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Clinical Profiling of a Bilingual Client with Anomic Aphasia

Clinical Profiling of a Bilingual Client with Anomic Aphasia Background: Aphasia is an acquired condition affecting auditory comprehension, verbal expression, reading, writing and word-finding abilities along with sensory-motor impairments. Anomia refers to difficulty in word retrieval or naming which is seen irrespective of the type of aphasia. However, if a patient shows word-finding difficulty, in specific, a diagnosis of Anomic aphasia is made. There are variations within anomic aphasia on which the management and recovery depend. The article provides one such case report. Purpose: Speech and language profiling in anomic aphasia, specific treatment strategies, the effect of bilingualism on recovery. Methods: Mr S, a 38-year-old bilingual male reported 5 months post-stroke with difficulty in expressing, difficulty in writing and weakness in the right side of the body. Medical history was checked and speech and language evaluations including both formal and informal assessments were performed. After this, a diagnosis of Anomic aphasia with mild dysarthria was made. An appropriate speech–language therapeutic plan and specific activities were formulated for Mr S in his first language (L1) and he was given a therapy for a span of 3 months. A follow-up evaluation in both first and second language of the patient yielded differential recovery patterns. Results: The diagnosis was affected by different variants of anomic aphasia; treatment was specific to the clinical profiling and followed life-participation approach of aphasia. The recovery was affected by differential recovery patterns between the languages. Discussion: Factors pertaining to diagnosis, recovery, bilingualism and treatment of the client with anomic aphasia are discussed. Keywords Anomic aphasia variants, residual aphasia, bilingualism, therapy, recovery A number of classification systems are available to describe Introduction the various language impairments of aphasia. One of the most Aphasia refers to the disturbance of any or all of the skills, influential classification systems was proposed by Goodglass associations and habits of spoken and written language and modified by Davis. Aphasia is broadly classified as fluent produced by injury to certain brain areas that are specialized and non-fluent type. Non-fluent aphasia is characterized by for these functions. Disturbances in communication that are because of paralysis or incoordination of the musculature of Junior Research Fellow, Department of Speech-language Pathology, All India speech or writing, or because of impaired vision or hearing, Institute of Speech and Hearing, Mysore, Karnataka, India are not, of themselves, aphasic. Corresponding author: M. Nikitha, Department of Speech-language Pathology, All India Institute of Thus, aphasia can affect auditory comprehension, verbal Speech and Hearing, Mysore, Karnataka 570006, India. expression, reading, writing, and word-finding abilities. E-mail: nikitham25@gmail.com Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 76 Annals of Neurosciences 27(2) faltering and effortful speech: impaired grammar, although may vary across languages and word class. However, content words are preserved in the speech. Further, there are contradictory findings also have been documented. The 3 major varieties under the non-fluent type such as (a) Broca’s former study was carried out with the dominant language of the bilingual patient, while the latter was carried out with Aphasia: poor in repetition of words/phrases, (b) Transcortical 8,9 both the languages known to the person. A dissociation was Motor Aphasia: exhibits strong repetition skills; may have poor noticed between the two languages in terms of word class. spontaneous speech, (c) Global Aphasia: severe impairment in The literature has highlighted language profiling in persons expressive and receptive language; may use facial expressions with AA in terms of word retrieval and recovery in bilinguals. and gestures to communicate. Fluent type is characterized by Naming nouns and verbs in persons with bilingual AA (Greek empty/meaningless speech and deficits in comprehension. as a first language and English as a second language) were Further there are four major varieties under the fluent type such as (a) conduction aphasia: poor word-finding abilities; observed to be language dependent. Further, the patterns of impaired repetition, (b) anomic aphasia (AA): good repetition naming and its interaction with word class in a person with skills; difficulty in word retrieval; uses common fillers (e.g., bilingual AA (Chinese and Mandarin) were examined. This “thing”) or circumlocution, (c) Wernicke’s aphasia: poor showed an effect on the recovery patterns in both languages repetition skills, (d) transcortical sensory aphasia: good in terms of word class. Thus, the findings highlighted the repetition of words/phrases; exhibits echolalia. importance of profiling word-retrieval abilities in both the Here, Broca’s aphasia, transcortical motor aphasia, languages and planning differential therapeutic plan in a person with AA. conduction aphasia and AA are the variants with relatively The earlier reports were limited to the tracking patterns intact language comprehension, whereas in global aphasia, of recovery and its relation to word retrieval in bilingual Wernicke’s aphasia and transcortical sensory aphasia, aphasia. However, profiling bilingual aphasia in terms of language comprehension is affected. Let us consider AA recovery patterns in both languages to cater to the therapeutic in specific here as the case report discussed ahead is a case needs was sensed. Thus, the present study aimed to highlight of AA. AA can be considered the mildest form of aphasia the importance of diagnosis and profiling the language when compared to all the other types. Persons with AA characteristics, and trace the recovery pattern with regard would represent with relatively spared spontaneous speech, to both languages and therapeutic goals concerning the life- comprehension, and repetition, and may have difficulty in participation approach and the quality of life. word finding or lexical access. Anomia in its literal sense refers to ‘without names’ and is a symptom seen in all forms of aphasia. However, when a patient exhibits word-retrieval Methods difficulty as a primary language dysfunction, AA is diagnosed. Many standardized language assessment tests are Participant Details used for diagnosis and categorization of aphasia. Western Aphasia Battery (WAB) is one of the most common, widely Mr S, 38-year-old male, reported difficulty in expressing, used, culturally accepted and standardized test which is difficulty in writing and weakness in the right side of the available in different languages for aphasia. It has high body. The patient reported these 5 months after stroke. The test–retest reliability along with high sensitivity to measure patient is an MBA graduate who worked as a sales executive the severity of language impairments in brain-damaged and is a Kannada– English bilingual. 