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.