The Incidence of Aphasia, Cognitive Deficits, Apraxia, Dysarthria, and Dysphagia in Acute Post Stroke Persian Speaking Adults

Abstract

Stroke is a major cause of serious disabilities in adults. While communication deficits post stroke are prevalent and disabling, early detection of them is important during acute phase. There is limited data published on the incidence of communication disorders in Persian speaking adults following post stroke to our knowledge. The present study aims to determine the incidence and associated factors of aphasia, cognitive deficits, motor speech disorders (apraxia and dysarthria) as well as dysphagia following acute post stroke in Persian speaking adults. 100 stroke patients were assessed using P-WAB, MMSE, Oral Apraxia test, Informal Dysarthria assessment, and MASA. The data was collected from 2 hospitals in Tehran using convenient sampling for the duration of 1 year. Based on our findings, the incidence of aphasia, cognitive deficits, oral apraxia, dysarthria, and dysphagia was in respectively 61.8%, 76%, 30%, 61%, and 39% of stroke patients during the acute phase. Patients with aphasia were significantly older (mean age, 59.29 vs. 64.95), and had fewer education years (9.21 vs. 5.45) compared to individuals without aphasia (p < .05). Co-occurrence of aphasia and dysarthria, dysphasia, cognitive deficits, and apraxia was in respectively 40%, 31%, 55%, and 25%. Due to the high incidence of neurogenic communication disorders and dysphagia during the acute post stroke, especially in the elderly and the less educated patients, prompt and rapid detection of these deficits and rehabilitation is essential to ameliorate patients' quality of life and social participation, and reduce the comorbidities risk.

Introduction

Stroke is a leading cause of adult mortality and disability [1]. Patients with stroke are faced with a wide range of deficits such as sensory and motor disabilities, communication disorders, cognitive deficits as well as dysphagia; though communication deficits are distinctive. Aphasia, cognitive deficits, and motor speech disorders (i.e., apraxia and dysarthria) are the most prevalent communication deficits post stroke. Dysphagia also appears in many patients after stroke [2, 3]. Speech and language pathologists (SLPs) assess all the above-mentioned disorders in post stroke patients, which provide a comprehensive profile of the patients. Given that the prevalence of stroke in the Iranian population is relatively high (33–50 cases per 100,000 people per year) [4–6], early detection of language disorders and post-stroke rehabilitation can have a significant impact on the quality of life of these patients.

According to the National Institute on Deafness and other Communication Disorders (NIDCD), approximately 1 in 250 people in the United States, are living with aphasia [7]. Aphasia is the most prevalent language disorder in left hemisphere stroke and is seen in about one-third of patients in the acute phase of stroke, which results from damage to the parts of the brain that manage language. All the language modalities, i.e., language comprehension and production, reading, and writing could be affected in aphasia [8]. It evidently has a negative impact on the patients' quality of life, limiting communication skills [9–11]. Different reports of aphasic frequencies have been presented between studies. Petheram and Code [12] reported 0.02–0.06% incidence and 0.1–0.4% prevalence of aphasia in developing countries. Lima et al. [13] stated that only 22.6% of patients with stroke had aphasia in the acute phase in a Brazilian hospital. Guyomard et al. [14] also analyzed 2983 patients with stroke reporting that 41.2% had aphasia. The findings of a study by Cook et al. [15] showed that aphasia was present in 23% of 151 first ischemic stroke patients.

In addition to language deficits, cognitive deficits are seen in a high proportion of stroke survivors [16–19]. Patients with cognitive deficits subsequent to stroke usually have memory and attention deficits, visuospatial impairments, and orientation deficits [16]. Although estimation of the prevalence of cognitive deficits subsequent to stroke is difficult, Pendlebury and Rothwell [20] reported that the prevalence of memory and attention deficits, and visuospatial impairments vary from 30 to 50%. Tang et al. [21] analyzed 179 patients with stroke in the acute stroke unit of Prince of Wales hospital in Hong Kong and reported that 18% of them had cognitive deficits.

Dysarthria post-stroke is another prevalent disorder in post-stroke patients. Speech production, intensity and frequency of speech, respiration and speech rhythm are affected in dysarthria. Dysarthria subsequent to stroke may also cause drooling. Drooling is defined as salvia flowing outside of the patient's mouth unintentionally [22–24]. Although dysarthria is present in many neurologic diseases, its true incidence and prevalence are not fully known. According to the American Speech-Language-Hearing Association (ASHA), between 8 and 60% of individuals with stroke have dysarthria [25]. As reported by Mitchell et al. [26], 28% of patients with stroke during the acute phase, had dysarthria and aphasia in the UK. In another study that was conducted in Bosnia and Herzegovina, 57.69% of stroke patients had dysarthria, and 82.37% of them had aphasia in the acute phase [27].

