Column: Aphasia affects language skills, but can be overcome

June is National Aphasia Awareness Month. Aphasia is the total or partial inability to use or understand language. It is typically the result of stroke, brain disease or injury. These patients have no intellectual impairment and no outward sign of handicap.

There are two broad categories of aphasia:

1. Non-fluent, or motor aphasia, is an inability to enunciate words. Patients with this form of aphasia fully understand language and accommodate for their loss of speech by writing or drawing responses.

2. Fluent, or receptive aphasia, is an inability to understand words. These patients will often have difficulty finding the right word or following a command. They will sometimes make up new words to try and express their thoughts.

Injuries causing aphasia involve the dominant brain hemisphere that contains the neural pathways necessary for speech. In 95 percent of right-handed people and the majority of left-handed people, this is the left hemisphere.

Aphasia is a treatable condition. Speech pathologists are trained to perform detailed testing to fully analyze the extent of the impairment and implement a rehabilitation program. These programs require intense effort and patience on the part of people with aphasia. Newly designed computer software provides drills for patients as they retrain the neural pathways necessary for speech. Recovery is often incomplete and can be frustrating for patients and those around them. Speaking slowly is essential, as is calmly waiting for a response. Aphasic patients are not deaf, yet there is often an inclination to speak loudly to someone who has a speech deficit.

Aphasia is a fascinating neurological condition. If you would like more information regarding aphasia, visit the Web site of The National Aphasia Association at www.aphasia.org. If someone you know is recovering from aphasia, applaud their efforts and never underestimate their intellectual ability.

Aphasia (NORD Guide to Rare Disorders)

Excerpt about 'Aphasia' from the book "NORD Guide to Rare Disorders" (Copyright © 2007 Lippincott Williams & Wilkins)


Aphasia (also called dysphasia), impaired expression or comprehension of written or spoken language, reflects disease or injury of the brain’s language centers. (See Where language originates.) Depending on severity, aphasia may slightly impede communication or may make it impossible. It can be classified as Broca’s, Wernicke’s, anomic, or global. Anomic aphasia eventually resolves in more than 50% of patients, but global aphasia is usually irreversible. (See Identifying types of aphasia, page 58.)

▲TopEmergency Actions
Quickly look for signs and symptoms of increased intracranial pressure (ICP), such as pupillary changes, decreased level of consciousness (LOC), vomiting, seizures, bradycardia, widening pulse pressure, and irregular respirations. If you detect increased ICP, administer mannitol I.V. to decrease cerebral edema. Also, make sure that emergency resuscitation equipment is readily available to support respiratory and cardiac function, if necessary. You may have to prepare the patient for emergency surgery.
▲TopHistory
If the patient doesn’t display signs of increased ICP, or if his aphasia has developed gradually, perform a thorough neurologic examination, starting with the patient’s history. You’ll probably need to obtain this history from the patient’s family or companion because of the patient’s impairment. Ask if the patient has a history of headaches, hypertension, seizure disorders, or drug use. Also ask about the patient’s ability to communicate and to perform routine activities before aphasia began.

▲TopPhysical assessment
Check for obvious signs of neurologic deficit, such as ptosis or fluid leakage from the nose and ears. Take the patient’s vital signs and assess his LOC. Be aware, though, that assessing LOC is typically difficult because the patient’s verbal responses may be unreliable. Also, recognize that dysarthria (impaired articulation due to weakness or paralysis of the muscles necessary for speech) or speech apraxia (inability to voluntarily control the muscles of speech) may accompany aphasia; so speak slowly and distinctly, and allow the patient ample time to respond. Assess the patient’s pupillary response, eye movements, and motor function, especially his mouth and tongue movement, swallowing ability, and spontaneous movements and gestures. To best assess motor function, first demonstrate the motions and then have the patient imitate them.

▲TopMedical causes
▲TopAlzheimer’s disease
With Alzheimer’s disease, a degenerative disease, anomic aphasia may begin insidiously and then progress to severe global aphasia. Associated signs and symptoms include behavioral changes, loss of memory, poor judgment, restlessness, myoclonus, and muscle rigidity. Incontinence is usually a late sign.

▲TopBrain abscess
Any type of aphasia may occur with brain abscess. Usually, aphasia develops insidiously and may be accompanied by hemiparesis, ataxia, facial weakness, and signs of increased ICP.

▲TopBrain tumor
A brain tumor may cause any type of aphasia. As the tumor enlarges, other aphasias may occur along with behavioral changes, memory loss, motor weakness, seizures, auditory hallucinations, visual field deficits, and increased ICP.

▲TopCreutzfeldt-Jakob disease
Creutzfeldt-Jakob disease is a rapidly progressive dementia accompanied by neurologic signs and symptoms, such as myoclonic jerking, ataxia, aphasia, vision disturbances, and paralysis. It generally affects adults ages 40 to 65.

▲TopEncephalitis
Encephalitis usually produces transient aphasia. Its early signs and symptoms include fever, headache, and vomiting. Seizures, confusion, stupor or coma, hemiparesis, asymmetrical deep tendon reflexes, positive Babinski’s reflex, ataxia, myoclonus, nystagmus, ocular palsies, and facial weakness may accompany aphasia.

