Aphasia Exam 2

Why do we use a classification system for aphasia?

Not all PWA produce same symptoms and severity level; it helps clinicians communicate with each other

Boston Classification System

System we use in this class to classify aphasia developed by and created Boston Diagnostic Aphasia Examination (BDAE); takes a “syndrome view” because there are different types of aphasia which vary by their symptoms; most widely used system favored by researchers, neurologists, etc.

Syndrome

A group of symptoms that consistently occur together or a condition characterized by a set of associated symptoms

Unitary view

Another view of classifying aphasia; believes that there aren’t different types of aphasia, they just vary by severity, and some people have co-existing diagnoses

Schuell’s classification system

Another view of classifying aphasia; believed we should classify aphasia (not by language modalities affected), but by severity, sensory/motor issues, and prognoses

Irreversible aphasia

Part of Schuell’s classification system; nearly complete multimodality loss of functional language skills with poor prognosis for recovery

Simple aphasia

Part of Schuell’s classification system; relatively mild multimodality language impairment with no specific perceptual sensorimotor or dysarthric component; prognosis is excellent

Alternatives to Boston

Weisenberg and McBride Receptive/Expressive Aphasia & Gardner Fluent vs. Nonfluent Aphasia

“Receptive Aphasia” Weisenberg and McBride definition

Ability to comprehend/understand language is impaired; able to produce language

“Expressive Aphasia” Weisenberg and McBride defintion

Ability to express language is impaired, but able to understand

Why do we not use Receptive/Expressive aphasia terms

Because everyone with aphasia has trouble expressing themselves with language and receiving language; this system tells you very little and is outdated

Gardner classification system

Uses fluent v. nonfluent aphasia; fluent is noneffortful production and nonfluent is effortful production

Do we use Gardner’s classification of fluent vs. nonfluent?

Doesn’t tell you a lot, but better place to start than receptive/expressive because it tells you how much speech is produced

Boston Classification System

Identifies 8 types of aphasias classifying people by fluency, auditory comprehension, and repetition (how well they repeat when given verbal task)

Repetition

Used for diagnosis; we never teach this in therapy

What does the Boston Classification System assume?

That various types of aphasias are due to damage to various brain areas or connections to them however not everyone agrees with this and the fact that aphasia types occur from specific damage to parts of the brain

Functional specialization

Idea that there are specific structures in each hemisphere with specific abilities

Localization

If damage to area causes impairment, then that area must be responsible for that function; based on lesion site however structure-function does not always hold true; lesion site is often involved in deficits, but it does not always predict an impairment

We treat what we ____ not what we ____

See and hear; lesion

Reading Comprehension and Written Expression

Boston does not use this to assess aphasia; reading comprehension mirrors auditory comprehension but reading is usually worse; written expression mirrors oral expression, but is usually worse than oral

Why is reading comprehension worse than auditory comprehension and written expression worse than oral expression sometimes?

Written language is not as embedded as well as spoken language because it is more complex and is developed later than spoken language, it is also more formal; some PWA may be stronger in written modality than spoken modality

Combining modalities spoken and written

This can be beneficial for people that have severe written language impairments

Aphasia over time

Most people’s aphasia evolves over time, but live with it forever; people who recover had a mild onset; symptoms of aphasia may change and most likely get better resulting in different type of aphasia/diagnosis; best case scenario is anomic aphasia; symptoms never get worse over time, they stay same or get better

Deafness and aphasia

Deaf individuals may get aphasia when using ASL; may not understand sign for toothbrush for example, but can still produce it

Crossed aphasia

Occurs when damaged hemisphere and preferred hand are on same side, and present with aphasia; i.e. damage to right hemisphere when right handed, language center assumed to be in right side of brain, symptoms do not fall neatly in Boston Classification System; may deal with extralinguistic issues

Extralinguistic issues

Difficulty with understanding changes in prosody, volume, pitch, etc. (extralinguistic information), difficulty with non-literal language such as metaphors, similies, humor, irony, etc. and abstract concepts

Subcortical aphasia

Damage to subcortical structures in language-dominant hemisphere that causes language impairments; we always see patients with this but they present with symptoms that don’t usually fit into Boston so we use different terms for subcortical structures and classify by lesion site not characteristics

