Journal of Communication Disorders

35 (2002) 171±186

Cognition and aphasia: a discussion and a study

Nancy Helm-Estabrooks*
Harold Goodglass Aphasia Research Center Ð 12A, Boston Veterans Administration Medical Center,
Boston University School of Medicine, 150 South Huntington Avenue,
Boston, MA 02130, USA
Received 23 October 2001; received in revised form 18 December 2001; accepted 18 December 2001

Abstract

The relation between other aspects of cognition and language status of individuals with
aphasia is not well-established, although there is some evidence that integrity of non-
linguistic skills of attention, memory, executive function and visuospatial skills can not be
predicted on the basis of aphasia severity. At the same time, there is a growing realization
among rehabilitation specialists, based on clinical experience and preliminary studies, that
all domains of cognition are important to aphasia therapy outcomes. This paper describes a
new study of the relation between linguistic and nonlinguistic skill in a group of individuals
with aphasia. No signi®cant relationship was found between linguistic and nonlinguistic
skills, and between nonlinguistic skills and age, education or time post onset. Instead,
individual pro®les of strengths and weaknesses were found. The implications of these
®ndings for management of aphasia patients is discussed.
Learning outcomes: Readers of this papers will be able to: list ®ve primary domains of
cognition and relate each to an aspect of aphasia therapy; describe at least three studies that
examined the relation between cognition and aphasia; describe four nonlinguistic tasks of
cognition that can be used with a wide range of aphasia patients. # 2002 Elsevier Science
Inc. All rights reserved.

Keywords: Aphasia; Cognition; Cognitive examination; Neuropsychological examination

*
Present address: 150 Medway Street, Providence, RI 02906, USA. Tel.: ‡1-617-232-9500x5844/
401-331-2866; fax: ‡1-401-861-0631.
E-mail address: nancyhe@bu.edu (N. Helm-Estabrooks).

0021-9924/02/$ ± see front matter # 2002 Elsevier Science Inc. All rights reserved.
PII: S 0 0 2 1 - 9 9 2 4 ( 0 2 ) 0 0 0 6 3 - 1
172 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186

1. Introduction

1.1. Cognition and aphasia

According to Sarno (1998), ``aphasia rehabilitation must be viewed as a

process of patient management in the broadest sense'' (p. 615). She went on to list
many factors that aphasia therapists must consider for execution of effective
interventions. Among these factors are ``neuropsychological de®cits.'' Yet,
despite the inherent importance of the neuropsychological (cognitive) status
of aphasia patients to the development of treatment plans and approaches and to
expectations of positive outcomes, most aphasia therapists are guided solely by
the results of language exams. Some exceptions are Luria (1966), a Russian
neuropsychologist actively engaged in aphasia rehabilitation, who looked
beyond language in developing his approaches, and Chapey (1994) who con-
ceptualized aphasia therapy as ``cognitive intervention.'' Interestingly, however,
no chapter in the widely used text edited by Chapey (2001) is devoted to the
neuropsychological examination of aphasia patients although in this fourth
edition, several excellent chapters on cognitive-psychological approaches to
aphasia therapy have been added. A chapter describing neuropsychological
assessment does appear in the Manual of Aphasia Therapy (Helm-Estabrooks &
Albert, 1991) but it is geared toward neuropsychologists. The second edition of
this text is in preparation and will have a chapter directed toward speech and
language pathologists interested in the cognitive examination of their aphasia
patients.
As a basis for developing an approach to determining the cognitive status of
aphasia patients, it is advisable to begin with a de®nition of cognition. Neisser
(1967) de®ned cognition as ``all the processes by which sensory input is
transformed, reduced, elaborated, stored, recovered and used'' (p. 4). More
recently, Bayles (2001) stated that ``cognition refers to what we know and the
processes that enable us to acquire and manipulate information.'' If cognition is to
be formally examined, however, we must go beyond these broad de®nitions and
consider the components or domains of cognition.
Cognition may be regarded as having ®ve primary domains: attention, memory,
executive functions, language, and visuospatial skills. Pertinent to the topic of this
paper, consider that each of these cognitive domains are recruited and used to
varying extents during the aphasia rehabilitation process. Most often, aphasia
therapy is directly related to language with pro®les of spared and impaired
language functions serving as the principle guides for making treatment decisions.
At the same time, attention is a powerful variable as it is basic and critical to all
activities. Failure to attend results in failure to process information despite what
may be relatively spared ability to understand spoken or graphic stimuli.
Furthermore, there is no question that aphasia therapy is a learning experience
and that learning relies upon memory processes. Moreover, it would be a rare
treatment protocol that did not call upon some aspect of visuospatial skills,
 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186 173

e.g., recognition and/or production of pictured, orthographic or gestured stimuli.

