Aphasia Test 4

YOU WILL TOTALLY KICK ASS ON THIS TEST!!

Behaviors of Left Neglect

• Excessive use of R Margin• Perseverative- strokes in writing• Safety Issues- hand in spokes of wheelchair• Appear hemiplegic- looks like they are

paralyzed. Can’t use leg or arm• Appear disinterested/unmotivated- won’t

smile at you or laugh at your jokes.• Do not complain of disorder.

Neglect• Attention Disorder• Affects recovery• Duration Unknown• Mild to severe- spectrum mild (if you help them

attend to neglected area, they’ll acknowledge it) to severe (won’t eat food on right side of plate).

• Fractionation (occurs in multiple modalities)- olfactory, auditory info- we only work on comm. though- reading & writing.

Assessment• Informal observation- as soon as you walk in

room- only looking to right.• Formal testing- very preliminary, not in depth• Tests of extinction (both sides of body)- testing

sensation, for ex. Which finger am I touching? etc.

• Line Dissection- draw a straight line, divide paper in half. Line will probably be over to the right.

• Cancellation- if you see “A” cross it out. Make x’s out of target etc.

Assessment• Drawings - ask patient to draw semmetrical

items. Draw a person, a flower, a clock etc.• Reading- (read ½ or less of text) read endings

of sentences. Confabulation is good.• Writing- omit letters, forget to cross “t”, dot

“i”. Perseveration, when you ask patient to write, they will write on top of their old writing.

Neglect• Subjective (point of view)- driven by patient.• Viewer centered- depends on the position of

patient (turn in wheel chair). The most important for severe neglect.

• Environment centered- more cognitive, there is another side to the door.

• Object Centered (different perspectives) looking at objects at different perspectives.

Neglect• Other Modalities:• Auditory- but they can understand you. For some

sounds though there is neglect.• Tactile- tests of extinction.• Olfactory- even if there is 1 olf. Bulb neglect, you can

still smell w/ other nostril.• Motor- Affects contralateral movement. Client will act

like hemiparesis.• Directional hypokinesia (moving limbs to contralateral

space) Affects dressing, applying make-up. Seems like a strangers limb, someone else stole their shoes. Etc.

Areas of Damage for L Neglect

• R MCA- middle cerebral artery• R Frontal Parietal Lesions• R Thalamus• R Basal Ganglia• R Hemisphere= less localization,

more holistic

Theories of L Neglect • Representational- disruption of internal

representation of space. How I see the flower. I can tell you what the flower and clock look like but can’t draw it.

• Attention-• When cued, neglect is reduced.• Orienting bias- RH attends to R + L sides; LH

attends to R- more specific.• Don’t see right neglect as often

Therapy for L Neglect• Bring awareness & attention to L side.• Severe deficits (tactile cue)• Physical Movement (wheel chair)• Moderate deficits (cue to neglected side) –

have them feel around the plate , TV or book.• Mild deficits (teach to self cue)• I’m gonna have you highlight all the words on

the left side of the page

Attention- Heirarchy• Arousal- eye contact (keeping eyes closed in bed).• Sustained Attention- attending to one thing for a

prolonged period of time. – Put a cold washcloth on their face.

• Selective Attention- knowing what is the most important task to focus on.

• Divided Attention (multi-task)- completing multiple tasks at the same time. More for mildly impaired.

• Treatment- task completion- – if they complete task, they can attend to it. If working

on neglect, do task that addresess the area of neglect.

Goals for Left Neglect• 1. client will draw symmetrical items with

100% accuracy with tactile & visual cues.• 2. Client will turn to the left (look to the left)

and/or describe items shown with 100% accuracy with tactile, visual and verbal cues.

• Mild—look to the left with 100%, highlight written text on the left side.

• If goal is to have a conversation, they can have a conversation for 5 minutes, attn OK.

Prosody• Melodic contour rhythm of speech.• Conveys meaning:– Emotional content– State of speaker- how is the speaker feeling?– Speaker’s attitude toward listener- sarcastic

• RHD- monotone or euphoric• Linguistic effects- stress & syllable duration. Ex.-

“green house”- spondee word.• Nonlinguistic (emotion, humor, formality) types

of prosody.

Prosody cont..• Pitch is vulnerable in RHBD (its affected)• Language can be intact, but prosody impaired.– Can cause divorce.

