Adult Language Disorders

Study Guide for Exam #1

• Differential Diagnosis

  • Differential Diagnosis: the process of discriminating a disease or condition from others that may resemble it

  • Explain what signs and symptoms are

    • Signs are characteristics that can be identified by a medical profession

    • Symptoms are characteristics that are identified by the patient

    • Signs and symptoms are not the same because one is identified by a medical professional while the other is identified by the patient.

    • How do you use these to aid in your differential diagnosis?

  • List and define the Seven Steps of the Clinical Method

    • Seven Steps of the clinical method

1. Gather information (history, chart review, interviews, examine the patient): getting information about the client

2. Evaluate the symptoms (subjective report) and signs (test results): see what they are experiencing and see if they spark any connections

3. Determine if data represents a syndrome: look to see if any of the information already gathered and what you have gathered points to a direct syndrome

4. Look for correlations among signs and symptoms to determine the underlying cause: look for connections to help narrow it down

5. If the patient fits a syndrome and we know the cause of the syndrome and potential outcomes, we then decide on a prognosis: start to develop a plan

6. Determine the effect of the syndrome on the patient’s life: how will it impact the person

7. Use all the above plus more to determine the effects of treatment and what treatment should be

• What might happen if you forget one of the steps?

The thing that might happen if a step is forgotten is not coming to the correct diagnosis or missing information that can help create a treatment plan for an individual.

• Be able to walk through each step and identify information you would need to come up with a differential diagnosis.

1. Gather information (history, chart review, interviews, examine the patient):

• Name, Age, PMHx, Diagnosis, where they are in the facility, reason for referral, prior level of functioning, independence, prior level of independence, site of lesion, cognitive status, impairments, precautions, emotional/social history, etc.

2. Evaluate the symptoms (subjective report) and signs (test results)

• lab results, patient reported symptoms, chronological story of care, progress notes from other professionals, vitals, etc.

3. Determine if data represents a syndrome

• Look at signs and symptoms, see if any possible conditions arise

  • Conduct assessments

4. Look for correlations among signs and symptoms to determine the underlying cause

• Narrow down based on results

  • Diagnostic label

5. If the patient fits a syndrome and we know the cause of the syndrome and potential outcomes, we then decide on a prognosis: start to develop a plan

• Prediction of course and outcome; affected by neurologic findings, associated conditions, patient characteristics

  • Wait until condition has stabilized

  • We discussed multiple sources of information to glean information about the patient during the collection of a case history and chart review. List them all and tell me the importance of each related to differential diagnosis.

    • Referral: who referred the patient, patient’s identity, the location of the patient, and reason for the referral

    • Demographics: patient’s age may indicate level of function and independence prior to referral

    • Medical diagnosis: nature and severity of impairments

    • Services requested: evaluation only, evaluation and treatment, incomplete orders

    • Medical record: patient identification, personal history, medical history- chief complaints, previous diagnoses, signs/symptoms, cognitive status, chronic medical conditions, past surgeries, impairments

Physical and Neurological exam: observation of appearance, mood, and orientation, physical exam results: vitals, overall function of body, cranial nerve function, results of labs and procedures

Physician’s orders: medications, precautions, diet, tests/procedures/standing orders, dietary needs/ restrictions, code status

• Progress Notes: various care providers, chronological story of care provided-physical, behavioral or mental status; admitting note-incident that brought them in; significant findings (ongoing, lab reports

  • Interviewing the client: first direct look at the patient’s physical, cognitive, and communicative abilities

  • Why do SLPs test neurogenic cognitive-communicative/language disorders? We discussed 7 reasons. Please be able to identify several reasons and provide an explanation of how assessment is relevant to each:

    • 7 Reasons why we assess

Detect presence of impairment

Diagnose impairment

Come to a prognosis for recovery

Determine nature and severity of impairment

Aid in the development of treatment plan

Measure progress (be careful!)

Measure treatment efficacy

• Prognosis- PREDICTION of the course and probable outcome of the disease/disorder

  • What are Prognosistic variables- list three:

Neurologic Findings

Associated Conditions

Patient Characteristics

• Efficacy- the existence of measurable change because of a treatment

  • SLP World: Did the person score higher on a standardized test?

  • Effectiveness- pertains to the effects of treatment on a patient's overall quality of life.

    • SLP World: Based on subjective reports of patients, family members, or observations of others

    • THINK: How can you be efficacious without being effective?

      • By not doing functional therapeutic tasks. They may be able to perform well on an assessment, but they may not be able to generalize this information elsewhere.

    • Explain how these would/could be the same or different for a given case.

      • If one is working on functional tasks that are based on areas of need identified by an assessment, the treatment could be seen as both efficacious and effective.

