Adult Aphasia and Other Cognitive-Based Dysfunctions Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education,

Adult Aphasia and Other Adult Aphasia and Other Cognitive-Based Cognitive-Based

DysfunctionsDysfunctions

JusticeCommunication Sciences and Disorders: An Introduction

Copyright ©2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458

All rights reserved.

IntroductionIntroductionLanguage and cognitive disorders

associated with acquired neurological injury:◦Aphasia: difficulties in expressing, understanding, reading, or writing oral and written language

◦Right Hemisphere Damage: memory impairment, attention and impulsivity problems, and visual dysfunction

◦Traumatic Brain Injury: cognitive impairment caused by brain damage from injury

◦Dementia: loss of linguistic and cognitive ability due to a progressive brain disease

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I. What is Aphasia?I. What is Aphasia?Literally means “without language”Definition:

◦A disturbance in the adult language system after the language has been established or learned

◦Results from neurological injury to the language-dominant hemisphere of the brain

◦Includes disturbances of receptive and/or expressive abilities for both spoken and/or written language

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Aphasia examplesAphasia examples

http://www.youtube.com/watch?v=Bk13HLma2CIhttp://www.youtube.com/watch?v=Aq2hoMO_-b8

&feature=relatedhttp://www.youtube.com/watch?v=JJAniFqS-zQhttp://www.youtube.com/watch?v=ML9YYfvDozo

&feature=relatedhttp://www.youtube.com/watch?

v=5e3Nk1uMfE8&feature=relatedhttp://www.youtube.com/watch?

v=IEkEOQd05xA&feature=relatedhttp://www.youtube.com/watch?v=RfZJWy2AlfA

Additional ConsiderationsAdditional ConsiderationsAphasia is not developmental, it is

acquired following a neurological injuryA person with aphasia usually has intact

psychosocial skills; ◦Must be careful not to confuse language deficits

of an individual with aphasia for a more general psychological disturbance

Aphasia is a language-based dysfunction, not a motor-based dysfunction, although the two sometimes coexist (dysarthria + aphasia)

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II. How is Aphasia Classified?II. How is Aphasia Classified? Aphasia types should be grouped or

classified (taxonomy), but some debate over how to do this

http://www.youtube.com/watch?v=b2GHf6TS490&feature=related

1. Categorization by cause and location of the brain damage

2. Categorization based on the language characteristics

-fluent vs. non-fluent speech-receptive vs. expressive deficits-motor vs. sensory deficits

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Behavioral SymptomsBehavioral Symptoms

Most professionals classify aphasia types based on distinct behaviors:◦Fluency of expression◦Language comprehension◦Naming◦Repetition◦Additional considerations:

Motor output: Are the motor systems involved with speech affected? This indicates a coexisting motor-speech disorder

Reading and writing: To what extent is reading and writing affected? This usually reflects the overall impact of aphasia on language more generally

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FluencyFluencyExpression of thoughts using a smooth,

uninterrupted flow and rate of speechFluent aphasia: spontaneous speech flow

with adequate phrase length◦Generally reveals posterior brain damage

(temporal/parietal regions)Non-fluent aphasia: diminished phrase

length, slowed or labored speech production, grammatical errors◦Generally reveals anterior brain damage

(frontal lobe)

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Language ComprehensionLanguage ComprehensionAbility to understand spoken messagesInfluenced by:

◦Amount of information◦Frequency of word usage◦Personal relevance of information◦Part of speech

Based on this ability, aphasia can be classified as predominantly receptive or predominantly expressive

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RepetitionRepetitionAbility to accurately reproduce verbal

stimuliIn order to display this ability, one must:

◦Receive and process incoming stimulus◦Convey the information to regions of brain that

formulate and plan motor sequence for speech◦Articulate to reproduce the initial stimulus

Repetition skills can subcategorize a more general classification

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NamingNamingAbility to retrieve and produce a targeted

wordAnomia: disturbance in the ability to nameMost pervasive and most persistent deficit

(good test question)Paraphasias (patterns of speech errors):

◦Phonemic: substitution or transposition of the targeted phoneme (non-fluent, expressive, motor aphasia group)

