Aphasia Notes

Aphasia Treatment
1. Impairment-based approach
a. Syndrome approach
b. Cognitive Neuropsychological approach (CNP)
2. Functional approach

Syndrome Approach CNP Approach

Assumption Language behaviors are related to
specific areas of the brain
Focus Diagnosis of classis anatomically Clarify the mechanisms of cognitive
based aphasic syndromes functions using evidence from
Neuropathology
* Identify functional lesions
Method 1. Use clearly defined and 1. Understand normal cognitive
standardized assessment and processing
classify the PWA into syndromes
2. Assessments are guided by
2. Patient’s performance could be theoretical models
compared with normative data;
provide a general profile of one’s 3. Reveal underlying impairments
language performance (i.e. functional lesions of individuals)

3. Studies performed on groups of 4. Relate one’s performance pattern

patients with vascular lesion(s) à to the model (single case
Results among groups studied experimental designs)
could be compared (e.g. controls
vs. aphasics) 5. Explain to the client about the
pattern (Better? Worse?) with the
4. Associate language behaviors hypothesis made on underlying
with specific brain regions reasons

Eight types of aphasia

Fluent Aphasia Non-fluent aphasia
√ Auditory Conduction Aphasia Broca’s Aphasia
Comprehension

Anomic Aphasia Transcortical Motor Aphasia

X Auditory Wernicke’s Aphasia Mixed Aphasia

Comprehension

Transcortical Sensory Aphasia Global Aphasia

 Anomia: locus of impairment à Semantic level/ access from semantic to output lexicon/
access from lexical to phonological level (phonological encoding)

Model of spoken word representation

1. Concept (non-linguistic in
nature) to be expressed

2. Activate
semantic features
specific to the
word (e.g. furry,
with tail, meow)

3. Access
corresponding
word form
representation

4. Access corresponding
phonemes (oral production)

Conceptual à semantic feature/ lexical semantic (word meaning) à lexical à phonological

Feedforward activation Vs Feedback activation

Phonologically-
Semantic Formal
Mixed error related nonword
paraphasia paraphasia
error
Conceptual <->
Semantic feature
Semantic feature <-> X (weak activation X (feedforward
Lexical network from semantic activation from
feature to lexical) semantic level)
Lexical network <-> X (feedback X (feedback X (impaired
Phonological network activation from activation from connections in
phono to lexical) phonological level) between)
Target lexical Degraded target lexical representation (weakened ability in
representation retrieving the meanings of the words)
CAB (Cantonese version of Western Aphasia Battery)
- Verbal communication, reading comprehension, writing, apraxia tests
- Classification of aphasia types: based on fluency, comprehension, repetition & naming

Birmingham Object Recognition Battery

- Picture Naming
- Minimal Feature View Task
- Foreshortened Task
- Item Match Task
- Associative Match Test

Pyramid and Palm Trees Test

Semantic Tests
1. Spoken/ written word-picture matching
2. Written version of the PPTT
3. Synonym Judgment
a. Recognize the visual stimuli orthographically as characters
b. Activate orthographic lexicon
c. Activate lexical semantic system as one has to understand the meaning
d. Identify whether the listed two have similar or different meanings and of
similar or different categories
4. Confrontation Naming
• Oral pictured object naming
a. Activate one’s visual representations, connecting them with the semantic
system, followed by activating the phonological output lexicon
b. Modal name, group naming accuracy and naming agreement are concerned
• Oral pictured action naming
a. Modal name, alternative names, group naming accuracy and naming
agreement are concerned
b. Mainly line-drawing à reduce distractions
• Relevant psycholinguistic variables:
o Age of acquisition
o Familiarity (= word frequency)
o Naming agreement
o Form class
o Word length
o Visual complexity

Word production Vs Repetition of words Vs Repetition of non-words

Semantic network Vs Lexical Network Vs Phonological Network
Anomia Therapy

Treatment: Impairment-based Vs Functional

Conceptual representation + Semantic feature network à belongs to semantic system

Lexical network (Output lexicon)
Phonological network (phonological encoding between lexical level to phonological

Semantic à Lexical (Treatment)

- Categorizing/ sorting objects
- Word-picture matching
- Contextual repetition of sets of semantically related words
- Semantic cueing hierarchy
- Generating or matching synonyms
- SFA
- Making judgments about functions and semantic features of objects
- Verb network strengthening treatment (VNEST)

