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The Aphasias

The Aphasias. Woodford A. Beach, MS, CCC/SP Senior Speech-Language Pathologist Clinical Instructor, Otolaryngology MCVH&P of VCUHS May 3, 2002. Objectives. Define aphasia Review Boston aphasia classification Consider atypical aphasias Note other neurogenic communication disorders.

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The Aphasias

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  1. The Aphasias Woodford A. Beach, MS, CCC/SP Senior Speech-Language Pathologist Clinical Instructor, Otolaryngology MCVH&P of VCUHS May 3, 2002

  2. Objectives • Define aphasia • Review Boston aphasia classification • Consider atypical aphasias • Note other neurogenic communication disorders

  3. 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

  4. Aphasia • characterized by impairment in connected speech and conversation, auditory comprehension, repetition, naming, reading, & writing

  5. What aphasia is not:

  6. What aphasia is not:dysarthriaapraxia of speech

  7. Dysarthria • group of speech disorders • neurogenic • associated with CNS, PNS, muscle pathology

  8. Dysarthria • movement disorder • abnormal neuromuscular execution • affects speed, strength, timing, accuracy • affects respiration, phonation, resonance, articulation, and prosody Darley, Aronson, & Brown 1975

  9. Apraxia of Speech • disorder of motor planning • absence of aphasia & neuromotor deficits • characterized by symptom variability • 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

  10. Apraxia of Speech • Often • articulatory struggle • phoneme metathesis • syllable transposition Duffy 1995

  11. 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

  12. Comatose patients are not aphasic

  13. Assessment of Aphasia

  14. Assessment of Aphasia:Formal • 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

  15. Assessment of Aphasia:Informal • Conversation & Connected Speech • fluent • hyperfluent (logorrhea or press of speech) • nonfluent • grammatic/paragrammatic/agrammatic • empty • appropriate without dyspragmias

  16. 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

  17. Assessment of Aphasia:Informal • Auditory Comprehension • commands • 1 part axial • 1 part other • 2 part • 3 part • yes/no questions with known answer • orientation • bizarre • complex

  18. 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

  19. 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

  20. Assessment of Aphasia:Informal • Word Retrieval Errors • paraphasias: word substitutions • circumlocutions: talk around target • neologisms: nonwords • stereotypy: restricted subpropositional forms (often yes & no) • frank dysnomia: no response or do not know

  21. 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

  22. 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

  23. Boston Aphasia Classification • Relative sparing vs relative impairment • Reading and writing always impaired • Differentiate aphasias in • fluency • auditory comprehension • repetition • naming

  24. Nonfluent Broca Global Transcortical Motor Mixed Transcortical (isolation syndrome) Fluent Wernicke Conduction Anomic Transcortical sensory Classic Boston Aphaisas

  25. Taxonomy of Nonfluent Aphasias

  26. Taxonomy of Fluent Aphasias

  27. 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

  28. 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

  29. 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!

  30. 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?

  31. Disclaimers & caveats re: aphasia taxonomy • Research by Nina Dronkers (2000) • Chronic Broca’s • 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 • 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

  32. Cortical Organization of Language

  33. Localization of Classical Aphasias • Broca: third left frontal convolution • Global: entire perisylvian region • Transcortical Motor: anterior watershed • Mixed Transcortical: anterior watershed & posterior watershed

  34. Localization of Classical Aphasias • Broca: third left frontal convolution • Global: entire perisylvian region • Transcortical Motor: anterior watershed • Mixed Transcortical: anterior watershed & posterior watershed

  35. Localization of Classical Aphasias • Broca: third left frontal convolution • Global: entire perisylvian region • Transcortical Motor: anterior watershed • Mixed Transcortical: anterior watershed & posterior watershed

  36. Localization of Classical Aphasias • Broca: third left frontal convolution • Global: entire perisylvian region • Transcortical Motor: anterior watershed • Mixed Transcortical: anterior watershed & posterior watershed

  37. Localization of Classical Aphasias • Wernicke: posterior, superior temporal lobe • Conduction: archuate fasciculus; inferior parietal lobe • Transcortical sensory: posterior watershed • Anomic: posterior: temporoparietal?

  38. Localization of Classical Aphasias • Wernicke: posterior, superior temporal lobe • Conduction: archuate fasciculus; inferior parietal lobe • Transcortical sensory: posterior watershed • Anomic: posterior: temporoparietal?

  39. Localization of Classical Aphasias • Wernicke: posterior, superior temporal lobe • Conduction: archuate fasciculus; inferior parietal lobe • Transcortical sensory: posterior watershed • Anomic: posterior: temporoparietal?

  40. Localization of Classical Aphasias • Wernicke: posterior, superior temporal lobe • Conduction: archuate fasciculus; inferior parietal lobe • Transcortical sensory: posterior watershed • Anomic: posterior: temporoparietal?

  41. Dorsolateral Syndrome • 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

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