Grand Rounds

Aphasia and Swallowing Problems in Subjects With Incident Stroke in Rural Northern Tanzania: A Case-Control Study Nick Miller,1 William K. Gray,2 Suzanne C. Howitt,2 Ahmed Jusabani,3 Mark Swai,3 Ferdinand Mugusi,4 Matthew P. Jones,2 and Richard W. Walker2 1 Institute of Health and Society, Speech Language Sciences, Newcastle University, Newcastle upon Tyne, UK; 2Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, Tyne and Wear, UK; 3Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro Region, Tanzania; 4Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania

Objectives: This study was carried out to quantify the degree of cognitive impairment and the extent of speech, language, and swallowing problems in a representative cohort of Swahili-speaking people with stroke in Tanzania. Methods: A casecontrol design was used, comparing people with and without stroke on a screening test for aphasia (spoken comprehension and expression), a water swallow test, and the Community Screening Instrument for Dementia (CSI-D). Results: Fiftyeight persons between 6 and 60 months (median 36) post stroke and 58 age- and gender-matched control subjects were assessed. Twenty-eight strokes were left hemisphere; 25, right; 2, posterior circulation; and 3, undetermined. Forty-nine of 58 (84%) control subjects scored 19 to 20 (maximum) on the language screen compared with 26 of 56 (46%) persons with stroke who completed the assessment. Higher age and lower educational attainment, but not gender or time since stroke, were associated with poorer performance on language and swallow assessments. Poorer CSI-D score was significantly correlated with all items. Greater disability (Barthel Index score) was significantly correlated with poorer performance in all items except rate of drinking water. Those with a left hemisphere stroke performed less well on understanding and expression items but better than other subjects with stroke on the water swallow task. Conclusions: This is the first attempt to describe aphasia incidence in a sub-Saharan African language. Further work on the psychometric properties of the screening instrument is warranted. Given that it delivers a relatively coarse indication of language disturbance, it is likely that incidence of aphasia in the current cohort is underestimated. Key words: aphasia, cognitive function, stroke, Swahili, Tanzania

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ommunication disorders are being increasingly recognized as a source of disability worldwide. 1,2 However, in many world regions little is known of the burden of such disorders. Only when the nature and causes of a condition are understood in a population can effective strategies to reduce its burden be implemented efficiently and effectively.3 In resource-poor settings, such as Africa, the need to allocate limited resources to programs that will provide the maximum benefit is being increasingly recognized.4 Aphasia represents an impairment of language ability caused by brain injury, although clinical presentation varies widely depending on the exact area of the brain affected. Aphasia is common in

Corresponding author: Nick Miller, Institute of Health and Society, Speech Language Sciences, George VI Building, Newcastle University, Newcastle upon Tyne, NE1 7RU UK; e-mail: [email protected]

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persons with stroke, with rates of 19% to 30% reported in studies from high-income countries.5-7 An incidence rate of aphasia attributable to stroke of 43 per 100,000 has been reported in a Swiss study.5 Variations in rates of poststroke aphasia reflect, among other things, differing times of assessment post stroke, the nature of the assessment used, and the threshold chosen to represent the presence of aphasia. Poststroke aphasia has been linked to poorer functional recovery and poorer quality of life.8-10 Around 80% of such language disorders are of vascular origin and can be accompanied by dysfunction of neuropsychological and motor systems.11 The need to screen for such problems as part of speech

Top Stroke Rehabil 2014;21(1):52–62 2013;20(1):52–62 © 2014 2013 Thomas Land Publishers, Inc. www.thomasland.com www.strokejournal.com

