Assessment by a speech pathologist

People with suspected aphasia should receive assessment by a speech pathologist to determine the presence and severity of aphasia

Reference: National Stroke Foundation, 2010
NHMRC level of Evidence: GPP

Rationale:  The Australian Clinical Guidelines for Stroke Management (NSF, 2010) aphasia guidelines recommend that patients with suspected communication difficulties undergo comprehensive evaluation by a specialist clinician.  In many healthcare institutions this evaluation is conducted by the speech pathologist.  A comprehensive clinical examination enables early identification and diagnosis of patients who, if unattended could be left with avoidable disability and resultant healthcare burden (Sackett, 1992). Expedient and accurate diagnosis results in treatment that is appropriate and cost-effective (Aliu & Chung, 2012).   Severity of aphasia has been demonstrated to be a predictor of patient prognosis and outcome (Kertesz & McCabe, 1977; Lazar et al., 2010; Pedersen, Vinter, & Olsen, 2004). Accurate determination of patient status is therefore paramount in planning treatment options and guiding management plans.  Early identification of the presence and severity of aphasia by a speech pathologist is therefore a vital step in ensuring the implementation of appropriate intervention plans and optimisation of service delivery options.

Acknowledgements:
This section was written by Alexia Rohde (The University of Queensland).

The identification of post-stroke aphasia

People with aphasia are often first referred to speech pathology  in the acute hospital setting.  In this environment, speech pathologists may only have a brief window (frequently limited to 15-30 minutes) in which to conduct a thorough clinical examination (LaPointe, 2011) to determine the presence and severity of aphasia.

Accurate identification of aphasia is dependent upon precise, thorough clinical examination. Studies by Vogel (2010) and Petheram, (1998) investigating language assessment practices of speech pathologists in the early stroke recovery phase reported a heavy reliance upon informal non-standardized evaluation approaches.   Comprehensive evaluation of language abilities by a speech pathologist is vital in developing a comprehensive knowledge of individual patient communicative strengths and weaknesses.  Aspects of patient language may often appear intact until these skills are challenged in certain ways.  Areas of difficulty may be masked by more general observations (such as reduced alertness) unless specific clinical attention is paid to investigate them (Spreen & Risser, 2003).  Appropriate choice and selection of each clinical task and question is therefore vital in revealing areas of deficit which may be missed in simple conversational interaction (Spreen & Risser, 2003). 

Determining the presence of aphasia

 The speech pathologist’s initial contact with an acute stroke patient is typically via informal bedside examination. This assessment may comprise unstructured evaluations focused around conversational interaction or more test-style tasks (LaPointe, 2011; Spreen & Risser, 2003).  The evolution of this informal, flexible approach has grown not only from individual clinician expertise, but also from an awareness of patient preferences and needs in the early recovery phase, and in response to the transient, time pressured environment of acute settings.  

Chapey (2008) reports that the use of non-standardized evaluations is useful in diagnosing the presence of aphasia and providing an indication of aphasia severity.  LaPointe (2011) argues that in acute settings it is neither feasible nor necessary to conduct comprehensive standardized testing for diagnostic purposes.  Current standardised tests have been reported to be too difficult to administer at the patient’s bedside (LaPointe, 2011), and are too lengthy to be administered in a single session (which rarely lasts over 30 minutes) (LaPointe, 2011; Vogel, 2010).  Current standardized tests have not been considered sufficiently sensitive to detect immediate post-stroke communication changes (Vogel, 2010).  Rapid changes in communication often seen in early post-stroke recovery mean that these tests, when administered over more than one session have not been considered a reliable or valid index of severity (LaPointe, 2011; Vogel, 2010). In addition, fast patient turnaround in acute wards has also been cited by clinicians as additional grounds for continued reliance on informal non-standardized approaches (Vogel, 2010).  LaPointe (2011) argues that the majority of clinicians would agree that in many clinical settings standardized testing is done after the diagnosis is established.  

Evaluations vary with respect to their length and content however where possible, speech pathologists typically evaluate the following key language areas:

1. Spontaneous speech (often including picture description and conversational interaction),
2. Repetition (words and sentences),
3. Comprehension of spoken language (e.g. following commands, answering ‘yes’ ‘no’ questions),
4. Word finding (e.g. naming body parts, objects and picture stimuli),
5. Reading, and
6.  Writing (LaPointe, 2011; Spreen & Risser, 2003). 

