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Published in final edited form as: Curr Neurol Neurosci Rep. 2017 Sep 19;17(11):83. doi: 10.1007/s11910-017-0797-z Search in PMC Search in PubMed View in NLM Catalog Add to search Aphasia As a Predictor of Stroke Outcome Ronald M Lazar Ronald M Lazar 1 Department of Neurology, University of Alabama at Birmingham, 1720 7th Ave S—SC 650, Birmingham, AL 35294, USA Find articles by Ronald M Lazar 1 , Amelia K Boehme Amelia K Boehme 2 Department of Neurology, Columbia University Medical Center, 710 W168th St, New York, NY 10032, USA Find articles by Amelia K Boehme 2 Author information Article notes Copyright and License information 1 Department of Neurology, University of Alabama at Birmingham, 1720 7th Ave S—SC 650, Birmingham, AL 35294, USA 2 Department of Neurology, Columbia University Medical Center, 710 W168th St, New York, NY 10032, USA ✉ Ronald M. Lazar, [email protected] Collection date 2017 Sep 19. PMC Copyright notice PMCID: PMC13077792 NIHMSID: NIHMS2152442 PMID: 28929424 The publisher's version of this article is available at Curr Neurol Neurosci Rep Abstract Purpose of Review Aphasia is a common feature of stroke, affecting 21–38% of acute stroke patients and an estimated 1 million stroke survivors. Although stroke, as a syndrome, is the leading cause of disability in the USA, less is known about the independent impact of aphasia on stroke outcomes. Recent Findings During the acute stroke period, aphasia has been found to increase length of stay, inpatient complications, overall neurological disability, mortality, and to alter discharge disposition. Outcomes during the sub-acute and chronic stroke periods show that aphasia is associated with lower Functional Independence Measures (FIM) scores, longer stays in rehabilitation settings, poorer function in activities of daily living, and mortality. Factors that complicate the analysis of aphasia on post-stroke outcomes, however, include widely different systems of care across international settings that result in varying admission patterns to acute stroke units, allowable length of stays based on reimbursement, and criteria for rehabilitation placement. Summary Aphasia arising from stroke is associated with worse outcomes both in the acute and chronic periods. Future research will have to incorporate disparate patterns in analytic models, and to take into account specific aphasia profiles and evolving methods of post-stroke speech-language therapy. Keywords: Aphasia, Stroke, Outcomes, Length of stay, Disability, Mortality Introduction Stroke remains common, with approximately 795,000 stroke events per year in the USA [ 1 ] and 6.5 million survivors in 2017 [ 2 ], as well as the leading cause of disability. While the mortality associated with stroke has decreased, the morbidity associated with the disease remains high, with a huge cost burden [ 3 ]. Stroke mortality reduction, coupled with the aging population in the USA, is expected to increase the prevalence of stroke by 3.4 million people between 2012 and 2030 [ 3 ]. The increase in stroke prevalence will correspondingly result in a larger impact on the personal and financial costs among survivors, their caregivers, and the healthcare system [ 4 ]. Among its sequela, aphasia remains a significant consequence of stroke, affecting 21–38% of acute stroke patients [ 5 ]. Occurring more frequently in ischemic stroke than in hemorrhagic stroke, aphasia affects an estimated 1 million stroke survivors in the USA [ 6 ]. Because of its impact on communication skills and thus reentry into home, the community, and the workplace, treatment for aphasia continues to be an important treatment target in both acute and post-acute rehabilitation. The purpose of this review is to demonstrate that beyond the effect on language, per se, aphasia also has a significant impact on overall stroke outcomes. Methodological Considerations There are inherent challenges seeking to derive generalizations regarding the effect of aphasia on stroke outcomes, especially at different points in the recovery process. Among them is that systems of care vary widely across countries. Investigators have reported stroke outcomes among those with aphasia from the USA [ 7 , 8•• ], Canada [ 9 ], Brazil [ 10 ], Sweden [ 11 ], the UK [ 12 ], and Denmark [ 13 ], each with a unique healthcare infrastructure. Mortality is a unique endpoint since there is no cross-cultural variation in outcome. In contrast, length of stay and disability at discharge vary widely, and are affected