6,7 individuals between 18 and 89 years of age. A cumulative score of four sections of the test, namely (a) spontaneous Medical History speech, (b) auditory verbal comprehension, (c) repetition and (d) naming provides the aphasia quotient (AQ), which The medical findings revealed no speech output immediately is a representation of the severity and type of aphasia; the post-stroke with high blood pressure at the time of admission maximum value achieved for this quotient is 100. Any score and right hemiparesis. The radiological findings (MRI reported less than 93.8 is categorized as aphasia and any score above cerebro vascular accident: right hemiplegic + hypertensive + 93.8 is considered non-aphasia as per the norms. Based on left putaminal intracerebral haemorrhage + left ganglionic the scores, classification of the type of aphasia can be done. haematoma. Further, the report read hyperdense lesion The test can be further used to profile the language deficits measuring 5.1 × 1.8 cm in the left ganglio-capsulonic area in persons with aphasia qualitatively. Profiling of language with effacement of ipsilateral ventricle and adjacent minimal deficits in terms of the effect of word retrieval, discourse and edema. Rest of the supratentorial brain parenchyma, cerebellum pragmatics could better represent the condition. Therefore, and brainstem showed normal attenuation. Scalp, extra-axial these details may better enable the speech–language therapist spaces and calvarium were normal. Interhemispheric fissure to choose goals during therapy. was in midline and no evidence of fracture was seen. With Considering that most of the individuals in the current this medical history and complaint, the patient was referred society are bilinguals, language profiling has to be carried to undergo speech and language evaluation, physiotherapy/ out in all the languages known. The word-retrieval deficits occupational therapy evaluation and neurological evaluation. Nikitha et al. 77 Mr S showed slightly affected lip, jaw, laryngeal and Evaluations tongue functions which explained his slurring (see Figure During the informal evaluation in speech–language out 1). Additionally, slight deviation of lips towards right and patient department (OPD), the following observation was reduced sensation on right oral and facial structures was made by the clinician: Mr S was able to give relevant noted. Thus, Mr S was diagnosed with mild dysarthria based answers to the questions asked, he could narrate events and on FDA. Alongside the physiotherapist made an impression use complete sentences to answer the questions, his speech of post-stroke writing difficulty and recommended for was unclear and inappropriate pauses were observed and he therapy. Overall, Mr S received a diagnosis of AA with mild could follow 3-step commands and general conversation. dysarthria at the speech–language OPD. Oral motor examination revealed structurally normal structures with affected lip retraction and protrusion range, Table 1. Pre-therapy WAB Scores (WAB as on 12 August 2015 in affected lip seal and deviation of the tongue to the right side the First Visit) of protrusion. 12 WAB Domains Max Score Patient Score Total for AQ Mr S was administered WAB-K (Kannada version) and an AQ of 89.2 was derived. Mr S performed relatively Spontaneous speech Information content 10 8 low in naming domain (86 on 100) as compared to all other Fluency 10 9 17 domains of WAB (spontaneous speech, 17 on 20; auditory Comprehension verbal comprehension, 196 on 200; repetition, 92 on 100; Yes/no question 60 60 see Table 1). Thus, Mr S was diagnosed with AA based on Auditory word rec- 60 60 9.8 the scores. ognition 80 76 Further, Frenchay Dysarthria Assessment (FDA) Sequential commands was administered as slurring of speech was noted along Repetition 100 92 9.2 with compromised speech mechanism. FDA is a test to Naming quantitatively assess the functioning of the speech subsystems Objective naming 60 60 (respiratory system, phonatory system, resonatory system Word fluency 20 8 8.6 and articulatory system) and speech intelligibility. The Sentence completion 10 8 results are represented graphically by shading the specific Responsive speech 10 10 subsection based on the performance of the patient on the Aphasia quotient 89.2 task. Shading is done to indicate the severity of dysarthria Source: Authors’ interpretation based on the performance on Frenchay (higher the shading, better is the performance). On FDA, dysarthria assessment (FDA) and Western aphasia battery (WAB). Figure 1. Pre-therapy Graphical Report of FDA (Administered as on 12 August 2015) Source: Authors’ interpretation based on the performance on Frenchay dysarthria assessment (FDA) and Western aphasia battery (WAB). 78 Annals of Neurosciences 27(2) Discourse and word retrieval were used as speech and lexical-generative naming abilities (phoneme fluency) samples to profile the language of Mr S because the repetition to 80% level, and to promote articulatory precision of Mr of longer sentences and word naming were difficult. Discourse S’s speech. Mr S was able to perform on discourse tasks sample revealed word-retrieval issues (difficulty in finding using Semantic Feature Approach and Response Elaboration and selecting words), code-mixing (alternating between Technique with an accuracy of 96% in Kannada and 80% in languages), syntactic errors (grammatically poor sentence English. The progress was well appreciated when compared structure and reduced sentence length), phonemic paraphasias to his baseline measures. Mr S was able to perform on naming (preserves at least a part of the intended word by substituting tasks with an accuracy of 90% in Kannada and 75% to 80% incorrect phonemes to form a non-word), circumlocutions in English, again indicating good progress. Articulation was (beating around the bush), hesitations, word-finding pauses achieved with consistency of 9/10 trials and accuracy of 95% and compromised speech intelligibility. Naming abilities in all levels (isolation, word and sentence) for the distorted revealed failed phoneme fluency (naming words beginning phonemes. with a specified phoneme/letter stimulus) and compromised The clinician had taken up the literacy skills wherein word fluency (naming words within a specified category). sentence completion, sentence construction and sentence However, confrontation naming (naming the picture or sequencing were worked upon to improve both reading object shown on request) and responsive naming (naming in and writing. There was sufficient improvement of up to response to an idea during conversation) were spared. 