Dysphagia affects some patients during the acute phase of stroke. A group of patients recovers after a week post stroke, but others may continue to experience Dysphagia for a longer period of time. As a result, food or saliva aspiration may cause pneumonia and patients may experience dehydration and malnutrition [28]. The prevalence of dysphagia in the acute phase of stroke varied between 30 and 40% in the USA [29]. Dysphagia was seen in 42–67% of patients 3 days after stroke according to Perry and Love's study [30, 31]. 19.5% to 42% of the patients also had aspiration during 5 days after stroke [30]. According to Guyomard et al. [14], 50.5% of patients had dysphagia and 27.7% experienced both dysphagia and aphasia. As documented by Cohen et al. [34], 28–65% of patients in the acute phase after the stroke had dysphagia. Among Iranian studies, Noruzi et al. [32] reported that about 70% of stroke patients experienced dysphagia during the acute phase of stroke. Sharifi et al. [33] showed that 31.2% of the patients with stroke in a hospital in Babol (a city in the north of Iran) had dysphagia. Some authors proposed that the different results are due to utilizing different assessment methods [34].

Apraxia is another motor speech disorder, also known as disturbed motor speech planning and programming, which is usually caused by unilateral lesions in the dominant hemisphere. According to ASHA, there are no reliable data on the prevalence of acquired apraxia of speech [35]. During the acute phase after stroke, apraxia may co-occur with dysarthria or aphasia [36]. Different estimates of the prevalence of apraxia in the acute phase have been reported. Pedersen et al. [37] documented that 7% of 776 patients diagnosed with stroke in Denmark had verbal apraxia. On the other hand, Donkervoort et al. [38] reported that 28% of the patients showed symptoms of apraxia in the Netherlands. One study reported a prevalence of apraxia during the sub-acute phase was 26.3% [39].

There are several reasons for the variability in reported prevalence and incidence of aphasia, dysarthria, dysphagia, cognitive deficits, and apraxia. Study of different populations, methodological differences, use of various definitions and assessment techniques has been proposed as the reasons for different findings [40–42].

Stroke, as an important cause of disability, loss of independence and decrease in the quality of life requires a great deal of attention due to its disabling nature. As previously stated, communication deficits are prevalent among persons with stroke in the acute phase, affecting patients' quality of life with short and long term impacts on language comprehension and expression skills as well as other speech and communication difficulties following motor speech disorders. Therefore, early detection of these deficits is essential for providing prompt speech and language rehabilitation services [43].

There is no other published research regarding the prevalence of aphasia, cognitive deficits, apraxia, dysarthria, and dysphagia in Iran. Estimating the prevalence of communication impairments among post-stroke patients in the acute phase would improve post-stroke rehabilitation guidelines [44]. In addition, referrals to SLPs for prompt and proper assessment and treatment with speech therapy services are not typically included in post stroke guidelines for Persian speaking patients in Iran. Therefore, in this study, we aim to shed light on the incidence and associated factors of communication deficits (aphasia, cognitive deficits, apraxia, and dysarthria) and dysphagia in the acute phase in Persian adults subsequent to stroke and also signify the necessity of incorporating early referrals to SLPs, as part of post stroke rehabilitation guidelines due to the incidence data.

Methods

Participants

During a time period of 1 year (February 2018–February 2019), 100 patients with stroke were assessed. Participants were recruited from the neurology ward of Firuzgar and Shohadaye Tajrish hospitals (two academic hospitals). According to Table 1, more than half of the participants were male (56%) and 44% of them were female. 41% of the patients were bilingual, and 59% of them were not. Among the patients, 83% were right-handed, 11% were left-handed, and 6% were bilateral. The mean years of education were 7.03 (± 5.24) years among patients. Also, the mean of post-stroke days was 6.17 (± 3.43) days. Inclusion criteria consisted of (a) stroke diagnosis by a neurologist; (b) first ever-stroke; (c) no history of psychiatric diseases; (d) no history of other neurological diseases, e.g., Parkinson's disease, and multiple sclerosis; (e) being in acute phase post stroke (up to 14 days after stroke) [45]. Exclusion criteria were (a) the patient's unwillingness to continue participating in the project. The research protocol was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran (Code: IR.USWR.REC.1395.401).

Table 1.

