Transcript Aphasiology - VCU Physical Medicine and

The Aphasias
Woodford A. Beach, MS, CCC/SP
Senior Speech-Language Pathologist
Clinical Instructor, Otolaryngology
MCVH&P of VCUHS
May 3, 2002
Objectives
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Define aphasia
Review Boston aphasia classification
Consider atypical aphasias
Note other neurogenic communication
disorders
Aphasia
• acquired language disorder, that is a CNS
disturbance of the capacity to interpret and
formulate symbols for communicative
purposes
• secondary to focal brain damage
– perisylvian region
– dominant hemisphere
– not due to diffuse or multifocal dysfunction
Aphasia
• characterized by impairment in connected
speech and conversation, auditory
comprehension, repetition, naming, reading,
& writing
What aphasia is not:
What aphasia is not:
dysarthria
apraxia of speech
Dysarthria
• group of speech disorders
• neurogenic
• associated with CNS, PNS, muscle
pathology
Dysarthria
• movement disorder
• abnormal neuromuscular execution
– affects speed, strength, timing, accuracy
– affects respiration, phonation, resonance,
articulation, and prosody
Darley, Aronson, & Brown 1975
Apraxia of Speech
• disorder of motor planning
• absence of aphasia & neuromotor deficits
• characterized by symptom variability
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mutism
difficulty initiating speech
problems in syllable transition
more difficulty in volitional than automatic
more difficulty in long than short
more difficulty in complex than simple
Apraxia of Speech
• Often
– articulatory struggle
– phoneme metathesis
– syllable transposition
Duffy 1995
• Aphasia is not language of confusion
• Aphasia is not due to psychiatric disease
• Aphasia is not due to primary cognitive
dysfunction
• it is focal, and not caused by multifocal or
diffuse brain disease
Comatose patients are not
aphasic
Assessment of Aphasia
Assessment of Aphasia:
Formal
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Boston Diagnostic Aphasia Examination
Western Aphasia Battery
Burns Left Hemisphere Inventory
Boston Assessment of Severe Aphasia
Aphasia Diagnostic Profiles
Boston Naming Test
Minnesota Test for the Differential Diagnosis of
Aphasia
Assessment of Aphasia:
Informal
• Conversation & Connected Speech
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fluent
hyperfluent (logorrhea or press of speech)
nonfluent
grammatic/paragrammatic/agrammatic
empty
appropriate without dyspragmias
Assessment of Aphasia:
Informal
• Conversation & Connected Speech
– if there is only minimal speech
• automatic series (counting, days of week)
• singing
– does the patient engage linguistically
Assessment of Aphasia:
Informal
• Auditory Comprehension
– commands
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1 part axial
1 part other
2 part
3 part
– yes/no questions with known answer
• orientation
• bizarre
• complex
Assessment of Aphasia:
Informal
• Repetition
– repeat sentences
• “No ifs, ands, or buts”
• “They heard him speak on the radio last night”
– repeat words
• vary length and familiarity
Assessment of Aphasia:
Informal
• Word Retrieval
– confrontation
• name objects
• name parts of objects
– responsive
• answer questions
– verbal fluency
• list words belonging to semantic class or beginning
with common letter
Assessment of Aphasia:
Informal
• Word Retrieval Errors
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paraphasias: word substitutions
circumlocutions: talk around target
neologisms: nonwords
stereotypy: restricted subpropositional forms
(often yes & no)
– frank dysnomia: no response or do not know
Assessment of Aphasia:
Informal
• Reading Comprehension
– silent reading of command
– silent reading of yes/no question
– oral reading is not reading comprehension any
more than dictation or copying are written
expression
– If reading comprehension compromised, assess
oral reading
Assessment of Aphasia:
Informal
• Written Expression
– generate sentence given stimulus word
– automatic writing (e.g. signature) is not written
expression
– If writing impaired, assess taking dictation, then
copying of words or figures
Boston Aphasia Classification
• Relative sparing vs relative impairment
• Reading and writing always impaired
• Differentiate aphasias in
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fluency
auditory comprehension
repetition
naming
Classic Boston Aphaisas
• Nonfluent
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Broca
Global
Transcortical Motor
Mixed Transcortical
(isolation syndrome)
• Fluent
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Wernicke
Conduction
Anomic
Transcortical sensory
Taxonomy of Nonfluent Aphasias
Aphasia
Fluency
Comprehension
Repetition
Naming
Broca
Impaired
Spared
Impaired
Impaired
Global
Impaired
Impaired
Impaired
Impaired
TMA
Impaired
Spared
Spared
Impaired
MTA
Impaired
Impaired
Spared
Impaired
Taxonomy of Fluent Aphasias
Aphasia
Fluency Comprehension Repetition
Naming
Wernicke
Spared
Impaired
Impaired
Impaired
TSA
Spared
Impaired
Spared
Impaired
Conduction Spared
Spared
Impaired
Impaired
Anomic
Spared
Impaired
Impaired
Spared
Disclaimers & caveats
re: aphasia taxonomy
• Receptive/expressive dichotomy invalid
– all aphasias have an expressive component
– all aphasias have a receptive component
• If you are binary, use the fluent/nonfluent
dichotomy
Disclaimers & caveats
re: aphasia taxonomy
• Other taxonomies exist
• Some researchers argue that aphasia is a
unary phenomenon
• Metter showed that PET scans demonstrate
metabolic hypodensities distal to site of
lesion (is this diaschisis of von Monokow?)
