VATA-L: visual-analogue test assessing anosognosia for language impairment

Lack of awareness (anosognosia) for one's own language impairments has rarely been investigated, despite hampering language rehabilitation. Assessment of anosognosia by means of self-report is particularly complex, as a patient's language difficulties may seriously prevent or bias the assessment. Other methods, such as measures of self-correction and error detection, have provided valuable information, although they are an indirect form of assessment of anosognosia and are not exempt from methodological criticisms. In this study we report on a new tool, the VATA-L (Visual-Analogue Test for Anosognosia for Language impairment), geared at assessing explicit anosognosia for aphasia. The VATA-L compares the patient's self-evaluation with caregivers' evaluations of the patient's verbal communication abilities in a series of common situations. By means of non-verbal support and a system of check questions, this test minimizes some of the methodological limitations of existing diagnostic tools (e.g., structured interviews), enhancing reliability, and enabling assessment of patients with aphasia. Finally, normative data provided in the study allow a clearer interpretation of the patient's performance and facilitate assessment of anosognosia.     

Vata-m: Visual-Analogue test assessing Anosognosia for motor impairment

There has been a growing interest in anosognosia in both clinical and research domains, yet relatively little attention has been paid to methods for evaluating it. Usually, the presence and severity of anosognosia is assessed by means of structured interviews or questionnaires. Both interviews and questionnaires can provide valuable information, but they rely heavily on self-evaluation and language, and are therefore prone to bias and pose more difficulty in the assessment of aphasic patients. The aim of this study was to develop a new tool, the VATAm (Visual-Analogue Test for Anosognosia for motor impairment), to assess explicit anosognosia for motor impairments. The VATAm is a questionnaire that compares a patient's self-evaluation with a caregivers’ evaluation of the patient's abilities on a series of motor tasks. In addition, the test overcomes some of the limitations of the existing structured interviews and questionnaires, by enhancing reliability, improving data interpretation and diagnosis, and enabling assessment of patients with aphasia.     

Understanding the relationship between language proficiency,language impairment and rehabilitation: Evidence from a case study

The goal of this study was to address the relationship between language proficiency, language impairment and rehabilitation in bilingual Russian–English individuals with aphasia. As a first step, we examined two Russian–English patients' pre-stroke language proficiency using a detailed and comprehensive language use and history questionnaire and evaluated their impairment using the Bilingual Aphasia Test. We then attempted to replicate and extend Kiran and Roberts' study in 2010, examining results of a primarily semantic treatment for anomia in one Russian–English bilingual patient. The patient's ability to name the trained and untrained items in both the trained (English) and untrained (Russian) languages significantly improved by achieving 100% accuracy. Finally, we examined whether improvements observed in treatment were captured by a broader language test such as the Bilingual Aphasia Test. Results are discussed with respect to factors contributing to the successful treatment and the implications of rehabilitation on assessment of language skills as a function of treatment.     

Anosognosia and self-correction of naming errors in aphasia

ABSTRACT

Background: There has been comparatively little research into anosognosia for aphasia (a lack of awareness of acquired language deficits). Direct assessments of metacognitive awareness tend to rely on high levels of verbal competence and are difficult for people with aphasia to complete. Therefore, indirect measures of awareness have been considered, notably the person’s self-correction of his or her naming errors. Different mechanisms for self-correction based in comprehension or production skills have been proposed. In addition, in other areas of cognition, the relationships between direct and indirect measures and underlying forms of awareness have not been clearly established.

Aims: The aims of this study were: (a) to investigate the relationship between a direct and an indirect measure of awareness of aphasia, (b) to examine the role of executive functioning in performance on both assessment types, and (c) to examine the relationship between these measures and underlying language comprehension and production skills.

Methods & Procedures: A total of 48 people with aphasia participated, drawn from rehabilitation hospital caseloads. Participants were assessed on a language battery, a non-verbal test of executive function, a direct measure of awareness (ratings of difficulties), and had self-correction behaviour examined in a 40-item naming test.

Outcomes & Results: There was a trend relationship between performance on the direct and indirect measures. Both related to overall severity of language impairment, with more severely impaired people being less aware of their difficulties. The two measures, however, dissociated with respect to single-word production and comprehension scores: the direct measure related to production and not comprehension, while the indirect measure related to comprehension and not production. Executive functioning related only to the direct measure of metacognitive awareness. Within production scores, the rate of correction success rather than pre-correction naming rate was associated with metacognitive awareness.

Conclusions: This study revealed different underlying bases, in language processes and executive function, for two measures of anosognosia for aphasia. When used to assess awareness of deficits, direct and indirect methods should not be regarded as equivalent.     