Demographic, clinical characteristics and stroke, and for aphasia, dysarthria and dysphagia (n = 100)

Variables		Whole sample (n = 100)	Patients with aphasia (n = 59)	Patients without aphasia (n = 41)	p- value	Patients with dysarthria (n = 58)	Patients without dysarthria (n = 42)	p- value	Patients with dysphagia (n = 36)	Patients without dysphagia (n = 64)	p- value
Gender (n) (%)	Male	56 (56%)	30 (50.8%)	26 (63.4%)		30 (51.72%)	26 (61.9%)		22 (61.1%)	34 (53.1%)
	Female	44 (44%)	29 (49.1%)	15 (36.5%)		28 (48.27%)	16 (38.09%)		14 (38.8%)	30 (46.8%)
Age, Mean (± SD)		62.61 (± 14.89)	64.95 (± 15.6)	59.29 (± 13.2)	.02*	63.09 (± 15.1)	61.95 (± 14.7)	.71	65.14 (± 16.6)	61.22 (± 13.7)	.21
Bilingualism (n) (%)	Yes	41 (41%)	29 (49.1%)	12 (29.6%)		24 (41.37%)	17 (40.47%)		14 (38.8%)	27 (42.1%)
	No	59 (59%)	30 (50.8%)	29 (70.7%)		34 (58.62%)	25 (59.52%)		22 (61.1%)	37 (57.8%)
Handedness (n) (%)	Right	83 (83%)	47 (79.6%)	36 (87%)		49 (84.48%)	34 (80.95%)		28 (77.7%)	55(85.9%)
	Left	11 (11%)	8 (13.5%)	3 (7.3%)		7 (12.06%)	4 (9.52%)		6 (16.6%)	5 (7.8%)
	Bilateral	6 (6%)	4 (6.7%)	2 (4.8%)		2 (3.44%)	4 (9.52%)		2 (5.5%)	4 (6.2%)
Education (years), Mean (± SD)		7.03 (± 5.24)	5.46 (± 5.02)	9.21 (± 4.78)	<.001**	6.58 (± 5.29)	7.68 (± 5.16)	.32	6.44 (± 5.1)	7.34 (± 5.2)	.43
Post-stroke days, mean (± SD)		6.17 (± 3.43)	6.08 (± 3.8)	6.29 (± 2.84)	.75	6.25 (± 3.57)	6.04 (± 3.26)	.76	5.91 (± 3.6)	6.31 (± 3.3)	.58
Lesion side (n) (%)	Right	53 (53%)	26 (44.06%)	27 (65.8%)		26 (44.82%)	27 (64.28%)		12 (33.3%)	41 (64%)
	Left	47 (47%)	33 (55.9%)	14 (34.1%)		32 (55.17%)	15 (35.71%)		24 (66.6%)	23 (35.9%)
Type of stroke a (n) (%)	Ischemic	93 (93%)	20 (33.89%)	12 (29.26%)		20 (34.48%)	12 (28.57%)		15 (41.6%)	17 (26.5%)
	Hemorrhagic	7 (7%)	2 (3.38%)	1 (2.43%)		3 (5.17%)	b		2 (5.5%)	1 (1.5%)

^aMissing data for 65 patients

^bMissing data for 30 patients

**p< 0.01

*p< 0.05 (A p-value less than 0.05 is statistically significant)

Materials

A demographic questionnaire and some screening tests were used in order to assess the language competence, cognitive function, sensory-motor, and swallowing abilities, which are discussed in the following.

Persian aphasia battery (P-WAB) contains six subtests including content, fluency, auditory perception, direction perception, repeating, and naming. The maximum score dedicated to each subtest is 10. The P-WAB test has a total score termed the Aphasia Quotient (AQ), which indicates the overall severity of language impairments. AQ rates severity as follows: 0–25 is very severe, 26–50 is severe, 51–75 is moderate, and 76–88 is mild. Any score of 89 or more (out of 30) is not considered aphasia. It’s necessary to mention that the bedside version of P-WAB was used in this project for screening aphasia [46].

The oral apraxia test evaluates the oro-motor function in the patients. This test consists of two verbal commands and imitational forms, which are scoring separately. The oral apraxia test has 22 questions and the patients get 0 score for each correct answer, 1 score for each wrong answer, and 2 scores when they couldn’t answer the question. According to the results of the test, we can diagnose apraxia and the severity of the disorder, as the score of 44 indicates the severest type of apraxia. Also, the cutoff score for diagnosing apraxia is score 4 and above [47].

