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Addressing cognitive skills in aphasia therapy?

A primer for clinicians

Short Term Memory/Working Memory

 Aphasia is defined as a linguistic pathology.

 Individuals with aphasia have impaired attention skills (Murray, 1999).

 Short term memory (STM): temporary storage of information (measured with digits forward task).

 SLPs do not typically include cognitive goals in aphasia therapy.

 Decreased attentional capacity and/or a deficit in allocating attention resources.

 Working memory (WM): manipulation, rehearsal, or processing of that information (measured with digits backward task).

 Subtle cognitive signs are typically associated with a patient’s performance:
• limited capacity
• slower information processing (i.e., slowing down helps)

 Sustained attention (vigilance) may be preserved (Korda & Douglas, 1997).

 These difficulties are not addressed directly in therapy.
“Is aphasia best thought of as a
language disorder or a disorder of those
processes which support language?”
(McNeil, 1981, p. 344).

Attention and resource allocation may underlie aphasic language and may be
responsible for the language performance variability (Hula & McNeil, 2008).
 Many individuals with aphasia experience concomitant measurable
cognitive difficulties (see Table 1), including attention, memory, processing
speed, executive functions, and even visuospatial/visuoconstructive skills
(Barker-Collo & Feigin, 2006; Helm-Estabrooks, 2002; Hochstenbach et al.,
1998; Riepe et al., 2004):
• slowness in information processing: 70% of patients
• impaired verbal memory: 40% of patients (Hochstenbach et al., 1998)
•impaired verbal memory: 75% of acute patients (Riepe et al., 2004).

ASHA Convention
New Orleans November 2009

STM/WM impairment is common with all aphasia types (Martin & Ayala, 2004; Martin & Saffran, 1997; Wright et al., 2007).

“Impairments in auditoryverbal span are ubiquitous in
aphasic individuals”
(Martin & Ayala, 2004, p. 464)

 The relationship between STM and comprehension is an important issue: if related, then therapy could be directed at STM.

 Allocation deficit may explain the intra-patient variability.
 Individuals with mild aphasia may be impaired at selective and divided attention
tasks, regardless of lesion location (Murray et al., 1997).

Consequences for Assessment
 There is a progressively louder call among researchers and clinicians to assess
attention (Helm-Estabrooks, 2002; Murray, 1999; Riepe et al., 2004).
 Use formal tests, questionnaires, or rely on observation while manipulating
distracter or competing variables.
 Assessing in “ideal” situations (quiet room, no distractions, etc.) may quantify
language competence, it does not assess language performance. Competing stimuli
should be manipulated when using more functional or naturalistic assessments.

 Correlation between WM and language comprehension (Caspari et al., 1998), and between WM and the WAB scores (Wright et al., 2003).
BUT: STM may not contribute to oral language comprehension unless some aspect of a sentence needs to be revised (e.g., syntax, semantics) using phonological WM (Friedmann &
Gvion, 2007; Papagno et al., 2007).
 A more recent research trend subdivides WM into specialized loops associated with language processing: phonological, syntactic, and semantic (Hoffman et al., 2009; Majerus et al.,
2004; Martin et al., 1994; Wright et al., 2007).
 Phonological STM is the cardinal feature of two specific disorders: repetition conduction aphasia and deep dysphasia (see Table 2)
 Patients with good comprehension and very poor STM scores comprehend language by accessing the semantic system directly and lose the phonological content of the message (Baldo
et al., 2008). This explains why these patients cannot repeat nonword and show semantic paraphasias in repetition (which becomes semantic decoding + naming) (Wilshire, 2008).
“…in an attempt to repeat the sentence The pastry
cook was elated, one of our patients with conduction
aphasia responded, Something about a happy baker.”
(Baldo et al., 2008, p. 135)

Consequences for Therapy
 Therapy for attention has shown to have positive results but minimal impact on
language (Murray et al., 2006; Sinotte & Coelho, 2007).
 Murray (1999) recommended treating attention before focusing on language.

Repetition Conduction Aphasia
Table 2: disorders
associated with
STM dysfunction

- Poor phonological STM
- Poor repetition (tend to paraphrase)
- No conduites d’approche
- Good spontaneous speech

Deep Dysphasia
- Poor phonological STM
- Semantic paraphasias in single word repetition
- Can’t repeat nonwords
- Relatively normal spontaneous language

 These two disorders may represent two different severity levels of a similar underlying dysfunction. Martin et al. (1996) described a patient with deep dysphasia who improved into
repetition conduction aphasia.

