Aphasia/TBI/Dementia

What is aphasia

absence/loss of language, without language

True or false: aphasia is a language disorder that is acquired AFTER an individual has developed language competence

true

Aphasia is a result of damage to where

the language center of the brain, Broca’s area, left temporal lobe

Receptive aphasia (aka Wernicke’s or fluent) disturbs

comprehension, making it difficult to understand spoken & written language

Expressive aphasia (aka Broca’s or nonfluent) hinders

ability to produce language, impacting speech and writing

What are the two ways aphasia can be classified

locus of lesions (characterized by cause & location of brain damage)

& based on language skills (characterized by strengths and weaknesses in language production, fluent vs. nonfluent)

What is the primary etiology of aphasia

stroke

(other causes = head injury, tumors, aging, etc)

What characteristics are considered when classifying aphasia

fluency, language comprehension, repetition, naming, motor output

Fluency

difficulty initiating speech, short choppy phrases, slow labored production of speech, grammatical errors, telegraphic quality, paraphasias

What is phonemic paraphasia

producing “sofa” as “tofa” or “fosa”, seen in expressive aphasia

What is semantic paraphasia

target word is substituted by another word in the same category, says “fork” for “knife”, seen in fluent & receptive classifications

Language comprehension impairment

referred to as receptive aphasia (Wernicke’s)

Repetition

ability or inability to repeat can lend insight into specifying/identifying type of aphasia (they could repeat but not comprehend what they’re repeating)

Naming (anomia)

absence of the ability to name familiar objects and people (hallmark sign of aphasia!)

Motor output

impairment associated w nonfluent aphasia/apraxia

Types of fluent aphasia

Wernicke’s, Conduction, Transcortical sensory

Types of nonfluent aphasia

Broca’s, Global, Transcortical Motor

Wernicke’s aphasia

injury to the superior, posterior regions of temporal lobe

fluent, normal prosody & length of utterance

neologisms (made up words)

phonemic paraphasia

language comprehension may be severe

impaired repetition

moderate-severe difficulty naming

Conduction aphasia

injury to temporal-parietal region of brain

fluent, mild-moderate expressive deficits, more hesitations than in Wernicke’s

language comprehension intact

significant difficulty in repetition but they are aware of errors and try to correct

mild-moderate naming impairments (especially in content words)

the more anterior the lesion…

the less fluent a person is

Transcortical Sensory aphasia

injury to language dominant hemisphere at border of temporal and occipital lobes or superior region of parietal lobe

classic symptoms of wernicke’s but have amazing repetition skills

echolalia

significant word finding difficulties, they can read aloud but with little to no comprehension

Broca’s aphasia

nonfluent, decreased utterance, intact self monitoring

omission of function words

mild-moderate receptive language impairments

mild-severe repetition impairment

mild-severe naming anomia

Global aphasia

large region of brain is impacted or multiple areas resulting in significant impairment

nonfluent AND poor comprehension

(doesn’t often stay global bc swelling goes down eventually, can turn into diff aphasia)

Transcortical Motor aphasia

damage to frontal lobe, secondary to trauma or tumor

nonfluent, expressive & motor impairments (apraxia), stuttering

difficulty with initiation of speech

repetition skills better than conversational skills (major diff from Broca’s)

success with oral reading & comprehension

Primary Progressive aphasia

diagnosis of exclusion

progressive language loss in the absence of stroke or tumor or anything

cognition & independent function intact

could evolve into dementia

What is TBI (traumatic brain injury)

damage to the brain due to an external force

(75% of all head injuries = mild TBI or concussions)

traumatically induced disruptions of brain function

acquired brain injury

causes of TBI

transportation related accidents, falls, trauma (struck by object), assaults

True or false: Females are 2x more as likely as males in every age group to get TBI

false

What age groups are the most at risk for TBI

birth-4 (learning to walk)

15-19 (sports, learning to drive)

65+ (deteriorating reflexes)

What is the most common head injury in sports

concussion

(most frequent in football and women’s soccer)

What are common complaints following a concussion

being off balance

having headaches

being mentally sluggish

True or false: the more concussions you get, the more likely you are to get them again

true

TBI is evidenced by at least one of the following

any period of loss of consciousness

any loss of memory for events immediately before or after the accident

any alteration in mental status at the time of the accident

Closed head injury

non penetrating brain injury

skull can be fractured but meninges are intact

results in diffuse injury

(dangerous bc there is nowhere for the swelling to go)

Penetrating head injury (open head injury)

fracturing or perforation of the skull resulting in meninges being torn or lacerated

Coup/contrecoup

coup: injury at the point of impact (frontal)

contrecoup: brain injury opposite from point of impact (occipital)

Symptoms of TBI

physical (dizziness, headaches, insomnia, nausea, vomiting)

cognitive (difficulty concentrating, memory, problem solving, perceptual deficits, executive functioning - includes expressive & receptive language)

behavioral (anxiety, depression, impulsivity, apathy, agitation, aggression)

True or false: TBI could decrease risk for epilepsy, Parkinson’s, and Alzheimers

false

initial effects of CHI and TBI

coma

confusion

amnesia

mild: 30 mins - 1 hour

moderate: 30 mins - 24 hrs

severe: 6 hrs - 7 days

very severe: over 7 days

chronic traumatic encephalopathy (CTE)

degenerative brain disease found in individuals with REPEATED head injury

symptoms of CTE

memory loss

confusion

impaired judgement

progressive dementia

Right hemisphere dysfunction (RHD)

neurological damage to the right hemisphere

(aphasia is left hemisphere)

