Impairment Based Assessment of Aphasia

SUZANNE PENNINGTON, MS, CCC-SLP & ESTHER HERRING, MS, CCC-SLP

Course Information

  • CD 839: Aphasia in Adults Module 3: Impairment Based Assessment of Aphasia

Today’s Learning Objectives

  • Identify key concepts of Supported Conversation for Adults with Aphasia (SCA).

  • Recognize different elicitation techniques to uncover PWA’s strengths and weaknesses.

  • Demonstrate understanding of aphasia tests that assess all language functions.

  • Compare difficulty levels within assessments.

  • Utilize the process approach during evaluation and clinical observation of a PWA.

  • Identify potential biases in standardized assessments for aphasia and revisions to counteract them.

Today’s Roadmap

  1. Impairment Based Assessment of Language

  2. Assessment of Non-Verbal Communication

  3. Special Considerations in Assessment

  4. Assessment Discovery Activity

  5. Supported Conversation for Aphasia

  6. Process Approach to Therapy Activity

  7. Non-English speaking PWA

  8. Multi-Lingual PWA

Lexical Retrieval - Connected Speech Tasks

  • **Errors: **

    • Paraphasias

    • Hesitations

    • False Starts

    • Circumlocution

    • Empty Speech

    • Jargon

    • Perseverations

    • Stereotypy

    • Echolalia

    • Logorrhea

    • Conduit d'approche

    • Conduit d'écart

Transcription as a Tool for Evaluating Connected Speech

  • Steps for evaluation:

    • Collect a sample of a PWA engaged in conversation

    • Transcribe the connected speech sample

    • Types of interaction:

      • Storytelling

      • Supported Interview

      • Picture Description

  • Determining fluency:

    • Assess fluency as the first step in classifying aphasia type

    • Characterize error types and identify patterns

    • Identify areas of relative strength and weakness

    • Compare language function over time

Fluency in Aphasia Types

  • Non-Fluent: PWA produces halting, effortful verbal output

  • Borderline Fluent: PWA shows aspects of fluent and non-fluent output (task/environment dependent)

  • Fluent: PWA produces relatively smooth, effortless verbal output

Intro to Aphasia Assessments

Complete Assessment of Aphasia

  • Important Areas:

    • Communication and language environment

    • Participation in life situations

    • Living with aphasia

    • Personal identity, attitudes, and feelings

    • Language and related impairments

Assessment of Language and Related Impairments in Aphasia

  • Aim 1: Establish profile of strengths and weaknesses

  • Aim 2: Establish aphasia diagnosis/classification

Diagnostic Importance

  • A diagnosis helps to:

    • Establish a shared language among the interprofessional team

    • Maximize treatment planning using evidence-based approaches

    • Inform discharge planning for safe, coordinated care

Aphasia Classification

  • Key Factors:

    • Fluency

    • Repetition

    • Auditory Comprehension

Assessment Types

  1. Standardized Assessment:

    • Has specific instructions for administration

    • Contains normative data

    • Includes clear rules for repetition, cueing and support

    • Facilitates consistency for comparison between assessment dates

  2. Dynamic Assessment:

    • Allows alteration and exploration of cueing and support

    • Encourages exploration of possible treatment approaches during assessment

    • Provides cultural adaptability during assessments

  3. Combined Assessment:

    • Administer standardized assessments as written for clear objective data

    • Followed by exploration of a dynamic approach

Quote: “Tests do not diagnose language disorders; clinicians do.” – Brooke Hallowell, Ph.D., CCC-SLP

Commonly Used Assessments

  1. Boston Diagnostic Aphasia Examination (BDAE)

  2. Western Aphasia Battery (WAB)

  3. Quick Aphasia Battery (QAB)

  4. Cognitive Linguistic Quick Test+ (CLQT+)

  5. Psycholinguistic Assessments of Language Processing in Aphasia (PALPA)

  6. Boston Naming Test (BNT)

  7. Assessment of Language Related Functional Activities (ALFA)

  8. Communication Activities of Daily Living—Third Ed (CADL-3)

  9. Boston Assessment of Severe Aphasia (BASA)

  10. Aphasia Diagnostic Profiles (ADP)

  11. Bilingual Aphasia Test (BAT)

Discovery Activity: Assessment Playground

  • Collaborate at tables to explore provided assessment

  • Complete the Aphasia Assessment Discovery Activity on D2L, focusing on Quick Aphasia Battery (QAB)

Case History Considerations

  • Important Information:

    • Age

    • Educational background and learning history

    • Occupational history

    • Cultural-Linguistic background

    • Handedness; familial handedness

    • Nature and duration of present illness

    • Lesion localization information: scans, motor signs, sensory signs, etc.

    • Prior treatment history

    • Additional relevant data

Techniques to Promote Patient Engagement in Assessment

  • Quote from Tierney-Hendricks et al., 2023:
    “A good guide engaged the traveler by being a friend and creating a partnership with the traveler on the journey.”

