Speech-language pathologists (SLPs) working in medical settings are frequently called upon to evaluate individuals who may have acquired language disorders. Determining whether a language disorder is present is not always a simple task. Language impairments may coincide with speech impairments, such as dysarthria or apraxia of speech, and/or with nonverbal cognitive impairments. The combination of impairments in these domains can affect communication in many ways. This chapter focuses on the process of diagnosing language disorders, which may or may not be accompanied by cognitive disorders, depending on the etiology and the specific nature of the impairment. The chapter serves as an overview and introduction to the subsequent chapters, which cover the assessment and management of individuals with aphasia (Chapter 5), dementia (Chapter 6), and traumatic brain injury (Chapter 7 and Chapter 8). This chapter does not cover speech disorders, such as dysarthria or apraxia of speech, and only briefly addresses other nonlanguage communication disorders, such as those associated with damage to the right hemisphere.
The second section of the chapter presents an overview of the domains of cognition that are important to consider when evaluating language disorders. This is followed in the third section by an introduction to diagnostic methods, including our particular use of the process approach. In the fourth section we present brief descriptions of the most common causes of acquired language disorders, using a general dichotomy of sudden- versus slow-onset disorders. Within this section we present five sample cases illustrating features of the disorders and the diagnostic challenges they pose. Individual cases of acute stroke, closed head injury, penetrating brain injury, brain tumor, and primary progressive aphasia were chosen to represent some of the most common types of adult language disorders SLPs are asked to evaluate in medical settings.
The primary goals of the chapter are (1) to highlight the importance of considering language impairments within the broader context of all areas of linguistic and nonlinguistic cognitive skills, (2) to present the reader with a panoramic view of the many types of disorders that may present with acquired language impairments in adults, and (3) to provide five case examples illustrating the diagnostic challenges inherent in evaluating language in adults.
4.2 Review of Cognition for the Speech-Language Pathologist
Somehow in the field of speech-language pathology, language became separated from cognition, but, in fact, language is one domain of cognition. Language does not exist in a cognitive vacuum; instead, it interrelates with all other primary domains of cognition. Thus, if SLPs are to diagnose and treat language disorders effectively, they need to have knowledge of all domains of cognition and how other cognitive domains interrelate with, and influence, language performance.
Broadly speaking, cognition is all of the processes by which sensory input is transformed, reduced, elaborated, stored, recovered, and used. 1 With this broad definition of cognition as a starting point, in this section we describe five primary domains of cognition: attention, executive functions, language, memory, and visuospatial skills. In doing so, we risk compartmentalizing concepts that overlap and interact. As Sivan and Benton 2 point out, cognitive abilities are inferred from behavior and all behavior is multiply determined. They illustrate this notion with an example in which a person’s poor performance on a test of abstract reasoning may be the result of problems with attention, verbal expression, or discrimination of stimuli, rather than impairment in conceptual thinking. Sivan and Benton’s conclusion that all behavior is multiply determined underscores the need for SLPs to understand aspects of cognition and how those aspects may influence language/communication performance. Therefore, SLPs must be prepared to apply a process approach (described below) for determining all the factors that might be contributing to impaired performance on any assessment or treatment task.
Again, we stress that tests and tasks designed to assess specific components of cognition do not, in fact, tap only that particular skill. Yet we use labels like executive function tests and sustained attention tasks. Cognitive scientists allow these designations because certain tasks may call upon one particular cognitive function to a greater extent than any other. For example, the classic trail-making task, which requires the person to draw a connecting line while switching between increasing numbers and the consecutive letters of the alphabet (a line from 1 to A to 2 to B and so on), is considered an executive function task because it requires mental flexibility and planning. This task, however, has a heavy language load and, therefore, may be impossible for people with aphasia (PWA), who no longer have access to alphabetic and/or number sequences. Trail-making also requires good attention, visual search and processing, and working memory (described below), and so requires relatively intact skills in these particular cognitive areas, which may be affected depending upon the type and site of brain damage.
It is also important to point out that while specific areas of the brain are associated with certain cognitive skills (e.g., the frontal lobes are so closely associated with executive functions, that these skills are sometimes called “frontal lobe behaviors”), the brain has widely distributed, overlapping neural networks that work together as we carry out various cognitive activities. With these caveats concerning the overlapping nature of domains of cognition and neural networks in mind, we now describe five primary domains of cognition and the areas of the brain that have been identified as largely providing the neurologic underpinnings for each form of cognition.
4.2.1 Attention
Simply speaking, attention is the ability to maintain a coherent line of thought or action. At the same time, “Attention is a complex neurobehavioral capacity without which the expression of all other higher functions of the human brain is impossible.” 3 Attention is closely related to, but distinctly different from, arousal. Arousal (as controlled by the thalamus and reticular activating system) is simply the degree of wakefulness exhibited by the individual. Note that disorders of arousal are always accompanied by attentional deficits but disorders of attention are not always accompanied by arousal deficits. Attention can be impaired even when arousal is normal. But, if individuals are not fully aroused, they will not have the capacity to demonstrate attention, and it will be impossible to validly assess all forms of cognition. Consider, too, that individuals in a subtle acute confusional state may be inattentive, distractible, and perseverative, yet have normal arousal as judged by the degree of wakefulness.
