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Chap.8 Assessment of Aphasia and Adult Lang. Disorders

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Suanne Wainwright

on 30 October 2013

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Transcript of Chap.8 Assessment of Aphasia and Adult Lang. Disorders

Assessment of Right Hemisphere Syndrome
Assessment of TBI
penetrating
- rips through soft tissues, damaging nerve fibers, nerve cells
- neuro damage is focal (localized)
- resulting behaviors vary, depending on the severity and location of the injury

Assessment of Aphasia
loss language due to an injury to the brain in the area associated with comp. and production
usually caused by CVA, but also by accident (trauma), tumor, infection, toxicity, nutritional and metabolic disorders, and degenerative diseases.

*Table 8.1 Neurolinguistic Features of the Major Types of Aphasia

3 methods of classifying:
1.) Fluent/non-fluent dichotomy: (based on length of utterance):
Nonfluent
Broca's
Transcortical motor
Isolation
Global
Fluent
Wernicke's
Conduction
Transcortical sensory
Anomic
Characteristics of Aphasia
impaired aud. comp.
impaired verbal express.
presence of paraphasias
perseveration
agrammatism, or grammatical errors
nonfluent speech
impaired prosody
difficulty repeating words, phrases, sentences
problems with naming and word finding
impaired reading
impaired writing
in bilingual, unequal impairment between 2 lang.
pragmatic deficits
difficulty using or understanding gestures
*Must identify strengths and deficiencies within all of these areas in order to make a complete and realistic diagnosis and treatment plan
*Form 11-4 Ship. and Mac pp.367-381 Assesses expressive and receptive language within each of these areas
- gives tasks for identifying skills and deficits
- arranged easy to difficult
- note specifics about client's behaviors such as delayed responses, self-corrections, numbers and types of cues, perseverations, visual neglect, response accuracy
-no score; just strengths and weaknesses
know client's medical history:
Major and secondary medical diagnoses (e.g. thrombosis of left middle cerebral artery, organic brain syndrome, diabetes, CVA with right hemiparesis, etc.)
Date of onset as regards etiology of communication disorder
localization of brain damage (hemisphere and lobes affected) and source of date (CT, MRI, etc.)
previous CNS involvement (type and date of onset)
Brainstem signs (e.g. facial weakness, extraocular movement, dysphagia, other bulbar signs)
limb involvement
vision (acuity, corrective lens, visual field deficits)
hearing (acuity, discrimination, amplification)
Review:
left hemisphere: basic language functions (phonology, syntax, simple-level semantics)
right hemisphere: complex linguistic processing (non-verbal, emotional aspects of communication)

Symptoms vary from one client to anther
Specific characteristics fall into 4 categories (Brookshire, 2003) and (Tompkins, 1995)
Neglect of the left visual field
difficulty with facial recognition (prosopagnosia)
difficulty with constructional tasks
impulsivity, distractibility, and poor attention to tasks
excessive attention to irrelevant information
denial of deficits (anosognosia)
visual hallucination
Perceptual and Attentional Deficits
difficulty expressing emotions
difficulty recognizing the emotions of others
depression
apparent lack of motivation
indifference reaction
Affective Deficits
difficulty with word retrieval
impaired auditory comprehension
reading and writing dificits
impaired prosodic features of speech
difficulty with pragmatics
dysarthria
Communicative deficits
disorientation
impaired attention
difficulty with memory
poor integration of information
difficulty with logic, reasoning, planning, and problem solving
impaired comprehension of inferred meaning
difficulty understanding humor
Cognitive dificits
Right hemisphere continued
* "The Cognitive-Linguistic Evaluation" Ship and Mac pp. 382-391 - identifies problem areas assoc. with right hem. injury
*may use Aphasia batteries as well
2 subcategories:
closed-head
- collision of head with object or surface
- skull usually intact
- brain damage is diffuse (nonlocalized)
- resulting behaviors vary depending on the severity and location of the injury

