Language is the usual “medium” for communication during mental status assessment. Like fundamental functions, the examiner must assess language early as disturbances can affect the rest of the examination. The first consideration is that language and speech are not the same. Language is the brain’s use of symbols for communication, and speech is the verbal motor expression of language. By this definition, language includes all symbolic communication whether spoken or written, sign language or Braille, or codes such as Morse Code or musical notation, and others. Speech, in contrast, is restricted to the verbal modality.To assess language, the examiner must divide language functions into their components. The most basic division is by spoken or written modality, hence this chapter is organized into Part 1 Spoken Language and Speech and Part 2 Written Language and Reading. Within these divisions, language testing includes encoding outgoing sequences of symbols (fluency, repetition, naming) and decoding incoming symbols (comprehension). Additional important aspects of the language examination focus on the association of language symbols with their meanings (semantics), prosody or the intonation of verbal output, the occurrence of paraphasic or word errors, and the evaluation of motor speech.The neural network subserving language function is a large system involving distributed regions and circuits. Despite their neuroanatomic impression, the classical modular centers and their disconnections remain useful for clinically characterizing language disorders if they are conceived as “hubs” of distributed neural networks. The classical model, known as the Wernicke-Lichtheim-Geschwind Model, focuses language functions around the perisylvian region of the left hemisphere ( Fig. 8.1 ). This model is anchored anteriorly in the Broca area in the inferior frontal region for production (fluency) and syntax (rules for combining words into clauses or phrases), and posteriorly in the Wernicke area in the superior temporal cortex for comprehension of phonemes (units of sound of a language) and facilitation of their semantic connections. Connections between the two travel along a dorsal, word sound or phonological circuit and along a ventral, word meaning or semantic circuit.
Part 1. Spoken Language and Speech
Aphasia (or “dysphasia”) is the loss or impairment of language caused by brain damage. With aphasia, there is a loss of ability to produce and/or understand written and/or spoken language. The aphasic syndromes are predominantly fluent versus nonfluent, which is a better dichotomy than “expressive” versus “receptive,” as all language impairments have an expressive component. The examiner further characterizes the aphasic syndromes in terms of the ability to comprehend, repeat, and name. These four characteristics—fluency, comprehension, repetition, naming—are the key to an aphasia examination, particularly for spoken language. Moreover, all those with aphasia have, to varying degrees, disturbances of reading and writing. In fact, disturbances in writing, in particular, is one way to assure the presence of an aphasia, rather than a primary speech problem.
Before describing the examinations there are some special issues to consider. First are differences depending on the hemispheric “dominance” of the individual. Left-hemisphere language dominance is present in strongly right-handed people, or approximately 90% of individuals. Those with left-handedness or a family history of left-handedness have less hemispheric specialization for language with more bilateral representation in the brain, particularly for more posterior language functions. Because of their greater bilaterality of language, compared with strong lateralized right-handers, left-handers who are language-impaired are less likely to fit into typical aphasia syndromes and more likely to have an initial aphasia with a better recovery. The incidence of true right-hemisphere “crossed-aphasia” in strongly lateralized right-handers is actually quite small. A further special consideration is the presence of bilingualism or multilingualism. Individuals who speak more than one language have different lexicons (vocabularies): “L1” for the first language, which is acquired directly from concepts, and “L2”, which is most commonly a later, sequentially learned language that may be acquired by translational equivalents from L1. Aphasic disorders in these patients may result in differential patterns or impairment and recovery, with L1 generally being the more robust.
SPOKEN LANGUAGE EXAMINATION
The examiner systematically evaluates the four basic elements of the spoken language examination: fluency, comprehension, repetition, and naming. The examination begins with determining the presence of elements of nonfluency. As part of the “spontaneous fluency” determination, the examiner also listens for prosody, or intonation and rhythm, and lexical stress. Testing “verbal fluency,” or word-list generation, further clarifies overall language fluency ability. The language examination continues with an assessment of auditory comprehension of both words and sentences. The examiner also listens for linguistic content and the presence of paraphasias or word errors. The spoken language examiner proceeds to an evaluation of the patient’s ability to repeat sentences and to name on confrontation a series of items, pictures, or drawings. Finally, the language examination is not complete without additionally assessing for speech disorders. Other related aspects, such the nonlinguistic content of verbal output and pragmatics or the effects of context, are usually manifestations of thought processes as discussed in Chapter 14 .
