+ ADULT LANGUAGE DISORDERS Week 5 Feb 10 th, 2011.

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ADULT LANGUAGE DISORDERSWeek 5

Feb 10th, 2011

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Assessment

+Outline

1. First visit

2. Diagnostic decisions

3. Standardized language assessments

4. Short screening tests/supplementary tests

+Health care settings

1. Acute – immediate and short term (acute care hospital)

2. Subacute – transition between acute hospitalization and independence at home (rehab hospitals/centers – inpatient or outpatient)

3. Chronic – long-term for persistent diseases or conditions, living with permanent residual impairment (outpatient rehab center, home health care, university clinic, nursing home

+The First Visit

First meeting takes 5 to 15 minutes

All that is needed is common objects in hospital room, a pen, and some paper

The patient answers some yes/no questions, points to things, and names and describes some other things.

See whether he or she can count or recite the days of the week

Bedside Evaluation Screening Test (BEST-2)

How does a clinical aphasiologist measure language skill in each modality?Level Comprehension

Listening Reading

ProductionSpeaking Writing

Word Listen to a word, read a word,then point to then point to an object an object

Name objects Write names of objects

Sentence Follow simple follow simple commands instructions

Describe simple Describe actionactions

Discourse/Text Listen to a story, answer questionsabout it

Describe a write a lettercomplex picture

Read a paragraph, then answer questions

A model of assessment for aphasia consisting of tasks at different levels of language in each modality

+The First Visit

Auditory Comprehension Reading

Is your name (Fred)

Point to the (window)

Point to the table and ceiling

Is Washington D.C. the capital of France?

Point to the object on this card

Do what it says on this card (e.g., point to your nose)

+The First Visit

Speaking Writing

Count to ten

Say Methodist Episcopal

What day is today?

What do you call this? (e.g., clock, pillow)

Tell me what happened to you.

Write your name

Write down some things you see in this room

+Diagnostic decisions

Does the patient have a communication disorder?

If so, is the disorder aphasia?

If so, what kind of aphasic disorder does the patient have?

Does the patient have other disorders besides aphasia?


Communicative disorder is determined in two ways 1. Comparing a patient’s test score to normative

standards

2. Compare an individual patient’s poststroke performance with some indication of prestroke performance.

Tests are constructed to minimize the influence of extraneous factors such as educational level, cultural variation, or reasoning skill


We also want to determine whether the deficits represents aphasia

Aphasia tests are constructed to evaluate language skills in the four major modalities

Each modality is tested independently so that nonaphasic, modality specific impairments can be exposed

+Comprehensive Tests of Language Function A. Boston Diagnostic Aphasia Examination (BDAE)

(Goodglass & Kaplan)

1. Aimed towards diagnosis of presence and type of aphasia leading to inferences concerning the location of the brain-damage

2. Contains 27 subtests

3. Samples language behaviors which have been demonstrated to be discriminative in the identification of aphasic syndromes – pattern of deficits is important for classification

+Comprehensive Tests of Language Function

A. Boston Diagnostic Aphasia Examination (BDAE) (Goodglass & Kaplan) The "cookie theft" picture from the Boston Diagnostic

Aphasia Examination


4. Takes approximately 2 hours to administer

5. A profile of speech characteristics and severity ratings are provided

6. Test does not provide a formalized basis for making predictions about recovery

7. Test also provides extended testing and supplementary testing of verbal and nonverbal functions (includes a parietal lobe battery)

+Comprehensive Tests of Language FunctionB. Western Aphasia Battery (WAB)

(Kertesz) 1. Based on the BDAE

2. Purpose is to identify the syndromes of aphasia

+Comprehensive Tests of Language FunctionB. Western Aphasia Battery (WAB)

(Kertesz) 3. Provides an Aphasia Quotient (AQ)

a. gives you a severity rating which is not based on the entire battery – only based on fluency, naming, auditory comprehension, and repetition measures

Presence of Aphasia is identified with an AQ cutoff score of 93.8

b. reflects Kertesz’ belief that these measures reveal the crux of the language impairment


4. Also provides a Cortical Quotient (CQ) which is a broader measure taking into account all the language and nonlanguage tasks (reading and writing, praxis, and construction).