According to Parasuraman, 4 “Attention is not a single entity, but the name given to a finite set of brain processes that can interact, mutually and with other brain processes, in the performance of different perceptual, cognitive, and motor tasks” (p. 3). Cognitive psychologists attempt to classify forms of attention, often under the broad classifications of noncognitive forms versus cognitive forms. The noncognitive form of attention is referred to as passive attention. This is activated without conscious effort. The two mechanisms for passive attention are the startle response and the orienting response, which serve to alert an organism to sudden environmental changes, allow a stimulus to enter awareness, and automatically elicit a somatic or autonomic response. An example of this behavior is when a loud, unexpected noise causes reflexive muscle movements and changes in heart rate. Because our concern here is cognition, we concentrate on the cognitive forms of attention: sustained attention (vigilance), selective attention, divided attention, alternating attention, and executive attention.
Forms of Cognitive Attention
Sustained attention, also referred to as vigilance, involves maintenance of a consistent behavioral response during a continuous and repetitive activity. It allows us to respond to infrequent, random events in the environment. In everyday life, vigilance is required to operate sonar and security surveillance equipment that must be monitored for infrequent but highly important signals. Vigilance is needed for many tasks involving language, such as listening for the numbers on your Bingo card to be called.
Selective attention involves a set of mechanisms that enhance extended processing of attended stimuli or features of stimuli while filtering, inhibiting, and ignoring irrelevant stimuli. This ability to maintain a behavioral or cognitive set in the face of distracting or competing stimuli is referred to as “freedom from distraction.” In everyday life, selective attention allows us, for example, to read a book in a busy, noisy café.
Divided attention allows us to attend concurrently to multiple activities or to multiple components within a task. Divided attention taxes mental resources, and carrying out high-level concurrent tasks results in deterioration in performance, a phenomenon designated “concurrent cost.” An everyday manifestation of the concurrent cost of divided attention is the increased incidence of auto accidents caused by people talking or texting on their cell phones while driving.
Alternating attention allows us to quickly and without error switch our attention back and forth between tasks having different requirements. Alternating attention, therefore, requires mental flexibility—a skill that also is included in descriptions of “executive functions.” In everyday life, we need to apply alternating attention skills if we are, for example, to listen to a lecture and write notes pertaining to the lecture.
Executive attention, also referred to as attentional control, is not as well understood as other types of attention. It has been described as the ability to choose the aspects of the environment to be attended to in order to carry out our goals. This requires the coordination of multiple tasks and regulation of our responses while maintaining these behavioral goals. In everyday life, executive attention/attentional control is called upon in novel and conflict situations where various plans and responses are possible, such as how to achieve our travel goals when the weather suddenly has suspended air travel.
Neuroanatomical Correlates of Attention
Humans are continually subjected to a flood of sensory input from within us and from external sources, so without some kind of filtering mechanism, the neurobehavioral capacities of the brain would be overwhelmed. Of course, it is crucial that the brain be able to focus on important events that come to consciousness, and to attend to relevant aspects of experience that can influence all aspects of behavior. In fact, ability to attend is crucial for the effective operation of any higher cognitive or emotional system.
The most fundamental aspects of attention are mediated by the diffuse attentional system (DAS), represented in the human brain as a widespread collection of interconnected structures that has been referred to as the attentional matrix. The DAS is responsible for maintaining a tonic level of attention that permits the monitoring of both external and internal sensory events, and for ensuring that we are continually updated about sensory data crucial to functional adaptation. The most important structures mediating diffuse attention are the thalamus and the cerebral hemispheres. The centrally located thalamus participates in both arousal and attention. Thalamocortical connections are vital for engagement of cortices in the many cognitive domains to which they are dedicated. Damage to white matter tracts connecting the thalamus with the cerebral cortex can produce a broad array of neurobehavioral disturbances, including disorders of attention.
While diffuse attention is subserved by the brain’s widespread attentional matrix, selective deficits of attention imply relatively circumscribed involvement of brain regions subserving various attentional functions. For example, the distributed neural network of the spatial attentional system (SAS) allows for the distribution of attention to focal spatial stimuli. The SAS distributes attentional resources to the contralateral hemispace. Because the right hemisphere in most people is dominant for attention, right hemisphere lesions are associated with more frequent, severe, and lasting attentional disorders than are comparably sized and placed left hemisphere lesions.
