cognition and aphasia
could have aphasia and cognition problems, but cognitive problems not a part of aphasia
relationship between degree of aphasia and cognitive problems
what is teh challenge in examining cognitive skills?
most tests require language
Four cognitive domains
3. executive functions
4. visuospatial skills
relationship between cognitive skills
overlap, but some skills will clearly tax a particular cognitive task over others
components of executive function
inhibition, planning, goal selection, initiation, problem-solving, flexibility, self-evaluation
what does trailmaking test tax?
what does Rey complex figure test?
attn, memory, executive function
if only time for one cognition test...
draw clock, put numbers, set for 10 minutes to 11. tests attn, executive funciton, visual neglect
make sure have one for evaluation AND treatment
5 important things regading assessment
1. have order
2. review file for etiology, past med history, family, work status
3. formal eval?
4. supplemental tests?
5. arrange to cotreat or observe
way to describe if don't knwo exactly
"most consistent with"
assessment concerns for broca's
comprehensive verbal skills and further examination of AC, bc mild deficits may be overlooked
five areas of verbal to look at for broca's
1. syntactic constructions
2. grammatical constructions
3. compensatory strategies
4. ability to initiate and maintain conversation
5. discourse ability
concern for wernicke's assessment
may benefit from more pragmatic approach that looks at all language modalities in real-life situations (invite clients to use all skills they have); thorough testing of AC. However, sicne third-party payers often demand functional progress, standardized tests have been developed
4 standardized tests to measure function
1. Assessment of Language Related Functional Abilities
4. Communicative Effectiveness Index
Formal tests for Wernicke's AC
1. Token Test or Revised Token Test, BUT need to look at comprehension of natural langauge SO
2. FUnctional Auditory Comprehnsion Test
3. Discourse Comprehension Test
assessment concerns for conduction
1. AC relatively good, so delve further
2. repetition -- multisyllabic words, sentences, real words v. nonwords to see phonologic deficits
3. word finding- mostly see phonemic paraphasias, but also semantic
tests for word finding
1. BNT, spontaneous pseech sample (paraphasias, empty words, circumlocution, pauses)
assessment for transcortical
difference between spontaneous and rep? they will not be perfect on reps, but we are looking for a discrepancy
assessment for global
do they have any strengths at all? --- formal assessemnt may not be possible. We need to knwo abilitiy to 1. follow simple commands, 2. use a simple communication board, 3. use and comprehend gestures, 4. answer YN Qs for ADLs, 5. read, write draw
who are comprehensive tests for?
moderately impaired clients; subtle deficits need supplemental tests, and severe aphasia requires BASA or informal assessment
3 comprehensive tests
BDAE, MTDDA, WAB
3 reasons for standardized for global
1. determien competency for legal purposes
3. payers like to see #s
why evaluate gestures?
tos ee if can use as comm mode, can help ID apraxia
why evaluate automatic speech/singing
allows us to access right hemisphere
lapointe 5 purposes of evaluation
1. aid differential diagnosis
2. aid treatment planning
3. establish prognosis
4. monitor change
5. evaluate maintenance of treatment gains
4 ways to assess anomia
2. generative naming
3. free recall
4. pictured scene description
how determien fluency
use three conditions that vary in emotional content, taxing memory and vocab, obtain three best utterances from each and average
4 areas of testing for AC
1. single words (various categories)
2. following commands
4. lengthier material
types of repetition to assess
words, phrases, sentences AND high/low frequency AND phonemic complexity
who talk to for case history
family, other therapists, nurses, physicians, dietician
areas we want to know about case history
2. responsibilities at home
3. work status
5. past medical history
8. current physical environment
10. hemiparesis or paralysis
11. visual impairment
what 2 things does eval depend on?
setting and pt ability to oparticipate
what you want to cover in eval
1. Ac and where break down
2. verbal expression, where break down, examples
3. reading comp
6. nice to know if sth helped
assessment may include any and all
1. standardized 4 areas and more
why use bedside?
determine if aphasia exists/strenthgs/wekaness
end line of report
Client presents with moderate Broca's aphasia, as evidenced by X. or Unable to differentially diagnose. Client appears most consistent with X.
