Assessment in Acquired Language Impairment - Aphasia

Why do we assess?/ Expected Outcomes of Assessment

  • Assessments are conducted to identify and describe several factors associated with communication impairments, in alignment with the World Health Organization (WHO) framework, including:

    • Impairments in body structure and function:

    • Identifying strengths and weaknesses in expressive and receptive language that affect communication performance.

    • Comorbid deficits:

    • Accounting for other health conditions and medications that can affect communication performance.

    • Activity and participation changes:

    • Understanding impact on functional status in communication and interpersonal interactions. How is it changing and how is communication impacting that. Who else is it affecting- communication partners. Home, places of work or social circle.

    • Environmental and personal factors:

    • Identifying barriers to or facilitators of successful communication and life participation.

    • Quality of life impacts:

    • Evaluating functional limitations relative to the individual’s premorbid social roles and the overall impact on the community.

    • Check progress

    • Inform MDT

    • Information gathering- detective working

    • Can feel vulnerable as you may be in a position where you’re not sure where to go from there.

    • Identify what they used to do as work- forms their identity.

When do we assess?

  • The assessment should allow for:

    • Establishing a diagnosis: Understanding the specific nature of the aphasia.

    • Seeking input from the Person with Aphasia (PwA) and their family regarding assessment and rehabilitation goals. Feeds in to goal setting.

    • Supporting initial communication interactions with the PwA. Initial communications. Facilitators and barriers in communication. Allows some ideas of how to provide goal setting for the patient (before tackling the impairment).

    • Providing accurate descriptions of the individual’s current strengths and weaknesses to family and healthcare team members. Education session first- explanation of what has happened with the families. Where the stroke is and why it has happened. What does it mean to them and why has it happened?

    • Describing and understanding all components of language functioning as well as related functions that may positively or negatively influence language (e.g., cognitive and emotional status). This understanding is crucial in helping families cope with the changes they face and aids in tailoring rehabilitation strategies that address both the linguistic and psychosocial effects of aphasia. Impairment and functions. Looking at the wider elements. Cognitive and emotional factors (guessing by the end of the assessments). Contextual information from assessments alongside assessment results.

    • Gathering background information about the individual with aphasia and their family to inform assessment.

When do we assess?

  • Assessment is typically advised during various stages of the clinical management process, whenever immediate insights into a patient's communication abilities and needs are required.

  • Ongoing assessment can occur throughout the episode of care - informally.

  • Intervention can also inform the assessment- see if there is an impact. Testing a compensatory strategy e.g. phonemic cue to see when/ if it works?

  • Particular targets in stroke- have to be assessed within 72 hours of post-stroke. National clinical stroke guidelines- SSNAP. Needs a SLT screening. Difference: Screening- anyone can do this. Tests to see if they are within normal limits or need more input e.g. Frenchay. Something going on with their communication, hard to know if it language, cognition, vision etc. May get an over referral depending on the screening that they’ve used so lots of things can impact this. Be mindful who has done it and if they are monolingual or multilingual, as this can significantly influence the test outcomes and the subsequent interpretation of the results. Assessment- more of a diagnosis.

Considerations for Assessment

  • Factors to consider during assessment include:

    • Language(s) & dialect(s) used- what/ when do they use a certain language. How our language will affect an assessment. How we go about the assessment after that.

    • Concurrent motor speech impairment- can happen concurrently (dysphagia and motor speech impairment). Testing modality is important to test if it motor speech or aphasia?

    • Limb/oral apraxia- e.g. pointing and expected from a patient to do so. If is understanding or an inability to do so. Keeping in touch with the OT. Adapting assessments with that.

    • Hearing status: pre-morbid and present changes

    • Concurrent cognitive impairment- big in aphasia. Difficult to determine.

    • Visual Acuity Deficits, Visual Agnosia (can have without a stroke, face blindness and can’t recognize someone’s face, object agnosia), no damage to the optic nerve. Visual field impairments: Can occur on different sides, pre-morbid and present changes. Can come with awareness or non-awareness.

    • Hemiparesis- a common motor impairment following a stroke, characterized by weakness on one side of the body, which can significantly impact functional communication and daily activities. Pointing and writing. Can be useful to know with strategies- taking that into account and the emotion associated with it. Feeling can also be impacted, temperature and touch, awareness of the arm is in a certain place (need support with this). Being aware of the whole person and looking at every area.