4.2.2 Executive Functions
Executive functions are considered the highest level of human cognition. Executive functions are critical to performing all nonroutine, productive, independent activities, and include the ability to plan, sequence, and accomplish goal-directed activities in an organized but flexible manner as demanded by situational and environmental changes. Among the skills subsumed under the label of executive functions are the ability (1) to perceive stimuli from the environment; (2) to respond adaptively; (3) to flexibly change direction of response; (3) to establish future goals; (4) to consider consequences; (5) to respond in an integrated and common-sense way, utilizing all these capacities to serve a common purposive goal. 5 Note that executive functions are critical to problem solving, which also requires reasoning skills. An everyday life example of an activity that calls upon our executive functions is the planning and successful execution of a fund-raising event.
Neuroanatomical Correlates of Executive Functions
Earlier in this section, we mentioned that the frontal lobes are so closely associated with executive functions that these skills are sometimes called frontal lobe behaviors. It is, indeed, generally accepted that executive functions are mediated primarily by prefrontal regions of the frontal lobes, but it is important to note that these areas have multiple connections with other cortical, subcortical, and brainstem regions. For example, the frontal lobes’ dorsal lateral section, which is considered particularly important to executive functions, is heavily interconnected to the structures of the basal ganglia and the thalamus. Thus, although dysexecutive syndrome is associated with frontal lobe damage, damage to these subcortical structures also may result in impairment of skills subsumed under the category of executive functioning.
4.2.3 Language
According to Bloom and Lahey, 6 language can be divided into three separate but overlapping components: form, content, and use. It is important to note, also, that language is a complex system of human behavior composed of many interrelated components, and that various modalities of language performance interrelate with other domains of cognition.
Language Form
Three components of language are subsumed under the category of language form: (1) phonology, (2) morphology, and (3) syntax.
Phonology refers to the speech sounds or phonemes of particular languages and the rules for combining them. Thus we know, for example, that no English word starting with the letter j will be followed by another consonant, that the plural s is pronounced /s/ following t (e.g., rats) but /z/ following d (e.g., raids), and that the combination mn in the initial position is so rare that it appears in only one root word (i.e., mnemonic).
Morphology refers to the rules that govern words at the most basic level of meaning: the morpheme. Morphology allows us to modify word meaning by adding or subtracting morphemes from root words; for example, by adding an –s to rat, we indicate the concept of “more than one.” By adding –ed to raid, we indicate that this activity took place sometime in the past. Morphology combines features of semantics and syntax, as is demonstrated in cases of aphasic agrammatism, in which conceptual, but not syntactic, knowledge may be retained. These patients may omit morphemes but indicate meaning with additional words (e.g., “rat – two” or “Yesterday…police raid house.”).
Syntax is the set of rules that govern word order in particular languages (i.e., the acceptable combinations and sequences for subtypes of words). Syntax also has a strong cognitive/semantic component, so that we know, for example, that transitive verbs are followed by another noun (e.g., “He cut …”). Syntactic rules also allow us to rearrange words to indicate the same concepts (e.g., “When things get tough, the tough get going.” versus “The tough get going, when things get tough.”) or to indicate different concepts (e.g., “She is smart” versus “Is she smart?”).
Language Content
Language content consists primarily of semantics.
Semantics refers to conceptual knowledge: the knowledge of meaning. This knowledge allows us to abstract single features of entities, to use these features for organizing the world, and to apply symbols to these concepts. It is our semantic knowledge that allows us, for example, to categorize whales as mammals because they breathe air and give birth to live young that they feed via mammary glands. Our semantic knowledge also provides us the basis for knowing that a living being may be killed by an inanimate object, such as a shovel, but the opposite cannot be true.
Language Use
Language use is often referred to as language pragmatics.
Pragmatics refers to the permissible ways language can be used (i.e., the rules that allow us to use the other aspects of language to communicate appropriately). Language pragmatics, therefore, may be regarded as a social tool. Examples of language utilization as guided by our pragmatic knowledge include how to enter, carry on, and exit a conversation; how to use the correct level of formality in our language when speaking or writing to a particular person (e.g., a professor versus a girlfriend); when and how to use humor or sarcasm; and how to understand the unstated meanings of indirect requests (e.g., “Don’t you think that we’ve been at this party long enough?”).
Neuroanatomical Correlates of Language
As is the case with all complex cognitive skills, language arises from the dynamic interaction of multiple anatomical regions. Still, it is the so-called zone of language that plays a primary role in this cognitive skill. We know this because damage to this area characteristically results in some form of aphasia. The zone of language, typically located in the left hemisphere within the distribution of the middle cerebral artery, surrounds the sylvian fissure on the lateral surface of the hemisphere, incorporating portions of the frontal, parietal, and temporal lobes. Broca’s area, which is associated with verbal expression, is located anteriorly in the premotor region. Wernicke’s area, which is associated with attaching meaning to incoming verbal messages, is located in the posterior portion of the superior temporal gyrus. Broca’s area is connected with Wernicke’s area by subcortical white matter pathways, including the arcuate fasciculus and superior longitudinal fasciculus. These white matter pathways pass through the angular gyrus and supramarginal gyrus at the posterior rim of the sylvian fissure. Both gyri are association areas, with neural interconnections from many regions of the brain. Helm-Estabrooks, Albert, and Nicholas 7 pointed out that it is a mistake to consider the zone of language as a “center” for language or the region of the brain where language is located. “Rather, the zone of language should be regarded as a critical component and major intersection of several overlapping neural networks, widely distributed throughout the brain, whose total combined activity has the effect of producing language as we know it.” 7 Furthermore, the pragmatic aspects of language use seem to have strong associations with areas of the nondominant (typically the right) cerebral hemisphere.