Subcortex

Area beneath the cortex; where white matter is, basal ganglia and thalamus live here

Thalamus

Largest subcortical structure, communicates information between brainstem and cerebrum

Basal ganglia

Plays a crucial role in motor movements; in subcortex

The thalamus and basal ganglia are

Very involved in language and communicate with cortical areas

Thalamic lesion

Lesion or damage to thalamus; characteristics include relatively good auditory comprehension and repetition, fluent speech, lots of semantic paraphasias and neologisms; may fluctuate between periods of drowsiness (w/ very severe characteristics) and alertness (with characteristics are much better); not typical of any other aphasia

Nonthalamic lesion

Lesion or damage to other subcortical structures including basal ganglila; characteristics include mildly impaired auditory comprehension, impaired repetition, nonfluent speech; may remind you of broca’s aphasia but without agrammatism; may also present with dysarthria

Subcortical aphasias compared to cortical aphasias

Tend to have more mild impairments and tend to have better prognosis than cortical aphasias

Primary Progressive Aphasia (PPA)

Dementia syndrome; also termed as “Aphasic Dementia”; slow, progressive, neurodegeneration in language networks of the brain; Starts with progressive loss of language and gets worse over time and as condition deteriorates you lose more cognitive skills (memory, etc.); usually after 5 years, it may turn into Global Aphasia where there are severe cognitive impairments; relatively new diagnosis in SLP field; language needs to be only thing impaired for roughly two years which causes other changes in cognition that are related to language

Three variants of PPA

Nonfluent/agrammatic variant (PPA-G)

Semantic variant (PPA-S)

Logopenic variant (PPA-L)

Alexia

Refers to reading problems due to recent neurological impairment; prior reading skills are impaired (acquired)

Dyslexia

Sometimes used mistakenly to refer to alexia but it is not the same, it is developmental not acquired

Agraphia

Writing problems associated with recent neurological impairment; writing skill is lost or impaired; using language to communicate in written modality through syntax, etc. (not motor problem)

Dysgraphia

Often mistakenly used in place agraphia but is not the same; refers to a motor impairment that affects writing abilties

Do not single out alexia/agraphia because..

Most PWA have degree of impaired reading comprehension and written comprehension and degree of alexia or agraphia; these are facets of aphasia

Pure aphasia

Sometimes there are isolated impairments in which there is only one modality affected woth others intact due to stroke, etc. (modality specific impairment; very rare but we assess, identify and treat them

Pure Alexia

Impaired reading comprehension but no other difficulties/impairments; able to write and spell, but won’t be able to read back to themselves seconds later; also called “pure word blindness”'; usually caused by damage in PCA which brings blood to occipital lobe; can see words on page but can not send to language center to process

Pure Agraphia

Impaired writing; no other impairment in other modalities; verbal and reading abilities are intact; retrieval and manipulation of letters/graphemes is impaired; typically caused by stroke causing damage to angular gyrus, supramarginal gyrus, and posterior portion of temporal lobe

Agnosia

Neurological condition in which a person doesn’t recognize sensory information even though senses are working typically (we care about sight and hearing most as SLPs); can have one affecting any sense

Verbal auditory agnosia

Type of auditory agnosia; Problem in recognition of verbal output; can hear speech, but don’t understand or intepret; severe auditory comprehension deficit; typically a pure aphasia; may understand other nonverbal sounds but won’t understand spoken language; oral comprheension is generally preserved

Nonverbal auditory agnosia

Type of auditory agnosia; May understand speech, but not nonverbal sounds like barks, telephone, etc.; all other modalities are intact

Amusia

Type of auditory agnosia; ability to not recognize prior heard musical sounds or songs

Visual agnosia

Impairment in recognizing visual stimuli, despite having intact visual perception i.e. put keys in front of you and may not know what they are; may understand what they are if someone describes their function; caused by damage in regions of parietal/occipital lobe; usually right hemisphere strokes result in this, doesn’t impair visual recognition of all things, may just be a category like faces, colors, etc.