Fluency. Language fluency is the ability to produce words, phrases, and sentences proficiently and smoothly. It is initially assessed qualitatively by listening to the patient’s spontaneous speech and discourse. The best way to elicit this is with open-ended questions: “Tell me why you are seeing a doctor?” “What brought you to this clinic visit?” “Tell me about yourself, your family, and what kind of work you have done.” The examiner may also have the patient describe an activity or a picture, such as the “Cookie Theft” picture from the Boston Diagnostic Aphasia Examination ( Fig. 8.2 ). During this period, the examiner listens for the main elements of nonfluency.
Nonfluent speech has at least four elements ( Table 8.1 ). First, there is sparse output, with a decreased number of words per minute (<50) and shortened phrases, typically less than four or five words. Decreased words/minute or slow verbal output are the most sensitive, but least specific, of the characteristics of dysfluency, and can result from many causes, including a simple reticence to speak. The decreased length of phrases is more specific for dysfluency and is often quantified as mean length of utterance, or the number of morphemes between a stretch of spoken language preceded and followed by silence. Even mean length of utterance, however, may vary considerably in a given patient depending on the emotional valence and complexity of the conversational topic. In addition to sparse output, nonfluent patients have an abnormal flow of speech, with frequent pauses, often to search for words, false starts and hesitations, as well as effortfulness with difficulty in word initiation, sometimes evident as an explosive onset to a word.
| 1.Quantity of verbal output |
| a. Decreased spontaneous words/minute (abnormal about <50; normal usually 100+) or slow output (further test for decreased word-list generation) |
| b. Short phrase length (abnormal 1.2; normal 4+) |
| 2.Flow of verbal output |
| a. Frequent word-finding pauses, halts, choppiness, or word searches |
| b. Labored word production with effort/struggle, delay/hesitancy, or explosive onset/breakthrough |
| 3.Grammar (i.e., syntax) |
| a. Agrammatism; both expression and comprehension of grammar (see Table 8.3 ) |
| b. Telegraphic sounding output lacking functor or grammatical words |
| 4.Speech or word sounds |
| a. Phonemic paraphasic or literal errors and impaired articulatory agility |
| b. Abnormal lexical stress (accented syllable) and prosody (intonation, rhythm) |
Nonfluent aphasics may still successfully convey information with a limited number of nouns, verbs, or substantive words. An example of the nonfluent, but understandable, response of a patient with Broca aphasia when asked why she had come to see the doctor: “ Ah, Ah, today, brought today, Ah, father prove today…come hospital for talking…bad talking…doctors for talking…words hard speeches .”
Agrammatism is the most specific characteristic of nonfluency, and often the most difficult to evaluate ( Table 8.2 ). It consist of simplified sentences, at least partially stripped of the elements that serve primarily to bind the sentence together. These elements are grammatical function or “functor” words (e.g., prepositions, articles, conjunctions) and grammatical morphemes (units of meaning) or inflections (e.g., “ed” for past events, “s” for plurals, “ly” for adjectives). The resulting oversimplified sentences, often confined to a noun-verb or verb-object phrases, are “telegraphic.” Other common agrammatic errors include errors of tense, of subject-verb agreement, and of word order. It is important to appreciate that in some patients agrammatism is primarily evident, not in verbal output, but in the impairment of the comprehension of the syntax of phrases (see auditory comprehension section).
| 1.Difficulty with grammatical elements for syntax (sentence construction) |
| a. Loss of function (“functor”) words (articles, preposition, auxiliary verbs, conjunctions, pronouns, “Wh” question words) |
| b. Loss of inflection morphemes (“s” for plural, tense, e.g., “ed” for past tense, gender agreement, comparisons agreement) |
| 2.Oversimplification (“telegraphic” sounding) |
| a. Preference for substantive words (nouns, verbs, adjectives, adverbs) |
| b. Decreased embedding and encoding of clauses, phrases |
| 3.Abnormal word stream |
| a. Abnormal word order, such as verb-noun agreement or other word concordance |
| b. Broken up and short phrases |
| 4.Decreased syntactical comprehension |
| a. Problems understanding complex sentences with noncanonical and passive grammar (e.g., The lion was killed by the tiger.) |
| b. Cannot use sentence structure to derive sentence meaning; loss of ability to map syntactic structure onto semantic structure |
Nonfluency also includes speech or word sound errors, especially at the phoneme level, the smallest unit of sound of a language. These primarily involve the substitution of one phoneme for another (phonemic or “literal” paraphasias). For example, on attempting to say “artery,” patients may say “argery” or “artory.” In addition, they may simply omit a syllable, for example, “arty,” or missequence them, for example, “erarty.” Nonfluent aphasia is often accompanied by further phonemic distortions and substitutions due to “apraxia of speech,” or problems with the motor planning of phonemes. Apraxia of speech is a breakdown in the ability to coordinate the articulatory movements required for comprehensible speech and is often tested as part of the speech examination as described later. Further aspects of both nonfluency and apraxia of speech is the presence of articulatory error groping or attempts at self-correction.