• Reliability dogs all taxonomies
Disclaimers & caveats
re: aphasia taxonomy
• Taxonomies often fail to capture
characterististics of aphasia which are
important therapeutically
• e.g., Broca’s Aphasia
– agrammatism
– dysfluency
• Labels are abbreviations. Describe Sxs!
Disclaimers & caveats
re: aphasia taxonomy
• Boston model fails to capture
– natural course and evolution of aphasia
– severity
– localization consistently
• Boston group admits:
– “In many instances (30-40% of unselected cases), inspection of the
speech characteristics leads directly to a diagnostic assignment”
Albert et al. 1981
– Therefore, are 60-70% aphasias mixed?
Disclaimers & caveats
re: aphasia taxonomy
• Research by Nina Dronkers (2000)
– Chronic Broca’s
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N=12 with Broca’s aphasia
2 had lesions sparing Broca’s area
10 others with Broca’s lesion had no persisting Broca’s aphasia
Chronic Broca’s Aphasia always involved insula
– Chronic Wernicke’s
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N= 7 with Wernicke’s aphasia
2 had lesions sparing Wernicke’s
7 others with Wernicke’s lesion had no persisting Wernicke’s aphasia
Chronic Wernicke’s always has large temporal lesion with destruction
of posterior MTG
– Data reflect structural lesions in chronic aphasias
Cortical Organization of
Language
Localization of Classical
Aphasias
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Broca: third left frontal convolution
Global: entire perisylvian region
Transcortical Motor: anterior watershed
Mixed Transcortical: anterior watershed &
posterior watershed
Localization of Classical
Aphasias
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Broca: third left frontal convolution
Global: entire perisylvian region
Transcortical Motor: anterior watershed
Mixed Transcortical: anterior watershed &
posterior watershed
Localization of Classical
Aphasias
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Broca: third left frontal convolution
Global: entire perisylvian region
Transcortical Motor: anterior watershed
Mixed Transcortical: anterior watershed &
posterior watershed
Localization of Classical
Aphasias
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Broca: third left frontal convolution
Global: entire perisylvian region
Transcortical Motor: anterior watershed
Mixed Transcortical: anterior watershed &
posterior watershed
Localization of Classical
Aphasias
• Wernicke: posterior, superior temporal lobe
• Conduction: archuate fasciculus; inferior
parietal lobe
• Transcortical sensory: posterior watershed
• Anomic: posterior: temporoparietal?
Localization of Classical
Aphasias
• Wernicke: posterior, superior temporal lobe
• Conduction: archuate fasciculus; inferior
parietal lobe
• Transcortical sensory: posterior watershed
• Anomic: posterior: temporoparietal?
Localization of Classical
Aphasias
• Wernicke: posterior, superior temporal lobe
• Conduction: archuate fasciculus; inferior
parietal lobe
• Transcortical sensory: posterior watershed
• Anomic: posterior: temporoparietal?
Localization of Classical
Aphasias
• Wernicke: posterior, superior temporal lobe
• Conduction: archuate fasciculus; inferior
parietal lobe
• Transcortical sensory: posterior watershed
• Anomic: posterior: temporoparietal?
Dorsolateral Syndrome
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Reduced selective attention
lack of drive & awareness
reduced initiation
dynamic aphasia of Luria
• Localize to frontal dorsolateral cortex
– anterior and inferior to Broca’s area
Frattali 2000
Aphasia in DLS
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decreased spontaneous speech
limits in amount and range of narrative
reduced verbal fluency
limited capacity to formulate propositions
Frattali 2000
DLS and TMA
• TMA lesion is larger and less
circumscribed.
• Fewer behavioral manifestations
Frattali 2000
Orbitomedial Syndrome
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Deficit in exclusionary attention
utilization behavior
impulsive
poor inhibition
impaired moral judgment
• localized to frontal orbomedial cortex
Frattili 2000
Subcortical aphasia
• Thalamic Aphasia
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fluent with occasional dysfluency
paraphasias, neologisms, & word finding impaired
repetition intact
perseveration
• Left caudate, putamen, ALIC Aphasia
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limited spontaneous speech
intact repetition
mild anomia
relatively spared comprehension
Atypical Aphasias
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Aphemia & Anarthria
Alexia without agraphia
Alexia with agraphia
Pure word deafness
Pure agraphia
Atypical Aphasias
• Gerstmann’s Syndrome
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r/l disorientation
finger agnosia
dyscalculia
dysgraphia
• Angular Gyrus Syndrome
– anomia
– alexia
– Gerstmann’s Syndrome
Nonaphasic Language Disorders
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TBI
Minor hemisphere CVA
Dementias
Primary progressive aphasia
Diffuse & multifocal neurological deficits
(encephalopathies)
• Seizures
Treatment in a Nutshell
• Aphasia therapy is efficacious
– Robey
– Frattali
• It must exceed 2 hours per week (i.e., rehab
frequency)
Treatment in a Nutshell
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Symptomatic
Multimodal
Gradually increasing in complexity
should focus on both deficits and
compensatory strategies
• should consider communicative handicap
Deglutition & Expectoration in
the camelid Lama glama