▲TopHead trauma
Any type of aphasia may accompany severe head trauma; typically, aphasia occurs suddenly and may be transient or permanent, depending on the extent of brain damage. Associated signs and symptoms include blurred or double vision, headache, pallor, diaphoresis, numbness and paresis, cerebrospinal otorrhea or rhinorrhea, altered respirations, tachycardia, behavioral changes, and increased ICP.

▲TopSeizures
Seizures and the postictal state may cause a transient aphasia if the seizures involve the language centers.

▲TopStroke
The most common cause of aphasia, stroke may also produce Wernicke’s, Broca’s, or global aphasia. Associated findings include decreased LOC, right-sided hemiparesis, homonymous hemianopia, paresthesia, and loss of sensation. These signs and symptoms may appear on the left side if the right hemisphere contains the language centers. (See Associated disorder: Stroke.)

▲TopTransient ischemic attack
Transient ischemic attacks can produce any type of aphasia, which occurs suddenly and resolves within 24 hours of the attack. Associated signs and symptoms include transient hemiparesis, hemianopia, and paresthesia (all usually right-sided), dizziness, and confusion.

▲TopSpecial considerations
Immediately after aphasia develops, the patient may become confused or disoriented. Help to restore a sense of reality by frequently telling him what has happened, where he is and why, and what the date is. Carefully explain diagnostic tests, such as skull X-rays, computed tomography scan or magnetic resonance imaging, angiography, and EEG. Later, expect periods of depression as the patient recognizes his disability. Help him to communicate by providing a relaxed, accepting environment with a minimum of distracting stimuli.

▲TopPediatric pointers
Recognize that the term childhood aphasia is sometimes mistakenly applied to children who fail to develop normal language skills but who aren’t considered mentally retarded or developmentally delayed. Aphasia refers solely to loss of previously developed communication skills.

Brain damage associated with aphasia in children most commonly follows anoxia — the result of near drowning or airway obstruction.

▲TopPatient counseling
Assist the patient with an alternate means of communication, such as a communication board. If aphasia is due to a stroke, teach the patient to reduce risk factors, such as not smoking, eating a healthy diet, and exercising regularly.

Copyright Details: NORD Guide to Rare Disorders, Copyright © 2003 Lippincott Williams & Wilkins.

Aphasia (In a Page: Signs and Symptoms)

Aphasia (In a Page: Signs and Symptoms)


Excerpt about 'Aphasia' from the book "In a Page: Signs and Symptoms" (Copyright © 2007 Lippincott Williams & Wilkins)


Aphasia refers to the inability to understand or express written or spoken words, despite preservation of the mechanical or visual means to do so; thus, facial weakness, oropharyngeal paresis, or primary disturbances of vision and hearing do not constitute aphasia. To localize the lesion within the cerebrum, aphasias are generally separated into receptive (Wernicke's aphasia) or expressive (Broca's aphasia) types. Further subgroups include anomic, conduction, and transcortical sensory, and transcortical motor.

▲TopDifferential Diagnosis

Stroke is the most common cause of aphasia
–Sudden onset suggests cerebral embolization from a cardiac (e.g., endocarditis, atrial fibrillation) or carotid artery source
–A stuttering onset suggests in situ arterial thrombosis
Less common etiologies include Alzheimer's dementia, postconcussion syndrome, Rasmussen's encephalitis, nonconvulsive status epilepticus, dissociative state, subdural hematoma, trauma, severe hypoglycemia, sedative-hypnotic drug intoxication, sensorineural hearing loss, herpes encephalitis, and tertiary syphilis
Types of aphasias
Receptive (Wernicke's) aphasia
–Inability to name objects, follow written or spoken commands, and repeat
–Verbal (semantic, neologistic) errors are abundant; however, speech is fluent
–Localized to the dominant posterior superior temporal lobe
Expressive (Broca's) aphasia
–Stuttering, nonfluent speech with literal (phonemic) errors; however, comprehension is preserved
–Repetition is poor, but naming is preserved
–Associated with hemiparesis
–Localized to the inferior lateral dominant frontal lobe
Anomic aphasia
–Isolated inability to name a seen object
–Localized to the angular gyrus
Conduction aphasia
–Isolated inability to repeat
–Localized to the arcuate fasiculus (white matter band connecting Wernicke to Broca areas)
Transcortical sensory aphasia
–Similar to Wernicke's aphasia, except for preserved repetition
–Localized to the superior posterior temporal lobe
Transcortical motor aphasia
–Similar to Broca's aphasia, but with preserved repetition, including urinary incontinence, echolalia (aimlessly repeating other's spoken words)
–Localized to medial dominant frontal lobe