Dysarthria examination/evaluation in this project, based on Brookshire, consists of cranial nerves assessment, maximum phonation time and diadochokinetic (DDK), respiratory insufficiency test, assessing phonation and articulation. The purpose of these tests is screening and for further assessments, comprehensive and common tests are suggested [48].

Mann Assessment of Swallowing Ability (MASA) is a 200-point bedside instrument which is used for identifying eating and swallowing disorders in patients. 24 items are dedicated to this screening tool and score 184–200 is considered normal, 174–183 is considered mild, 164–173 is considered moderate, and score 163 and below is considered as a severe disorder [49].

Mini-Mental State Examination (MMSE) is the last test that was used in this study for assessing cognitive functions. Orientation, repetition, attention and calculation, memory, language, copying, and complex commands are evaluated in this test. The highest possible score in this instrument is 30 and the cutoff score is 25 [50]. Using the above-mentioned tests, the data was collected and analyzed using SPSS statistics version 25.

Results

The present study focuses on 100 post-stroke patients during the acute phase who survived, with 91.4% diagnosing ischemic and 8.6%, hemorrhagic. As demonstrated in Table 1, the incidence of aphasia was about 59%, with experiencing 47% LHD. 50.8% of patients with aphasia and 63.4% of patients without aphasia were male. Compared to individuals without aphasia, patients with aphasia were significantly older (59.29 vs. 64.95,$p=.028$), and had fewer education years (9.21 vs. 5.45, $p<.001$), but there was no difference between women and men for the presence/absence of aphasia ($p>.05$).

There was a significant relationship between the two variables of damaged hemisphere and occurrence of aphasia so that patients with left hemisphere damage had the highest occurrence of aphasia $\left({\chi }_1^2,=,4.60,,,p,=,03\right)$. Between groups two-way ANOVA (2 × 2) revealed that there was significant main effects for the occurrence of aphasia $\left(f_{1,3},=,6568,,,p,<,001,,,{\eta }_p^2,=,.,40,,,p,o,w,e,r,=,1.00\right)$ and damaged hemisphere $\left(f_{1,3},=,15.67,,,p,<,001,,,{\eta }_p^2,=,.,14,,,p,o,w,e,r,=,1.00\right)$ on Aphasia Quotient (AQ), with obtaining lower AQ on P-WAB for patients with aphasia (P-WAB) compared to patients without aphasia as well as individuals with LHD compared to RHD. The interaction of these two factors was found to be significant, either $\left(f_{1,3},=,10.81,,,p,=,001,,,{\eta }_p^2,=,.,10,,,p,o,w,e,r,=,.,9\right)$, so that PWA with left hemisphere damage showed significantly lowest AQ on the P-WAB test. As shown in Table 2, PWA with left hemisphere damage had significantly lower AQ compared to PWA with right hemisphere damage $(p=001)$. According to Table 3, nearly 70.2% of the post-stroke patients with LHD had language impairments, whereas 49.1% of the RHD patients experienced a language disturbance during the acute phase of stroke.

Table 2.

The incidence of aphasia and mean Aphasia Quotient (AQ), apraxia and mean apraxia score, dysarthria, dysphagia and mean MASA test score in post-stroke patients during the acute phase based on the lesion side

			RHD	LHD	p-value
Aphasia	Frequency (n) (%)	Patients with aphasia (n = 59)	26 (44.1%)	33 (55.9%)
		Patients without aphasia (n = 41)	27 (65.9%)	14 (34.1%)
	Aphasia Quotient (AQ) M (± SD)	Patients with aphasia	78.66 (± 11.27)	52.92 (± 27.22)	.001
		Patients without aphasia	95.76 (± 3.07)	93.38 (± 3.75)	.204
Apraxia	Frequency (n) (%)	Patients with apraxia (n = 27)	9 (33.3%)	18 (66.7%)
		Patients without apraxia (n = 73)	44 (60.3%)	29 (39.7%)
	Apraxia score M (± SD)	Patients with apraxia	11 (± 7)	15 (± 10)	.51
		Patients without apraxia	0	0	1.00
Dysarthria	Frequency (n) (%)	Dysarthric patients (n = 58)	26 (44.9%)	32 (55.1%)
		Non- dysarthric patients (n = 42)	27 (64.3%)	15 (35.7%)
Dysphagia	Frequency (n) (%)	Dysphasic patients (n = 36)	12 (33.3%)	24 (66.7%)
		Non-dysphasic patients (n = 64)	41 (64.1%)	23 (35.9%)
	MASA test score M (± SD)	Dysphasic patients	125 (± 40)	114 (± 44)	.47
		Non-dysphasic patients	195 (± 9)	196 (± 6)	.74

A p-value less than 0.05 (typically < 0.05) is statistically significant

Table 3.