Clinicoanatomical correlation in stroke related aphasia

Context:

With advances in neuroimaging, traditional views regarding the clinicoanatomic correlation in stroke patients with aphasia are being challenged and it has been observed that lesions at a given cortical or subcortical site may manifest with different aphasia profiles.

Aims:

To study as to whether there is a strict clinicoanatomical correlation between the type of aphasia and lesion site in patients with first ever stroke.

Settings and Design:

Observational study, based in a tertiary care center.

Materials and Methods:

Stroke patient''s ≥18 years of age were screened and those with first ever stroke and aphasia were subjected to a detailed stroke workup and language assessment using the Hindi version of Western Aphasia Battery (WAB). Statistical analysis was done with χ² test with Yates correction and Kruskal-Wallis test. The level of significance was set at P < 0.05.

Results:

Overall aphasia was detected in 27.9% of the 260 screened cases with stroke. Amongst 60 cases with first ever stroke and aphasia, the aphasia type was: Global (33.33%), Broca''s (28.3%), transcortical motor (13.33%), transcortical sensory (10%), Wernicke''s (8.33%), anomic (5%), and conduction (1.67%) aphasia. A definite correlation between the lesion site and the type of aphasia as per the traditional classification was observed in 35% cases only.

Conclusions:

No absolute correlation exists between the lesion site and the type of clinical aphasia syndrome in majority of the patients with cortical and subcortical stroke.     

CASE STUDY Testamentary capacity and aphasia: A descriptive case report with implications for clinical practice

Background: Testamentary capacity (the capacity to make a will) is recognised in the literature as an important issue for speech‐language pathologists' assessment of people with aphasia, but current guidelines for clinical practice lack an empirical base. Aims: The research aimed to suggest some guidelines for clinical practice based on information considered relevant for the court in determining testamentary capacity. Methods & Procedures: A recent legal case involving a challenge to the will of a woman with severe aphasia was critically examined with reference to current guidelines in the literature regarding assessment of testamentary capacity. Outcomes & Results: Examination of the information available on the case indicated that the judge gave priority to accounts of the everyday communication of the person with aphasia (including reported discourse samples) over the information provided by expert medical witnesses. The extent to which communication effectiveness could be maximised was found to be a matter of key significance to the determination of capacity. Conclusions: This study has implications for speech‐language pathologists' assessment practices and reports, as well as for scope of practice with regard to legal decision making of people with aphasia. These issues are discussed in relation to the World Health Organisation's ICF framework of functioning for social participation.     

Why Is It Difficult to Predict Language Impairment and Outcome in Patients with Aphasia after Stroke?

One of the most devastating consequences of stroke is aphasia. Communication problems after stroke can severely impair the patient''s quality of life and make even simple everyday tasks challenging. Despite intense research in the field of aphasiology, the type of language impairment has not yet been localized and correlated with brain damage, making it difficult to predict the language outcome for stroke patients with aphasia. Our primary objective is to present the available evidence that highlights the difficulties of predicting language impairment after stroke. The different levels of complexity involved in predicting the lesion site from language impairment and ultimately predicting the long-term outcome in stroke patients with aphasia were explored. Future directions and potential implications for research and clinical practice are highlighted.     

A Case Study of Primary Progressive Aphasia: Improvement on Verbs After rTMS Treatment

This case-report shows that high frequency repetitive Transcranial Magnetic Stimulation (hf-rTMS), applied to the left prefrontal cortex, may improve the linguistic skills in Primary Progressive Aphasia (PPA). The patient's performance was evaluated on a battery of language production and memory span tasks, before and after two hf-rTMS treatments and one SHAM treatment. We observed a significant and lasting improvement of the patient's performance on verb production following the application of hf-rTMS versus Baseline and SHAM conditions. This finding suggests that hf-rTMS may directly strengthen the neural connections within an area of metabolic dysfunction and encourages the use of rTMS as an alternative therapeutic tool for neurodegenerative forms of aphasia.     

Crossed aphasia with jargon aphasia in two right-handed patients (author's transl)]

Two cases of crossed aphasia in right-handed patients are reported. The oral language of these two patients was characterized by a reduction in its lexical and grammatical content. Their written language, however, was a veritable jargon with anosognosia. The jargon aphasia of the first patient consisted mainly of neologisms. The written language of the second patient was slightly less disorganized and corresponded to an asemantic jargon. The existence of this jargon aphasia gives these two observations an exceptional character in relation to other cases of crossed aphasia in right-handed patients. It supplies new information which can be the basis for discussion on the relations between cerebral laterlization of language functions and manual preference.     