doi: 10.1310/tsr12-86R1

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and language assessment has been recognized, but few studies of the nature and prevalence of poststroke aphasia from low- and middle-income countries have been published.12,13 A 2-year prospective study of the incidence and nature of poststroke aphasia in a defined region of Greece demonstrated that of 555 individuals identified with first-ever stroke, 126 (22.7%) had aphasia.6 Twenty-eight days post stroke, only 405 individuals had survived, of whom 77 (19.0%) had aphasia. The study authors noted that higher rates of aphasia were independently associated with female gender, greater motor impairment (modified Rankin Scale score14), diabetes mellitus, atrial fibrillation, left hemisphere stroke, and heart disease. We are unaware of any studies of poststroke aphasia in African subjects. Although there is no reason to expect the incidence of aphasia after stroke to be any different in a Tanzanian population, the ways in which aphasia may be manifested can be markedly affected by the structural properties of the language spoken. The primary aim of this study was to establish the nature and extent of speech, language, and swallowing disorders in an incident cohort of people with stroke in rural Tanzania. To achieve this, we wanted to develop a short screening instrument for such disorders that could be used by nonspecialist health care workers.15 In a resource-poor setting, the use of nonspecialists can be a cost-effective way to screen large populations in the absence of sufficient numbers of medical personnel.16 In addition, we wished to assess whether the items devised were relevant to the types of dysfunction likely to occur in Swahili. It was hoped that identifying areas of unmet need would be a first step in the development of cost-effective, sustainable, and culturally appropriate rehabilitation strategies for people with poststroke aphasia in sub-Saharan Africa. Methods Ethical approval for this study was obtained from the National Institute of Medical Research in Tanzania and from the Newcastle and North Tyneside Joint Ethics Committee in the United Kingdom. Signed informed consent was obtained

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from each participant. We obtained a thumbprint from those who could not read and write, and the purpose and implications of the study were explained orally. In cases in which participants were unable to give valid consent because of cognitive impairment, written assent was obtained from a close relative. Participants and setting

Most participants were part of the Tanzanian Stroke Incidence Project (TSIP), which recruited persons with stroke from June 2003 to June 2006. After the end of the formal TSIP study, recruitment was continued for a further 18 months in the Hai district until December 2007 with the same methodology.17 TSIP operated in 2 sites: the rural Hai district and urban Dar-es-Salaam. The results presented here are based on follow-up assessment of persons living in the Hai district. In previously published results of this study, outcomes for persons with stroke were investigated in terms of their activities of daily living (ADLs), quality of life, social functioning, employment, and psychological well being.18 Tanzania is one of the world’s poorest countries.19 The Hai district is located in the north of the country on the lower slopes of Mount Kilimanjaro. The economy is based on agriculture. Most people are subsistence farmers, but some, who have slightly more land, are able to sell crops, such as tomatoes and coffee, for cash. There are 3 small hospitals in the district and a larger tertiary referral hospital in the adjacent district. Identification of case and control subjects

Stroke was defined according to the World Health Organization criteria.20 Surviving case subjects were followed up and assessed as part of this study between June and September 2008. Follow-up occurred 6 to 60 months post stroke, depending on the date of the stroke. None of the case subjects had received any form of speech or language therapy before they were interviewed. Control subjects were pool-matched to patients for age and sex. They were identified from census records of the study area and selected by convenience sampling by local health care workers.

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Relatives and carers of stroke case subjects were excluded as potential control subjects. Assessment

Case and control subjects were assessed in Swahili by the study doctors (S.H. and M.J.) in their homes in the presence of a relative or close family friend. A local health care worker was also present to assist in the assessment and to act as a translator. The health care workers involved were those trained by the Tanzanian Adult Morbidity and Mortality Project, a demographic surveillance study that began in the mid 1990s and included the Hai district as one of its sites.21 Information on background demographics (sex, age, education, marital status, abode, etc), traditional healer intervention, previous and current medical care, medical history, drug history, social history, blood pressure readings, psychosocial functioning, neurological recovery, and motor function were collected from case and control subjects. Education was categorized as none at all, primary schooling, or secondary schooling. Physical and cognitive impairment assessment

The Barthel Index was used to assess physical disability. It is a 10-item (maximum score of 20) measure of the functional impairment of an individual with regard to carrying out ADLs.22 The Community Screening Instrument for Dementia (CSI-D) cognitive assessment was developed in the mid 1990s to measure cognitive function in low- and middle-income countries.23 It involves a series of questions and tasks that are divided into a number of domains with items relating to naming objects (7 items), abstract thinking (4 items), language fluency (2 items), language comprehension (2 items), orientation to time and place (9 items), long- and short-term memory (6 items), and praxis (3 items). Speech, language, and swallowing assessment