The incidence of language disturbance in post-stroke patients during the acute phase based on the lesion side

	With language disturbance (n) (%)	Without language disturbance (n) (%)
Right hemisphere damage	26 (49.1%)	27 (50.9%)
Left hemisphere damage	33 (70.2%)	14 (29.8%)

Based on P-WAB scores, 42% of the participants experienced mild aphasia, 17% had moderate aphasia, 9% experienced severe aphasia, and 6% had very severe aphasia (Table 4). The mean age among different aphasia severity was not significant $\left(f_{3,69},=,1.07,,,p,=,.,36\right)$.

Table 4.

The incidence of aphasia in post-stroke patients during the acute phase based on aphasia severity

Aphasia severity (n) (%)		Aphasia Quotient (AQ) M(± SD)	p-value
Non-aphasic patients	26 (26%)	97.15 (± 1.97)	<.001
Mild	42 (42%)	86.80 (± 4.42)
Moderate	17 (17%)	64.38 (± 7.75)
Severe	9 (9%)	36.38 (± 9.89)
Very severe	6 (6%)	12.37 (± 8.23)

A p-value less than 0.05 (typically < 0.05) is statistically significant

Based on Table 5, 82% of the participants experienced cognitive deficits. Moreover, 30.5% of the participants with cognitive impairments experienced mild deficits, 43.9% experienced moderate deficits and 25.6% experienced severe deficits. Fisher's exact test showed that there is a significant relationship between the occurrence of aphasia and the presence of cognitive deficits $\left(p,=,.,001\right)$. Aphasia and cognitive deficits co-occurred in 55% of patients. One-way ANOVA showed that the mean of MMSE score was significantly different between different severities of aphasia $\left(f_{1,3},=,23.5,,,p,<,001,,,{\eta }_p^2,=,.,55,,,p,o,w,e,r,=,1.00\right)$. The results of the post hoc (Bonferroni test) showed that the difference between mild, moderate and severe classes as well as between moderate, severe and very severe was significant.

Table 5.

The incidence of cognitive deficits and mean MMSE in post-stroke patients during the acute phase according to cognitive deficit severity

Cognitive deficits (n) (%)			MMSE test score M(± SD)	p-value
With cognitive deficits, n = 82	Mild	25 (30.5%)	5.28 (± 3.59)	< .001
	Moderate	36 (43.9%)	15.90 (± 3.03)
	Severe	21 (25.6%)	22.64 (± 1.26)
Without cognitive deficits, n = 18			28.25 (± 2.01)

A p-value less than 0.05 (typically < 0.05) is statistically significant

The incidence of apraxia was 27%, with 33.3% experiencing RHD and 66.7% LHD (Table 2). 25% of patients with apraxia had concomitant aphasia, while 22% of them had dysarthria and 19% had dysphagia.

As demonstrated in Tables 1 and 2, the incidence of dysarthria symptoms was about 58% in our participants, with 55.1% of them having LHD and 44.9% of them with RHD. There was a significant relationship between the occurrence of aphasia and the presence of dysarthria $\left({\chi }_1^2,=,5.66,,,p,=,.,017\right)$. Aphasia and dysarthria co-occurred in 40% of patients. In order to assess some of the speech subsystems (i.e., respiration, phonation, and articulation), maximum phonation time and DDK rate were evaluated. According to the results, the mean of MPT in non-dysarthric participants was longer compared to dysarthric participants $\left(9.05,v,s,.,6.74,,,p,=,.,03\right)$. Also, the rate of /pataka/ in non-dysarthric patients was higher than dysarthric patients $\left(7.21,v,s,.,4.79,,,p,=,.,001\right)$ (Table 6). According to Table 6, 18% of all of the participants had drooling. Among participants with dysarthria, the incidence of drooling was about 24.1% and it was dropped to 9.5% among the participants without dysarthria. Based on the results in Table 6, 60% of the patients had face hemiplegia. The incidence of face hemiplegia among dysarthric and non-dysarthric patients respectively was 84.5% and 26.2%.

Table 6.

