DYSPHASIA

EXPRESSION IS ALWAYS

IMPAIRED

OVERVIEW

• REVIEW FUNCTIONAL ANATOMY AND COMPONENTS OF

DYSPHASIA

• CLARIFY TERMINOLOGY

• BEDSIDE EXAM, INCLUDING INTERROGATION OF THE

FUNCTIONAL COMPONENTS OF THE LANGUAGE NETWORK

• HOW TO APPROACH THE FAMILY OF A DYSPHASIC PATIENT

• VIDEO EXAMPLES OF DYSPHASIA

• DEFINE THE IDEAL PROVIDER AND STAFF SIGN OUT

THE SUBPLOT

• DROP THE “EXPRESSIVE-RECEPTIVE” TERMINOLOGY, TOO VAGUE

• USE THE ESTABLISHED “COMPREHENSION, FLUENT vs.

NONFLUENT” DISTINCTION

• THIS TERMINOLOGY IS CLINICALLY DESCRIPTIVE AND

ANATOMICALLY FOCUSED

• DEVELOPED BY CARL WERNICKE (1848-1905)

• ADVANCED BY NORMAN GESCHWIND (1926-1984)

• EMBEDDED IN THE BOSTON DIAGNOSTIC APHASIA CLASSIFICATION

DYSPHASIA/APHASIA

TYPES OF DYSPHASIA

• GLOBAL

• WERNICKE‟S

• TRANSCORTICAL SENSORY

• ALEXIA w/o AGRAPHIA

• ALEXIA WITH AGRAPHIA

• APHASIC ALEXIA

• CONDUCTION

• BROCA‟S

• TRANSCORTICAL MOTOR

• APHEMIA

• SUBCORTICAL APHASIAS

• ANOMIC APHASIA

FOCUS ON COMPREHENSION AND

FLUENCY

ANATOMY OF THE LANGUAGE NETWORK

ANATOMY OF THE LANGUAGE NETWORK

• THE CORE LANGUAGE NETWORK IS WERNICKE‟S AREA AND

BROCA‟S AREA, CONNECTED BY THE SUPERIOR

LONGITUDINAL FASCICULUS*.

• AN ABNORMALITY IN ANY PART OF THIS FUNCTIONAL

NETWORK WILL CAUSE A PROBLEM WITH EXPRESSION

*ALSO KNOW AS THE ARCUATE FASCICULUS

ANATOMY OF THE LANGUAGE NETWORK

• AN ABNORMALITY IN BROCA‟S AREA WILL UNDERMINE FLUENCY

• AN ABNORMALITY IN THE SUPERIOR LONGITUNDINAL FASCICULUS WILL

UNDERMINE REPETITION

• AN ABNORMALITY IN WERNICKE‟S AREA WILL UNDERMINE

COMPREHENSION

VASCULAR SUPPLY TO THE LANGUAGE NETWORK

VASCULAR SUPPLY TO THE LANGUAGE NETWORK

• ISCHEMIC STROKE IS BY FAR THE LEADING CAUSE OF DYSPHASIA

• THE MIDDLE CEREBRAL ARTERY DISTRIBUTION SUPPLIES THE CORE

LANGUAGE NETWORK

• WERNICKE‟S AREA, POSTERIOR BRANCHES TO THE TEMPORAL LOBE

• BROCA‟S AREA, ANTERIOR BRANCHES BRANCHES TO THE FRONTAL LOBE

HANDEDNESS AND LEFT HEMISPHERE DOMINANCE

• AMONG ALL PATIENTS THE LEFT HEMISPHERE IS MOST

LIKELY LANGUAGE DOMINANT

• 96% OF RIGHT HANDERS

• 85% OF AMBIDEXTEROUS

• 75% OF STRONGLY LEFT HANDED

• S. KNECHT et. al., via functional transcranial Doppler studies in 326

healthy individuals; BRAIN 2000, Vol. 123, Issue 12, 2512-2518)