by factors such as the economics of insurance reimbursement and clinical services rendered. In the USA, for example, the average length of stay among all ischemic stroke patients in 2009 was 5.3 days [ 14 ], governed in part by the associated reimbursement rates assigned to specific diagnoses based on average resources used by Medicare patients, but was 9.1 days in Canada [ 15 ]. Compared to a 23% admission rate to an acute stroke unit in Canada [ 16 ], stroke unit admissions in Sweden are > 80%, 75% in England, and 50% in Australia [ 15 ], with a Cochrane analysis showing stroke patients who receive organized inpatient care in a stroke unit are more likely to be alive, independent, and living at home 1 year after the stroke [ 17 ]. Finally, these disparities across national boundaries make meta-analyses of treatment effects difficult to interpret, since included studies use widely different criteria regarding length of stay, cost bases, adverse events, and disability, along with cultural differences in the characteristics of post-discharge social support systems and public assistance. As a result, few testable hypotheses for further research have emerged from these analyses. Therefore, the emphasis on the next sections is on the positive findings described in individual sites or stroke systems. Outcomes During the Acute Stroke Period There is a significant, independent impact of aphasia on acute stroke outcomes. Bersano et al. reported in an Italian case series that out of the 11,572 stroke patients hospitalized within 48 h from stroke onset, included in the PROSIT study, 9594 alert cases were used for the estimation of aphasia frequency [ 18 ]. Among this group, 24% were found to have aphasia on admission, more frequently among women. As expected, aphasia was found to be associated with more severe stroke syndromes than those without aphasia, based on the Scandinavian Stroke Scale. There was more frequent use of a nasogastric tube among those with aphasia. There was also a longer length of stay (LOS) among aphasics than those without aphasia, based on a dichotomous outcome of < or ≥7 days ( p < 0.0001). Moreover, in-hospital mortality was 11% among those diagnosed with aphasia on admission, compared to 3% for those without aphasia ( p < 0.0001). Guyonard et al. conducted an analysis of 2983 cases of acute stroke admitted to a single hospital institution in the UK over a 13-year period [ 12 ]. The mean length of stay was significantly longer among those admitted with aphasia (14.2 ± 94 days), compared to that of those without aphasia (12.6 ± 8.3 days). Mortality was also significantly greater among those with aphasia (24.4%) compared to that of those without aphasia (11.5%). Accounting for age, sex, pre-morbid-modified Rankin Score, stroke subtype, and previous stroke with residual disability, they found that the likelihood of either death or increased length of stay did not increase among aphasia vs non-aphasia victims if they were younger than 65 years of age, whereas the risk of death more than doubled among older patients if they had aphasia. More recently, Boehme et al. probed the Tulane Stroke Registry for the period between 2008 and 2014 to determine whether the presence of aphasia had any impact on length of stay, inpatient complications, and discharge-modified Rankin Score (mRS) [ 8•• ]. The presence of aphasia was defined by a score of > 1 on the aphasia item on the NIH Stroke Scale (NIHSS). Among 1847 patients, 866 (46%) had aphasia on admission, including 708/1599 with ischemic stroke and 158/248 with hemorrhagic stroke. Patients with aphasia had higher odds of inpatient complications (OR 2.99, 95% CI 2.34–3.81, p < 0.0001), and this association remained after adjusting for admission NIHSS score and loss of consciousness (OR 1.46, 95% CI 1.09–1.97, p = 0.0121) when aphasia is defined as a score of 1 or more. When adjusting for coronary artery disease, female sex, atrial fibrillation, hypertension, and congestive heart failure in the mediation model, 53% of the relationship between aphasia and discharge-modified Rankin Score (mRS) 3–6 is explained by inpatient complications, indicating that regardless of these prior comorbidities, aphasia is strongly linked to outcomes through inpatient complications. Accounting for NIHSS at baseline, inpatient complications, and loss of consciousness, patients with aphasia stayed an average of 1.22 days longer than those without aphasia ( ß 1.22, SE 0.61, p = 0.0450). In a mediation analysis among aphasia, inpatient complications, and