AHD Robilllard Shultz SLP Lecture Apr 15

8/11/2019 AHD Robilllard Shultz SLP Lecture Apr 15

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Copyright Judith Robillard Shultz20091

Aphasia Classification and Assessment

Judith Robillard Shultz MSc. SLP(C)Speech-Language PathologistMGH-MUHC


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Purpose of Assessment

Determine if aphasia is present or absentDistinguish it from other related conditions

Motor speech disordersCognitive-communication disorders


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Lecture goals

Components of communication andnormal language processingSyndromes of aphasia

Features of related conditionsCommon assessment tools, diagnosticallyrelevant tasksHow to communicate with an aphasicpatient


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Definition of Aphasia

Disturbance of language caused by braindamage affecting:Comprehension

auditoryreading

Expressionspeakingwriting


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Important Distinctions

LanguageVocabulary, grammar..

SpeechMovement tongue, lips.

Cognition Attention, memory, problem solving.


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Theoretical Basis for Classification of Aphasia:

Boston Classification(Kertesz & Poole; Goodglass & Kaplan)

A contemporary localizationist viewLanguage localizable in the brain

Perisylvian region in the left hemisphereanterior language zone = left frontal lobeposterior language zone = lefttemporal/parietal lobes


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Boston Classification

Consists of cortical centers and connectingpathways Aphasia Syndromes

Broca, Wernicke, GlobalConduction, TC Motor, TC Sensory, Mixed TC

AnomicSupplied by left MCA

Anterior and posterior branches, main trunk


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How the Brain PerformsLanguage

Comprehension of LanguageHow is it accomplished?


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Comprehension of SpeechEars

Auditory Cortices

Wernickes areaConstructs an overall meaning

Assigns meaning to words/relation among words

Evaluates the context (literal vs figurativemeaning)


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Reading ComprehensionEyesVisual CorticesWernickes area


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Spontaneous Spoken Language?


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Spontaneous Spoken LanguageWernickes area retrieves words, sentencestructure

Sends it to Brocas area via the ArcuateFasciculusBroca formulates an action planSends plan to primary motor cortexPrimary motor cortex refines it and sends to thecranial nerves for speech muscles via thepyramidal system


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What single language task tests the entirecircuit?


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Repetition (tests the entire language circuit)Primary auditory cortexWernickeBroca via the AFBroca recodes into articulatory plan

Primary motor cortexPyramidal system to CNs


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Oral ReadingVisual Cortex to Wernicke and the sameprocesses as for repetition follows

WritingWernicke via AF to premotor cortex for

arm and hand, movement planned, sent tomotor cortex


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Boston Classification: KeyDiagnostic Distinctions

Fluent vs Nonfluent AphasiaSpeech fluency

Prosody, melody, rate, pauses

Subtypes further distinguished by:Repetition

Language ComprehensionParaphasia


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Boston Classification: KeyDiagnostic Distinctions

ParaphasiaLiteral/phonemic = shooshbruss/ toothbrush;tevilision/television

Verbal/semantic = table for chair, cranberryfor teapotNeologism = chantlast/refrigerator

Perseverative = comb, fork/toothbrush,comb/key


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Boston Classification: FluencyDimension

Nonfluent AphasiaLesions to anterior portion of language centerof dominant hemisphere

Slow, effortful, pauses, disturbed prosodyFluent AphasiaLesions to posterior language center of

dominant hemisphereEffortless with normal/fast rate, goodintonation and stress patterns


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Nonfluent aphasias: subtypes

Brocas aphasiaComprehension

Relatively preserved, some difficulty with complex syntaxReading comprehension relatively spared

ExpressionSlow & effortful productionLimited word outputFour words or less per utteranceFrequent perseverations

AgrammaticWriting usually parallels oral expression

Repetitionpoor


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1 2 3 4 5 6 7artic agility _________________________________________________________________________

unable sometimes clumsy never impaired

phrase length _________________________________________________________________________ 1 word 4 words 7 words

grammatical form _________________________________________________________________________ no syntactic word groupings simplified/incomplete normal range

melodic line _________________________________________________________________________ word by word limited to short phrases normal

paraphasias _________________________________________________________________________ present in every utterance 1-2 instances per minute absent

word finding __________________________________________________________________________ fluent but empty information prop to fluency primarily cont words

sentence repetition __________________________________________________________________________ 0-20 30 40 50 60 70-80 90-100

auditory comprehension ___________________________________________________________________________

0-20 30 40 50 60 70-80 90-100

Brocas Aphasia Rating Scale Profile of SpeechCharacteristics Boston Diagnostic Aphasia Examination


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Transcripts: Cookie TheftBrocas Aphasia

Water dripping. Boy. GirlOkay. Okay. MotherMother(Clinician prompt..Whats going

on?) No.


