M1: APHASIA AND COG D/O

aphasia

language and communication impairment, most frequently caused by damage to left-sided areas of the brain, affecting a person’s communicative and social functioning and quality of life and the QoL of his/her close social network

21-38

aphasia occur in ___% of stroke survivors

• handedness

• previous stroke

• laterality of lesion

• type of stroke

risk factors of aphasia in the ph

dysarthria

impairment in articulation (intact comprehension)

result of an acquired brain lesion

difference of aphasia from dysarthria

ischemic stroke

most common cause of aphasia

• neurodegenerative diseases

• tbi

• mass lesions in the brain

other causes of aphasia

frontotemporal dementia, alzheimer’s disease

neurodegenerative diseases

primary or secondary brain tumors

mass lesions in the brain

PNS, neuromuscular junction, muscles

aphasia cannot be caused by diseases affecting the…

classical model

NATURE OF APHASIA: MODEL

• developed by Wernicke and Lichtheim, further refined neuroanatomically by Geschwind

• provides the foundation for understanding aphasia’s clinical features and the related neuroanatomical lesions

fluent aphasia

APHASIA SYNDROMES:

• A posterior lesion involving the Wernicke’s area

• characterized by:

  • impaired comprehension

  • severe paraphasia

→ type of aphasia (language disorder after stroke) with poor comprehension. Speech is effortless, but the meaning is impaired

nonfluent aphasia

APHASIA SYNDROMES:

• An anterior lesion affecting the Broca area

• patients have

  • normal comprehension

  • speech that is telegraphic, effortful, and dysprosodic

  • without paraphasic errors

conduction aphasia

APHASIA SYNDROMES:

• A lesion in the arcuate fasciculus

• characterized by:

  • impaired repetition

  • phonemic paraphasia

• fluent speech with word finding errors, and often with use of filler words or talking around the word.

• Repetition of speech may be poor.

• Comprehension is typically, relatively intact.

arcuate fasciculus

the white matter tract connecting the Wernicke and Broca areas

global aphasia

APHASIA SYNDROMES:

• most common types of aphasia

• impacts both language comprehension and expression to varying extents

• with severe apraxia

  • what someone says may be the same words or phrases over and over

transcortical motor aphasia

APHASIA SYNDROMES:

• nonfluent

• similar to Broca aphasia, but within preserved repetition

transcortical sensory aphasia

APHASIA SYNDROMES:

• fluent aphasia with impaired comprehension,

• resembling Wernicke aphasia but with intact repetition.

transcortical motor/sensory aphasia

APHASIA SYNDROMES:

• often display excessive repetition

  • preservation or echolalia

Anomia

APHASIA SYNDROME:

• milder form of aphasia resulting from a small lesion in the dominant peri-Sylvian region

anomic aphasia

APHASIA SYNDROME:

• difficulty word finding

broca’s aphasia

APHASIA SYNDROMES:

• relatively intact comprehension

• word retrieval difficulties

• evident frustration

contemporary language model

NATURE OF APHASIA: MODEL

• aka dual stream model

• Developed by Hickok and Poeppel

• supported by modern neuroimaging studies, including functional magnetic resonance imaging (MRI), diffusion tensor imaging, and MRI tractography

• outline 2 main language processing streams involving cortical and subcortical structures

  • dorsal and ventral stream

dorsal stream

DUAL STREAM MODEL:

• located in the dominant hemisphere region

• processes auditory-to-articulation information, connecting the frontal speech areas and the temporoparietal junction

  • crucial in fluent speech production

• Lesional analysis indicates that the dorsal stream primarily involves the gray matter of the frontoparietal regions

ventral stream

DUAL STREAM MODEL:

• located in both temporal lobes

• processes auditory-to-meaning information, which is essential for auditory comprehension

• encompasses much of the gray matter in the lateral temporal lobe

-→ Conduction aphasia results from lesions in gray matter, particularly in the area SPT (Sylvian fissure, parietal-temporal junction), a posterior region that is part of the dorsal stream, rather than from involvement of the white matter tract of the arcuate fasciculus

thalamic aphasia

TYPE OF APHASIA:

• occurs when the left-sided ventral anterior or paramedian nuclei are affected and can be either fluent or nonfluent

• primarily results in lexical-semantic deficits, with relative preservation of repetition

subcortical aphasia

TYPE OF APHASIA:

• tends to be milder and associated with a better prognosis

aphasia resulting from basal ganglia lesions

• typically mild

• characterized by:

  • impaired language expression

    • word fluence

  • comprehension and repetition remain intact

aphasia resulting from cerebellar lesions

• typically characterized by:

  • deficits in word retrieval, semantics, and syntax

anomia

FEATURES OF APHASIA:

• Difficulty in recalling words, names, and numbers, despite knowing what the object is

• Circumlocution

circumlocution

anomia: talking around the word

paraphasias

FEATURES OF APHASIA:

• production of unintended syllables, words, or phrases

phonemic (literal) paraphasia

TYPES OF PARAPHASIA:

• within a word

verbal (semantic) paraphasia

TYPES OF PARAPHASIA:

• replacing an intended word with an incorrect, often related word

neologistic paraphasia

TYPES OF PARAPHASIA:

• using entirely new, nonsensical words

• screening

• assessment

• management

• education and counselling

• referral and discharge

roles of SLPs in interventions

right-hemisphere syndrome

• most commonly caused by a stroke or other acquired brain injury (e.g., tumor) that impacts the right hemisphere of the brain

• constellation of changes in pragmatics, discourse, cognitive-communication skills

pragmatics

RHD CHANGES:

• the ability to convey or comprehend meaning or intent of a message

discourse

RHD CHANGES:

• the ability to understand or produce verbal and written language in units longer than single sentences

cognitive-communication skills

RHD CHANGES:

• skills that are needed for effective, clear communication, including attention, memory, executive function, visual-perceptual skills, and/or awareness of deficits

causes of RHD

• may result from a variety of changes in the structure or function of the right hemisphere of the brain

  • can range in severity and may result in chronic or acute deficits

• Changes in the brain include tumors, surgery, infection, stroke, seizure, neurodegenerative conditions, and traumatic brain injury

anosognosia

COMMUNICATION DIFFICULTIES RHD:

• reduced awareness of neurological deficits and other changes, following brain injury

unilateral left neglect

COMMUNICATION DIFFICULTIES RHD:

• Reduced attention to and awareness of stimuli on the left side of an individual’s visual field, body, or environment

egocentric unilateral spatial neglect

COMMUNICATION DIFFICULTIES RHD:

• most common unilateral left neglect

• i.e., reduced awareness of visual stimuli to one side of an individual’s midline

neglect

COMMUNICATION DIFFICULTIES RHD:

• may involve visual, auditory, somatosensory. or kinetic modalities

neglect dyslexia

COMMUNICATION DIFFICULTIES RHD:

• misreading or not detecting text on the left side of the page or on the left side of words

• may co-occur with unilateral left neglect

crossed aphasia

COMMUNICATION DIFFICULTIES RHD:

• rare

• this condition may occur in people with language dominance in the right hemisphere at baseline

•  deficits occur with right hemisphere stroke in a small percentage of patients

  • word retrieval, syntax, morphology, and phonological processing

• anosognosia

• unilateral left neglect

RHD communication difficulties

apragmatism

RHD:

• when a person has difficulty conveying or comprehending the meaning or intent of a message within a specific context

  • Contexts can include the conversational partner(s), environment, culture, or goals of the interaction

• primary impairment in RHD

linguistic apragmatism

AREAS APRAGMATISM:

•  inability to use contextually appropriate words to convey or understand meaning

• person with RHD:

  • have trouble using or recognizing sarcasm, jokes, figurative language, or information that can be interpreted in multiple ways

  • have difficulty making inferences or understanding global meanings of discourse— such as the implied main idea or the overall gist of the story or discussion

  • Be tagential or verbose and may interrupt or may have reduced verbal output (Blake, 2006).

paralinguistic apragmatism

•  inability to use changes in the intonation, pitch, amplitude, or stress of speech (i.e., prosody) to convey or understand meaning

• person with RHD:

  • have aprosodia

aprosodia

• inability to understand and express meaning and emotion through the use of variations in pitch, loudness, intonation, and rhythm

extralinguistic apragmatism

AREAS APRAGMATISM:

• inability to use nonverbal aspects to convey meaning

• person with RHD:

  • reduced ability to use or interpret other nonverbal communication, such as:

    • variations in facial expressions

    • body language

    • use of gestures or eye contact

cognitive communication

RHD:

• affects aspects of ___ ___ that impact how the person interacts with others and with their environment

• awareness of deficits

• attention

• memory

• ef

• problem solving

• reasoning and judgment

• sequencing

RHD COG COMM: common areas of impairment

(AAMEPRS)

coherence

RHD DISCOURSE:

• ability to maintain a topic and to connect statements, ideas, and thoughts across a conversation

• May have difficulty identifying and including important information

  • May include too little relevant information about stories and procedure

  • May disproportionately exclude inferred content (vs. explicit content)

cohesion

RHD DISCOURSE:

• ability to consistently refer to content the same way throughout a conversation (e.g., using the pronoun "she" to refer to a singular person unless a new person is introduced)

  • Requires functional attention and working memory to

    • track references from sentence to sentence,

    • plan and adapt to listener knowledge, and

    • monitor listener understanding

• may have difficulty with:

  • ambiguity, such as when to use “a” versus “the” to convey introduced content

  • may vary the label when referring to the same subject, which can lead to confusion for their conversational partner

conversational or social skills

RHD DISCOURSE:

• ability to initiate conversation, ask questions and take turns

• may have difficulty:

  • identifying instances of communication breakdown and misunderstanding

  • achieving effective conversational repair when they do identify a breakdown

pseudobulbar affect

RHD OTHER DEFICITS:

•  can cause lability (e.g., crying or inappropriate laughing)

• difficulty interpreting and conveying emotions

egocentrism

RHD OTHER DEFICITS:

• use of language that is excessively self-focused and preoccupied with the person’s own thoughts, feelings, and needs

• pseudobulbar affect

• reduced empathy

• egocentrism

• dysphagia

• dysarthria

• hemiparesis/hemiplegia

rhd other deficits

traumatic brain injury syndrome

• brain injury that can happen from a bump or blow to the head or when an object goes through the skull and into the brain

• no matter what type you have, damage to your brain happens right away

• later, you may develop seizures or brain swelling.

• falls

• car accidents

• being hit by or running into an object

• violent assaults

• sports injury

common causes of TBI

• physical problems

• sensory problems

• behavior changes

• problems with thinking skills

• speech and language problems

• social communication issues

• swallowing problems

signs and symptoms of TBI

physical problems

TBI S+S:

• fainting, seizures, headaches, dizziness and vomiting, problems with balance, and muscle weakness

sensory problems

TBI S+S:

• sensitivity to lights, sound, and touch; hearing loss or ringing in the ears; changes in vision or double vision

behavior changes

TBI S+S:

• being more emotional or feeling anxious or angry; feeling depressed or having mood swings

problems with thinking skills

TBI S+S:

• difficulty paying attention, remembering, and learning new information; difficulty planning, setting goals, and problem solving

speech ang language problems

TBI S+S:

• problems being understood because of weak speech muscles (dysarthria) or problems controlling your speech muscles (apraxia of speech in adults and childhood apraxia of speech); problems understanding what others say or what you read; problems finding the words to say what you want or need

social communication issues

TBI S+S:

• difficulty following conversational rules, like taking turns and not interrupting; difficulty understanding nonverbal cues, like when someone shrugs their shoulders

swallowing problems

TBI S+S:

• trouble chewing, or coughing and choking when you eat (swallowing disorders in adults and feeding and swallowing disorders in children

executive function

• refers to a group of interrelated cognitive processes, including but not limited to controlling initiation and inhibition; sustaining and shifting attention; organization; goal setting, and completion; and determining plans for the future

• skills that allow individuals to plan and execute tasks, and interact and communicate successfully with others

• depends on foundational cognitive functions working together

  • attention

  • processing speed

  • memory

early ef skills

EF:

• begin to develop in infancy, continue to grow throughout adolescence, and may continue to develop during adulthood

• working memory

• inhibitory control

• cognitive flexibility

EF: core cognitive dimensions

• metacognition

• abstract reasoning skills

• multifactorial probelm solving

• advanced ToM skills

other higher order cognitive skills (MAMA)

metacognition

EF:

• ability to consider one’s own thought process

• includes:

  • self-awareness

  • self-monitoring

interlap with ot and psychologists

• providing prevention, screening, consultation, assessment and diagnosis, treatment, intervention, management, counseling, and follow-up for disorders of cognitive aspects of communication (e.g., attention, memory, problem solving, executive functions)

• collaborating in the assessment of central auditory processing disorders and providing intervention where there is evidence of speech, language, and/or other cognitive-communication disorders

dementia

• difficulty with ef skills

  • typically present in all forms once the disease has reached its advanced stages

  • impacts independence and overall QoL

• ef decline

  • associated with falls and gait speed decline in older adults