4.2.4 Memory
Memory is not a single cognitive behavior; instead, there are several forms of memory subserved by various brain structures. Forms of memory depend on the way different stimuli are encoded, stored, and retrieved. 8 One approach to discussing various forms of memory is to first make the distinction between nondeclarative and declarative types.
Nondeclarative Memory
Nondeclarative memory systems are less accessible to conscious recollection and verbal retrieval. There are two forms of nondeclarative memory: (1) procedural memory and (2) implicit memory.
Procedural memory is used in the acquisition of skills and habits. It results from repeated practice and allows us to perform automatic tasks that were learned gradually. Some procedural memories are learned without ever having entered our conscious awareness and are used to perform tasks without thinking about them. This allows us to turn our attention and thoughts to stimuli and tasks requiring purposeful use of cognitive resources. Procedural memory is relatively impervious to effects of decay and interference and may be the last form of memory to be affected by Alzheimer’s disease. In everyday life, procedural memory allows us, for example, to brush our teeth while thinking about how to approach our boss about a bothersome issue.
Implicit memory does not require awareness of the learning episode and there is no conscious effort to retrieve the information. Instead, something you have seen or heard before subconsciously influences your subsequent performance. One of the experimental techniques used to demonstrate implicit memory involves “priming.” Often, priming studies involve confrontation naming tests and are designed to prime a later response with an earlier test item. These studies demonstrate that, for example, subjects are able to name the item “syringe” faster if they named the item “nurse” earlier than if no medically related items preceded the presentation of “syringe.” In everyday life, we may demonstrate implicit memory and the priming effect when doing crossword puzzles. For example, if we wrote “glasses” in response to the clue “spectacles” early in the puzzle, we would be quicker to respond “gaze” to the later clue “stare.”
Declarative Memory
Declarative forms of memory involve the storage of facts that can be stated or discussed. Two types of declarative memory are (1) episodic memory and (2) semantic memory.
Episodic memory allows us to recall and explicitly state conscious experiences from our personal past. Therefore, episodic memory is often referred to as “autobiographical memory.” The characteristic components of episodic memory involve perceptual, conceptual, and affective information. In everyday life, episodic memory allows us, for example, to remember our high school prom—the smell of a corsage, the rotating crystal balls of light, and the excitement of wearing our first ball gown or tuxedo.
Semantic memory involves the acquisition and retention of generic factual information not referenced to a specific learning context. It encompasses a wide range of information that can be explicitly stated, such as facts about the world, meanings of words and concepts, and names attached to objects and people. Some entries in our semantic memory are acquired with a single exposure (e.g., learning that limes are a citrus fruit, while others are gradually acquired, e.g., understanding the concept of the Internet). In everyday life, semantic memory allows us, for example, to play along with the contestants on “Jeopardy.” Semantic memory is also one component of the memory system that overlaps with the language system.
Working Memory
Working memory (WM) is regarded both as a form of memory and a component of executive functions. As such, it is conceptually separate from the declarative/nondeclarative dichotomy presented above. WM is used in performing tasks requiring short-term storage and manipulation of new, or previously learned, information. It is integral to performing a variety of cognitive tasks, such as reading and understanding stories and performing online reasoning tasks. Working memory requires flexible, quick, frequent updating of information. Therefore, it is limited in its capacity. Its contents are fragile and, if not rehearsed, decay rapidly. In everyday life, it is working memory that allows us to perform such tasks as mentally adding up the prices of items in our shopping cart. Neuropsychologists typically assess verbal working memory with the task known as digits backward: a series of numbers is spoken aloud and the person being evaluated is required to say the numbers back in the reverse order. To do this successfully, one has to recall the sequence and manipulate it internally into a reverse order. Holding onto information and then performing some further manipulation with it is the essence of the cognitive skill known as working memory.
Neuroanatomical Correlates of Memory
Many brain structures are involved in memory, and these areas are integrated in complex ways. For example, Moscovitch et al 9 used lesion and neuroimaging information to examine the neuroanatomical bases for episodic, semantic, and spatial memory. They found that the hippocampus system (part of the limbic system) plays a role in these three forms of memory. Other structures involved in various forms of memory are the prefrontal cortex, which subserves working memory, and the basal ganglia, which are involved in procedural memory. But, again, it is important to remember that all brain structures involved in various forms of memory are reciprocally interrelated.