◦Semantic: error is related or in the same category but is incorrect (fluent, receptive, sensory aphasia group)

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Reading and WritingReading and Writing

Written language disturbances usually parallel spoken language impairments◦Non-fluent speakers will also be non-fluent in

writing and reading◦Individuals with auditory comprehension

problems also have problems comprehending written information

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Aphasia SyndromesAphasia SyndromesMore refined labeling of the aphasias

facilitates communication across professional disciplines

Described based on the defining, salient characteristics

Aphasia syndromes include: -Broca’s -transcortical motor-global -Wernicke’s-conduction -transcortical sensory-anomic

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Broca’s AphasiaBroca’s Aphasiahttp://www.youtube.com/watch?v=RCVRGEhT0wo&NR=1http://www.youtube.com/watch?v=RCVRGEhT0wo&NR=1

Location of damage: frontal lobe, specifically Broca’s area

Non-fluent, expressive, motorSlowed, labored, telegraphic speech; short

phrases, agrammatical speechExpressive problems are hallmark of this type,

but also receptive deficitsRepetition and naming difficulties range from

mild to severeReading is slowed and laborious, writing is

effortful and oversized (macrographia)http://www.youtube.com/watch?v=12dO78c6-

q8&feature=related

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Transcortical Motor AphasiaTranscortical Motor AphasiaLocation of damage: frontal lobe, typically

superior and anterior portionsNon-fluent, expressive, motorCharacteristics are the same as Broca’s

aphasia except these clients show far better repetition skills

Also show strong performance in oral reading

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Global AphasiaGlobal Aphasia

Location of damage: large region of brain or multiple sites of injury

Non-fluent, both receptive and expressive, and both motor and sensory

Severe problems communicatingOften non-verbal with limited gesturesReading and writing deficits

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Wernicke’s AphasiaWernicke’s AphasiaLocation of damage: temporal lobe, possible

parietal also, specifically Wernicke’s areaFluent, receptive, sensorySpontaneous speech with normal prosody,

sometimes even logorrhea, but meaningful content is limited

Semantic paraphasias, neologisms, jargonPoor auditory comprehension, repetition, and

naming (use circumlocution), writing is fluent but message is unclear (like verbal)

http://www.youtube.com/watch?v=B-LD5jzXpLE&feature=related

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Transcortical Sensory AphasiaTranscortical Sensory AphasiaLocation of damage: border of the

temporal and occipital lobes or the parietal lobe (superior region)

Fluent, receptive, sensoryCharacteristics are the same as

Wernicke’s aphasia except these clients show far better repetition skills◦Sometimes even frequent verbal repetitions of

random auditory stimuli (echolalia)

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Conduction AphasiaConduction AphasiaLocation of damage: temporal-parietal

region, usually a connector pathway called arcuate fasciculus

Fluent, mild deficits in expression or reception

Inabilities to repeat verbal stimuli or read aloud – receive and process stimuli but cannot transfer this to the verbal output area

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More on Conduction AphasiaMore on Conduction Aphasia

Patients with conduction aphasia show the following characteristics:

speech is fluent comprehension remains good oral reading is poor Major Impairment in repetition many phonemic paraphasias (phone

substitution errors) transpositions of sounds within a word

("television" → "velitision") are common (this info from Wikepedia)

Anomic AphasiaAnomic AphasiaLocation of damage: no specific areaFluent and meaningfulWord retrieval deficits in both spoken and

written languageMost pervasive and most common aphasia

profile

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Aphasia - CausesAphasia - CausesResults from neurological damage or brain

injury◦Stroke: most common cause – blood supply

providing nutrients and oxygen to the brain is interrupted (when language area of the brain is affected, aphasia can happen)

◦http://www.yo utube.com/watch?v=F16q32hA31c

◦Infectious diseases◦Tumors◦Exposure to toxins or poisons◦Hydrocephalus◦Nutritional or metabolic disorders

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Aphasia Aphasia Prevalence and IncidencePrevalence and Incidence

National Stroke Association:◦Stroke occurs every 45 seconds in the U.S.◦750,000 people each year◦Total number of surviving stroke victims in the

United States: 4 million◦Health care costs in this country for stroke:

$30 billion annually

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Aphasia – Risk FactorsAphasia – Risk FactorsUncontrollable factors

◦Age◦Gender◦Racial or ethnic background◦Family history

Controllable factors◦Hypertension◦Diabetes◦Tobacco smoking◦Alcohol use

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III. How is Aphasia Identified?III. How is Aphasia Identified?Assessment of speech and language

disturbances – important componentAssessment and treatment completed

by interdisciplinary team of professionals using a holistic approach

Evaluation goals will address:◦Presence or absence of aphasia◦Type or syndrome of aphasia◦Most beneficial treatment plan◦Prognosis for recovery◦Referrals to other professional as needed

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Assessment of AphasiaAssessment of AphasiaInitial informal clinical assessment

(survey of speech and language performance in about 30 minutes):◦Aphasia Language Performance Scales (ALPS)◦Bedside Evaluation Screening Test (BEST)

Extensive, comprehensive assessment (after client becomes more medically stable):◦Choice of Aphasia battery influenced by clinician

preference, test availability and unique client needs

Assessment should be ongoing and comprehensive

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IV. How is Aphasia Treated?IV. How is Aphasia Treated?A. Prognostic Indicators Factors that predict or determine which

clients will benefit from therapy Include:

◦ Site, type, and size of brain injury◦ Time post onset (TPO)◦ Type and severity of aphasia◦ Handedness◦ Age◦ Pre-injury status

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B. Designing Treatment Plans Treatment strategies: the client’s

compensatory strategies◦ Self-directed◦ Clinician-directed

Treatment approaches: target the specific deficits and the underlying processes that produce the errors

When designing treatment plan, consider evidence-based practice (interventions that have been studied and proven effective in a controlled setting for a particular disorder)

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C. Determining the Setting Multiple environments should be used

for treatment to facilitate carryover of improvements

◦ Co-treatments with occupational therapist◦ Community reentry programs◦ Group therapy (most beneficial for chronic

aphasia) helps with socialization.

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D. Measuring Outcomes Carryover of test scores to real-world

communication is the standard for effectiveness of treatment

Outcomes: functional communication improvements with intervention

Instruments to measure outcomes:◦ Communication Abilities of Daily Living,

Second Edition (CADL-2)◦ Functional Independence Measures (FIMS)◦ ASHA Functional Assessment of

Communication Skills (ASHA-FACS)

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V. Cognitive-Based DysfunctionsV. Cognitive-Based DysfunctionsRight Hemisphere Dysfunction

Traumatic Brain Injury

Dementia

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What is Right Hemisphere What is Right Hemisphere Dysfunction (RHD)?Dysfunction (RHD)?Neurological damage to the right cerebral

hemisphereCommunication profile is different than

aphasias (left hemisphere is usually language hemisphere)

Cognitive, perceptual or behavioral disruptions are most prevalent, but still language difficulties

Cognitive-linguistic disorderhttp://www.youtube.com/watch?

v=iZMJeQ4yPPk&feature=related

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LEFT BRAIN FUNCTIONSuses logicdetail orientedfacts rulewords and languagepresent and pastmath and sciencecan comprehendknowingacknowledgesorder/pattern perceptionknows object namereality basedforms strategiespracticalsafe

RIGHT BRAIN FUNCTIONSuses feeling"big picture" orientedimagination rulessymbols and imagespresent and futurephilosophy & religioncan "get it" (i.e. meaning)believesappreciatesspatial perceptionknows object functionfantasy basedpresents possibilitiesimpetuousrisk taking

Defining Characteristics of RHDDefining Characteristics of RHDLack of insight to deficitsLack of attention or complete neglect of

the left side of the bodyDifficulty recognizing facesCompromised pragmaticsProblems understanding and/or using

higher-level cognitive-linguistic skillsNeuromotor compromise, resulting in

dysarthria or dysphagia

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How is RHD Identified?How is RHD Identified?Comprehensive speech-language

assessment by interdisciplinary teamAdditionally, further assessment of:

◦Higher-level language skills◦Visual-perceptual performance◦Pragmatic appropriateness

Available standardized batteries:◦Mini Inventory of Right Brain Injury (MIRBI)◦Right Hemisphere Language Battery (RHLB)◦Clinical Management of Right Hemisphere

