Aphasia: Types, Assessment, and Analysis of a Case Study

This report provides an overview of aphasia, its types, and assessment methods. It analyzes a case study of a patient with Broca's aphasia and uses the cognitive neuropsychology model to explain the impairments. The report also discusses the psycholinguistic variables and their impact on the patient's lexical decisions.

A Report on Aphasia
A REPORT ON APHASIA
Introduction
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,
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A Report on Aphasia
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.
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A Report on Aphasia
Background Information
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.
Analysis and Interpretation of client data
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
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,
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A Report on Aphasia
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.
Pyramids and Palm Trees Assessment
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).
1. 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.
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A Report on Aphasia
2. 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.
3. 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.
4. 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.
5. 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
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A Report on Aphasia
only two out of six simple words, compared to the mean of 5.81, while in the other two
components he could not score.
The Disability Questionnaire
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.
Set of 24 words tested in two different modalities
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.
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A Report on Aphasia
Classification an Rationale of David’s Aphasia
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.
Cognitive neuropsychology model
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A Report on Aphasia
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.
Conclusion
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,
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A Report on Aphasia
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.
REFERENCES
Ansaldo, A. (2008). Language therapy and bilingual aphasia: Clinical implications of
psycholinguistic and neuroimaging research. Journal of Neurolinguistics 21(6), 539-
557.
Fazio, P., Cantagallo, A., Craighero, L., D’Ausilio, A., Roy, A., Pozzo, T.. (2009). Encoding
of human action in Broca's area. Brain , 1980-1988.
Grillo, N. (2008). Generalized minimality: Syntactic underspecification in Broca’s aphasia.
LOT, 49-54.
Hickok, G., Costanzo, M., Capasso, R., & Miceli, G. (2011). The role of Broca’s area in
speech perception: Evidence from aphasia revisited. Brain and language , 214-220.
Hula, W. (2010). Item response theory analysis of the Western Aphasia Battery.
Aphasiology , 1326-1341.
Jonkers, R., & de Bruin, A. (2009). Tense processing in Broca's and Wernicke's aphasia.
Aphasiology , 1252-1265.
Klein, L., & Buchanan, J. (2009). Psychometric properties of the pyramids and palm trees
test. Journal of Clinical and Experimental Neuropsychology , 803-808.
Mesulam, M., Wieneke, C., Rogalski, E., Cobia, D., Thompson, C., & Weintraub, S. (2009).
Quantitative template for subtyping primary progressive aphasia. Archives of
neurology , 1545-1551.
Montant, M., Schon, D., Anton, J., & Ziegler, J. (2011). Orthographic Contamination of
Broca’s Area. Frontiers in Psychology , 378.
National Aphasia Association. (2018, September 11). Aphasia Definitions. Retrieved
September 11, 2018, from National Aphasia Association:
https://www.aphasia.org/aphasia-definitions/
Nickels, L. (2012). Theoretical and methodlogical issues in the cognitive neurophysiology of
spoken word production. APHASIOLOGY , 3-19.
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Paradis, M., & Libben, G. (2014). The assessment of bilingual aphasia. Psychology Press,
174-176.
Patterson, K., & Shewell, C. (2013). Speak and spell: Dissociations and word-class effects.
The Cognitive Neuropsychology of Language. Lawrence Erlbaum Associates , 273-
294.
Swinburn, K., Porter, G., & Howard, D. (2005). Comprehensive Aphasia Test Manual.
Psychology Press, 11-45.
Whitworth, A., Webster, J., & Howard, D. (2014). A cognitive neuropsychological approach
to assessment and intervention in aphasia: A clinician's guide. Psychology Press, 21-
25.
Yee, E., Blumstein, S., & Sedivy, J. (2008). Lexical-semantic activation in Broca's and
Wernicke's aphasia: Evidence from eye movements. Journal of cognitive
neuroscience , 592-612.
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