▲TopWorkup and Diagnosis

History and physical examination
–History should include a complete past medical history, family history, psychiatric history, and medication history
–Exam should include a comprehensive neurologic exam, cardiovascular exam, and head and neck exam
–Fever and headache with aphasia suggests embolization from endocarditis or herpes simplex encephalitis
–Gradual onset with other signs of intellectual decline suggests dementia
The cornerstone of diagnosis is cerebral imaging (MRI has the highest sensitivity and specificity)
Initial laboratory tests should include CBC, electrolytes, BUN/creatinine, calcium, glucose, RPR, and vitamin B12 level
Consider toxicology screen
Echocardiography (transesophageal echocardiogram is best) and blood cultures may be indicated to diagnose endocarditis
CSF analysis and EEG to diagnose viral encephalitis versus status epilepticus
Psychometric testing necessary for dementia
Normal brain imaging with or without associated psychiatric signs may suggest status epilepticus, hypoglycemia, or a dissociative state

▲TopTreatment

Embolic stroke: Anticoagulation; however, if secondary to endocarditis, do not initiate anticoagulation, because of increased risk of hemorrhage; instead, treat with antibiotics
Thrombotic stroke: Antiplatelet therapy (e.g., aspirin or clopidogrel) and risk factor reduction (e.g., lipid and hypertension therapy)
Viral encephalitis: IV acyclovir for 10–14 days
Dementia: Acetylcholinesterase inhibitors are of variable effectiveness in Alzheimer's disease
Status epilepticus: IV lorazepam and anticonvulsants
Hypoglycemia and other electrolyte abnormalities: Correction of underlying metabolic problem
Dissociative state: Oral or IV benzodiazepines may “break the spell” of psychiatric separation of attention from the environment; ECT may be necessary
Speech therapy is useful to help maintain motivation to improve language function and avoid depression from communication impairment

What is adult aphasia. . .

Aphasia is the condition in which an individual has difficulty expressing thoughts and understanding what is said or written by others. Aphasia is caused by brain damage, resulting most often from a stroke or direct injury to the head.


What are some of the language problems associated with aphasia?

Persons with aphasia will have difficulty understanding what is said to them and expressing their own thoughts. They will also have reduced ability to read, write, gesture, or use numbers. Speech may be limited to short phases or single words such as names of objects or actions. Frequently, the smaller words in speech are left out so that the sentence is shortened to "key words" like a telegram. The word order may be incorrect, or the message may be turned around and difficult to understand. Sometimes, sounds and words get changed, for example, calling a table a "chair" or calling a bank teller a "tank beller." Nonsense words like "baba" or "shanna" may even be used. Some people with aphasia may produce speech with obvious effort and misarticulations. The most common characteristic is difficulty in naming. The person with aphasia may know what to do with a toothbrush, for example, but will have forgotten what to call it. Contact us for more information.


Why does it take a person with aphasia so long to respond?

Persons with aphasia need extra time to understand what is being said to them. They hear the words, but they may not immediately recall the meaning of the word. In some cases, it may sound to the person with aphasia as if the speaker is talking in a foreign language. In addition, they need time to think of the words they want to use. Once individuals with aphasia think of the word they want to use, will they remember it? Often they will forget the word once they use it and will have to renew the searching process when they need it again. Their child's name, for example. They may say it several times, but then not be able to recall the name a few minutes later.


Is it typical for individuals with aphasia to swear?

Yes, many times they retain certain automatic responses, such as swearing, counting, naming the days of the week and social responses, such as "fine," "thanks," and "hi." Don't criticize them for swearing. They often won't realize they're saying anything inappropriate.


What other problems can be caused by a stroke or head injury?

Some individuals may have trouble pronouncing words properly. Their speech may be slurred. They may also be more emotional. For example, they may become frustrated more easily, and they may laugh or cry excessively. They may also be confused or forgetful at times. Contact us for more information.


What are some of the physical problems connected with brain damage?

Aphasia usually is caused by injury to the left side of the brain. When one side of the brain is hurt, the opposite side of the body is affected. Often times persons with aphasia have a weakness of the right arm and leg. Vision may also be affected. In fewer instances, seizures will occur.


What is spontaneous recovery?

As the body recovers from the brain damage on a physical level, some individuals with aphasia will regain former skills, like talking or writing. Improvement may be within days or continue for at least six months, or even longer. This immediate improvement is called spontaneous recovery. Spontaneous recovery seldom produces complete return of function, however.


What help is available for the person with aphasia?

There is help, both for the person with aphasia and for the family who needs to understand aphasia. The speech-language pathologist is the professional who is trained at the master's or doctoral level to evaluate the problem and execute a rehabilitation plan. Although few people can be "cured," most can be helped. Your speech-language pathologist will be licensed by the state of NJ and will hold the Certificate of Clinical Competence (CCC) from the American Speech-Language-Hearing Association (ASHA) and/or licensing from your state.


How soon should an individual with aphasia see a speech-language pathologist?

Usually within the first few days following the injury. In addition to providing help for speech and language recovery, the speech-language pathologist can offer hope to the individual and guidance for the family. Often the testing information obtained by the speech-language pathologist will be helpful to the medical staff in caring for the person with aphasia. Contact us for more information.


Can family and friends help?

Family members and friends are a vital part of the rehabilitation program. The more they understand the problem, the more they can help the recovery of the person with aphasia. The speech-language pathologist will work closely with the family to help them help their loved one.