Summary

Aphasia is an acquired impairment of language that affects comprehension and production of words, sentences, and/or discourse. It is typically characterised by errors in word retrieval or selection, including:

• Semantic paraphasias (substituting a semantically related word for a target word, e.g., calling a horse a cow)

• Phonemic paraphasias (substituting one or more sounds in the word, e.g., calling a horse a force or using a non-word such as porse)

• Neologisms (a series of sounds that do not comprise a word and are not similar to the target word)

• Circumlocutions (e.g., calling a horse an animal that you ride with a saddle).

Typically, both oral and written language are affected, but occasionally only one modality of input or output is impaired.

Definitions: aphasia, dysarthria, and apraxia

It is important to distinguish aphasia from dysarthria or apraxia.

• Aphasia is a selective impairment of language or the cognitive processes that underlie language. Individuals with dementia often have language problems, but they also have at least equally severe deficits in episodic memory, visuospatial skills and/or executive functions (e.g., organisation, planning, decision making).

• Dysarthria is an acquired disorder of speech production due to weakness, slowness, reduced range of movement, or impaired timing and coordination of the muscles of the jaw, lips, tongue, palate, vocal folds, and/or respiratory muscles (the speech articulators).

• Apraxia of speech is an impairment in the motor planning and programming of the speech articulators that cannot be attributed to dysarthria.

These 3 disorders can co-exist, but often occur separately. They can be distinguished by evaluation of language (tests of word and sentence comprehension, naming, repetition, spontaneous speech, reading, and writing), as well as tests of articulation (tests assessing the strength, coordination, rate, and range of movement of the muscles of speech articulation) and motor speech programming.

Vascular classification of aphasias

The most common classification of aphasia divides the disorder into clinical syndromes of frequently co-occurring deficits that reflect the vascular territory affected in stroke. [1] [2] For example, the Western aphasia battery [3] and Boston diagnostic aphasia examination [4] were designed to distinguish vascular syndromes. The relationship between the symptoms and the vascular territory that is affected is not always consistent, but is more reliable acutely than chronically. [5] .

• Broca's aphasia is characterised by nonfluent, poorly articulated, and agrammatic speech output (in both spontaneous speech and repetition) with relatively spared word comprehension. Individuals with Broca aphasia often have difficulty understanding syntactically complex or semantically reversible sentences (e.g., "touch your nose after you touch your foot") but have little trouble understanding simple, semantically nonreversible sentences. This collection of syndromes is usually associated with ischaemia or other lesions in the left posterior inferior frontal cortex, in the distribution of the superior division of the left middle cerebral artery (MCA).

• Wernicke's aphasia is characterised by fluent but meaningless speech output and repetition, with poor word and sentence comprehension. It is typically due to ischaemia in the posterior superior temporal cortex, in the distribution of the inferior division of the left MCA.

• Conduction aphasia is characterised by disproportionately impaired repetition with otherwise fluent speech. It is typically due to ischaemia affecting the inferior parietal lobule.

• Transcortical aphasia is characterised by relatively spared repetition. Transcortical sensory aphasia usually results from ischaemia involving the watershed area between the left MCA and left posterior cerebral artery (PCA) territory.

• Transcortical motor aphasia usually results from ischaemia involving the watershed area between the left MCA and left anterior cerebral artery (ACA) territory. Mixed transcortical aphasia results from ischaemia in both of these "watershed" territories.

• Anomic aphasia is characterised by impaired naming and tissue damage in the angular gyrus or posterior middle/inferior temporal cortex.

• Global aphasia denotes severe impairment in all aspects of language; the area of ischaemia often involves both anterior and posterior language areas (Broca and Wernicke areas).

Fluency classification of aphasias

Fluency is a multi-dimensional term referring to the melody, prosody, phrase length, rate of speech, grammaticality, effort, and articulation precision of spontaneous speech. This is often tested by asking the patient to describe a complex picture depicting a number of activities.

Patients with fluent aphasia (melodious, effortless, well-articulated speech, which may have little content) tend to have posterior lesions in the left hemisphere, whereas patients with nonfluent aphasia (effortful, poorly-articulated speech, with more accurate content than speech sounds) tend to have anterior lesions in the brain. However, because fluency is a multi-dimensional term based on factors that can dissociate (grammatical accuracy, rate of speech, prosody, effort, articulatory precision, hesitations), it is often difficult to judge. A patient can be fluent on one dimension and nonfluent on another. Therefore, there is often disagreement between two people in judging fluency of an aphasic individual.

Fluent aphasias are typically due to lesions posterior to the central sulcus:

• Wernicke aphasia with fluent, jargon speech and poor comprehension

• Transcortical sensory aphasia, characterised by well-preserved repetition abilities in the context of poor comprehension and fluent but meaningless propositional speech

• Conduction aphasia in which fluent spontaneous speech is preserved but repetition is impaired

• Anomic aphasia with deficit of word finding and naming.

Nonfluent aphasias encompass the regions anterior to the central sulcus:

• Broca's aphasia

• Transcortical motor aphasia with difficulty in initiating and organizing responses, but relatively preserved repetition

• Mixed transcortical aphasia in which echolalia (repetition) is the only preserved language skill

• Global aphasia characterised by severe impairment in speech and comprehension, and stereotypical utterances.

Disorders that only affect reading are referred to as types of alexia. Those that only affect writing are types of agraphia. [6] [7]

An important variable that complicates these deficit associations is the remarkable reorganisation of structure-function relationships that often occurs after brain lesions, such that undamaged parts of the brain assume the functions of the damaged part over time, resulting in recovery from even the most severe aphasias (usually only after appropriate language therapy).

Follow-up treatment

After identifying and treating the underlying cause of aphasia, such as acute stroke or herpes encephalitis, patients may have a residual aphasia. Such aphasic individuals benefit from referral to a speech language pathologist specialising in aphasia therapy. Treatment should be individualised to address the person's residual deficits, communicative needs and priorities, and available resources. [8] Therapy often addresses the impaired cognitive processes underlying the individual's altered performance of language tasks. It is sometimes argued that intensive therapy (e.g., 5 days per week) is often more effective than less intensive therapy, [9] [10] unless the person is able to practice emerging skills on their own, often with the aid of a computer. However, the dose (number of sessions) may actually may be more important than the intensity. [11] [C Evidence] Alternatively, caregivers can be trained by the speech language pathologist to provide effective practice. [10] [A Evidence] Sometimes, therapy is augmented with medications, such as bromocriptine or dextra-amphetamine, [12] [13] [14] [C Evidence] or with transcranial direct current stimulation. [15] [16] [C Evidence]