8a. Neurologically Based Communication Disorders and Dysphagia -- APHASIA Flashcards
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Types of Neuropathologies/Brain Trauma (6)
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Aphasia AoS Dysarthrias Dementia Right hemisphere syndrome TBI
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Q
Aphasia: Foundational Concepts
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*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
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Q
Ischemic vs Hemorrhagic Strokes
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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)
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Q
Aphasia: Definition and Classification
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- 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
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Q
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]
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- Broca’s Aphasia
- Transcortical Motor Aphasia
- Mixed Transcortical Aphasia
- Global Aphasia
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Q
Broca’s Aphasia
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- 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
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Q
Broca’s Aphasia: General Characteristics
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- 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
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Q
Transcortical Motor Aphasia
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- 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
9
Q
Transcortical Motor Aphasia: General Characteristics
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- 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
10
Q
Mixed Transcortical Aphasia
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- 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
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Mixed Transcortical Aphasia: General Characteristics
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- 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
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Q
Global Aphasia
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- 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
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Global Aphasia: General Characteristics
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- 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
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Q
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]
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- Wernicke’s Aphasia
- Transcortical Sensory Aphasia
- Conduction Aphasia
- Anomic Aphasia
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Q
Wernicke’s Aphasia
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- 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
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Wernicke’s Aphasia: General Characteristics
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- 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
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Q
Transcortical Sensory Aphasia
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- 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
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Transcortical Sensory Aphasia: General Characteristics
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- 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
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Q
Conduction Aphasia
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- 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
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Q
Conduction Aphasia: General Characteristics
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- *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
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Q
Anomic Aphasia
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- 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
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Q
Anomic Aphasia: General Characteristics
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- *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
23
Q
SUBCORTICAL APHASIA
[Caused by lesions in the BG and surrounding structures and the thalamus]
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- 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
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Q
Subcortical aphasia caused by lesions in the BG and surrounding structures in the L hemisphere is characterized by:
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- 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
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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
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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
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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
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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
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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
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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
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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)
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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)
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Aphasia Treatment: Skill areas (5)
Generally involves the following skill areas: auditory comprehension, verbal expression (naming), verbal expression (expanded utterances), reading, and writing
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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
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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
