Adult Language Disorders and Cognitive-Based Dysfunction

CHAPTER 8: ADULT LANGUAGE DISORDERS AND COGNITIVE-BASED DYSFUNCTION

DR. LEANN SCHOUTEN

COMD 242

FOCUS QUESTIONS

  • What is aphasia?

  • How is aphasia classified?

  • What are the defining characteristics of aphasia syndromes?

  • How is aphasia identified and treated?

  • What are right-hemisphere dysfunction, traumatic brain injury, and dementia?

INTRODUCTION

  • Key topics discussed:

    • Aphasia

    • Right Hemisphere Dysfunction

    • Traumatic Brain Injury (TBI)

    • Dementia

WHAT IS APHASIA?

Definition

  • Aphasia is:

    • A language disorder acquired after an individual has developed language competence.

    • Literally defined as “absence of language” or “without language.”

    • Comprehensively defined as a disturbance in the language system existing after language has been established or learned.

    • It results from neurological injury to the language-dominant hemisphere of the brain.

    • Encapsulates disturbances in both receptive and expressive abilities for spoken and written language.

Considerations

  • Aphasia is:

    • Not a developmental disorder.

    • Not a psychiatric problem.

    • Not a motor speech disorder.

  • Related terminology:

    • Dysarthria: A motor speech disorder.

    • Apraxia: A motor speech disorder.

TYPES OF STROKES

Ischemic Strokes

  • Occur when blood supply to the brain is inhibited due to an occlusion in the artery.

  • Types of Ischemic Stroke:

    • Thrombosis: Formation of a blood clot within a blood vessel of the brain.

    • Embolism: An obstruction that lodges in a blood vessel, often originating from another region of the body.

Hemorrhagic Strokes

  • Characterized by:

    • Blood leakage into brain tissue.

    • Occurs from the rupture of weakened or diseased blood vessels.

RISK FACTORS FOR STROKES

Uncontrollable Risk Factors

  • Age: Increased risk with older age.

  • Gender: Differences in risk between genders.

  • Racial/Ethnic Background: Certain groups may be more susceptible.

  • Family History: Genetics play a role in susceptibility.

Controllable Risk Factors

  • Hypertension: High blood pressure significantly increases stroke risk.

  • Diabetes: Contributes to vascular damage.

  • Tobacco Smoking: Major risk factor impacting blood vessel health.

  • Alcohol Use: Excessive alcohol consumption is linked with increased risk.

HOW IS APHASIA CLASSIFIED?

Taxonomy of Aphasia

  • Based on characteristics that differentiate types of aphasia.

  • Classification revolves around:

    • Location of brain damage (site of lesion).

    • Symptoms associated with language disorders.

THE BEHAVIORAL SYMPTOMS OF APHASIA

  • Variability in symptoms:

    • Some individuals may be completely unable to initiate speech.

    • Others may be able to produce long, elaborate but disorganized speech.

  • Language deficits affect:

    • Fluency

    • Motor output

    • Comprehension

    • Repetition

    • Naming

    • Reading

    • Writing

FLUENCY

  • Definition: A qualitative aspect of communication indicating the forward flow of speech, including phrasing, intonation, and rate.

  • Types of Fluency:

    • Fluent Speech: Normal rate and rhythm.

    • Non-Fluent Speech: Includes short, choppy phrases, slow speech with grammatical errors, often described as having a telegraphic quality (also referred to as sensory aphasia).

MOTOR OUTPUT

  • Compromise in motor systems leads to a motor speech disorder when areas controlling motor planning for speech are injured.

  • Individuals may exhibit:

    • Slow and labored articulation.

    • Groping of articulators lacking control.

LANGUAGE COMPREHENSION

  • Also known as auditory comprehension; refers to the ability to comprehend spoken language.

  • Aphasia affecting comprehension is termed receptive aphasia.

REPETITION

  • Definition: The ability to reproduce verbal stimuli accurately on demand. This capability is crucial in differentiating types of aphasia.

  • Repetitive ability is often significantly compromised in individuals with aphasia.

NAMING

  • Known as word retrieval; refers to the ability to successfully retrieve and produce targeted words in conversation or tasks.

  • Associated terminologies:

    • Anomia: Difficulty in naming.

