Aphasia Unit 2

Boston Classification System

aphasia classification system that is developed by Harold Goodglass, Edith Kaplan, and Norman Geschwind called the Boston Diagnostic Aphasia Examination (BDAE)

most widely used in the US, favored by researchers, neurologists, and other professionals

takes a syndrome view

diagnostic criteria are fluency, auditory comprehension, and repetition

syndrome

group of symptoms which consistently occur together, condition characterized by a set of associated symptoms

syndrome view

different types of aphasia that vary by symptoms, Boston Classification System uses this

anomic aphasia

intact fluency, auditory comprehension, and repetition

conduction aphasia

intact fluency, auditory comprehension, and poor repetition

transcortical sensory aphasia

intact fluency, poor auditory comprehension, and intact repetition

Wernicke’s aphasia

intact fluency, poor auditory comprehension, and repetition

transcortical motor aphasia

non fluent, intact auditory comprehension, and repetition

Broca’s aphasia

non fluent, intact auditory comprehension, and poor repetition

transcortical mixed aphasia

non fluent, poor auditory comprehension, and intact repetition

global aphasia

non fluent, poor auditory comprehension, and repetition

unitary view of aphasia/Schuell’s classification system

there aren’t different types of aphasia and everyone that has aphasia just has it

the variation is on severity, it is classified by the severity, sensory/motor deficits, and prognosis for recovery

irreversible aphasia and simple aphasia

irreversible aphasia

very impaired, poor prognosis for recovery

simple aphasia

mild aphasia, good prognosis for recovery

Weisenberg and McBride classification system

receptive and expressive aphasia

do not use this, tells you very little about the aphasia because there are expressive and receptive difficulties in all types of aphasia

Gardner classification system

fluent and nonfluent aphasias

can be used as a broad characterization as a starting point

nonfluent aphasias in the Boston classification system

transcortical motor, Broca’s, transcortical mixed, and global aphasia

fluent aphasias

anomic, conduction, transcortical sensory, and Wernicke’s aphasia

words of caution

Boston assumes the aphasia types result from disruptions to certain areas, not everyone agrees and that aphasia types are from damage to specific areas

functional specialization and localization, and they do not always hold true although the lesion site is often involved

functional specialization

the idea that structures within the hemispheres have specific abilities

localization

if damage to the area causes impairment, then that area is responsible for the impaitment (lesion type)

characteristics that Boston does not use to classify

reading comprehension and written expression

reading comprehension

mirrors auditory comprehension and usually more severe

written expression

mirrors oral expression and usually more severe

using written and spoken modalities together

can improve overall comprehension and written expression can improve oral expression

helpful in severe cases as well

evolution of aphasia

aphasia can evolve over time, symptoms can change, most people live with it for the rest of their lives

when symptoms change, the diagnosis changes

symptoms should not get worse

aphasia and deafness

they can gesture but cannot produce and understand the sign

left language hemisphere whether the language output is verbal or gestural

crossed aphasia

damaged hemisphere and the dominant hand on the same side, very rare

does not fall typically on the Boston and there are extralinguistic issues

ex. damage to the right hemisphere and right-handed

extralinguistic issues

difficulty understanding prosody, tone, pitch

difficulties with nonliteral language and abstract concepts

subcortical aphasia

damages to the subcortical areas causing aphasia

symptoms do not fit the Boston, classified with the lesion site

impairments tend to be milder and make better recovery

subcortex

within the white matter is the basal ganglia and the thalamus

thalamus

largest subcortical structure, communicates information between the brain stem and the cerebrum

basal ganglia

crucial for motor movements

thalamic lesion

good auditory comprehension, repetition, fluent speech, a lot of semantic paraphasias and neologisms

nonthalamic lesion

not in the thalamus, could be basal ganglia, have mild impaired auditory comprehension, repetition, nonfluent, reminded of Broca’s without agrammatism, also present with dysarthria

primary progressive aphasia (PPA)

dementia syndrome, progressive neurodegenerations in the language networks of the brain

language is first affected and over time it gets worse and cognitive abilities are lost

with present with global dementia ~5 years and language has to be the only thing affected for about 2 years

three variants of primary progressive aphasia (PPA)

nonfluent/agrammatic, semantic, and logopenic

alexia

reading problems due to recent neurological impairment, loss of reading ability, impaired comprehension

agraphia

writing problems associated with recent neurological impairment, loss of ability to write, using language to communicate in written language

pure aphasia

it is possible have an impairment in only one modality while the others are intact

rare, identify and treat using classifications

pure alexia

reading comprehension difficulties with no other deficits, pure word blindness

can write and spell but unable to read it back seconds later

often caused by PCA damage

pure agraphia

isolated impairment of writing, verbal and reading remain intact, decreased ability to retrieve and manipulate the letters

stroke in the angular gyrus, supramarginal gyrus, and posterior regions of the temporal lobe

agnosia

problem in recognition

neurological condition where one does not recognize sensory information even though the senses are operating normally

