Aphasia is clinically defined by the National Aphasia Association as the “impairment of language, affecting the production or comprehension of speech and the ability to read or write, that is caused by damage to the areas of the brain that control the said abilities (National Aphasia Association, 2018). In a person with aphasia, auditory comprehension, one or many of the communication modalities, such as verbal expression, reading and writing, and functional communication are affected. Depending on the severity of impact and the area of brain affected, aphasia is classified into various types, which divides the symptoms into various categories.
According to the most widely accepted “Boston’s Classification”, Aphasia is categorized into eight types (Mesulam, Wieneke, Rogalski, Cobia, Thompson, & Weintraub, 2009). One, Broca’s Aphasia (Expressive Aphasia), where the Broca’s area in the frontal lobe of the brain responsible for speech comprehension and production is affected, thus the person has issues in comprehending and repeating speech. Two, Wernicke’s Aphasia (Receptive Aphasia), where the Wernicke ’s area in the temporal lobe of the brain that is responsible for speech comprehension is affected and the person has severe issues in comprehending speech. Three, Conduction Aphasia where the arcuate fasciculus that connect the Broca’s and Wernicke’s areas are affected, thus though there is a good level of speech comprehension, there is poor speech production. Four, Mixed transcortical Aphasia, where the areas that control speech and communication are isolated from the rest of the brain, and there is both impaired comprehension and expression. The person is unable to comprehend the speech and start a new conversation, but is able to repeat the said words. Five, Transcortical Motor Aphasia where, the frontal lobe of the language dominant hemisphere of the brain is affected, thus though there is a good level of speech production, the speech comprehension is affected. Six, Transcortical Sensory Aphasia, where, the area near the Wernicke’s area in the temporal lobe is affected, thus the person’s comprehension and speech production is affected, while repetition is intact. Seven, Global Aphasia, where all the speech and language processing areas of the brain are affected, which leads to poor comprehension, speech production, and repetition of the individual. Eight, Anomic Aphasia, where parts of the parietal/temporal lobe of the brain are affected, which leads to the person presenting with difficulty in retrieval of words, usually names from memory.
Assessment of Aphasia is usually a difficult process, as it involves testing the components of language and comprehension in the affected people, which might be ambiguous. The four components of communication, namely verbal expression, reading and writing, and functional communication are assessed by the use of different assessment scales and indices (Whitworth, Webster, & Howard, 2014). The Boston Diagnostic Aphasia Examination, the Boston Naming Test, the Western Aphasia Battery, the Comprehensive Aphasia test, the Psycholinguistic Assessments of Language Processing in Aphasia, are some of the common tools used in the assessment of aphasia.
In this report, the background information of the patient in the case study (David) is provided, along with a detailed analysis of the type of disorder faced by the patient, impairments, and the standardized assessment measures of David’s condition is made. A comparison of the standardized assessment and the functional assessment is also done.
The assessment was made in January 2016. The patient David was a 71 year old man. He had suffered from stroke involving the embolic infarct of the left Middle Cerebral Artery in June 2008. The stroke was secondary to his pre-existing condition of infective endocarditis. At the time of the stroke, he presented with a complete left hemiplegia with total inability to speak. Presently, David is unable to use his right arm, and is unable to speak, but he is able to walk. David is a married person who lives along with his wife. He used to be a typesetter prior to his stroke, and is presently retired. David reads books and information on the internet, and goes for walking with his dog. He is right handed, and is a monolingual English speaker. David has a normal corrected vision, and an unimpaired hearing. He is a regular participant of researches on Aphasia, but has not benefitted from any aphasia therapies.
David was assessed for his aphasia by four different clinical assessment tools and scales. His communication abilities and the resultant observation from the assessments are described below.
The Western Aphasia Battery (Revised) Test was performed and its four components were assessed (Hula, 2010). In the component spontaneous speech, David was able to respond to almost all basic conversations and questions. He was able to describe the picture in short incomplete sentences, and lacked the fluency to complete the sentence, with poor sentence construction and disjointed words. Auditory and verbal comprehension was assessed by giving a set of yes-no questions, in which David answered almost all questions correctly, David was able to perform all tasks in the assessment of sequential commands. He was able to repeat small words with ease, but had difficulty in repeating longer phrases, indicating moderate verbal apraxia. Out of twenty objects, he was able to successfully name ten objects, needed phonemic cues for two objects, and could not name eight objects. In word fluency component, David was able to five animals spontaneously, and two with clues. He was able to complete sentences correctly but in his responsive speech he could answer only three out of the five questions correctly.
In the semantic system for associative memory by the Pyramids and Palm trees assessment (Klein & Buchanan, 2009). David scored a total of 49 out of 52, and was adjudged to be within normal limits.
The Comprehensive Aphasia Test (CAT):
Here, nineteen items of the Comprehensive Aphasia Test were assessed (Swinburn, Porter, & Howard, 2005).
- Cognitive Screening Tasks
In this, non linguistic cognitive abilities are tested, under the components Semantic Memory, Word Fluency, and Recognition memory. David had issues in the word fluency component, where he was asked to tell all the words that came under a specific category, where he scored seven out of a mean score of 32. However, he scored well in the other two components.
- Language Comprehension tasks:
In this, the comprehension of spoken words, written words, spoken sentences, written sentences, and spoken paragraphs were assessed. David scored well in all tasks except the comprehension of written sentences, where David had difficulty in selecting sentences from a group that had phonological or visually related images, where he scored 22 out of 32, where the mean scores were 29.78.