Supported Conversation for Adults with Aphasia (SCA)

  • Based on the works of Kagan (1999) and colleagues

  • Aim: Training communication partners to support PWA in conversation

  • SCA facilitates the access of PWA who “know more than they can say”

SCA as an Integral Part of SLP Intervention

  • Conversation as ‘Currency’ for Participation

  • Role of Communication Specialists and Equity Advocates

Principles of SCA

  • Acknowledge:

    • Competence • Choose adult, complex topics • Use natural tone of voice and loudness • Acknowledge shared frustration • Use affirming statements (e.g., “I know that you know”) • Attribute breakdowns to the communicator's limitations, not the PWA • Integrate supports into natural conversation

  • Reveal:

    • Competence in Comprehension • Eliminate distractions; use simple sentences, gestures, and visual aids

    • Competence in Expression • Use yes-no and fixed choice questions, logical sequencing, offer response methods, and provide times for responses

Example Supports for SCA Principles

  1. Acknowledge:

    • Write scales on paper as a tool for engagement.

  2. Reveal:

    • Request clients to draw their information to facilitate conversation.

  3. Verify:

    • Summarize messages accurately; utilize gestures or written keywords when summarizing for clarity.

Tips for Success in SCA

  • Wait moments for responses when in doubt

  • Use only essential techniques

  • Accept breakdowns as part of the process

  • Be patient in forming questions/comments

  • Keep a pen and paper handy for visual support

Areas of Assessment

  • Clinicians should aim to evaluate four primary areas:

    1. Expressive Language

    2. Receptive Language

    3. Spoken Modality

    4. Written Modality

Parameters for Assessment Tasks

  • Consider Difficulty Levels: within each domain

  • Inputs and Stimuli: used during assessment

  • Output Domain and Level: expected from assessments

Auditory Comprehension Levels

  • Input/Stimuli Types:

    • Conversation: Verbal (asking relevant yes/no questions)

    • Word Comprehension: Verbal + Visual (directing to match pictures)

    • Following Directions: Verbal + Visual (one-step, two-step commands)

    • Syntactic Processing: Verbal + Visual (pointing to picture that matches sentences)

    • Narratives: Verbal (narrative length followed by yes/no questions)

Expressive Language Level

  • Input/Stimuli Types:

    • Conversational: Social Greetings or Open-Ended Questions

    • Repetition: Verbal (repeat words/phrases/sentences)

    • Confrontation Naming: Verbal + Visual interaction

    • Generative Naming: Verbal responses to prompts within a time frame

    • Narrative/Expository Language: Verbal responses associated with visual prompts

Limitations of Standardized Assessments

  • Standardized tests have limitations that can impact the accuracy of diagnosis and treatment planning.

The Process Approach

  • Definition:

    • The clinician must probe, explore, and record patient responses across various stimuli and task parameters. (Ashendorf et al., 2013)

Practical Terms of the Process Approach

  • Recording Techniques:

    • Notes on PWA responses regardless of target response

    • Observations of simultaneous behaviors during tasks

    • Successful communication strategies during evaluation

Learning Activity – Process Approach

  • Resources Needed: Process Approach worksheet

  • Roles: Transcriber for PWA’s verbal response, Observer for behaviors

  • Discussion: Prepare to share observations in group discussions

  • Assignment: Reflection based on learning activity (graded)

Written Expression Levels

  • Writing Personal Information: Written prompt on basic personal details

  • Writing Automatics: Writing needed alphabets/numbers consecutively

  • Dictation Writing: Writing specified words, sentences ranging from regular to complex forms

  • Copying Tasks: Reproducing sentences and words

  • Written Language Formulation: Creating narratives based on visual prompts

Non-Verbal Cognition Assessment

  • NVC: Non-linguistic cognition

  • Importance: NVC impacts communication skills and relates to therapeutic response.

  • Recommendation: Cognitive Linguistic Quick Test–Plus (CLQT+) and Ravens Coloured Progressive Matrices (RCPM) as valid assessments

Cognitive Domains Assessed with CLQT+

  • Domains include Attention, Memory, Language, Executive Functions, and Visuospatial Skills

Knowledge Check Questions

  • What are the 4 areas of language tested in an aphasia assessment?

  • Why is a picture description task vital in aphasia assessments?

  • Describe the role of cognitive evaluations in PWA assessments and name one common cognitive-linguistic assessment used.

Aphasia of Speech Assessment

  • Tool: Apraxia Battery for Adults (ABA-2)

  • Includes tests for Diadochokinetic Rates, oral/apraxia assessments, and articulation characteristics

Interviews for Bilingual Clients

  • Utilize the Language Experience and Proficiency Questionnaire (LEAP-Q) to assess language exposure, proficiency level, and cultural identity

Considerations for Bilingual Assessment

  • Evaluate each language thoroughly using culturally appropriate tests for bilingual speakers

  • Consider the limitations of standardized tests when translated into other languages

Bilingual Aphasia Test (BAT)

  • Developed for evaluating multilingual proficiency with three key components: History, Systematic Assessment, and Translation Skills

  • Availability: Offered in 60 languages, though some limitations exist, such as lack of normative data and lengthy assessment duration

Other Assessments Available in Different Languages

  • Includes the Spanish version of various assessments such as the Western Aphasia Battery, the Cognitive Linguistic Quick Test, and others for comprehensive evaluation of bilingual patients