Communication allows us to express needs, share opinions, maintain relationships and participate in decisions about our lives. Neurodegenerative conditions can gradually affect speech, voice, language and cognition. Although these changes can be challenging, timely support can help preserve communication, independence and identity for as long as possible.
Parkinson's disease, Amyotrophic lateral sclerosis (ALS) and Huntington's disease are all progressive neurological conditions, yet they affect communication in different ways. In Parkinson's, changes in movement may also be heard and seen in communication. In most cases, the voice can become quieter or flatter, speech may become faster or less clear, and facial expression and swallowing may also be affected. With ALS, a form of motor neurone disease, increasing muscle weakness can gradually make speech more effortful and difficult to understand, even when the person knows exactly what they want to communicate. Huntington's disease is inherited and can affect both movement and thinking, meaning that difficulties with coordination may occur alongside changes in attention, memory and the organisation of thoughts (MedlinePlus Genetics, 2020).
Early involvement from a speech-language pathologist (SLP) is therefore essential. Therapy may focus on maintaining existing abilities, introducing compensatory strategies and planning for future changes. Early referrals allow strategies to be practiced while communication remains relatively strong. This is particularly important in ALS, where speech may deteriorate rapidly once intelligibility begins to decline (Beukelman et al., 2011).
Intervention is tailored to the individual. It may address voice volume, breath support, articulation, speech rate, word-finding, attention and memory. Strategies can include pacing, "clear" speech, shorter phrases and choosing a quieter environment. Communication-partner training is equally important: allowing more time, reducing background noise and confirming messages can improve conversations without taking away the person's control.
One specialised option for people with Parkinson's is the Speak Out!® therapy programme, developed by Parkinson Voice Project and now also delivered in Malta. It teaches people to "speak with intent", making speech a more deliberate act, and combines individual therapy, daily home practice and ongoing group sessions. In a study of 40 people with Parkinson's, participants
improved in speech intensity, aspects of prosody, voice quality and voice-related quality of life (Behrman et al., 2020). Further independent controlled research remains valuable, but these findings support structured, ongoing intervention.
Group intervention offers opportunities for conversation, encouragement and social connection. In Malta, SLP services for individuals with neurodegenerative conditions operate at St Vincent de Paul, in community clinics, and in residential settings, where group-based communication and reminiscence sessions are also carried out.
Reminiscence therapy is particularly relevant to dementia. Dementia is an umbrella term for a decline in thinking, remembering, personality and reasoning that interferes with daily life. Reminiscence therapy uses photographs, music, familiar objects and personal experiences to stimulate conversation. Such groups can support participation while affirming personal history and identity (Woods et al., 2018).
As a condition progresses, augmentative and alternative communication (AAC) may become increasingly important. AAC supplements replaces spoken communication. However, introducing it does not mean abandoning speech. A person may continue speaking when verbal speech is deemed effective, but may opt to use AAC when tired, in noise or for an important message. Ideally, it is introduced early enough for the person and their communication partners to become confident before it is urgently needed.
Low-tech AAC requires no battery or electricity. It may include writing, alphabet boards, communication books, topic boards, pictures, key words, yes-and-no systems or partner-assisted scanning. These options can be personalised and kept available as a reliable backup. High-tech AAC includes tablets, specialised communication devices and computers that produce speech. Users may select letters, words, phrases or symbols to construct messages. Evidence from ALS care supports planning across both low- and high-tech options as physical and communication needs change (Beukelman et al., 2011).
Access also needs to match a person's movement. Some people use touch, a mouse or a keyboard. Others use switches activated through consistent movement, while choices are scanned on a screen. When limb movement becomes very limited, eye-gaze technology can track where someone is looking, enabling the person to select items, type and operate a speech-generating device with their eyes. Research involving people with ALS has associated eye-tracking devices with improved quality of life and reduced caregiver burden, although suitability and outcomes vary between individuals (Hwang et al., 2014). Assessment and regular review are therefore essential; the most sophisticated system is not automatically the most appropriate.
Planning may also include voice banking and message banking. Voice banking involves recording speech to create a personalised synthetic voice capable of producing new messages. Message banking records specific words, sentences and meaningful sounds in the person's natural voice (Royal College of Speech and Language Therapists [RCSLT], n.d.). Research with people living with motor neurone disease indicates that preserving identity is a central motivation for voice banking (Cave & Bloch, 2021).
Receiving a neurodegenerative diagnosis can be overwhelming, and communication therapy may not seem urgent while speech remains functional. Yet preserving communication requires planning, practice and regular review. If you or someone close to you has received a diagnosis or noticed changes in speech, voice, language or communication, seek help early. Contact an SLP to arrange an assessment and begin therapy aimed at preserving current communication skills, preparing for future needs and ensuring that the person's voice continues to be heard.
The Association of Speech and Language Pathologists Malta are full members of Malta Health Network: www.maltahealthnetwork.org
Terrence Mifsud is a committee member of the Association of Speech and Language Pathologists