- Email: [email protected]
Cognitive assessment and aphasia severity
Brain and Language 103 (2007) 8–249 www.elsevier.com/locate/b&l
Cognitive assessment and aphasia severity Jacqueline Hinckley a
, Carine Nash
b
Communication Sciences & Disorders, University of South Florida, 4202 E. Fowler Ave., PCD1017, Tampa, FL 33620 USA b PeopleFirst Rehabilitation, USA
Individuals with aphasia demonstrate a high degree of variability in cognitive performances such as attention, memory, and executive function. Assessment measures intended for nonaphasic populations may be too linguistically complex to offer a valid evaluation, and cognitive assessment batteries designed for aphasia are still developing and lack multi-site replication. The purpose of this study was to describe the performance of adults with different severity levels and types of aphasia on the Global Aphasic Neuropsychological Battery (Van Mourik, Verschaeve, Boon, Paquier, & Van Harskamp, 1992), initially designed for participants with global aphasia. Materials and methods A modified version of the Global Aphasic Neuropsychological Battery (GANBA) (Van Mourik et al., 1992) was administered. The tasks included: Visual Cancellation, Face and Object Recognition subtests of the Rivermead Behavioral Memory Test (RBMT) (Wilson, Cockburn, & Baddeley, 1985), the Raven’s Coloured Progressive Matrices (RCPM) (Raven, Court, & Raven, 1979), the Developmental Test of Visual Perception (DTVP) (Hammill, Pearson, & Voress, 1993), and the non-verbal auditory recognition task from the Communicative Abilities of Daily Living (CADL) (Holland, 1980). Twenty-nine participants with aphasia, four women and twenty-five men, were administered the modified version of the GANBA. Their ages ranged from 19 to 85 years, with a mean of 52 years. The time post-onset at the time of testing ranged from 4 months to 102 months, with a mean of 53 months. Three participants were pre-morbidly left handed. Two participants had a lesion in the right hemisphere (participants 4 and 22) and still presented with aphasia. Seven participants had a fluent aphasia. All other participants presented with a non-fluent aphasia type. The tasks were administered in random order across two to three different testing sessions within one to two weeks. Results The means, standard deviations, and ranges of performance scores on each component of the GANBA for the three severity levels in the current sample are displayed in the Table 1. Performance levels, even for those participants with severe aphasia, were generally substantially higher and *
a,*
Corresponding author. Fax: +1 813 974 0822. E-mail address: [email protected] (J. Hinckley).
doi:10.1016/j.bandl.2007.07.112
more compressed in the present sample compared to the Van Mourik et al. (1992) data. More performance variability occurred on measures of recognition memory, non-verbal reasoning, and visual–perceptual abilities. Unexpectedly, the four participants with mild aphasia demonstrated a similar range and average performance as those with global aphasia in Van Mourik et al. (1992) on the recognition memory assessment. ANOVA analysis suggested that there was a significant difference in performance between the aphasia severity levels on the Visual Cancellation and Non-verbal Auditory Recognition tasks (F = 3.09 and 4.18, respectively, p < 0.05). This was accounted for by the relatively low performance of a few individuals with either severe or mild aphasia. Correlations between severity and the cognitive tasks revealed a significant correlation between severity and performance on the recognition memory task. This suggested a tendency toward a more linear relationship between severity and memory performance. When performances were analyzed based on classification of non-fluent vs. fluent aphasia, there were no statistically or clinically significant differences. Discussion In our case, the GANBA was able to detect some cognitive impairments among adults with moderate or mild aphasia, not just global or severe aphasia. The GANBA is a battery that is designed as an intermediate assessment tool; it provides more in-depth information that any brief assessment or screening. The performance ranges of our participants suggest a high degree of variability on cognitive tasks that is not consistently related to either aphasia severity or fluency category (e.g., Helm-Estabrooks, 2002). This underscores the necessity for individual cognitive assessment since results of language assessment alone does not seem to predict cognitive abilities. There is beginning to be a convergence of agreement on the types of cognitive tasks that are important to administer in a brief cognitive assessment in aphasia. Visual or symbol cancellation, recognition memory, and non-verbal or analogical reasoning have all shown important performance differences that are not associated with aphasia type or severity (e.g., Helm-Estabrooks, 2002; Kalbe, Reinhold, Brand, Markowitsch, & Kessler, 2005). Indeed, Kalbe et al. (2005) reported that memory was the most frequently impaired cognitive domain in their sample of 154 adults with aphasia. Other measures of executive function may also be very important in treatment planning, and measures such as trail-making should be more routinely explored for use in aphasia (e.g., Keil & Kazniak, 2002).
