8a. Neurologically Based Communication Disorders and Dysphagia -- APHASIA Flashcards
Types of Neuropathologies/Brain Trauma (6)
Aphasia AoS Dysarthrias Dementia Right hemisphere syndrome TBI
Aphasia: Foundational Concepts
*A neurologically based language disorder
(distinct from neurologically based speech disorders such as AoS and dysarthria)
*Caused by various types of neuropathologies (usually strokes aka cerebrovascular accidents (CVA)); More than 50% of people w/ strokes have aphasia
*Strokes may be ischemic or hemorrhagic
*Other causes of aphasia: brain trauma, intracranial tumors, and infections
Ischemic vs Hemorrhagic Strokes
Ischemic: caused by blocked or interrupted blood supply to brain caused by either thrombosis (blood blockage) or embolism (traveling clot)
Hemorrhagic: caused by bleeding in brain due to ruptured blood vessels; Ruptures may be intracerebral (w/in brain) or extracerebral (w/in meninges)
Aphasia: Definition and Classification
- Numerous definitions exist; Some are non-typological (suggest a single disorder) and others are typological (classify aphasia into types); Other definitions are based on cognitive functions
- General definition: A loss or impairment of language caused by a recent brain injury. Comprehension and expression of language, along with reading and writing, may be impaired
- Most contemporary experts classify aphasia into types: fluent, nonfluent, or subcortical
Types of NONFLUENT APHASIA (4)
[Characterized by limited, agrammatic, effortful, halting, and slow speech w/ impaired prosody; Generally caused by lesions in the anterior brain structures]
- Broca’s Aphasia
- Transcortical Motor Aphasia
- Mixed Transcortical Aphasia
- Global Aphasia
Broca’s Aphasia
- Caused by damage to Broca’s area (Brodmann’s area 44 and 45) in posterior inferior frontal gyrus of the L hemisphere of brain
- Broca’s area is supplied by the upper div. of the middle cerebral artery
- Damage to Broca’s area is not always necessary to produce this type of aphasia…
- Patients may have 1+ independent speech disorders (Aos, dysarthria)
- May have R-sided paralysis or paresis
- Some pts may be depressed or react emotionally when confronted w/ difficult assessment tasks
Broca’s Aphasia: General Characteristics
- Nonfluent, effortful, slow, halting, and uneven speech
- Limited word output; short phrases and sentences
- Misarticulated or distorted sounds
- Agrammatic or telegraphic speech
- Impaired repetition or words and sentences, esp. grammatical elements of a sentence
- Impaired naming, esp. confrontation naming
- Rarely normal but better auditory comprehension of spoken language vs production
- Diff. understanding syntactic structures
- Poor oral reading and comprehension of read material
- Writing problems (slow/laborious + sp. errors; possibly due to having to use nonpreferred L hand)
- Monotonous speech
Transcortical Motor Aphasia
- Caused by lesions in the anterior superior frontal lobe, often below/above Broca’s area, which is not affected
- The areas supplied by anterior cerebral artery and ant. branch of middle cerebral artery are affected in TMA
- Pts tend to exhibit such motor disorders as rigidity of upper extremities, absence or poverty of movement (akinesia), lowness of movement (bradykinesia), buccofacial apraxia, and weakness of legs
- Apathy, withdrawal, and little interest in comm. may be additional behavioral characteristics of some pts
Transcortical Motor Aphasia: General Characteristics
- Speechlessness
- Echolalia and perseveration
- Absent or reduced spontaneous speech
- Nonfluent, paraphasic, agrammatic, telegraphic speech
- *Intact repetition (distinguishing characteristic of TMA)
- Awareness of grammaticality
- Refusal to repeat nonsense syllables
- Unfinished sentences
- Limited word fluency
- Simple and imprecise syntactic structures
- Attempts to initiate speech w/ help of motor activities
- Usu. good comprehension of simple conversation
- Slow and difficult reading aloud
- Seriouly impaired writing
Mixed Transcortical Aphasia
- Somewhat rare variety of nonfluent aphasia
- Caused by lesions in the watershed area or the arterial border zone of the brain (between the areas supplied by the middle cerebral arteries and the anterior and posterior arteries)
- Varied neurologic symptoms are seen in pts; these may include: bilateral UMN paralysis (spastic paralysis that affects the volitional movements), weakness of all limbs (quadriparesis) and visusal field defects
Mixed Transcortical Aphasia: General Characteristics
- Limited spontaneous speech
- Automatic, unintentional and involuntary nature of comm.