when do formal assessement
when past natural recovery
5 comprehensive tests
1. Boston diagnostic Aphasia Evaluation
2. Western Aphasia Battery
3. Minnesota Test for Differential Diagnosis of Aphasia
4. Boston Assessmento f Severe Aphasia
5. Porch Index of Communicative Abilities
8 exampleso f supplmental standardized
2. ASHA functional Assessment of Communicative Skills for Adults
3. Northwestern University Sentence Comprehension Test and Verb Production Battery
4. Token Tests
5. Auditory comrehenson test for Sentences ACTS
6. Discourse Comprehension Test DCT
7. Functional Auditory Comprehension Test FACT
8. Reading Comprehension Battery for Adults RCBA
to transition to AC during ifnormal
let's takea break from talking now,a nd just listen
parts of informal
6. reading and writing if time
to transiton to reps
OK, great, now just listen to me and say exactly what I say.
what do you use to sweep?
three ways to assess naming
confrontation, responsive, generative
when assess reading?
if ac was poor
when assess writing?
if verbal expression was poor
deblocking, or asset approach
use intact skills and abilities to restore unavailable skills. for example, use intact reading ability to deblock AC and naming. write key words down adn allow pt to read them. pair pictures with their written worda dn eventually remove written cue.
response elaboration training
for nonfluent. 1. offer stimulus to get open-ended
2. acknowledge corretness
3. model longer
4. they imitate
ultimate goal of ret
improve patient's ability to elaborate on conversational topics
if we improve AC, improve overall communication
schuell's stimulation approach
intensive auditory stimulation, to creat new pathways to stimulate old learning.
Pace stands for
Promoting Aphasics Communication Abilities
feedback is simply the success of communicating
encouraged to use any expressive modality. natural convo that goes back and forth with cards.
goal in medical model
goal in social model
promote positive change; bridge gap btwn language barriers and real-life needs; may target compensation
most likely to observe anomia...
which two systems scientists agree we need to name
semantic and phonological
4 ways to activate semantic system
1. phonologic input. say it.
2. object recognition
3. read it
4. it;s used to make a sandwich
which 2 aphasias may have semanti csystem probs?
TSA and global. bc posterior. anteror has syntactic probs, not semantic or phono.
if patient recognizes object, what level of cue?
another way to activate phonological system, besides phonemic cue
1. tell me somethign aobut it.
2. semantic cue
5 goals of treatment
1. neuroanatomical change (restorative)
3. education and counseling
4. self-confidence adn attitude
5. supportive communicaiton environment
another name for restorative approach
how do you tell what can adn can't do
how do you tell what does do
bridge gap bgtwn what
can, can't, does AND want, need (impairment and functional communication)
5 different approaches
3. social model
5. published treatment procedures
what affects tx outcome?
1. neurological variables -- progressive? TBI or RHD? hemorrhagic or thromboembolic?
2. cognition -- attention, mem, exec function, visuospatial skills
3. metacognitive skills
4. langauge profile -- severity, strenths/weaknesses
6. premorbid skills
8. past med history
9. extent and location - smaller, fewer better
12. timing of treatment
14. intensity of treatment
15. family involvement
five components of metacognitive
3. self monitoring
4. self initiation
5. goal oriented behvaior
how soon initiate tx?
at least 6 months
how often tx?
at least 3 h week/5 months
any recovery after how logn is due to treatment?
3 explanations for neuroanatomical change
2. rebuilding connections (axonal resprouting)
3. other parts of brain take over, either due to redundancy or reorganization
what subtests are included in the bdae?