Lexical à Phonological (Treatment)

- Phonological cueing hierarchy
- Phonological priming
- Contextual repetition of sets of phonologically related words
- Rime judgments, counting syllables/ phonemes segmentation of words into
phonemes
- Reading aloud

Multiple baseline designs (RCT)

- Across behaviors of the same individual
- Across individuals
- Across settings

Evaluating efficacy of single case treatment

1. Baseline phase
2. Treatment phase
3. Post-treatment
4. Maintenance phase

Measurement of Statistical significance: Chi-square Vs McNemar’s test

- Frequency data à Chi-square or McNemar’s test
- McNemar’s: Repeated measure of Chi-square
- Compare differences in performance level between two sets of items (e.g. trained vs
untrained) à Chi-square
- Compare changes in performance on a set of items (before and after treatment) à
McNemar’s test
 Estimation of effect size of change
Tau-U Vs SMD (Standard Mean Difference, d-index)
- SMD: affected by SD à no variance à cause problems (use variance of naming
accuracy of all probe items during baseline)
- Very small SD in baseline à effect size overly inflated

Trained Items Vs Untrained Items Vs Control Items

Sentence-production Deficits
Syndrome approach Vs CNP approach

Description of events
à non-verbal
Formulate linguistic representation:
- Abstract representation: Entities +
relations to each other by relational
term (i.e. verb)

Find syntactic form for the functional

representation (i.e. sentence structure
+ grammatical morphemes) Phonological representation of
the sentence to be produced

Orally produce the sentence:

Phonological representation à Phonetic representation
Garrett Model
- Assumes sentence production entails a number of processing levels or stages
- Agent à Theme à Goal
- Assumes two stages of lexical access:

Garden Path Model

- Late closure: people prefer to attach new words to the current phrase/ clause
- Minimal attachment: people prefer to analyze a sentence with the fewest syntactic
nodes, i.e. simplest syntactic structure

Investigative techniques:
1. Self-paced reading task
2. Eye movements during reading using eyetracker
3. EEG (electroencephalogram) or ERP (event-related potential)

Comprehension/ Parsing models of sentence comprehension:

1. Parsing: Assigning syntactic structure to a linear string of incoming words
2. Assigning thematic roles (e.g. agent, patient/theme, instrument, goal)
a. Agent Vs Patient Vs Instrument Vs Goal
3. Co-indexing anaphoric element
a. Pronoun à John Vs He
b. Tenses à went & did
4. Converting the string to a propositional representation

Predicate argument structure

Assessment of sentence processing:

1. Discourse:
a. picture description, story-telling, procedural description
b. Conversation/ interview
à Connected speech produced

2. Verb/ action naming

à Verbs are core elements of a sentences

3. Sentence anagram: arranging sentence fragments into a sentence (do not require
verbal production)
à Evaluate access to predicate structure and word order

4. Eliciting a sentence in response to a picture by restricting the first word

a. E.g. Picture: [A boy is chasing a girl] à A girl…
à For production of specific sentence structure

5. Production of grammatical morphemes

Sentence comprehension:
1. Sentence-picture matching
a. Semantically reversible Vs Semantically non-reversible sentences
i. Non-reversible > reversible à deficits in processing word order
b. Canonical Vs Non-canonical sentences
i. “Agent-patient” Vs “Patient-agent”
ii. Canonical > Non-canonical: problem in processing sentence structure
due to deficits in understanding grammatical morphemes
c. Target and distractors
i. Distractors: lexical Vs role reversal

Group Vs Single case study (Syndrome Vs CNP Approaches)

- Syndromes: too coarse-grained; symptoms may co-occur for anatomical rather than
functional reasons

Agrammatism Paragrammatism
Fluency Non-fluent Fluent
Characteristics 1. Omission of grammatical 1. Substitution of grammatical
morphemes morphemes
- Incorrect use of verb
2. Simplified syntactic inflections
structures - Incorrect choice of
prepositions
3. Reduced verb production - Errors in the use of
gender and pronouns
Telegraphic? √ X
Co-occurring disorder? AOS N/A

CAB Rating scale for fluency:

Sentence Production Priming Test
- Describe a picture modeling the sentence structure (Canonical Vs Non-canonical)
o Canonical: Active + Object-relative
o Non-canonical: Passive + Subject-relative
- Generalization of the group level performance did not hold up in individual level

Sentence Anagram à Active, passive, BA-construction

- Active & BA-construction: Canonical

Fluent and non-fluent speakers differ in performance regarding grammatical morphemes

quantitatively
Sentence comprehension of Chinese PWA performance (different syntactic structures)

Treatments of sentence processing:

Phases/ Levels of deficits Treatments/ Approaches
Conceptual Show a video of an action event à highlight the character
in perspective (e.g. chase Vs flee)
Predicate argument structure/ - Match pictures with semantically reversible sentences
Word order - Answer questions about specific thematic role (i.e. Who)
Verb impairments - Word-picture matching; picture naming with semantic or
phonological cues; naming by definition
- VNEST (Verb Network Strengthening Treatment) à form
semantic associations with target verbs (e.g. generate
agents and themes for given verbs)
E.g. Verb=cook
à Agents: e.g. chef, housewife
à Themes: e.g. meat, vegetables, food
Grammatical morphology - Auditory (same Vs difference)
- Discrimination à grammatical morphemes (e.g. washes
Vs washed)
- Lexical decision à non-word/ inappropriately
conjugated verbs (e.g. washed Vs digged)
- Judging sentence anomalies à contradictory
information conveyed by functors (e.g. yesterday à will)
- Sentence-picture matching based on tense (Future Vs
Progressive Vs Past)
 Levels Tasks
Functional Creates the predicate argument structure (Lexical access)
- Semantic/ syntactic processing à Phonological processing
Positional Construct the surface form of the sentence
- Specify phrase structure à Retrieve phonology of words
Phrase: grammatical morphology;
Phonological Phonetic encoding à articulation

Assessment of Discourse Production

Discourse: a language unit whose organization supersedes any single word or sentence // a
unit of language above and beyond the sentence level
à E.g. conversations, personal recount, story telling etc.

Breakdown levels may arise from disruption to

- Formulating a thought
- Formulating a complete linguistic output
- Word and sentence levels
- Cognitive domains – WM, attention, EF

Features of impaired discourse:

1. Restricted abilities to convey feelings and emotions à semantically abstract
2. Reduced information content
3. Production of errors e.g. paraphasias + neologisms
4. Deficits in grammatical output and reduced grammatical complexity
5. Decreased efficiency in conveying ideas
6. Reduced use of cohesive devices e.g. anaphoras (pronouns), connectives etc.
7. Reduced overall coherence

Discourse Elicitation Tasks

Monologues Interactive Dialogues
Differences in the aspects of…
1. Format of stimuli
2. Degree of control over content in stimuli
3. Cognitive demand

Cantonese Aphasia Bank Project

Descriptive Discourse
Single picture - Black-and-white line drawings, colored pictures, photos
- E.g. Cat Rescue, Flood à Cantonese AphasiaBank
** Beware of tendency of listing content items
Picture sequence - E.g. Broken window, Refuse Umbrella
** Tend to elicit longer speech samples with a higher total word
counts, lexically more diverse, more sentence production from PWA
Procedural Discourse
- Explanation of a series of actions to perform a task or achieve a goal
- Use of stimuli is optional
 - Written words, pictures/ photos of target items, pre-recorded video clips à cues
- E.g. Making a ham-and-egg sandwich
Expository Discourse
Story-retelling/ telling à systematic examination of cohesion and coherence of language
Story-retelling - May use videos or cartoons
- Involves auditory/ verbal short-term memory
Story-telling - May use a picture book (without words)
- Involves visual-spatial processing skills and visual STM
Conversational Discourse
Assess pragmatics 1. Greeting
2. Turn-taking (without interrupting)
3. Relevant contribution
4. Clear contribution
5. Ending appropriately
6. Speech acts à making statement, request/ asking questions/
giving orders/ thanks/ offering apology
Methods Obtain case history from a new client/ family members

Corpora
1. CANtonese corpus of Oral Narratives (CANON)
2. Database of Speech and GEsture (DoSaGE)