Prosopagnosia

Inability to recognize faces

Treatment, assessment, etc. will impact our role as SLPs based on

Work setting

Acute care hopsital

First place people go after brain injury; average length of stay is 11 days but depends on severity etc., different kinds include communuity care hospitals that are small and veteran hospitals, and specialized hospitals

Acute inpatient rehab/Rehabilitation hospitals

Next step after acute care hospital; clients usually need to be able to tolerate 3 hours of therapy 5 days a week; usually stay for 2 weeks but depends on insurance; places like Kessler and JFK; SLPs may work weekends and holidays; some are part of acute care hospitals and some have own campus; after this many clients go home and some go to skilled nursing facilities; more treatment of aphasia

Subacute/Skilled Nursing Facility

Provides 24 hr nursing care and therapy services; goal is to try to get patient to go home; can stay longer here; most insurance companies require that you’ve been in hospital for 3 days to get into SNF; can see PWA but less than in rehab hospital; may be hired through agency

Long-term care facility

Assisted living facility; often times people live here; don’t have to come from a hospital; can be admitted from home; may see PWA usually because they have other medical needs; in assisted living, people live in own apartments and units with different levels of care, but it is very expensive; they give you meals, help with meds, and give lots of support; usually therapists are hired by agency contracted to facility (may be part time work)

Home care/Visiting Nurse Services

When you go to person’s home and provide therapy; may have OT, PT, SLP, nurses, aides, physicians that come in; may also do this at assisted living home when patient lives there; usually don’t see them for that long because medicare wants them to go to outpatient; usually 10 sessions across all therapies; allows you to see what therapy helps them in their everyday evironment

Outpatient

PWA lives at gome in community and when they need care they get it at a center (rehabilitation center/hospital, private office, university, telehealth)

Community

Places like Adler; community based services; may do telehealth sometimes

Discharge

Not getting any more therapy; usually due to insurance, not recovery

Role as SLPs for preparing discharge

As an SLP you should prepare clients for home program or connect them with aphasia communities so they can still get support; educate clients that they can return to therapy when insurance allows; discharge shgould. never be a surprise and SLPs should prepare them mentally for next steps

Interdisciplinary team includes

Doctors, nurses, CNAs, PTs, OTs, social workers, recreational therapists, rehab technicians, psychologists, neuropsychologists, dieticians

Clinical method of assessment is

Used to combine facts about client, knowledge of client, baseline knowledge of aphasia, and assessment results

What might influence our assessment?

Level of care - Where is the client in their journey of aphasia? Priorities change causing assessment process to change.

Access to assessments

Screening for aphasia

Should be done right when they get to hospital if they have symptoms; won’t tell you what kind of aphasia, details, or severity, but will tell you if they have symptoms; most look at all modalities of language while some do not (choose appropriately); screens should be very brief and given easily

Fail/Pass on aphasia screening

Fail - further assessment necessary

Pass - assessment not necessary

Why might someone get screened even when they pass?

A doctor may request screen

Names of some of aphasia screenings

Frenchay Aphasia Screening Test (FAST)

Aphasia Language Performance Scale (ALPS)

Acute Aphasia Screening Protocol (AASP)

Bedside Evaluation Screening Test (BEST)

Mississipi Aphasia Screening Test (MAST)

Language Aphasia Screening Test (LAST)

Assessments used in a hospital

Won’t be standardized assessments because there isn’t enough time; will most likely rely on informal methods

Assessments for aphasia

Necessary to make a diagnosis and perhaps specify the type of aphasia and find severity of deficits and nature of deficits; also important for prognosis; good for counseling and advocating for services based on needs shown in assessment to family; may be necessary when something else is going on in which you make a referral; can be used to measure recovery and outcomes, efficacy of treatments, and improvement pre and post treatment

Formal assessments

Standardized tests with strict protocols and scoring rules; rely on quantitative information with test score; variety of tests used to test linguistic skills; can be good at finding area of difficulty, but not great at finding what client can do; do not rell you everything; only part of the picture, need to gather other details

Informal assessment

Non-standardized methods that are flexible; based on client’s needs and symptoms; based on your analysis of your observations, etc.; doesn’t give you a score; may use cues and run mini experiments to test what might work before treatment

