Laura L. Murray

Comprehensive Overview of Nursing and Interdisciplinary Rehabilitation Care of the Stroke Patient: A Scientific Statement From the American Heart Association

In the United States, the incidence rate of new or recurrent stroke is approximately 795 000 per year, and stroke prevalence for individuals over the age of 20 years is estimated at 6.5 million.1 Mortality rates in the first 30 days after stroke have decreased because of advances in emergency medicine and acute stroke care. In addition, there is strong evidence that organized postacute, inpatient stroke care delivered within the first 4 weeks by an interdisciplinary healthcare team results in an absolute reduction in the number of deaths.2,3 Despite these positive achievements, stroke continues to represent the leading cause of long-term disability in Americans: An estimated 50 million stroke survivors worldwide currently cope with significant physical, cognitive, and emotional deficits, and 25% to 74% of these survivors require some assistance or are fully dependent on caregivers for activities of daily living (ADLs).4,5 Notwithstanding the substantial progress in acute stroke care over the past 15 years, the focus of stroke medical advances and healthcare resources has been on acute and subacute recovery phases, which has resulted in substantial health disparities in later phases of stroke care. Additionally, healthcare providers (HCPs) are often unaware of not only patients’ potential for improvement during more chronic recovery phases but also common issues that stroke survivors and their caregivers experience. Furthermore, even with evidence that documents neuroplasticity potential regardless of age and time after stroke,6 the mean lifetime cost of ischemic stroke (which accounts for 87% of all strokes) in the United States is an estimated

Review Attention and aphasia: theory, research and clinical implications

140 000 (for inpatient, rehabilitation, and follow-up costs), with 70% of first-year stroke costs attributed to acute inpatient hospital care1; therefore, fewer financial resources appear to be dedicated to providing optimal care during the later phases of stroke recovery. Because there remains a …

The effects of varying attentional demands on the word retrieval skills of adults with aphasia, right hemisphere brain damage, or no brain damage

Over the past decade, there has been increasing interest in the integrity of attention in adults with aphasia. This review paper examines this issue by first introducing attention theory and associated terminology. Next, the paper summarizes the growing literature which documents that not only may adults with aphasia present with attention deficits, but also that their attention deficits may negatively a ect both their language comprehension and production skills. Lastly, the clinical implications of adopting an attentional model of aphasia are considered with respect to strategies for both the assessment and treatment of adults with aphasia.

Functional measures of naming in aphasia: Word retrieval in confrontation naming versus connected speech

Adults with mild aphasia, right hemisphere brain damage (RBD), or no brain damage (NBD) provided one-word phrase completions under isolation, focused attention, and divided attention conditions and in response to relatively constrained or unconstrained phrase stems. Despite comparable word retrieval accuracy among groups during the isolation condition, aphasic and RBD groups performed less accurately than the NBD group during focused and divided attention conditions. Across conditions, there were no significant differences between aphasic and RBD groups. Only aphasic subjects demonstrated a significant effect of phrase type, responding more accurately when completing constrained versus unconstrained stimuli. For aphasic and RBD groups, error type analysis indicated that semantic and phonological aspects of word retrieval were influenced by increased attentional demands. These findings suggest that for adults with aphasia or RBD, there is a negative relation between attention impairments and word retrieval abilities.

Productive syntax abilities in Huntington's and Parkinson's diseases

Background: Word-finding difficulties are central to aphasia and as such have received a great deal of attention in aphasia research. Although treatment for lexical retrieval impairments can be effective, studies often use measurement of single-word performance (e.g., confrontation naming) to support such claims. In contrast, what matters most to patients with aphasia and their families is the ability to converse. Few aphasia studies, however, have addressed word retrieval in connected speech. Furthermore, one could debate whether generating names for single pictured stimuli bears resemblance to the online, multifaceted retrieval required during conversation. Aims: The purpose of this study was to assess the adequacy of Percent Word Retrieval (%WR) as well as two supplementary analyses, Percent Substantive Verbs (%SV) and Percent Corrected Errors (%CERR), to depict word retrieval in connected and conversational speech with respect to lexical class (noun vs verb) and aphasia severity (mild vs moderate). Specifically, we examined: (1) the relationship between lexical retrieval in confrontation naming, composite description, and conversational samples; and (2) the clinical utility and feasibility of %WR, %SV, and %CERR in quantifying such data. Methods & Procedures: A total of 14 individuals with aphasia, divided into mild (n = 7) and moderate (n = 7) groups based on aphasia severity, participated. Word retrieval was tested in three different contexts: single-word confrontation naming, composite description, and conversational speech. Lexical retrieval was analysed in each context using the analyses described above (%WR, %SV, and %CERR). The effects of context, grammatical class, and measurement technique were explored using repeated measures ANOVA and correlational analyses. Outcomes & Results: Statistical analyses revealed a significant effect of context for both %WR and %CERR, with superior lexical retrieval and self-correction of errors in connected speech versus single-word naming tasks. Moreover, %SV in conjunction with %WR was sensitive to possible verb retrieval deficits undetected by %WR alone, particularly for mild patients. Confrontation naming scores were strongly related to aphasia severity classification (mild vs moderate), but were not significantly correlated with naming abilities in connected speaking tasks. Conclusions: These findings endorse the incorporation of discourse-level tasks into aphasia assessment and treatment protocols. Use of simple and easily quantifiable measures (e.g., %WR) may be an option to extend current methodology and reconcile issues of ecological validity and clinical feasibility.

Measuring working memory deficits in aphasia.

