Aphasia Classification and Assessment - McGill University

1 Copyright Judith Robillard Shultz 20091 Aphasia Classification and AssessmentJudith Robillard Shultz MSc. SLP(C)Speech-Language PathologistMGH-MUHCC opyright Judith Robillard Shultz 20092 Purpose of Assessment Determine if Aphasia is present or absent Distinguish it from other related conditions Motor speech disorders Cognitive-communication disordersCopyright Judith Robillard Shultz 20093 Lecture goals Components of communication and normal language processing Syndromes of Aphasia Features of related conditions Common Assessment tools, diagnostically relevant tasks How to communicate with an aphasic patientCopyright Judith Robillard Shultz 20094 Definition of Aphasia Disturbance of language caused by brain damage affecting: Comprehension auditory reading Expression speaking writingCopyright Judith Robillard Shultz 20095 Important Distinctions Language Vocabulary, Speech Movement tongue, Cognition Attention, memory, problem Judith Robillard Shultz 20096 Theoretical Basis for Classification of Aphasia .

2 Boston Classification (Kertesz Goodglass & Kaplan) A contemporary localizationist view Language localizable in the brain Perisylvian region in the left hemisphere anterior language zone = left frontal lobe posterior language zone = left temporal/parietal lobesCopyright Judith Robillard Shultz 20097 Boston Classification Consists of cortical centers and connecting pathways Aphasia Syndromes Broca, Wernicke, Global Conduction, TC Motor, TC Sensory, Mixed TC Anomic Supplied by left MCA Anterior and posterior branches, main trunkCopyright Judith Robillard Shultz 20099 How the Brain Performs Language Comprehension of Language How is it accomplished?Copyright Judith Robillard Shultz 200911 How the Brain Performs LanguageComprehension of Speech Ears Auditory Cortices Wernicke s area Constructs an overall meaning Assigns meaning to words/relation among words Evaluates the context (literal vs figurative meaning)Copyright Judith Robillard Shultz 200912 How the Brain Performs LanguageReading Comprehension Eyes Visual Cortices Wernicke s areaCopyright Judith Robillard Shultz 200913 How the Brain Performs Language Spontaneous Spoken Language?

3 Copyright Judith Robillard Shultz 200915 How the Brain Performs LanguageSpontaneous Spoken Language Wernicke s area retrieves words, sentence structure Sends it to Broca s area via the ArcuateFasciculus Broca formulates an action plan Sends plan to primary motor cortex Primary motor cortex refines it and sends to the cranial nerves for speech muscles via the pyramidal systemCopyright Judith Robillard Shultz 200916 How the Brain Performs Language What single language task tests the entire circuit?Copyright Judith Robillard Shultz 200918 How the Brain Performs LanguageRepetition (tests the entire language circuit) Primary auditory cortex Wernicke Broca via the AF Broca recodes into articulatory plan Primary motor cortex Pyramidal system to CNsCopyright Judith Robillard Shultz 200919 How the Brain Performs LanguageOral Reading Visual Cortex to Wernicke and the same processes as for repetition followsWriting Wernicke via AF to premotor cortex for arm and hand, movement planned, sent to motor cortexCopyright Judith Robillard Shultz 200920 Boston Classification : Key Diagnostic DistinctionsFluent vs Nonfluent Aphasia Speech fluency Prosody, melody, rate, pauses Subtypes further distinguished by.

4 Repetition Language Comprehension ParaphasiaCopyright Judith Robillard Shultz 200921 Boston Classification : Key Diagnostic Distinctions Paraphasia Literal/phonemic = shooshbruss/ toothbrush; tevilision/television Verbal/semantic = table for chair, cranberry for teapot Neologism = chantlast/refrigerator Perseverative = comb, fork/toothbrush, comb/keyCopyright Judith Robillard Shultz 200922 Boston Classification : Fluency Dimension Nonfluent Aphasia Lesions to anterior portion of language center of dominant hemisphere Slow, effortful, pauses, disturbed prosody Fluent Aphasia Lesions to posterior language center of dominant hemisphere Effortless with normal/fast rate, good intonation and stress patterns Copyright Judith Robillard Shultz 200923 Nonfluent aphasias: subtypesBroca s Aphasia Comprehension Relatively preserved.

5 Some difficulty with complex syntax Reading comprehension relatively spared Expression Slow & effortful production Limited word output Four words or less per utterance Frequent perseverations Agrammatic Writing usually parallels oral expression Repetition poorCopyright Judith Robillard Shultz 2009251234567artic agility_____unablesometimes clumsynever impairedphrase length_____1 word4 words7 wordsgrammatical form_____no syntactic word groupingssimplified/incompletenormal rangemelodic line_____word by wordlimited to short phrasesnormalparaphasias_____present in every utterance1-2 instances per minuteabsentword finding_____fluent but emptyinformation prop to fluencyprimarily cont wordssentence repetition_____0-20 30 40 50 60 70-80 90-100 auditory comprehension_____0-20 30 40 50 60 70-80 90-100 Broca s Aphasia Rating Scale Profile of Speech Characteristics Boston Diagnostic Aphasia ExaminationCopyright Judith Robillard Shultz 200927 Copyright Judith Robillard Shultz 200928 Transcripts: Cookie TheftBroca s Aphasia Water (Clinician s going on?)