90% in Kannada and 80% in English. However, legibility remained poor in both languages. Mr S was also stimulated to promote cognitive-linguistic skills with a variety of tailor- Management made activities. With this, Mr S showed progress in terms of immediate memory, recent memory, conceptual relationships A consolidated therapy plan focusing on combating all and associations, organization and categorization. the issues was made and the therapy was started. The Follow-up evaluation was made 3 months post-intensive speech and language therapy was provided in Kannada, speech and language therapy which involved re-administration the patient’s first language (L1), for 3 months though the of WAB, FDA and other naming tests. WAB was done in patient was a Kannada–English bilingual. The reasons both L1 (Kannada) and L2 (English) for the patient. In behind were Kannada being the mother tongue, frequency of L1 Mr S’s post-therapy scores on various domains were L1 being more in home and work environment, immediate as follows: spontaneous speech (19/20), auditory verbal and primary exposure to Kannada post-stroke and also the comprehension (200/200), repetition (94/100) and naming patient was found to be a successive bilingual, wherein he (95/100), yielding an AQ score of 95.8 (see Table 2). There was was exposed to English as his second language (L2) only a 10% improvement in the spontaneous speech domain, 2% during his middle school years. The therapy plan was made improvement each in the auditory–verbal comprehension and with the following goals: (a) to improve oro-motor skills, repetition domain and 9% improvement in the naming domain. (b) to improve linguistic skills (repetition abilities, lexical Thus, an obvious improvement in terms of AQ (95.8) was generative naming, discourse and articulatory precision), (c) noticed when compared to baseline AQ (89.2). Further, in L2 to improve cognitive-linguistic skills (immediate memory, Mr S’s post-therapy scores were: spontaneous speech (17/20), recent memory, conceptual relationships and associations, auditory–verbal comprehension (192/200), repetition (86/100) organization and categorization), (d) to promote literacy and naming (85/100), yielding an AQ score of 87.7 (see Table skills (reading comprehension and writing). The specific 2), therefore, indicating an improvement in AQ scores in only goals taken up under the broad goals and the progress made L1 in which the therapy was provided but not in Mr S’s L2. in both L1 and L2 by Mr S is discussed further. Considering the AQ scores were depicted in WAB for L1 The clinician had taken up tailor-made and specific and L2, it is evident that the scores are better in L1 than L2. activities such as to promote symmetry of lip closure at rest The speech and language therapy provided in L1 for 3 months and during movement, strengthen the lips, improve lip seal and had resulted in improvements in the specific language alone. intra-oral breath pressure under oro-motor domain. Mr S was FDA was also administered post-therapy which revealed no able to achieve 95% accuracy for lip symmetry and improved dysarthric component (see Figure 2). A skilled observer could in terms of speed, range and accuracy. This was achieved make out the slight deviation of upper and lower lips of Mr with the use of both isotonic and isometric exercises. Mr S S. Further, naming assessments in terms of retrieval of nouns, was also able to maintain intra-oral pressure for non-speech retrieval of verbs and semantic fluency were carried out to activities and plosives. Thus, sufficient improvements in the estimate the progress. From the naming assessments it was oral motor abilities promoted better clarity in speech and evidenced that there was significant progress in naming skills reduced slurring of speech in Mr S. in L1 but not in L2. Thus, with these post-therapy evaluations, Further, under the linguistic domain, specific goals such a diagnosis of non-aphasia in L1 and AA in L2 were made. It as the following were taken up: to improve comprehension was also noted that Mr S progressed with respect to his mood and expression at the discourse level through picture and showed controlled emotions, though not treated directly. description, narration and spontaneous speech up to > 90% Nikitha et al. 79 Table 2. Post-therapy WAB Scores on L1 and L2 WAB Domains Max Score Kannada AQ English AQ Spontaneous speech Information content 10 10 9 Fluency 10 9 19 8 17 Comprehension Yes/no question 60 60 60 AWR 60 60 10 56 9.75 Sequential commands 80 80 76 Repetition 100 94 9 9.4 86 8.6 Naming Objective naming 60 60 56 Word fluency 20 17 9 Sentence completion 10 8 90.5 10 8.5 Responsive speech 10 10 10 Aphasia quotient 95.8 87.7 Source: Authors’ interpretation based on the performance on Frenchay dysarthria assessment (FDA) and Western aphasia battery (WAB). Figure 2. Post-therapy Graphical Report of FDA (Administered on 15 November 2015) Source: Authors’ interpretation based on the performance on Frenchay dysarthria assessment (FDA) and Western aphasia battery (WAB). In summary, Mr S had a stroke on 18 March 2015 therapy was provided for a duration of 4 months between and reported to our institute on 12 August 2015, wherein 17 August 2015 and 27 December 2015. Further, detailed pre-therapy and baseline evaluations were done to yield a post-therapy evaluations were conducted on 15 November diagnosis of AA with mild dysarthria. Speech and language 2015 which yielded a diagnosis of AA only in L2. Thus, a 80 Annals of Neurosciences 27(2) differential recovery pattern has been noticed between the adequate coherence between words, sentences and within a languages (L1 and L2). The major clinical issues encountered topic with affected spontaneous speech. The features did not in the patient during diagnosis, recovery and treatment were support the diagnosis of residual aphasia, though a formal test as follows: the diagnosis was affected by different variants currently is not possible to rule out the diagnosis. of AA, recovery in terms of differential recovery patterns Yet another consideration in the diagnosis was aphasia between the languages and treatment in terms of adequacy of in L2 and non-aphasia in L1. Literature has provided several goals taken up. pieces of evidence which can be considered. A bilingual is a person who poses some amount of competence in his/her second language. There could be variations within bilingualism Discussion in terms of acquisition, i.e., (a) simultaneous bilingualism: both languages acquired simultaneously since birth wherein AA has two variants theoretically, that is, primary and the individual probably would have equal dominance secondary variants. The primary variant usually caused over both the languages and (b) sequential bilingualism: post-stroke due to damage to a parietal–temporal junction L1 is learnt earlier compared to L2 wherein the individual or angular gyrus. A person with primary variant is supposed probably would have dominance over L1 compared to his/ to have deficits in word selection and the language output her L2. If a person was a dominant bilingual pre-morbidly, and would have predominant paraphasia. The response to he has to be diagnosed on the basis of language deficits in treatment is relatively slow. The secondary variant manifests the dominant language or on the results of a standardized test as global or Broca’s aphasia at the acute stage which may battery carried out in the dominant language. If the person resolve to conduction aphasia initially and AA eventually. In is a balanced bilingual, aphasia can be diagnosed if the AQ this context, aphasia itself may be mild in nature and greater is lesser than the stipulated value in any of the 2 languages. difficulty is seen in different tasks which impose relatively The other determinants are social use, predominately used more cognitive-linguistic load. The responsiveness to language, etc., all of which indicate to L1 (Kannada) in the treatment is relatively