ADULT LANGUAGE DISORDERS

Week 2Jan 20, 2011

Objectives

Aphasia: definition and its symptomatology

Differences between Aphasia and other neurogenic communication disorders such as Dysarthria and Apraxia of Speech

Explanations for Aphasic behaviors

An Example..

Not long ago, Prof. Martin was home practicing an important lecture when he suddenly stopped, stared at his wife Jackie, and dropped to the floor. An ambulance rushed him to the hospital. He did not recognize Jackie at first, was not quite sure where he was, and could not talk. She tried to get him to write, but he had to hold the pen with his left hand and just threw it at his feet. “I can’t ….talk” was all he could say. He looked frightened, and she was scared to death. The doctor told her that her husband probably had suffered a stroke. A couple days later she remembered the doctor also mentioned something called “aphasia”. She thought she knew what a stroke was, but she had never heard of aphasia before.

(P.1; Davis, 2007)

What is Aphasia?

What is Aphasia?

Frederic Darley (1982) –fundamental diagnostic features of aphasia

Impairment, as a results of brain damage, of the capacity for interpretation and formulation of language symbols; multimodality loss or reduction in efficiency of the ability to decode and encode conventional meaningful linguistic elements (morphemes and larger syntactic units); disproportionate to impairment of other intellective functions; not attributable to dementia, confusion, sensory loss, or motor dysfunction; and manifested in reduced availability of vocabulary, reduced efficiency in application of syntactic rules, reduced auditory attention span, and impaired efficiency in input and output channel selection. (P. 42, Darley, 1982).

Language Disorder

1. Multimodality deficit• Modalities of speaking,

listening, reading and writing are all impaired, although not equally.

• Aphasic people comprehend better than they talk or write, and reading-writing skills usually more impaired than auditory-speech skills (e.g., Duffy and Ulrich, 1976).

Modality Specific Disorders

Davis, A. (2007). Aphasiology, 2nd Edition. Pearson

Modality Specific Disorders Agnosia: impairment in the ability to interpret

incoming stimuli (aware of it but can’t assign meaning)

Dysarthrias: impairments of the ability to execute movement with the muscle used for speaking.

Muscle weakness, rigidity or uncontrollable movement Speech may be slurred or slowed; patient may also

have difficulty chewing and swallowing food.

Apraxia of speech (AOS), an impaired programming of movement for the purpose of speaking without neuromuscular deficit

Language disorder

When Jackie first met SLP, she remarked that “Marty doesn’t talk but his mind is OK”.

Darley description- “disproportionate to impairment of other intellective functions”.

With aphasia many of the non-verbal skills may be preserved.

Low marks- linguistic tasks, high marks- nonverbal tasks such as drawing a flower or putting a puzzle together.

Propositional Use of Language

Jackie was amazed when the SLP got Martin to count to ten. Counting came out much easier than any talking

Aphasic people tend to retain so-called subpropositional forms, which “come ‘readymade’ or preformulated for the speaker” (Eisenson, 1984).

▪ E.g., counting to ten, singing a song, or producing routine greetings like “how are you?” or I’ am fine.

Aphasic errors are observed in the propositional use of language

A creative formulation of words with specific and appropriate regard to the situation (Eisenson, 1984).

Important distinction from Dysarthria

Other disorders

Brain damage can cause other patterns of difficulty and success.

Darley – language problems of aphasia are “not attributable to dementia, confusion…”

Robert Wertz (1985) wrote about the “language of confusion” in which discourse can be twisted by disorientation, inability to sustain attention, failures of recollection, and extreme impatience and irritation.

A patient may be said to be incoherent.

Distinguishing amnesia from aphasia may be help in diagnostic distinction

Other disorders

Dementias are somewhat similar to confusion because of their involvement of varied intellectual skills, but are associated with different causes

Confusion is associated with TBI

Irreversible dementias are associated progressive deterioration over months or years.

Patients with confusion or dementia tend to have substantially reduced performance on clinical tests beyond the tests for language.

Other disorders

Besides language skills, visuospatial or musical skills can be uniquely impaired by stroke.

These functions contribute to artistic expression as well as orientation to everyday sights and sounds.