    • Paraphasias: Errors in word use where substitutions may occur.

      • Phonemic Paraphasias: Speech errors where the person substitutes words that sound similar.

      • Semantic Paraphasias: Errors where synonyms or related words may be substituted.

READING AND WRITING

  • Involves comprehension and expression of written language.

  • Deficits in written language often parallel issues in verbal communication.

    • Further details can be found in Table 8.1.

DEFINING CHARACTERISTICS OF APHASIA SYNDROMES

Classification of Aphasia Types (Table 8.2)

  • Analyzing language difficulties aids in grouping aphasias into distinct syndromes:

    • Broca’s Aphasia: Characterized by halting speech, comprehension difficulties.

    • Transcortical Motor Aphasia: Similar to Broca’s, with intact repetition.

    • Global Aphasia: Broad deficits across all language modalities, presenting as severely limited speech and comprehension.

    • Wernicke’s Aphasia: Fluent speech with nonsensical output and comprehension issues.

    • Transcortical Sensory Aphasia: Like Wernicke's but with better repetition skills.

    • Conduction Aphasia: Difficulty with repetition and reading due to injury in the arcuate fasciculus.

    • Anomic Aphasia: Characterized by fluent speech but significant difficulty in naming.

BROCA’S APHASIA

  • Caused by damage to the frontal lobe.

  • Symptoms include:

    • Slow, halting speech with a telegraphic quality.

    • Mild to moderate auditory comprehension issues, especially with complex messages and lack of cues.

TRANSCORTICAL MOTOR APHASIA

  • Resulting from damage to the frontal lobe (superior and anterior aspects).

  • Symptoms:

    • Similar to Broca’s with better preservation of repetition skills.

    • Strong oral reading performance.

GLOBAL APHASIA

  • Result of extensive damage in the language-dominant hemisphere.

  • Displays deficits across all modalities, typically nonfluent with poor comprehension.

WERNICKE’S APHASIA

  • Arises from injury to the superior and posterior temporal lobe (possibly reaching parietal lobe).

  • Features:

    • Fluently produced spontaneous speech, normal prosody.

    • Possible issues include logorrhea (excessive talking), neologisms (made-up words), and jargon.

TRANSCORTICAL SENSORY APHASIA

  • Injury site: Language-dominant hemisphere border of temporal and occipital lobes, or parietal lobe.

  • Symptoms resemble Wernicke’s profile except with exceptional repetition skills and possible echolalia (automatic repetition of speech).

CONDUCTION APHASIA

  • Damage to the temporal-parietal region, particularly the arcuate fasciculus.

  • Major challenges in repetition and reading aloud are hallmarks.

ANOMIC APHASIA

  • Not linked to a specific brain area or lesion.

  • Described as fluent and expressive yet limited in naming ability.

  • Most common and pervasive chronic condition even post-treatment.

IDENTIFICATION AND TREATMENT OF APHASIA

Assessment Process (Table 8.3)

  • Requires a multidisciplinary team for evaluation:

    • Questions to address include:

      • Is aphasia present?

      • What type and where is the site of the injury?

      • What treatment plan is appropriate?

      • What is the prognosis?

      • Are referrals to other professionals needed?

PROGNOSTIC INDICATORS

  • Factors aiding in the prediction of recovery include:

    • Site and size of brain injury

    • Type and severity of aphasia

    • Handedness

    • Age

    • Preinjury health

    • Motivation for treatment

  • Often used to tailor treatment approaches.

TREATMENT OF APHASIA IN EVIDENCE-BASED PRACTICE

  • The primary objective is to correct or accommodate speech-language deficits enabling functional communication in daily routines.

  • Evidence-based practice ensures practices align with verified recovery strategies.

WORKING WITH CULTURALLY AND LINGUISTICALLY DIVERSE CLIENTS

  • Individuals speaking multiple languages: Optimal assessments should evaluate across all spoken languages.

  • Potential findings in research (Roberts, 2001):

    • Parallel impairments: Similarities in language deficits across languages.

    • Differential impairment: Variances in competence across different languages.

    • Differential aphasia: Quality of deficits can differ based on language.

    • Blended impairment: Mixed characteristics in impairment.

    • Selective aphasia: Specific language impacts.