Primary progressive aphasia in a bilingual speaker: a single-case study

We report on the case of an elderly bilingual woman presenting with a diagnosis of primary progressive aphasia. The participant's native language was Friulian (L1), a predominantly oral Romance language, and her second language was Italian (L2), formally learned at primary school in oral and written forms. We investigated her linguistic abilities by means of the Bilingual Aphasia Test ( . The assessment of bilingual aphasia. Hillsdale, NJ: Lawrence Erlbaum Associates), which is specifically devised for studying language levels and skills in bilingual/polyglot individuals with aphasia. Specifically, we focused on different tasks extracted from the Bilingual Aphasia Test, targeting phonology, morphology, syntax and lexical semantics. Results show that both languages were affected to a clinically significant degree, but with different profiles in terms of linguistic levels, suggesting the presence of greater phonological, morphological, grammatical and syntactic impairments in L2. Results are discussed in terms of possible dissociations both within the language system of each language and between languages, within the Procedural/Declarative theoretical framework of language acquisition in bilinguals.     

Time reference in nonfluent and fluent aphasia: a cross-linguistic test of the PAst DIscourse LInking Hypothesis

Recent studies by Bastiaanse and colleagues found that time reference is selectively impaired in people with nonfluent agrammatic aphasia, with reference to the past being more difficult to process than reference to the present or to the future. To account for this dissociation, they formulated the PAst DIscourse LInking Hypothesis (PADILIH), which posits that past reference is more demanding than present/future reference because it involves discourse linking. There is some evidence that this hypothesis can be applied to people with fluent aphasia as well. However, the existing evidence for the PADILIH is contradictory, and most of it has been provided by employing a test that predominantly taps retrieval processes, leaving largely unexplored the underlying ability to encode time reference-related prephonological features. Within a cross-linguistic approach, this study tests the PADILIH by means of a sentence completion task that 'equally' taps encoding and retrieval abilities. This study also investigates if the PADILIH’s scope can be extended to fluent aphasia. Greek- and Italian-speaking individuals with aphasia participated in the study. The Greek group consisted of both individuals with nonfluent agrammatic aphasia and individuals with fluent aphasia, who also presented signs of agrammatism. The Italian group consisted of individuals with agrammatic nonfluent aphasia only. The two Greek subgroups performed similarly. Neither language group of participants with aphasia exhibited a pattern of performance consistent with the predictions of the PADILIH. However, a double dissociation observed within the Greek group suggests a hypothesis that may reconcile the present results with the PADILIH.     

A proposed reinterpretation and reclassification of aphasic syndromes

Background: Different classifications of aphasic disorders have been proposed over the years. During recent decades new approaches to aphasia study have been developed, suggesting that current aphasia classifications can and should be reconsidered.

Aims: The purpose of this paper is to attempt to integrate contemporary knowledge about brain organisation of language and to propose a new aphasia classification.

Main Contribution: It is emphasised that there are two fundamental forms of aphasia, which are linked to impairments in the lexical/semantic and grammatical systems of language (Wernicke‐type aphasia and Broca‐type aphasia, respectively). Grammar correlates with the ability to represent actions (verbs) and depends on what is known as Broca's area and its related brain circuits, but it is also related to the ability to quickly carry out the sequencing of articulatory movements required for speaking (speech praxis). Lexical/semantic and grammatical systems not only depend on different brain circuitries, but also on different types of memory and learning (declarative and procedural). Other aphasic syndromes do not really impair language knowledge per se, but rather peripheral mechanisms required to produce language (conduction aphasia and aphasia of the supplementary motor area), or the executive control of the language (extra‐Sylvian or transcortical motor aphasia).

Conclusions: A new classification of aphasic syndromes is proposed: primary (or “central”) aphasias (Wernicke's aphasia—three subtypes—and Broca aphasia); secondary (or “peripheral”) aphasias (conduction aphasia and supplementary motor area aphasia); and dysexecutive aphasia (extra‐Sylvian—transcortical—motor aphasia), are distinguished.     