auditory agnosias

verbal auditory agnosia, nonverbal auditory agnosia, amusia

verbal auditory agnosia

pure word deafness, hears speech, but unable to understand it

can understand other auditory stimuli but not spoken

nonverbal auditory agnosia

cannot make sense of nonverbal sounds, all other modalities intact

amusia

inability to distinguish music

visual agnosia

impairment in recognizing visual input but the function of the eyes is intact

lesions are in the parietal and occipital lobe and often in the right hemisphere

acute care hospital

the first place that people go, don’t go for very long and on average people stay for 11 days

there are different kinds and could be community or a larger one with hundreds of beds, federally funded and some hospitals are specialized

rehabilitation hospital

must tolerate a minimum of 3 hours of therapy a day 5 days a week

stay for about 2 weeks, some are a separate facility than the hospital

assessment and treatment happen here

skilled nursing facility/subacute

24-hour nursing care and therapy services, trying to get the patient ready to go home

less intense than a rehab hospital, ranges in sizes

most insurance companies say you have to be in the acute care hospital for 3 days

therapists are on staff through an agency, less often for clients here

long term care

nursing home, there for the rest of their lives

may see clients here, may have complex medical needs and typically here not because of aphasia alone

shared room with 2 beds, therapists on staff through an agency

assisted living

in own apartment with different levels of care

very expensive, gives all meals, helps with meds

therapists are hired by an agency and very rare full-time work for SLPs

homecare/visiting nurse services

people are seen at home, may be with family or at assisted living

not seen for very long (10 sessions allowed total) and very expensive

fills the gap to outpatient

outpatient

live at home and travel for services

rehabilitation/hospital setting, private office, university, telehealth

community

places like Adler Aphasia Center

discharge

typically, due to insurance, there is a time where clients cannot get therapy anymore

it is very scary for most, so it is important to give them a home program and resources

they can also return when insurance will allow, this should never be a surprise, and you have to tell clients this

interdisciplinary team

doctors, nurses, PT, OT, recreational therapy, rehab techs, psychologists, neuropsychologists, dietitians, social workers

assessment

rooted in medicine and uses the clinical methods

process varies on level of care, where the client is, and how long they have lived with aphasia

first step of assessment

screening, happens at acute care when they get to the hospital

tells you if they have signs of aphasia, symptoms, cannot tell you the type

results of screening

determine whether testing is necessary, pass/fail dependent, need a doctor’s order

screening probably done by nurse or physician

common screening tools

FAST, ALPS, AASP, BEST-2, MAST, LAST

most screenings look at all modalities, but some do skip

time of screening

should be very short, 15-20 minutes, should be done without a lot of fuss

assessment

necessary to make a diagnosis of aphasia and specify the type

determines the severity and nature, important for prognosis

can be used to determine outcome or efficacy of treatment as well

formal assessments

standardized, strict protocol and directions, quantitative

assesses linguistic skills and good at telling you what an individual cannot do

informal assessment

non-standardized, based on the client’s needs, and very flexible

good at telling goals, can tell you what helps them

can answer the question when do you have difficulties

assessment steps

1 case history

2 conduct an interview

3 formal assessments

4 informal assessments

5 analyze

6 make a differential diagnosis

7 counsel

aphasia batteries

a large scale comprehensive standardized assessment for aphasia

western aphasia battery-revised (WAB-R)

3 sections and you don’t have to give all 3

there is a bedside version that takes 15 minutes

aphasia quotient (AQ) of the WAB-R

45-minute section that is most often given

language quotient (LQ) of the WAB-R

includes the AQ and reading and writing

takes 1 hour

cortical quotient (CQ) of the WAB-R

includes the AQ, LQ, block design, drawing, calculation, and nonverbal reasoning

takes an extra 16 minutes

spontaneous speech score task WAB AQ

spontaneous speech information content, spontaneous speech fluency, picture description and personal questions

auditory verbal score task WAB AQ

yes/no questions, auditory word recognition, sequential commands

repetition score task WAB AQ

repeat words, sentences, and phrases

naming score task WAB AQ

object naming, word fluency (divergent naming), sentence computation, responsive speech

understanding scores WAB AQ

tasks within scores make up specific scores, overall score is out of 100 which determines severity

indicates patterns of strengths, weaknesses, and discrepancies

0-25: very severe

26-50: severe

51-75: moderate

76+: mild

93.8- cutoff of score, considered latent, if scored within this category do other testing to help get services

WAB-R bedside

spontaneous speech information content

spontaneous speech fluency

yes and no questions

sequential commands

repetition

object naming

reading

writing

BDAE-3 Boston Diagnostic

2 options, long form (1-5 hours) and short form (40-60 minutes)

same components but long form has more items

subtests of the BDAE-3

conversational and expository speech (discourse)

auditory comprehension

oral expression

reading

writing

comprehensive aphasia test (CAT)

3 sections, takes 90-120 minutes and usually done over 2 sessions

cognitive screen, impact questionnaire, and language portion

language portion of the CAT

comprehension of receptive language skills, spoken and written, words, sentences and paragraphs

expression section of repetition, naming (objects and actions), reading, writing

Informal assessment

test all 4 modalities of language

informal auditory comprehension

respond to commands that vary in complexity and get more difficult

picture/object identification

yes/no questionnaire responses

end with story retell, listen to a story