LOS, 77% of the relationship between aphasia and LOS was explained through inpatient complications. Accounting for NIHSS score at baseline and inpatient complications, patients with aphasia were at higher odds of discharge mRS 3–6 than those without aphasia (OR 1.42, 95% CI 1.05–1.92, p 5 0.0246). Based on all these factors, it was concluded that aphasia is independently associated with a significantly increased cost burden in US acute stroke care. Flowers et al. performed a chart review of 221 patients with first-time ischemic stroke from the Registry of the Canadian Stroke Network, of whom 30% were identified as having aphasia [ 9 ]. Consistent with other reports, patients with aphasia had a worse mean score on the Canadian Neurological Scale (6.4 ± 3.1) than those without aphasia (8.7 ± 2.6). The median LOS was also longer among those with aphasia (13 days) than that of those without aphasia (9 days). Score on the modified Rankin Scale was also worse among aphasics (3.2 ± 1.5) than that of those without a language disorder (2.7 ± 1.5). Unfortunately, no significance values were offered. As noted earlier, discharge disposition after the acute stroke admission is affected by multiple factors, such as functional status, cultural beliefs, and healthcare insurance. Others have found increases in LOS among those with aphasia at acute presentation, but Ellis et al. used billing codes and a nonstandardized and non-validated proxy for the diagnosis of aphasia, which for the non-specialist examiner is frequently difficult to distinguish from other communication disorders, such as dysarthria, apraxia of speech, and akinetic mutism. They reported only a 12% frequency of aphasia, far lower than any other study [ 19•• ]. In another study, patients were excluded if aphasia was still present on discharge within 7 days after admission, indicating a bias to less severe syndromes [ 7 ]. Outcomes During the Sub-Acute and Chronic Period Acute inpatient rehabilitation is often synonymous with the sub-acute period after stroke onset, and most of the outcome data from this period is described with reference to the time of discharge from the rehabilitation setting. Gialanella et al. carried out a study of 262 patients admitted with a primary diagnosis of stroke to an inpatient unit in Italy, half of whom were with and half without aphasia [ 20 ]. Overall, patients with aphasia had lower motor Functional Independence Measures (FIM) and cognitive FIM scores both at admission and at discharge, compared to those without aphasia, and those with severe aphasia had significantly lower FIM scores compared to those with lesser degrees of aphasia. Moreover, only those with severe aphasia had long LOS during inpatient rehabilitation, which was also associated with lower Fugl-Meyer and motor-FIM scores at admission than patients without aphasia. Overall, these data showed that severe aphasia is correlated with high risk of low response on activities of daily living. Ferriera de Oliveira and Damasceno enrolled 37 patients who arrived in the emergency unit within 72 h after first-ever ischemic stroke and were evaluated within this period for speech and language by a neurologist blinded to the results of imaging [ 10 ]. Global aphasia was identified in 11 patients, all of whom had left hemisphere lesions. Of the subgroup, five of them died within 42 days after stroke onset and nine were mute. Of the remaining 37 in the initial group, only three others who did not have aphasia died. At 1 year, it has been found that post-stroke aphasia compared to those suffering stroke without aphasia adds to the cost of stroke-related care, above the cost of stroke alone, according to the sample noted above that reported only a 12% of their total sample of 3200 beneficiaries of US Medicare payments in South Carolina [ 7 ]. Laska et al. found that among their small sample of 119 aphasic patients that mortality among the patients with aphasia over an 18-month follow-up was twice that of non-aphasics (36 vs 16%). Finally, Tsouli et al. conducted a 10-year study of aphasia attributable to first-time ishemic stroke among 2297 patients in a Greek cohort [ 21 ]. Based on the Scandinavian Stroke Scale (lower scores are worse), those with aphasia (35.1%) on acute stroke admission had a mean score of 19.1 (SD = 15.2), vs 32.4 (SD = 12.9) among those without aphasia ( p = 0.001). Modified Rankin Scores at 1 year were available for 1603 patients, and after adjusting for several factors, severe aphasia was found to be an independent predictor