Prosody. Nonfluency includes changes in prosody or intonation at the sentence level and in the stressed or accented syllable in a word (lexical stress). In addition to listening for changes in pitch (rising or falling) and stress (often increased loudness), further screening for prosody can be done with repetition of sentences in different tones and asking the patient to interpret them and then to repeat them with a certain meaning. The examiner usually combines specific testing for prosodic fluency with testing for prosodic comprehension. For example, start by saying the following sentence repeated with different emphasis on the bolded and italicized word and asking the patient the meaning: ____ I AM going to the other movies. ____ I am going to the OTHER movies. ____ I am going to the other movies. ____ I am going to the other MOVIES . ____ I am GOING to the other movies. For prosodic fluency, ask the patient to say the same sentence with determination, sadness, anticipation, emphasis on himself/herself, and type of place or action.
Word-List Generation (verbal fluency). The inability to produce words is a very sensitive measure of language dysfunction. Although not specific for fluency, word-list generation provides a means for rapid assessment of word production, word access, and word knowledge (semantic memory). First, ask the patient to do a category word generation task. For example, ask the patient to generate a list of as many animals as possible (or other category of items such as grocery items, articles of clothing, cities, colors) in one minute. “ I am going to ask you to name as many animals as you can in one minute. An animal is any living thing that is not a plant. Please wait until we are ready to begin .” Do not count proper nouns, plurals, and repetitions in the total correct, but do count word variations or subcategory items (e.g., include both dogs and beagles). Do not suggest subcategories (e.g., “zoo animals”). Normal subjects can list 18 ± 6 animals per minute without cueing. Second, ask the patient to generate as many words as possible that begin with the letter “F” (or it can be “A” or “S,” the other letters used in the Controlled Oral Word Association Test). These letters reflect word frequencies in English and vary with the language tested (e.g., in Spanish the letters would be “P,” “M,” and “R”). “ I will say a letter of the alphabet. Then I want you to give me as many English words that begin with that letter as quickly as possible. I do not want you to use words that are proper names. Also do not use the same word again with a different ending such as ‘eat’ and ‘eating’ or ‘sixty’ and ‘sixty-one.’ Begin when I say the letter .” Do not count close word variations of the same word, such as “four,” “foursome,” “fourfold,” “fourth,” but do count word variations with a different meaning (e.g., “fourteen”). Normal subjects can list 15 ± 5 words per minute for each letter.
Auditory Comprehension. The examination of sentence comprehension involves a series of tasks of increasing difficulty. First, there are simple axial and one-step commands, for example, “close your eyes” and “touch your nose,” followed by “show me two fingers” and “point to the floor.” In evaluation of auditory comprehension with pointing commands, remember that motor weakness or apraxia may interfere with pointing. Second, ask yes-or-no questions, for example, “Are you sitting down?” “Is a hammer good for cutting wood?” “Does March come before April?” “Will a stone float in water?” Third are sequential commands, for example, “Touch your nose and then your chin,” “Point to your right knee and then your left shoulder,” “First point to the ceiling and then to the door,” “Point to the chair, then the table, and then the door.” Commands that require a body part to cross the midline are more complex than those that do not, and the handling of sequences also challenges the ability to maintain a serial order. Finally, evaluate complex grammatical sentence comprehension, for example, “If the lion was killed by the tiger, which animal is dead?” “If we were in a crowd of people and I said, ‘there’s my wife’s brother,’ would I be pointing to a man and a woman?”
The isolated impairment of comprehension of grammatical sentences suggests agrammatism, as occurs in Broca aphasia (see prior fluency section). One method to test this is with noncanonical sentence comprehension. Noncanonical examples are those with a passive voice (e.g., The cat is chased by the dog) or a clause that relates to an object (e.g., Pete saw the cat who the dog is chasing) or an object-extracted wh- question (e.g., Who is the dog chasing?). The examiner may further test the ability to comprehend grammatical relations with a series of commands using common items arrayed on a table, such as pens, keys, or coins. This is patterned after the Token Test, which presents 20 tokens of 5 colors each having 2 shapes and 2 sizes and giving commands such as “put the red circle on the green rectangle” or “before touching the yellow circle, pick up the red rectangle.” Using readily available items in the environment, the examiner can ask the patient to perform a similar series of commands of increasing complexity ( Table 8.3 ).
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