quick. Based on this, our patient showed present case. As these conditions are satisfied, the case can be features favouring the secondary variant of AA. Further, Mr a diagnostic label of non-aphasia. S had problems related to expression before reporting to us. The second clinical issue encountered was a recovery It is speculated that Mr S would have progressed from non- pattern. Literature has reported various recovery patterns fluent to anomic because of micro/macro levels of recovery. such as parallel recovery, selective recovery and pathological He had lesser problems on confrontation naming but had mixing of two languages. Recovery patterns in bilingual greater word-retrieval deficits at higher levels of language, aphasia involve selective recovery of any one language, such as discourse. The language output was not embedded parallel recovery of both languages and antagonistic recovery with paraphasia and he benefited with all types of cues. This of one language by interfering with another language or finding is unlikely in accordance with the literature, which alternate antagonistic recovery of selective difficulty in shows that 78% of persons with AA do well with semantic comprehension and production across the 2 languages. A cues. Another evidence suggesting secondary variant is the case study on a bilingual person with aphasia reported parallel presence of dysarthria which studies have reported to be pattern of recovery, and also the importance of using both associated with Broca’s aphasia. Further, we speculate with formal and informal assessment tools to track the progress. evidence in the literature that the stimulating and facilitating Let us consider the patient’s performance in L1 and L2 to environment would have led to progression from non-fluent check which of the patterns of recovery was followed. Mr S to AA, leaving the dysarthric component to be persisting in its performed equally well in both L1 and L2 in domains such mild form. Again, proving to be the secondary variant of AA. as noun and verb naming and repetition. In domains such Another consideration is residual aphasia, an intermediate as spontaneous speech, narration and picture description, or transitory stage between aphasia and non-aphasia. Residual he performed relatively better in L1 than L2. It can be aphasia refers to the disturbance in which the person may be speculated that there could be factors influencing the pattern able to converse yet have subtle deficits in finding the right of recovery such as the order of acquisition of languages, word or providing information density or understanding structural distances between languages, proficiency in one complex conversation. The term residual aphasia is often language, language used in therapeutic intervention and the governed by operational definitions given by researchers/ environment. Overall, Mr S showed a better recovery in first authors and can be confirmed only by Aachen aphasia test. language than second language (later learned language) in Our clinical situation does not allow the diagnosis of residual all the aspects of language indicating a differential recovery aphasia and is not accounted on WAB. However, we analyzed pattern in L1 and L2. This is supported by the hypothesis of the features presented by Mr S such as intact information differential reliance on declarative memory, it can be expected content (evidenced by score on information content of WAB section), appropriate use of content words, good lexical that older the patient, the recently learned language is more diversity (evidenced by performance on naming assessments), likely to be affected. Nikitha et al. 81 The last clinical issue was the adequacy of therapeutic Ethical Statement goals taken up. The therapeutic plan made was based on the Procedures of the present study were duly approved by AIISH Ethics considerations of language profile and to maximize quality Committee, All India Institute of Speech and Hearing, Mysore, of life and communication success of Mr S. The therapeutic Karnataka, India. goals taken up were effective and it was evident from the progress seen. The goals taken up were (a) restoring language Funding abilities, (b) training family and caregivers, (c) generalization The authors received no financial support for the research, authorship of skills and strategies, (d) strengthening intact modalities and and/or publication of this article. behaviours, (e) educating persons with aphasia, (f) cognitive and linguistic goals, (g) bilingual considerations and (h) effect References of environment. These goals were based on ‘Life Participation Approach to Aphasia’ (LPAA). LPAA is a ‘consumer-driven 1. Goodglass H. Background. In: Goodglass H, Kaplan E, and service-delivery approach that supports individuals with Barresi B, eds The assessment of aphasia and related disorders. aphasia and others affected by it in achieving their immediate 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001, and long-term life goals’. The major consideration of LPAA pp. 1–5. is to focus on the real-life goals, establishing the requisites in 2. Goodglass H. The nature of the deficits. In: Goodglass H and addition to the residual skills, activity execution based on the Kaplan E, eds The assessment of aphasia and related disorders. individual’s preference and interest, and consideration of the 1st ed. Philadelphia, PA: Lea & Febiger, 1972. dual function of communication. Thus, the considered goals 3. Davis GA. Clinical assessment and diagnosis. In: Davis GA, ed met all the criteria of LPAA and showed sufficient progress Aphasiology: Disorders and clinical practice. 2nd ed. Pearson in the patient. College Division, 2007, pp. 40–64. 4. ASHA (American Speech–Language–Hearing Association). Conclusion Common classifications of aphasia. https://www.asha.org/ Pr a c t i c e - Po r t a l / C l i n i c a l -To pi c s/ Ap ha si a / C o m m o n- The language characteristics of a bilingual patient with AA Classifications-of-Aphasia/ were profiled in both languages. Adequate goals to foster the 5. Kertesz A. Western aphasia battery test manual. United States: patient’s life participation were chosen based on LPAA in Psychological Corp., 1982. accordance with the language profile. It was observed that 6. Nilipour R, Pourshahbaz A, and Ghoreyshi ZS. Reliability and Mr S showed differential recovery pattern in both languages, validity of bedside version of Persian WAB (P-WAB–1). Basic wherein he performed better in first language in comparison Clin Neurosci. 2014; 5(4): 253. to the second. This finding was attributed to various factors such as variants of AA, bilingualism and the therapy approach 7. Kertesz A and Poole E. The aphasia quotient: The taxonomic which focussed on the quality of life. Thus, the importance of approach to measurement of aphasic disability. Can J Neurol considering the possible factors that could affect the process Sci. 1974; 1(1): 7–16. of diagnosis and therapeutics is highlighted in this case study. 