Discussion
Aphasia Evaluation: Practices of
Malaysian SLPs
In the present study, we revealed practices of SLPs and related issues
pertaining to the evaluation of aphasia. In general, it was found that
SLPs reported consistency of practices in certain aspects of aphasia
evaluation. Four trends were identified related to their aphasia
evaluation practices.
Firstly, SLPs were found to consistently obtain case history and
background information through patient/caregiver interviews and medical
records. As mentioned earlier, Shrubsole and colleagues recommended for
the involvement and collaboration of SLPs with PWA and individuals who
are relevant in their intervention. Involvement of family and caregivers
in speech-language management of aphasia is crucial to ensure positive
intervention outcomes following carry-over of SLPs recommendation in
home environment 21. The results of this study may
indicate that Malaysian SLPs are aware of the importance of family
involvement in successful aphasia care. Unlike family involvement,
collaboration of SLPs with other healthcare professionals was less
consistent. Malaysian SLPs seemed to rely more on medical records as
compared to direct engagement with other healthcare professionals.
Direct communication with professionals from other disciplines may
support in-depth understanding of patients’ conditions, roles of SLPs in
aphasia intervention, and gain perspectives of the professionals
regarding needs, facilitators and barriers that may impact aphasia
recovery 22. It is important to note that most of the
participants worked in acute public hospitals. In this type of setting,
SLPs and non-SLP professionals tend to have heavy caseloads and might
only confer on select cases 23.
Secondly, SLPs were found to focus their evaluation on auditory language
comprehension, spoken language/verbal expression, repetition of words
and sentences, and pragmatic/social communication skills. Since aphasia
is affecting the ability of PWA to understand, produce, and use language
for communication 2, it was expected that SLPs direct
their evaluation on those abilities. Across the evaluation components
rated by the participants, all of them unanimously reported that
pragmatic and social communication skills are consistently evaluated.
Findings from pragmatic and social communication assessments may inform
SLPs regarding competency of PWA to use language when communicating with
others 24. Although reading comprehension and written
expression abilities are also defining characteristics of
aphasia2, it is surprising that SLPs demonstrated
lower consistency in evaluating those abilities. Lack of consistency in
evaluating reading and writing abilities may be related to the limited
available time for SLPs to complete assessments during the initial
session. In other countries, limited time with individual patients have
reportedly been a challenge for SLPs, not only in assessing PWA, but
also in providing treatment 25–27. While initial
evaluation findings are useful for determining the presence and severity
of aphasia, continuous evaluations must be conducted to ensure provision
of appropriate treatment based on the needs of individuals with
aphasia2,28. Language and communication abilities
among people with aphasia (PWA) have been proven to change with
time29. Continuous assessment of aphasia also may
address components that have not been thoroughly evaluated during the
initial session.
Thirdly, SLPs were found to rely upon unstructured and informal means to
evaluate PWAs’ language and communication abilities. Unlike the
practices of SLPs in Singapore (a neighboring country), the participants
reported moderate consistency in utilizing formal assessment tools,
which primarily aim to determine the skills that are impaired and the
extent of impairment. In the Singaporean study, more than 90% of their
SLP participants utilized an assessment tools for evaluation of aphasia30. In the present study, only about 50% of the
participants have been using formal assessment tools frequently, while
the remaining half either use the tools infrequently or not at all. This
may be due to the lack of standardized tools can be accessed by SLPs,
which has been identified by the participants as a common challenge.
Three tools were found to be used in both Singapore and Malaysia, which
are the Boston Diagnostic Aphasia Examination (BDAE)31, Psycholinguistic Assessments of Language
Processing in Aphasia (PALPA) 32 and Comprehensive
Aphasia Test (CAT) 33. Although these tools are more
often used in both countries, SLPs utilized those tools minimally. More
consistently, Malaysian SLPs have been employing informal approach to
gather evaluation findings.
Finally, evaluation of aphasia was found to be primarily limited to
clinical settings. This may be due to nature of service provision at
SLPs’ workplaces. More than 80% of study participants reported to work
in acute hospitals, which is a trend that has been reported in other
studies 17,18,34,35. According to Ahmad and colleague,
the Malaysian Ministry of Health has been a primary source of employment
for graduates of local SLP university programs, thus, many SLPs are
working in public hospitals through the country 19.