Identification of RHD

predicting

insight

reasoning

understanding humor

figurative language

pragmatics

facial recognition (prosopagnosia)

problem solving

visual spatial skills/VISUAL NEGLECT

(lady in video - her attention was not on the left side of the flower she was drawing)

Dementia

chronic progressive decline in memory, cognition, language, and personality

result of central nervous system dysfunction

dementia manifests itself in…

Alzheimer’s disease (70%)

parkinsons

huntingtons

etiologies of reversible dementia

depression

drug toxicity

infection

hydrocephalus

resectable brain lesions

types of irreversible dementia

AIDS

alzheimer’s disease

pick’s disease

huntington’s chorea

multi-infarct disease

diagnostic criteria of dementia

memory impairment (short and long term)

a disturbance in at least 3 of the following:

• orientation in time and place

• judgement in problem solving

• difficulty in community affairs (shopping, handling finances)

• home affairs

• personal care

gradual onset and progression

duration of at least 6 months or longer

impact of dementia on communication

Words: may omit words, anomia, reduced lexicon, lack of comprehension, increased jargon (made up words)

Grammar: sentence fragments & difficulty understanding complex phrases, lack of comprehension of grammar

Content: poor topic maintenance, difficulty generating meaningful sentences, vague, repetition of ideas, unable to sequence ideas

Use: difficulty initiating convos, difficulty understanding humor, may fail to greet or correct mistakes, unaware of surroundings & context, insensitive to others, little meaning to language, could be mute or echolalic

Cortical dementia

lesions in hippocampus

Alzheimer’s and pick’s disease

no impaired motor function until late stages

patients unaware/indifferent to deficits

subcortical dementia

lesion in basal ganglia, rostral brain stem, & thalamus

parkinson’s & Huntington’s disease

early motor involvement (dysarthria; bradykinesia)

more aware of deficits so more prone to depression

In Alzheimer’s, there has been found to be a correlation between cognitive decline and …

hearing loss

True or false: nearly all dementias include brain atrophy and neurochemical deficiencies

true

identification of dementia

imaging (MRI, CT) - look for lesions for aphasia, stroke, brain injury, tumor

tests to rule out vitamin deficiency, drug toxicity (when these are ruled out, you have dementia)

standardized assessments by SLPs

Pick’s disease

progressive neurologic disease - gradual decrease in brain mass (especially in temporal and frontal lobes)

early changes show deterioration in social behaviors

excessive eating and weight gain

decline in morphology, syntax, and phonology (vs content)

Multi-Infarct disease (vascular dementia)

result of several small strokes

emotional fragility and depression

etiology: frequent hypertension & arteriosclerosis

impulse control & personality changes

inconsistent memory losses & gradual intellectual loss

language impact depends on site of lesion

True or false: once you’ve had a stroke, the likelihood of getting another one within the same month is pretty LOW

false

Parkinson’s disease

distinguished by motor impact (resting tremors, hypo kinetic dysarthria, etc)

early cognitive disturbances (impact on attention, memory, executive functioning)

high level comprehension impairments

Huntington’s disease

early stages reflect changes in behavior & personality (depression, anxiety, irritability, emotional outbursts)

language becomes profoundly impaired, less verbal output

language deficits can occur prior to dementia

less content in speech

pre-assessment interview

opportunity to support client and family

serve as sounding board for frustrations

promote a sense of well being & acceptance

show empathy

empower client & family to be part of assessment & treatment process

explain purpose of evaluation

give them a voice, encourage them to ask questions

neurological exam

general observations/mental state

cranial nerve exam

observations w staff and family (how are they functioning in the hospital vs. at home)

questions to ask yourself (CVA/TBI)

is aphasia present

what type of aphasia

what treatment will be most beneficial

what is the prognosis for recovery

what other referrals are necessary

Why might full assessments not be feasible right away post-injury

patient could be sleeping/in coma

they need to be checked for other stuff early on

hospitals can be noisy and distracting

family members can get in the way

spontaneous recovery

process of natural healing of the brain w/o intervention

peak is between 6-8 weeks post injury

(timing of your assessment is important)

When an individual is ready to participate:

standardized assessments are administered

hearing screening

oral motor evaluation

screenings

aphasia language performance scales (ALPS)

quick assessment for aphasia

(benefits of completing a screening is that they are short and may be beneficial to a patient if they fatigue easily)

assessment of language in adults aim to look at

cognition (recognition, understanding, memory, problem solving, abstract reasoning)

linguistics (content & form)

pragmatics (discourse - cohesion, coherence, topic navigation)

assessment of TBI

mood & behavior may be impacted

assessment of auditory and visual processing skills

attention skills should be evaluated (sustaining, selective, divided, alternating)

language assessment should focus on

comprehension of single words and sentences

auditory discrimination

expressive language skills

memory and learning should be evaluated…

in conjunction with language

Alzheimer’s disease stages

1. no cognitive impairment

2. very mild decline

3. mild cognitive decline

4. moderate cognitive decline (mild or early-stage Alzheimer’s disease)

5. moderately severe cognitive decline (moderate or mid stage AD)

6. severe cognitive decline (moderately severe or mid stage AD)

7. very severe cognitive decline (severe or late-stage AD)