8. Hernandez M, Costa A, Sebastian-Galles N, et al. The organisation of nouns and verbs in bilingual speakers: A case of Acknowledgments bilingual grammatical category-specific deficit. J Neurolinguist. The authors are grateful to the Director, All India Institute of Speech 2007; 20(4): 285–305. and Hearing, Mysuru, for the support and permission to carry out the 9. Hernandez M, Cano A, Costa A, et al. Grammatical category- research at the institute. specific deficits in bilingual aphasia. Brain Lang. 2008; 107(1): 68–80. Author Contributions 10. Kambanaros M. Action and object naming versus verb and M.N. was responsible for data collection and for drafting the noun retrieval in connected speech: Comparisons in late manuscript, H. S. D. participated in data collection and edited the bilingual Greek–English anomic speakers. Aphasiology. 2010; manuscript, B. P. A. guided throughout the development of the 24(2): 210–230. manuscript and also contributed towards the discussion and editing 11. Dai EY, Kong AP, and Weekes BS. Recovery of naming of the manuscript, and S. P. G. supervised and was responsible for proofreading of the manuscript. and discourse production: A bilingual anomic case study. Aphasiology. 2012; 26(6): 737–756. Declaration of Conflicting Interests 12. Chengappa SK and Kumar R. Normative and clinical data on the Kannada version of Western aphasia battery (WAB-K). The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. Lang India. 2008; 8(6): 1. 82 Annals of Neurosciences 27(2) 13. Enderby, P. Frenchay dysarthria assessment. Texas: Pro-Ed, 18. Centeno JG. Working with bilingual individuals with aphasia: 1983. The case of a Spanish–English bilingual client. Perspect Commun Disord Sci Culturally Linguistically Diverse (CLD) 14. Grande M and Huber W. Computer based analysis of spontaneous Populations. 2005; 12(1): 2–7. speech to differentiate between patients with residual aphasia and healthy controls. J Neurolinguist. 1999; 13: 87–123. 19. Paradis M. Bilingual aphasia. In: Paradis M ed A neurolinguistic theory of bilingualism. Philadelphia, PA: John Benjamins, 15. Willmes K, Poeck K, Weniger D, and Huber W. Facet theory 2004, pp. 63–96. applied to the construction and validation of the Aachen aphasia test. Brain Lang. 1983; 18(2): 259–276. 20. Chapey R, Duchan JF, Elman RJ, et al. Life participation approach to aphasia: A statement of values for the future. The 16. Abutalebi J and Green D. Bilingual language production: ASHA Leader. 2000; 5(3): 4–6. The neurocognition of language representation and control. J Neurolinguist. 2007; 20(3): 242–275. 17. Green DW and Price CJ. Functional imaging in the study of recovery patterns in bilingual aphasia. Biling-Lang Cogn. 2001; 4(2): 191–201. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Annals of Neurosciences SAGE

Clinical Profiling of a Bilingual Client with Anomic Aphasia

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Abstract

Background: Aphasia is an acquired condition affecting auditory comprehension, verbal expression, reading, writing and word-finding abilities along with sensory-motor impairments. Anomia refers to difficulty in word retrieval or naming which is seen irrespective of the type of aphasia. However, if a patient shows word-finding difficulty, in specific, a diagnosis of Anomic aphasia is made. There are variations within anomic aphasia on which the management and recovery depend. The article provides one such case report. Purpose: Speech and language profiling in anomic aphasia, specific treatment strategies, the effect of bilingualism on recovery. Methods: Mr S, a 38-year-old bilingual male reported 5 months post-stroke with difficulty in expressing, difficulty in writing and weakness in the right side of the body. Medical history was checked and speech and language evaluations including both formal and informal assessments were performed. After this, a diagnosis of Anomic aphasia with mild dysarthria was made. An appropriate speech–language therapeutic plan and specific activities were formulated for Mr S in his first language (L1) and he was given a therapy for a span of 3 months. A follow-up evaluation in both first and second language of the patient yielded differential recovery patterns. Results: The diagnosis was affected by different variants of anomic aphasia; treatment was specific to the clinical profiling and followed life-participation approach of aphasia. The recovery was affected by differential recovery patterns between the languages. Discussion: Factors pertaining to diagnosis, recovery, bilingualism and treatment of the client with anomic aphasia are discussed. Keywords Anomic aphasia variants, residual aphasia, bilingualism, therapy, recovery A number of classification systems are available to describe Introduction the various language impairments of aphasia. One of the most Aphasia refers to the disturbance of any or all of the skills, influential classification systems was proposed by Goodglass associations and habits of spoken and written language and modified by Davis. Aphasia is broadly classified as fluent produced by injury to certain brain areas that are specialized and non-fluent type. Non-fluent aphasia is characterized by for these functions. Disturbances in communication that are because of paralysis or incoordination of the musculature of Junior Research Fellow, Department of Speech-language Pathology, All India speech or writing, or because of impaired vision or hearing, Institute of Speech and Hearing, Mysore, Karnataka, India are not, of themselves, aphasic. Corresponding author: M. Nikitha, Department of Speech-language Pathology, All India Institute of Thus, aphasia can affect auditory comprehension, verbal Speech and Hearing, Mysore, Karnataka 570006, India. expression, reading, writing, and word-finding abilities. E-mail: nikitham25@gmail.com Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-Commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 76 Annals of Neurosciences 27(2) faltering and effortful speech: impaired grammar, although may vary across languages and word class. However, content words are preserved in the speech. Further, there are contradictory findings also have been documented. The 3 major varieties under the non-fluent type such as (a) Broca’s former study was carried out with the dominant language of the bilingual patient, while the latter was carried out with Aphasia: poor in repetition of words/phrases, (b) Transcortical 8,9 both the languages known to the person. A dissociation was Motor Aphasia: exhibits strong repetition skills; may have poor noticed between the two languages in terms of word class. spontaneous speech, (c) Global Aphasia: severe impairment in The literature has highlighted language profiling in persons expressive and receptive language; may use facial expressions with AA in terms of word retrieval and recovery in bilinguals. and gestures to communicate. Fluent type is characterized by Naming nouns and verbs in persons with bilingual AA (Greek empty/meaningless speech and deficits in comprehension. as a first language and English as a second language) were Further there are four major varieties under the fluent type such as (a) conduction aphasia: poor word-finding abilities; observed to be language dependent. Further, the patterns of impaired repetition, (b) anomic aphasia (AA): good repetition naming and its interaction with word class in a person with skills; difficulty in word retrieval; uses common fillers (e.g., bilingual AA (Chinese and