Aphasia Flashcards
what is aphasia
Aphasia is a communication disability due to an acquired impairment of language modalities caused by focal brain damage (Berg, 2022), usually damage to the left hemisphere as it is specialised for language processing in most right-handed people. Depending on the exact location and type of damage, the aphasia can affect different language domains, including oral, written, expressive and receptive language. The severity of the aphasia can vary depending on the extent of the damage. Aphasia can occur as a result of a traumatic brain injury, a stroke, a brain tumour, or some neurodegenerative diseases.
aphasia categorisation
Aphasia can be classified into different categories depending on the presenting symptoms and area of damage. Some of the categories include: Broca’s aphasia (also called non-fluent aphasia) which is characterised by slow, effortful and non-fluent speech; comprehension is usually intact; and Wernicke’s aphasia, which is characterised by fluent but grammatically incorrect, jargon-filled speech, these people usually have impaired comprehension and poor self-monitoring. These categories are anatomical. Another type of categorisation is symptom-based and includes Global aphasia, which affects all aspects of language production and comprehension; and Anomic aphasia, which is characterised by significant word-finding difficulties which result in long pauses and circumlocution.
use of aphasia categorisation
It is important to note, however, that these categories may have limited clinical usefulness, as many aphasia patients’ symptoms and presentations can change over time after the onset of the aphasia. Other people may not fit neatly into any of these categories. For this reason, assessment should not aim to place people into these categories. According to Marshall (2010), however, these classifications do have some uses. Firstly, by providing a broad descriptive characterisation that is understood by the wider clinical community, they allow for ease of transfer of care, additionally, classification may prove useful for exclusion and inclusion criteria for research.
assessment considerations
It is important for the clinician to keep in mind that the neurological disorder responsible for aphasia is likely to have other consequences which may interfere with treatment and recovery. These may sometimes obscure the assessment procedure, if the clinician is not aware of them, acting as confounding factors. Some examples include: sensory deficits, agnosias, neglect, motor impairments, medical conditions, post-stroke psycho behavioural disorders, and cognitive functions.
goals of assessment
The goal of assessment is to obtain information that will help you to plan a therapy approach (Ballard et al., 2002), and as such an assessment will have multiple aims. The first of these is assessing to diagnose. Because aphasia occurs as a result of brain damage, there are other disorders that it can present similarly to, or co-occur with such as dysarthria and apraxia of speech (AOS). Although they may appear to be similar, the three disorders are very different and require different interventions - and giving the incorrect kind could result in poorer outcomes for the patient. Therefore the first aim of assessment should be to reach a diagnosis. The second aim is to identify which areas of language the client has difficulties with, which will inform what needs to be addressed in therapy. Additionally, an assessment should show which areas of language are a strength for the client, which can then be built upon in therapy to help scaffold their difficulties. Finally, an assessment will allow the therapist to liaise with the client and their family to discover what their biggest concerns and goals are, and use this information to set intervention goals which are achievable, measurable and meaningful.
ICF
When assessing aphasia, it’s important to refer to the International Classification of Functioning, Disability, and Health (ICF) (WHO, 2013). This is a framework which views health through the biopsychosocial model of disability and thus is ideal for providing client-centred care. It includes biological, individual and social perspectives of health and acknowledges the complexities of their interactions. A language assessment should take all of its domains into account: it should examine any impairments to the client’s body structures and functions; as well as activity limitations, which are difficulties an individual may have in executing activities, for example being unable to order a coffee in a coffee shop; participation restrictions, - problems an individual may experience in involvement in life situations such as being unable to participate in work or hobbies. SLTs should also examine environmental factors which are the physical, social, and attitudinal environment in which people live and conduct their lives, and any facilitators or barriers that come along with them.
A-FROM
When assessing aphasia, it is important to view and treat the client holistically. This can be done by following the Aphasia Framework for Outcome Measurement (A-FROM) (Kagan et al., 2008). This is a framework which considers the nature of outcomes of aphasia. Similar to the framework provided by the ICF it guides the clinician to view the client holistically, taking into account their own environment and context. The A-FROM has four areas: language and related impairments; personal identity, attitudes and feelings; communication and language environment; and finally, participation in life situations. Any aphasia assessment should assess all four of these areas in some way.