- Severe echolalia
- Repetition of an examiner’s statement
- Severely impaired fluency
- Severely impaired auditory comprehension for even simple conversation
- Marked naming difficulty and neologism; impaired confrontation naming
- Mostly unimpaired automatic speech (e.g., reciting months in a year) if initiated and not interrupted
- Severely impaired reading, reading comprehension, and writing
Global Aphasia
- Most severe form of nonfluent aphasia
- Caused by extensive lesions affecting all language areas (the perisylvian region)
- Widespread destruction of fronto-temporoparietal regions of brain is common
- The more common sites of damage are supplied by the middle cerebral artery
- Verbal and nonverbal apraxia, although technically not part of aphasia, may be present
- Strong neurological symptoms, incl. R-sided paresis or paralysis, R-sided sensory loss, and neglect of L side of body may be observed in many pts
Global Aphasia: General Characteristics
- Profound impaired language skills and no significant profile of differential skills
- Greatly reduced fluency
- Expressions limited to a few words, exclamations, and serial utterances
- Impaired repetition
- Impaired naming
- Auditory comprehension limited to single words at best
- Perseveration (repetition of short utterances)
- Impaired reading and writing
Types of FLUENT APHASIA (4)
[Characterized by relatively intact fluency but generally less meaningful, or even meaningless, speech; Generally caused by lesions in the posterior brain structures]
- Wernicke’s Aphasia
- Transcortical Sensory Aphasia
- Conduction Aphasia
- Anomic Aphasia
Wernicke’s Aphasia
- Caused by lesions in Wernicke’s area (the posterior portion of the superior temporal gyrus in the L hemisphere of the brain)
- Wernicke’s area is supplied by the posterior branch of the left middle cerebral artery
- Pts may sound confused
- B/c of lack of insight into their lang. probs, pts are less frustrated w/ their failed attempts at comm.
- Pts may also be paranoid, homicidal, suicidal, and depressed; Therefore, they may be confused with psychiatric patients
- Pts are generally free from obvious neurological symptoms; Paresis and paralysis are uncommon
Wernicke’s Aphasia: General Characteristics
- Incessant, effortlessly produced, flowing speech with normal, or even abnormal, fluency (logorhea, or press of speech) with normal phrase length
- Rapid rate of speech w/ normal prosodic features and good articulation
- Intact grammatical structures
- Severe word-finding problems
- Paraphasic speech containing semantic and literal paraphasias, extra syllables in words, and creation of meaningless words (neologisms)
- Circumlocution (talking around words that can’t be recalled)
- Empty speech (freq. use of this, that, thing, stuff, etc)
- Poor auditory comprehension, esp. with b/g noise
- Impaired conversational turn-taking
- Impaired repetition skill
- Reading comprehension probs (word sounds/meaning)
- Writing probs (meaningless, misspellings, neologistic)
- Generally poor comm. in spite of fluent speech
Transcortical Sensory Aphasia
- Caused by lesions in the temporoparietal region of brain, esp. in posterior portion of middle temporal gyrus
- This region is supplied by the posterior branches of the left middle cerebral artery
- A hemiparesis associated w/ onset of TSA may disappear, leaving pt w/ no obvious neurologic impairment; Neglect of one side of body is common
- Pts w/ TSA sound similar to those with Wernicke’s BUT repetition is intact in pts with TSA
Transcortical Sensory Aphasia: General Characteristics
- Fluent speech w/ normal phrase length, good prosody, normal articulation, and appropriate grammar and syntax
- Paraphasic and empty speech
- Severe naming problems and accompanying pauses
- Good repetition but poor comprehension of repeated words
- Echolalia of grammatically incorrect forms, nonsense syllables and words from foreign langs (unlike TMA pts)
- Impaired auditory comprehension of spoken lang
- Difficulty in pointing, obeying commands, answering simple yes/no questions
- Normal automatic speech (E.g., counting)
- Tendency to sentences started by clinician
- Good reading (aloud) but poor comprehension
- Generally better oral reading vs other lang. skills
- Writing probs that parallel those in expressive speech
Conduction Aphasia
- Rare variety of fluent aphasia
- Caused by lesions in the region between Broca’s and Wernicke’s area, esp. in the supramarginal gyrus and the arcuate fasciculus
- Lesion sites of conduction aphasia are controversial, as is this aphasia type
- Symptoms are similar to those of Wernicke’s aphasia but a main difference is that pts with conduction aphasia have good to normal auditory comprehension
- While some pts may have no neurological symptoms, others may have paresis of the R side of face, limb, or oral apraxia and R sensory impairment; Pts may recover from most of these impairments
Conduction Aphasia: General Characteristics
- *Disproportionate impairment in repetition (a distinguishing characteristic)
- Variable speech fluency across pts; usu. less fluent than pts w/ Wernicke’s aphasia
- Paraphasic speech
- Marked word-finding problems, esp. for content words
- Empty speech b/c of omitted content words
- Efforts to correct speech errors (not always successful)