Considerations during discourse assessments

1. Use culturally appropriate stimuli? Use of instructions?
2. Practicality of recording? (Audio Vs. Video)
3. Representativeness of performance? à Collecting on more than one occasion?
Different communication contexts? Communication partners?
4. Avoid providing directive cues or prompts

Analyses of disordered discourse

Subjective Quantitative Analysis (Objective) Conversation
Ratings Analysis
Criterion- Linguistically-based Content-based - Count turn
referenced - Brief, quick, easily learned - Transcription- completions
- Fluency rating - Can be detailed and research-oriented less - Determine
@ CAB Clinically-oriented Research-oriented successful and
Scoring methods for Quantitative - Emphasizes the unsuccessful
- Functional picture description Production Analysis quantification of strategies
Assessments of (QPA) amount of - Analyze manner
Communication 1. Shewan Spontaneous proposition or of feedback by CP
Skills for Adults Language Analysis (SSLA) * Analyse lexical information - Determine
(FACS) @ASHA content and facilitative or
2. Linguistic sentence structure disruptive
- Functional Communication (e.g. open class/ strategies
Communication Measure (LCM) closed class, Conversation
Analysis Profile
Measures morphology, for People with
(FCMs) @ASHA 3. Cantonese Linguistic sentence Aphasia (CAPPA)
Communication embedding) Area 1: Linguistic
Measure (CLCM) à abilities
reduce the effect of Area 2: Repair
familiarity or practice for Area 3: Initiation
monitoring changes and turn-taking
Area 4: Topic
management
Comparison across methods under Clinically-oriented linguistically-based analyses
Shewan Spontaneous Linguistic Communication Cantonese Linguistic Communication
Language Analysis (SSLA) Measure (LCM) Measure (CLCM)
12 indices N/A 8 indices
Semantic: Index of lexical efficiency: Amount of information:
- content units - Number of words/ - Total number of words (NW) à X
- paraphasias content units interjection, hesitation, false starts…
- Number of informative words (IW) à key
Phonological: Index of grammatical words
- melody support:
- articulation - average number of Efficiency and rate of information
correct function words and transmission
Syntactic: grammatical morphemes - Index of lexical efficiency (ILE)
- length of utterances per content unit - Index of communication efficiency (ICE) à
- complex sentences total # i-words/ duration of recording in
minutes
Content units
Time Performance at phrase level
Communication efficiency - Index of grammatical support (IGS)
- Index of elaboration (IEI) à total # of stem
morphemes in content units/ total # of i-
words e.g. 又肥又大嘅貓

Error production
- Index of error (IEr) à total # of jargons,
neologisms, phonemic or semantic
paraphsias/ total # of i-words

Lexical diversity
- Index of lexical richness (ILR) à type-token
ratio (TTR) of pooled text (= pooling speech
samples from all four pictures)
 All four areas of CAPPA
Area 1: Area 2: Area 3: Area 4:
Linguistic abilities Repair Initiation & turn-taking Topic Management
- Failure in word - Self-initiated: initiate - Ability to initiate - Ability of initiate new
retrieval and repairs on own error/ conversation topics
comprehension on CP’s turn
- Delay in responding or - Failure to orient CP to
- Difficulty in indicating - Self-initiated & self- failure to respond when new topics
yes or no reliability repair: repair own error selected as next speaker
after self-initiation - Ability to maintain
- Production of apraxic without help - Production of long topics
errors pauses in the middle of
- Other-initiated & self- turns - Repeated initiations of
- Production of repair: repair own error ‘favorite’ topics
agrammatic speech when initiated by CP - Violation of CP’s turn

- Production of - Other-initiated & - Failure to hand over

circumlocutions other-repair conversational floor

- Production of - Reliance on minimal

uncorrected semantic acknowledgements
paraphasia, jargon and
neologism

Right Hemisphere Disorders (RHD)