Based on the patient’s performance on these measures it is determined if language skills correspond to what is considered the normal performance for that patient population.  This clinical information is interpreted in the context of other possible clinical factors which may also influence patient abilities and performance (Davis, 2014).

Determining the severity of aphasia

Aphasia is a condition which varies greatly in its clinical presentation.  No two patients with aphasia present in the same way.  Individual diversity in presentation as well as variation in performance across language modalities mean that the clinical judgement of a patient’s overall severity rating is often a highly clinically complex procedure (Davis, 2014).  A judgement of severity however is a clinically useful measure.  In addition to assisting with the process of prognosticating (Kertesz & McCabe, 1977), severity ratings may also provide a useful guide for selecting treatment goals (Chapey, 2008) and intervention plans (such as assigning patients to language treatment groups) (Beeson & Holland, 1994).

The ICF provides guidelines as to the how to evaluate the severity of impairment:

Severity of condition: Aphasia of all severity ranges (1 Mild - 4 Complete) as determined by extent of impact on body functions and structures:

• 0 No Impairment- Means the person has no problem.
• 1 Mild impairment - Means the problem that is present less than 25% of the time, with an intensity a person can tolerate and which happens rarely over the last 30 days.
• 2 Moderate impairment - Means that a problem that is present less than 50% of the time, with an intensity, which is interfering in the persons day to day life and which happens occasionally over the last 30 days.
• 3 Severe impairment - Means that a problem that is present more than 50% of the time, with an intensity, which is partially disrupting the persons day to day life and which happens frequently over the last 30 days.
• 4 Complete impairment - Means that a problem that is present more than 95% of the time, with an intensity, which is totally disrupting the persons day to day life which happens every day over the last 30 days.  (ICF checklist, World Health Organization, September 2003).

Clinicians need to be flexible in adapting their clinical examination to evaluate patient skill across a range of different severity levels.  Item difficulty usually ranges from “very easy” to “very difficult” (Spreen & Risser, 2003).  This range ensures patients with severe conditions have their communicative abilities recognised and identified, and patients with milder conditions do not go undetected.  Below are examples of how the six areas of evaluation (Spreen & Risser, 2003) can be hypothetically modified to assess different patient skill levels:

 

Language area	Task Difficulty
	Simple	Complex
Spontaneous speech	Counting 1-10 (Davis, 2014) Day of the week	Describing tasks and role requirements of their previous employment
Repetition	Single sounds or phonemes Simple words (‘Mum’, ‘Bye’)	Complex sentences (dependent upon memory function)
Comprehension of spoken language	Following commands (Davis, 2014):
	‘Smile’, ‘blink’ or ‘whistle’	Raise your left arm towards the ceiling, then with your right arm tap your nose three times with your eyes are closed.
	Yes/No questions
	Is your name John?	Do you cut the grass with an axe?
Word finding	Name Objects (Davis, 2014) What is this? (object = ‘pen’)	What is the word that means you have the odd experience of feeling like you have been somewhere before? (déjà vu)
Reading	Single words: ‘Bed’ “Close your eyes”	Answering questions about a paragraph (Davis, 2014) (often including complex multi-faceted subject matter and inference)
Writing	Write names of objects (Davis, 2014), Patients name.	Paragraph composition (e.g. Write a letter) (Davis, 2014)

As part of their clinical examinations speech pathologists often examine other factors such as evaluation of alertness, orientation, attention, memory, (Brookshire, 2003), verbal fluency and ability to manage visual stimuli (Spreen & Risser, 2003).  For the majority of patients, this evaluation permits a broad diagnosis with an estimation of severity as well as a sense of the patient’s strengths and weaknesses (LaPointe, 2011).  

Differential Diagnosis

Further investigation is often required when a patient is unable to perform a certain task.  Patient performance alone cannot be automatically attributed to the presence of a language disorder.  The possible presence of other conditions such as sensorimotor limitations, hearing deficits, visual deficits, cognitive decline, motor, or even vocal difficulties may all influence performance on language and communication tasks (Spreen & Risser, 2003).  Accurate differential diagnosis and thorough knowledge of relevant medical history is vital in ensuring the patient’s presentation is accurately attributed to the right condition (Chapey, 2008).

