General Management Goals

Language and speech are so basic for human existence that their loss is often catastrophic. Most patients lose their ability to communicate in a sudden and unexpected way. In addition to the loss of language itself, patients may lose their employment, social position, recreational opportunities, and many other stabilizing factors of personal existence.'^ The prognosis of any speech and language disorder depends on many factors, including etiology, lesion site, severity, profile of aphasic deficits, age at onset, individual (crossed aphasics), or group characteristics (left-handedness).

Most clinicians agree that speech therapy may be helpful and begin treatment as soon as possible, but delays in treatment are not detrimental and are warranted until the patient is neurologically stable. y Therapy should be goal driven, not simply to maximize or optimize language function. The therapist should identify limiting factors, establish treatment plans for the treatable factors, and specify both the expected outcome and specific duration of treatment.

Treatment should also include addressing complications of speech and language disorders. Depression is associated with left hemisphere injury, particularly in the deep frontal regions, and is associated with Broca's aphasia, global aphasia, or subcortical aphasia with anterior extension. y , y Treatment of depression includes support and encouragement, concentration on domains in which the patient succeeds, and antidepressant medication. Paranoid and agitated behavior is occasionally observed in patients with posterior aphasic syndromes, particularly those with Wernicke's aphasia and pure word deafness '571 ; management consists of antipsychotic drugs in a low dose. Finally, patients with associated bulbar or pseudobulbar palsy are at increased risk for aspiration and secondary lung infection and should be monitored closely and considered for percutaneous gastric feeding tube.

Patients with aphasia are often assumed to be incompetent because of their reduced communication ability; the inability to communicate, however, through verbal or written language does not preclude aphasic patients from nonverbal communication, thinking, and expressing opinions. Even severe aphasic patients can live semi-independently and develop new interests and goals.

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