Mandarin) were examined. This “thing”) or circumlocution, (c) Wernicke’s aphasia: poor showed an effect on the recovery patterns in both languages repetition skills, (d) transcortical sensory aphasia: good in terms of word class. Thus, the findings highlighted the repetition of words/phrases; exhibits echolalia. importance of profiling word-retrieval abilities in both the Here, Broca’s aphasia, transcortical motor aphasia, languages and planning differential therapeutic plan in a person with AA. conduction aphasia and AA are the variants with relatively The earlier reports were limited to the tracking patterns intact language comprehension, whereas in global aphasia, of recovery and its relation to word retrieval in bilingual Wernicke’s aphasia and transcortical sensory aphasia, aphasia. However, profiling bilingual aphasia in terms of language comprehension is affected. Let us consider AA recovery patterns in both languages to cater to the therapeutic in specific here as the case report discussed ahead is a case needs was sensed. Thus, the present study aimed to highlight of AA. AA can be considered the mildest form of aphasia the importance of diagnosis and profiling the language when compared to all the other types. Persons with AA characteristics, and trace the recovery pattern with regard would represent with relatively spared spontaneous speech, to both languages and therapeutic goals concerning the life- comprehension, and repetition, and may have difficulty in participation approach and the quality of life. word finding or lexical access. Anomia in its literal sense refers to ‘without names’ and is a symptom seen in all forms of aphasia. However, when a patient exhibits word-retrieval Methods difficulty as a primary language dysfunction, AA is diagnosed. Many standardized language assessment tests are Participant Details used for diagnosis and categorization of aphasia. Western Aphasia Battery (WAB) is one of the most common, widely Mr S, 38-year-old male, reported difficulty in expressing, used, culturally accepted and standardized test which is difficulty in writing and weakness in the right side of the available in different languages for aphasia. It has high body. The patient reported these 5 months after stroke. The test–retest reliability along with high sensitivity to measure patient is an MBA graduate who worked as a sales executive the severity of language impairments in brain-damaged and is a Kannada– English bilingual. 6,7 individuals between 18 and 89 years of age. A cumulative score of four sections of the test, namely (a) spontaneous Medical History speech, (b) auditory verbal comprehension, (c) repetition and (d) naming provides the aphasia quotient (AQ), which The medical findings revealed no speech output immediately is a representation of the severity and type of aphasia; the post-stroke with high blood pressure at the time of admission maximum value achieved for this quotient is 100. Any score and right hemiparesis. The radiological findings (MRI reported less than 93.8 is categorized as aphasia and any score above cerebro vascular accident: right hemiplegic + hypertensive + 93.8 is considered non-aphasia as per the norms. Based on left putaminal intracerebral haemorrhage + left ganglionic the scores, classification of the type of aphasia can be done. haematoma. Further, the report read hyperdense lesion The test can be further used to profile the language deficits measuring 5.1 × 1.8 cm in the left ganglio-capsulonic area in persons with aphasia qualitatively. Profiling of language with effacement of ipsilateral ventricle and adjacent minimal deficits in terms of the effect of word retrieval, discourse and edema. Rest of the supratentorial brain parenchyma, cerebellum pragmatics could better represent the condition. Therefore, and brainstem showed normal attenuation. Scalp, extra-axial these details may better enable the speech–language therapist spaces and calvarium were normal. Interhemispheric fissure to choose goals during therapy. was in midline and no evidence of fracture was seen. With Considering that most of the individuals in the current this medical history and complaint, the patient was referred society are bilinguals, language profiling has to be carried to undergo speech and language evaluation, physiotherapy/ out in all the languages known. The word-retrieval deficits occupational therapy evaluation and neurological evaluation. Nikitha et al. 77 Mr S showed slightly affected lip, jaw, laryngeal and Evaluations tongue functions which explained his slurring (see Figure During the informal evaluation in speech–language out 1). Additionally, slight deviation of lips towards right and patient department (OPD), the following observation was reduced sensation on right oral and facial structures was made by the clinician: Mr S was able to give relevant noted. Thus, Mr S was diagnosed with mild dysarthria based answers to the questions asked, he could narrate events and on FDA. Alongside the physiotherapist made an impression use complete sentences to answer the questions, his speech of post-stroke writing difficulty and recommended for was unclear and inappropriate pauses were observed and he therapy. Overall, Mr S received a diagnosis of AA with mild could follow 3-step commands and general conversation. dysarthria at the speech–language OPD. Oral motor examination revealed structurally normal structures with affected lip retraction and protrusion range, Table 1. Pre-therapy WAB Scores (WAB as on 12 August 2015 in affected lip seal and deviation of the tongue to the right side the First Visit) of protrusion. 12 WAB Domains Max Score Patient Score Total for AQ Mr S was administered WAB-K (Kannada version) and an AQ of 89.2 was derived. Mr S performed relatively Spontaneous speech Information content 10 8 low in naming domain (86 on 100) as compared to all other Fluency 10 9 17 domains of WAB (spontaneous speech, 17 on 20; auditory Comprehension verbal comprehension, 196 on 200; repetition, 92 on 100; Yes/no question 60 60 see Table 1). Thus, Mr S was diagnosed with AA based on Auditory word rec- 60 60 9.8 the scores. ognition 80 76 Further, Frenchay Dysarthria Assessment (FDA) Sequential commands was administered as slurring of speech was noted along Repetition 100 92 9.2 with compromised speech mechanism. FDA is a test to Naming quantitatively assess the functioning of the speech subsystems Objective naming 60 60 (respiratory system, phonatory system, resonatory system Word fluency 20 8 8.6 and articulatory system) and speech intelligibility. The Sentence completion 10 8 results are represented graphically by shading the specific Responsive speech 10 10 subsection based on the performance of the patient on the Aphasia quotient 89.2 task. Shading is done to indicate the severity of dysarthria Source: Authors’ interpretation based on the performance on Frenchay (higher the shading, better is the performance). On FDA, dysarthria assessment (FDA) and Western aphasia battery (WAB). Figure 1. Pre-therapy Graphical Report of FDA (Administered as on 12 August 2015) Source: Authors’ interpretation based on the performance on Frenchay dysarthria assessment (FDA) and Western aphasia battery (WAB). 