 Complicating conditions include:

• Auditory and visual sensitivity (e.g. hearing impairment or cataracts)
• Auditory and visual agnosia
• Behaviours frequently associated with right hemisphere functions (e.g. inattention or neglect)
• Motoric impairments (e.g. apraxia, dysarthria or hemiparesis)
• Medical conditions (e.g. diabetes, learning disability, dementia)
• Post-stroke psycho-behavioural disorders (e.g. clinical depression)  (Chapey, 2008).

Ways to optimise the initial contact:

• Obtain a thorough understanding of current medical status and medical history prior to approaching the patient. This knowledge will assist you not only with the process of diagnosis, but also differential diagnosis during and after your evaluation. The chart contains a summary of admission information including the neurologist’s clinical findings, medical status, presence of possible complicating conditions and current medications.  Relevant information regarding family, vocational history and personal environment should also be obtained (Davis, 2014).
• Obtain information from family members regarding patient pre-morbid functioning, personal interests and personally relevant factors to enable you to individualise your care. At every opportunity clinicians should tailor their evaluations to suit the particular needs of the patient and family members.  Each patient’s unique characteristics and living circumstances may have a significant influence their individual communicative needs and requirements (McCooey-O’Halloran, Worrall & Hickson, 2004). 
• Provide education and support for patients and their family members from your very interest point of interaction (Davis, 2014). Clinicians need to quickly gauge the patient’s and family’s readiness for counselling and support (LaPointe, 2011; Holland & Fridriksson, 2001), need for information, for control and independence and also their need to contribute to the decision making in their care (Worrall et al., 2011).
• Draw from the clinical experience in your workplace. Clinical experience is a significant factor in guiding the nature and structure of current informal bedside clinical evaluations.  Experienced clinicians are considered to be adept at making optimal use of patient responses and obtain adequate aphasia screening under almost any set of clinical circumstances (Brookshire, 2003; Chapey, 2008; Davis, 2000; Spreen & Risser, 2003).  Spreen & Risser (2003) report that experienced clinicians can perform valid bedside testing in an ad hoc, informal manner and the skill of anticipating the range of patient performance that encompasses both normal and abnormal responses is considered to be part of the routine repertoire of the experienced clinician (Spreen & Rissser, 2003).
• Draw from a range of clinical sources of information to inform your clinical opinion. Information obtained during the assessment process is based upon various sources such as reported observations of a patient’s language abilities as well as direct observation of patient performance during set language tasks and communication interaction (Chapey, 2008; Lahey, 1988).  Take into account individual information obtained from the client from initial conversational contact, such as apparent difficulties in understanding questions, as well as self or carer report (Whitworth, Webster & Howard, 2014 p. 21)
• Where possible use research findings to back up your rationale and clinical intervention and management plans.  Evidence based practice is the incorporation of clinically relevant research into clinical decision making (Straus, 2011).  Application of relevant research findings into clinical management should occur whenever possible.  An elderly patient with aphasia, for example, may find it useful to hear that the outcome for language function is not dependent upon age (Pederson, Vinter & Olsen, 2004).  A clinician could use this research finding to advocate for this patient to be referred for ongoing rehabilitation.  Clinicians however need to be mindful of the areas where research findings are currently lacking.  There is currently heavy reliance upon informally created language measures to structure clinical examination procedures (Vogel, 2010).  The majority of informally created language measures have not undergone psychometric analysis and therefore the accuracy and precision of these tools in detecting aphasia is unknown (Spreen & Risser, 1998; Vogel, 2010).  The absence of research, guidance and support to improve the reliability and validity of clinical examination practices hampers the development of a professional systematic body of knowledge about the evaluation of communication immediately after stroke (Vogel, 2010).  Further research is warranted to investigate clinical validity of speech pathology practices in this area.   
• Liaise closely with the multidisciplinary team regarding clinical presentation, intervention and management plans. Relevant clinical information is collected by all members of the multidisciplinary team.  Information regarding the patient’s physical, psychological, social or occupational functioning is important in influencing management decisions and care.  Such a team may be composed of the medical team, occupational therapist, physiotherapist, neuropsychologist, social worker and dietician (among others).  Good communication among the team members is crucial to ensure the best possible care, particularly in clinical settings where other team members such as the neuropsychologist or occupational therapist share the responsibility of evaluating the domains of cognitive and linguistic functioning (Chapey, 2008).

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