1. conversational and expository speech
3. oral expression
6. apraxia assessment
different versions of bdae
1. short form
2. standard form
3. extended testing
standard encompasses short form.
how do you select which subtests to administer from the conversational and expository speech section?
simple social responses, free conversationa nd picture description are ALL essential
which subtests contribute to severity rating?
simple social responses, free conversation and picture description
which subtests on bdae for discourse analysis?
picture description and free conversation
voluntary control of involuntary utterances best for...
severely nonfluent aphasic NOT Wernicke's, who can match words correctly to pictured objects and actions. unilateral, left-hemisphere stroke, often subcortical.
best candidate for using more intact modality of reading comp to stimulate oral reading, then repetition, then AC
Wernicke's who are moderately to severely impaired with single-word processing. overall AC score less than or equal to 40th percentile on bdae. single word discrimination less than or equal to 45th percentile. repetition on bdae less than or equal to 30th percentile. Relatively good ability to comprehend written stimuli at single word level, greater than or equal to 50th percentile.
overall AC score for twa
less than or equal to 40th
single word discrimination for twa
less than or equal to 45th
repetition score for twa
less than or equal to 30th
new name for HElpps
SPPA -- sentenece production program for aphasia
best candidate for melodic intonation therapy
fairly severe broca's but better than vciu. moderately preserved AC -- greater than 45th percentile. Poorly articulated speech.
best candidate for visual action therapy vat
client who is already using gestures...global or severe apraxia
best candidate for treatment of aphasic perseveration (tap)
clients who perseverate, but have mdoerately preserved AC and good memory
best candidate for anagram copy and recall therapy
severely impaired writing, fairly good VE OR limited VE but has retained some writing. good graphomotor skills. good single word reading comp. relatively spared memory. semantic skills.
treatment for Broca's
PACE, CVT adn HELPSS (sppa), MIT, RET
treatment for Wernicke's
deal with AC and poor self-monitoring, press of speech first -- TWA, Schuell's , conversational therapy liek PACE, comprehensive variety of strategies
treatment for conduction
NOT AC work, NOT MIT, NOT syntax
capitalize on spared naming to expand sentence structure
treatment for global
3 ways to work on single word AC
body parts, action pictures, object/picture identification
3 ways to work on sentence AC
yes/no (simple to complex, A only or with pic), commands, choose picture being described from field
3 ways to work on discourse AC
reading them simple to complex paragraphs, conversation, narratives followed by quesitoning for main idea, details and implied details
3 ways to work on funcitonal AC
conversation providing natural cues, directions presentaed naturally, using stimuli from his life
name a therapy that uses asset approach
how decide where to start based on bdae results
1. look where some skills NOT 0-20th percentile
2. Look where make biggest impact on communication
why allow communication failure?
1. in order for them to trust you
2. allows them to modify their communication
why is it important to create tasks where client can respond correctly?
1. build confidence
2. not reinforce negative practice
ways to make task easier
1. just make easier.
2. reduce # items
3. pay attention to semantics
ways to cue if they're not gettin git
1. give simpler explanation
2. use gestures
3. pre-cue them
who is more likely to have cognitive deficits?
client with aphasia in R hemisphere
explain difference in progress btwn thromboembolic and hemorrhagic
ischemic more progress at beginning, but plateau. hemorrhagic slow to start progress but better overall.
what type of lesion will make wernicke's mroe persistent?
if it extends into parietal
what to do when talking to famiy
1. strengths that contribute to good prognosis
2. strengths related to what he can do language-wise.
3. explain type of aphasia and explain related terms like paraphasia
better way to say poor prognosis
whether anomia is semantic or phonemic, difference in way of addressing?
yes. if phonemic, road map is missing, but still has semantic info. if semantic, storage place is bombed.
what type of anomia: knowing how to activate meanings and interconnections won't help because knowledge is not there
before using the TAP you must administer what?
the 7 naming categories form the bdae
never use MIT for these people
neuroanatomical change -- 2 types
both communicators, any type of comm, feedback based on whether they adequately conveyed message
4 major categories that affect prognosis
1. neurological variables
3. metacognitive skills
4. language profile
what helps for verbal expression
high frequency words, manipulable objects better than those that can't be held, objects better than pictures, realistic drawings better than line, give extra time for response, sentence completion, running cues, functional description, alphabet board
what types of cues to use first
weaker, to determine where to start
semantic feature analysis
teach client to provide descriptions including physical features and function
three types of semantic treatment
word associations, semantic feature analysis, gestures
four types of phonological treatments for naming
word repetition, oral word reading, phonologic training, semantic category rhyme therapy