Consequences for Assessment

 Cognitive skills may be affected independent of language, as they are not
correlated with aphasia severity (Helm-Estabrooks, 2002).

 Candidacy: individuals with milder aphasia when selective attention is a major
barrier to communication..

 STM should be screened in all patients and more carefully assessed in patients with repetition difficulties. The stimuli should include digits and words, and the response modality
should be verbal and nonverbal (e.g., the pointing task of Martin & Saffran, 1992).

 Clinical interest for cognitive impairments associated with aphasia is
focused on attention capacity and short-term/working memory (which are

 Possibly use available attention training programs (e.g., APT II).

 Working memory subtypes can be assessed using n-back tasks (Wright et al., 2007). Phonological: rhyme/no rhyme; Semantic: same/different semantic category; Syntactic:
same/different (with active/passive sentences).

Murray et al.
Riepe et al.

N & type
16 Chronic
mild aph.
209 CVA:
Acute &

- Attention
- Resource
- Memory

Hochstenbach 229 CVA:
et al. (1998)
Range of

- Processing
- memory


- Executive

13 Chronic
Range of

Table 1: co-morbidity of cognitive impairments
and aphasia

 At some point, selective attention should be used as a variable in therapy to
practice functional communicative situations and facilitate generalization.
 At least at the beginning, SLPs should focus on family training (speak slowly,
simple syntax, be redundant, etc.).

Baldo, J. V., Klostermann, E. C., & Dronkers, N. F. (2008). It’s either a cook or a baker: Patients with conduction aphasia get the gist but lose the trace. Brain and Language, 105, 134-140.
Barker-Collo, S., & Feigin, V. (2006). The impact of neuropsychological deficits on functional stroke outcomes. Neuropsychology Review, 16, 53-64.
Caspari, I., Parkinson, S. R., LaPointe, L. L., & Katz, R. C. (1998). Working memory and aphasia. Brain and Cognition, 37(2), 205-23.
Francis, D. R., Clark, N., & Humphreys, G. W. (2003). The treatment of an auditory working memory deficit and the implications for sentence comprehension abilities in mild “receptive” aphasia. Aphasiology, 17(8), 723-750. doi:10.1080/02687030344000201
Friedmann, N., & Gvion, A. (2007). As far as individuals with conduction aphasia understood these sentences were ungrammatical: Garden path in conduction aphasia. Aphasiology, 21(6/7/8), 570-586.
Helm-Estabrooks, N. (2002). Cognition and aphasia: A discussion and a study. Journal of Communication Disorders, 35, 171-186.
Hochstenbach, J., Mulder, T., van Limbeek, J., Donders, R., & Schoonderwaldt, H. (1998). Cognitive decline following stroke: A comprehensive study of cognitive decline following stroke. Journal of Clinical and Experimental Neuropsychology, 20(4), 503-517.
Hoffman, P., Jefferies, E., Ehsan, S., Hopper, S., & Lambon Ralph, M. (2009). Selective short-term memory deficits arise from impaired domain-general semantic control mechanisms. Journal of Experimental Psychology: Learning, Memory, and Cognition, 35(1), 137-156.
Hula, W. D., & McNeil, N. R. (2008). Models of attention and dual-task performance as explanatory constructs in aphasia. Seminars in Speech and Language, 29(3), 169-187.
Kalinyak-Fliszar, M., Kohen, F., Martin, N., DeMarco, A., & Gruberg, N. (2008). Remediation of language processing in aphasia: Improving activation and maintenance of linguistic representations in verbal short-term memory. Lecture at ASHA convention.
Chicago, IL.
Koenig-Bruhin, M., & Studer-Eichenberger, F. (2007). Therapy of short-term memory disorders in fluent aphasia: A single case study. Aphasiology, 21(5), 448-458. doi:10.1080/02687030600670593
Korda, R. J., & Douglas, J. M. (1997). Attention deficits in stroke patients with aphasia. Journal of Clinical and Experimental Neuropsychology, 19(4), 525-542
Majerus, S., van der Kaa, M. A., Renard, C., Van der Linden, M., & Poncelet, M. (2005). Treating verbal short-term memory deficits by increasing the duration of temporary phonological representation: A case study. Brain and Language, 95, 174-175.
Majerus, S., Van der Linden, M., Poncelet, M., & Metz-Lutz, M.-N. (2004). Can phonological and semantic short-term memory be dissociated? Further evidence from Landau-Kleffner syndrome. Cognitive Neuropsychology, 21(5), 491-512.
Martin, N., & Ayala, J. (2004). Measurements of auditory-verbal STM span in aphasia: Effects of item, task, and lexical impairment. Brain and Language, 89, 464-483.
Martin , N., & Saffran, E. M. (1992). A computational account of deep dysphasia: Evidence from a single case study. Brain and Language, 43, 240-274.
Martin, N., & Saffran, E. M. (1997). Language and auditory-verbal short-term memory impairments: Evidence for common underlying processes. Cognitive Neuropsychology, 14(5), 641-682.
Martin, N., Saffran, E. M., & Dell, G. S. (1996). Recovery in deep dysphasia: Evidence for a relation between auditory-verbal STM capacity and lexical errors in repetition. Brain and Language, 52, 83-113.
Martin, R., Shelton, J., & Yaffee, L. (1994). Language processing and working memory: Neuropsychological evidence for separate phonological and semantic capacities. Journal of Memory and Language, 33, 83-111.
McNeil, M. R. (1981). Auditory comprehension in aphasia: A language deficit or reduced efficiency of processes supporting language? In R. H. Brookshire (Ed.), Clinical Aphasiology (pp. 342-345). Minneapolis, MN: BRK Publishers.
Murray, L. L. (1999). Attention and aphasia: Theory, research and clinical implications. Aphasiology, 13(2), 91-111.
Murray, L. L., Holland, A. L., & Beeson, P. M. (1997). Auditory processing in individuals with mild aphasia: A study of resource allocation. Journal of Speech, Language, and Hearing Research, 40, 792-808
Murray, L. L., Keeton, R. J., & Karcher, L. (2006). Treating attention in mild aphasia: Evaluation of attention process training-II. Journal of Communication Disorders, 39, 37-61.
Papagno, C., Cecchetto, C., Reati, F., & Bello, L. (2007). Processing of syntactically complex sentences relies on verbal short-term memory: Evidence from a short-term memory patient. Cognitive Neuropsychology, 24(3), 292-311.
Riepe, M. W., Riss, S., Bittner, D., & Huber, R. (2004). Screening for cognitive impairment in patients with acute stroke. Dementia and Geriatric Cognitive Disorders, 17, 49-53.
Sinotte, M. P., & Coelho, C. A. (2007). Attention training for reading impairment in mild aphasia: A follow-up study. NeuroRehabilitation, 22, 303-310.
Wilshire, C. E. (2008). Cognitive neuropsychological approaches to word production in aphasia: Beyond boxes and arrows. Aphasiology, 22(10), 1019-1053.
Wright, H., Newhoff, R., Downey, R., & Austermann, S. (2003). Additional data on working memory in aphasia. Journal of the International Neuropsychological Society, 9(2), 302.
Wright, H. H., Downey, R. A., Gravier, M., Love, L., & Shapiro, L. P. (2007). Processing linguistic information types in working memory in aphasia. Aphasiology, 21(6/7/8), 802-813.
Youse, K., & Coelho, C. A. (2009). Treating underlying attention deficits as a means for improving conversational discourse in individuals with closed head injury: A preliminary study. Neurorehabilitation, 24, 355-364.