    • Pain (chronic or new)- sensory impairment- can process sensory input as pain.

    • Endurance & Fatigue- can be tempting to possibly push someone too much, especially if they look that they are doing well. Body needs to so a lot of work and the impact of this.

    • Pre-morbid abilities

    • Mental health status, such as anxiety- increases to 50% post stroke.

    • Input from other professionals- how we work with other people. Assess the early days by going in with OT or physio etc. Can see in other real life contexts.

    • Getting to know the person. Person centered consideration.

Formal vs Informal Assessment Procedures

  • Formal Assessments:

    • Typically published tools, many being norm-referenced or standardized.

    • Highly controlled with detailed administration procedures. Evidence based and looked at a population.

    • Can also use formal assessments/ subtests informally but you give more of a qualitative analysis of it.

  • Informal Assessments:

    • Include all strategies a Speech-Language Therapist (SLT) employs to translate symptomatology into clinically useful information.

    • Generally based on a hypothesis question (e.g., "Does phonemic cueing help Mrs. Jones?").

    • Observation. Turn it to clinical information. The “so what” so give a clinical hypothesis.

    • Can use both- but you need to be able to justify it.

Psychometric Properties

Key Concepts in Psychometrics

  • Standardisation:

    • Ensuring assessments are systematically applied.

  • Norm-Referenced:

    • Tools compared against a larger population.

  • Criterion-Referenced:

    • Tools compared against a specific standard or criterion. More paediatrics. Ticked off against something.

  • Reliability:

    • Consistency of results across different administrations. Repeated consistent results. Have done it the same with each person the same. Test/re-test in weeks so they don’t get used to doing the same test.

  • Validity:

    • The degree to which an assessment measures what it claims to measure. Construct validity- degree to how they are testing similar things e.g. CAT and the aphasia battery.

    • Ecological validity- functional tasks.

Observation Techniques

  • Types of observation:

    • Analog Tasks e.g. communication partner training. More set up activities.

    • Naturalistic Observation- see them in their everyday setting. Works best when they don’t know they are being observed, more for mealtime observations.

    • Systematic Observation & Contextual Analysis- more comprehensive and looking at it across different scenarios and contexts. Transcripts of the communication partner training and in depth analysis of this in connected speech.

    • Have a think about what you are looking for when you are observing.

Assessing the Biopsychosocial Factors

  • Implementing A-FROM (Aphasia Framework for Outcome Measurement) to evaluate multiple aspects including:

    • Participation in Life Situations

    • Communication and Language Environment

    • Living with Aphasia

    • Personal, Identity, Attitudes and Feelings

    • Language and Related Impairments

    • Understanding factors that act as barriers and facilitators to participation.

Assessing Body Function and Structure

  • Aphasia Batteries:

    • Various tests designed to evaluate specific linguistic skills, including:

    • Discourse analysis- in depth connected/ conversation speech and picking on patterns. Linguistic skills.

    • Tests of cognitive skills- if there are specific concerns.

    • Norm referenced

    • Can split it it to different sessions. Only if they can cope with this.

    • Can go to the PALPA to look where to further test.

    • Pyramids and palm trees- low level test. Testing semantic associations that doesn’t reply on verbal output.

    • CAT, Boston Naming Test, sentence production tests

Assessing Activity / Participation

  • Possible Assessment Methods:

    • Analog/Naturalistic Observation- seeing them in the context they exist. How are they perceiving how they are managing.

    • Rating Scales

    • Some Test Batteries- CADL - Communication and activity in daily living. Managing in specific situations. Can be seen as more of an impairment based.

Assessing Environmental & Personal Factors

  • Key assessment considerations include:

    • Information from caregivers, family, and communication partners (Environmental)

    • Utilization of rating scales and naturalistic observation (Environmental). Are they able to access that information, making the communication accessible. Need to assess that, especially if they have global aphasia.

    • Assessing the environment’s impact on Quality of Life (QoL) measurements (Personal)

    • Addressing the needs for assessments to be communicatively accessible (Personal)

    • Caution regarding the use of proxy raters (Personal)

Formative Task

  • You will be provided with CAT (Comprehensive Aphasia Test) and AIQ (Aphasia Impact Questionnaire) data for your cases.

  • Required Actions:

    • Score and analyse the CAT data.

    • Summarize the assessment results from both CAT and AIQ, highlighting key findings.

    • Discuss the repercussions of aphasia in your summary.