case history
The first part of a language assessment should always be taking a case history to gather information. It’s important to remember that when conducting a case history interview with a client who has a communication disorder, the client themselves may not be able to answer many questions, and sometimes recounting the event which caused the communication disorder can be very distressing. In these cases the SLT should consult the medical chart, other members of the MDT, and with consent, family members wherever possible to make sure they get the information they need. In doing this, the SLT then only needs to ask the client the questions that nobody else can answer for them - namely their concerns about their communication and their goals for attending with the SLT. Some important aspects to inquire about in the case history include the client’s baseline speech and language function - it can be helpful to ask family members if they have any recordings of the client speaking before the onset of the communication difficulty, giving the SLT insight into what baseline was for that particular client. Other aspects to inquire about are baseline literacy - important for assessment and therapy; native language; lesion location - specifically because the left hemisphere is usually associated with communication; their hearing and vision; and any other neurological issues they are presenting with post-lesion. The case history should give the clinician some insight into all four of the areas described by the A-FROM.
formal assessment
The next step after a case history is to carry out a formal assessment. These are assessments which are standardised; the clinician administers the assessment in a predetermined manner and the client’s responses are recorded and scored according to a standardised scoring system. Their score is then converted into a standardised score which can be compared to normative data to evaluate whether the client’s language functions could be classed as aphasia. Formal assessments have advantages: they provide a significant amount of qualitative data which can then be used to inform an intervention plan and the score they provide can be used to reach a diagnosis. They are also useful for goal setting, report writing and providing objective evidence of change. However, it is important to remember that formal tests have disadvantages too: communication is context sensitive, and as formal assessments do not take this into account and therefore may not be a completely accurate reflection of the client’s abilities. It is for this reason that formal assessment tools should be used in conjunction with other assessment methods in order to gain the most accurate and complete information possible.
CAT
One formal assessment which is commonly used is the Comprehensive Aphasia Test (CAT) (Swinburn et al., 2004). This assessment is an in-depth analysis of language functioning. It contains a cognitive screening, a language battery and a disability questionnaire. The cognitive screening includes line bisection, semantic memory, word fluency, recognition memory, gesture object use, and arithmetic subtests. It allows the clinician to screen for any other cognitive or neurological deficits the client could have post-lesion. The language battery includes 5 receptive subtests (auditory and visual comprehension) and 16 expressive subtests (repetition, naming, reading and writing). The disability questionnaire assesses the impact communication deficits are having on the client’s well-being, activities and participation in daily life.
WAB
Another comprehensive assessment of aphasia is the Western Aphasia Battery (WAB) (Kertesz, 2006). It is standardised on adults between 18 and 89 years of age. It was designed to evaluate the major clinical aspects of language function. There are four language subtests - spontaneous speech, comprehension, repetition and naming. Additionally, it assesses reading, writing, calculation skills, and nonverbal skills such as drawing, block design and praxis. The scoring provides two main totals in addition to the subscale scores. These are the Aphasia Quotient (AQ) score and Cortical Quotient (CQ) score. AQ is a general measure of language ability and CQ is a general measure of cognitive ability. Scores rate severity as follows: 0-25 is very severe, 26-50 is severe, 51-75 is moderate, and 76–above is mild.
narrow focus assessment tools
In addition to comprehensive aphasia assessments, the SLT may also choose to administer formal assessments which assess only one aspect of language function. This can be due to the client identifying a specific aspect of language they have difficulties with during the case history assessment or because the comprehensive assessment demonstrated an aspect of language that requires further investigation. These narrow-focus assessments can assess naming, semantics, discourse and more.
boston naming test
One commonly used naming test is the Boston Naming Test (Goodglass et al., 2001), which assesses the client’s knowledge of nouns by asking them to identify pictures. Naming tests can be analysed to provide a significant amount of information about the client’s underlying language processing deficits. This is done by analysing their error patterns. For example, there are different types of semantic naming errors: coordinate errors - calling a chair a table, superordinate errors - calling a chair furniture, and associative errors - calling a car a tyre. Other error types include compensatory errors such as using gesture, drawing of circumlocution to get around saying the word; phonological errors which may either be whole word - calling a table a tablet - or just sound errors - calling a tablet a talet; jargon errors which is replacing a work with a nonsensical one. The SLT should notice any other behaviours such as latency and perseveration.
semantics
Another narrow-focus assessment is the assessment of semantics, which assesses the client’s ability to understand word meanings. One test for this is the Pyramids and Palm Trees test (Howard & Patterson, 1992). The purpose of this test is to assess semantic access using pictures and words. The assessments demonstrates the client’s ability to access semantic and conceptual information, it indicates whether the client has a central, modality impairment to semantic knowledge ie. whether the difficulty persists regardless of how the information is presented. It is useful because it can establish semantic processing deficits as a root cause for a client’s difficulty with naming.