The general pattern of performance is the opposite of the pattern with aphasia, namely, deficits of nonverbal functions with verbal functions relatively spared.

▪ E.g., they do not get the punch line of jokes, or they randomly stray from the point of conversation.

Aphasia

Demographic information▪ 1. caused by damage to areas of brain

primarily responsible for language▪ 2. important to note that it is an acquired

disorder▪ 3. etiology primarily being a CVA (stroke) of

the LH▪ 4. average age of clinical population with

aphasia around 55-57 years of age▪ 5. onset of aphasia is usually sudden

Aphasia Symptomatology

General descriptions• Acquired impairment of language

processes▪ 1. general language disorder underlying

receptive and expressive modalities

▪ 2. reduces person’s ability to derive meaning from language that is read or heard

▪ 3. reduces ability to express ideas with language, especially in speaking, writing and gesture

Aphasia Symptomatology

General descriptions• Acquired impairment of language

processes▪ 4. reduces person’s ability to receive and send

messages in conversations▪ 5. disorder affects all communication

modalities▪ 6. disorder of symbolization▪ 7. disturbance to central processor of verbal

information▪ 8. Multimodality disorder

▪ a. comprehension deficits in listening and reading▪ b. expressive deficits in speaking and writing

Aphasia Symptomatology

General descriptions• Acquired impairment of language processes

▪ 9. degree of impairment often differs among modalities

▪ a. expressive modalities are usually more impaired than receptive modalities

▪ b. reading is usually more impaired than auditory comprehension

▪ c. writing is usually more impaired than verbal output

▪ 10. Propositional and volitional use of language is impaired with nonpropositional and nonvolitional use of language preserved to a greater degree.

Aphasia Symptomatology

Spoken Language• A. Word finding (Anomia)• http://www.youtube.com/watch?v=f2IiMEbMnPM

▪ Problem of finding words

▪ Linguistic units cannot be retrieved or are partially omitted

▪ circumlocution: upon failure to retrieve a word, patient gives definition and/or descriptions

▪ “I wear it right here, and I tell time with it. Mine goes tick, tick”

▪ “clock” when thinking about a watch -------- word substitution errors

Aphasia Symptomatology

B. Paraphasias

▪ 1. Commission error in which incorrect word or sound is substituted for intended or target word

▪ 2. Produced unintentionally

▪ 3. Major types: Based on the linguistic relationship between target word and the error.

Paraphasias

Type Target Error

Phonemic Tiger Kiger

Semantic Tiger Lion

Mixed semantic & phonemic

Telephone Telegraph

Unrelated Tiger flag

Neologistic Tiger Floosis

Davis, A. (2007). Aphasiology, 2nd Edition. Pearson

Aphasia Symptomatology

Spoken Language

Sentence production

Right after stroke, Martin’s utterances were similar to nonfluent aphasia, in which patients produce fewer words than normal.

Bathroom ….. Shave Sleeping…..get up….bathroom….fall

down….um….wife….um….ambulance… I was standing mirror…..shave…the…uh….fall on

floor…..and I did, too…..I could not talk.

Aphasia Symptomatology Spoken Language

D. Agrammatism▪ 1. Inadequacies in sentence production▪ 2. content words are produced but function words

and bound morphemes are omitted▪ 3. similar to telegraphic speech▪ 4. utterances are described as nonfluent▪ 5. same pattern may also be observed in reading

aloud▪ 6. agrammatic speakers may also have difficulty

processing function words in comprehension▪ http://www.youtube.com/watch?v=NUTpel04Nkc&

feature=related

Aphasia Symptomatology

Spoken Language Another style of sentence production

When you get into the car, close your door. Put your feet on those two things on the floor. So all I have to do is pull…I have to put my… You just put your thing which I know of which I cannot say right now, but I can make a picture of it…you put it in…on your…inside the thing the thing that turns the car on. You put your foot on the thing that makes the stuff come on. It’s called the , uh….

http://www.youtube.com/watch?v=aVhYN7NTIKU&feature=related

http://www.youtube.com/watch?v=67HMx-TdAZI&feature=related

Aphasia Symptomatology Spoken Language

Problem with selection of words.

When a word does not come to them, they often resort to vague wording or circumlocution.