      • If one is not performing functional tasks, the treatment would be efficacious but not effective.

      • If one is engaging in palliative care measures, the treatment would be effective but not efficacious. The focus of palliative care is on increasing quality of life rather than progressing towards goals.

  • Impairment- structural abnormality (e.g.. brain injury) or functional abnormality (e.g. hemiplegia)

  • Disability- effects of an impairment (e.g aphasia and poor ambulation)

  • Handicap (participation)- effects of disability on one's ability to participate in daily life (e.g.employment, sports)

    • We talked in class about how labeling a patient’s cognitive communicative disorder serves the following purpose/purposes:

Suggests the location of the nervous system abnormality responsible for the patient’s symptoms

• It is a way to communicate substantial amounts of information about a patient in a few words

  • Attention is the ability to choose and concentrate on relevant stimuli. Attention is the cognitive process that makes it possible to position ourselves toward relevant stimuli and consequently respond to them. This cognitive ability is very important and is an essential function in our daily lives. Define the five types of attention we discussed:

    • Focused: the ability to respond to stimulation (responding to your name)

      • Example. If a light turns on you react

    • Sustained (vigilance): maintaining attention to task over time

      • Example. Reading a book

    • Selective: ability to attend to specific stimuli in the presence of competing stimuli

      • Example. Stroop test

    • Alternating: shifting from one stimulus to another due to changes in task requirements

      • Example. On the phone and then responding to a text message

    • Divided: attending to more than one thing as time

      • Example. Singing favorite song while driving

  • Memory: the process by which the mind stores information. Define the types of attention below and give an example of a functional task that would require each.

    • Immediate Memory (short-term memory or working memory)

The number of items of discrete information (e.g., numbers, letters, words) that can be held in immediate memory at one time (for average normal adults, this is 7 ± 2 units).

Provides temporary mental space

The information in immediate memory decays unless rehearsed, freeing space for new information

3 Parts:

• Phonologic Loop: phonologic memory traces

  • Visuospatial sketch pad: visual and spatial information

  • Central Executive: selects, begins, and ends cognitive processing operations and coordinates the other 2 subsystems; important for logical reasoning, mental calculation, comprehension

  • Long-Term Memory (secondary memory)

Very large, possibly infinite, capacity

Considered a static repository for knowledge acquired from schooling, books, movies, television, radio, and everyday experiences

Information in decays slowly, if at all

• Recent & Remote Memory: recent past (the past few hours to several months)

Cannot be separated in typical adults but may be affected differently in adults with a brain injury

Example: Adults with dementia struggle with things that happened recently but can recall events in detail from childhood

• Retrospective Memory: made up of…

Declarative Memory:

Episodic: facts about self and personal experiences

Semantic: facts about the world

Procedural Memory: remembering steps to routine behaviors; somewhat automatic; knowing how to do things

• Prospective Memory: past knowledge governs present behavior

Example: keeping appointments, feeding pets, etc.

• Define Executive Functioning and explain how we might be involved in evaluation and treatment of it.

  • Executive Functioning: incorporates aspects of attention, memory, planning, reasoning, and problem solving to organize and regulate purposeful behavior

Areas:

• Planning, organization, self-control, task initiation, time management, metacognition, working memory, attention, flexibility, perseverance, etc.

Involvement:

• SLPs are involved in assessment because they need to determine the nature and severity of a client’s deficits and how these deficits impact the client’s quality of life.

  • SLPs are involved in treatment to improve the client’s quality of life.

  • Language Assessment: List the components of a comprehensive assessment. Provide some examples of standardized and non-standardized was to test it.

    • Components of Comprehensive assessment:

Auditory Comprehension

• Standardized: Western Aphasia Battery or Boston Diagnostic Aphasia Examination

  • Non-Standardized: Ask the client a simple question.

Visual Comprehension:

• Standardized: Western Aphasia Battery or Boston Diagnostic Aphasia Examination

  • Non-Standardized: Provide images and ask client to point to a particular image

Expressive Language

• Standardized: Western Aphasia Battery or Boston Diagnostic Aphasia Examination

  • Non-Standardized: Ask client to tell you what they see in a photograph. (Obsereve client language when conducting interview).

Reading

• Standardized: Western Aphasia Battery or Boston Diagnostic Aphasia Examination

  • Non-Standardized: Ask client to read a short passage.

Receptive Language:

• Standardized:Western Aphasia Battery or Boston Diagnostic Aphasia Examination

  • Non-Standardized: Ask client to point to raise their hand.

Cognition:

• Standardized: Western Aphasia Battery or Boston Diagnostic Aphasia Examination

  • Non-Standardized: Ask client to remember a short series of numbers then repeat them back to you.

