Assessment of Aphasia PDF

Assessment of Aphasia Dr. Dalal Alali Preassessment Knowledge  Preassessment Knowledge Before beginning assessment, SLPs can gain information and form initial hypotheses from: Referral Verbal information from multidisciplinary team members Medical notes ...

Assessment of Aphasia Dr. Dalal Alali Preassessment Knowledge  Preassessment Knowledge Before beginning assessment, SLPs can gain information and form initial hypotheses from: Referral Verbal information from multidisciplinary team members Medical notes  The Referral Patients with cognitive communicative disorders are referred to SLPS through a doctor’s referral. Referrals typically include the following information about the patient: o Who the patient is (i.e., the patient’s name, birth date, medical file number). o Where the patient is housed (i.e., hospital ward, unit). o The purpose of the referral (i.e., what the referring individual wants from the consultant). o The referring individual’s name and phone numbers  Medical Diagnosis The location & severity of damage suggests the nature & severity of impairments & prognosis Damage in the brain hemispheres, may cause speech, language & cognition impairments Damage in the brainstem may cause motor & sensory impairments, but leave language & cognition intact Massive damage in the zone of language of the left hemisphere causes more profound, pervasive, and permanent language impairments.  The Medical Record The medical record provides important indications about the nature and severity of the patient’s potential swallowing and cognitive-communicative disorders. The medical record includes 1. Patient Identification: Patient’s name, DOB, ward 2. Personal History: Information about the patient (occupation, marital status, social history) 3. Medical history: Patient’s previous & current medical conditions 4. Physical & Neurologic Examination: Observations of patient’s physical status, orientation & cranial nerves. 5. Doctor’s Orders: Lab tests ordered, medications, diet modifications, therapies requested & specialists consulted. 6. Progress Notes: Professionals' documentations of a patient's clinical status or achievements during hospitalization. 7. Laboratory Reports: Include results of blood tests, CT scans, MRIs, etc.  Goals of Assessment To determine the presence and severity of communication impairment To determine prognosis To monitor change & assess progress To identify intervention goals To define factors that facilitate/ worsen comprehension, production of language  Primary Components of an Assessment The primary components of an aphasia assessment usually include: 1. Case history 2. Informal Assessment 3. Formal Assessment 4. Quality of life Assessment Case History  Case History A case history is obtained from medical records & during interview. It includes: ◦ Personal history ◦ Family & Social history ◦ Work & educational history ◦ Medical history ◦ Speech-Language history  Case History Guidelines Review the patient’s medical record to gain an insight about the patient Conduct the interview in a quiet place, free from distractions Introduce yourself and tell the patient the purpose of your visit Make the patient feel comfortable Sit down during the interview Listen to the patient’s story from their perspective Be a patient, concerned, and understanding listener Talk to the patient at the patient’s level- avoid technical terminology Treat the patient as an adult who merits respect Reassure the patient Include family members or significant others in the interview Informal Assessment  Informal Assessment Informal tests are those tests/tasks administered in an unstructured, conversational fashion. Informal observational findings should supplement formal assessments.  Informal Language Assessment How to assess? Introduce yourself to the patient Establish rapport with patient Check reading by having the patient attempt to read get well soon cards to you or any signs in the room. Ask the patient to complete a hospital menu and read what was selected. Ask the patient to write a few words such as the names of family or friends for word retrieval and writing. Ask the patient to name a few objects around the room, while listening to speech and naming ability. Have the patient attempt to follow a few commands and answer yes/no questions. Track higher level comprehension by assessing the patient’s ability to engage in conversation with you.  Informal Language Assessment During informal assessments, it is important to examine how the patient made errors. What strategies were used to assist in word retrieval- using gestures, writing, semantic, or phonetic cues? Did the patient seem to perseverate? Did the patient give synonyms or associations for words when asked to name pictures or objects? Was the patient attempting to correct errors? Are responses significantly delayed? How did the patient respond to various cueing techniques? At what level of complexity did the responses break down?  Informal Language Assessment The informal assessment provides an excellent time to observe patient-generated facilitation strategies such as: Gesturing an action to aid in word retrieval Requesting repetitions Delaying response to gain extra processing time  Informal Language Assessment Patient-generated facilitation strategies help the SLP when designing treatment. Questions that should come to the mind of the SLP include the following: Which of the patient’s strategies should be capitalized on and reinforced?’ Which can be made more effective? Which strategies are counterproductive and interfering? Should alternative modes of communication be employed to develop functional responding?  