Dysfunction-Revised (RICE-R)

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How is RHD Treated?How is RHD Treated?Initial therapy:

◦Management of attention and visual disruptionsFurther treatment:

◦Higher-level cognitive-linguistic tasks◦Activities for explain abstract thoughts or

making inferences◦Pragmatics of communication interactions◦Both individual and group treatment

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What is Traumatic Brain Injury?What is Traumatic Brain Injury?Neurological damage resulting from

external forces impacting upon the brainTBI occurs mostly from motor vehicle

accidents, falls, and acts of violenceLeading cause of death and disability in U.S.Males twice as likely to suffer from TBILower SES backgrounds more likelyInfants, adolescents, and senior citizens

more likelyhttp://www.youtube.com/watch?

v=FgtHvBF4t-E

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Defining Characteristics of TBIDefining Characteristics of TBIOpen-head injuries: skull and brain have

been penetrated – focal injuries(gunshot wond to head)

Closed-head injuries: no penetration of skull or brain, but brain jostled – diffuse injuries

Diverse group: cognitive impairments are a result of the size, location, and overall severity of the injury

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How are Cognitive-Linguistic How are Cognitive-Linguistic Deficits of TBI Identified?Deficits of TBI Identified?

Early phases of TBI:◦Glascow Coma Scale: observes eye opening, motor

behavior, and verbal responses◦Rancho Los Amigos Levels of Cognitive Function:

eight levels of cognitive functioningLater phases (after client improves

medically) – more extensive testing:◦Brief Test of Head Injury◦Scales of Cognitive Ability for TBI◦Ross Information Processing Assessment – 2nd

Edition

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How are Cognitive-Linguistic How are Cognitive-Linguistic Deficits of TBI Treated?Deficits of TBI Treated?Early stages – Rancho Levels I-III:

◦Stimulation treatment: activities to facilitate arousal, altering, and attention

Middle stages – Rancho Levels IV-VI:◦Tasks to establish basic communication

systemsLater stages – Rancho Levels VII-VIII:

◦Focus on facilitating independence

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What is Dementia?What is Dementia?Chronic and progressive decline in memory,

cognition, language, and personality resulting from CNS dysfunction

Alzheimer’s disease is the most common disorder producing dementia

Dementia is the most prevalent in the older population

DSM-IV Criteria:◦Memory impairment◦Cognitive skills deficits◦Either aphasia, apraxia, or agnosia◦Must have a gradual onset and progressive

functional decline

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Characteristics of Mild Characteristics of Mild DementiaDementia

Forgetfulness, even of basic information and common routines

Decreased vocabulary choicesReduced or verbose conversationAnomia – word finding.Pragmatics and motor function are still

intacthttp://www.youtube.com/watch?

v=smIASqFha04&feature=related

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Characteristics of Moderate Characteristics of Moderate DementiaDementiaDisoriented to time and placePoor attention and memoryMarked language difficulties (anomia,

repetition problems, “empty” conversation, difficulty understanding humor)

Restlessness and roaming may occur

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Characteristics of Severe Characteristics of Severe DementiaDementia

DisorientationMinimal cognitive abilityVery poor language and comprehension

skillsMotor skills vary, but many are confined to

a wheelchair and unable to control bowel and bladder functions

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How is Dementia Identified?How is Dementia Identified?

Screening of mental status:◦Mini Mental State Examination◦Mental Status Subtest of the Arizona Battery for

Communication Disorders of DementiaComprehensive testing:

◦Arizona Battery for Communication Disorders of Dementia (ABCD): tests linguistic comprehension, linguistic expression, verbal memory, visuospatial skills, and mental status

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How is Dementia Treated?How is Dementia Treated?Mild to moderate cases:

◦Activities to compensate for deficits◦Environmental changes to promote safety◦Education for family members◦Active support groups for caregivers

Severe cases:◦Resources necessary are probably beyond

capabilities of the family◦Long term placement in a nursing home or

supported group environment is necessary

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Adult Aphasia and Other Cognitive-Based Dysfunctions Justice Communication Sciences and Disorders: An Introduction Copyright ©2006 by Pearson Education,