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Aphasia Test 4. YOU WILL TOTALLY KICK ASS ON THIS TEST!!. Behaviors of Left Neglect. Excessive use of R Margin Perseverative- strokes in writing Safety Issues- hand in spokes of wheelchair Appear hemiplegic- looks like they are paralyzed. Can’t use leg or arm

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Aphasia test 4

Aphasia Test 4



Behaviors of left neglect
Behaviors of Left Neglect

  • Excessive use of R Margin

  • Perseverative- strokes in writing

  • Safety Issues- hand in spokes of wheelchair

  • Appear hemiplegic- looks like they are paralyzed. Can’t use leg or arm

  • Appear disinterested/unmotivated- won’t smile at you or laugh at your jokes.

  • Do not complain of disorder.


  • Attention Disorder

  • Affects recovery

  • Duration Unknown

  • Mild to severe- spectrum mild (if you help them attend to neglected area, they’ll acknowledge it) to severe (won’t eat food on right side of plate).

  • Fractionation (occurs in multiple modalities)- olfactory, auditory info- we only work on comm. though- reading & writing.


  • Informal observation- as soon as you walk in room- only looking to right.

  • Formal testing- very preliminary, not in depth

  • Tests of extinction (both sides of body)- testing sensation, for ex. Which finger am I touching? etc.

  • Line Dissection- draw a straight line, divide paper in half. Line will probably be over to the right.

  • Cancellation- if you see “A” cross it out. Make x’s out of target etc.


  • Drawings - ask patient to draw semmetrical items. Draw a person, a flower, a clock etc.

  • Reading- (read ½ or less of text) read endings of sentences. Confabulation is good.

  • Writing- omit letters, forget to cross “t”, dot “i”. Perseveration, when you ask patient to write, they will write on top of their old writing.


  • Subjective (point of view)- driven by patient.

  • Viewer centered- depends on the position of patient (turn in wheel chair). The most important for severe neglect.

  • Environment centered- more cognitive, there is another side to the door.

  • Object Centered (different perspectives) looking at objects at different perspectives.


  • Other Modalities:

  • Auditory- but they can understand you. For some sounds though there is neglect.

  • Tactile- tests of extinction.

  • Olfactory- even if there is 1 olf. Bulb neglect, you can still smell w/ other nostril.

  • Motor- Affects contralateral movement. Client will act like hemiparesis.

  • Directional hypokinesia (moving limbs to contralateral space) Affects dressing, applying make-up. Seems like a strangers limb, someone else stole their shoes. Etc.

Areas of damage for l neglect
Areas of Damage for L Neglect

  • R MCA- middle cerebral artery

  • R Frontal Parietal Lesions

  • R Thalamus

  • R Basal Ganglia

  • R Hemisphere= less localization, more holistic

Theories of l neglect
Theories of L Neglect

  • Representational- disruption of internal representation of space. How I see the flower. I can tell you what the flower and clock look like but can’t draw it.

  • Attention-

  • When cued, neglect is reduced.

  • Orienting bias- RH attends to R + L sides; LH attends to R- more specific.

  • Don’t see right neglect as often

Therapy for l neglect
Therapy for L Neglect

  • Bring awareness & attention to L side.

  • Severe deficits (tactile cue)

  • Physical Movement (wheel chair)

  • Moderate deficits (cue to neglected side) – have them feel around the plate , TV or book.

  • Mild deficits (teach to self cue)

  • I’m gonna have you highlight all the words on the left side of the page

Attention heirarchy
Attention- Heirarchy

  • Arousal- eye contact (keeping eyes closed in bed).

  • Sustained Attention- attending to one thing for a prolonged period of time.

    • Put a cold washcloth on their face.

  • Selective Attention- knowing what is the most important task to focus on.

  • Divided Attention (multi-task)- completing multiple tasks at the same time. More for mildly impaired.

  • Treatment- task completion-

    • if they complete task, they can attend to it. If working on neglect, do task that addresess the area of neglect.

Goals for left neglect
Goals for Left Neglect

  • 1. client will draw symmetrical items with 100% accuracy with tactile & visual cues.

  • 2. Client will turn to the left (look to the left) and/or describe items shown with 100% accuracy with tactile, visual and verbal cues.

  • Mild—look to the left with 100%, highlight written text on the left side.

  • If goal is to have a conversation, they can have a conversation for 5 minutes, attn OK.


  • Melodic contour rhythm of speech.

  • Conveys meaning:

    • Emotional content

    • State of speaker- how is the speaker feeling?

    • Speaker’s attitude toward listener- sarcastic

  • RHD- monotone or euphoric

  • Linguistic effects- stress & syllable duration. Ex.- “green house”- spondee word.

  • Nonlinguistic (emotion, humor, formality) types of prosody.

Prosody cont
Prosody cont..

  • Pitch is vulnerable in RHBD (its affected)

  • Language can be intact, but prosody impaired.

    • Can cause divorce.

  • Emotional prosody most impaired.

  • Difficulty producing & comprehending emotions**

    • Facial expressions

    • Content of story- might not understand emotion of story.