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Assessment severe non-fluentaphasia

48 year old maleReceived tPAInfarct = left frontal inferior and medial gyri andtemporal-parietal operculumYes/no only speech output

Accurate yes/no responses to personallyrelevant questionsGesturing to express himself Right arm weakness


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Nonfluent Aphasias

Global AphasiaSevere language deficits in all modalitiesResponds to personally relevant language

Responds to nonverbal cues Automatic speech may be preservedVerbal stereotypes commonExtensive (L) hemisphere lesion involvingBrocas and Wernickes area


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Neurophysiology of brain damage

and the neurological exam 16


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Nonfluent aphasia

Transcortical Aphasias (TCM nonfluent;TCS fluent)Preserved repetitionSpare central language areas,disconnects from rest of brain

Watershed, borderzones


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Nonfluent aphasiaTranscortical Motor:

Lesion= anterior and superior to Brocas areaReduced speech output, good auditorycomprehension, striking ability to repeat

Reduced speech outputFrontal lobe dysfunction (initiation, maintenance)Brief answers when highly structured (e.g., tell methe name of the hospital vs. tell me what you thinkof the hospital)Pathological inertia


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Fluent AphasiasWernickes aphasia

Comprehension (auditory & reading) impairedOral Expression:

fluent, well-articulated, good prosodyrapid rateincessant (logorrhea, press of speech)verbal and literal paraphasiasneologismsempty speech

paragrammaticRepetition poor Lack of awarenessLesion site: temporo-parietal region involving Wernickes

area and adjacent white matter


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1 2 3 4 5 6 7artic agility _________________________________________________________________________ unable sometimes clumsy never impaired








0-20 30 40 50 60 70-80 90-100

Wernickes Aphasia BDAE


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Thats on fairble my own Clinician: yes your family


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That s on fairble my own. Clinician: yes, your family .Stuck at that feek already.. On the fff..starting to

goof uf already. Clinician: ok, do you have a largefamily? Do you have a big family? No, yes welltheres 3, 4-4 all told but we only see masically onceof a time at home and 2 of them occasionally athome..the other 3 rd well hes always away at ff foambut masically on on the boys always failinghesliving at home and belonging to the future show.

Clinician: There not all at home all at once? Justone at home all the time, he goes to goes toschool? ..its a high school , its like a hymn schoollike I dont know what you call itfffforgetting andKathys shes a married man and has a daughter athome.. a new daughter.. The other girl is seeing herboyfriend but going give a poy part with her parents.

And what does your wife do?


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Fluent aphasias

Conduction aphasiaRepetitiondisproportionately severeworsens with length of stimuli

Comprehension: relatively goodExpression:

word finding errors and produce literal/phonemicparaphasiasconduite dapproche (lumpily, lutikly)


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Fluent aphasias

Awareness:Self correction, disturbed prosody

Lesion site: Arcuate fasciculusDisconnects Wernickes area from Brocas area


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1 2 3 4 5 6 7artic agility _________________________________________________________________________ unable sometimes clumsy never impaired








0-20 30 40 50 60 70-80 90-100

Conduction Aphasia


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Cest la cuisine.uh cest la cuisine.. uh..lvier uh

qui avec leau okleau, teau puis elle lalan.lela lanche..lanche..ok..elle essuie les fisisse essuieles siesse avecokavec.puisuhouiok.okok..nonok.non il y a dautre choseuh.. il y a dautrechose la..il y a leau qui le vayeau, qui le plancher bon ok cest le garf, le garf et la feuille, la fillette, puisla elle est, elle tambor, le tam, le tambourin, letambourin le tambourin va va banche, va bancher entout cas..cest effrayant!.cest effrayant! Oui legaron, ben la, lui aussi il veut il veut ga gatter gatter les gteaux uh.. puis cest a.