• Conceptual Framework for Therapy

  • The interdisciplinary team is important; they are your collaborators in care. The team membership depends on the needs of the patient. Team members could include: Neurologists, Recreational Therapists, Physiatrists, Neuropsychologists, Physical Therapists, Clinical Psychologists, Occupational Therapists, Psychiatrists, Vocational Therapists, Dieticians, Corrective Therapists, Social Workers.

    • Know role of PTs, OTs, Recreational Therapist, and Neurologists

PTs: muscle strength and range of motion for limbs

• Reteaching sitting, walking (aided and unaided), wheelchair mobility

  • Passive range of motion to those who are unable to move (prevents contractures)

OTs: ADLs (dressing and bathing) and I (instrumental) ADLs (grocery shopping) and upper body strength and mobility

Recreational Therapists: leisure activities

Neurologists: manage the overall care in some facilities

• Assess the nature, location, and severity of nervous system pathology

  • What is Resource Allocation: There is a limited amount of resources. A brain injury will affect executive functioning, putting limits on even more.

  • Explain Intensity and Salience

    • Intensity is the strength of the stimuli, leading to salience.

      • Example: If a client is performing well at providing 5 items within a more simplistic category, such as vegetables, the clinician may ask them to provide 10 cities instead. This creates a more difficult task to complete, increasing the intensity of the exercise.

    • Salience is the prominence of the stimuli, including the relationship of the stimuli to the environment.

      • Example: If the hallway is noisy and the clinician is attempting to work on auditory comprehension, the clinician may shut the door to block out the noise.

  • Explain Redundancy and Context. What happens when you do not consider these in your therapy planning?

    • Redundancy: information beyond what is needed to specify a target response under ideal conditions

Redundancy can be beneficial (repetition, paraphrasing, multimodal approach)

Adding some information can improve response

• Context: setting a situation that allows the encouragement of accuracy

Functional context improves accuracy in people with aphasia, but not necessarily those with a TBI or right hemisphere damage

• Types of Aphasia

  • Aphasia is a disorder that affects how you communicate. It can impact your speech, as well as the way you write and understand both spoken and written language (gestures).

  • How the brain performs language

    • This is a telephone effect, starts in one place ends in another, and if there is a breakdown then you will have trouble either understanding language or getting it out

    • A typical conversation includes

    • 

    • 1. Hearing sound coming from another person, that goes up the primary auditory cortex

    • 2. Sound is sent to wernicke’s area where it is synthesized

      • Where we apply rules of syntax, phonology, and break down the message and summarize what it is

      • Ex. determining the meaning behind the message and how you should respond

    • 3)Then the idea is shipped through the arcuate fasciculus to…

    • 4. Broca's area (where the action plan is created)....

      • How are you going to get the message out, (sentence level, one word, yell, whisper)

    • 5)Then send message all the way up the motor cortex and the motor cortex tells our speech muscles what to do to get it out effectively

• Etiology and Neuropathology of Aphasia

  • Define Ischemic and hemorrhagic Strokes: What happens to cause them?

    • Ischemic Stroke: Occlusion, clot blocking blood flow to an area of the brain

      • Reason for ischemic stroke is arteriolar sclerosis= thickening or hardening of the arterial walls

    • Hemorrhagic: Rupture, bleeding inside or around brain tissue

      • Typically happens as a result of an aneurysm= weakening of the vessel that balloons to the point of explosion

        • Aneurysm will happen between pia mater and arachnoid mater or intracerebral mater

  • Due to the interruption of blood flow to Middle cerebral artery:

    • Middle cerebral artery-> artery of aphasia because it feeds the region of the perisylvian gyrus known for language (includes Broca’s and Wernickes)

    • If the middle cerebral artery is impacted then so is the whole left side of our brain

  • Define all of the types of aphasia we have covered in class. Be able to identify type of aphasia based on site of lesion and commonly associate deficits.

    • Fluent Aphasia (posterior)- has an expressive output that is perceived by the listener as smooth and effortless, some show hyper-fluency vs.

    • Nonfluent Aphasia (anterior)-perceived by the listener as having difficulty with getting words out, there is a visible struggle

    • Broca’s Aphasia

Nonfluent, dysprosodic, agrammatical

Common in the presence of apraxia and dysarthria

Comprehension is better than expression

Demonstrate difficulty with syntax (comprehension)

Repetition is alway abnormal

Naming (confrontation) is poor

Reading (oral and comprehension are poor)

Writing is poor with many misspellings and letter omissions

Accompanied by right-sided hemiparesis

• Wernicke’s Aphasia

Fluent aphasia: posterior damage

Difficulty with written and spoken language comprehension

Difficulty in repetition

Paraphasias are present (verbal/semantic (word substitutions); Literal (phoneme substitutions); Neurologist-invented word))