We developed a speech, language, and swallowing screening instrument for this study (Appendix 1). The general layout and content reflect that used in numerous validated aphasia

screening tests, but it was adapted to suit the study population.15,24 Items involving reading, writing, and drawing were removed, because many of the subjects had little formal education and such activities were not part of everyday life. The assessment involved items relating to the following categories: Understanding and expression: These items were designed to detect dysfunction in the ability of people to express themselves and to understand instructions. The instrument consisted of 30 questions, split into 6 domains of 5 questions each. Understanding was assessed by domains requiring the subject to point to 5 named objects, point to 5 objects by function, point to 1 of 5 pictures representing actions using simple Swahili sentences, and carry out 5 complex actions. For a response to be considered correct, all grammatical elements (subject, verb, and object) had to be present and appropriate words had to be used. One point was given for each correct answer, resulting in a maximum possible score of 20. Expression was assessed by domains requiring the subject to repeat 5 words and to describe 5 pictures that showed a named action. One point was given for each correct answer, resulting in a maximum possible score of 10. Intelligibility: According to a subjective assessment of performance in previous test items, intelligibility was rated on a scale from 1 to 5, with 1 representing no obvious speech abnormality and 5 indicating that the person was very difficult to understand. (See Appendix 1 for further details.) Speech production: Speech production was assessed by recording the time (seconds) taken to complete 3 separate tasks: 10 repetitions of “paa” (antelope); 10 repetitions of “kaa” (coal/crab); and 5 repetitions of “paa-taa (light)-kaa.” Sustaining “ah”: Subjects were asked to sustain an “ah” sound for as long as possible. Less than 5 seconds scored 1, 6 to 10 seconds scored 2, 11 to 16 seconds scored 3, and 16 or more seconds scored 4. Swallowing: Subjects were asked to drink 150 mL of water, and the number of milliliters per second was recorded.25 In addition, a failure to drink the full 150 mL was noted, as was a cough during drinking, a cough after drinking, breathlessness during drinking, and breathlessness after drinking.

Aphasia and Swallowing Problems in Tanzania

Statistics

The data were quantitative in nature and collected at nominal, ordinal, and interval/ ratio levels. Data were analyzed using standard statistical software, PASW-18 for Windows (SPSS Inc, Chicago, IL). The Mann-Whitney U test (ordinal and interval/ratio data) and chi-square test (nominal data) were used to compare data between case and control subjects and between subgroups. Correlations between items were assessed by using Spearman’s test if both items were measured at least at the interval/ratio level and a point biserial test if at least one item was a dichotomy. Linear (log-transformed rate of drinking water) and logistic regression (lower than median aphasia score) models were used to identify independent predictors of outcome. Models were constructed using backward elimination based on the Wald statistic. The model fit and robustness were assessed by examining residuals and performing collinearity diagnostic tests. Missing values were treated as missing at random. Two-tailed tests were used throughout, and the significance level was set at 5%. Results The 3 years of the TSIP stroke incidence study identified 132 cases, with a further 52 cases identified subsequently, providing a total of 184 case subjects.17 By the start of this study on June 1, 2008, 102 case subjects had died, 16 were unable to be assessed because of comorbidity or illness, and 8 had left the study area or could not be traced. Therefore, a cohort of 58 case subjects was assessed post stroke; these were frequencymatched for age and sex to 58 control subjects. Details of the cohort have been described previously and are summarized in a study by Howitt et al.18 There was no significant difference in age at stroke (U = 3114.5, z = -1.608, P = .108) or gender [χ2(1) = 0.047, P = .828] between the 58 case subjects who were assessed post stroke and those not followed up. Case subjects were assessed at a median of 36 months post stroke (range, 6-60). The mean age of case subjects was 67.1 years (range, 30-88), and 28 (48.3%) were male. The mean age of control subjects was 61.7 years (range, 27-86), and 30 (51.7%) were male. Although

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control subjects were, on average, younger than case subjects, there were no significant differences in age (U = 1368.0, z = -1.596, P = .111) or gender [χ2(1) = 0.138, P = .853] between case subjects and control subjects. On clinical assessment, 28 case subjects had had a left hemisphere stroke, 25 had had a right hemisphere stroke, and 2 had had a stroke affecting the posterior circulation. In the remaining 3 case subjects, the stroke territory was uncertain because of general frailty. Comparison of case and control subjects