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Abstract / Brain and Language 103 (2007) 8–249
Table 1 Means, standard deviations, and ranges for the current study on each of the GANBA components by severity level, compared to the means and ranges reported for participants with global aphasia by Van Mourik et al. (1992) Van Mourik et al. (1992)
Hinckley & Nash (this study)
Severe aphasia (n = 17)
Severe aphasia (n = 4)
Moderate aphasia (n = 21)
Mild aphasia (n = 4)
Visual cancellation
63.8
Recognition memory (RBMT)
0–100 66.0
Non-verbal reasoning (RCPM)
0–100 24.8
Visual perceptual abilities
0–75 75.6
Non-verbal auditory recognition
53–100 58.6
96.25 (4.35) 90–100 85.00 (30.0) 40–100 91.50 (2.08) 89–94 79.00 (20.05) 58–99 87.75 (14.15) 75–100
99.29 (1.42) 95–100 94.11 (8.99) 71–100 86.86 (16.51) 41–100 91.29 (8.30) 71–99 98.81 (5.45) 75–100
98.75 (2.50) 95–100 65.00 (39.59) 37–93 81.00 (6.68) 77–91 82.25 (8.30) 73–93 91.67 (14.43) 75–100
10–100 Performance scores are in percentage correct.
The differences in ranges and average performances on the GANBA tasks between the initial sample reported in Van Mourik et al. (1992) and our sample also emphasize that the variability of cognitive performance in aphasia requires large sample sizes and replication across multiple samples and multiple sites. In smaller samples such as ours and Van Mourik et al. (1992), individual differences may be magnified by variations in classifying severity and type of aphasia. Thus any cognitive assessment that is accepted for wide-scale use in aphasia should meet the test of multiple samples and multiple sites. References Hammill, D. D., Pearson, N. A., & Voress, J. K. (1993). Developmental test of visual perception (2nd ed.). Austin, TX: Pro-Ed. Helm-Estabrooks, N. (2002). Cognition and aphasia: A discussion and a study. Journal of Communication Disorders, 35, 171–186.
Holland, A. (1980). Communicative abilities in daily living. Baltimore: University Park Press. Kalbe, E., Reinhold, N., Brand, M., Markowitsch, H. J., & Kessler, J. (2005). A new test battery to assess aphasic disturbances and associated cognitive dysfunctions – German normative data on the aphasia check list. Journal of Clinical and Experimental Neuropsychology, 27, 779–794. Keil, K., & Kazniak, A. (2002). Examining executive function in individuals with brain injury: A review. Aphasiology, 16, 305–335. Raven, J. C., Court, J. H., & Raven, J. (1979). Manual for Raven’s progressive matrices and vocabulary scales. London: Lewis & Co. Van Mourik, M., Verschaeve, M., Boon, P., Paquier, P., & Van Harskamp, F. (1992). Cognition in global aphasia: Indicators for therapy. Aphasiology, 6, 491–499. Wilson, B., Cockburn, J., & Baddeley, A. (1985). Rivermead behavioural memory test. Los Angeles, CA: Western Psychological Services.
Cognitive assessment and aphasia severity Jacqueline Hinckley a
, Carine Nash
b
Communication Sciences & Disorders, University of South Florida, 4202 E. Fowler Ave., PCD1017, Tampa, FL 33620 USA b PeopleFirst Rehabilitation, USA
Individuals with aphasia demonstrate a high degree of variability in cognitive performances such as attention, memory, and executive function. Assessment measures intended for nonaphasic populations may be too linguistically complex to offer a valid evaluation, and cognitive assessment batteries designed for aphasia are still developing and lack multi-site replication. The purpose of this study was to describe the performance of adults with different severity levels and types of aphasia on the Global Aphasic Neuropsychological Battery (Van Mourik, Verschaeve, Boon, Paquier, & Van Harskamp, 1992), initially designed for participants with global aphasia. Materials and methods A modified version of the Global Aphasic Neuropsychological Battery (GANBA) (Van Mourik et al., 1992) was administered. The tasks included: Visual Cancellation, Face and Object Recognition subtests of the Rivermead Behavioral Memory Test (RBMT) (Wilson, Cockburn, & Baddeley, 1985), the Raven’s Coloured Progressive Matrices (RCPM) (Raven, Court, & Raven, 1979), the Developmental Test of Visual Perception (DTVP) (Hammill, Pearson, & Voress, 1993), and the non-verbal auditory recognition task from the Communicative Abilities of Daily Living (CADL) (Holland, 1980). Twenty-nine participants with aphasia, four women and twenty-five men, were administered the modified version of the GANBA. Their ages ranged from 19 to 85 years, with a mean of 52 years. The time post-onset at the time of testing ranged from 4 months to 102 months, with a mean of 53 months. Three participants were pre-morbidly left handed. Two participants had a lesion in the right hemisphere (participants 4 and 22) and still presented with aphasia. Seven participants had a fluent aphasia. All other participants presented with a non-fluent aphasia type. The tasks were administered in random order across two to three different testing sessions within one to two weeks. Results The means, standard deviations, and ranges of performance scores on each component of the GANBA for the three severity levels in the current sample are displayed in the Table 1. Performance levels, even for those participants with severe aphasia, were generally substantially higher and *
a,*
Corresponding author. Fax: +1 813 974 0822. E-mail address: [email protected] (J. Hinckley).