There are NO unique set of characteristics of all TBI, but some are:
inconsistency
attention deficits
impaired memory
impaired language
disorientation to time and place
poor organization
impaired reasoning
reduced ability to write and draw
anomia
restlessness
irritability
distractibility
high frustration and anxiety
aggressive behavior
inconsistent responses
disorders of smell and taste
poor judgement
poor control of emotions
denial of disability
poor self care
Glasgow Coma Scale (GCS) -assesses level of conciousness following TBI (p.352)
looks at Eye opening (E),
verbal response (V), and
motor response (M)
Rancho Los Amigos Levels of Cognitive Functioning
recent onset
8 levels
descriptive
assessment with vary depending on age, severity of injury, current level of consciousness
obtain thorough case history
dates and results from other studies (MRI,CT)
continually review medical chart during assessment
may use Aphasia batteries/sub-batteries
look at pragmatic assessment
inventories/questionaires for caregivers
REMEMBER:
Dementia - the progressive deterioration of memory, orientation, intellectual ability, and behavioral appropriateness.
most common form is Alzheimer's disease
others are multi-infarct dementia, Pick's disease, Parkinson's disease, Hunington's disease, supranuclear palsy, Creutzfeldt-Jakob disease, and Korsakoff's syndrome
most are classified according to Stages
may result from infectious disease, tumor, multiple strokes
affected brain area may be cortical, sub-cortical, or both and is diffuse
gradual, insidious onset
Assessment of Dementia
1. Case history - for determining the etiology and prognosis
2. Interview of primary caregivers and family members - to provide details related to the onset and progression
Important components of the evaluation:
Additional important case history questions:
What behaviors were first noticed and when?
How have the behaviors changed over time?
Was the onset sudden or gradual?
What other events were occurring in the client's like at the time of onset?
What is the client's psychiatric history?
What problems is the client having taking care of his or her daily needs?
How has the client attempted to compensate for his or her deficits?
How do you and others currently communicate with the client?
http://www.mhpcn.ca/uploads/MMSE.1276128605.pdf
Assessment tools/screening:
1. Mini-Mental State Examination (MMSE)
2. Cognitive Linguistic Quick Test
Commercially available formal assessment batteries:
Arizona Battery for Communication Disorders of Dementia (ABCD) (Bayles and Tomoeda, 1993)
Communication Activities of Daily Living (CADL-2)
Dementia Rating Scale (DRS)
Functional Linguistic Comminication Inventory (Bayles)
Global Deterioration Scale
Ross Information Processing Scale
Wechsler Memory Scale - Revised
* take care in selecting tools that are appropriate for the client's level of cognition and awareness because assessment tools vary widely in their focus, length, and application.
* may adapt materials such as "Cognitive Linguistic Evaluation" (p.382) for assessing orientation, memory, aud. processing and comprehension, thought organization and pragmatics.
* use "pictures" for the evaluation of thought organization, confrontational naming, and lang. skills
stats:

500,000 children receive medical attention for TBI

145,000 children live with persistent disability following TBI

24,602 each year receive Sp.Ed.
services due to TBI

Because hospital stays are often short, the SLP often becomes the de facto provider of long term services for children with TBI
As many as 60% of children with TBI fail to receive services because of:
1. delayed effects of the injury
2. adults failure to realize the need for ongoing TBI monitoring (Todis, 2007)
Monitoring of cognitive changes that may affect:
new learning
development
educational placement
participation in social activities
Reasons for more TBI awareness in the schools:
"neurocognitive stall" - children under 5 may not demonstrate academic or behavioral difficulties until they begin school
medical info. may not travel with the child as he progresses in school
injured high schoolers may graduate with their class rather than take advantage of services that could advance teens' long term career development
transition plan
CVA:
3rd leading cause of death in the US (heart disease and cancer, 1 and 2)
est. 1/4 present with aphasia
new pharmacology aids in brain recovery immediately following CVA
medicines are improving cognition
Etiology
CVA
abrupt onset
improvement more likely
less wide differences across modalities
tumor:
insidious onset
wide difference across modalities (reading, writing, listening, speaking)
trauma:
greater variety of cognitive dificits
faster recovery
2.) Boston and 3.) Western Aphasia Battery (both use fluency, aud. comp., repetition, and naming to arrive at a diagnostic label
site of lesion:
left hemisphere (primary language)
anterior lesions - nonfluent aphasia (Broca's and transcortical motor)
posterior lesions - fluent aphasia (Wernicke's, conduction, and transcortical sensory)
determined through CT, PET, MRI
single photon emission computed tomography (SPECT)
medical chart

entries from: neurologist, social worker, nurse, radiologist
family members/caregivers

premorbid personality, social orientation, vocation, etc.

1. review pertinent medical information
2. interview patient's spouse or close relative
3. case history (impact of brain injury and how much spontaneous recovery)
4. inventory the client's language/communication performance
5. observation and related testing (informal assessments, oral peripheral exam, hearing test, etc.)
6. diagnostic determination/prognosis
Comprehensive Aphasia Evaluation:
#4 inventory of client's language/communication performance
Screening for Aphasia:
quick way to advise relatives and health care professionals about the best means of communication with the patient
allows for frequent reassessments of progress during the first few days following brain injury when symptoms are changing rapidly
screening:
* often essential prior to requesting an order for an evaluation.
* third party reimbursement agencies require that the evaluation be medically necessary
purpose of screening:
1. determine if a communication problem exists
2. determine the need for further testing (physician order)
3. determine which tests will be suited for the patient's level of functioning
Standardized Testing:
For prediction of the patient's recovery:
PICA (Porch Index of Communication Ability
Western Aphasia Battery - Revised (WAB-R)
For Site of lesion:
Boston Diagnostic Aphasia Examination (BDAE-3)
WAB-R
For performance on basic-t0-complicated language functions:
Minnesota Test for Differential Diagnosis of Aphasia
To sample a patient's communication ability in natural settings:
Functional Assessment of Communication Skills for Adults
Communicative Abilities in Daily Living
Areas of assessment:
1. Auditory Comprehension: assessment in the area is crucial since the integrity of the auditory modality is so crucial in predicting recovery
* adaptations may be used for nonstandardized testing

2. Expressive abilities: except for the Boston, most don't assess spontaneous speech.
* may need to use discourse analysis

