Document yrGw7gdo16w3bQ1baONBKgMRE

/-"X / X 2 - f BW *' APHASIA, ALEXIA, VND AGRAPHIA I. FRANK BENSON, MD D rector. Neurobehavioral Center B<ston Veterans Administration Medical Center Piofessor, Neurology B<ston University School o f Medicine Brston, Massachusetts nmm m m n Churchill Livingstone New York, Edinburgh, and London 1979 36 I A f lu lia . A lr.iia. Agrn/ilita liy utilizing these tests and neighborhood neurologic and aphasic signs, a number of distinct varieties or unomia can be postulated and a neuroanalomical correlation suggested for each variation (see Ch. IS). It must be remembered that a number of "nonaphasic" cerebral abnor malities such as dementia, confuslonal states and others also produce notable problems in word-finding. Word-finding difficulty is not an exclusive indication of aphasia. When anomia is present, however, aphasia must be seriously coh* sidered and the responses to word-finding tests may prove helpful in establish ing the appropriate diagnosis. Reading Loss of the ability to read following brain damage (alexia), cither with or without accompanying aphasia, has been recognized for centuries and reading is comparatively easy to evaluate, at least in a gross manner. When quantified results are required, however, standardized test material will be necessary. Simply offering the written name of a body pan or room object for the patient to identify is an easy reading test to perform at the bedside. If the patient is successful at this level, more difficult written material Including phrases or sentences, dependent on low frequency or relational types of words, can be presented for interpretation. An even more challenging bedside lest of reading ability is to request understanding of paragraph-length material from a newspa per or magazine. A simple determination of the retention of reading comprehension is to request that the aphasic patient recognize words spelled aloud by the examiner (Geschwind, 1962; Howes, 1962). While not always accurate, mast patients with parietal-temporal alexia fall to recognize words spelled aloud, while those with occipital alexia perform quite well (see Ch. II for details). The most common error made in the testing of reading ability is equat ing the ability to read out loud with the ability to comprehend written material. Manyaphasics with verbal output disturbances fail when asked to read aloud but some or them comprehend written material adequately. The opposite can also be seen, aphasic patients who read aloud flawlessly but in whom comprehension of what has been read cannot be demonstrated. It Is the ability to comprehend written language that is to be monitored; it is (he loss of this ability that is called alexia. Alexia will be further discussed in Chapter II. Writing Almost without exception, every aphnsic suffers some difficulty in writing Uifirtipliitt), An initial lest is to request that the patient write his own name. Some aphasics fail even this most elementary test, but many succeed and it must be recognized that the ability to sign one's name is sufficiently over learned that many aphasics with severe writing disturbance produce their own signature readily even when they cannot write any other words. Testing of writing ability, therefore, should.not slop at the level of the patient's signature. Writing tests should include the'ability to write words and sentences to dicta- i ( , ; i 1 t i 1 j M t llt t u li ttf A p h i i n i i - l e i l i t i f I 37 lion and lo produce written sentences to command (i.e.. describe your job). In nonhemiplegic patients, writing should be tested in each hand. Comparison can be made of the ability lo copy written materia] with the ability to produce similar words lo dictation. There are qualitative variations in agraphia and four aspects of writing disorder deserve specific attention: I) defects of the mechanics of handwriting (onhography); 2) abnormalities of written syntax; 3) disorders of semantic content and 4) an inability to spell. Unfortunately, the variations of writing disorders that can follow brain damage combined with marked premorbid individual variations have defied demonstration of exact clinical'anatomica! correlations of agraphia. At present, tests of writing ability are primarily used as screening devices for language disturbance, but in ihd future variations In agraphia should come to have considerable meaning for the student of language problems. In summary, the clinical testing of aphasia is inexact, nonstandardized and constantly being altered. Therein lies both the weakness and the strength of the clinical approach. Many of the techniques utilized in the formal aphasia bat teries and in the research tests of language dysfunction were derived from the experiences gained in (he clinic oral the bedside. An experienced examiner can perform a clinical evaluation on an aphasic patient's language in only a few minutes and, by focusing on the primary problem, obtain an in-deptb view of the type of aphasia that is often more accurate and exacting than that available from either the formal aphasia batteries or the most advanced research tech niques. However, even in the best hands, the results of clinical testing arc subject to theoretical biases and in the hands of inexperienced examiners the clinical evaulation can prove disastrously misleading. The need for more exact, standardized testing techniques is obvious. FORMAL TESTS OF APHASIA Following the lead of Henry Head (1926), Wcisenburg and McBride (1935) produced a battery of tests lo define the language qualities of aphasic patients. While never widely used, this battery was the harbinger of a new era in aphasia assessment. In the past 25 years a large number of formal test batteries have been devised for the assessment of aphasia, standardized to a greater or lesser degree and utilized widely. While there is considerable overall similarity in the tests, there are also a number of significant differences. Then is no consensus as lo which battery or batteries are best and all of the tests to be mentioned are favored and in use somewhere nt the present time. Almost every aphasic enter ing n formal aphasia thenpy program is given pun or nil or one or more of these tests and the results from the tests are widely used in both research projects and clinical reports. This section will list some of the currently popular tests along with some of their more distinctive characteristics. The test batteries will not be outlined in full detail; readers desiring such information are referred lo the references given for each test battery. One of the earliest tests and one still in wide use is Eisenson:s Examining