- Good syntax, prosody, and articulation
- Severe to mild naming problems
- Near-normal auditory comprehension
- Pointing to named stimulus>Confrontation naming
- Highly variable reading probs; better comprehension of silently read material
- Writing problems in most cases
- Buccofacial apraxia (difficulty performing buccofacial movements when requested) in most pts
Anomic Aphasia
- Controversial; May be caused by lesions in different regions of brain, incl. angular gyrus, the 2nd temporal gyrus, and juncture of temporoparietal lobes
- Anomic aphasia is a syndrome, whereas anomia is a naming difficulty (a symptom) common to most aphasias
- The distinguishing feature of anomic aphasia is that, generally, most language functions, except for naming, are relatively unimpaired
- A residual symptom may be a persistent naming probs in most pts who recover from any type of aphasia
Anomic Aphasia: General Characteristics
- *A most debilitating and pervasive word-finding difficulty, which is the distinguishing feature; however, pointing to named objects is unimpaired
- Generally fluent speech
- Normal syntax except for pauses (b/c word-finding?)
- Use of vague/non-specific words–> empty speech
- Verbal paraphasia (word substitutions)
- Circumlocution (beating around bush b/c lack of access to precise words)
- Good auditory comprehension of spoken lang
- Intact repetition
- Unimpaired articulation
- Normal oral reading and good reading comprehension
- Normal writing skills
SUBCORTICAL APHASIA
[Caused by lesions in the BG and surrounding structures and the thalamus]
- Aphasia is typically produced by cortical damage; however, aphasia due to subcortical injury has been reported in recent years
- Extensive subcortical damage, with possible involvement of the L cortical areas of the brain, may underlie this type of aphasia
- Lesions in the areas of the brain surrounding the BG and thalamus have been linked to subcortical aphasia
Subcortical aphasia caused by lesions in the BG and surrounding structures in the L hemisphere is characterized by:
- Fluent speech, which may incl. pauses and hesitations
- Intact repetition skills
- Normal aud. comprehension for routine conversation
- Articulation probs (similar to those in Broca’s aphasia)
- Prosodic problems
- Word-finding problems
- Semantic paraphasia in some cases
- Relatively preserved writing skills
- Limb apraxia if the lesions extend posteriorly to deep white matter in the parietal area
Subcortical aphasia caused by lesions or hemorrhages in the L thalamus is characterized by:
- Hemiplegia, hemisensory loss, R-visual field probs, and in some cases, coma
- Initial mutism, which may improve to paraphasic speech
- Severe naming problems
- Good auditory comprehension of simple material and poor comprehension of complex material
- Good repetition skills
- Impaired reading and writing skills
Aphasia in Bilingual Populations
- Patterns of recovery from aphasia vary; Some may recover both languages, some only one lang, and some only the dom. lang; Some pts may recover one lang first and the other after months; Some pts may lose the first recovered lang as they begin to recover the other lang
- Some pts may mix langs or automatically translate their/others utterances into one of their langs
- Clinicians should analyze individual patterns, not just known patterns, in person who are bilingual and have aphasia
Aphasia in L-Handed Individuals
- Little research due to limited incidence
- Of the 4% of the pop. that is L-handed, 1/2 have lang represented in L hemisphere (other 1/2 in R); In essence, only 2% have R-dominance for lang
- Symptom complex and recovery patterns of aphasia in L-handed individuals (either w/ R or L hemisphere damage) are comparable to those found in typical pts
Standardized Aphasia Tests: Screening Tests (6)
- Aphasia Language Performance Scale (ALPS)
- Sklar Aphasia Scale (SAS)
- Children’s Acquired Aphasia Screening Test (CAAST)
- Bedside Evaluation and Screening Test (BEST-2)
- Aphasia Screening Test (AST)
- Quick Assessment for Aphasia
Standardized Aphasia Tests: Diagnostic Tests (8)
- Boston Diagnostic Aphasia Examination (BDAE-3): Tries to classify aphasia into types
- Western Aphasia Battery (WAP): Tries to classify aphasia into types
- Minnesota Test for Differential Diagnosis of Aphasia (MTDDA): Evas 5 areas of performance/”disturbances”
- Neurosensory Center Comprehensive Examination for Aphasia (NCCEA)
- Multilingual Aphasia Examination (MAE): Comes in English, French, German, Italian, and Spanish
- Bilingual Aphasia Test (BAT): Evals skills in 40 langs
- Porch Index of Communicative Ability (PICA): Reqs intensive training to administer and score
- Aphasia Diagnostic Profiles (ADP): Evals overall severity w/ specific skills; Helps classify aphasia
Functional Assessment Tools (5)
[Targets daily communication skills in everyday settings]
- Functional Communication Profile (FCP): Evals 45 behaviors in 5 categories using 9 point rating scale
- Communicative Abilities in Daily Living (CADL-2)
- Communicative Effectiveness Index (CETI): Evals 4 domains of functional comm. skills incl. social needs, basic needs, life skills, and health threats
- ASHA Functional Assessment of Communication Skills for Adults (ASHA-FACS): Helps rate social comm.