3. Word-finding abilities: (anomia) May use the Boston Naming Test (BNT)

4. Reading ability: Reading Comprehension Battery for Aphasia (RCBA-2)

5. Neuropsychyological/neurolinguistic analysis: assessment from a different perspective - Psycholinguistic Assessment of Aphasia (PALO)

6. Others: oral-peripheral, motor, and hearing
Differential Diagnosis:
Some disorders that might be confused with aphasia
Psychosis
Language of confusion
Dementia
Right hemisphere impairment
TBI
Psychosis
Although aphasics do experience psychotic episodes and periods of sever depression, they usually try hard to communicate.

the psychotic:
-gross disturbances in processing reality
-distortion of or lack of contact with reality
-severe personality decomposition
Language of Confusion
-unclear, confabulatory language, unclear thinking, reduced recognition of the environment, faulty memory, disorientation to time and place

- unlike aphasia, language (syntax, word retrieval, aud. comp., ability to repeat) is usually good

-onset is sudden

-brain injury is widespread and may involve both hemispheres

- assess areas of orientation, memory, reasoning, story telling, and verbal explanations

- prognosis may be mild and temporary (concussion, hypothermia) to profound and chronic (head injury, drug overdose)
Key features that must be present:

1. sustained deterioration of memory, plus a disturbance in a least 3 of the following:
a. orientation in time and place
b. judgement and problem solving
c. community affairs (shopping, etc.)
d. home and avocations
e. personal care
2. gradual onset and progression
3. duration of a least six months or longer
*Mini Inventory of Right Brain Injury (MIRBI)
*Important to ask how the patient made the errors
Did pt. perseverate?
What level of complexity did the responses break down?
Did the pt. give synonyms or associations? -might be a "better error"
response delays?
response to cuing techniques?

*standardized tests may lend to statistical validity and reliability important for EBP, but functional communications skills are relevant to designing treatment

*informal evaluation allows opportunities for
patient generated facilitation strategies
(ex. gesturing to aid word retrieval, tapping for pacing of speech production, etc.)



Informal assessment
Prognosis:
4 important principles:
1.) Do not make final prognosis based on a single evaluation session.

2.) Do not make prognosis based on one test

3.) Do make evidence based decisions (such as knowing the poor relationship between a patient's motivation and improvement potential

4.) be sure to understand the value of predictors - they can be potent self-fulfilling prophecies
**Keeping those principles in mind, the following is a list of interrelated factors that can help make a prognosis:
1.) Initial Severity - More severe lang. impairment, the poorer the prognosis
auditory recognition - patients who make errors when identifying pictures or common objects named by the examiner have an unfavorable prognosis
comprehension - difficulty comprehending verbal messages, poor treatment candidates
speech fluency - more fluent make better recoveries; jargon with lack of self-monitoring, euphoria, or denial, is a poor clinical sign
2.) Time lapsed since onset - 6 months
3.) Type of Aphasia
global = poor
Broca's = fair to good (when symptoms diminish, retain word-retrieval diff, and disfluency)
Wernicke's = Split (improve toward symptoms of conduction or anomia)
Conduction improves toward symptoms of anomia or complete recovery
anomic aphasia also shows complete recovery or recovery toward mild word retrieval difficulties
4.) Etiology - depending in the location and extent of lesion, patients who have suffered traumatic brain injury ten to make better recoveries than do individuals who have had thrombotic or other vascular episodes and tumors

5.) Age - generally, younger patients tend to recover faster and more adequately (more plasticity, older pt. have widespread damage due to arteriosclerosis, and younger may be more motivated)

6.) Presence of other health problems - pt. with additional health problems often do poorly (diabetes, systemic vascular disease, or kidney disease)

7.) Family response - family support results in favorable outcome

8.) Extent of the Lesion - greater extent, the poorer the prospects for recovery
(However, CT scan date are not predictive of patient outcome)
9.) Location of the lesion - damage occurring posterior to the fissure of Rolando, especially at the junction of the parietal and temporal lobes, tends to result in more persistent aphasia

10.) Premorbid personality - more outgoing, flexible pt. responds better to treatment

11.) Intelligence and education - better candidates. (however a few were so aware that they withdrew in futility)

12.) self-monitoring - pt. that is aware have a more favorable prognosis

13.) Handedness - left-handed have better prognosis. However, it may be that left-handed pt. are more likely to become aphasic regardless of which hemisphere of the brain is damaged, suggesting that left-handers show bilateral language representation
Conclusion:
In accordance with ASHA's Preferred Practice Patterns (2004), the SLP is expected to:
Assess the individual's underlying strengths and deficits related to spoken and written language factors
Appraise effects of the language disorder on the individual's activities and participation in ideal settings and in everyday contexts
Explore contextual factors that serve as barriers to or facilitators of successful communication and participation
*There is a direct relationship between a person's quality of life and the severity of the persisting aphasia or other adult lang. disorder.

*One to three years after a stroke or brain episode, the person's quality of communication is related to the presence or severity of depression: the more severe the communication disorder the more severe the depression
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