- Expressive Language Repetition Tasks
In this, the repetition ability of simple words, complex words, non words, and sentences were assessed. In this David had issues in repeating complex words and non words, he could repeat only two complex out of six, which was also the mean score, and four nonwords out of ten words, where the mean score was 9.23, while he could do the rest correctly.
- Spoken Language Production Tests
In this, the spoken output from the person is assessed involving the naming of objects, actions, and spoken picture descriptions. David scored poorly in all the three components, where he was unable to name objects correctly scoring 29 out of 48 compared to the mean of 46.37, unable to name actions scoring 4 out of 10, compared to the mean of 9.88. He also was unable to describe a picture coherently, providing only 9 words and a sole grammatical feature, compared to the mean of 52.19.
- Reading aloud
In this, the semantic and phonological system is assessed, containing the components reading simple words, complex words, functional words, and non words. In this segment, David was able to read only 26 out of 48 simple words, compared to the mean of 47.42, read only two out of six simple words, compared to the mean of 5.81, while in the other two components he could not score.
In this, the person rates himself under seven components, which are Disability in talking, understanding, reading, writing, and impact in intrusion, self image, and emotional consequences. David rated his disability high in talking as13 out of 16, in writing as 11 out of 16, and low on understanding as zero and reading as 2 out of 16 respectively. His impact ratings in intrusion are 11 out of 16, when compared to moderate rating on self image as 6 out of 16, and emotional consequences as 14 out of 28.
The Psycholinguistic assessments of Language processing in Aphasia (PALPA)
Three subtests were selected, namely the auditory and written synonym judgments where the person is asked to judge whether two words given together are synonyms or not, and the nonword repetition, where the person is made to repeat non words as they are (Ansaldo, 2008). David scored well in the synonym judgment tasks, but scored poorly in repeating nonwords as 17 out of 30, where he tended to substitute the correct word in the place of the nonword.
A standard set of 24 different words were tested under two tasks, which were spoken picture naming and repetition. Here, David scored poorly in the picture naming, where he could not recall a few words, and used semantic substitutions for a few other words, scoring 12 out of 24 items. He scored moderately in repetition, with a few phonemic and semantic substitutions, scoring 19 out of 24 items.
Synthesizing the various assessments made on David, the list of the issues faced by him are his difficulty in word fluency, repetition of long phrases and non words, word production and expression, reading aloud, and difficulty in speaking and writing, all of which have impacted his self image. Thus, David can be diagnosed to have Broca’s Aphasia. The rationale for this diagnosis is that David has a loss of expressive speech and writing, wherein he has no issues with comprehension (Hickok, Costanzo, Capasso, & Miceli, 2011). His fluency of speech is greatly altered, as his spoken sentences have the important content words, but very less grammatical components (Jonkers & de Bruin, 2009). He has a difficulty in constructing speech, which was seen in the spoken picture description tests. The functions that are out of the scope of the Broca’s area, which were repetition, comprehension of simple words and phrases, understanding, listening, and reading are intact (Grillo, 2008). Furthermore, David’s stroke was caused by the infarct of the left Middle Cerebral artery, which supplies to the Broca’s area.
In order to demonstrate David’s impairments at the phonological output lexicon and phonological output buffer, a cognitive neuropsychology approach is used, (Nickels, 2012) which is the Multiple Component Model of Language Processing proposed by Patterson and Shewell (1987) The approach determines the differences and impairments in the individual’s task performance (Patterson & Shewell, 2013). In the case of David, who exhibited expressive aphasia, his acoustic analysis and auditory input lexicon was good (Yee, Blumstein, & Sedivy, 2008). The route to the acoustic to phonological conversion mode was disrupted, causing impairments in repetition of nonwords. This causes disruptions in the route to the auditory response buffer, thereby impairing speech. However, the route from the auditory input lexicon to the phonological input lexicon is intact, thus spontaneous speech is not greatly affected. In David’s case, there was no scope for graphemic expression (Montant, Schon, Anton, & Ziegler, 2011), as his dominant right hand was affected by stroke, and his writing ability was impaired.
Psycholinguistic variables such as semantics, phonemics, orthographics and imageability were heavily relied on by David to make lexical decisions, as seen in his response to the assessments. Moderate verbal apraxia (Fazio, et.al. 2009) was seen in the WAB-R test, in addition to various paraphrasic errors made in the course of the assessment such as phonemic paraphrasia, and visual-semantic paraphrasia.
David’s condition as Broca’s aphasia is confirmed by the variety of tests performed, as well as the neuropsychological model. The results of the WAB-R test showed that the patient had difficulty in repeating, as well as a moderate verbal apraxia. The results of the Pyramids and Palm trees assessment showed that David was within normal limits of semantic associative memory. The CAT scores highlighted his poor sentence construction and fluency, difficulty in grasping long sentences, difficulty in repeating non words, which was also highlighted in the PALPA scores, inability in naming and describing spoken or visual objects, which was also highlighted in the standardized 24-word test, and difficulty in reading words and phrases. In the Disability Questionnaire, a qualitative self analysis of disability, David has rated his disability high in talking, writing, and impact intrusion, moderate on impact self image and emotional consequences, and low on understanding and reading. Both the standardized assessments and the functional assessments have produced similar results, highlighting the key areas of David’s aphasia (Paradis & Libben, 2014)
David currently makes the most of the linguistic abilities that are intact, such as reading and comprehension, in his daily life. A comprehensive plan of working on David’s disabilities, and a focus on his abilities would enable David manage with his aphasia better.
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