Urban-Rural Differences in Service Utilization and Costs of Care for Racial-Ethnic Groups Hospitalized With Poststroke Aphasia.

OBJECTIVE: Although residence is a key contributor to cost and utilization in stroke patient care, its contribution to the care of persons with aphasia (PWA) is unknown. The objective of this study was to use discharge-level hospital inpatient data to examine the influence of patient residence (rural vs urban) and race-ethnicity on service utilization and cost of care among PWA. DESIGN: Cross-sectional. SETTING: Administrative data from acute care hospitals in the state of North Carolina. PARTICIPANTS: Individuals (N=4381) with poststroke aphasia. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Length of stay (LOS), speech-language pathology (SLP) service utilization, costs of care. METHODS: The 2011-2012 Healthcare Cost and Utilization Project State Inpatient Database data were analyzed to examine the effect of rural or urban residence on LOS, SLP service utilization, as well as total inpatient and SLP service costs. These outcomes were further analyzed across both residence and racial groups (non-Hispanic white and non-Hispanic black). Outcomes were analyzed using generalized linear model. RESULTS: Both rural and urban black PWA experienced longer average LOS after controlling for demographics, illness severity, and the hospital where they received care. Rural blacks experienced longer LOS, received greater SLP services, and incurred greater average total hospital costs than their rural white counterparts after adjusting for differences in their demographics and stroke or illness severity. The differences were attenuated after controlling for the hospital where they received care. CONCLUSIONS: For PWA, race-ethnicity has a larger effect on average total medical costs, SLP service utilization, and LOS than residence. It is unclear how and why blacks with aphasia have greater service utilization and costs in acute care, yet their aphasia outcomes are worse. Future studies are required to explore potential factors such as quality of care.

Racial-Ethnic Differences in Word Fluency and Auditory Comprehension Among Persons With Poststroke Aphasia.

OBJECTIVES: To examine aphasia outcomes and to determine whether the observed language profiles vary by race-ethnicity. DESIGN: Retrospective cross-sectional study using a convenience sample of persons of with aphasia (PWA) obtained from AphasiaBank, a database designed for the study of aphasia outcomes. SETTING: Aphasia research laboratories. PARTICIPANTS: PWA (N=381; 339 white and 42 black individuals). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Western Aphasia Battery-Revised (WAB-R) total scale score (Aphasia Quotient) and subtest scores were analyzed for racial-ethnic differences. The WAB-R is a comprehensive assessment of communication function designed to evaluate PWA in the areas of spontaneous speech, auditory comprehension, repetition, and naming in addition to reading, writing, apraxia, and constructional, visuospatial, and calculation skills. RESULTS: In univariate comparisons, black PWA exhibited lower word fluency (5.7 vs 7.6; P=.004), auditory word comprehension (49.0 vs 53.0; P=.021), and comprehension of sequential commands (44.2 vs 52.2; P=.012) when compared with white PWA. In multivariate comparisons, adjusted for age and years of education, black PWA exhibited lower word fluency (5.5 vs 7.6; P=.015), auditory word recognition (49.3 vs 53.3; P=.02), and comprehension of sequential commands (43.7 vs 53.2; P=.017) when compared with white PWA. CONCLUSIONS: This study identified racial-ethnic differences in word fluency and auditory comprehension ability among PWA. Both skills are critical to effective communication, and racial-ethnic differences in outcomes must be considered in treatment approaches designed to improve overall communication ability.

Language-Specific Attention Treatment for Aphasia: Description and Preliminary Findings.

The need for a specific, language-based treatment approach to aphasic impairments associated with attentional deficits is well documented. We describe language-specific attention treatment, a specific skill-based approach for aphasia that exploits increasingly complex linguistic tasks that focus attention. The program consists of eight tasks, some with multiple phases, to assess and treat lexical and sentence processing. Validation results demonstrate that these tasks load on six attentional domains: (1) executive attention; (2) attentional switching; (3) visual selective attention/processing speed; (4) sustained attention; (5) auditory-verbal working memory; and (6) auditory processing speed. The program demonstrates excellent inter- and intrarater reliability and adequate test-retest reliability. Two of four people with aphasia exposed to this program demonstrated good language recovery whereas three of the four participants showed improvements in auditory-verbal working memory. The results provide support for this treatment program in patients with aphasia having no greater than a moderate degree of attentional impairment.

Sentence planning following traumatic brain injury.