DETERMINING THE TREATMENT SETTING

  • Aphasia therapy may extend beyond traditional clinical settings to include different environments enhancing carryover to daily activities.

  • Considerations include:

    • Group therapy: A collaborative approach for treating aphasia.

MEASURING OUTCOMES

  • Effective treatments are evaluated based on the individual's actual ability to communicate effectively in real-life situations, emphasizing functional communication.

WHAT ARE RIGHT-HEMISPHERE DYSFUNCTION, TRAUMATIC BRAIN INJURY, AND DEMENTIA?

RIGHT-HEMISPHERE DYSFUNCTION (RHD)

  • Definition: Neurological damage to the right cerebral hemisphere which may lead to cognitive-linguistic disorders distinct from aphasia.

  • Symptoms may differ significantly from those observed with aphasia resulting from left-hemisphere damage.

CHARACTERISTICS OF RHD

  • Noteworthy symptoms:

    • Lack of awareness of cognitive-linguistic deficits and denial of problems.

    • Neglect of the left side of one’s body or perception of left stimuli.

    • Challenges in recognizing faces (prosopagnosia).

    • Compromised pragmatic skills affecting social communication.

    • Long-winded communication that provides tangential information.

    • Issues with higher-level cognitive-linguistic skills.

    • Dysarthria or dysphagia may arise from neuromuscular complications.

IDENTIFICATION OF RHD

  • Requires comprehensive assessment protocols as part of an interdisciplinary approach.

  • Specialized assessments such as the Mini Inventory of Right Brain Injury (MIRBI) are available for RHD evaluation.

TREATMENT OF RHD IN EVIDENCE-BASED PRACTICE

  • Knowledge in RHD treatment is less abundant than in left-hemisphere damage and aphasia.

  • Initial therapies target attention and visual disturbances.

  • Higher-level cognitive-linguistic tasks are developed to address everyday problem-solving.

TRAUMATIC BRAIN INJURY (TBI)

Definition

  • Refers to neurological damage resulting from external forces impacting the brain.

  • Epidemiological studies indicate TBI is a leading cause of death and disability in the USA, signifying major health care concerns due to long-term needs.

CHARACTERISTICS OF TBI

  • Types of injuries:

    • Open-head Injury: Penetration through skull and meninges.

    • Closed-head Injury: Brain is displaced within the skull leading to diffuse damage.

    • Polytrauma: Combination of open and closed head injuries, with other complications like PTSD.

IDENTIFICATION OF TBI

  • The Speech-Language Pathologist (SLP) functions within a rehabilitation team post-TBI.

  • Utilization of the Glasgow Coma Scale (GCS) for characterizing the individual’s functioning based on eye-opening, verbal, and motor responses.

TREATMENT OF TBI IN EVIDENCE-BASED PRACTICE

  • Treatment varies per impairment level as indicated by the Rancho scales:

    • Levels I to III: Severe (early recovery phase)

    • Levels IV to VI: Moderate (middle recovery phase)

    • Levels VII to X: Mild (late recovery phase)

WHAT IS DEMENTIA?

Definition

  • A chronic and progressive decline in memory, cognition, language, and personality stemming from central nervous system dysfunction.

  • Diagnostic criteria from the American Psychiatric Association identifies three key traits of dementia:

    • Memory impairment

    • Impairment in cognitive skills

    • Presence of aphasia, apraxia, or agnosia

Characteristics of Dementia

  • Dementia progresses through stages:

    • Mild Dementia - Beginning memory and cognitive issues.

    • Moderate Dementia - More prominent memory loss and cognitive decline.

    • Severe Dementia - Significant functional impairments.

IDENTIFICATION OF DEMENTIA

  • Evaluations involve a multidisciplinary team to determine presence, causes, and intervention strategies.

  • Medical testing aims to exclude other conditions resembling dementia.

  • SLP implementation of comprehensive assessments, such as the Arizona Battery for Communication Disorders of Dementia.

TREATMENT OF DEMENTIA

  • Current research is aimed at improving pharmacological treatments for degenerative changes associated with dementia.

  • Approved medications primarily target individuals in mild to moderate stages.

CLIENT AND CAREGIVER PERSPECTIVES

  • Importance of recognizing the impact of language disorders on clients and their families, ensuring holistic support and care.