• Emotional prosody most impaired.• Difficulty producing & comprehending

emotions**– Facial expressions– Content of story- might not understand emotion of

story.• Tx- patients need to identify their own emotions

and others..

Emotional Prosody• Difficulty matching to emotion (pictures of

sad, happy etc)• Monotone (no prosodic features)- for mild

populations.– Prosodic contours- draw on paper where the

stress should be. Ex. Yesterday was what?• Reliance on semantic info instead of prosody.

Must be up front and literal.• Difficulty understanding sarcasm

Linguistic Prosody• Difficulty with compound nouns vs. noun

phrases. (ex- light house)• Minimal emphatic stress (ex- she wore that

dress)• Can’t correct prosody- can always teach them

to be louder on stressed words.

• RH perceives linguistic & emotional prosody• LH contributes to linguistic prosody.

MORE PROSODY!!!• Severe L Neglect= severe prosody deficits.

• Prosody comprehension- R Anterior & Posterior cortical lesions

• Linguistic prosodic deficits- R Frontal, temporal & parietal lobes, caudate nucleus, internal capsule, thalamus.

• -- neglect guides how severe rest of deficits are.

Prosodic exercise…• List 5 sentences that provoke emotion:• 1. You look beautiful.• 2. What’s wrong?• 3. I had an amazing day.• 4. How do you feel about healthcare reform?• 5. I feel like I’m gonna throw up.• 6. Will you marry me?• 7. This food is delicious!• 8. Are you serious?

Linguistic Deficits• Perform normal on aphasia tests (w/ assistance

for L Neglect)• Problems: Convergent & Divergent thinking.• Convergent: clues to the big picture- don’t get

humor. Ex. It is small, you sharpen it, it has lead, an eraser.. etc

• Divergent- single concept to more concepts (more clues) ie. problems with humor. Can only think of one meaning per word. Ex- give me 3 reasons that you would move to a different city.

Linguistic Deficits• Words with dual meanings are difficult• RH (works slower than LH) RH adds the nuances

to language– Important for single word processing– Less frequent meanings– Slower & Less selective than LH

• LH– Strong semantic overlap (words w/ several meanings)– Highly selective– Rapid in selection

Linguistic Deficits• Problems with collective nouns (eg. Furniture)• Abstract categories (ex- liquids) really difficult• More L Neglect= worse linguistic deficits.• Problems with Generative naming. Ex FAS.

Name words that begin with F, A, S.

Think of 3 items that are more abstract than 3 concrete

Abstract• Things that are soft• Things that are rectangular

shaped• Things that smell bad• Things that make you happy• Things that turn you on

Concrete• Types of fish• Fruits• Vegetables• Farm animals• Types of music

• Affect vs. emotion• Affect- outward expression of emotion (flat

affect- show no emotion, look bored)• Emotion- subjective mood, state; internal

experiences. How the person is feeling is not being shown.

• RH Dominance Theory:– Perception– Comprehension– Expression of emotion

• Emotional lability- used to describe affect- means constant crying or euphoria. Affect is impaired

Problems

• With facial expressions (comprehension & production)

• Promotes social isolation• Can comprehend gestures & posture• Problems w/ verbal emotions (stories,

conversation)• Better identifying emotion when interested in

story (written text)• Reduced prosody for emotional memories.

Depression (DSMR-IV)• 30-60% of RHD• 2 or more of the following:• Poor appetite or over eating• Insomnia or hypersomnia• Low energy or fatigue• Low self esteem• Poor concentration or difficulty making

decisions• Feelings of hopelessness

Depression and RHD

• Organic effects- change in neurotransmitters- serotonin

• Reactive effects- response to deficits• Refer to neuropsych

• Ask them if they are sad or unhappy. If they are depressed refer out.

Delusions & Confusions• Agitated Confusion- will see w/ TBI, because

they are forming new connections.– Incoherent thoughts- similar to jargon– Easily distractible– Restlessness– Violent outbursts– Can occur w/ RHD but rare

• Anterior Frontal & temporal damage (prefrontal cortex and executive function

• Misidentification syndromes (person, place, body parts)– Will see them confabulate, make things up. – Look at own body parts and not know whose they

are.• Reduplicative Paramnesia (place & person)– Imposter- they think you are one– Bifrontal or RH frontal and/or parietal lesions

• Korsakoff’s syndrome- totally confused and paranoid.– Lack of Thiamine– Prolonges alcoholism- etiology– Looks like Wrnicke’s aphasia, fluent, jargon,

neologisms

• Campgrass Syndrome– Imposters- family members, friends- get

neuropsych– Psychiatric component

• Prosopagnosia (agnosia- sensory disturbance, occur w/ tactile & visual senses)– Visual agnosia- inability to recognize faces– Bilateral posterior lesions– No recall of familiar face

• Tx.- if they can recognize voices work on that.