of 1-year dependence. Cox proportional hazard analysis showed that after adjustment for several factors, severity of aphasia was an independent predictor of 10-year mortality. Future Research The extent to which aphasia impacts short- and long-term stroke outcomes has yet to take into consideration a number of factors that could mediate this analysis. First, aphasia is usually an evolving syndrome, and initial syndrome severity is a weak predictor of syndrome severity at acute stroke discharge [ 22 ], and the least reliable predictor of 90-day severity in stroke-related impairment occurs among those with the most severe aphasias at stroke onset [ 23 ]. Similarly, aphasia subtype at onset has often been classified at mild, moderate, and severe, and there has been little consideration for the specific aphasia syndromes and their associated deficits. Most data from the acute stroke setting are derived from stroke scales, such as the NIH Stroke Scale [ 24 ], the Scandinavian Stroke Scale [ 25 ], and the Canadian Stroke Scale [ 26 ], which do not provide much specificity regarding language status made possible by more refined instruments. They are, however, influenced by aphasia; patients with aphasia have more severe scores (higher on NIHSS, lower on SSS) than those without aphasia. It is therefore difficult, for example, to ascertain the extent to which disorders of comprehension or language output contribute to these findings. Patients with auditory and reading comprehension deficits have been shown to have increased odds of being discharged to a setting other than home [ 27 ], and are more likely to have worse functional status at admission to an acute rehabilitation setting [ 28 ]. It has been assumed, but not yet shown empirically, that patients with a disorder of comprehension are less able to understand instructions critical to their own care, and that an inability to express complaints could contribute to the worsening of physical status and thus increase rates of complications. Adding to the complexity of this analysis, one reason for a longer length of stay during the acute stroke admission in the USA lies in the determinants for medical necessary for an admission to an acute rehabilitation unit. Under Medicare, there is a requirement for either physical or occupational therapy based on physical impairment, often not found in Wernicke’s aphasia. Second, the nature and intensity of speech-language therapy during acute inpatient rehabilitation also varies widely within and across national settings, as well as across inpatient and outpatient venues. The impact of specific aphasia treatments has not yet been incorporated into stroke outcome models, given that there is some indication that speechlanguage therapy at high intensity, high dose, or over a longer period may be beneficial [ 29 ]. Newer treatment modalities, such as constraint-induced language therapy [ 30 ] and speech entrainment [ 31 ], as well as adjuvant treatment with devices such as transcranial magnetic stimulation [ 32 ] and transcranial direct current stimulation [ 33 ] are increasingly under investigation and could well alter recovery trajectories and outcomes. Conclusions The purpose of this review was not to provide an exhaustive summary of the literature evaluating the impact of aphasia on stroke outcomes, nor to perform a meta-analysis designed to establish overall treatment effects. At present, there remain too many confounding factors to conduct these analyses. Nevertheless, the data are uniform in showing that aphasia is independently associated with increased lengths of stay in both the acute stroke and acute rehabilitation settings, more short- and long-term complications, worse performance in activities of daily living, increased financial costs, and increased risk of mortality. These findings suggest that more attention is needed to address communication disorders during the acute and chronic stroke periods and that resources are needed to further develop effective rehabilitation methods to improve post-stroke language recovery. Footnotes Conflict of Interest Ronald M. Lazar and Amelia K. Boehme declare no conflict of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors. References Papers of particular interest, published recently, have been highlighted as: •• Of major importance 1. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation. 2016;133(4):e38–360. [ DOI ] [ PubMed ] [ Google Scholar ] 2. Centers for Disease Control and Prevention. 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