This study examined syntactic changes in the spoken discourse of patients with Huntingtons (HD) or Parkinsons disease (PD) and explored possible relationships between their syntactic changes and concomitant cognitive and motoric symptoms. Patient and control groups participated in a conversational discourse activity and completed a battery of standardized speech and cognitive tests. The HD group used shorter and fewer grammatically complete utterances than their healthy, age-matched peers, whereas there were no significant syntactic differences between PD patients and their healthy, age-matched peers or between PD and HD patients. Productive syntax abilities in HD and PD were meaningfully related to both neuropsychological and motor speech changes. These findings indicate that patients with subcortical disease, at least those with HD, may present with language production deficits and that these deficits are most likely the product of not only motor speech limitations (i.e., dysarthria) but also underlying cognitive impairments.

Approaches to the treatment of alexia in chronic aphasia

PURPOSE Many adults with aphasia demonstrate concomitant deficits in working memory (WM), but such deficits are difficult to quantify because of a lack of validated measures as well as the complex interdependence between language and WM. We examined the feasibility, reliability, and internal consistency of an n-back task for evaluating WM in aphasia, then explored the influence of domain-general (WM load, reaction time, age) and domain-specific (language) factors. METHOD Fourteen adults with aphasia and 12 age-and education-matched controls completed n-back tasks varying in stimulus type (high-frequency, low-frequency, or non-nameable stimuli) and WM load (0-, 1-, and 2-back). Data analyses explored the impact of these variables within and across participants and groups. RESULTS n-Back scores were collectively reliable across conditions. Both groups performed similarly across stimulus types with significantly greater WM accuracy for nameable versus non-nameable stimuli. Compared to the controls, adults with aphasia were significantly more affected by increasing WM load. RT effects generally paralleled accuracy data, whereas age effects were inconsistent across tasks. CONCLUSIONS These data are consistent with WM deficits in aphasia, for which the n-back task holds promise for clinical quantification. LEARNING OUTCOMES Readers will be able to: (a) define working memory, (b) discuss the difficulty inherent in removing language from a complex cognitive task, and (c) describe how the n-back task may contribute to measuring working memory capacity in individuals with aphasia.

Discourse Comprehension in Huntington’s and Parkinson’s Diseases

Background: Reading problems are a common consequence of brain damage, whether as an isolated symptom or part of an aphasic syndrome. Despite the prevalence of acquired alexia, accurate and reliable assessment and treatment strategies have not yet been definitively identified. Furthermore, a growing volume of research has documented generalised cognitive deficits (separate from language-specific deficits) in individuals with acquired disorders of spoken or written language. Little to no data exist regarding whether addressing those deficits (e.g., attention and working memory) might facilitate reading abilities. Aims: The purposes of the current study were to determine the following: (1) Whether a variation of a text-level reading treatment, modified to address comprehension, would have a specific rehabilitative effect with a mildly aphasic and alexic patient. (2) Whether a working memory treatment would generalise to improve the cognitive processes (working memory and attention) necessary for decoding and comprehending high-level text. (3) Which treatment, the specific reading programme or generalised cognitive protocol, would yield a greater positive effect on reading speed and comprehension accuracy. Methods & Procedures: A cognitive neuropsychological analysis of deficit patterns in a subject with acquired alexia was utilised to identify two possible sources of reading difficulty: (1) diminished lexical-semantic abilities for decoding and analysing complex orthographic stimuli, and (2) deficits in attention and working memory. Based on this pre-treatment analysis, two treatment protocols were implemented and compared via a single subject, alternating treatment design. The first was a variation of Multiple Oral Reading (MOR; Beeson, 1998), a text-level reading treatment, and the second was an experimental cognitive treatment, Sequenced Exercises for Working Memory (SEW), created to address cognitive components relevant to reading disorders. Outcomes & Results: Both approaches yielded within-treatment positive effects. Probes indicated improved reading rates with little to no improvement in comprehension. Neither treatment effected greater or more rapid change than the other. Post-treatment testing revealed modest improvements in reading comprehension, processing efficiency, and working memory abilities. Conclusions: Results are discussed in terms of cognitive neuropsychological theories of reading, possible treatment alternatives, and the need for a multi-factorial model of reading, to extend the single-word models postulated by current theories. Without an adequate model, current reading assessments inadequately depict the nature of high-level reading impairments. This allows clinicians limited resources from which to document and treat such deficits.

A treatment for written verb retrieval and sentence construction skills

This study compared the discourse comprehension abilities of patients with Huntington’s disease (HD) or Parkinson’s disease (PD) to those of age-matched control participants with no brain damage. R...

Linguistic Specific Treatment: Just for Broca's aphasia?

This study examined the effects of a writing treatment on the verb retrieval and sentence construction abilities of a 50-year-old male with chronic, moderate Wernickes aphasia. The treatment protocol consisted of a cueing hierarchy, word prompt software and home practice, and was applied in the context of a modified multiple-baseline across behaviours design. Following each treatment phase, the patient demonstrated improvements in writing trained verbs at both the word and sentence levels. During the final maintenance probe eight weeks following treatment cessation, the patients handwritten accuracy had begun to decline but continued to exceed baseline accuracy rates. Furthermore, when he was allowed to use the word prompt software during this final probe, his writing accuracy approximated or exceeded that which he had achieved immediately following the termination of the last treatment phase. Generalization of improved verb retrieval and sentence construction abilities to written and spoken discourse as well as positive qualitative changes in verb retrieval error patterns were observed. Hypotheses regarding the cognitive mechanisms that may underlie these treatment and generalization effects are discussed.