Case and control subjects are compared in Table 1 and Table 2. A small number of case subjects were unable to complete the full assessment because of cognitive impairment; this accounts for missing values detailed in the tables. All differences between case and control subjects for understanding, expression, intelligibility, speech production, swallowing, and cognitive function were significant. For the understanding subscore, 49 of 58 control subjects (84.4%) scored either 19 or the maximum score of 20, compared with only 26 of 56 case subjects (46.4%). Of the 30 case subjects who scored less than 19, 16 (53.3%) had had a left hemisphere stroke and 12 (40.0%) a right hemisphere stroke; whereas of the 26 case subjects who scored 19 or 20, 12 (46.2%) had had a left hemisphere stroke and 13 (50.0%) a right hemisphere stroke. For the expression score, of 28 who scored less than the maximum score of 10, 18 (64.3%) had had a left hemisphere stroke, and only 8 (28.6%) had had a right hemisphere stroke; whereas of the 28 who scored the maximum, 10 (35.7%) had had a left hemisphere stroke and 17 (60.7%) had had a right hemisphere stroke. Association between variables for case subjects

There was a strong correlation within all items related to speech, language, and swallowing assessment (r = 0.282 to 0.559), but there was no obvious pattern. The time taken for the repetitions on the speech production items was combined to give a total time for all 3 tests. Correlations among speech, language, and swallowing items and other variables are shown in Table 3. Greater age and

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Table 1. Understanding, expression, and intelligibility scores for case and control subjects

Understanding subscore Expression subscore Intelligibilitya

Case (n = 56), 2 missing values Control (n = 58) Case (n = 56), 2 missing values Control (n = 58) Case (n = 55), 3 missing values Control (n = 58)

No. of subjects scoring maximum possible score

Median (IQR)

12 (21.4%)

18 (17-19)

34 (58.6%) 28 (50.0%)

20 (19-20) 9.5 (8-10)

47 (81.0%) 25 (45.5%)

10 (10-10) 2 (1-2)

55 (94.8%)

1 (1-1)

Significance U = 814.0, z = -4.801, P < .001 U = 1054.5, z = -3.832, P < .001 U = 798.5, z = -5.757, P < .001

Note: IQR = interquartile range. For item, 1 indicates least impairment and 5 indicates most impairment; the maximum score refers to those scoring 1. a

Table 2. Speech production, swallowing, and cognitive scores for case and control subjects Median (IQR) Speech production (seconds for 10 repetitions of “paa”) Speech production (seconds for10 repetitions of “kaa”) Speech production (seconds for 5 repetitions of “paa-taa-kaa”) Sustaining “ah” (higher rating = better) Rate of drinking water (mL/s)

Case (n = 52), 6 missing values Control (n = 58) Case (n = 52), 6 missing values Control (n = 58) Case (n = 51), 7 missing values Control (n = 58) Case (n = 53), 5 missing values Control (n = 58) Case (n = 53), 5 missing values Control (n = 58)

4.5 (3-6) 3 (3-4) 5 (4-6) 3 (3-4) 4 (4-5) 3 (3-4) 2 (1-3) 3 (3-4) 15.0 (11.1 -21.4)

Significance U = 582.0, z = -5.639, P < .001 U = 446.0, z = -6.475, P < .001 U = 611.0, z = -5.404, P < .001 U = 656.5, z = -5.407, P < .001 U = 341.0, z = -7.046, P < .001

50.0 (26.3-50.0)

Note: IQR = interquartile range.

lower education level were significantly correlated with poorer performance in understanding and expression items and rate of drinking water. Poorer cognitive function (CSI-D score) was significantly correlated with all items. Greater disability (Barthel Index score) was significantly correlated with poorer performance in all items except rate of drinking water. Gender and time since stroke were not associated with performance in any items. The correlations of a left hemisphere stroke, compared with a right hemisphere or posterior circulation stroke, with test results for speech,

language, and swallowing are shown in Table 3. As expected, those who had had a left hemisphere stroke performed less well on understanding and expression items. However, left hemispheric stroke case subjects performed better than other stroke case subjects in the task that involved drinking a glass of water. Cognitive function

CSI-D cognitive assessment scores in the domains of abstract thinking, orientation to time and place,

