Aphasia incidence and intervention in the acute hospital setting

ii Acknowledgements.v Introduction.1 Cost and Impact of Aphasia.1 Neuroplasticity.3 Treatment Intensity and Efficacy.3 When to Commence Therapy.3 Intensity of Therapy.4 Current Level of Care in Australia.5 Research Aims.7 Method.8 Setting.8 Participants.8 Procedure.8 Statistical Analysis.10 Results . 11 Discussion.19 Limitations.27 Future Research.28 Implications.29 Conclusion.30 References.31 Appendix.37 APHASIA IN THE ACUTE HOSPITAL SETTING 1 Aphasia Incidence and Intervention in the Acute Hospital Setting In recent years the role of the speech pathologist within the acute hospital setting has transformed dramatically as a result of time constraints (Armstrong, 2003; Enderby & Petheram, 2002; Lalor & Cranfield, 2004), reduced funding, and service provider organisational policies (Verna, Davidson, & Rose, 2009). Dysphagia referrals have increased exponentially, as has the time spent managing swallowing function in the acute setting (Enderby & Petheram, 2002). Despite aphasia referrals to speech pathology departments also having increased, the time spent working with people with aphasia has decreased (Enderby &Petheram, 2002). The changing demands of clinical services may mean those people with communication impairments, such as aphasia and right hemisphere communication impairments, do not receive the intervention they require. Cost and Impact of Aphasia Cerebrovascular disease, including stroke, was the second leading cause of death in Australia in 2010 (Australian Bureau of Statistics, 2010). It is estimated that in Australia each year approximately 60 000 people suffer a stroke and as the population ages this number will increase further (National Stroke Foundation [NSF], 2010). Stroke impacts greatly upon the healthcare system and it is estimated that Australian stroke expenditure is $2.14 billion per annum (NSF, 2010). Following a first ever ischaemic stroke, approximately one third of people will suffer from aphasia (Dickey et al., 2010; Lalor & Cranfield, 2004; Laska, Hellblom, Murray, Kahan, & Von Arbin, 2001; Law et al., 2009; Pedersen, Jorgensen, Nakayama, Raaschou, & Olsen, 1995; Tsouli, Kyritsis, Tsagalis, Virvidaki, & Vemmos, 2009) and that one year later approximately 18-27% of these people have chronic aphasia (Paolucci et al., 2005). APHASIA IN THE ACUTE HOSPITAL SETTING 2 The presence of aphasia is a good predictor of short and long-term mortality (Laska et al., 2001; Tsouli et al., 2009). People with aphasia have almost a fourfold mortality rate when compared to stroke survivors without aphasia in the acute phase (Laska et al., 2001). At ten years post-stroke this difference is maintained (Tsouli et al., 2009). Likewise, aphasia is associated with lower functional improvements during rehabilitation (Gialanella & Prometti, 2009; Guyomard et al., 2009) and is an independent predictor of increased hospital length of stay (LOS). People with aphasia have up to a 14 day longer LOS in hospital than stroke survivors without aphasia (Guyomard et al., 2009; Paolucci et al., 2005), placing an increased burden on the healthcare system and greatly increasing costs (Gialanella & Prometti, 2009; Guyomard et al., 2009). The consequences of aphasia are devastating for the psychosocial well-being of an individual and their family (Tsouli et al., 2009). Aphasia is a strong predictor of increased depression, poor functional recovery and is associated with compromised independence in activities of daily living (Tsouli et al., 2009). People with aphasia are more frequently discharged to long-term rehabilitation and residential care than people without aphasia (Dickey et al., 2010; Guyomard et al., 2009; Laska et al., 2001;Tsouli et al., 2009). Aphasia is an expense on the healthcare system, and its management is time consuming and relies on extensive community resources. Research suggests rehabilitation during the very early post-stroke recovery phase is both feasible and results in greater communication outcomes as a result of enhanced neuroplastic changes (Godecke, Hird, Lalor, Rai, & Phillips, 2011; Paolucci et al., 2005; Robey, 1994, 1998). APHASIA IN THE ACUTE HOSPITAL SETTING 3 Neuroplasticity The principles of neuroplasticity can be applied to provide aphasia management that maximises language recovery and reduces the negative outcomes associated with aphasia. A restitution model of neuroplasticity suggests the majority of neuroplastic processes occur in the early stroke recovery phase until four weeks post-stroke (Rothi & Horner,1983). This model outlines a pattern of neurorecovery, whereby the function of the lesioned area is not entirely lost as a result of stroke. Consequently rehabilitation has the potential to support the recovery of the reduced function by facilitating the process of neurorecovery (Godecke et al., 2011; Rothi & Horner, 1983). Therapeutic models suggest a significant proportion of spontaneous recovery in language function occurs within the first three months post-stroke (Robey, 1998) and so providing aphasia therapy during this phase corresponds with the optimum timing of neural recovery. However, there is ongoing debate surrounding the efficacy of aphasia therapy in the early phase after stroke. Factors believed to influence outcomes include the timing of therapy commencement and the intensity of treatment (Godecke et al., 2011). Treatment Intensity and Efficacy When to commence therapy. Research literature is divided as to the feasibility and impact of very early intervention. The NSF (2010) proposed that early intervention results in superior communication outcomes for individuals with aphasia. This is supported by two meta-analyses by Robey (1994, 1998) that concluded the commencement of aphasia intervention during the first three months post-stroke results in treatment effects which are nearly twice that of spontaneous recovery. Additionally, Paolucci et al. (2005) demonstrated that treatment responsiveness within the first 20 days post-stroke is six times higher than after APHASIA IN THE ACUTE HOSPITAL SETTING 4 delayed intervention. Although early intervention has shown improved communication outcomes, some propose that aphasia therapy during the very early phase is not feasible due to medical instability and compromised physical and mental ability (Bakheit et al., 2007a; Laska et al., 2001). In contrast, two randomized controlled trials (Godecke et al., 2011; Laska, Kahan, Hellblom, Murray, & von Arbin, 2008) demonstrated individuals with aphasia tolerated therapy as early as three days post-stroke. It is recognised that some people may not tolerate very early aphasia therapy. Lazar et al. (2010) proposes that as long as therapy is commenced within the first three months post-stroke, positive communication gains are achieved. Thus, whilst aphasia therapy during the very early period results in greater treatment effects than intervention during the post-acute period (Robey, 1994), it is significant to note that intervention during both these phases results in superior communication outcomes than spontaneous recovery alone (Godecke et al., 2011; Robey, 1994). Recent evidence (Godecke, Ciccone, Granger, Hankey, & Phillips, 2009) demonstrated the importance of very early aphasia therapy when Godecke et al. (2009) compared a very early intervention cohort to a usual care cohort (Godecke et al., 2011). The comparison study by Godecke et al. (2009) demonstrated that people who received very early aphasia therapy achieved positive communication outcomes at therapy completion and these gains continued to outstrip improvements made by the usual care cohort at a 26 week follow-up. Intensity of therapy. The terms ‘intensity’ and ‘frequency’ are used interchangeably within the literature, however the terms have different meanings when considering the provision of therapy. Therapy intensity is defined as the quantity of time engaged in therapeutic activity, whereas