What tools should I use to holistically assess a stroke patient with aphasia, beyond history and physical examination (PE)?

Holistic Assessment Tools for Stroke Patients with Aphasia

For holistic assessment of stroke patients with aphasia, the Western Aphasia Battery (WAB) is recommended as the primary assessment tool due to its comprehensive evaluation of language function, strong psychometric properties, and ability to classify aphasia severity. 1

Primary Assessment Tools

Language-Specific Assessment Tools

• The Western Aphasia Battery (WAB) should be used as the primary comprehensive assessment tool for patients with aphasia as it evaluates spoken and written language production and comprehension, calculation, drawing, and visuoconstruction skills 1
• The Quick Aphasia Battery (QAB) is recommended when time constraints exist, as it provides reliable multidimensional assessment of language function in approximately 15 minutes while maintaining excellent test-retest reliability (ICC = 0.98) and inter-rater reliability (ICC = 0.99) 2
• The Boston Naming Test should be included to assess word retrieval abilities, which is a common deficit in post-stroke aphasia 1
• For reading assessment, include the Reading Comprehension Battery, which has acceptable psychometric qualities and is appropriate for patients with aphasia 1

Functional Communication Assessment

• The Assessment of Language-Related Functional Activities should be used to evaluate practical communication skills in everyday activities such as check writing and telephone tasks 1
• The ASHA Functional Assessment of Communication Skills for Adults should be included to assess social communication, basic needs communication, reading, writing, and number concepts 1
• The Quality of Communication Life Scale should be administered to evaluate the impact of communication deficits on quality of life and social participation 1

Cognitive Assessment Tools

Aphasia-Friendly Cognitive Assessments

• The Cognitive Assessment Scale for Stroke Patients (CASP) is recommended for cognitive assessment in patients with aphasia as it can be administered without using language and has better feasibility than MMSE and MoCA in aphasic stroke patients 3
• The Non-language-based Cognitive Assessment (NLCA) is particularly valuable for patients with non-fluent aphasia, as it avoids the language bias present in traditional cognitive screening tools 4
• The Cognitive Linguistic Quick Test can be used to assess attention, memory, executive function, language, and visuospatial perception in patients with diverse neurological diagnoses 1

Executive Function Assessment

• The Stroop Test should be included to evaluate executive functions, including psychomotor speed, cognitive flexibility, and response inhibition in patients with suspected vascular cognitive impairment 5
• The Behavioral Assessment of the Dysexecutive Functioning Syndrome should be used to evaluate executive skills in everyday activities and includes a questionnaire that can be completed by both patient and caregiver 1
• The Color Trails Test is recommended for assessing sustained attention and attention switching with minimal language or cultural bias 1

Memory Assessment

• The Rivermead Behavioral Memory Test is recommended to evaluate everyday memory abilities with parallel versions allowing for reliable repeated administrations 1
• The Location Learning Test should be used to assess visuospatial learning and recall in older adults 1

Assessment Considerations

Timing and Approach

• All stroke patients should be screened for communication disorders using simple, reliable, validated tools 1
• Patients with any suspected communication deficits should be referred to a Speech-Language Pathologist (SLP) for comprehensive assessment 1
• Consider the validity and standardization of selected tools with regards to factors such as age, culture, language fluency, physical function, and education levels 1
• Be aware of the potential impact of multiple assessments on both validity of test results and patient fatigue; use different equivalent assessment forms when available to avoid practice effects 1

Special Considerations

• For patients with non-fluent aphasia, the NLCA is recommended over MoCA or MMSE as these traditional cognitive assessments have higher classification rates of cognitive impairment in non-fluent aphasia 4
• When assessing patients with significant language impairments, use alternative means of communication such as gesture, drawing, writing, and augmentative and alternative communication devices 1
• For patients from culturally and linguistically diverse backgrounds, trained healthcare interpreters may be needed 1

Imaging and Laboratory Assessment

• All patients with suspected vascular cognitive impairment should undergo MRI (preferred) or CT to evaluate cerebrovascular disease 1
• Laboratory testing should include CBC, TSH, B12, calcium, electrolytes, creatinine, ALT, lipid panel, and HbA1c to assess stroke risk factors and possible contributing factors to cognitive impairment 1

Pitfalls and Caveats

• Traditional cognitive screening tools like MMSE and MoCA have limited utility in patients with aphasia, particularly those with non-fluent aphasia 3
• The presence of non-cognitive neurological deficits (visual field deficits, motor deficits) must be considered when performing cognitive assessments 1
• Assessing non-language cognitive domains is challenging when aphasia is present; in complex cases, formal evaluation by a neuropsychologist and/or repeated assessments may be required 1
• The Stroop test should be interpreted within a comprehensive assessment battery, considering potential confounding factors such as educational level, language proficiency, visual impairments, and cultural background 5