Mean of maximum phonation time, diadochokinetic (DDK) rate /pa/ and /pataka/, the incidence of drooling and face hemiplegia in post-stroke patients and with/without dysarthria during the acute phase

		Dysarthric	Non- dysarthric	p-value
Maximum phonation time (seconds) M(± SD)		6.74 (± 5.77)	9.05 (± 5.91)	.03
DDK rate /pa/		7.74 (± 4.64)	10 (± 3.68)	.08
DDK rate /pataka/		4.79 (± 3.50)	7.21 (± 2.99)	.001
Drooling (18%)	Drooling	14 (24.1%)	4 (9.5%)
	Not drooling	44 (75.9%)	38 (90.5%)
Face hemiplegia (60%)	Paralysis	49 (84.5%)	11 (26.2%)
	Non-paralysis	9 (15.5%)	31 (73.8%)

A p-value less than 0.05 (typically < 0.05) is statistically significant

Based on the results demonstrated in Tables 1 and 2, Dysphagia was seen in 36% of the participants, whereas most of them experienced LHD (66.7%) and 33.3% of dysphasic patients had RHD. The mean MASA test scores among RHD and LHD dysphasic patients was 125 (± 40) and 114 (± 44) respectively, that this difference was not statistically significant $\left(p,=,.,47\right)$. There was a significant relationship between the occurrence of aphasia and the presence of dysphasia $\left({\chi }_1^2,=,17.09,,,p,<,.,001\right)$. Aphasia and dysphagia co-occurred in 31% of patients while only 5% of dysphasic patients did not have aphasia. Dysarthria and dysphagia co-occurred in 32% of patients. All five impairments co-occurred in 9% of the whole sample. These findings indicate a high co-occurrence of these disorders in stroke patients.

Discussion

In the present study, we reported the incidence of aphasia, cognitive deficits, apraxia, dysarthria, and dysphagia in acute post-stroke Persian speaking adults. The reason for insisting on the acute phase of stroke is the brain changes during this phase. Disruption of neurophysiological and metabolic processes that happen in different sections of the brain causes some communication and swallowing problems. In this situation, speech and language interventions may be needed [51]. Also, after a two-week duration of the acute phase, the sub-acute phase starts, when the patient is discharged and might not refer to the SLP. Therefore, the acute phase, when the patient is hospitalized, is a proper time for SLP interventions. On the other hand, for having suitable treatment plans, SLPs should be informed about all stroke phases. The first step is to study the acute phase [52], which is focused in this paper.

Our findings showed that more than half of the post-stroke patients experienced communication disorders during the acute phase. Along with the research conducted by Mitchell et al. [53], communication deficits are prevalent in the acute phase of stroke. These authors also reported that 64% of the participants with stroke had communication impairments that are consistent with our findings.

According to our findings, more than half of the post-stroke patients during the acute phase were diagnosed with aphasia. Aphasia diagnosis was expected in LHD patients, anticipating that they experience language impairments in different aspects (i.e., language modalities) and scopes. Also, our findings showed that over half of the participants with aphasia had LHD, which indicates the importance of the damaged hemisphere in the occurrence of aphasia.

Half of the post-stroke patients with RHD in the acute phase had language disturbances. The mean aphasia quotient (AQ) in RHD post-stroke participants was 78.66 (± 11.27), which demonstrates a mild language deficit, not a crossed aphasia. According to the P-WAB scores, RHD patients had higher scores in all subsets (content, fluency, auditory perception, direction perception, repeating, naming) compared to LHD. Language impairments in the right hemisphere after stroke generally manifest differently from language impairments in the left hemisphere. In RHD, in contrast to patients with LHD, patients generally experience nonverbal language processing disorder and discourse deficits, as reported by Bryan [53], these patients have problems using language in context [53]. However, the connected speech deficits seen in this population may lead us to misdiagnose patients with RHD as having aphasia. Therefore, since language deficits are prevalent in both patients with right and left hemisphere damages [54, 55], referring patients to SLPs is crucial for accurate diagnosis of specific language impairments pertinent to these damages.

According to Flowers et al. [56], about one-third of the patients with stroke in their study had aphasia in the acute phase. Fewer patients were reported to have aphasia in their study compared to our study. The different criteria used in aphasia diagnosis is the reason for this discrepancy, as Flowers et al. [56] diagnosed aphasia based on naming problems, but we used P-WAB to determine aphasia, considering all of the language modalities. Some of the previous studies support our findings of the incidence of aphasia during the acute phase of stroke. Based on Kadojić et al. [57], nearly half of the ischemic stroke patients had aphasia. As a result of the high incidence of aphasia during the acute phase of stroke, SLPs play a crucial role in the diagnosis and treatment of aphasia.