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and language comprehension were all highly correlated with items measuring understanding, expression, and intelligibility (r = 0.337 to 0.617), but not with items relating to speech production, breath capacity, and swallowing. The CSI-D verbal fluency tasks (naming as many animals as possible in 1 minute and repeating a common phrase) were highly correlated with items relating to understanding (r = 0.476), expression (r = 0.448), speech production (r = -0.524), and breath capacity (r = 0.462). The short-term memory item, which involves recalling elements of a story, was highly correlated with understanding (r = 0.580), expression (r = 0.428), intelligibility (r = -0.432), and breath capacity (r = 0.399). None of the domains or individual items of the CSI-D were significantly correlated with rate of drinking water.

r = -0.343, P = .013 r = -0.129, P = .357 r = 0.366, P =.009 r = -0.065, P = .648 r = 0.474, P < .001 r = 0.181, P = .200 r = 0.278, P = .048

Independent predictors of aphasia in case subjects

Note: CSI-D = Community Screening Instrument for Dementia. a 1 = males, 2 = females. b 1 = none at all, 2 = primary, 3 = secondary. c 1 = right hemisphere stroke or posterior circulation, 2 = left hemisphere stroke.

r = -0.205, P = .146 r = -0.235, P = .091 r = 0.156, P =.275 r = -0.207, P = .145 r = -0.018, P = .899 r = 0.357, P = .009 r = 0.377, P = .005 r = 0.082, P = .565 r = 0.226, P = .111 r = -0.183, P = .209 r = 0.221, P = .128 r = -0.069, P = .638 r = -0.317, P = .025 r = -0.350, P = .012 r = -0.298, P = .027 r = 0.002, P = .987 r = 0.310, P = .025 r = -0.019, P = .889 r = -0.400, P = .003 r = 0.416, P = .002 r = 0.363, P = .008 r = -0.311, P = .021 r = 0.125, P = .357 r = 0.376, P = .006 r = -0.033, P = .812 r = -0.296, P = .030 r = 0.369, P = .006 r = 0.554, P < .001

r = 0.141, P = .309 r = -0.064, P = .642 r = -0.248, P = .076 r = 0.055, P = .696 r = 0.209, P = .134 r = -0.319, P = .019 r = -0.430, P = .001

Sustaining ”ah” Combined speech production Intelligibility Expression subscore Understanding subscore

Age at interview Gendera Maximum education levelb Time since stroke (mo) Left hemisphere strokec Barthel Index score CSI-D cognitive score

Table 3.

Correlation of speech, language, and swallowing scores with other variables for stroke subjects

Drinking rate (mL/min)

Aphasia and Swallowing Problems in Tanzania

An overall aphasia score was constructed by combining the understanding and expression subscores. These data were found to be heavily skewed toward higher values. In the absence of an obvious cut-off score for aphasia, the median value for stroke subjects (27.5) was used. A binary logistic regression model was constructed with people scoring less than the median as the outcome variable and the variables listed in Table 3 as the predictor variables. Only the CSI-D dementia score was an independent predictor of outcome (odds ratio [OR], -0.781; 95% confidence interval [CI], -0.660 to -0.925; P = .004), with a lower CSI-D score associated with a lower-than-median aphasia score. Independent predictors of slower water drinking time in case subjects

The data for the rate of drinking a glass of water followed a Poisson distribution. The data were transformed to a normal distribution by taking the natural logarithm of the drinking rate. This log-transformed variable was used as the outcome variable to construct a linear regression model with the variables listed in Table 3 as the predictor variables. Younger age at stroke (β = -0.013; 95% CI, -0.023 to -0.004; P = .007) and having had a left hemispheric stroke (β = 0.589; 95% CI, 0.302 to 0.875; P < .001) emerged as independent

