ACQ Vol 13 no 2 2011

(decline rather than stability or improvement), there are additional considerations in the assessment of progressive language impairments that we will discuss below. Nickels (2005) suggested that in the context of non- progressive aphasia, assessment should allow the speech pathologist to develop a hypothesis about areas of strength and weakness in functioning. Furthermore, assessment should identify factors that are barriers to and facilitators of successful communication, and the impact of these factors on quality of life, to enable appropriate goal-setting for therapy in collaboration with the client and significant communication partners (see also, for example, Byng, Kay, Edmundson, & Scott, 1990; Howard & Hatfield, 1987), and to track change over time, which includes evaluating the outcome of the therapy process. We suggest the same is true for progressive language disorders. This article will therefore outline principles of assessment of clients with primary progressive aphasia (which will be referred to as progressive aphasia for the remainder of this paper). The two primary aims of assessment that we will discuss are: 1. to identify the current status of the person’s language impairment, and the impact on communication activities, participation, and quality of life to enable goal planning for treatment, and 2. to establish the nature, extent, and rate of change in language skills over time. We will conclude with discussion of some further considerations for assessment that are encountered in this population. Assessment aims To identify the current status When working with an individual with progressive aphasia (as with every individual with language impairment), the speech pathologist aims to optimise the person’s current communication. In other words, given a certain language impairment with a particular impact on that individual’s life participation and quality of life, the speech pathologist may ask: what can be done to lessen the impact of impairment, facilitate participation, and improve quality of life? When considered in light of the client’s own goals, assessment allows the speech pathologist to determine the best course of action. Traditionally the first step in assessment would have been to use a standard aphasia battery, such as the Western Aphasia Battery – Revised (WAB-R; Kertesz, 2006) or the Boston Diagnostic Aphasia Assessment (BDAE; Goodglass, Kaplan & Barresi, 2001). These batteries will give a broad overview of how well the individual is performing across a range of language tasks such as picture naming, understanding spoken words, repeating words, reading, writing, and so on. However, some clinicians and researchers now believe this is not the most efficient way of learning what is wrong and deciding how best to treat the problem. For example, Byng et al. (1990) question whether “the clinician’s time is well spent in carrying out any of these assessments if they neither clarify what is wrong nor specify what treatment should be provided” (p. 67). Instead they argue for a more targeted approach to assessment driven by (a) hypotheses that are generated based on observation, and (b) joint discussion/decision- making with the individual with aphasia and their primary communication partners (e.g., Byng et al., 1990; Nickels, 2005, 2008). This hypothesis-driven assessment allows the

speech pathologist to prioritise the order in which skills and processes are assessed. For example, the clinician may suspect a problem in semantic processing, on the basis of difficulties in understanding conversation and/or with word finding in conversation. However, whether further investigation of this hypothesised impairment (and its functional consequences) initially focuses on spoken production, written production, or written comprehension (for example) will depend on the relative priority of the skill as perceived by the individual with progressive aphasia and their communication partners. For an individual for whom reading and understanding the newspaper each day is a high priority, investigation may emphasise written comprehension. In contrast, for the individual who feels the ability to exchange social greetings with neighbours is critical to their quality of life, initial assessment may focus on spoken language. Which assessments can be used to test our clinical hypotheses? Appropriate measures could include selected subtests of standardised batteries, specialised assessments such as subtests of the Psycholinguistic Assessments of Language Processing in Aphasia (PALPA; Kay, Lesser, & Coltheart, 1992), and informal assessments devised for that individual. Whitworth, Webster, and Howard (2005) present a clear, clinically oriented guide to which assessments are best suited to assess particular aspects of the language processing system. Importantly, the choice of assessment should be influenced by the fact that it will be required both to determine the current status of the language system, and also to track change over time, including change which is the result of treatment. A comprehensive assessment should not only focus on targeted, hypothesis-driven testing at the level of the impairment. It is also vital to understand the impact of that impairment on functional language (i.e., to address the level of activity/participation), personal relationships, and psycho-social well-being. Here too, we agree with clinical researchers who propose that hypothesis-driven assessment is preferable (e.g., Sacchett & Marshall, 1992). Moreover, Worrall (1992, 2000; Worrall, McCooey, Davidson, Larkins, & Hickson, 2002) suggests that it is naïve to expect that a single assessment will be appropriate to assess all individuals with aphasia from all cultures, all impairments, and all settings, and consequently clinicians should not rely on a single assessment of functional communication. In an attempt to address this problem, the Everyday Communication Needs Assessment (Worrall, 1992) and the Functional Communication Therapy Planner (Worrall, 1999) include an interview to evaluate an individual’s communicative needs, a questionnaire to assess social support, and observations and ratings of interactions in the individual’s natural environment. This assessment goes some way towards the goal of functional communication assessment that reflects what really happens (in the aphasic and non-aphasic population), what is really important (to the individual with aphasia and their communication partners), and what can be acted upon for rehabilitation. It is therefore highly suitable for use with clients with progressive aphasia. More recently, it has been suggested that assessment beyond the impairment level should focus on detailed ethnographic interviews with the person with aphasia and their communication partners (e.g., Simmons-Mackie & Damico, 2001; Worrall, 2006; Worrall et al., 2011). Such interviews are vital not only to

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ACQ Volume 13, Number 2 2011

ACQ uiring Knowledge in Speech, Language and Hearing