  • Tx- patients need to identify their own emotions and others..

Emotional prosody
Emotional Prosody

  • Difficulty matching to emotion (pictures of sad, happy etc)

  • Monotone (no prosodic features)- for mild populations.

    • Prosodic contours- draw on paper where the stress should be. Ex. Yesterday was what?

  • Reliance on semantic info instead of prosody. Must be up front and literal.

  • Difficulty understanding sarcasm

Linguistic prosody
Linguistic Prosody

  • Difficulty with compound nouns vs. noun phrases. (ex- light house)

  • Minimal emphatic stress (ex- she wore that dress)

  • Can’t correct prosody- can always teach them to be louder on stressed words.

  • RH perceives linguistic & emotional prosody

  • LH contributes to linguistic prosody.

More prosody

  • Severe L Neglect= severe prosody deficits.

  • Prosody comprehension- R Anterior & Posterior cortical lesions

  • Linguistic prosodic deficits- R Frontal, temporal & parietal lobes, caudate nucleus, internal capsule, thalamus.

  • -- neglect guides how severe rest of deficits are.

Prosodic exercise
Prosodic exercise…

  • List 5 sentences that provoke emotion:

  • 1. You look beautiful.

  • 2. What’s wrong?

  • 3. I had an amazing day.

  • 4. How do you feel about healthcare reform?

  • 5. I feel like I’m gonna throw up.

  • 6. Will you marry me?

  • 7. This food is delicious!

  • 8. Are you serious?

Linguistic deficits
Linguistic Deficits

  • Perform normal on aphasia tests (w/ assistance for L Neglect)

  • Problems: Convergent & Divergent thinking.

  • Convergent: clues to the big picture- don’t get humor. Ex. It is small, you sharpen it, it has lead, an eraser.. etc

  • Divergent- single concept to more concepts (more clues) ie. problems with humor. Can only think of one meaning per word. Ex- give me 3 reasons that you would move to a different city.

Linguistic deficits1
Linguistic Deficits

  • Words with dual meanings are difficult

  • RH (works slower than LH) RH adds the nuances to language

    • Important for single word processing

    • Less frequent meanings

    • Slower & Less selective than LH

  • LH

    • Strong semantic overlap (words w/ several meanings)

    • Highly selective

    • Rapid in selection

Linguistic deficits2
Linguistic Deficits

  • Problems with collective nouns (eg. Furniture)

  • Abstract categories (ex- liquids) really difficult

  • More L Neglect= worse linguistic deficits.

  • Problems with Generative naming. Ex FAS. Name words that begin with F, A, S.

Think of 3 items that are more abstract than 3 concrete
Think of 3 items that are more abstract than 3 concrete



Types of fish



Farm animals

Types of music

  • Things that are soft

  • Things that are rectangular shaped

  • Things that smell bad

  • Things that make you happy

  • Things that turn you on

  • Affect vs. emotion

  • Affect- outward expression of emotion (flat affect- show no emotion, look bored)

  • Emotion- subjective mood, state; internal experiences. How the person is feeling is not being shown.

  • RH Dominance Theory:

    • Perception

    • Comprehension

    • Expression of emotion

  • Emotional lability- used to describe affect- means constant crying or euphoria. Affect is impaired


  • With facial expressions (comprehension & production)

  • Promotes social isolation

  • Can comprehend gestures & posture

  • Problems w/ verbal emotions (stories, conversation)

  • Better identifying emotion when interested in story (written text)

  • Reduced prosody for emotional memories.

Depression dsmr iv
Depression (DSMR-IV)

  • 30-60% of RHD

  • 2 or more of the following:

  • Poor appetite or over eating

  • Insomnia or hypersomnia

  • Low energy or fatigue

  • Low self esteem

  • Poor concentration or difficulty making decisions

  • Feelings of hopelessness

Depression and rhd
Depression and RHD

  • Organic effects- change in neurotransmitters- serotonin

  • Reactive effects- response to deficits

  • Refer to neuropsych

  • Ask them if they are sad or unhappy. If they are depressed refer out.

Delusions confusions
Delusions & Confusions

  • Agitated Confusion- will see w/ TBI, because they are forming new connections.

    • Incoherent thoughts- similar to jargon

    • Easily distractible

    • Restlessness

    • Violent outbursts

    • Can occur w/ RHD but rare

  • Anterior Frontal & temporal damage (prefrontal cortex and executive function

  • Misidentification syndromes (person, place, body parts)

    • Will see them confabulate, make things up.

    • Look at own body parts and not know whose they are.

  • Reduplicative Paramnesia (place & person)

    • Imposter- they think you are one

    • Bifrontal or RH frontal and/or parietal lesions

  • Korsakoff’s syndrome- totally confused and paranoid.

    • Lack of Thiamine

    • Prolonges alcoholism- etiology

    • Looks like Wrnicke’s aphasia, fluent, jargon, neologisms

  • Campgrass Syndrome

    • Imposters- family members, friends- get neuropsych

    • Psychiatric component

  • Prosopagnosia (agnosia- sensory disturbance, occur w/ tactile & visual senses)

    • Visual agnosia- inability to recognize faces

    • Bilateral posterior lesions

    • No recall of familiar face

  • Tx.- if they can recognize voices work on that.