Abricot


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Abricot

Escalier ChampignonHlicoptre

HippopotameTchcoslovaquieRfrigrateur Vous savez bienIl tombe par terre

Les cls sont jetesJe vais au travailNe lui dites pas


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Fluent aphasias

Anomic aphasiaComprehension: goodExpression:

Word finding problemsEmptyFew substantivesCircumlocutions

Repetition: good Awareness of deficits


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1 2 3 4 5 6 7artic agility _________________________________________________________________________



grammatical form _________________________________________________________________________

no syntactic word groupings simplified/incomplete normal range






0-20 30 40 50 60 70-80 90-100

Anomic Aphasia


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Fluent aphasias

Transcortical SensoryLesion in the watershed area of junction PCAand MCA territory of the hemisphereSpares Wernickes area but isolates it fromrest of brainResemble severe Wernickes aphasia butwith preserved repetitionRepetition characterized by echolalia repeats without understanding


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Mixed transcortical aphasia

Some consider fluent; some non-fluentSimilar to global but repetition better Multiple lesions in anterior and posteriorborder zones


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Subcortical aphasias

May cause language disturbancesbecause alter the physiology of theoverlying cortex and not due to subcortical

structures per seResearchers divide into thalamic and non-thalamic


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Alexia with Agraphia

Lesion = angular gyrusSurface and deep alexia/agraphiaIf speech affected = anomic aphasiaMay be accompanied by non-languageparietal lobe signs (calculation, clock

setting, finger id, r-l discrim)

Pure Alexia (pure word blindness;


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Pure Alexia (pure word blindness;

alexia without agraphia)Writes but cannot read (words, letters)Usually hemianopic in the right visual fieldTwo critical lesions

Lesion destroys visual cortex of lefthemisphere and damages splenium of thecorpus callosum

Wernickes area is intact but isolated fromvisual input from both hemispheres


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Pure Agraphia

Severe disorder of writing with little or noinvolvement of readingDamage to the left angular gyrus

Limitations of Classical


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Limitations of Classical

Explanations of AphasiaDamage confined to Brocas Area orWernickes area does not produce chronicaphasia

Aphasia from damage deep in the brainSyndromes better for groups thanindividuals

Center for reading the AG? At best only 50% can be classified


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Contemporary Theoretical


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Contemporary Theoretical

Orientations

Cognitive NeuropsychologyModel normal cognitive processing Analyze performance of brain damaged

against normal modelLess concerned with localizationError analysis

Single case studies

Reading


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Reading

Figure 25-1. Schematic representation of the component representations and processes for single-word reading and writing.

The solid lines depict lexical-semantic routes and the dashed lines indicate sublexical routes.


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Differential DiagnosisMotor Speech Disorders:

DysarthriasWeakness/paralysis, incoordination, rigidity,involuntary movementConsistent errors

Apraxia of SpeechMotor planning problem

Absence of weakness etcInitiation, groping, revisions, inconsistent


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Case Example

He said I'd never bake again


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Apraxia of Speech


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Language of Confusion

Not a primary disorder of languageIrrelevant, confabulated contentNot usually focal brain damageIn confusion, language is better than theability to communicate

In aphasia, language is worse than theability to communicate


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Differential Diagnosis

Cognitive-Communication Disorders:Right Hemisphere Deficits

He can talk but hes not the same person


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Wab004.jpg


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1 2 3 4 5 6 7artic agility _________________________________________________________________________



grammatical form _________________________________________________________________________

no syntactic word groupings simplified/incomplete normal range






0-20 30 40 50 60 70-80 90-100

Brocas Aphasia Rating Scale Profile of SpeechCharacteristics Boston Diagnostic Aphasia Examination


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Getting Your Message Across


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Adapted from: Simmons-Mackie, 2001; Brookshire, 1993; The Aphasia Institute(http://www.aphasia.ca/training/tips.html)

Modify Your Speech:One idea at a timePause between ideasSimple sentencesMain ideas

State your point directlyUse tone of voice/emphasis to highlight key pointsUse alerting strategies (persons name, touch)Key information at end

Signal new topic (Lets talk about.)Signal end of topic (Thats the end of that)Be redundant (Mary, your sister)


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Getting your message acrossRepeat, rephrase, verify, summarize

Avoid pronouns (Jim vs. he)Supplement Speech:

Gestures/pantomime/facial expressionWrite down key words, draw as you talkUse pictures, magazines, photos as props

Make use of the surroundings (talk about apicture/photo in the room)


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Copyright Judith Robillard Shultz

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Encourage writing or drawingEncourage pointingIdentify general topic first, then details

Ask yes/no questionsUse a written yes/noIf you dont have time, say when you will return

Encourage the person to use your written words

To Help the Aphasic Person Get Messages Across


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Questions about aphasia An aphasic patient who cant answer questions about

person, place and time is disoriented An aphasic patient who is having difficulty speaking hasan expressive aphasiaIf an aphasic patient does not respond to a question orfollow instructions, it is because he/she does notunderstand

An aphasic patient who laughs and smiles at the righttime during a conversation understands everything

An aphasic patient should be able to benefit from analphabet or picture board


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AHD Robilllard Shultz SLP Lecture Apr 15

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