Cognitive √ Attention deficits à visual neglect (esp. left side)
à Leads to disconnect content + reduced sensitivity to situational and
affective cues
√ Executive dysfunction in planning, reasoning, organization & problem
solving
√ Hypo-arousal à less attentive, less oriented and alert
Language X anomia à unlike PWA, TBI, Dementia etc. (not necessarily have
anomia/ word-finding difficulties)
Pragmatics √ Reduced sensitivity to shared knowledge
√ Reduced appreciation of emotional content
√ Limited understanding of indirect/ implied meanings
√ Limited ability to draw inferences
√ Literal interpretation of verbal messages
X Use figurative language, idioms, sarcasm, humor, indirect requests
X Employ facial expressions, gestures or postures for expressing emotions
Paralinguistic √ Difficulties in perceiving and employing paralinguistic elements
à Speech prosody (for communicating emotions)
à Non-verbal behaviors: e.g. gestures, facial expressions, body language
etc.
Components in narrative discourse
1. Orientation: Giving background and setting information
2. Complicating action: Telling the next event in response to ‘And what happened?’
3. Evaluation: An assessment or emotional comment on the consequences
4. Resolution: Finishing off the event and resolving any complications
5. Coda: Closing the story and connecting the ending to the present context

Narrative discourse’s essential components:

- Orientation + Complicating action + Resolution à carry critical informational load
Procedural discourse’s essential components:
- Steps necessary to complete the tasks

Disorders of reading (Dyslexia) with narration

Dual-route model of reading

= involved in spontaneous
language production also
E.g. L consists of a vertical line
and a horizontal line

Recognizing the letter and its

relative position in a letter string Early stages

Written word forms of Later stages

a language (e.g. cat)

Lexico-semantics
(word meanings)
Spelling-to-sound
rules (e.g. ph à [f])

Spoken word forms

of a language

Segmenting the phonological

word form in individual phonemes
for speech production)
 Types of Acquired Dyslexia
Peripheral Acquired Dyslexia
Affect the early stage of the reading process and perceiving the written word
Pure Neglect Attentional Visual
1. Letter-by-letter 1. Incorrectly identify 1. Reading errors 1. Reading responses
reading or omit initial or final resulting from correspond to words
letters in a word interference from that are visually similar
2. Process letters in a E.g. book à [but]/ cart other letters in the to the targets
word in a serial fashion, à [khar] written context E.g. butter à better/
but not parallel E.g. bare à rare/ prince à price
2. Specific to reading, butterfly à flutterfly
3. Resources limited to not the same as a 2. Impairment may
processing one letter at general visual neglect 2. Disruption in originate from letter
a time encoding the relative recognition; or from
3. Impairment in positions of some Orthographic Input
4. Impairment at visual encoding the identities letters Lexicon à erroneous
feature analysis, letter of letters on one or the selection of a visually
analysis or in between other end of a word similar orthographic
representation

Central Acquired Dyslexia

Affect the later stages and involve impairment along the lexical or sub/non-lexical reading routes
Surface Phonological Deep
1. Can read aloud the regularly 1. Can read aloud both regular 1. Impaired pseudowords
spelled words, e.g. bike, dog and irregular words reading

2. Can read aloud pseudowords, 2. Poor reading of pseudowords 2. Semantic errors in reading
e.g. brane, steek, liston e.g. blaf à black, soof à soot aloud, e.g. apple à banana

3. Make regularization errors 3. Overreliance on lexical 3. Visual errors, e.g. goal à goat
when reading irregular words, reading routes
e.g. pint à [pɪnt] 4. Morphological errors, e.g.
baking à baked
4. Impairment along the lexical
reading routes, and overreliance 5. Imageability effect: concrete
on GPC words > abstract words

Phonological
dyslexia
Surface
dyslexia
Assessment of acquired dyslexia (English):
Psycholinguistic Assessments of Language Processing in Aphasia (PALPA)
- √ 60 subtests
- Tests on components of language structures such as orthography and phonology,
word and picture semantics, morphology and syntax.
- Heavy emphasis on reading and writing tasks
- Reading and spelling module à 29 tasks
- Letter discrimination, oral reading, spelling to dictation of real words
and non-words
- Picture and lexical semantics à 8 tasks
- Picture matching, picture naming, and synonym judgment

Acquired dyslexia in Chinese

** People having anomia without dyslexia
à have word-searching difficulties
à semantic system impaired/ connections between semantic system and
phonological output lexicon impaired
à able to read aloud the written names of the objects they cannot search
without cues
à indicating that they read aloud the words relying on the Lexical non-
semantic (direct) reading route!