• Somatoparaphasia:• Misidentification of own body parts (crossing

midline)• Confabulation- about whose body part it is.• L Neglect

• RHD disrupts the feeling of being connected and united.

RCVA• Discourse Deficits– Communicative event– Info conveyed by speaker to listener(s)– Requires situations content– Not all RHD have discourse problems- • may be high functioning patient

– Cognitive problems= discourse deficits. • Cognition affect communication.

• L Neglect= discourse affected• Simple discourse is intact.

• Right hemisphere good verbal output. Abstract words difficult.

Anomia Goal

• During anomic episode client will use semantic description, embedding and sentence completion

• Verbal cues (sentence completion)- “describe cup” – Semantic descriptors- describe the cup, tell me the

color, tell me where you find it.• Visual- point to the handle etc. Word Map.

Aud Comp goal

• Client will answer yes/no question with verbal cues

• Cues: repeat question, provide key words- Name Jamie?

• Visual- point to Jamie.• Tactile- put jamie’s hand on herself when asked

“Are you Jamie?”

Goals Continued

• Complex yes/no questions-• Do you cut the grass with an ax?• How can you make it easier?• Does it snow in July? Simplify to two words• Repeat the ques.• Gestures for snow, July. Show pictures• Aud comp- major goal- UNDERSTAND

CONVERSATION!!!

• Cognitive communication- organization is an issue. They have problems with attention, organization.

• L= neglect affects discourse too.• TYPES OF DISCOURSE:• Procedural- perform an activity• Expository- single topic/1 speaker (for TBI

everything is expository)• Conversation- between 1 or more speakers• Narrative- event or story. Most difficult because it

requires organization and structure.

Problems:

• Inferencing:– Individual clues missed (attn)– Irrelevant clues selected– No intergration of clues (ie. No big picture)– Dissassociation of clues to prior experience

• Indirect requests (ex. Boy, it’s cold in here)• Sarcasm (ex graceful!)• Humor (problems with punchline)

More deficits

• Misunderstanding gist if info (macrostructure)• Difficulty with implied meaning (inferencing)• Providing alternative meanings• Lack of referent usage (Sam- who is Sam?)• Lack of sensitivity to communication content (ie.

Comm. knowledge with listener

• Higher level language– Figurative Language (Raining cats and dogs) – Literal info is easier (ie. Reduce sarcasm)

• Cognitive Deficits:• WM- short term• Attention (because of L neglect)• Organization• Problem solving• Executive Function- lack insight etc.• Speed of processing- a lot slower..

Pragmatic Deficits (Social Language)

• Initiation• Roles & Purpose (ex- code switching)• Turntaking (verbose, tangential)• Poor eye contact- related to L neglect• Poor organization

Theory of Mind

• Understanding internal mental state of others (requires inferencing)

• Assists in interpretation of external behavior• Informs about motivation(s), emotional state &

knowledge base.

Evaluation of RHB

• Medical chart• Interview• Informal assessment• Formal testing:– Burns Brief Inventory (neuropathologies & RH)– MIRBI-2 (mini inventory of right brain inventory)– Rehab institute of Chicago Assessment

• Review Findings

Areas of Assessment• Cognitive (exec function, attn)• Orientation- to person, place, time, event• L neglect- tests of extinction, writing etc.• Discourse- Convo.• Prosody- listen for lack of prosody• Affective disorder- outward signs of emotion

(wont get it)• Higher language function- abstract language• Pragmatic abilities- give them some jokes

Screening

• 20 minutes• Tell me where you are today• What kinds of problems have you noticed?• What are your future plans?• What does your family/friends think about your

plans?• What are you going to do today?• What kinds of people have you seen here?

Screening cont…

• Picture: humor or inferencing• Emotion• Affect• Prosody• Higher lang function• L neglect

L neglect Screening

• Cancellation task- make x’s out of paper.• Symmetrical drawing- clock, flower, person• Line Bisection- draw a line, divide it in half• Tests of extinction- touch hands or both hands• Reading/Writing- everything presented at midline