doi:10.1016/j.bandl.2007.07.112
more compressed in the present sample compared to the Van Mourik et al. (1992) data. More performance variability occurred on measures of recognition memory, non-verbal reasoning, and visual–perceptual abilities. Unexpectedly, the four participants with mild aphasia demonstrated a similar range and average performance as those with global aphasia in Van Mourik et al. (1992) on the recognition memory assessment. ANOVA analysis suggested that there was a significant difference in performance between the aphasia severity levels on the Visual Cancellation and Non-verbal Auditory Recognition tasks (F = 3.09 and 4.18, respectively, p < 0.05). This was accounted for by the relatively low performance of a few individuals with either severe or mild aphasia. Correlations between severity and the cognitive tasks revealed a significant correlation between severity and performance on the recognition memory task. This suggested a tendency toward a more linear relationship between severity and memory performance. When performances were analyzed based on classification of non-fluent vs. fluent aphasia, there were no statistically or clinically significant differences. Discussion In our case, the GANBA was able to detect some cognitive impairments among adults with moderate or mild aphasia, not just global or severe aphasia. The GANBA is a battery that is designed as an intermediate assessment tool; it provides more in-depth information that any brief assessment or screening. The performance ranges of our participants suggest a high degree of variability on cognitive tasks that is not consistently related to either aphasia severity or fluency category (e.g., Helm-Estabrooks, 2002). This underscores the necessity for individual cognitive assessment since results of language assessment alone does not seem to predict cognitive abilities. There is beginning to be a convergence of agreement on the types of cognitive tasks that are important to administer in a brief cognitive assessment in aphasia. Visual or symbol cancellation, recognition memory, and non-verbal or analogical reasoning have all shown important performance differences that are not associated with aphasia type or severity (e.g., Helm-Estabrooks, 2002; Kalbe, Reinhold, Brand, Markowitsch, & Kessler, 2005). Indeed, Kalbe et al. (2005) reported that memory was the most frequently impaired cognitive domain in their sample of 154 adults with aphasia. Other measures of executive function may also be very important in treatment planning, and measures such as trail-making should be more routinely explored for use in aphasia (e.g., Keil & Kazniak, 2002).
196
Abstract / Brain and Language 103 (2007) 8–249
Table 1 Means, standard deviations, and ranges for the current study on each of the GANBA components by severity level, compared to the means and ranges reported for participants with global aphasia by Van Mourik et al. (1992) Van Mourik et al. (1992)
Hinckley & Nash (this study)
Severe aphasia (n = 17)
Severe aphasia (n = 4)
Moderate aphasia (n = 21)
Mild aphasia (n = 4)
Visual cancellation
63.8
Recognition memory (RBMT)
0–100 66.0
Non-verbal reasoning (RCPM)
0–100 24.8
Visual perceptual abilities
0–75 75.6
Non-verbal auditory recognition
53–100 58.6
96.25 (4.35) 90–100 85.00 (30.0) 40–100 91.50 (2.08) 89–94 79.00 (20.05) 58–99 87.75 (14.15) 75–100
99.29 (1.42) 95–100 94.11 (8.99) 71–100 86.86 (16.51) 41–100 91.29 (8.30) 71–99 98.81 (5.45) 75–100
98.75 (2.50) 95–100 65.00 (39.59) 37–93 81.00 (6.68) 77–91 82.25 (8.30) 73–93 91.67 (14.43) 75–100
10–100 Performance scores are in percentage correct.
The differences in ranges and average performances on the GANBA tasks between the initial sample reported in Van Mourik et al. (1992) and our sample also emphasize that the variability of cognitive performance in aphasia requires large sample sizes and replication across multiple samples and multiple sites. In smaller samples such as ours and Van Mourik et al. (1992), individual differences may be magnified by variations in classifying severity and type of aphasia. Thus any cognitive assessment that is accepted for wide-scale use in aphasia should meet the test of multiple samples and multiple sites. References Hammill, D. D., Pearson, N. A., & Voress, J. K. (1993). Developmental test of visual perception (2nd ed.). Austin, TX: Pro-Ed. Helm-Estabrooks, N. (2002). Cognition and aphasia: A discussion and a study. Journal of Communication Disorders, 35, 171–186.
Holland, A. (1980). Communicative abilities in daily living. Baltimore: University Park Press. Kalbe, E., Reinhold, N., Brand, M., Markowitsch, H. J., & Kessler, J. (2005). A new test battery to assess aphasic disturbances and associated cognitive dysfunctions – German normative data on the aphasia check list. Journal of Clinical and Experimental Neuropsychology, 27, 779–794. Keil, K., & Kazniak, A. (2002). Examining executive function in individuals with brain injury: A review. Aphasiology, 16, 305–335. Raven, J. C., Court, J. H., & Raven, J. (1979). Manual for Raven’s progressive matrices and vocabulary scales. London: Lewis & Co. Van Mourik, M., Verschaeve, M., Boon, P., Paquier, P., & Van Harskamp, F. (1992). Cognition in global aphasia: Indicators for therapy. Aphasiology, 6, 491–499. Wilson, B., Cockburn, J., & Baddeley, A. (1985). Rivermead behavioural memory test. Los Angeles, CA: Western Psychological Services.