78 Annals of Neurosciences 27(2) Discourse and word retrieval were used as speech and lexical-generative naming abilities (phoneme fluency) samples to profile the language of Mr S because the repetition to 80% level, and to promote articulatory precision of Mr of longer sentences and word naming were difficult. Discourse S’s speech. Mr S was able to perform on discourse tasks sample revealed word-retrieval issues (difficulty in finding using Semantic Feature Approach and Response Elaboration and selecting words), code-mixing (alternating between Technique with an accuracy of 96% in Kannada and 80% in languages), syntactic errors (grammatically poor sentence English. The progress was well appreciated when compared structure and reduced sentence length), phonemic paraphasias to his baseline measures. Mr S was able to perform on naming (preserves at least a part of the intended word by substituting tasks with an accuracy of 90% in Kannada and 75% to 80% incorrect phonemes to form a non-word), circumlocutions in English, again indicating good progress. Articulation was (beating around the bush), hesitations, word-finding pauses achieved with consistency of 9/10 trials and accuracy of 95% and compromised speech intelligibility. Naming abilities in all levels (isolation, word and sentence) for the distorted revealed failed phoneme fluency (naming words beginning phonemes. with a specified phoneme/letter stimulus) and compromised The clinician had taken up the literacy skills wherein word fluency (naming words within a specified category). sentence completion, sentence construction and sentence However, confrontation naming (naming the picture or sequencing were worked upon to improve both reading object shown on request) and responsive naming (naming in and writing. There was sufficient improvement of up to response to an idea during conversation) were spared. 90% in Kannada and 80% in English. However, legibility remained poor in both languages. Mr S was also stimulated to promote cognitive-linguistic skills with a variety of tailor- Management made activities. With this, Mr S showed progress in terms of immediate memory, recent memory, conceptual relationships A consolidated therapy plan focusing on combating all and associations, organization and categorization. the issues was made and the therapy was started. The Follow-up evaluation was made 3 months post-intensive speech and language therapy was provided in Kannada, speech and language therapy which involved re-administration the patient’s first language (L1), for 3 months though the of WAB, FDA and other naming tests. WAB was done in patient was a Kannada–English bilingual. The reasons both L1 (Kannada) and L2 (English) for the patient. In behind were Kannada being the mother tongue, frequency of L1 Mr S’s post-therapy scores on various domains were L1 being more in home and work environment, immediate as follows: spontaneous speech (19/20), auditory verbal and primary exposure to Kannada post-stroke and also the comprehension (200/200), repetition (94/100) and naming patient was found to be a successive bilingual, wherein he (95/100), yielding an AQ score of 95.8 (see Table 2). There was was exposed to English as his second language (L2) only a 10% improvement in the spontaneous speech domain, 2% during his middle school years. The therapy plan was made improvement each in the auditory–verbal comprehension and with the following goals: (a) to improve oro-motor skills, repetition domain and 9% improvement in the naming domain. (b) to improve linguistic skills (repetition abilities, lexical Thus, an obvious improvement in terms of AQ (95.8) was generative naming, discourse and articulatory precision), (c) noticed when compared to baseline AQ (89.2). Further, in L2 to improve cognitive-linguistic skills (immediate memory, Mr S’s post-therapy scores were: spontaneous speech (17/20), recent memory, conceptual relationships and associations, auditory–verbal comprehension (192/200), repetition (86/100) organization and categorization), (d) to promote literacy and naming (85/100), yielding an AQ score of 87.7 (see Table skills (reading comprehension and writing). The specific 2), therefore, indicating an improvement in AQ scores in only goals taken up under the broad goals and the progress made L1 in which the therapy was provided but not in Mr S’s L2. in both L1 and L2 by Mr S is discussed further. Considering the AQ scores were depicted in WAB for L1 The clinician had taken up tailor-made and specific and L2, it is evident that the scores are better in L1 than L2. activities such as to promote symmetry of lip closure at rest The speech and language therapy provided in L1 for 3 months and during movement, strengthen the lips, improve lip seal and had resulted in improvements in the specific language alone. intra-oral breath pressure under oro-motor domain. Mr S was FDA was also administered post-therapy which revealed no able to achieve 95% accuracy for lip symmetry and improved dysarthric component (see Figure 2). A skilled observer could in terms of speed, range and accuracy. This was achieved make out the slight deviation of upper and lower lips of Mr with the use of both isotonic and isometric exercises. Mr S S. Further, naming assessments in terms of retrieval of nouns, was also able to maintain intra-oral pressure for non-speech retrieval of verbs and semantic fluency were carried out to activities and plosives. Thus, sufficient improvements in the estimate the progress. From the naming assessments it was oral motor abilities promoted better clarity in speech and evidenced that there was significant progress in naming skills reduced slurring of speech in Mr S. in L1 but not in L2. Thus, with these post-therapy evaluations, Further, under the linguistic domain, specific goals such a diagnosis of non-aphasia in L1 and AA in L2 were made. It as the following were taken up: to improve comprehension was also noted that Mr S progressed with respect to his mood and expression at the discourse level through picture and showed controlled emotions, though not treated directly. description, narration and spontaneous speech up to > 90% Nikitha et al. 79 Table 2. Post-therapy WAB Scores on L1 and L2 WAB Domains Max Score Kannada AQ English AQ Spontaneous speech Information content 10 10 9 Fluency 10 9 19 8 17 Comprehension Yes/no question 60 60 60 AWR 60 60 10 56 9.75 Sequential commands 80 80 76 Repetition 100 94 9 9.4 86 8.6 Naming Objective naming 60 60 56 Word fluency 20 17 9 Sentence completion 10 8 90.5 10 8.5 Responsive speech 10 10 10 Aphasia quotient 95.8 87.7 Source: Authors’ interpretation based on the performance on Frenchay dysarthria assessment (FDA) and Western aphasia battery (WAB). Figure 2. Post-therapy Graphical Report of FDA (Administered on 15 November 2015) Source: Authors’ interpretation based on the performance on Frenchay dysarthria assessment (FDA) and Western aphasia battery (WAB). In summary, Mr S had a stroke on 18 March 2015 therapy was provided for a duration of 4 months between and reported to our institute on 12 August 2015, wherein 17 August 2015 and 27 December 2015. Further, detailed pre-therapy and baseline evaluations were done to yield a post-therapy evaluations were conducted on 15 November diagnosis of AA with mild dysarthria. Speech and