We also evaluated predictors related to the occurrence of aphasia. In the present study, patients with aphasia were older and with fewer education years. The association between old age and the occurrence of aphasia after stroke has also been shown in previous studies [13, 57–60]. There is some evidence that elderly patients show a decrease in age-related language ability [61], which may be exacerbated by stroke. So, based on our results, older age and education (years) are predictors of the occurrence of aphasia.

Cognitive deficits are prevalent among patients with stroke, affecting various aspects of patients' functioning. During the acute phase of stroke, more than three-quarters of the participants in our study had cognitive deficits. According to Rasquin et al. [62], 71.1% of stroke patients had cognitive deficits in the acute phase in the Netherlands, which is consistent with our results. Nakling et al. [18]), reported that 60% of the patients with stroke had cognitive deficits. They used the Memory and Thinking Scale, while we used the Mini-Mental State Examination (MMSE). Although different tests were used in these two studies, the results are similar. Both studies concluded that more than half of the persons with stroke may have cognitive deficits in the acute phase. However, cognitive deficits are usually left untreated, and the reason might be the lack of an appropriate stroke guideline [63]. MMSE test suits for assessing cognitive deficits, although the results are affected by the language abilities in aphasia. Cognitive deficits seen in aphasic patients are due to language and communication disorders, which leads us to use the MMSE test to detect cognitive-communication disorders [64].

Based on our findings, about one-third of the patients with stroke had oral apraxia during the acute phase; one-third of them had RHD and two-thirds, LHD. As the left hemisphere is more related to praxis, LHD tends more to cause apraxia [65, 66]. Edwards et al. [67], also reported that the prevalence of apraxia is about 30–60%; which is consistent with our results. Since Oral apraxia affects patients’ communication ability, appropriate treatment planning should be provided as soon as possible by SLPs [68].

More than half of the participants in our study had dysarthria in the acute phase of stroke. The incidence of dysarthria in patients with LHD was more than the incidence in patients with RHD. The prevalence rate of dysarthria was reported as 8–80% in patients with stroke [15, 69, 70]. Cock et al. [71], also reported that 44% of the first ischemic stroke patients experienced dysarthria in the acute phase. The incidence of dysarthria in our study is higher than in the mentioned study. Assessing patients using different methods is the reason for this significant variability in the results of different studies on the incidence of dysarthria.

Maximum phonation time, DDK rate /pa/ and /pataka/ tests in 5 s, drooling, and face hemiplegia were used in the assessment of dysarthria. Maximum phonation time, which indicates laryngeal function and respiratory volume, is typically about 22 s in normal people over 60 years [72]. In our study, the maximum phonation time was about 6.74 (± 5.77) seconds in patients with stroke having dysarthria. This number was about 9.05 (± 5.91) seconds in patients with stroke but without dysarthria. Lim et al. 73] in their study measured maximum phonation time in 106 patients with stroke. Similar to our findings, the results showed that maximum phonation time was about 9.22 (± 2.55) seconds in patients with stroke.

Also, according to our results, dysarthric participants produced /pa/, 7.74 (± 4.64) times and /pataka/, 4.79 (± 3.50) times during 5 s. Ziegler [74] also reported that patients with dysarthria can produce 3 to 9 syllables during 5 s which is consistent with our results [74].

Among our participants, less than one-quarter of them had drooling. The prevalence of drooling was reported about 11% in the paper of Han et al. [75], which is similar to our findings. Face hemiplegia is another complication of stroke. In the current study, more than three-quarters of the participants had face hemiplegia in the acute phase of stroke.

As stated above, in our study, more than half of the post-stroke patients had dysarthria during the acute phase. It is apparent that dysarthria affects speech intelligibility and disturbs communicative efficiency [76]. Therefore, early detection of symptoms is crucial for accurate diagnosis as well as treatment considerations.

Dysphagia, as another symptom of stroke, was prevalent in less than half of the participants in our study. Nearly two-thirds of this group had LHD and one-third of them had RHD. As previously reported, dysphagia is more prevalent in patients with LHD. Martino et al. [77] reported that 30–55% of the patients with stroke have dysphagia, which is also consistent with our findings. Considering the high incidence of dysphagia, referring post-stroke patients to SLPs is crucial.