  • Somatoparaphasia:

  • Misidentification of own body parts (crossing midline)

  • Confabulation- about whose body part it is.

  • L Neglect

  • RHD disrupts the feeling of being connected and united.


  • Discourse Deficits

    • Communicative event

    • Info conveyed by speaker to listener(s)

    • Requires situations content

    • Not all RHD have discourse problems-

      • may be high functioning patient

    • Cognitive problems= discourse deficits.

      • Cognition affect communication.

  • L Neglect= discourse affected

  • Simple discourse is intact.

    • Right hemisphere good verbal output. Abstract words difficult.

Anomia goal
Anomia Goal

  • During anomic episode client will use semantic description, embedding and sentence completion

  • Verbal cues (sentence completion)- “describe cup”

    • Semantic descriptors- describe the cup, tell me the color, tell me where you find it.

  • Visual- point to the handle etc. Word Map.

Aud comp goal
Aud Comp goal

  • Client will answer yes/no question with verbal cues

  • Cues: repeat question, provide key words- Name Jamie?

  • Visual- point to Jamie.

  • Tactile- put jamie’s hand on herself when asked “Are you Jamie?”

Goals continued
Goals Continued

  • Complex yes/no questions-

  • Do you cut the grass with an ax?

  • How can you make it easier?

  • Does it snow in July? Simplify to two words

  • Repeat the ques.

  • Gestures for snow, July. Show pictures

  • Aud comp- major goal- UNDERSTAND CONVERSATION!!!

  • Cognitive communication- organization is an issue. They have problems with attention, organization.

  • L= neglect affects discourse too.


  • Procedural- perform an activity

  • Expository- single topic/1 speaker (for TBI everything is expository)

  • Conversation- between 1 or more speakers

  • Narrative- event or story. Most difficult because it requires organization and structure.

Problems: problems with attention, organization.

  • Inferencing:

    • Individual clues missed (attn)

    • Irrelevant clues selected

    • No intergration of clues (ie. No big picture)

    • Dissassociation of clues to prior experience

  • Indirect requests (ex. Boy, it’s cold in here)

  • Sarcasm (ex graceful!)

  • Humor (problems with punchline)

More deficits
More deficits problems with attention, organization.

  • Misunderstanding gist if info (macrostructure)

  • Difficulty with implied meaning (inferencing)

  • Providing alternative meanings

  • Lack of referent usage (Sam- who is Sam?)

  • Lack of sensitivity to communication content (ie. Comm. knowledge with listener

  • Higher level language problems with attention, organization.

    • Figurative Language (Raining cats and dogs)

    • Literal info is easier (ie. Reduce sarcasm)

  • Cognitive Deficits:

  • WM- short term

  • Attention (because of L neglect)

  • Organization

  • Problem solving

  • Executive Function- lack insight etc.

  • Speed of processing- a lot slower..

Pragmatic deficits social language
Pragmatic Deficits problems with attention, organization.(Social Language)

  • Initiation

  • Roles & Purpose (ex- code switching)

  • Turntaking (verbose, tangential)

  • Poor eye contact- related to L neglect

  • Poor organization

Theory of mind
Theory of Mind problems with attention, organization.

  • Understanding internal mental state of others (requires inferencing)

  • Assists in interpretation of external behavior

  • Informs about motivation(s), emotional state & knowledge base.

Evaluation of rhb
Evaluation of RHB problems with attention, organization.

  • Medical chart

  • Interview

  • Informal assessment

  • Formal testing:

    • Burns Brief Inventory (neuropathologies & RH)

    • MIRBI-2 (mini inventory of right brain inventory)

    • Rehab institute of Chicago Assessment

  • Review Findings

Areas of assessment
Areas of Assessment problems with attention, organization.

  • Cognitive (exec function, attn)

  • Orientation- to person, place, time, event

  • L neglect- tests of extinction, writing etc.

  • Discourse- Convo.

  • Prosody- listen for lack of prosody

  • Affective disorder- outward signs of emotion (wont get it)

  • Higher language function- abstract language

  • Pragmatic abilities- give them some jokes

Screening problems with attention, organization.

  • 20 minutes

  • Tell me where you are today

  • What kinds of problems have you noticed?

  • What are your future plans?

  • What does your family/friends think about your plans?

  • What are you going to do today?

  • What kinds of people have you seen here?

Screening cont
Screening cont… problems with attention, organization.

  • Picture: humor or inferencing

  • Emotion

  • Affect

  • Prosody

  • Higher lang function

  • L neglect

L neglect screening
L neglect Screening problems with attention, organization.

  • Cancellation task- make x’s out of paper.

  • Symmetrical drawing- clock, flower, person

  • Line Bisection- draw a line, divide it in half

  • Tests of extinction- touch hands or both hands

  • Reading/Writing- everything presented at midline