Consequences for Therapy
 Four studies focused rehabilitation on phonological STM using repetition (Francis et al., 2003) or an increasing delay paradigm (Kalinyak-Flitzar et al., 2008; Koenig-Bruhin &
Studer-Eichenberger, 2007; Majerus et al., 2005). Some minimal improvements were reported in (some but not all) STM/WM measures and limited improvements in comprehension
(Francis et al., 2003; Majerus et al., 2005). These results are encouraging, but provide insufficient support for systematic STM therapy at this time.
 Is it possible that the therapy actually improves the attention component of WM rather than comprehension per se? For example, one patient (Majerus et al., 2005) reported that her
comprehension had improved in group conversations; and another (Francis et al., 2003) improved performance in the digits backward task, but not the digits forward condition. If this
hypothesis is correct, linguistic comprehension is not necessarily expected to improve concurrently.


 Cognitive difficulties often coexist with aphasia.
 We should understand their severity for clinical purposes.
 Targeting these cognitive skills in therapy does not seem to impact on language to a large extent, but they may be a necessary step
before focusing on language. That is, improving memory and attention may be necessary but not sufficient for a subsequent
improvement in language-related skills.
 This may also be the case in TBI. Youse and Coelho (2009) attempted to improve conversation by focusing therapy on attention
skills, but the results were disappointing.

Handout at

Aphasia and Cognition

Patrick Coppens, Ph.D.
SUNY Plattsburgh, NY