4.2.5 Visuospatial Skills
Visuospatial skills are complex processes and are the higher-level visual processes that allow us to discriminate, analyze, understand, and manage spatial components of our visual experiences. Visuospatial skills have two main components: visuoperception and visuoconstruction.
Visuoperception involves the ability to discriminate, identify, synthesize, and analyze simple and complex forms. It also allows us to analyze novel stimuli as well as to recognize familiar stimuli and to interpret what is seen.
Visuoconstruction combines visual perception skills with motor responses. It also allows us to mentally or manually manipulate parts of objects and combine them to depict the whole. Visuoperception problems will affect visuoconstruction even in the presence of good motor skills because of faulty visual analysis. Poor construction skills also can result from motor problems alone in the presence of good perception. In everyday life, visuospatial skills allow us, for example, to perceive and analyze the speed and distance of vehicles in order to cross a busy street safely, and to draw a map showing someone how to get to our house.
Neuroanatomical Correlates of Visuospatial Skills
The right and left cerebral hemispheres have differential influences on visuospatial skills. For example, the right hemisphere is more engaged in the distribution of spatial attention and in perceiving and producing global structure. In contrast, the left hemisphere is more engaged in the perception and production of elements of structures. Fragmentation of visual processing can occur with damage to either hemisphere, but visual dissociation and neglect are associated more commonly with right hemisphere damage, particularly in the ventral and occipitotemporal region. Other brain areas that appear to subserve aspects of visuospatial skills are the right corpus striatum for mental rotation, and the caudate nucleus and putamen (as part of the cortical-subcortical network) for receiving direct input from parietal regions that are important for integrating both visuoperceptual and visuoconstruction processes.
4.3 The Diagnostic Process in Assessing Language Disorders
The diagnostic challenge for the SLP in medical settings can be daunting, given the wide variety of etiologies leading to language disturbances in adults and the likelihood of also having accompanying speech and/or cognitive deficits in any of the domains of cognition described above. An important first step prior to beginning the evaluation is to carefully read the available medical records related to the pertinent medical, social, and treatment history of the individual. The frequent complexity of cases seen in medical settings is one reason why the use of the “process approach” in assessment is crucial. 7, 10, 11 The process approach 7, 10, 11 refers to a diagnostic mindset in which all aspects of behavior are carefully observed and recorded during an evaluation session.
When using the process approach with standardized measures, responses are recorded not just as correct or incorrect. Correctness is important, but other aspects of behavior are carefully noted and subject to analysis as well. These include how long the person is taking to respond, the specific nature of each error response, how responses to one stimulus might relate to previous responses made on the exam, whether one input modality seems better preserved than another (e.g., spoken language input versus written language input), and how behavior might be affected by the specific environmental context and testing room conditions. When administering informal assessment measures, the observant diagnostician uses the process approach to determine what needs to be probed further. In addition, the process approach clinician will often explore what types of cues are most likely to elicit a correct response after an error response has been made.
The process approach mindset is related to the concept of conducting a task analysis. In both assessment and treatment tasks, the SLP needs to be aware ahead of time exactly what cognitive processes are required by the task that she or he is asking the person to perform. For example, does the task load heavily on verbal working memory, or draw upon visuoconstruction skills, or perhaps a combination of these? Careful determination of the stimulus characteristics as well as response requirements is part of the task analysis. For example, questions about the test or treatment stimulus should be asked, such as, Is the stimulus a spoken word, a written word, a combination of both? Is the stimulus a picture or an abstract form? Is the stimulus in a test booklet or is it an object in the world? If it is in a test booklet, where on the page is it? Is it part of a vertical list or a horizontal list? How complex are the task instructions in terms of syntactic and semantic complexity? These are just a few examples of the kinds of questions the SLP needs to consider when planning for a diagnostic session. Without a careful task analysis, interpretation of performance may be erroneous.
When analyzing responses made by the person being evaluated, the process approach clinician is continually observing and noting all on-task as well as off-task behaviors. An example of how the process approach provides the clinician with important information is illustrated in the following scenario.
A woman with suspected aphasia post-stroke is being evaluated with a standardized measure, such as the Boston Diagnostic Aphasia Examination-3 (BDAE-3). 12 A subtest designed to evaluate auditory comprehension of single words is administered. The task analysis indicates that the input is a spoken single word or phrase, such as “show me the bear,” and the woman is asked to respond by pointing to the picture that matches the word “bear” from a set of four pictures. In this particular case, she pointed to only 6 of 30 items correctly, indicating she likely had a significant difficulty with the auditory comprehension of single words. The SLP was somewhat surprised by this, however, because in an earlier conversation with the patient about her family, it seemed as if she understood almost all questions quite well. The observant SLP also noted that the individual spontaneously and correctly repeated 25 of the 30 stimulus words on the subtest, even though repetition of the word was not part of the task requirements. The score sheet contained the 6 “correct” checkmarks and a number of “x” marks indicating the error responses. The examiner also recorded exactly which pictures were pointed to in error so she could analyze afterward whether there were any patterns to these errors. In order to do this, the SLP also needed to be aware of how the picture foils may have related to the target stimulus. For example, for the stimulus “bear,” were the foil pictures also animals? Or were they other types of items? Was there any pattern to the errors in terms of where items that were pointed to were placed on the page? For example, if the target picture was placed on the right or the left of the page, did this interact with the patient’s ability to point to the correct target? Finally, why did her auditory comprehension seem so much better in the earlier social conversation on personally relevant topics?