BACKGROUND: Current descriptions of the language problems following traumatic brain injury (TBI) generally emphasize evaluating discourse production and explaining the observed outcomes in terms of disruptions to executive processes. The notion of sentence production impairments at the sentence level has generally been ignored. To respond to this issue, we examined patterns of intrasentential pausing and sentence planning during sentences produced by normal and TBI speakers. METHODS: Seven individuals with TBI functioning at Rancho Level V-VI and seven age-matched controls participated in this pilot experiment. Group performances were compared for pause time and verbal initiation time during the production of sentences varying in syntactic complexity under two conditions (reading and repetition). RESULTS: Significant group differences were observed in pausing during both conditions. Pausing patterns of the participants with TBI were strongly correlated with the syntactic complexity of sentences. No significant group differences were observed on verbal initiation time of repeated sentences, although increased initiation times were present among the TBI participants. CONCLUSIONS: These findings of this pilot project suggest that the deficits in language production following TBI may include specific impairments to sentence planning. This evidence suggests that the language profile of TBI may be one of both microlinguistic and macrolinguistic impairments.

Dysarthria impact profile: development of a scale to measure psychosocial effects.

BACKGROUND: The psychosocial impact of acquired dysarthria on the speaker is well recognized. To date, speech-and-language therapists have no instrument available to measure this construct. This has implications for outcome measurement and for planning intervention. This paper describes the Dysarthria Impact Profile (DIP), an instrument that has the potential to meet this need in clinical practice. AIMS: To describe the development of the DIP, which was devised as part of a larger study to measure psychosocial impact of acquired dysarthria from the speaker's perspective. METHODS & PROCEDURES: The current psychometric properties of the DIP are examined. The scale was administered to 31 participants with acquired dysarthria. The internal consistency of the scale items and their intra-rater reliability were investigated. Concurrent validity was assessed for the portion of the scale (Section A) assessing impact of acquired dysarthria on self-perception, self-concept and self-esteem by comparing the results with changes in self-concept as determined by the Head Injury Semantic Differential Scale (HISD II). OUTCOMES & RESULTS: The DIP shows good internal consistency and strong intra-rater reliability overall. There was a strong, statistically significant, correlation between results on Section A of the DIP and the results of the HISD II suggesting convergent validity for this portion of the scale. There are some limitations to the scale in its current format and these are highlighted. CONCLUSIONS & IMPLICATIONS: The scale is now ready for further refinement and development. Once validated, it should act as a robust outcome measure for clinicians.

Clinical Outcomes Following Language-Specific Attention Treatment Versus Direct Attention Training for Aphasia: A Comparative Effectiveness Study.

Purpose This study was conducted to examine the comparative effectiveness of 2 different approaches, 1 domain-specific and the other domain-general, to language and attention rehabilitation in participants with stroke-induced aphasia. The domain-specific treatment consisted of language-specific attention treatment (L-SAT), and the domain-general treatment consisted of direct attention training (DAT) using the computerized exercises included in Attention Process Training-3 (Sohlberg & Mateer, 2010). Method Four individuals with mild-moderate aphasia participated in this study. A randomized controlled cross-over single-subject design was used to assess the effectiveness of the 2 treatments administered in this study. Treatment outcomes were evaluated in terms of participants' task performance for each program, standardized language and attention measures, tests of functional abilities, and patient-reported outcomes. Results Visual comparisons demonstrated linear improvements following L-SAT and variable patterns following DAT. Omnibus effect sizes were statistically significant for 9 of the 13 L-SAT tasks. The weighted standardized effect sizes for posttreatment changes following L-SAT ranged from small to large, with the exception of 1 task. The average group gain following DAT was 5%. The Western Aphasia Battery-Revised Aphasia Quotients (Kertesz, 2007) demonstrated reliable improvements for 3 of the 4 participants following L-SAT, whereas only 1 of the participants improved reliably following DAT. The margins of improvements in functional language were substantially larger following L-SAT than DAT. Performance on the Test of Everyday Attention improved significantly for 2 participants following L-SAT and for 1 participant following DAT on selected Test of Everyday Attention (Robertson, Ward, Ridgeway, & Nimmo-Smith, 1994) subtests. Patient-reported outcomes for communication and attention following treatment favored L-SAT compared to DAT. Conclusions The results support the view that attention is allocated in ways that are particular to specific tasks rather than as a general resource that is allocated equivalently to all processing tasks. Domain-specific treatment for language deficits due to attentional impairment appears to be a suitable, if not preferable, approach for aphasia rehabilitation. Supplemental Material https://doi.org/10.23641/asha.8986427.

Progressive apraxia of speech as a sign of motor neuron disease.

PURPOSE: To document and describe in detail the occurrence of apraxia of speech (AOS) in a group of individuals with a diagnosis of motor neuron disease (MND). METHOD: Seven individuals with MND and AOS were identified from among 80 patients with a variety of neurodegenerative diseases and AOS (J. R. Duffy, 2006). The history, presenting complaints, neurological findings, and speech-language findings were documented for each case. RESULTS: Spastic or mixed spastic-flaccid dysarthria was present in all 7 cases. The AOS was judged as worse than the dysarthria in 4 cases. Nonverbal oral apraxia was eventually present in all cases. Aphasia was present in 2 cases and equivocally present in another 2. Dementia was present in 1 case and equivocally present in 2. CONCLUSIONS: AOS can occur in MND, typically also with dysarthria, but not invariably with aphasia or other cognitive deficits. Thus, a diagnosis of MND does not preclude the presence of AOS. More importantly, MND should be a diagnostic consideration when AOS is a prominent sign of degenerative disease.