Surface Dyslexia Deep Dyslexia

- Regularization errors (or Legitimate - Pure semantic errors: e.g. 蕃茄 à 薯仔
Alternate Reading of Component, LARC)
e.g. 骷 à 古, 吠 à 犬 (有邊讀邊) - Partial semantic errors: e.g. 青椒 à 辣椒

- With poor word comprehension - Association errors: e.g. 凳 à 坐, 井 à 水

Overall review of all reading errors

Semantic The response and the target belong to the 笛 à 簫；
same semantic category 蕃茄 à 薯仔
Partial semantic The response and the target are somehow 青椒 à 辣椒；
related, having one word overlapping 羊 à 羊毛
Association The target and response together form a 凳 à 坐 (坐凳)
word 重 à 量 (重量)
Regularization The response is phonologically the same as 骷à古
the phonetic radical 吠à犬
Phonological The target and the response share at least 哄 hung3 à gung1
the same rhyme 霆 ting4 à cing4
Visual The target is read as another character 篤à罵
having the same phonetic radical
Unrelated No phonological, semantic or visual 期à免
relationships exist between the target and *totally irrelevant
the response
Test Battery for Acquired Dyslexia and Dysgraphia in Chinese
Tasks Details
Written lexical decision Whether the stimulus is a real character or correspond
to a real word (in case of two-character stimuli)
Verbal semantic tests
Written word-picture matching Presentation of a written word and three pictures
- Target + semantic distractor + unrelated distractor
Written version of PPTT E.g. 十字架 (Target) à 教堂 Vs 城堡
Synonym Judgment Presentation of two written words (pairs of concrete or
abstract nouns/ verbs)
- Determine whether they have similar meaning or not
E.g. 員工 Vs 學生；時鐘 Vs 鬧鐘
Five word lists To assess reading aloud and writing to dictation abilities
Frequency - High (e.g. 頭) Vs Low (e.g. 尾) with form class (noun,
verb, functors) controlled
- Monosyllabic
Form Class - Monosyllabic Vs Disyllabic
à e.g. 音, 爭, 又 Vs 朋友, 喜愛, 所以
- Imageability balanced between nouns and verbs
Imageability High (e.g. 野獸) Vs Low (e.g. 天使)
Phonetic compounds Different positions of phonetic radical
形聲字 - Left: 勉
- Right: 恢
- Top: 型
- Bottom: 爺
Different phonological relationships between phonetic
radical and whole character (regularity/ consistency)
- Regular: 稀
- Semi-regular: 酬
- Irregular: 填
Homophone Identification Test
Syllable-character matching
Character-character matching E.g. 走 à 酒, 跑, 奏, 去, 手

*PALPA & Test Battery for Acquired Dyslexia and Dysgraphia in Chinese à Impairment-based
*Client-oriented assessment (e.g. client’s reading ability) à inform rehabilitation
Life Participation Approach to Aphasia (LPAA)
- Emphasizes the consumer’s viewpoint, attainment of meaningful life changes and
outcomes, and participation in desired social roles and activities
à Client-centered approach in principle
à Functional communication: √ receive or convey message regardless of the mode

Domains:
1. Language and related processing
2. Participation: roles, relationships, activities that PWA may take part in
3. Personal factors and identity: demographics and personality
4. Environment: other people in the environment, knowledge, attitudes and
communication support

10 Factors related to Client-centered Aphasia Therapy

Respect for individuality and Be sensitive to differences in culture, age, gender, SES and
values personal factors
Meaning Be understanding of the client’s experience of illness,
change and impaired language
Therapeutic alliance To convey realistic hope.
- Social communication/ language processes/
conversation skills/ life participation
- Feelings of less and recovery/ confidence and
identity
- Diminishing barriers to effective communication/
facilitating social connectedness
Inclusive model of health and Assessment and intervention outcomes (measures of
well-being impairment, activity, participation, personal and
environmental factors)
Shared responsibility Collaborative goal setting, beware of their rights and
responsibilities, increase patient’s motivation
Social context and Increased attention given to other family members, friends
relationships and work associates
Communication Supported communication à Focus: training CP
Expert lay knowledge PWA and family may contribute to service delivery and
evaluation of services
Autonomy Conceptualize intervention à adult learning > clinical care
Professional as person Be reflective