On a subsequent test of single-word repetition skills, the woman was not able to repeat any of the stimulus words correctly. How should this repetition performance be interpreted, when this same individual repeated 25 of 30 stimulus words in the earlier subtest of auditory comprehension? What does a task analysis reveal about the difference between these two tasks? In the first (auditory comprehension of single words), no verbal expression is required; for the other (repetition), overt and specific verbal expression is required. The specific target words also are not the same across the two tasks. Was this an important factor? In attempting to answer these questions, the clinician may decide to administer further standardized measures or may develop additional stimuli to test various hypotheses she may have about what is occurring. There are no clear-cut answers to any of these questions. The point of the example is to highlight how the process approach allows for a much deeper understanding than simply stating that both auditory comprehension and single-word repetition were severely impaired, which is the result of the accuracy scores alone on the standardized subtests. Clearly, auditory comprehension in some contexts could be quite good for this woman, as could repetition of single words in other contexts. The process approach to diagnosis allows for a more nuanced and accurate interpretation of performance.
Many standardized assessments are targeted toward specific populations of individuals, for example the Western Aphasia Battery (WAB), 13 and the BDAE 12 are for patients with suspected aphasia. The BADS (Behavioral Assessment of the Dysexecutive Syndrome 14) was designed for people with traumatic brain injury (TBI) and other etiologies expected to display difficulties with executive functioning. Subtests on these measures and, indeed, almost any formal assessment, require both language and nonlinguistic cognitive skills to various degrees. A person with aphasia may perform poorly on the BADS, but the SLP should consider whether this is because of the aphasia or because of executive system dysfunction. Similarly, a person without aphasia may perform poorly on the BDAE or the WAB not because of language impairment but because the subtests of these measures also rely to some extent on nonverbal cognitive skills. For this reason, every assessment should include aspects of both language and nonverbal cognition. The skilled diagnostician learns to interpret individual performances on formal assessments very carefully. In Chapter 5, Chapter 6, Chapter 7, and Chapter 8, details about the assessment of aphasia, TBI, and dementia are presented. For convenience, some of the common standardized assessments available for the disorders likely to affect language and cognition in adults are presented in ▶ Table 4.1.
Test and Authors | Target Population | Features |
Boston Diagnostic Aphasia Examination, 3rd Edition (BDAE-3) by H Goodglass, E Kaplan, & B Barresi (2001) 12 Includes Boston Naming Test (BNT) | Adults with aphasia | Comprehensive battery for evaluating auditory comprehension, verbal expression, reading, and writing in people with aphasia. Aphasia Severity Rating (ASR), syndrome descriptions, and profiles of speech/language characteristics. |
Western Aphasia Battery–Revised (WAB–R) by A Kertesz (2006) 13 | Adults with aphasia | Comprehensive battery for evaluating auditory comprehension, verbal expression, reading, and writing in people with aphasia. Aphasia Quotient (AQ) and syndrome descriptions. |
Aphasia Diagnostic Profiles (ADP) by N Helm-Estabrooks (1992) 56 | Adults with aphasia | Diagnostic profiles similar to Boston Diagnostic Aphasia Examination and Western Aphasia Battery. |
Cognitive Linguistic Quick Test (CLQT) by N Helm-Estabrooks (2001) 32 | Adults with aphasia; Adults with acquired brain damage | Provides assessment of language ability and nonverbal cognitive abilities in attention, memory, executive functioning, and visuospatial skills. Norms available for healthy controls. |
Porch Index of Communicative Abilities Revised (PICA-R) by B Porch (2001) 57 | Adults with aphasia or other communication impairments | Unique, detailed, multidimensional scoring system for all responses. |
Psycholinguistic Assessments of Language Processing in Aphasia (PALPA) by J Kay, M Coltheart & R Lesser (1992) 58 | Adults with aphasia | Sixty subtests. Uses a psycholinguistic model approach. |
Reading Comprehension Battery for Aphasia-2 (RCBA-2) by L LaPointe & J Horner (1998) 59 | Adults with aphasia | Reading Comprehension and Oral Reading subtests, single words to paragraph length. |
Communication Activities of Daily Living, 2nd edition (CADL-2) by A Holland, C Frattali, & D Fromm (1999) 60 | Adults with aphasia | Assessment of functional, pragmatic communication in role-play situations |
Functional Assessment of Communication Skills for Adults (ASHA FACS) by C Frattali, A. Holland, C Thompson, C Wohl, & M Ferketic (2003) 61 | Adults with communication impairment | Behaviors rated in four domains: Social Communication; Basic Needs; Reading, Writing and Number Concepts; and Daily Planning. Uses 7-point scale of independence. Family member or caregiver reports used. |