CONDITIONS CAUSING DYSPHASIA

• STROKE

• TRAUMATIC BRAIN INJURY

• FRONTO-TEMPORAL

DEMENTIA

• ALZHEIMER‟S DISEASE

• OTHER DEMENTIAS

• TUMOR

• SUBDURAL HEMATOMA

• TIA

• MIGRAINE VARIANT

• PARTIAL SEIZURES

INTERROGATING THE FUNCTIONAL

COMPONENTS OF THE LANGUAGE

NETWORK: THE BEDSIDE EXAM

• WERNICKE‟S AREA (BRODMANN AREA 22)

TEMPORAL LOBE, COMPREHENSION

• ARCUATE FASCICULUS, REPETITION

• BROCA‟S AREA (BRODMANN AREAS 44 & 45)

FRONTAL LOBE, FLUENCY

BEDSIDE EXAM:

GROUND RULES

• ELIMINATE NON-VERBAL GESTURES

• “HANDS BEHIND YOUR BACK”, MINIMIZE FACIAL

EXPRESSION

• MAINTAIN EYE CONTACT TO AVOID VISUAL CUES

• FOCUS ON THE PATIENT‟S PURE LANGUAGE

ABILITY

• REMEMBER THAT PATIENTS OFTEN ACT LIKE

THEY UNDERSTAND

BEDSIDE EXAM

• OBSERVE

• ENGAGE

• INTERROGATE THE FUNCTIONAL COMPONENTS:

WERNICKE‟S AND BROCA‟S AREAS

• NAMING

• REPETITION

• READING/WRITING (OPTIONAL)

OBSERVE

• IS THE PATIENT ALERT?

• AWARE OF SURROUNDINGS?

• ATTEMPS TO, OR SPEAKS SPONTANEOUSLY?

• ENGAGES YOU NON-VERBALLY?

• IS THE PATIENT CAPABLE OF COMPLYING TO THE

EXAMINATION?

• IF THEY CAN‟T COMPLY, YOU CAN‟T TELL IF THEY

ARE DYSPHASIC.

ENGAGE

• INITIATE NORMAL INTERACTION

• CAPABLE OF A NORMAL CONVERSATION?

• IF YES, THERE STILL COULD BE MILD LANGUAGE

IMPAIRMENT

• IF NO, CAN THE PATIENT COMPLY TO THE

LANGUAGE EXAMINATION?

• NORMAL CONCENTRATION AND ATTENTION

SPAN?

• NORMAL BEHAVIOR?

INTERROGATE WERNICKE’S AREA:

IS COMPREHENSION NORMAL?

• AXIAL COMMANDS: CLOSE YOUR EYES, STICK OUT YOUR

TONGUE

• APPENDICULAR COMMANDS: RAISE YOUR ARM, SHOW ME

TWO FINGERS

• COMMANDS ABOUT THE ENVIRONMENT: POINT TO THE

WINDOW, THE CEILING, THE TELEVISION

• YES/NO QUESTIONS, INCLUDING NONSENSE QUESTIONS:

CAN PIGS FLY?

• TWO AND THREE STEP COMMANDS

• NAMING & REPETITION

INTERROGATE BROCA’S AREA:

IS THE PATIENT FLUENT?

• GET THEM TALKING

• QUESTION AND ANSWER ABOUT A FAMILIAR

TOPIC

• DESCRIBE A PICTURE

• NAMING & REPETITION

INTEROGATE BROCA’S AREA:

THE NONFLUENT PATIENT

• CAN‟T SPEAK IN COMPLETE SENTENCES

• LIMITED TO SINGLE WORDS OR SHORT PHRASES

• LIMITED USE OF PREPOSITONS AND ARTICLES

• HESITATION AND FREQUENT PAUSES ARE TYPICAL

• IN SOME CASES, CAN‟T SPEAK AT ALL

• IN SOME CASES, CAN‟T MAKE SOUND AT ALL

INTERROGATING BROCA’S AREA:

TWO KINDS OF NORMAL FLUENCY

• NORMAL SPONTANEOUS SPEECH

• NORMAL SPONTANEOUS GIBBERISH, ALSO

KNOWN AS WORD SALAD OR JARGON SPEECH

• BOTH HAVE SIMILAR PACE AND PROSODY AT

ROUGHLY 100-150 WORDS PER MINUTE

• THE DIFFERENCE: WORD SALAD CONTAINS VERY

FEW DISCERNABLE WORDS

INTEROGATE THE ARCUATE FASCICULUS:

REPETITION

• THE DOG CHASED THE CAT.