Combo of both formal and informal assessments are useful for

Making meaningful goals

Picture naming

Example of informal assessment; if a person doesn’t do well, it only means they’re impaired in just that task; they mostly look at retrieval of nouns; doesn’t show whether cues help retrieval; still should test other areas, such as discourse tasks, written, etc.; keep track of whether clues help he client

Conducting Assessment Steps

Get a case history, conduct an interview, formal assessment, informal assessment, analyze, make a differential diagnosis, counsel

Case history

Includes medical history through family/client interview, demographics to get details on impairment; use techniques to speak to PWA

Circle of care for PWA

May be family or friends; always ask for permission to be talking to them from PWA (informed consent); some might want to talk separately from PWA

With formal and informal assessments, _____ results

Integrate

Counseling in assessment

Includes sharing results, explaining diagnosis and prognosis, answering questions, discussing treatment options, depending on setting

Battery

Large scale, comprehensive standardized assessment

Aphasia batteries

Western Aphasia Battery Revised (WAB-R)

Boston Diagnostic Aphasia Examination 3rd Edition (BDAE-3)

Comprehensive Aphasia Test (CAT)

Western Aphasia Battery Revised (WAB-R)

-Aphasia Quotient (AQ) - 45 min; portion of test frequently given

-Language Quotient (LQ) - all information of AQ with additional reading/writing (60 min)

-Cortical Quotient (CQ): AQ + LQ+ block design, drawing, calculation, and nonverbal reasoning (more than 60 min)

-Beside version (15 min)

WAB-R AQ tasks

Spontaneous speech score, auditory verbal score, repetition score, naming score

Spontaneous speech score

Based on performance of 2 tasks; show picture description e.g. picnic scene) and you gather spontaneous speech information content and spontaneous speech fluency

Auditory verbal score

Includes yes/no questions, auditory word recognition (6 items; point and say what is it), sequential commands (complete commands spoken by you with increasing difficulty)

Repetition score

Client asked to repeat words and sentences in increasing difficulty

Naming score

Naming objects in various semantic categories

-Word fluency (divergent naming task- e.g. name as many animals as you can in one min); doesn’t actually show you how much fluency you have its just the name

-Sentence completion: complete sentences given to them

-Responsive speech: answer questions they would know answer to e.g. “what color is snow"?”

How can we understand scores?

Make comparisons, look at patterns, difficulties, or strengths in set of skills

AQ scoring

Max is 100 and is sum of scores and is used to determine severity; 0-25 means very severe, 26-50 means severe, 51-75 means moderate, 76+ means mild, and 93.8 is cutoff meaning that anything above this number is called not aphasic by WAB; considered “latent aphasia” however should still look at other areas of language and keep testing if they say they have aphasia

How does WAB AQ tell you type of aphasia?

Looks at fluency, auditory verbal score, repetition, and naming score to tell you type of aphasia

WAB-R bedside

Short version of WAB-R; good with time constraints

-Spontaneous speech information content

-Spontaneous speech fluency

-Yes/no questions

-Sequential commands

-Repetition

-Object naming

-Reading

-Writing

BDAE-3 subtests

Conversational and expository speech (discourse, fluency, etc.), auditory comprehension, oral expression, reading, writing

BDAE-3

Short form (40-60 min) and long form (5 hrs) that have same components; used to determine aphasia type and severity, each section has subtests, research shows preference of WAB over BDAE

Comprehensive Aphasia Test (CAT) Language Battery

Includes 3 sections, takes 90 min-120 min; usually done in 2 sessions; includes Cognitive screen, Impact Questionnaire, and Language Battery

Cognitive Screen for CAT

Looks for presence if if visual deficits, memory, arithimitic skills, ability to use gestures

Impact Questionnaire for CAT

Gathers information about emotional well-being of PWA from their perspective, and social impacts (not always appropriate for acute settings because person hasn’t lived with it long enough)

Language Battery for CAT Comprehension

Comprehension of written and spoken words, sentences, and paragraphs

Language Battery for CAT Expression

Expression of written and spoken words, sentences, and paragraphs

Language Battery for CAT Repetition

Digit strings, words, complex words, non-words, sentences

Language Battery for CAT Naming

Naming objects and actions

Language Battery for CAT Reading

Reading words, complex words, non-words