Informal Assessment: Screening Tests One of the informal assessments used is a screening test. It evaluates the presence or absence of impairment It gives a general sense of nature & severity. May indicate certain characteristics of aphasia. Does not require technical knowledge of speech pathology for competent administration or interpretation. Can be completed by a trained nursing staff.  Informal Assessment: Screening Tests Main Areas & Tasks: Auditory comprehension Answering closed open questions Point to objects/ to pictures named by the examiner Follow spoken directions/ commands Answer questions about spoken discourse Speech Object/ picture naming Phrase or sentence completion Phrase/ sentence repetition Produce single sentences  Informal Assessment: Screening Test Main Areas & Tasks: Reading Match pictures, letters, geometric forms Match printed words to pictures Read aloud: numbers, letters, words, phrases Answer written questions Silent reading/ comprehension- answer questions about a written text Writing Copy letters, numbers, shapes, words Write to dictation: numbers, letters, words, phrases Write a paragraph/ written narrative Formal Assessment  Types of Formal Aphasia Assessments 1. Standardized assessments 2. Functional assessments: Assess the ability to functionally communicate in daily life activities  Standardized Assessments Standardized assessments give a format to assess various skills. They provide standard procedures for scoring and interpreting the patient’s responses.  Standardized Assessments Example of standardized assessment tools Test Name Author Western Aphasia Battery (WAB) Kertesz (1982) Psycholinguistic Assessment of Language Processing in Aphasia (PALPA) J. Kay, R. Lesser, & M. Coltheart (1992) Comprehensive Aphasia Test (CAT) Swinburn (2005)  Western Aphasia Battery- Revised (WAB) A. Kertesz (USA) Purpose of test Test overview Admin time A comprehensive 31 subtests including: 60 minutes assessment that identifies Spontaneous speech the individual’s aphasia Comprehension syndrome and their severity Repetition of aphasia. Reading Writing  The Comprehensive Aphasia Test (CAT) (2005) K. Swinburn, G. Porter, & D. Howard (UK) Purpose of test Test overview Admin time The assessment provides: 34 subtests including: 90–120 minutes A profile of performance across A cognitive screen. all modalities of language Disability questionnaire production and comprehension. Language battery Identifies associated cognitive The language battery is designed deficits. to assess (i) language Reveals the psychological and comprehension, (ii) repetition, social impact of impairment from (iii) spoken language production, the perspective of the person (iv) reading aloud, and (v) with aphasia. writing. Predicts and follows changes in severity over time.  Psycholinguistic Assessment of Language Processing in Aphasia (PALPA) (1992) J. Kay, R. Lesser, & M. Coltheart (UK) Purpose of test Test overview Admin time An extensive assessment that 60 subtests that assess: 90–120 minutes provides information about the Auditory processing integrity of the language-processing Reading system. The knowledge provides a Spelling firm grounding on which a treatment Picture and word semantics programme can be based. Sentence comprehension  Pros & Cons of Standardised Assessments Pros Cons Assist in determining nature of problem, Potentially important aspects of language and severity, resources that may be used in therapy communication are not adequately assessed and potential for recovery. (Simmons-Mackie, 2001). May be useful for less experienced clinicians Provide a measure of language impairment whose observation skills may not be fully rather than communication activities of daily developed. living (e.g. conversation). Provides a summary of the persons profile. Lengthy and timely. May highlight difficulties that had been Time taken may be better used in observation of underestimated. the individual person with aphasia.  Functional Assessments One limitation of standardized tests is that responses to structured questions may not resemble everyday communication situations in which the environment is less structured, highly variable, and rich in contextual cues. To overcome such problems of standardized tests, clinicians developed functional assessment tools.  Functional Assessments Target communication in relatively natural settings. These tools require regular observation of a patient’s social interactions in everyday situations. Less standardized and allow for more informal and spontaneous measures of communication. In functional assessments social use of language (pragmatics) and effective communication are more important than phonologic, morphologic, and syntactic accuracy of productions.  Functional Assessments Example of functional assessment tools Test Name Author Communication Abilities of Daily Living (CADL) Holland, Frattali, and Fromm (1998) The Communicative Effectiveness Index (CETI) Lomas (1989) Functional Assessment of Communication Skills for Adults Frattali, Thompson, Holland, Wohl (1995) (FACS)  Functional Assessment- CADL Assess functional communication skills using a variety of simulated communication activities. Involves people reading timetables, pretending to go to the doctor, making a phone call The patient may be asked to read a map and tell the SLP how to get to a certain location. The patient may be asked to list 3 items from a grocery store.  Functional Assessment- CETI This tool assesses 4 domains of functional communication skills: 1. Basic needs such as eating and dressing 2. Life skills such as shopping, understanding traffic signals and using the telephone 3. Social needs such as texting a friend 4. Health threats such as calling the police or ambulance for help The skills may be rated as “not at all able” to “as able as before the stroke”. A spouse, another family member, a friend or neighbour may rate the skills.  