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predictors of better performance in drinking water for stroke subjects. Discussion This is the first published study in which aphasia and swallowing problems in persons with stroke from sub-Saharan Africa are examined. These problems were significantly more common in persons with stroke than in age- and sexmatched control subjects. For the understanding (receptive aphasia) subscore, almost 85% of control subjects but less than half of case subjects scored either 19 or 20. Similarly, for the expression and intelligibility subscores, more than 80% of control subjects, but only half of case subjects, scored the maximum score. Poorer performance in both the understanding and expression subscores was significantly correlated with having had a left hemisphere stroke. By using a control population, we are able to compare our findings with the background population. Further work is needed to assess the psychometric properties of our screening instrument when used in the setting of this study. Performance of the instrument in comparison with “gold standard” methods of diagnosing speech, language, and swallowing problems is needed; this would allow cut-offs for the presence of clinical aphasia and swallow dysfunction to be established. Nevertheless, according to our findings, a cut-off score of less than 19 of 20 may be appropriate for receptive aphasia and less than the maximum score of 10 for expressive aphasia. Cognitive impairment in persons with stroke has been well studied in high-income countries, but less well so in African countries.10,26 A Nigerian study found that 17.4% of persons with stroke had cognitive deficits (Mini-Mental State Examination score less than 16) compared with only 4.6% of control subjects.27 The inter-relationship between cognitive function and language ability has been noted previously, as has the need to screen for cognitive impairment as an integral part of an aphasia assessment.12,13,28,29 The Aphasia Check List, developed by Kalbe et al,12 includes a cognitive assessment based on 3 nonverbal items designed to distinguish linguistic dysfunction from cognitive dysfunction. There

was a strong correlation between scores for cognitive and linguistic items among subjects with aphasia, suggesting that it may be difficult to distinguish cognitive ability from components of aphasia. Furthermore, the nonverbal cognitive items in the study by Kalbe et al12 are heavily biased toward factors associated with schooling. Thus, it may prove to be more of a challenge to devise equivalent tasks for differentiating language versus nonlanguage effects of stroke in the current population. It is notable that items contained in the CSI-D are heavily language based. Even those items designed to measure memory and praxis require a high degree of receptive function and expressive ability. Thus, it may not be possible to fully separate out the confounding effects of these impairments with the instruments used in the current study. Future examination of this will require use of a cognitive screen that can be accomplished with minimal language capacity. Although there was some gradation of expected difficulty in items within subtests and across subtests (eg, understanding of word as direct label vs word as function), the screening items used here are likely to deliver a relatively coarse measure of presence or absence of aphasia, rather than one more sensitive to milder and more subtle types of language disturbance. Hence, the incidence of language disorder may underestimate the presence of aphasic disturbance in this respect. Swallowing impairment appears to be somewhat distinct from aphasia within this cohort. It was most closely associated with right hemisphere stroke and increasing age and appears to be unrelated to cognitive function. Given that lesion sites likely to affect processes and neuromuscular functions involved in a simple water swallow test are different from lesion sites associated with language disturbance, this is not a surprising finding. The same account is likely to represent a main factor in the low association of articulatory agility and breath capacity with cognitive scores. Limitations of this study

This study has several limitations against which interpretation of results should be balanced. First, a small number of case subjects were unable to complete all items of the assessments because of

Aphasia and Swallowing Problems in Tanzania

cognitive impairment and/or severe aphasia. Given the relatively straightforward nature of the analysis conducted, we chose not to use a method of imputation in these cases. It is likely that these case subjects would have scored poorly and, thus, our results are likely to represent an underestimation, rather than an overestimation, of the extent of such problems in the population of persons with stroke. Stroke subjects identified by the original incidence study were given follow-up care by the study team. Thus, the medical care received by the cohort may not be truly representative of that received by the wider stroke population in rural Tanzania. Although the items in the speech-language screen followed patterns identical to those of other validated screening instruments,24 we were unable to carry out a pilot study to test the appropriateness of the wording and language used in the various sections of the screening instrument in advance. Furthermore, the need to develop a screening instrument that could be administered by nonspecialists limited the nature of the items included. We recognize that some aspects of speech, language, or swallowing may not have been fully assessed by the instrument. However, people thought to have a disorder based on the brief screen could be further assessed if it were deemed necessary. Finally, visual and hearing problems and other comorbidities were often uncorrected by glasses, hearing aids, or medical intervention in our study cohort. This gave rise to a number of problems, such as when visual interpretation of an image was required. Therefore, we recognize that speech, language, swallowing, and cognitive function screening as part of clinical assessment should not be conducted in isolation but should take into account the interrelatedness of much of the stroke sequelae and its potential influence of levels of disability as defined by the International Classification of Functioning, Disability and Health.30 Conclusions

We have developed a screening tool that is capable of differentiating people with and without aphasia who speak Swahili. The tool requires further psychometric evaluation and validation. Although every effort was made to minimize possible cultural and schooling effects in the test construction, in as