6 No .Copyright Judith Robillard Shultz 200929 Assessment severe non-fluent Aphasia 48 year old male Received tPA Infarct = left frontal inferior and medial gyri and temporal-parietal operculum Yes/no only speech output Accurate yes/no responses to personally relevant questions Gesturing to express himself Right arm weaknessCopyright Judith Robillard Shultz 200930 Nonfluent aphasias Accompanied by: Apraxia of speech Dysarthria Right hemiplegia affecting lower half of face and arm more than leg Lesion Site: Broca s area Extending to primary motor cortex or parietal lobeCopyright Judith Robillard Shultz 200931 Nonfluent Aphasias Global Aphasia Severe language deficits in all modalities Responds to personally relevant language Responds to nonverbal cues Automatic speech may be preserved Verbal stereotypes common Extensive (L) hemisphere lesion involving Broca s and Wernicke s areaNeurophysiology of brain damage and the neurological exam16 Copyright Judith Robillard Shultz 200933 Nonfluent aphasiaTranscortical Aphasias (TCM nonfluent.)

7 TCS fluent) Preserved repetition Spare central language areas, disconnects from rest of brain Watershed, borderzonesCopyright Judith Robillard Shultz 200934 Nonfluent aphasiaTranscortical Motor: Lesion= anterior and superior to Broca s area Reduced speech output, good auditory comprehension, striking ability to repeat Reduced speech output Frontal lobe dysfunction (initiation, maintenance) Brief answers when highly structured ( , tell me the name of the hospital vs. tell me what you think of the hospital ) Pathological inertiaCopyright Judith Robillard Shultz 200935 Non-Fluent Aphasia Mixed Non-fluent Resembles Broca but auditory comp below 50thpercentile Auditory comprehension too good to be global Not good enough to classified as BrocaCopyright Judith Robillard Shultz 200936 Fluent AphasiasWernicke s Aphasia Comprehension (auditory & reading) impaired Oral Expression: fluent, well-articulated, good prosody rapid rate incessant (logorrhea, press of speech) verbal and literal paraphasias neologisms empty speech paragrammatic Repetition poor Lack of awareness Lesion site.

8 Temporo-parietal region involving Wernicke sarea and adjacent white matter1234567artic agility_____unablesometimes clumsynever impairedphrase length_____1 word4 words7 wordsgrammatical form_____no syntactic word groupingssimplified/incompletenormal rangemelodic line_____word by wordlimited to short phrasesnormalparaphasias_____present in every utterance1-2 instances per minuteabsentword finding_____fluent but emptyinformation prop to fluencyprimarily cont wordssentence repetition_____0-20 30 40 50 60 70-80 90-100 auditory comprehension_____0-20 30 40 50 60 70-80 90-100 Wernicke s Aphasia BDAEC opyright Judith Robillard Shultz 200939 That s on fairble my own.

9 Clinician: yes, your family. Stuck at that feek On the to goof uf : ok, do you have a large family? Do you have a big family?No, yes well there s 3, 4-4 all told but we only see masically once of a time at home and 2 of them occasionally at other 3rdwell he s always away at ff foam but masically on on the boys always s living at home and belonging to the future show. Clinician: There not all at home all at once? Just one at home all the time, he goes to school?..it s a high school , it s like a hymn school like I don t know what you call and Kathy s she s a married man and has a daughter at a new The other girl is seeing her boyfriend but going give a poy part with her parents. And what does your wife do?Copyright Judith Robillard Shultz 200941 Fluent aphasias Conduction Aphasia Repetition disproportionately severe worsens with length of stimuli Comprehension: relatively good Expression: word finding errors and produce literal/phonemic paraphasias conduite d approche (lumpily, )Copyright Judith Robillard Shultz 200942 Fluent aphasias Awareness: Self correction, disturbed prosody Lesion site.

10 Arcuate fasciculus Disconnects Wernicke s area from Broca s area 1234567artic agility_____unablesometimes clumsynever impairedphrase length_____1 word4 words7 wordsgrammatical form_____no syntactic word groupingssimplified/incompletenormal rangemelodic line_____word by wordlimited to short phrasesnormalparaphasias_____present in every utterance1-2 instances per minuteabsentword finding_____fluent but emptyinformation prop to fluencyprimarily cont wordssentence repetition_____0-20 30 40 50 60 70-80 90-100 auditory comprehension_____0-20 30 40 50 60 70-80 90-100 Conduction AphasiaC est la c est la vier uh qui avec l eau eau, teau puis elle l l a l essuie les fisisse essuieles siesse avec il y a d autre il y a d autrechose y a l eau qui le vayeau, qui le plancherbon ok c est le garf, le garf et la feuille, la fillette, puisla elle est, elle tambor, le tam, le tambourin, le tambourin le tambourin va va banche, va bancher en tout est effrayant!