Linking inter- and intra-sentential processes for narrative production following traumatic brain injury: Implications for a model of discourse processing.

Some suggest that traumatic brain injury (TBI) produces dissociation between the macrolinguistic and microlinguistic levels of discourse production. This assumption is based primarily on studies that have found preserved intersentential cohesion and/or intra-sentential processing in narratives produced by these individuals. However, few studies exist, if any, that have investigated the relationship between these processes in TBI speakers who do demonstrate such microlinguistic impairments. This study investigated the relationship between impairments of intersentential cohesion and intra-sentential processing in the discourse of 15 speakers with severe TBI. The results demonstrated a significant relationship between the production of cohesive ties and instances of intra-sentential impairment that suggests that utilization of resources for adequate cohesion appears to negatively affect intra-sentential processing following TBI. We propose that macrolinguistic and microlinguistic processes are not independent of one another, as has been proposed, but share cognitive resources that support the planning and production of both local (microlinguistic) and long-distance (macrolinguistic) relationships expressed through discourse.

Acquired apraxia of speech: features, accounts, and treatment.

The features of apraxia of speech (AOS) are presented with regard to both traditional and contemporary descriptions of the disorder. Models of speech processing, including the neurological bases for apraxia of speech, are discussed. Recent findings concerning subcortical contributions to apraxia of speech and the role of the insula are presented. The key features to differentially diagnose AOS from related speech syndromes are identified. Treatment implications derived from motor accounts of AOS are presented along with a summary of current approaches designed to treat the various subcomponents of the disorder. Finally, guidelines are provided for treating the AOS patient with coexisting aphasia.

Phonemic characteristics of apraxia of speech resulting from subcortical hemorrhage.

UNLABELLED: Reports describing subcortical apraxia of speech (AOS) have received little consideration in the development of recent speech processing models because the speech characteristics of patients with this diagnosis have not been described precisely. We describe a case of AOS with aphasia secondary to basal ganglia hemorrhage. Speech-language symptoms consistent with subcortical AOS and aphasia are reported as well as description of the patient's speech characteristics using broad phonemic transcription. Significantly more phoneme substitution errors were observed than other types of errors and these occurred significantly more often in the initial rather than the medial or final positions of words. No differences were observed in the number of errors produced for the various types of phonemes included in this analysis. These findings challenge the hypothesis that speech motor planning disorders are uniquely the result of cortical damage. They also argue against the notion that subcortical AOS is indistinguishable from the cortical syndrome. LEARNING OUTCOMES: The reader will learn (1) the phonemic characteristics of AOS due to subcortical brain damage, (2) the similarities and differences between AOS due to cortical versus subcortical lesions, and (3) the implications of these patterns for current models of speech motor processing.

The cognitive basis for sentence planning difficulties in discourse after traumatic brain injury.

PURPOSE: Analyses of language production of individuals with traumatic brain injury (TBI) place increasing emphasis on microlinguistic (i.e., within-sentence) patterns. It is unknown whether the observed problems involve implementation of well-formed sentence frames or represent a fundamental linguistic disturbance in computing sentence structure. This study investigated the cognitive basis for microlinguistic deficits in individuals with TBI. METHOD: Fifteen nonaphasic individuals with severe TBI and 6 age- and education-matched non brain-injured adults participated in this study. Monologic discourse samples were analyzed for pausing patterns, mazes, errors, and abandoned utterances. Measures of cognitive abilities were correlated with the sentence measures. RESULTS: The speakers with TBI produced more pauses between clauses (but not within clauses) as well as more mazes than did the non brain-injured speakers. Significant regression models were built. Raven's Coloured Progressive Matrices (Raven, 1965), a measure associated with working memory, predicted pause behavior, and Likenesses-Differences (Baker & Leland, 1967), a measure of executive function, predicted maze behavior. CONCLUSIONS: Sentence planning impairments following TBI are associated with deficient organization and monitoring of language representations in working memory. These findings suggest that the deficits are due to problems in the recruitment and control of attention for sentence planning. These findings bear on sentence processing models that emphasize the activation, organization, and maintenance of language representations for accurate sentence production.

Treating the fluent aphasias.

The origin of the term fluent aphasia is reviewed as well as the characteristics and syndromes of patients presenting with this type of aphasia. Three strategies are presented for describing the impairments and disabilities associated with fluent aphasia: (a) syndrome-based, (b) model-driven, and (c) functionally oriented. Treatment approaches that conform to each of these strategies are discussed. Current methods for assessing the effectiveness of treatment efforts with fluent aphasic patients are described. Some recent findings regarding the causes and characteristics of fluent aphasia are presented with regard to their potential impact on future interventions for these patients.