language 2015 which yielded a diagnosis of AA only in L2. Thus, a 80 Annals of Neurosciences 27(2) differential recovery pattern has been noticed between the adequate coherence between words, sentences and within a languages (L1 and L2). The major clinical issues encountered topic with affected spontaneous speech. The features did not in the patient during diagnosis, recovery and treatment were support the diagnosis of residual aphasia, though a formal test as follows: the diagnosis was affected by different variants currently is not possible to rule out the diagnosis. of AA, recovery in terms of differential recovery patterns Yet another consideration in the diagnosis was aphasia between the languages and treatment in terms of adequacy of in L2 and non-aphasia in L1. Literature has provided several goals taken up. pieces of evidence which can be considered. A bilingual is a person who poses some amount of competence in his/her second language. There could be variations within bilingualism Discussion in terms of acquisition, i.e., (a) simultaneous bilingualism: both languages acquired simultaneously since birth wherein AA has two variants theoretically, that is, primary and the individual probably would have equal dominance secondary variants. The primary variant usually caused over both the languages and (b) sequential bilingualism: post-stroke due to damage to a parietal–temporal junction L1 is learnt earlier compared to L2 wherein the individual or angular gyrus. A person with primary variant is supposed probably would have dominance over L1 compared to his/ to have deficits in word selection and the language output her L2. If a person was a dominant bilingual pre-morbidly, and would have predominant paraphasia. The response to he has to be diagnosed on the basis of language deficits in treatment is relatively slow. The secondary variant manifests the dominant language or on the results of a standardized test as global or Broca’s aphasia at the acute stage which may battery carried out in the dominant language. If the person resolve to conduction aphasia initially and AA eventually. In is a balanced bilingual, aphasia can be diagnosed if the AQ this context, aphasia itself may be mild in nature and greater is lesser than the stipulated value in any of the 2 languages. difficulty is seen in different tasks which impose relatively The other determinants are social use, predominately used more cognitive-linguistic load. The responsiveness to language, etc., all of which indicate to L1 (Kannada) in the treatment is relatively quick. Based on this, our patient showed present case. As these conditions are satisfied, the case can be features favouring the secondary variant of AA. Further, Mr a diagnostic label of non-aphasia. S had problems related to expression before reporting to us. The second clinical issue encountered was a recovery It is speculated that Mr S would have progressed from non- pattern. Literature has reported various recovery patterns fluent to anomic because of micro/macro levels of recovery. such as parallel recovery, selective recovery and pathological He had lesser problems on confrontation naming but had mixing of two languages. Recovery patterns in bilingual greater word-retrieval deficits at higher levels of language, aphasia involve selective recovery of any one language, such as discourse. The language output was not embedded parallel recovery of both languages and antagonistic recovery with paraphasia and he benefited with all types of cues. This of one language by interfering with another language or finding is unlikely in accordance with the literature, which alternate antagonistic recovery of selective difficulty in shows that 78% of persons with AA do well with semantic comprehension and production across the 2 languages. A cues. Another evidence suggesting secondary variant is the case study on a bilingual person with aphasia reported parallel presence of dysarthria which studies have reported to be pattern of recovery, and also the importance of using both associated with Broca’s aphasia. Further, we speculate with formal and informal assessment tools to track the progress. evidence in the literature that the stimulating and facilitating Let us consider the patient’s performance in L1 and L2 to environment would have led to progression from non-fluent check which of the patterns of recovery was followed. Mr S to AA, leaving the dysarthric component to be persisting in its performed equally well in both L1 and L2 in domains such mild form. Again, proving to be the secondary variant of AA. as noun and verb naming and repetition. In domains such Another consideration is residual aphasia, an intermediate as spontaneous speech, narration and picture description, or transitory stage between aphasia and non-aphasia. Residual he performed relatively better in L1 than L2. It can be aphasia refers to the disturbance in which the person may be speculated that there could be factors influencing the pattern able to converse yet have subtle deficits in finding the right of recovery such as the order of acquisition of languages, word or providing information density or understanding structural distances between languages, proficiency in one complex conversation. The term residual aphasia is often language, language used in therapeutic intervention and the governed by operational definitions given by researchers/ environment. Overall, Mr S showed a better recovery in first authors and can be confirmed only by Aachen aphasia test. language than second language (later learned language) in Our clinical situation does not allow the diagnosis of residual all the aspects of language indicating a differential recovery aphasia and is not accounted on WAB. However, we analyzed pattern in L1 and L2. This is supported by the hypothesis of the features presented by Mr S such as intact information differential reliance on declarative memory, it can be expected content (evidenced by score on information content of WAB section), appropriate use of content words, good lexical that older the patient, the recently learned language is more diversity (evidenced by performance on naming assessments), likely to be affected. Nikitha et al. 81 The last clinical issue was the adequacy of therapeutic Ethical Statement goals taken up. The therapeutic plan made was based on the Procedures of the present study were duly approved by AIISH Ethics considerations of language profile and to maximize quality Committee, All India Institute of Speech and Hearing, Mysore, of life and communication success of Mr S. The therapeutic Karnataka, India. goals taken up were effective and it was evident from the progress seen. The goals taken up were (a) restoring language Funding abilities, (b) training family and caregivers, (c) generalization The authors received no financial support for the research, authorship of skills and strategies, (d) strengthening intact modalities and and/or publication of this article. behaviours, (e) educating persons with aphasia, (f) cognitive and linguistic goals, (g) bilingual considerations and (h) effect References of environment. 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Published: Apr 1, 2020

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