Communicative Effectiveness Index (CETI) by J Lomas et al (1989) 62 | Adults | Checklist filled out by caregiver that asks questions referring to 16 different functional communication situations. |
Boston Assessment of Severe Aphasia (BASA) by N Helm-Estabrooks, G Ramsberger, A Morgan & M Nicholas (1989) 63 | Adults with severe aphasia | Both verbal and gestural responses scored. Includes auditory comprehension, reading comprehension, praxis, repetition, gestural production, drawing, and signature items. |
The Bilingual Aphasia Test (BAT) by M Paradis et al 64 | Adults with aphasia | Available in many different languages online: http://www.mcgill.ca/linguistics/research/bat/ |
Wechsler Adult Intelligence Scale–4th Edition (WAIS–IV) 33 | Adults with or without brain damage | Comprehensive assessment administered by psychologists; scores for both Verbal IQ (VIQ) and Performance IQ (PIQ) are obtained. |
Wechsler Memory Scale–4th Edition (WMS-IV), by Pearson Education (2008) 65 | Adults with or without brain damage | Comprehensive assessment results in five Index Scores: Auditory Memory, Visual Memory, Visual Working Memory, Immediate Memory, and Delayed Memory |
Ravens Coloured Progressive Matrices by JC Raven (2003) 34 | Children and adults | Visual pattern matching and visual analogical reasoning |
Behavioural Assessment of the Dysexecutive Syndrome (BADS), by B Wilson, N Alderman, et al (1996) 14 | Adults with TBI | Designed to predict everyday problems associated with the dysexecutive syndrome. |
The Ross Information Processing Assessment, 2nd Edition (RIPA-2) by D Ross-Swain (1996) 66 | Adolescents and adults with TBI | Assesses cognitive-linguistic functioning |
The Mini Mental State Examination (MMSE) by MF Folstein, SE Folstein, & PR McHugh (1975) 67 | Adults | Short screening of mental status, including language and cognition. Used widely by physicians. |
The Mini Inventory of Right Brain Injury–Second Edition (MIRBI-2) by P Pimental & J Knight (2000) 68 | Adults with right hemisphere brain injury or stroke | Screen for neurocognitive deficits associated with right hemisphere lesions |
The Arizona Battery for Communication Disorders of Dementia (ABCD) by K Bayles & C Tomoeda, (1993) 69 | Adults with dementia | Fourteen subtests that evaluate linguistic expression, linguistic comprehension, verbal episodic memory, visuospatial construction, and mental status |
Frequently, the SLP in medical settings is faced with the need to conduct a more informal bedside evaluation as a first step in the diagnostic process. The informal assessment can be conducted with the same process approach mindset as the formal assessment. At a minimum, the SLP should attempt to evaluate something from each of the key domains of cognition, including language, that are outlined earlier in this chapter. Sample items to be included in an informal bedside assessment of language functions are listed in ▶ Table 4.2. Sample items for an informal assessment of nonverbal cognition, including items assessing attention, memory, executive function, and visuospatial processing, are presented in ▶ Table 4.3.
Note: Responses of individual patients are used to guide modifications of suggested tasks and stimulus choices so as to enhance performance of patients with more severe impairments and to identify deficits in patients with mild impairments. | ||
Take to exam: Matches, standard watch, variety of coins and dollars, pen and paper Wear: Jacket with collar, lapels, pocket(s) | ||
Core Tasks | Responses | |
A. Obtain discourse sample | Probe question: “What happened to you?” | |
Optional probes if first does not elicit speech sample: “What problems are you having now?” “What did (do) you do for a living?” “Tell me about your family” | ||
B. Assess auditory comprehension skills | “I’d like you to follow some commands for me.” “Sit up straight.” “Close your eyes.” “Open them.” “Look around the room” “Point to the door.” “Point to the source of illumination.” “Point to the floor and the exit.” | |
Transition to body part identification | “Point to your nose.” “Point to your cheek.” “Point to your elbow.” “Where are your lungs?” If did not point to cheek: “There’s a smudge on your cheek. Wipe it off.” | |
Place penny, nickel, dime, quarter, and a $1, $5, and $10 bill in random order before the patient | “Where’s the penny?” “Where’s the quarter?” “Give me the dime and the nickel.” (Replace) “Give me six dollars.” (Replace) “Which bill is worth the most?” | |
C. Assess naming skills: Use standard watch | “What do you call this (these)?” Point to the Watch Band Numbers Buckle Stem Face/Crystal | |
Use standard examiner’s jacket | “What do you call this (this part)?” Indicate the Jacket Collar Sleeve Lapel Cuff | |
Use money items | “What is this?” Hold up the Penny Quarter Five dollar bill | |
Optional for detecting milder naming problems | Generative naming “Tell me as many different animals as you can.” (allow 1 minute) | |
D. Assess repetition skills | “Repeat after me:” “Bed” “Pizza” “Money” “I love you” “She may be with him” “One hundred seventy-two” “Happy hippopotamus” | |
Optional Tasks | ||