• THE SPY FLED TO GREECE.

• NO IF‟S, AND‟S OR BUT‟S ABOUT IT.

• „ROUND THE RUGGED ROAD, THE RAGGED RASCAL RAN.

THE TRUTH ABOUT NAMING AND

REPETITION

• PROBLEMS WITH EITHER SUGGEST THAT

DYSPHASIA IS PRESENT

• PROBLEMS WITH EITHER CAN OCCUR WITH

ISOLATED INJURY TO BROCA‟S OR WERNICKE‟S

AREAS…..AND WITH REPETITION NOT JUST THE

ARCUATE FASCICULUS

EXPRESSION PROBLEMS THAT ARE

NOT DYSPHASIA

• DYSARTHRIA

• CONFUSIONAL STATES

• PSYCHIATRIC CONDITIONS

• TRANSIENT GLOBAL AMNESIA, A PURE MEMORY

DEFICIT

• “PREPHASIA”: A JOY NOT A PROBLEM

DYSARTHRIA

• AN ABNORMALITY OF THE NEUROACTIVATION OF SPEECH

MUSCLES

• THIS CAN AFFECT THE SPEED, TIMING, RANGE AND

ACCURACY OF WORD ARTICULATION.

• CAN BE CONFUSED WITH NONFLUENT APHASIA

• THERE MAY BE PAUSES AND SHORT OR BROKEN PHRASES

• IN A COOPERATIVE PATIENT YOU SHOULD BE ABLE TO SORT

THIS OUT BY INTERROGATING THE NETWORK

DYSARTHRIA vs. APHASIA

• COMPREHENSION SHOULD BE INTACT

• IF NOT, APHASIA IS PROBABLY PRESENT AND FLUENCY MAY

ALSO BE IMPAIRED

• IF COMPREHENSION IS INTACT, THE PATIENT COULD STILL

HAVE DYSARTHRIA AND IMPAIRED FLUENCY.

• INSTRUCT THE PATIENT TO SLOW SPEECH TO A MORE THAN

COMFORTABLE PACE

• FOCUS ON QUESTION AND ANSWER, OR REPETITION

WITHOUT TONGUE TWISTERS

• HESITANT OR SLURRED SPEECH THAT CAN BE

TRANSCRIBED INTO NORMAL LANGUAGE POINTS AWAY

FROM APHASIA

CONFUSION vs. DYSPHASIA

• ALTERATIONS IN ATTENTION SPAN CAN CAUSE LANGUAGE

ERRORS

• THESE PATIENTS CAN HAVE PROBLEMS WITH WORD FINDING,

REPETITION, COMPLETING SENTENCES AND COMPREHENSION

• CONFUSION MAY BE MISTAKEN FOR DYSPHASIA

• DYSPHASIA MAY BE MISTAKEN FOR CONFUSION

• APHASIC PATIENTS USUALLY ARE NOT CONFUSED OR AGITATED,

AND THEY USUALLY BEHAVE APPROPRIATELY

• THE ATTENTION SPAN IS KEY. IF THE PATIENT IS ALERT, FOCUSED

AND THEY ARE MAKING ERRORS IN LANGUAGE, THEN DYSPHASIA

IS LIKELY.

PSYCHIATRIC CONDITIONS:

PSYCHOSIS VS DYSPHASIA

• A PSYCHOTIC PATIENT COULD BE MUTE OR USE AN

IDIOSYNCRATIC LANGUAGE THAT SOUNDS LIKE WORD

SALAD

• WITH PSYCHOSIS, BEHAVIOR AND SPEECH CONTENT IS

MORE LIKELY ABNORMAL, WITH NORMAL GRAMMATIC

DELIVERY

• IF YOU STILL SUSPECT DYSPHASIA AND THE LANGUAGE

EXAM IS EQUIVOCAL LOOK FOR OTHER SIGNS OF

DOMINANT HEMISHPERE DYSFUNCTION: HEMIPARESIS OR

A VISUAL FIELD DEFICIT.

