Introduction

Geriatric Essentials

• Speech and language skills commonly become mildly impaired with aging.
• Speech or language disorders can lead to isolation, depression, or loss of independence in the elderly.
• About 3 to 4% of people >= 65 yr have a speech or language disorder.
• Clinicians should be aware of impairments that can interfere with speech and language evaluation (eg, impairments in cognition, hearing, vision, or breathing).
• Speech therapy, assistive devices, or both may help patients who have lost the capacity to communicate.

Speech is oral communication. Language is a way of communicating that follows certain semantic and syntactic rules; it may be vocal or nonvocal (eg, written, gestural). Speech and language disorders are common among the elderly. Recognizing, diagnosing, and treating these disorders are important because they can interfere with the ability to call or ask for help, which can make the difference between dependent and independent living. These disorders can also contribute to social isolation and depression. Language (affecting vocabulary and grammar), speech (affecting the sound of spoken words), or both may be affected. Impairments in cognition (eg, delirium, depression), hearing, vision, or breathing can also interfere with speech and language.

Language comprehension and expression are complex processes that involve sensory input, language and nonlanguage areas of the brain, and motor output. Language areas in the frontal lobe (including Broca's area) control primarily language production, and language areas in the temporal and parietal lobes (including Wernicke's area) control primarily language comprehension. These language areas are located in the left cerebral hemisphere for 99% of right-handed people and in either or both hemispheres of left-handed people.

Speech production involves primary and secondary motor areas of both hemispheres, other motor and sensory systems of the brain, and cranial nerves. Speech requires coordination of muscles involved in respiration, phonation (sounds produced by passage of air through the vocal cords), articulation (sound modification by the pharynx, palate, tongue, jaw, teeth, lips, and face), and resonance (sound modification by air cavities of the throat, mouth, and nose). Respiratory muscles (eg, diaphragm, abdominal and intercostal muscles) must generate enough pressure to make speech audible during expiration. During phonation, laryngeal muscles move the vocal cords together and cause them to vibrate. Muscles of articulation modify vocal tone. Subglottic air pressure, vocal cord tension, and laryngeal position affect resonance and vocal pitch.

Aging, speech, and language: With aging, the vocal cords become thinner and less elastic. Laryngeal muscle function deteriorates. The voice becomes deeper and quieter, and a speech tremor may develop. Speech becomes slower; prosody (speech melody, or the pattern of stress and intonation) may become abnormal, varying in stress, pitch, and rhythm. Articulation becomes less precise. Fewer syllables can be uttered per breath. Elderly people may use more words to convey the same idea and have difficulty recalling a name, particularly a unique name (eg, a person's name); however, they usually recognize the correct name when provided, and they understand language normally.

Diagnosis

Speech and language disorders are usually obvious when a medical history is taken. When evaluating speech and language, a clinician should try to differentiate problems that may impair hearing (eg, ear disorders), breathing (eg, pulmonary disorders), reading (eg, eye disorders), or writing (eg, arthritis, hand disorders). Abnormalities in behavior, mood, and aspects of cognition that affect communication (including attention, memory, perception, spatial skills, and executive abilities) may also need to be differentiated.

Speech evaluation usually focuses on phonation and articulation; patients can be asked to repeat the basic sounds of speech. Voice volume, quality, resonance, modulation, and pitch are also evaluated.

Oral language (speech expression and comprehension) and written language (writing and reading) are evaluated. Evaluation includes spontaneous speech, naming, language production, language comprehension, and speech repetition (for language production rather than for articulation).

Spontaneous speech is evaluated for the rate and ease of speech, length of word phrases, prosody, and word choice. Normally, speech is fluent (effortlessly produced at a normal rate), and prosody is preserved. Speech should contain a variety of grammatical forms, including function words (words that primarily indicate grammatical relations, such as prepositions and conjunctions as opposed to nouns and verbs). At least some word phrases are of normal length (>= 7 words).

Naming is evaluated by observing spontaneous speech and by asking patients to name objects (eg, sleeve, cuff, wrist, thumb) presented by the clinician. Anomia (difficulty finding words, or inability to name objects) occurs in all aphasias. Patients with anomia may use circumlocutory phrases (eg, "what you use to tell time" for "clock"), nonspecific words (eg, "thing" or "stuff"), or incorrect words (paraphasias; eg, "watch" or "crock" for "clock"). To evaluate auditory comprehension, the clinician may ask patients to point to objects named by the clinician, carry out one-step and multistep commands, and answer simple and complex yes-or-no questions. Repetition is evaluated by asking patients to repeat grammatically complex phrases (eg, "no ifs, ands, or buts").

Written language should be evaluated separately; evaluation includes spontaneous writing, reading aloud, reading comprehension, spelling, and writing in response to dictation. Formal cognitive testing by a neuropsychologist or speech pathologist may detect finer levels of dysfunction and help the clinician plan treatment and evaluate potential for recovery.

Diagnosis of speech and language disorders typically requires a complete neurologic examination, otolaryngologic examination (including evaluation of laryngeal nerve function), or both, as well as neuroimaging (eg, brain MRI).

This topic was last updated March 2006.