A Cognitive Approach to
Treatment of Aphasia:
Evidence From A Case Study
Karen Prescott Copeland | St. John Medical Center | Tulsa, OK
[email protected]
DEFINING
APHASIA
TYPOLOGICAL
NONTYPOLOGICAL
COGNITIVE
APHASIA: A selective impairment of the cognitive
system specialized for comprehending and formulating
language, leaving other cognitive capacities intact.1
Cognitive definitions of aphasia suggest that aphasia
results from impairment of the cognitive processes which
support language function.2
C
O
G
N
I
T
I
O
N
IMPAIRED LANGUAGE/
GOOD COGNITION
consider direct language
focus
GOOD COGNITION/
LIMITED LANGUAGE
Consider combination of
language and cognitive
interventions
IMPAIRED LANGUAGE/ IMPAIRED COGNITION/
IMPAIRED COGNITION
LIMITED LANGUAGE
Consider combination of language
and cognitive interventions
OR perhaps
supported conversation training
Candidates for
cognitive approach to
intervention
LANGUAGE
• Some have suggested that when aphasia is present
AND when cognitive abilities are weak relative to
language functioning, it may be beneficial to address
these cognitive limitations as a means of improving
language and communication.3
CASE STUDY
HISTORY
• 87 y.o. female
• Right hand dominant
• Prior Medical History:
– L hemisphere CVA 11/00
• aphasia
• dysphagia (PEG placed)
• R hemiparesis
– HTN
– Depression
– Anemia
TIMELINE
• Discharged from acute care to a long-term
care facility. By family report, no direct
rehabilitation services were initiated in that
setting
• 1/3/01: Re-admitted to acute care with UTI
• 1/8/01: Transferred to inpatient rehabilitation
where ST services were ordered and initiated.
A pureed diet in addition to TF was ordered
ASSESSMENT
• Aphasia Diagnostic Profiles
4
Differential Diagnosis: Moderate Wernicke’s aphasia
• Clock drawing task5
• Various basic scanning/cancellation
tasks6
• Visual memory screening
• Clinical swallowing evaluation
• Activity limitations:
– inability to communicate basic needs to
caregivers
– difficulty completing tasks
– reduced ability to socialize
Spontaneous response
Score 4/37
Response to copy task
Score 9/37
Note perseveration and
relative inability to use a
model to improve response
Note frequent errors of
omission to the right of
midline.
• Features of communication:
–
–
–
–
–
Relative fluency with poor content
Poor initiation of speech attempts
Poor auditory comprehension
Verbal perseveration
Lack of repair attempts
• Non-linguistic difficulties
– Difficulty shifting sets
– Poor selective attention
– Diminished visual-perceptual skills with
significant inattention to the right
– Reduced working memory
• TREATMENT PLAN:
– Individual 1/2 hr. sessions twice daily
5 days per week over a 2-week period
– Treatment activities focused on strengthening
underlying cognitive processes rather than
stimulating specific language functions7
– Written goals were worded to reflect an emphasis
on improved language as the outcome
• ACTIVITIES:8
–
–
–
–
Visual scanning/cancellation exercises
Object sorting tasks
Trail making activities
Semantic concept training
PRE/POST TREATMENT DATA
COMPARISON
ADP Parameter
1/8/01
(standardized scores)
1/24/01
(standardized scores)
Lexical Retrieval*
Personal Information
Information Units*
Naming*
Auditory Comprehension
Repetition*
10
8
11
11
9
9
11
8
12
14
10
12
Aphasia Severity*
100
105
*Statistically significant increase in scores
FUNCTIONAL CHANGES
• Increased frequency of verbal initiations
• Improved task persistence and fewer
perseverations
• Improved self-awareness, indicated by attempts at
language repair
• Staff/team reports of more successful verbal
expression
• Son reports increased ease of conversation
• Improved ability to tell a “personal story”
• Advance in diet texture with increased oral intake
also took place during this timeframe
Discussion
•
The results of this descriptive case study constitute an example of Level
III evidence in support of the treatment methods under consideration
and suggest that interventions which targets select cognitive abilities
can have a positive impact on communication. Significant gains were
noted on several specific language measures. The differential diagnosis
post-treatment was anomic aphasia, a form qualitatively less severe
than Wernicke’s aphasia since auditory comprehension is a relative
strength.
•
It should be noted that the treatment provided occurred within the 6month period post-stroke, commonly recognized as the timeframe for
spontaneous recovery.8 Another consideration is that while treatment
did not seek to teach specific language skills, one cannot discount that
everyday communication encounters may help to promote improved
language. Carefully designed randomized clinical trials would help to
address these issues.
•
Finally, there is the question of whether these gains were maintained
following transition to another setting. A longitudinal study could be
designed to determine the durability of language gains resulting from
cognitive-linguistic treatment.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Davis, G.A. (2007). Aphasiology: Disorders and Clinical Practice.
Boston, MA: Pearson Education, Inc.
Hegde, M.N. (1998). A Coursebook on Aphasia and Other Neurogenic
Language Disorders. San Diego: Singular Publishing Group, Inc.
Estabrooks, N. et. Al. (1997).“Treatment of cognitive linguistic deficits in
stroke.” CCISD Conference. Cape Cod, MA. March 1997.
Helm-Estabrooks, N. (1992). Aphasia Diagnostic Profiles. Pro-Ed: Austin,
TX
Helm-Estabrooks, N. & Bayles, K. “Clock drawing protocol” from the
Perseveration Project, NCCD at University of Arizona (NIH/NCCD Grant)
Bayles, K and Tomoeda, C. (1993). Arizona Battery for Communication
Disorders of Dementia. Pro-Ed: Austin, TX.
Helm-Estabrooks, N. (1998). “A cognitive approach to treatment of an
aphasic patient” In N. Helm-Estabrooks and A. Holland (ed.), Approaches to
the treatment of aphasia (pp. 69-89). San Diego, CA: Singular Publishing
Group.
Helm-Estabrooks, N. (1995). Cognitive Linguistic Task Book. Cape Code
Institute for Communication Disorders: Cape Cod, MA.
Greener J., Enderby P., Whurr R.(1999). Speech and language therapy for
aphasia following stroke. Cochrane Database of Systematic Reviews 1999,
Issue 4. Art. No.: CD000425. DOI: 10.1002/14651858.CD000425.