PSYCHIATRIC CONDITIONS:

HYPOKINETIC CATATONIA VS

DYSPHASIA?

• AWAKE, ALERT

• MINIMALLY AWARE OF SURROUNDINGS

• MINIMALLY INTERACTIVE

• MUTE, BUT WON‟T ENGAGE

• PATIENT WON‟T COMPLY TO LANGUAGE EXAMINATION?

THIS BEHAVIOR POINTS AWAY FROM DYSPHASIA

• ALSO LOOK FOR SIGNS OF DOMINANT HEMISHPERE

DYSFUNCTION

PURE MEMORY DISTURBANCE:

TRANSIENT GLOBAL AMNESIA

• ACUTE ANTEROGRADE AND RETROGRADE AMNESIA

• PATIENT ASKS REPETITIVE QUESTIONS ABOUT HIS OR HER

ENVIRONMENT

• THIS CAN BE MISTAKEN FOR DYSPHASIA

• PATIENTS WILL HAVE NORMAL FLUENCY,COMPREHENSION,

NAMING AND REPETITION, JUST INTERROGATE THE

LANGUAGE NETWORK!

“PREPHASIA”

A JOY NOT A PROBLEM

• MEMORY INTACT

• FULL SPECTRUM OF MOOD

AND EMOTION

• CURIOSITY

• ABLE TO PLAY

APHASIC PATIENTS REMAIN SENTIENT

• INTACT MEMORY

• FULL SPECTRUM OF EMOTION, MOOD

• DIGNITY AND CURIOSITY INTACT

• CAPABLE OF COMMUNICATION, BUT WITH

LANGUAGE LIMITATION

• WE SHOULD TREAT THEM ACCORDINGLY (ACT

NATURALLY)

FAMILY INVOLVEMENT

• NAÏVE ABOUT APHASIA AND FOCAL BRAIN INJURY

• EMOTIONAL CONECTION WITH THE PATIENT, WITH

A LONGSTANDING HISTORY OF COMPLEX VERBAL

AND NONVERBAL COMMUNICATION

• FIRST TO NOTICE IMPROVEMENT

• FIRST TO BELIEVE THAT PURE LANGUAGE

COMMUNICATION IS BETTER THAN ACTUAL

“PREPHASIA” REVISITED

• HOW OLD ARE YOU?

• IS SHE THE MOST GIFTED

ONE YEAR OLD?

• DOES SHE COMPREHEND

THE LANGUAGE, OR HAS

SHE LEARNED THE

GESTURE FROM

NONVERBAL REPETITION?

FAMILY AND APHASIC PATIENTS:

STAFF APPROACH

• ACKNOWLEDGE THAT APHASIC PATIENTS OFTEN

COMMUNICATE BETTER WITH FAMILIES THAN WITH STAFF

• ENCOURAGE FAMILY TO ACT NATURALLY WITH THEIR

LOVED ONE, i.e. SHOW AFFECTION, HUMOR

• EXPLAIN THAT THE PATIENT IS STILL SENTIENT WITH

INTACT AWARENESS, MEMORY AND FULL SPECTRUM OF

EMOTION

• MODEL THE GROUND RULES OF THE BEDSIDE EXAM TO

ILLUSTRATE YOUR PERSPECTIVE AND THE DEGREE OF

PURE LANGUAGE IMPAIRMENT

VIDEO EXAMPLES:

NOW IT’S YOUR TURN

• CAPABLE OF COMPLYING TO AN EXAM?

ALERT, AWARE AND ENGAGED?

• FLUENT OR NONFLUENT:

FRONTAL LOBE/BROCA‟S AREA INTACT OR NOT?

