SPA 127 - Ch. 12: Acquired Neurogenic Language Disorders

What is Aphasia?

• Aphasia is a language disorder typically caused by damage to the left hemisphere of brain

• Aphasia causes problems with any or all of the following:

  • Spontaneous speech

  • Comprehension

  • Verbal repetition

Primary Cause of Aphasia

• Cerebrovascular Accident (CVA)

  • Hemorrhagic Stroke: Bleeding in brain

  • Ischemic Stroke

    • Embolus: Moving clots

    • Thrombosis: Clot from gradual accumulation of plaque

Ischemic Stroke: Clot

• Embolism

  • Clot cuts off blood supply to part of brain

• Thrombosis

  • Plaque buildup causes clots

  • Piece of artery that is clogged breaks off

Hemorrhagic Stroke

• Artery will break or burst

• Causes blood to touch tissue, which would cause cells to die

Common Causes of Stroke

• Primary Causes:

  • Obesity

  • High cholesterol/hyperlipidemia

    • High levels of fat proteins in the blood

  • Hypertension (high blood pressure)

  • Diabetes

  • Smoking

  • A-fib

  • Alcohol abuse (ETOH)

Classification of Aphasia

• Classified by SLP following an assessment of:

  • Naming

  • Fluency

  • Auditory Comprehension

  • Repetition

• Naming deficits common across different types of aphasia

  • Indicative of neurogenic communication disorder

Types of Aphasia

• Aphasia is caused when cortical centers of language are damaged

  • Global

  • Broca’s

  • Wernicke’s

  • Conduction

  • Transcortical

• Aphasia without a clear localization

  • Anomic (refers to word finding difficulty)

Broca’s Aphasia

• Damage to Broca’s area (L inferior frontal lobe)

• Hallmark - laborious, halting, non-fluent speech

  • Paraphasias (e.g., pike for pipe, kipe for pipe)

  • Agrammatic or telegraphic output

    • Use mostly content words (nouns, verbs, and sometimes adjectives)

    • Function words are missing (e.g., articles, prepositions, conjunctions, bound morephemes)

• Often occurs with right-sided hemiplegia or hemiparesis

• Comprehension of spoken and written language relatively preserved

• Repetition: Laborious, misarticulated

• Naming: Impaired

Wernicke’s Aphasia

• Damage to Wernicke’s area (L superior temporal lobe)

• Spontaneous Speech:

  • Fluent, empty speech; can produce long syntactically well formed sentences

  • Semantic paraphasias (substituting one word for another (for example ‘bed’ is called ‘table’)

  • Content word replaced by neologisms (made up words)

• Hallmark - impaired comprehension of spoken and written language

• Repetition: Impaired, poor short term memory

• Naming: Impaired

Conduction Aphasia

• Arcuate fasciculus damaged

• Minimally impaired auditory comprehension

• Fluent spontaneous speech

• Hallmark - poor repetition

• Literal paraphasias (dat for hat)

• Aim for correction

Transcortical Aphasia

• Widespread damage to frontal lobe - transcortical motor

  • Good comprehension but difficulty initiating utterances

• Widespread damage to parietal lobe - transcortical sensory

  • Poor auditory comprehension but good repetition

Global Aphasia

• Severe impairment in all language functions

  • Typically caused by widespread damage to the left hemisphere

• Spontaneous Speech

  • Non-fluent: Limited to single words to stereotypic utterances (stereotypes)

• Poor comprehension of spoken and written language

• Poor repetition

• Naming is severely impaired

• Frequently leads to complete inability to communicate verbally, very difficult to treat

Anomia

• Spontaneous Speech

  • Fluent speech, grammatically correct, with frequent word retrieval problems

  • Circumlocutions (talking around the missing word) and semantic paraphasias common

• Comprehension of spoken and written language preserved

• Repetition is preserved

• Naming/word retrieval deficit is the most prominent symptom

Aphasia Assessment

• Case history (initial conversation with the person with aphasia and family)

• Review of medical records

• Check orientation to time, place, person (might have to use alternate modalities such as pointing to written choices as needed)

• Oro-facial examination

• Check for hearing and vision issues

Intervention

• Empower the patient to communicate successfully

• Communication tasks to activate neural plasticity mechanisms

• Cues and prompts - pictures, phonemic cues, phonological rhyming, etc.