sentence production
The next type of narrow-focus assessment is sentence production. Deficits in sentence production are commonly observed in people with aphasia, resulting in communication breakdowns. Some common sentence production deficits include limiter verb access, sentence construction difficulties, and impaired thematic and grammatical role assignment. One test which assesses this is the Verb and Sentence Test (VAST) (Bastiaanse et al., 2003). It assesses comprehension and production. The comprehension subtests include verbs as single words, sentence comprehension and grammaticality judgement. The production subtests include picture naming, filling in finite verbs and infinitives in sentences, sentence construction, sentence anagrams with pictures, sentence anagrams without pictures, and wh-question anagrams. The VAST is similar to aphasia batteries but is more focused on sentences. It is useful for consideration of different levels of sentence processing.
assessing connected speech
Another important aspect of assessment is assessing connected speech. This is because a client’s connected speech will reflect all underlying deficits in any of the speech and language domains (Vermeulen, Bastiaanse, & Van Wageningen, 1989), as well as giving a more accurate picture of the client’s overall language functioning than single word or sentence tests will. One way to assess connected speech is by using Linguistic Communication Measures (LCM). This is when the SLT analyses a picture description task such as “cookie theft” following certain parameters. These parameters include: total number of words, which is counting the total number of real words, word-like paraphasias, and neologisms that the client produces; number of content units: which is the number of pieces of information which correctly describe elements of the stimulus picture; number of correct words in content units; and number of correct bound grammatical morphemes in content units. Connected speech can also be assessed more informally to be tailored to specific therapeutic goals. These include: word count in specific number of minutes (with the aim of increasing or reducing); number of full grammatical sentences in X minutes; number of distracting pauses in 3 minute monologue; successful circumlocutions; reduced commenting on own difficulties/ swearing; number of content words: nouns/ verbs/ adjectives; and information content: e.g. time to convey key points in action picture description or composite picture description.
functioning test
In keeping with a holistic approach to assessment, it is important to assess the client’s level of functioning in everyday life. One test which assesses this is the Scenario Test (Hilari & Dipper, 2020). This test which is validated in the UK is a daily life communication measure for people with aphasia. It measures how a person with aphasia conveys everyday messages in any modality in an interactive setting. It presents six everyday scenarios and asks the client to adopt the role of a character who is faced with a communicative task. Scores can range from 0 to 54, with higher scores indicating better functional communication. The Scenario Test also elicits information on the type, and frequency of verbal communication, frequency and effectiveness of non-verbal communication (gesture, drawing, device), the flexibility in shifting the communicative mode, the quantity and type of help needed from the examiner, and the comprehension of the scenarios. One disadvantage of this test is that it requires the client to roleplay, which some clients will find difficult, silly or embarrassing as a result may choose not to participate. The main strength of the Scenario Test is that it captures all types of communication and how effective they are and it is thus suitable for people with severe aphasia, with no or very limited verbal language. This test covers assessment of the communication and language environment aspect of the A-FROM by assessing the client’s communication skills in a variety of contexts. It also covers assessment of the participation in life situations aspect of the framework by assessing the client’s ability to participate in six life situations: shopping, taking a taxi, visiting the doctor, a social visit, talking to the housekeeper, and in a restaurant.
QoL questionnaire
A final important aspect of an aphasia assessment is a quality of life questionnaire. These are important to carry out because they “give outcome measures that evaluate the impact of health on a person’s ability to lead a fulfilling life, and generally incorporate the individual’s perceptions of physical, mental/emotional, family, and social functioning” (Spaccavento et al., 2014). One such example is the Aphasia Impact Questionnaire-21 (Swinburg et al., 2023) which replaces the disability questionnaire in the most recent version of the Comprehensive Aphasia Test. Its subtests include communication, participation and well-being/emotional state. It uses a pictorial rating scale, the client is asked a series of questions and asked to pick the scale they most closely identify with. This is then scored as between 0 and 4 for each question, and entered into a summary score sheet, summed to give a domain total and an AIQ-21 total. This scale gives insight into multiple domains of the client’s life and the impact aphasia has on them, which in turn helps inform goal setting and allows the SLT and client to collaborate and choose an intervention plan that will be meaningful and functional for them. This final aspect of assessment covers the personal identity, attitudes and feelings aspect of the A-FROM, thus ensuring all aspects of the framework have been covered in assessment.