SLPs in acute public hospitals tend to serve individuals with
communication and/or swallowing impairments across the lifespan, which
result in high caseloads and limited time to engage with PWA in
non-clinical settings 34. Since aphasia affects
communication abilities of PWA, it has been noted that aphasia
evaluation that is conducted in social and personally-relevant
environment, such as their workplace and personal homes, may provide
critical information for designing an effective treatment program36.
Issues on Cultural and Linguistic Diversity in Aphasia
Evaluation
Across the nine challenges presented in the survey, linguistic barriers
and lack of standardized resources were rated to be more common among
SLPs. As mentioned earlier, the Malaysian population consists of diverse
ethnic groups, who are using a variety of languages and/or dialects. A
huge majority of Malaysians are able to communicate in more than one
language 13,14. In the case of aphasia, proficiency of
one or more language may be affected differently, hence the need to
evaluate functioning of all languages used by PWA prior to the onset of
aphasia 37,38. Varied effects of language impairment
on PWAs’ abilities in different languages may be due to the extent in
which one language is better preserved than another37. In addition, the age when one acquire the second
and additional languages have been found to influence aphasia recovery
for that particular language 39.
It can also be inferred that those two challenges (i.e., linguistic
barrier and lack of standardized language tools) are related. In
conducting language evaluation, SLPs commonly translate and adapt
assessment tools that has been developed and normed based on
English-speaking population 30,37,40. The complexity
of the processes involved in translating and adapting standardized
English language tools is well acknowledged 41.
Clinicians are required to consider various attributes associated with
diverse cultures, linguistic features (including semantics,
grammaticality, and syntactic structures) and factors that may influence
performance level in those test, such as item familiarity, word
frequency, and age of word acquisition 40,42. Because
linguistic and culture-related aspects must be considered in order to
adapt English tools to local languages, the progress of resource
development for aphasia evaluation tend to be slow, thus, affecting the
availability of standardized language tools for local populations.
Additionally, lack of expertise and financial support may also restrict
the progress in developing tools for aphasia evaluation19,43.
Experts have suggested strategies to address these challenges. One of
the strategies involve the adaptation of tools that are generally
neutral in terms of the stimuli used in testing 44.
For example, the Revised Token Test (RTT) 45 primarily
includes basic colors, prepositions, and shapes for its language
stimuli. It is important to note that this strategy may not address all
issues related to cultural and linguistic diversity. In adapting the RTT
into standard Indonesian language, Jap and Arumsari found that the
usability of the adapted version is limited for individuals who are
using various other Indonesian dialects 46. Therefore,
assessment findings based on the adapted tests must be treated
cautiously.
Another strategy for addressing assessment of aphasia with multilingual
and culturally diverse population is related to the discourse analysis
approach, where language and communication samples are collected by SLPs
within and outside of clinical contexts 47. Discourse
analysis was found to provide SLPs with accurate diagnosis of aphasia,
as well as its types and severity 48. However,
discourse analysis requires training for SLPs to acquire specific skill
set in eliciting language and communication samples and analyze content
and linguistic characteristics accurately 49. Bryant
and colleagues found that even among SLPs who have been trained to
conduct discourse analysis, many did not apply the method due to time
constraint at their workplace 49.
Although cultural and linguistic issues related to aphasia evaluation
cannot be resolved immediately, strategies suggested by previous
researchers and experts can be applied with proper consideration. At the
same time, effort to develop assessment resources for diverse
populations must be enhanced and supported in order to speed up the
process. Building professional network may also encourage support among
SLPs via sharing resources, experience and methods that may be applied
relevant to the local contexts.
Limitation of the Study.
The present study only focused on evaluation of language functions in
aphasia assessment and challenges faced by SLPs related to it. Focus on
other aspects of evaluation was minimal. This study did not include the
practices of SLPs in the evaluation of access to communication for PWA
and impacts of aphasia on the lives of PWA. Future studies are needed
for discovering the frequency and extent of evaluation processes in
addressing all facets proposed in WHO ICF 50. Based on
the ICF, evaluation of aphasia must also include impacts of
communication impairment on the lives of PWA, as well as factors that
may affect aphasia recovery and opportunities for PWA to participate in
social and personally relevant activities, including management of
personal finances, involvement in hobbies before the onset of aphasia,
and recommencement of roles prior to aphasia in the context of family
and community. By looking at various psychosocial aspects, cultural
impacts on evaluation practices might be more visible. Participation of
PWA and their caregivers may also give better insights for improving
guidelines and protocols for aphasia evaluation.