A. Briefly assess reading (if response to auditory comprehension is poor) | Show the following printed words, one at a time. Indicate that patient should point to body parts to match the word: Nose Cheek Elbow Lungs | |
Place money before patient. Show the following printed words and ask patient to point to matching money item: Penny Quarter Six dollars | ||
B. Briefly assess writing (if response to naming exam is poor) | Place paper pad in front of patient and provide a pen. Indicate object or part and ask patient to write names: Watch Buckle Jacket Cuff Penny Dime Patient’s own name | |
C. Briefly assess praxis | “Use this hand and without talking; show me how you” (if patient is unable to execute each command, provide a model for imitation) “Wave Goodbye” “Use a hammer to pound a nail” “Stick out your tongue” “Blow out candles on a birthday cake” (If patient is unable to imitate blowing, use a lit match, then unlit match, then do command once more) | |
D. Assess singing | “Do you like to sing? Let’s see if singing helps your speech.” Assist patient in singing “Happy Birthday” If singing facilitates speech, try another familiar song. | |
Adapted from Appendix 10.A Suggestions for an Informal Exam, in Manual of Aphasia and Aphasia Therapy, 2nd Ed. (pp. 134-137), by N. Helm-Estabrooks and M. L. Albert, 2004, Austin, TX: PRO-ED. Copyright 2004 by PRO-ED, Inc. Adapted with permission. Further reproduction is prohibited without permission of the publisher. | ||
Take to exam: 12 sheets of blank 8 ½ x 11 inch unlined paper, felt-tip pen for examinee and pen/pencil for examiner; 6 common objects (e.g., pen, watch, keys, glasses, cell phone, ring) and two $1 bills. Present the blank sheets of paper in landscape orientation. | ||
Core Tasks | Responses | |
A. Prospective memory task Assesses the ability to encode a new memory about the location of a hidden item and retrieve that information after a delay of 10–20 minutes. | Hold up the dollar bill and show it to the examinee. Say, “Watch me, because I am going to hide this dollar bill and I want you to remember where I put it.” Then hide the bill somewhere in the near vicinity of the examinee but not in plain sight. Make sure the examinee is attending well to you as you do this. Ask, “Where did I put it? Show me.” If the examinee fails to point to the correct location, take the bill out again and show again where you are hiding it. Ask the examinee to point to the location once more. Say, “Now remember where it is, I’ll ask you later.” | |
B. Clock Drawing Assesses visual planning and graphomotor ability to create a drawing of a clock. Requires auditory comprehension of syntactically complex instructions. | Say, “Use this pen and draw a clock on this piece of paper. Put in all the numbers and set the hands of the clock at 10 minutes after 11.” Also write these same instructions on the top of the page. If the examinee cannot get started, draw a circle and repeat the instructions, “This is a clock, put in all the numbers and set the hands at 10 minutes after 11.” | |
C. Line bisection Assesses visual scanning and visual analysis. Used to detect visual hemi-attention deficits. | On a new sheet of paper, draw approximately 8 to 10 lines of varying lengths (½ inch long up to 2 inches long), at various orientations on the piece of paper. Hand the examinee a pen and say “See all these lines? I want you to put a mark exactly in the center or the middle of each one.” Demonstrate by drawing a center mark on one of the lines, if needed. | |
D. Repeated graphomotor patterns Assesses visual analysis and graphomotor control. Used to detect perseveration in graphomotor production. | On a new sheet of paper, draw a pattern like the following with three repetitions of the pattern and ask the examinee to repeat the pattern all the way across the page.
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Assesses visual analysis and graphomotor control. Used to detect perseveration in graphomotor production. Assesses cognitive flexibility required to produce new pattern. | On a new sheet of paper, draw a (different) pattern like the following with three repetitions of the new pattern and ask the examinee to repeat the new pattern all the way across the page.
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E. Figure copying and drawing Assesses ability to represent two–dimensions in a drawing from a model. | Drawing to Copy. On a new sheet of paper in the top half of the sheet, draw a cube showing a front, a top, and a side and ask the examinee to copy the drawing under it. (See example cube below).
If the examinee has difficulty, draw a simple square and repeat the request for a copy of the square. Then reintroduce the Necker cube. | |
Assesses immediate visual memory and ability to represent two–dimensions in a drawing from a model. | Immediate Recall. Immediately after the copy task, present a new piece of paper and remove the earlier drawings. Say, “Remember that drawing you just did? Please do it again.” | |
Assesses short-term visual memory and ability to represent two–dimensions in a drawing from a model. | Delayed Recall. After an interval of at least 5 minutes, but not more than 15 minutes, present a new piece of paper and remove the earlier drawings. Say, “Remember that drawing you just did? Please do it again.” | |