5. Test uses scores to place patients in classification (aphasia types) – based on score pattern only

+ Fluency Comprehension

Repetition Naming

Global 0-4 0-3.9 0-4.9 0-6

Broca’s 0-4 4-10 0-7.9 0-8

Isolation 0-4 0-3.9 5-10 0-6

Transcortical Motor

0-4 4-10 8-10 0-8

Wernicke’s 5-10 0-6.9 0-7.9 0-9

Transcortical Sensory

5-10 0-6.9 8-10 0-9

Conduction 5-10 7-10 0-6.9 0-9

Anomic 5-10 7-10 7-10 0-9


6. Validity of classification procedure

a. Wertz et al. – compared performance on WAB and BDAE and classified patients based on tests – looking at overall severity rating, tests were highly correlated (.80 - .95) – however, agreement was only 27% per aphasia type (best agreement was for the most severely involved patients – globals)

b. Swindell et al. – comparing WAB classification to clinical judgment – agreement was only 54% (percentage was better for nonfluent than fluent patients)

+Comprehensive Tests of Language FunctionC. Neurosensory Center Comprehensive

Examination for Aphasia (Spreen and Benton) 1. Consists of 20 subtests with administration

including the use of 32 objects arranged on 4 trays for several of the tasks

2. Scoring is +/- for most subtests and a 5-point scale for the naming subtests

3. Takes approximately 2 hours to administer 4. Profile sheet is provided on which the pattern of

deficit is recorded 5. Test has been frequently used in studies of

recovery

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A. Sklar Aphasia Scale (Sklar) 1. Provides a measure of degree of impairment of

language function in 4 language modalities

2. Takes about 20 mins to half-hour to administer

B. Aphasia Language Performance Scale (Keenan & Brassell)

1. Looks at 4 language modalities in 20 minutes to half-hour

2. Items increase in complexity within each modality

Assessment of Aphasia: Screening Tools/ Short Tests

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C. Bedside Evaluation Screening Test (Fitch-West and Sands)

1. 20 minute test that can be conducted at bedside using a portable kit with magnetic display board

2. language screening instrument using seven subtests to assess competence across three modalities: speaking, comprehension, reading

3. It has been found to correlate highly with BDAE and PICA


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D. Acute Aphasia Screening Protocol (Cray et al.)

10 minute check of attention and orientation, auditory comprehension, and basic expressive abilities

E. Aphasia Screening Test (Whurr)

1. Language screening test aimed at the moderate to severe patient

2. It yields quantitative as well as qualitative information and provides a profile on which to base treatment


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Supplementary tests are used to assess special aphasic populations such as the

most mildly or severely impaired assess skills not represented in traditional

batteries, such as functional communication more in-depth evaluation of a language skill,

such as reading

Assessment of Aphasia: Supplementary Tests

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A. Functional Communication Profile (Sarno) 1. Focuses on the use of language in natural everyday

situations

2. Examines aphasic individual’s independence as a language user

3. Each item is rated on a 9-point scale looking at 45 communicative behaviors divided into 5 categories (gesture, speaking, understanding, reading, and other

4. Ratings are obtained partly from an informal interview with the patient which precedes formal testing


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B. Communicative Activities of Daily Living (CADL)

1. Test of functional language skills (not necessarily a test of aphasia per se – examines communicative adequacy)

2. Looks at how a patient communicates in a variety of situations (role-playing using a scoring system developed by Boller and Green: 2, 1, 0 – 2 = appropriate response, 1 = in the ballpark, 0 = inappropriate response)


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B. Communicative Activities of Daily Living (CADL)

3. Well- normed in regard to cutoff scores for normal and aphasic subjects (broken down by gender, age, institutionalization)

4. Correlation between CADL and PICA was .94, correlation between CADL and BDAE was .86.

5. Takes about 35-40 minutes to administer

6. Has been used as a post hoc measure of recovery


+The CADL-2 has 50 test items in seven areas: Reading, Writing, or Using Numbers

These items reflect skills from a variety of contextual reading tasks (signs, directions), require the patient to make estimations, or calculations based on numerical ability.

Examples include counting change and setting dates. 26 items

Social Interactions It tests pragmatic interchanges in which speech gestures or writing are

used to convey both information and intent. Examples include requesting clarification, asking for repetition, making

inferences, and greetings. 18 items

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Divergent Communication Items test behaviors that involve generation of logical

alternatives from given information and a readiness to change the direction of ones responses.