• Compensatory strategies

• Family support groups

Intervention Approaches

• Restorative approaches

  • Constraint-Induced Language Therapy: Inhibits use of intact language skills and encourages use of impaired language skills

• Compensatory approaches

  • Promoting Aphasic Communication Effectiveness (PACE): Facilitates use of multiple modalities

  • Supported communication for aphasia: Focuses on training of conversational partners

Group Intervention

• Non-threatening and supportive environment

• Opportunity to practice communication skills

• Observe others’ communication strategies

• Open discussion of life-quality consequences of aphasia and effective strategies

• Connection with other families throughout grief process

Bilingual Interventions

• Challenges:

  • Lack of standardized measures

  • Differences in language proficiency vs. impairment

  • Individual differences in pattern of language recovery

  • More research needed regarding assessment instruments and treatment method effectiveness

Right Hemisphere Damage (RHD)

• Damage to the side of the brain that is non-dominant for language functions

• Causes

  • CVA (primarily)

  • Other Causes:

    • Infection/illness

    • Surgery

    • Traumatic brain injury (TBI)

    • Tumor

Characteristics of RHD

• Can be broadly separated into:

  • Perceptual and Attentional Deficits

  • Communication Deficits

  • Other Cognitive Deficits

Perceptual and Attentional Deficits

• Visual Neglect

  • Difficulty processing and attending to information from the left side (contralateral) of the body/visual field

  • Unawareness of objects (may hit objects when walking or moving wheelchair), may leave food on side of plate

  • May neglect contralateral side of body

    • Deny body parts - “This isn’t my arm”

    • Fail to dress, groom one side

Prosopagnosia

Inability to recognize faces (even familiar faces, family members)

Communication with RHD

• Impaired pragmatic skills

  • Tangential speech or off topic

  • Poorly organized stories

• Have difficulty conveying emotion in their speech (flat affect)

• Show reduced ability to respond to others emotions

• Difficulty with both using and understanding prosody (intonation), and body language (facial expressions) to express information

Other Cognitive Deficits with RHD

• Disorganized thoughts

• Impaired self-monitoring

• Impaired planning, reasoning, and problem solving

• Difficulty with memory

• Anomia

Traumatic Brain Injury (TBI)

• Most Common Causes:

  • Motor vehicle accident (MVA)

  • Falls

  • Sports-related injuries

  • Gun shot wounds

  • Blast injuries

  • Abuse

• Types:

  • Open head injury (penetrating)

  • Closed head injury (non-penetrating)

mTBI (mild TBI) aka concussion

• 1.7 million TBIs occur each year (United States)

  • 70-90% of these are mild

TBI: Behavioral Features

• Range in deficits: mild, moderate, severe

• Cognitive deficits

• Speech and language deficits

• Emotion/personality changes

Cognitive Deficits Associated with TBI:

• Difficulty with attention

  • Sustained, alternating, divided

• Executive function deficits

  • Executive functions allow individuals to generate and regulate goal-oriented behaviors

  • Includes:

    • Self awareness, self-monitoring of behavior

    • Planning

    • Initiation

    • Inhibition

    • Task completion

    • Cognitive flexibility

Other Deficits Associated with TBI:

• Speech and Language deficits:

  • Dysarthria (e.g., slurred speech)

  • Pragmatic and functional language

    • Difficulty with topic maintenance, awareness of social uses of language, sequencing in conversation, relevance to context

  • Emotional/Personality Changes

    • Aggression, denial/unawareness of deficit (anosognosia), socially inappropriate behavior, anxiety/depression

What is dementia?

• Deterioration of cognitive functions

  • Including language and communication

Causes of Dementia

• Progressive death of nerve cells in the brain

  • Alzheimer’s Disease —> Alzheimer’s dementia

  • Parkinson’s Disease —> Lewy Body dementia

  • Vascular Disease (multiple strokes) —> Vascular dementia

• Tumors (glioblastoma)

• Repeated Head Injury (CTE)

• Infections (e.g., chronic encephalitis)

Dementia due to Alzheimer’s Disease (AD)

• Most common cause of dementia (about 70% of all cases)

• 6.9 million Americans are currently living with AD

• Was the 6th leading cause of death in the US

• Primary initial symptom = memory problems

  • Difficulty with recent memory

  • Difficulty remembering newly learned information

  • Word finding problems

As AD progresses…

• More severe memory problems, inability to recognize family/self

• Disorientation (confusion about events, time and place)

• Mood and behavioral changes occur

• More prominent changes in language occur

  • Difficulty focusing on/following conversations (tangential speech, difficulty staying on topic)

  • Difficulty comprehending complex language

  • Easily losing their train of thought when talking

  • Having difficulty organizing words logically

  • Speaking less often

Late Stage of AD

• Not aware of surroundings

• Bed-ridden

• Limited to no verbal output

• Difficulty swallowing

• Loss of bowel and bladder control

Assessment of RHD, TBI, and Dementia

• Case history

• Review of medical records

• Check orientation to time, place, person (use alternate modalities such as pointing to written choices as needed)

• Oro-facial examination

• Check for hearing and vision issues

• Informal evaluation of language

• Formal evaluation of language once patient is stable

Treatment of RHD, TBI, and Dementia

• In RHD and TBI: Focus is on addressing deficits associated with communication disorder

• In dementia, the goal is to maintain functional communication by providing supportive and engaging environment