Language processing in aphasia: changes in lateralization patterns during recovery reflect cerebral plasticity in adults

During single word processing the negative cortical DC-potential reveals a left frontal preponderance in normal right-handers as well as in patients with a history of transient aphasia. Lateralization of DC-negativity therefore provides a reliable and robust method for the assessment of language dominance. In 11 stroke patients with permanent aphasia this physiological pattern changed to bilateral activation reflecting an additional right-hemispheric involvement in compensatory mechanisms in aphasia. Along with complete clinical recovery the classical aphasic syndromes revealed specific differences in changes of their lateralization patterns. In Broca's aphasia the initial right-hemispheric preponderance changed to a left frontal lateralization while in Wernicke's aphasia a presumably permanent shift towards the right-hemisphere occurred. Differences in lateralization patterns might reflect different mechanisms of recovery such as the initial disinhibition of homologous areas contralaterally and subsequent collateral sprouting and synaptic modulation. The assessment of changes in lateralization of the cortical DC-potential during language tasks is a non-invasive, safe method with excellent time resolution that might provide further insights in the neural basis of recovery from aphasia.     

Anosognosia during Wada testing.

Anosognosia, the verbally explicit denial of hemiplegia, is more often reported after right- than left-hemisphere lesions. However, this asymmetric incidence of anosognosia may be artifactual and related to the aphasia that often accompanies left-hemisphere lesions. Anosognosia has been attributed to psychological denial and the emotional changes associated with hemispheric dysfunction. Eight consecutive patients undergoing intracarotid barbiturate (methohexital) injections as part of their presurgical evaluations for intractable epilepsy were assessed for anosognosia after their hemiplegia and aphasia had cleared. After their left-hemisphere anesthesia, all subjects recalled both their motor and language deficits. However, after right-hemisphere anesthesia, none of the eight patients recalled their hemiplegia. These results suggest that anosognosia is more often associated with right- rather than left-hemisphere dysfunction and that it cannot be attributed to either psychological denial or the emotional changes associated with hemispheric dysfunction.     

A diagnostic formulation for anosognosia in Alzheimer's disease

Objective

To determine the earliest symptoms of anosognosia in people with Alzheimer''s disease and to validate a criteria‐guided strategy to diagnose anosognosia in dementia.

Methods

A consecutive series of 750 patients with very mild or probable Alzheimer''s disease attending a memory clinic, as well as their respective care givers, was assessed using a comprehensive psychiatric evaluation.

Results

The factors of anosognosia for (1) basic activities of daily living (bADL), (2) instrumental activities of daily living (iADL), (3) depression and (4) disinhibition were produced by a principal component analysis on the differential scores (ie, caregiver score minus patient score) on the anosognosia questionnaire for dementia. A discrepancy of two or more points in the anosognosia‐iADL factor was found to have a high sensitivity and specificity to identify clinically diagnosed anosognosia in people with Alzheimer''s disease. By logistic regression analysis, the severity of dementia and apathy were both shown to be noticeably associated with anosognosia in people with Alzheimer''s disease.

Conclusion

Anosognosia in those with Alzheimer''s disease is manifested as poor awareness of deficits in iADL and bADL, depressive changes and behavioural disinhibition. The frequency of anosognosia is found to increase considerably with the severity of dementia. The validity of a specific set of criteria to diagnose anosognosia in people with Alzheimer''s disease was shown, which may contribute to the early identification of this condition.Anosognosia (from the Greek “nosos” (illness) and “gnosis” (knowledge)) is a term coined by Babinski to refer to the phenomenon of denial of hemiplegia.¹ From an etymological perspective, the term anosognosia may be construed as the lack of knowledge or awareness of an illness. Anosognosia has also been reported among patients with Wernicke''s aphasia, who do not attempt to correct paraphasias and who may become irritable with others when their jargon‐loaded speech is not properly understood. Anton''s syndrome occurs in patients with cortical blindness, who deny being blind and confabulate responses when asked to recognise visually presented objects. In the context of people with Alzheimer''s disease, anosognosia was construed as the denial or lack of awareness of impairments in activities of daily living (ADL) or about neuropsychological deficits.^2,3 Different strategies have been used to assess anosognosia in Alzheimer''s disease, and these are briefly described as follows (see Clare^4,5 for a thorough review).     

A short history of the Veterans Administration's influence on aphasia assessment tools

Background: The United States Veterans Administration (VA) has a long history of supporting medical developments, including those in the rehabilitation sciences. Its large patient population, numerous facilities, and funding of research, education, and training have resulted in many medical advances. Its positive influences also have extended to the profession of speech‐language pathology, particularly regarding the assessment and treatment of aphasia.

Aims: This paper is a short review of how the VA has contributed significantly to the development of aphasia assessment tools. Beginning with the Minnesota Test for Differential Diagnosis of Aphasia in 1948, the VA has played an essential role in the creation of a number of well‐known, widely used aphasia tests.

Methods & Procedures: Ten major aphasia assessment tools that had significant VA involvement are examined. The features of each test are described, as well as how the VA contributed to the test's development.