Functional Assessment- FACS This tool requires direct observation of clients to rate behaviours in four domains: 1. Social communication e.g. use of familiar names, explanation of how to do something 2. Communication of basic needs e.g. expression of likes & dislikes, request for help 3. Reading, writing and number concepts e.g. completion of forms, making money transactions 4. Daily planning e.g. telling time, following a map. SLPs or significant others may make the observation and complete the rating form. The domains are rated on a 7-point scale of independence, where 7 means the patient performs it without assistance and 1 means the patient failed to perform even with assistance.  Subtests for Assessing Language Skills Subtests for assessing language skills include: 1. Auditory (listening) comprehension 2. Reading comprehension 3. Speech production 4. Writing  Auditory Comprehension: Single Words The simplest word comprehension tests require the patient to point to body parts or objects in the environment SLPs often use these simple tests as part of a screening assessment because they do not require special materials In most word comprehension tests, the examiner says the names of the items in random order Some word comprehension tests assess verb comprehension with drawings or photographs representing actions  Auditory Comprehension: Single Words Variables affecting single-word comprehension in brain injured adults: Frequency of occurrence- how often a word may appear. Parts of speech- nouns vs. verbs Referent ambiguity- picture stimuli not clear Fidelity: quality of spoken stimulus; how accurate stimuli is Semantic/ acoustic similarity between stimulus  Auditory Comprehension: Sentences Tested by asking patients to perform gestural responses to spoken instructions or yes-no questions. The yes-no questions in these tests may assess comprehension of different kinds of information: Personal information Awareness of the surrounding environment Knowledge learned in school General knowledge Opinions or inferences Comprehension of temporal relationships Numeric relationships Comparative relationships Interpret with CAUTION- Is it a language deficit or simply lack of knowledge of person.  Auditory Comprehension: Sentences Sometimes patient must point to several items in sets of pictures, objects or body parts. “Point to the ____ and then to the ____” Sometimes patients must manipulate objects or body parts “Ring the bell, close the box, and give me the keys.  Auditory Comprehension: Sentences Variables affecting sentence comprehension: Length & syntactic complexity Personal relevance Reasoning & inference Rate Speech stress Number, similarity of the response choices Redundancy  Reading Comprehension Two things to look when assessing reading comprehension: 1. Reading rate- Reading & understanding under time constraints. 2. Reading capacity- Reading & understanding with unlimited time to finish.  Speech Production: Single Words Automated sequences, sentence completion, word repetition, confrontation naming. Variables that may affect retrieval & production of words in naming tests: Frequency of occurrence Length & phonological complexity Form of stimuli Context  Speech Production: Sentences Sentence production may include defining words, making sentences from words supplied by the examiner or expressing simple ideas.  Speech Production: Discourse Picture description, storytelling or story retelling  Writing Writing subtest in comprehensive language tests include: General automated sequence Copying Writing to dictation Confrontation naming using visual stimulus Writing self-formulated material Given 6 words, write a sentence Given objects, write what you would do with objects. Given pictures, write a paragraph  Quality of life Assessment Quality of life (QOL): The degree to which an individual is healthy, comfortable, and able to participate in or enjoy life events. Disease and deficit affect different people in different ways and to varying degrees. Many SLPs measure the presence or severity of disease and deficit and ignore the impact of the disease/deficit on a person’s QOL. SLPs must assess QOL to understand the impact the disease is having on the person, set appropriate therapy goals, and measure the impact on QOL any therapies may have. QOL measures are usually survey tools  Quality of life Assessments 1. Stroke and Aphasia Quality of Life Scale–39 (SAQOL-39; Hilari & Smith, 2009). The SAQOL-39 evaluates four domains: physical, psychosocial, communication, and energy. The SAQOL-39 can be used to effectively evaluate quality of life in people suffering from aphasia. 2. Quality of Communication Life Scale (ASHA QCL; Paul et al., 2004). The QCL evaluates the psychosocial, vocational, and educational effects of communication disorders.  Example of SAQOL-39 During the past week how much trouble did you have Speaking? Couldn’t do A lot of Some A little No trouble it at all trouble trouble trouble at all Speaking clearly enough to use Couldn’t do A lot of Some A little No trouble the phone? it at all trouble trouble trouble at all Getting other people to Couldn’t do A lot of Some A little No trouble understand you? it at all trouble trouble trouble at all Finding the word you wanted to Couldn’t do A lot of Some A little No trouble say? it at all trouble trouble trouble at all Example of QOL Question  Prognosis Predictors of possible levels of recovery are: 1. Age: Younger individuals have greater levels of recovery than older individuals. 2. Lesion size: Larger lesions cause more deficits 3. Lesion location: Lesions that damage more tissue within the language areas create more persistent aphasias 4. Aphasia severity & type: The more severe the aphasia is, the longer and more difficult the recovery will be.