Another finding of our study was the co-occurrence of aphasia with concomitant disorders such as dysarthria (40%), apraxia (25%), dysphagia (31%), and cognitive deficits (55%). In comparison to the present study, previous studies have reported different percentages of co-occurrence of disorders. Lima et al. [13] reported 49.4% of patients with aphasia had concomitant dysarthria. Mitchell et.al [44] in a study with 150.000 stroke patients found that only 21% of patients with aphasia had dysarthria. Flowers et.al [56] also reported that aphasia and dysarthria co-occurred in 15% of patients, while dysarthria and dysphasia co-occurred in 28% of patients. They also reported that dysphasia and aphasia co-occurred in 17% of patients. This finding highlights the importance of assessing and early identifying a variety of impairments including communication, language, speech motor, swallowing, and cognition in stroke patients by a speech and language pathologist.

It is also noteworthy to state that the reason for insisting on the acute phase of stroke is the brain changes during this phase. Disruption of neurophysiological and metabolic processes that happen in different sections of the brain causes some communication and swallowing problems. In this situation, speech and language interventions may be needed [51]. Also, after the two-week duration of the acute phase, the sub-acute phase starts, when the patient is discharged and might not refer to the SLP. Therefore, the acute phase, when the patient is hospitalized, is a proper time for SLP interventions. On the other hand, for having suitable treatment plans, SLPs should be informed about all stroke phases. The first step is to study the acute phase [52], which is focused in this paper.

Based on the findings, it can be said that that proper referral and diagnosis in the acute phase is not only critical for predicting intervention of stroke and diagnosing aphasia, but also it is important for the rehabilitation of subsequent communication and language. This is important because we should take into account the spontaneous recovery rates and how they variable for neurological function between different individuals [78]. For instance, due to various factors such as age, lesion size and location, the severity of deficit, other medical comorbidities, and further possible complications, recovery of language function, cognition, and memory [79] may vary and extend for months to even years after stroke. For this reason, comprehensive assessment and proper diagnosis of language and communication skills by SLPs during the acute phase as well as other phases of post stroke in months and years is needed, to monitor language improvement and to guide speech therapy services over time. Same mechanism should be applied for Dysphagia, Dysarthria, Apraxia, and cognitive deficits using validated screening measures and prompt follow-ups and referrals to SLPs for comprehensive assessments.

Therefore, we insist that early referral to speech and language therapy services for receiving accurate and proper assessment and treatment at the right time after stroke should be included in patient stroke guidelines for Persian speaking adults.

Conclusion and Limitations

Based on the findings of the present study, the incidence of aphasia was higher in the elderly and the less educated patients. Accordingly, demographic information is an important predictor for the occurrence of aphasia. According to our findings, communication deficits are prevalent in patients with stroke during the acute phase. Our findings also showed a high co-occurrence of aphasia with cognitive, motor, and swallowing disorders. More than 50% of the participants had communicative disorders like aphasia, dysarthria, and cognitive deficits, considerably affecting their communicative abilities and quality of life. The role of SLPs in assessing and early identification of communication, cognitive, motor speech, and swallowing impairment in post-stroke patients is very important. SLPs are important members of the multidisciplinary post-stroke care team. They have a key role in post-stroke intervention, which is proposed to be included and highlighted in patient stroke guidelines for Persian speaking adults. Therefore, health services with a stroke unit should include guidelines providing comprehensive multidisciplinary rehabilitation evaluation for stroke survivors and their caregivers. In addition, all patients should be screened for communication deficits using valid and reliable screening instruments. Then, if suspected of communication difficulties patients should receive formal, comprehensive assessments by the SLP members of the multidisciplinary team.

We also faced some limitations in this study. Non-medical SLPs administered the assessments, so there were some limitations in accessing the patients. They were allowed to visit the patients for a few hours per day, and in those hours all the patients were not available. On the other hand, the incidence of communication deficits is needed in all of the stroke phases, and in the present study, we focused on the first phase i.e., the acute phase. Following a group of stroke patients and evaluating communication disorders in all the acute, sub-acute, and chronic phases are suggested, which wasn’t possible in our study.

Authors’ Contributions

ZG: Conceptualization, Methodology, Writing—Review and Editing, Supervision, Funding acquisition. RN: Conceptualization, Project administration. NB: Investigation, Writing—Original Draft, Visualization. SSN: Writing—Original Draft. MM: Conceptualization, Methodology. TA: Formal analysis, Writing—Review and Editing.

Funding

This work was supported by the Deputy of Research and Technology of the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran (Grant No. 14188).

Availability of Data and Materials

The datasets generated during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of interests

The authors declare that they have no competing interests.

Ethics Approval

The subjects have given their written informed consent and the research protocol was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran (Code: IR.USWR.REC.1395.401).

Consent to Participate

Consent forms provided and all the participants agreed to participate in the study.

Consent for Publication

Consent for publication obtained from all the participants.