Conclusions: VA's substantial support was an essential part in the development of these important aphasia assessment tools.     

Dissociation of Visual and Auditory Language Comprehension Capacity in Aphasia

Visual language comprehension capacity was compared with auditory language comprehension capacity in 26 aphasic subjects. The Token Test was used for both modalities. By the means of the difference in scores on the two tests three groups were separated, that is (1) a group with no essential difference between the two capacities, (2) a group with superior reading capacity and (3) a group with superior auditory capacity. Particular attention was directed to the second group. Seven subjects showed this type of dissociated comprehension. The group was found to be heterogeneous in their linguistic characteristics, The clinical type of aphasia included not only Wer-nicke's aphasia but also Broca's aphasia. A possible psychological explanation underlying this phenomenon was attempted. Anatomical correlation was also attempted. The hypothesis of sparing the left inferior parietal lobe is proposed as an explanation of why visual comprehension was better preserved than auditory comprehension.     

Assessment of a Samoan–English speaker with bilingual aphasia: “it’s hard”

Background: Speech-language therapists need to provide culturally and linguistically appropriate services for their clients. However, language assessment with bilingual adults with aphasia can be challenging for clinicians, due to the complexity surrounding both aphasia and bilingualism. There are few investigations focusing on the assessment of bilingual speakers with aphasia. More research is needed, particularly in relation to the specific experience of the individuals involved in the assessment process.

Aim: This study aimed to explore the experience of an outpatient language assessment involving a Samoan–English speaker with bilingual aphasia, from the perspectives of the participants in the process.

Methods & Procedures: An instrumental case study was used to explore one case involving a community speech-language therapist’s assessment of a bilingual Samoan–English speaker with aphasia. Data collection involved three phases: participant observation of the two assessment sessions; semi-structured interviews with the individual with aphasia, her family member, her speech-language therapist, and one of the interpreters; and a stimulated-recall interview with the speech-language therapist. Qualitative content analysis was used to identify themes within the data.

Outcomes & Results: Eight themes were revealed in relation to assessment of a bilingual adult with aphasia: Samoan–English language assessment is a hard process for the individuals involved; Samoan–English language assessment as a team process; differences in understanding of communication impairments and the assessment process; time; preparation; appropriateness of assessment tasks and resources; uncertainty; and flexibility.

Conclusions: The findings highlight the complex nature of language assessment involving a bilingual Samoan–English speaker with aphasia and provide valuable insights into the experience of the process. The investigation identified a number of useful clinical implications that can help to inform clinical practice for clinicians working with assessment of bilingual aphasia both in Samoan–English speakers and in other bilingual populations.     

MR diffusion tensor imaging documented arcuate fasciculus lesion in a patient with normal repetition performance

Background: The pathophysiology of the syndrome of conduction aphasia has been thought to involve a disconnection between posterior and anterior language areas. The arcuate fasciculus has been one of the principal candidates for an anatomical link between Wernicke's and Broca's area, but direct evidence for its involvement in conduction aphasia has been difficult to obtain. Aims: The purpose of this study was to examine white matter tract integrity, using the novel magnetic resonance imaging technique of diffusion tensor imaging, in a patient with transcortical aphasia. Methods & Procedures: A case study of a 55-year-old, right-handed man with aphasia following a left hemisphere stroke is reported. The patient's language performance was assessed with the Boston Diagnostic Aphasia Examination twice: at 10 days and at 2 years after his stroke. An MR diffusion tensor imaging study was obtained approximately 2 years after his stroke using the 1.5 T Phillips Gyroscan NT system. White matter fibre tracts maps were reconstructed using the “FACT” algorithm. Outcomes and Results: Ten days after his stroke, the patient had a non-fluent aphasia with marked impairment of both auditory comprehension and spontaneous speech. However, repetition was relatively intact. By 2 years, when the MR diffusion tensor imaging study was performed, repetition was completely normal and the patient had only subtle deficits in areas of naming and auditory comprehension. The MR diffusion tensor imaging study revealed a lesion of the dominant hemisphere arcuate fasciculus. Conclusions: This study documents normal repetition performance in a patient who on subsequent MR diffusion tensor imaging was found to have a lesion involving the dominant hemisphere arcuate fasciculus lesion. This case adds to previously published cases of normal repetition performance despite a documented lesion of the arcuate fasciculus, and thus further challenges the traditional model of conduction aphasia invoking a critical role of this white matter tract. Our case also suggests that MR diffusion tensor imaging may be a potentially useful technique to evaluate regional involvement of specific white matter tract projections in patients with aphasia.