Different treatment approaches

Impairment-based Drill-based Communication-based
- Word-finding problems, - For PWA with more sever - Conduct intervention in a
syntactic errors, use of language impairment communicative context à
cohesive device etc. à - Emphasize on repetition highlight dialogue features
Based on the errors and give and careful selection of
tailor-made treatments training materials with ref to
their limitations and needs
Therapy promoting functional communication
Conversation Therapy Group Therapy
- Focus on how well… √ Practice conversational skills using a total
1. A speaker can convey a meaning communication approach
2. Repair communicative breakdowns
3. Construct message or idea √ Develop a sense of self
collaboratively
4. Take conversational turns Features:
* Facilitative CP à Acknowledge and reveal - Focus on everyday communicative events
the competence of PWA
- Multiple communication modes (gestures,
Supported communication: pointing, writing, drawing etc.)
1. Verbal and non-verbal means
2. Communicative strategies - Calibrating corrections à mediated talk or
3. Importance of a facilitative CP and implicit correction √; medicating
caregiver trainings communication by clinician when needed

- Discourse equality

- Aiding turn allocation by applying

solicitation questions/ request, silence and
gaze solicitation etc.

- √ educational materials, new techniques,

problem-solving skills etc.

Communication with PWA

PWA Talking CP Talking
1. Writing (whole or part) 1. Speak slower
2. Gesturing/ pantomiming 2. Say again/ Repeat
3. Trying again 3. Say another way/ Paraphrase
4. Signaling/ Asking for more time 4. Speak louder
5. Signaling/ Asking for help
6. Circumlocution
7. Drawing/ Diagramming
PWA Comprehension CP Comprehension
1. Ask CP to speak slower 1. Reading partial or whole word
2. Ask for repetition 2. Check accuracy (ask for clarification/
3. Ask for paraphrasing confirmation of message)
4. Ask CP to speak louder 3. Providing honest feedback
4. Say ‘I understand’ only when you do

Why include functional communication assessment?

1. √ achieve a global view of a patient’s communication profile
2. √ facilitate the selection of realistic goals, appropriate intervention approaches and
effective modes of communication for the patient
3. √ serve as an outcome measure
Life participation approach examples:
1. ASHA Functional Assessment of Communication Skills for Adults – Cantonese Version
(ASHA FACS)
2. ASHA Functional Communication Measures (FCMs)
à Both illustrate the important role of family member(s) in assessment and rehabilitation

Cantonese ASHA FACS

Two scales
1. Scale of Communication Independence “7” à no assistance or prompting by others
“1” à cannot complete the item
2. Scale of Qualitative Dimensions of Adequacy, Appropriateness, Promptness à
Communication for all domains:
- “5”: Highest frequency
- “1”: Lowest frequency
Communication Sharing (Only SC and CBN)
- “5”: Minimal communication burden
on the CP
- “1”: Maximal burden on CP
Four aspects (43 functional communicative abilities)
1. Social communication 21 items
2. Communication of Basic Needs 7 items
3. Reading, Writing and Number Concepts 10 items
4. Daily Planning 5 items
Other points (validation)
- Significant differences in Communication Independence (CI) & Qualitative Dimension
(QD) mean and overall scores à function of Aphasia severity level
- Significant relationships between CI and QD scores and education à PWA with higher
education level à higher scores

ASHA FCMs
15 FCMs
à Describing different aspects of a patient’s functional communication and swallowing
pre- and post-treatment abilities
à Not dependent on administration of any particular formal or informal assessments
7-point rating scales: Level 1 à least functional; Level 7 à most functional
1. Alaryngeal communication 9. Reading
2. Attention 10. Spoken language comprehension
3. Augmentative-alternate communication 11. Spoken language expression
4. Fluency 12. Swallowing
5. Memory 13. Voice
6. Motor speech 14. Voice following tracheostomy
7. Pragmatics 15. Writing
8. Problem solving
**Only a few FCMs per patient will be selected
 Frequency of cueing
Consistent Required 80-100% of the time
Usually 50-79% of the time
Occasionally 20-49% of the time
Rarely Less than 20% of the time
Intensity of cueing
Maximal Multiple cues that are obvious to non-clinicians
Any combination of auditory, visual, pictorial, tactile or
written cues
Moderate Combination of cueing types, some may be intrusive
Minimal Subtle and only one type of cueing