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far as lower education was linked to lower scores, this may be a factor in need of further investigation. Similarly, the inclusion of comparator groups in rural and urban centers may be relevant. Currently, the screen delivers a relatively coarse measure of aphasic disturbance. It is highly likely that it does not detect more isolated or subtle alterations to word retrieval/semantics, syntax (grammar), or language disturbances associated with right hemisphere lesions. Future work can focus on addition of supplementary materials in these areas. One consequence of giving only a general indication of the presence or absence of aphasia is that the incidence of aphasia in the cohort in this study is almost certainly underestimated. Future, more extensive testing with the supplementary materials will enable a more balanced estimation of aphasia incidence. This study was based on a stroke population. Future research can extend the perspective to examine other etiologies of acquired language dysfunction. This study highlights that aphasia, swallowing problems, and cognitive impairment are ongoing problems up to 60 months post stroke in this African cohort. These impairments may affect a patient’s ability to interact with family members, eat, and drink, which are crucial daily activities. The resulting poststroke morbidity from such factors could cause significant emotional strain for patients and carers living in a society that is already stretched financially. Consideration should be given to ways in which low-cost speech and language therapy and activities stimulating the mind could be administered on a community level in developing world settings to try to improve functional outcome after stroke. Acknowledgments Financial support/disclosures: This work received no specific funding, and there are no conflicts of interest to disclose. Additional contributions: We would like to thank all participants, their carers, and family members included in this study. We would also like to acknowledge all health care workers and officials who assisted in the identification of patients, the inputting of data, and the examination and assessment processes.

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disorders: Development of a Swahili screening test. S Afr J Commun Disord. 2012;59:27-33. Dewhurst F, Dewhurst MJ, Orega G, et al. Neurological disorder screening in the elderly in low-income countries. J Neurol. 2012;259(10):2189-2197. Walker R, Whiting D, Unwin N, et al. Stroke incidence in rural and urban Tanzania: A prospective, community-based study. Lancet Neurol. 2010;9(8):786-792. Howitt SC, Jones MP, Jusabani A, et al. A crosssectional study of quality of life in incident stroke survivors in rural northern Tanzania. J Neurol. 2011;258(8)1422-1430. The World Bank. Data: Countries and economies. 2012. http://data.worldbank.org/country. Accessed April 19, 2012. WHO MONICA Project. The World Health Organization MONICA Project (monitoring trends and determinants in cardiovascular disease): A major international collaboration. WHO MONICA Project Principal Investigators. J Clin Epidemiol. 1988;41(2):105-114. Adult Morbidity and Mortality Project (AMMP). Policy implications of adult morbidity and mortality: Final report. 2004. http://research.ncl.ac.uk/ ammp/finrep/. Accessed 6 November 6, 2013. Mahoney FI, Barthel D. Functional evaluation: The Barthel Index. Md State Med J. 1965;14:56-61. Hall KS, Hendrie HC, Brittain HM, et al. The development of a dementia screening interview in 2 distinct languages. Int J Methods Psychiatr Res. 1993;3(1):1-28. Salter K, Jutai J, Foley N, Hellings C, Teasell R. Identification of aphasia post stroke: A review of screening assessment tools. Brain Inj. 2006;20(6):559-568. Nathadwarawala KM, Nicklin J, Wiles CM. A timed test of swallowing capacity for neurological patients. J Neurol Neurosurg Psychiatr y. 1992;55(9):822-825. Madureira S, Guerreiro M, Ferro JM. Dementia and cognitive impairment three months after stroke. Eur J Neurol. 2001;8(6):621-627. Fatoye FO, Komolafe MA, Eegunranti BA, Adewuya AO, Mosaku SK, Fatoye GK. Cognitive impairment and quality of life among stroke survivors in Nigeria. Psychol Rep. 2007;100(3 pt 1):876-882. Kauhanen ML, Korpelainen JT, Hiltunen P, et al. Aphasia, depression, and non-verbal cognitive impairment in ischaemic stroke. Cerebrovasc Dis. 2000;10(6):455-461. Huber W, Poeck K, Weniger D. Klinischneuropsychologische Syndrome und Störungen: Aphasie. In: Hartje W, Poeck K, eds. Klinische Neuropsychologe. Stuttgart: Thieme; 2002:93-173. World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva: Author; 2001.