E. Paragrammatism▪ 1. occurs in primarily fluent form with complete

sentences

▪ 2. mistakes are made in the use of grammatical elements

Aphasia Symptomatology Spoken Language

Jargon Another type of fluent production, makes little

sense.

▪ 1. lengthy, fluently articulated utterance making little or no sense to the listener

▪ 2. contains verbal paraphasias and neologisms and an excess of words

▪ 3. tendency to start talking before another speaker has relinquished his turn in conversation (press for speech)

Aphasia Symptomatology

Spoken Language C. Jargon

▪ 4. Types ▪ a. Neologistic jargon: high proportion of neologisms

in patient’s speech

▪ b. Semantic jargon: contains a higher proportion of semantic paraphasias

Semantic and neologistic jargon may represent different stages in recovery of language

Aphasia Symptomatology

Example of mainly semantic jargon with one neologism tossed in:

Oh sure, go ahead, any old think you want. If I could I would. Oh, I’m taking the word the wrong way to say, all of the barbers here whenever they stop you it’s going around around, if you know what I mean, that is tying and tying for repucer, repuceration, well, we were trying the best that we could while another time it was with the beds over there same thing…

Aphasia Symptomatology Traditional contrasting features of

agrammatism (nonfluent) and jargon (fluent)

Utterance lengthContent wordsGrammatical morphemesInitiation and flow

prosody

Agrammatism Jargon

Reduced normal or increasedOn target paraphasic substitutionsOmissions or errors Occasional substitutionsHesitant, slow smooth

Reduced seemingly normal

Aphasia Symptomatology Recurring or stereotypic utterances

Some people with severe aphasia are unable say anything except some repeated involuntary and seemingly subpropositional utterances.

These occur at the onset and persist for months

▪ E.g., dee, dee, dee▪ use of yes or no incorrectly

Aphasia Symptomatology

Behavioral Symptomatology: Written Language A. Description

▪ 1. aphasic writing usually shows patterns which are similar to speaking impairment

▪ 2. usually called agraphia

▪ 3. because writing is usually more severely impaired than speech, examination of writing is valuable for detection of mild aphasia

Graphic word retrieval errors are called paragraphias

Aphasia Symptomatology

Reading▪ 1. reading problems are referred to as alexia or

acquired dyslexia

▪ 2. observed either during silent reading for comprehension or during reading aloud

▪ 3. in reading aloud, dyslexias are inferred from patient’s incorrect verbalizations (paralexias)

Aphasia Symptomatology

Auditory comprehension▪ 1. mild problems are usually reflected in

delayed responses or requests for repetitions▪ 2. failure to follow instructions correctly▪ 3. patient may comprehend words but not

sentences or paragraphs▪ 4. may be unable to process sentences

containing particular units of speech such as function words

▪ 5. may have difficulty answering questions▪ 6. very important measure when dealing with

severity of aphasia

Neurological Explanation for Aphasia

Features and severity of neurogenic communication disorders depend on location and magnitude of the damage… (Brookshire, 1997)

Focal lesions, multifocal lesions, and diffuse lesions

Anterior regions – motor functions Posterior regions – sensory function Left H – language functions

Anterior lesions- nonfluent aphasia Posterior lesions – fluent aphasia

Right H – nonverbal functions

Cognitive Explanation for Aphasia

• Relationship between ideas and words

Cognitive Explanation for Aphasia

Two features of cognition Knowledge (stable storage) – about the

world and language we speak Process – transient activity of mind, a

response to stimulus

Memory is the key to carryout all cognitive functions

Memory

Long-term memory (LTM) Different types of knowledge

Episodic memory Semantic memory- common knowledge Procedural memory Lexical memory- words and knowledge

about words

Memory

Working memory (WM) – work space of any cognitive activity

Short-term memory is one component of WM

Aphasia

Cognitive processing including language processing Constrained by the capacity of WM Draws knowledge from LT storage Operates at automatic and controlled levels

In aphasia language storage system is relatively intact Impairment of processing

Aphasia

Aphasia is a selective impairment of the cognitive system specialized for comprehending and formulating language, leaving other cognitive capacities relatively intact. (Davis, 2007, p.15)