Examples include selecting from a menu and identifying a newspaper headline from a photo.

10 items

Humor/Metaphor/Absurdity Items directly relate to humor, metaphor, and absurdity.

These abilities involve high level linguistic cognitive operations.

Examples include finding the funny picture out of three pictures, interpreting figurative language, and identifying outlandish recommendations by a physician.

3 items

+ Nonverbal Communication

Items concern only nonverbal communication and symbols, or movement related or movement dependent communicative behaviors.

Examples include using a map and association between facial expression and emotion.

8 items Sequential Relationships

Items require the ability to perform sequences of behavior. Examples include making a phone call and finding a store

item given a choice of store aisles. 6 items

Contextual Communication Examples of items include indicating what to wear on a rainy

day and identifying environmental hazards. 10 items

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C. Token Test (DeRenzi and Faglioni developed the original test in 1962)

1. Measures subtle comprehension and memory deficits

2. A shortened version was developed in 1978 (Cortex)

3. It contains 6 parts which incorporate most of the changes of content since the original version


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C. Token Test (DeRenzi and Faglioni developed the original test in 1962)

4. Uses plastic tokens

5. Does not provide for differential diagnosis

6. Revised Token Test – McNeil and Prescott have a more elaborate scoring system in which administration and scoring are fashioned after the PICA


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D. Auditory Comprehension Tests for Sentences (ACTS) (Shewan)

1. Examines contribution of length, vocabulary difficulty, and syntactic complexity to auditory comprehension

2. Intended primarily to help treatment planning

3. Takes approximately 15 minutes to administer with each item judged as correct/incorrect

4. Test consists of 25 sentences and patient points to one of four pictures that represents the meaning of the sentence


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E. Reading Comprehension Battery for Aphasia (RCBA) (Lapointe and Horner)

1. Investigates the nature and degree of reading impairment

2. Limitation of the test has been the absence of norms, validation or reliability data

3. Consists of subtests which progress from word to paragraph level of difficulty


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F. Reporter’s Test (DeRenzi and Ferrari) 1. Turned around Token Test in order to create a

measure of mild to moderate disorders of verbal expression

2. Experimenter moves tokens and patient reports the action verbally

3. Purpose is a screening tool of minimal expressive difficulties

4. Limitation of test is that content is so specific that conclusions about results may not be generalized to language function as a whole


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G. Boston Naming Test (Kaplan, Goodglass, & Weintraub, 2001)

1. Vocabulary naming test consisting of black and white pictures which increase in difficulty as they decrease in word frequency

2. It is used to assess the extent of word finding difficulty


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H. Test of Adolescent/Adult Word Finding (German, 1990)

1. Standardized test of word retrieval skills in adolescents and adults

2. Word retrieval is measured on the dimensions of accuracy and speed with the test divided into picture naming for nouns and verbs, category naming, sentence completion, and descriptive naming.


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I. Boston Assessment of Severe Aphasia (BASA) (Helm-Estabrooks, Ramsbarger, Morgan, & Nicholas)

1. Test is used for early poststroke administration at bedside, particularly probing the spared language abilities of severely aphasic adults

2. Both gestural and verbal responses to items are scored


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K. Efficiency of Communication in Assessment (Yorkston & Beukelman) 1. Looking for way to quantify higher level

verbal expression A. No. of content units – bit of information typically

expressed in one unit – amount of information patient is conveying

B. Syllables per minute – measure of speaking - older normals speak at 193 syllables per minute whereas mild aphasic patients speak at 121 syllables per minute

C. contents per minute – older normals produced approximately 33. 7 content units per minute whereas mild aphasic patients produced 18.7 content units per minute


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L. Pragmatic Protocol (Prutting & Kirchner)

1. Directs the examiner to score patients on 30 parameters after observing their participation in a 15-minute structured conversation with familiar communication partners

2. The 30 parameters are divided into 7 areas and include speech acts, topic, turn-taking, lexical selection/use, stylistic variations, paralinguistic aspects, and nonverbal acts


+ ADULT LANGUAGE DISORDERS Week 5 Feb 10 th, 2011.

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