MILD, MODERATE OR SEVERE IMPAIRMENT

• NORMAL OR DIMINISHED COMPREHENSION:

TEMPORAL LOBE/WERNICK‟S AREA INTACT OR NOT?

IMPAIRMENT MILD, MODERATE OR SEVERE

• EXAMPLE: 75 YEAR OLD RIGHT HANDED MALE WHO IS

MODERATELY NONFLUENT AND HAS GOOD COMPREHENSION

CASE 1

CAN THE PATIENT

COMPLY?

ALERT, AWARE,

ENGAGED?

FLUENT OR

NONFLUENT?

COMPREHENSION

INTACT?

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HYPOKINETIC CATATONIA

• THE PATIENT WOULD NOT COMPLY TO OUR EXAM,

BUT HIS BEHAVIOR POINTS AWAY FROM

DYSPHASIA

• DYSPHASIC PATIENTS USUALLY BEHAVE

APPROPRIATELY

SIMPLE SIGN OUT

• FLUENT OR NONFLUENT:

FRONTAL LOBE/BROCA‟S AREA INTACT OR NOT?

MILD, MODERATE OR SEVERE IMPAIRMENT

• NORMAL OR DIMINISHED COMPREHENSION:

TEMPORAL LOBE/WERNICK‟S AREA INTACT OR NOT?

MILD, MODERATE OR SEVERE IMPAIRMENT

• EXAMPLE: 75 YEAR OLD RIGHT HANDED MALE WHO IS

MODERATELY NONFLUENT AND HAS GOOD COMPREHENSION

CASE 2

• CAN THE PATIENT COMPLY

TO EXAMINATION?

ALERT, AWARE, ENGAGED?

• FLUENT OR NONFLUENT?

• BROCA‟S AREA

FRONTAL LOBE INJURY?

• COMPREHENSION INTACT?

• WERNICKE‟S AREA

TEMPORAL LOBE INJURY

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CASE 2: SIGN OUT

• ELDERLY MAN WITH MODERATE-SEVERE

NONFLUENT DYSPHASIA, WITH FAIR-GOOD

COMPREHENSION

• BROCA‟S AREA/FRONTAL LOBE INVOLVEMENT

CASE 3

• CAN THE PATIENT COMPLY TO

EXAMINATION?

ALERT, AWARE, ENGAGED?

• FLUENT OR NONFLUENT?

• BROCA‟S AREA

FRONTAL LOBE INJURY?

• COMPREHENSION INTACT?

• WERNICKE‟S AREA TEMPORAL

LOBE INJURY?

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CASE 3: SIGN OUT

• LATE MIDDLE AGED FEMALE WITH MILD TO

MODERATE NONFLUENT DYSPHASIA, WITH FAIR

TO GOOD COMPREHENSION

• BROCA‟S AREA/FRONTAL LOBE INVOLVED

CASE 4

• CAN THE PATIENT COMPLY

TO EXAMINATION?

ALERT, AWARE, ENGAGED?

• FLUENT OR NONFLUENT?

• BROCA‟S AREA

FRONTAL LOBE INJURY?

• COMPREHENSION INTACT?

• WERNICKE‟S AREA

TEMPORAL LOBE INJURY

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CASE 4: SIGN OUT

• LATE MIDDLE AGED FEMALE WITH A FLUENT

DYSPHASIA AND SEVERE COMPREHENSION

DEFICIT

• WERNICKE‟S AREA/TEMPORAL LOBE INVOLVED

CASE 5

• CAN THE PATIENT COMPLY

TO EXAMINATION?

ALERT, AWARE, ENGAGED?

• FLUENT OR NONFLUENT?

• BROCA‟S AREA

FRONTAL LOBE INJURY?

• COMPREHENSION INTACT?

• WERNICKE‟S AREA

TEMPORAL LOBE INJURY?

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CASE 5: SIGN OUT

• ELDERLY MAN WITH A FLUENT DYSPHASIA AND

MODERATELY DIMINISHED COMPREHENSION

• WERNICKE‟S AREA/TEMPORAL LOBE INVOLVED