Aphasia and Swallowing Problems in Tanzania

APPENDIX 1

4. Understanding simple to complex instructions Instruction and explanation: “I’m going to ask you to move these objects around. Listen carefully to what I say and see if you can carry out the instruction.”

Speech, Language, and Swallowing Screening Instrument *Swahili translations of the words are shown in brackets.

1. Understanding single words: Show me the…. Score (1 = yes, 0 = no) A B C D E F G

Score

Practice items: Able to understand instructions? Chair [Kiti] Wall [Ukuta] Bed/table [Kitanda] Ceiling [Dari] Cup/beaker [Kikombe/kikombe kikubwa] Total score for section (B-F: Max 5)

A B

C

D

E

F

2. Pointing to objects by function: Show me the one you use to…. A B C D E F G

C D E F G

Practice items: Able to understand instructions? The dog is chasing the horse. [Mbwa anayemkimbiza farasi.] The man is on the horse. [Mwanaume aliyepanda farasi.] The horse is chasing the man. [Farasi anayemkimbiza mwanaume.] The man is riding the horse. [Mwanaume anayeendesha farasi.] The man is chasing the horse. [Mwanaume anayekimbiza farasi.] Total score for section (B-F: Max 5)

Score

Practice items: Able to understand instructions? Put the book/newspaper under the cup/beaker. [Weka kitabu/gazeti chini ya kikombe/kikombe kikubwa.] Put the spoon/fork inside the book and the watch next to the cup/beaker. [Weka kijiko/uma ndani ya kitabu na saa ya ukutani karibu na kikombe/ kikombe kikubwa.] Put the one you eat with on top of the one you read. [Weka kitu unachotumia kulia juu ya unachosoma.] Put the one you tell the time with behind the one you drink from. [Weka kitu unachotumia kujua muda nyuma ya unachotumia kunywea.] Put the one you write with on top of the one you tell the time with. [Weka unachotumia kuandika juu ya unachotumia kujua muda.] Total score for section (B-F: Max 5)

Score

Expression

Practice items: Able to understand instructions? Drink [Kunywea] Tell the time [Kujua muda] Write [Kuandika] Eat [Kula] Read [Kusoma] Total score for section (B-F: Max 5)

3. Understanding simple grammatical structures: Instruction and explanation: “I’m going to show you some pictures and ask you to point to one at a time. Listen carefully to what I say and point to the picture of that.” Practice item: “Show me the dog is running.” Second practice item: “Show me the white horse running.” A B

G

61

5. Repeat these words after me: A B C D E F G

6. Naming actions A B Score

C

D

E F

G

Score

Practice items: Able to understand instructions? Taa Omba Mzazi Kitandani Pakukutana Total score for section (B-F: Max 5, good)

Practice items: Able to understand instructions? The man is talking to the boy. [Mwanaume anaongea na mvulana.] He is smoking a pipe/standing by his fork/ standing in the field. [Anavuta kiko/amesimama karibu na jembe lake/amesimama shambani.] The man is climbing a ladder/the man is on the ladder/he is climbing up/down. [Mwanaume anapanda ngazi/mwanaume yupo juu ya ngazi/ anapanda juu/chini.] He is giving him the money/something/a piece of paper. [Anampa hela/kitu/kipande cha karatasi] The man is pouring himself a drink./The newspaper is on the table. [Mwanaume anajiwekea kinywaji./ Gazeti lipo juu ya meza] Total score for section (B-F: Max 5, good)

Score

62

TOPICS IN STROKE REHABILITATION/JAN-FEB 2014

Summary of scores Total for understanding Total for expression Total whole test

/20 /10 /30

Intelligibility: Tick the description that applies to the person.

Score

No changes to the way the person speaks; they speak like anyone else. The person’s speech sounds different now/doesn’t sound normal, but you can still understand all the words they say, even if it’s the wrong word sometimes. Easy to understand. You can still understand most (75%) of what the person says, but you have to listen very carefully and sometimes ask them to repeat. Difficult to understand. You can only understand around half (50%) of what is being said, and you often have to ask them to repeat for you. Very difficult to understand. Only the odd word now and then (

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