and sheds some light on the inward spiral of social withdrawal that so often accompanies the downward spiral of disease progression in PD [5]. Themes that emerged from in-depth interviews highlight the demoralising effect of losing track mid-sentence, the impact on self-perception and family dynamics as well as the sheer physical and mental effort involved in staying in the conversation. Patients employ a variety of strategies, including withdrawal depending on the situation but also influenced by their perception of the listeners attitude (busy clinic, rushed physician with students in tow?). Non-verbal factors are probably underestimated but reduced facial expression and even subtle changes in speech have been shown to engender negative personality judgments of PD patients amongst health professionals [6, 7] and are likely to similarly impact on personal relationships.
Standards 4 and 5 of the National Service Framework for long-term conditions stress the need for timely rehabilitation services—but what is timely [8]? The draft PD NICE guidelines review the evidence base and recommend speech therapy input for people with PD but again give no guidance on who and when to refer [9]. This article highlights the negative impact of even early speech changes insufficient to impair intelligibility and provides a rationale for early referral. The findings also suggest the need to shift the research and therapeutic emphasis away from the current focus on speech parameters to include cognitive, psychological and physical aspects as well as the role of strategies to facilitate and maintain communication.
What are the lessons for the clinicians?
Speech encompasses much more than simple intelligibility. Take account of subtle difficulties with self-expression including cognitive and language difficulties; keep it simple and write things down. Health professionals also have a responsibility to help carers, and patients develop constructive coping strategies based on an understanding of the effects of PD on verbal and non-verbal self-expression.
Communication is central to every patient encounter but, to quote George Bernard Shaw, ‘the greatest problem with communication is the illusion it has been accomplished’. Perhaps a useful starting point is to routinely ask ‘have you anything else you want to say?’—and then to listen.
The Older People’s Unit Royal United Hospital, Bath, UK Email: dorothyr{at}btinternet.com
References
- Angwin AJ. Summation of semantic priming and complex sentence comprehension in Parkinson’s disease. Brain Res Cogn Brain Res 2005; 25: 78–89.[CrossRef][Medline]
- Forrest K, Weismer G, Turner GS. Kinematic, acoustic and perceptual analysis of connected speech produced by Parkinsonian and normal geriatric adults. J Acoust Soc Am 1989; 85: 2608–22.[CrossRef][Medline]
- Ackermann H, Ziegler W. Articulatory deficits in parkinsonian dysarthria: an acoustic analysis. J Neurol Neurosurg Psychiatry 1991; 54: 1093–8.
[Abstract/Free Full Text] - Goberman AM, Elmer LW. Acoustic analysis of clear versus conversational speech in individuals with Parkinson’s disease. J Commun Disord 2005; 38: 215–30.[Medline]
- Miller N, Noble E, Jones D, Burn D. Life with communication changes in Parkinson’s disease. Age Ageing 2006; 35: 239–5.
- Pentland B. The effects of reduced expression in Parkinson’s disease on impression formation by health professionals. Clin Rehabil 1987; 1: 307–13.
- Pitcairn TK, Clemie S, Gray JM, Pentland B. Impressions of parkinsonian patients from their recorded voices. Br J Disord Commun 1990; 25: 85–92.[Web of Science][Medline]
- The National Service Framework for Long Term Conditions. 2005. http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/LongTermConditions/fs/en/.
- NICE. Guidelines for PD: second consultation. http://www.nice.org.uk/page.aspx?o=289464.
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