FACS FCMs

Task Oriented √ X
(e.g. ask Qs: 能說出熟悉的人的名字)
Input from √ X
Caregivers (Some items required to be scored with
reference to the caregiver’s response)
Coverage of ↓ ↑
FC (More aspects including voice,
cognition, swallowing, language and
pragmatics)
Selecting Entire test Select a few domains

Cognitive Communication Disorder

CCD: Difficulty with any aspect of communication that is affected by disruption of cognition
- Neurocognitive domains:
1. Complex attention
2. Executive functions
3. Learning and memory
4. Language
5. Perceptual-motor abilities
6. Social cognition

Neurocognitive Disorders (NCD)

Symptoms related to speech and language performance:
- Naming and word retrieval
- Verbal fluency
- Discourse processing
à Major NCD = Dementia (Degenerative disorder)
à Diagnosis was made by psychologists/ geriatric doctors
à Subtypes x 6 (Mainly)
Subtypes of NCD:
1. Alzheimer’s Dementia
2. Vascular Dementia
3. Parkinson’s Disease
4. Frontotemporal Lobar Degeneration
5. Lewy Body Disease
6. Huntington’s Disease

Alzhemer’s Disease:
1. Cognitive:
a. Memory impairments (esp. episodic memory/ working memory)
a. Executive function impairment
b. Language (content/ use/ form)
i. Word retrieval
ii. Discourse
2. Non-cognitive: Agitation/ Aggression/ Distress/ Psychosis (BPSD)
a. Suspicions and memory problems
b. Hallucinations
c. Distress and memory problem
d. Agitation and difficulties in handling activities of daily living

Screening (Assessment) of NCD

1. MMSE
2. MoCA (full or 5-min version)
3. Mini-Cog

Scales for indicating stages/ severity

1. Clinical Dementia Rating
2. Global Deterioration Scale for Assessment of Primary Degenerative Dementia

Cognitive-communication therapies for NCD

- Person-centered à Compensatory + Restorative

Interventions to promote cognition, independence and wellbeing

- √√√ Activities promoting wellbeing that are tailored to one’s preferences
- √√√ Group cognitive stimulation
--------------------------
- √ Group reminiscence therapy
- √ Cognitive rehabilitation or Occupational therapy à support functional ability
--------------------------
- X Cognitive training à Alzheimer’s disease
- X Interpersonal therapy à treat cognitive symptoms of Alzheimer’s Disease
- X Non-invasive brain stimulation
- X Acupuncture/ eat ginseng, Vitamin E etc.
 Cognitive Interventions
Interventions Supporting strategies Indirect interventions
- Cognitive Stimulation - Spaced retrieval training - Memory book
à CST - Errorless learning - Multi-sensory stimulations
- Reminiscence Therapy
- Reality Orientation

Meta-cognitive/ Multi-sensory stimulations

- Activities for people with dementia at different stages
- Meta-cognitive stimulations from multiple intelligence:
- Orientation, learning, intellectual process, problem-solving, attention,
memory, fund of knowledge, creativity, planning and organizing, social skill
- Linguistic, kinesthetic, musical, logical-mathematics, interpersonal, intra-
personal, naturalistic
- Multi-sensory stimulations:
- Visual, auditory, tactile, olfactory, gustatory

Caregiver’s training and counselling

à FOCUSED Program:
- Face-to-face + Orientation + Continuity + Unsticking + Structure + Exchange + Direct

Common strategies for managing people with severe Dementia/ NCD:

1. Melodic Intonation Therapy (MIT)
a. Limitation in verbal responses
b. Co-morbid AOS
2. Total communication: Pointing/ gestures
3. AAC (Augmentative and Alternate Communication)
a. Traditional communication book
b. Assistive technology

Aphasia CCD

Etiologies Sudden onset (e.g., stroke, TBI) Both sudden (TBI) and degenerative
Progression Non-progressive; spontaneous Progressive; deteriorates over time
recovery is possible
Prognosis Depends on post-onset period; Generally less positive
generally more positive
Impairment:
- Linguistic Depends on lesion site; lexico- Depends on etiologies/ whether lesions
semantic/ lexico-phonological are focal or diffused/ sub-types of NCDs
- Non- Deficits in attention/ executive Depends on etiologies/ whether lesions
linguistic functions/visual-spatial processing are focal or diffused/ sub-types of NCDs
may accompany