- Amsterdam-Nijmegan Everyday Language Test (ANELT): 2 forms w/ 10 items each to assess pragmatic skills of daily life
Auditory Comprehension and Reading Tests (3 each)
[In addition to diagnostic aphasia tests, clinicians may use independent tests of specific skills such as auditory comprehension and reading]
Auditory Comprehension Tests: Token Test, Auditory Comprehension Test for Sentences (ACTS), and Functional Auditory Comprehension Task (FACT)
Reading Tests: Reading Comprehension Battery for Aphasia (RCBA-2), the Nelson Reading Skills Test (NRST), and the Gates-MacGinitie Reading Test (GMRT)
Outline of Aphasia Assessment
- Detailed case hx
- Orofacial exam
- Hearing Screening
- Assessment of the following (9) speech and language skills that affect diagnosis of aphasia:
1. repetition
2. naming (responsive, confrontation, word fluency)
3. auditory comprehension of spoken lang (hearing and visual eval; comprehension of commands)
4. comprehension of single words (single items and semantic groups of items; words that vary semantically/phonetically)
5. comprehension of sentences and paragraphs (stories)
6. reading (silent, oral; matching words w/ pics; completion of printed sentences)
7. writing (general, automatic, prepositional, confrontation, narrative, writing to dictation, graphomotor skills (letter formation))
8. gestures/pantomime (expression/comprehension)
9. automated speech and singing (recitation of ABC’s, days of week, months, #s; prayers, poems, nursery rhymes; humming in tune)
Aphasia Treatment: Skill areas (5)
Generally involves the following skill areas: auditory comprehension, verbal expression (naming), verbal expression (expanded utterances), reading, and writing
Alexia, Agraphia, and Agnosia
[All may be seen in patients with aphasia]
- Alexia: Loss of previously acquired READING skills due to recent brain damage (Dyslexia is difficulty in learning to read); Due to cortical damage
- Agraphia: Loss or impairment of normally acquired WRITING skills due to lesions in the foot of the second frontal gyrus of the brain (aka Exner’s writing area); Due to cortical damage
- Agnosia: Sensory disorder; impaired understanding of the meaning of certain stimuli even though there is no peripheral sensory impairment. Pts can see, feel, and hear stimuli but cannot understand their meaning; Impairment often limited to one sensory modality and meaning may be grasped in another modality; There are 4 forms of agnosia: Auditory, Auditory-verbal, Visual, and Tactile
Forms of Agnosia (4)
Auditory: Associated w/ bilateral damage to auditory association area; Characterized by impaired understanding of meaning of auditory stimuli, normal hearing, difficulty matching objects w/ their sound
Auditory-verbal (pure word deafness): Associated w/ bilateral temporal lobe lesions that isolate Wernicke’s area; Characterized by impaired understanding of spoken words and normal hearing
Visual (rare): Associated w/ bilateral occipital lobe damage or posterior parietal lobe damage; Characterized by impaired visual recognition of objects and normal auditory or tactile recognition of objects
Tactile: Associated w/ lesions in parietal lobe; Characterized by impaired tactile recognition of objects when visual feedback is blocked, impaired naming and describing of objects clients can feel in their hand
