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ACQ
Volume 13, Number 2 2011
ACQ
uiring Knowledge in Speech, Language and Hearing
speech pathologist to prioritise the order in which skills and
processes are assessed.
For example, the clinician may suspect a problem
in semantic processing, on the basis of difficulties in
understanding conversation and/or with word finding in
conversation. However, whether further investigation of this
hypothesised impairment (and its functional consequences)
initially focuses on spoken production, written production,
or written comprehension (for example) will depend on the
relative priority of the skill as perceived by the individual with
progressive aphasia and their communication partners.
For an individual for whom reading and understanding the
newspaper each day is a high priority, investigation may
emphasise written comprehension. In contrast, for the
individual who feels the ability to exchange social greetings
with neighbours is critical to their quality of life, initial
assessment may focus on spoken language.
Which assessments can be used to test our clinical
hypotheses? Appropriate measures could include
selected subtests of standardised batteries, specialised
assessments such as subtests of the
Psycholinguistic
Assessments of Language Processing in Aphasia
(PALPA;
Kay, Lesser, & Coltheart, 1992), and informal assessments
devised for that individual. Whitworth, Webster, and Howard
(2005) present a clear, clinically oriented guide to which
assessments are best suited to assess particular aspects
of the language processing system. Importantly, the choice
of assessment should be influenced by the fact that it will
be required both to determine the current status of the
language system, and also to track change over time,
including change which is the result of treatment.
A comprehensive assessment should not only focus
on targeted, hypothesis-driven testing at the level of the
impairment. It is also vital to understand the impact of
that impairment on functional language (i.e., to address
the level of activity/participation), personal relationships,
and psycho-social well-being. Here too, we agree with
clinical researchers who propose that hypothesis-driven
assessment is preferable (e.g., Sacchett & Marshall,
1992). Moreover, Worrall (1992, 2000; Worrall, McCooey,
Davidson, Larkins, & Hickson, 2002) suggests that it is
naïve to expect that a single assessment will be appropriate
to assess all individuals with aphasia from all cultures, all
impairments, and all settings, and consequently clinicians
should not rely on a single assessment of functional
communication. In an attempt to address this problem,
the
Everyday Communication Needs Assessment
(Worrall,
1992) and the
Functional Communication Therapy
Planner
(Worrall, 1999) include an interview to evaluate
an individual’s communicative needs, a questionnaire to
assess social support, and observations and ratings of
interactions in the individual’s natural environment. This
assessment goes some way towards the goal of functional
communication assessment that reflects what really
happens (in the aphasic and non-aphasic population), what
is really important (to the individual with aphasia and their
communication partners), and what can be acted upon
for rehabilitation. It is therefore highly suitable for use with
clients with progressive aphasia. More recently, it has been
suggested that assessment beyond the impairment level
should focus on detailed ethnographic interviews with the
person with aphasia and their communication partners
(e.g., Simmons-Mackie & Damico, 2001; Worrall, 2006;
Worrall et al., 2011). Such interviews are vital not only to
(decline rather than stability or improvement), there are
additional considerations in the assessment of progressive
language impairments that we will discuss below.
Nickels (2005) suggested that in the context of non-
progressive aphasia, assessment should allow the speech
pathologist to develop a hypothesis about areas of strength
and weakness in functioning. Furthermore, assessment
should identify factors that are barriers to and facilitators
of successful communication, and the impact of these
factors on quality of life, to enable appropriate goal-setting
for therapy in collaboration with the client and significant
communication partners (see also, for example, Byng, Kay,
Edmundson, & Scott, 1990; Howard & Hatfield, 1987), and
to track change over time, which includes evaluating the
outcome of the therapy process. We suggest the same
is true for progressive language disorders. This article will
therefore outline principles of assessment of clients with
primary progressive aphasia (which will be referred to as
progressive aphasia for the remainder of this paper). The
two primary aims of assessment that we will discuss are:
1. to identify the current status of the person’s language
impairment, and the impact on communication activities,
participation, and quality of life to enable goal planning
for treatment, and
2. to establish the nature, extent, and rate of change in
language skills over time.
We will conclude with discussion of some further
considerations for assessment that are encountered in this
population.
Assessment aims
To identify the current status
When working with an individual with progressive aphasia
(as with every individual with language impairment), the
speech pathologist aims to optimise the person’s current
communication. In other words, given a certain language
impairment with a particular impact on that individual’s life
participation and quality of life, the speech pathologist may
ask: what can be done to lessen the impact of impairment,
facilitate participation, and improve quality of life? When
considered in light of the client’s own goals, assessment
allows the speech pathologist to determine the best course
of action.
Traditionally the first step in assessment would have been
to use a standard aphasia battery, such as the
Western
Aphasia Battery – Revised
(WAB-R; Kertesz, 2006) or the
Boston Diagnostic Aphasia Assessment
(BDAE; Goodglass,
Kaplan & Barresi, 2001). These batteries will give a
broad overview of how well the individual is performing
across a range of language tasks such as picture
naming, understanding spoken words, repeating words,
reading, writing, and so on. However, some clinicians and
researchers now believe this is not the most efficient way
of learning what is wrong and deciding how best to treat
the problem. For example, Byng et al. (1990) question
whether “the clinician’s time is well spent in carrying out
any of these assessments if they neither clarify what is
wrong nor specify what treatment should be provided” (p.
67). Instead they argue for a more targeted approach to
assessment driven by (a) hypotheses that are generated
based on observation, and (b) joint discussion/decision-
making with the individual with aphasia and their primary
communication partners (e.g., Byng et al., 1990; Nickels,
2005, 2008). This hypothesis-driven assessment allows the