Poor insight into deficits (lack of awareness of deficits)

typically , do not have limb weakness

• Conduction Aphasia

Damage to the arcuate fasciculus typically (but can also be the left temporal lobe in the auditory association area)

Poor in repetition tasks

Fluent speech: lateral paraphasia-phonemic errors (substitutions) are common

Word retrieval is affected

Poor spelling and writing

Silent reading/comprehension is spared

Oral reading results in increased paraphasia

May have right-sided weakness or sensory loss

• Global Aphasia

Associated with a large lesion in the perisylvian area

Receptive and expressive language is affected

May not be able to initiate speech (nonverbal)

Echolalic

• May have simple words (expletives are common)

  • May be able to sue inflection

Comprehension is typically better than expression

Cannot repeat

Naming, reading, and writing are severely impaired

May not be reversible with therapy

• Transcortical Aphasias

Site of lesion outside of the perisylvian area (responsible for language)

Damage to the association area

Ca repeat when all other aphasias have deficits in repetition

• Transcortical motor: non-fluent

Damage anterior or superior to Broca’s area

Serial speech, repetition, and comprehension are maintained

• Transcortical sensory: Fluent

Damage deep and posterior to Wernicke’s

Poor comprehension, reading, writing, and naming

• Transcortical Mixed: very rare

Severe expressive and receptive deficits with exception of repetition

• Anomic Aphasia

Called this when anomia is the most prominent symptom

Common inn most aphasias and dementia along with other medical conditions (encephalitis, subarachnoid hemorrhage, concussion, encephalopathy)

Expression is typically spared; however, disfluencies present with word-finding difficulties. Comprehension is typically spared as well

Often the only major language residual after recovery from aphasia of any clinical type and may remain a long-lasting problem in the recovered aphasic

May be the first sign of primary progressive aphasia

Reading and writing skills vary

• Subcortical Aphasia

Damage to the thalamus (sensory information relay station) or basal ganglia (responsible primary for motor control, as well as other roles such as motor learning, executive functions and behaviors, and emotions)

Thalamic damage yields: Hypophonia (low speaking volume), impaired comprehension, and intact repetition skills

Basal ganglia damage yields dysarthria, decreased fluency (longer phrase length than Broca’s aphasia), paraphasias

• Define the following Central Disturbances of Aphasia

  • Agnosia: sensory issue that prevents the ability to recognize (people, items, sounds, shapes, and smells)

  • Agraphia: an inability to write due to lesions of language areas or pathways

  • Apraxia: motor speech

  • Alexia: an inability to comprehend the written or printed word as the result of a cerebral lesion

  • Aphasic Alexia: difficulty reading due to the confounds of language disturbance

MOCK CASE STUDY

Walk me through the 7 steps of the clinical method for diagnosing a client with a specific type of aphasia. You should incorporate information gleaned from the following: referral, chart/medical record review, interviews, physical and neurological exam results from MD, progress notes, lab and radiology reports, and your assessments (name one you could use to comprehensively assess aphasia) to land on a diagnosis and prognosis. All you know at the time of referral is that the patient was referred 3 days post CVA, demonstrates moderate levels of alertness, and has, moderate decreased expression. Your answer should demonstrate knowledge of each step and identify the following: location of CVA, and type of aphasia**. (hint: the best way to answer this question would be to list the 7 steps and enter what type of information you get at each step. You will need to make up the information for some areas (create a case)**

Syndrome: Broca's Aphasia

Site of lesion: Brocas area

1. Pt has hx of UTIs and HTN. She has a medical history of depression and alcohol abuse. Through interviewing her husband, I found out that she was working part time as a neonatal intensive care unit (NICU) nurse and had an associates degree.

2. She was brought to the hospital because she was experiencing dizziness and numbness on the right side of her face. At the hospital, the Dr. noticed decreased alertness. The patient's husband reported the patient “had increased difficulty getting what she wanted to say out.”

3. She was assessed with the Western Aphasia Battery (WAB), which revealed she may have Broca’s Aphasia.

4. The CT scan showed that she had lesion on the anterior perisylvian region on the left hemisphere of her brain indicating Broca’s aphasia.

5. Due to having a moderate level of expressive language and her ability to maintain attention during tasks, the patient should be able to participate and make progress with expressive language skills in speech therapy.

6. The patient’s ability to return to work will be dependent on physical abilities, as well as any progress that is made towards other necessary therapeutic goals. She will most likely have difficulty expressing herself, and it is possible that her expression may never return to the level that it was prior to the CVA. This could impact both her occupationally and socially.

7. The speech therapist will provide therapeutic tasks to improve her expressive language tasks based on any identified areas of breakdown.