Finally, the ultimate goal of aphasia therapy is to improve individuals' ability to
communicate within everyday settings with all their unpredictable demands and
¯uctuating conditions. This task requires goal-oriented behavior and ¯exible
problem-solving, both hallmarks of executive functions. Thus, one can make a
strong case for factoring the relative integrity of all domains of cognition into the
treatment process for a particular patient with aphasia.
To establish individual pro®les of cognitive functions, a neuropsychological
assessment is required. Unfortunately, many commonly used neuropsycholo-
gical tests have linguistic processing and/or production demands that make
them largely invalid for use with aphasic individuals. Thus, studies of cognition
in people with aphasia typically have employed cognitive tests with no obvious
linguistic demands. For example, one of the tests used by Basso, DeRenzi, Scotti
and Spinnler (1973) was the Raven's coloured progressive matrices (Raven,
Court, & Raven, 1979), a test of visual analogic thinking in which each item
consists of a visual matrix with a missing piece. The task is to select the piece
that best completes the particular design from an array of six. Interestingly,
Basso et al., found that the correlation between scores earned by 33 subjects
with left hemisphere damage on the Raven's and scores earned on a language
test of naming and comprehension was ``practically zero.'' In other words, it was
impossible to predict analogic thinking ability on the basis of language test
performance.
In a study of cognition and aphasia, Helm-Estabrooks, Bayles, Ramage and
Bryant (1995) found that scores earned on a battery of ``nonverbal'' cognitive
tasks did not correlate signi®cantly with aphasia severity scores of 32 aphasic
patients, none of whom had global aphasia. Thus, this study provided additional
evidence that clinicians cannot predict the relative integrity of other domains of
cognition on the basis of language de®cits in aphasic stroke patients.
A study by Van Mourik, Vershaeve, Boon, Paquier, et al. (1992) focused on
cognition in 17 patients with global aphasia. They used a battery of nonlinguistic
tasks that they referred to as the global aphasic neuropsychological battery
(GANBA), and a test of auditory comprehension. (Although not explained by
the authors, this reader assumes that none of the patients had meaningful verbal
output given their diagnosis, so this was not tested). The GANBA was comprised
of six tasks, tests and subtests from published sources, and one task designed by
the investigators. Together, the GANBA tasks targeted the areas of attention/
concentration, memory, intelligence (as tested by the Raven's progressive
matrices), visual recognition and nonverbal auditory recognition. All subjects
could perform the tasks. Van Mourik et al. reported that scores earned on the
GANBA were independent of the level of spoken language comprehension.
Although GANBA pro®les re¯ected patient heterogeneity, test results also
allowed the investigators to identify two main groups of globally aphasic patients
that they discussed in terms of implications for treatment. Group 1 patients
performed well on the GANBA and were thought to have suf®ciently intact
174 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186

cognitive functions to respond to language-oriented aphasia treatment. Group 2

patients had variable patterns of de®cits (e.g., impaired concentration, visual
skills), suggesting that these impairments must be addressed directly before
language treatment is initiated. Van Mourik et al. also described a third group of
globally aphasic patients who were excluded from their study because they could
not perform the basic requirements of the GANBA tasks. Given the apparent
severity of their cognitive de®cits, it was suggested that therapy time be directed
toward work with the communicative partners of these individuals.
Although Van Mourik et al. only discussed the implications of aspects of
cognition for language treatment, Hinckley, Carr, and Patterson (2001) studied the
relationship between cognitive abilities, and speci®c treatment type (``context-
based'' versus ``skill-based'' and treatment duration with 18 chronically aphasic
patients. The goal of the treatment was to improve performance on the functional
task of ordering items from a catalogue. Nine patients received ``context-based''
therapy that involved the use of individualized compensatory strategies such as
using notebooks for graphic cueing and pressing keys for electronic speech
output. The other nine received ``skill-based'' therapy in which clinicians used
cueing hierarchies to improve retrieval and production of words related to
catalogue-ordering.
Hinckley et al. found that the lower the scores on the Raven's and Wisconsin
card sort test (WCST; Grant & Berg, 1993), the longer it took patients to achieve
performance criterion with ``context-based'' therapy. Furthermore, scores earned
on these tests by individuals receiving the context-based treatment were sig-
ni®cantly related to the ability to perform the functional task 6 months after
treatment ended. In discussing their ®ndings, these investigators discuss the roles
that executive functions, learning and memory skills played in the success of their
particular treatment protocols.

1.2. Assessing cognitive status of individuals with aphasia

Ideally, aphasia therapists obtain information as to their patients' current

cognitive status from neuropsychologists experienced in testing of individuals
with aphasia. Unfortunately, neuropsychological test data are rarely available in
most clinical practices. Furthermore, few tools exist for speech and language
pathologists to brie¯y examine the neuropsychological status of their aphasia
patients. One exception is the Raven's progressive coloured matrices (Raven,
1995), which is easily obtained and can be administered to most individuals with
aphasia independent of their language de®cits. This test, however, mainly targets
only one type of cognitive behavior, i.e., visual analogic thinking. To test a
broader spectrum of skills, researchers typically assemble batteries of nonlin-
guistic tests and tasks (e.g., Van Mourik et al., 1992; Helm-Estabrooks et al.,
1995) that may include subtests of standardized assessment tools, or nonstan-
dardized tasks. Not only are these batteries dif®cult and costly to assemble, their
administration time may be prohibitively long within the current environment of
 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186 175

health care. Furthermore, some tests such as the Wechsler memory scale
(Wechsler, 1997), from which speech±language pathologists might wish to extract
certain subtests, can be purchased only by Ph.D. level professionals.
The cognitive linguistic quick test (CLQT; Helm-Estabrooks, 2001) was
recently developed to meet the needs of clinicians who want to obtain basic
information about the relative status of attention, memory, executive functions,
language, and visual spatial skills of their patients. The CLQT consists of 10 tasks
and can be administered in 15±30 minutes. Field testing was conducted with both
nonclinical (no known neurological dysfunction) and neurologic examinees who
were demographically representative of the United States adult population
according to sex, age, education level, race/ethnicity, and region. The target
ages were 18±89 years. One pilot test and three research studies led to the ®nal
version of the CLQT. In Study 1, 30 certi®ed speech±language pathologists and
licensed psychologists tested 92 individuals, 28 with one of the following
neurologic diagnoses: left CVA, right CVA, bilateral CVA's, Alzheimer's disease,
and closed head injury. Each of these individuals was matched by age, race/
ethnicity and educational level to at least two clinical examinees (except for those
clinical cases with 11 years or less of education who had one match each) for a
total of 64 nonclinical examinees. In Study 2, 61 clinicians in 31 states tested 154
nonclinical examinees. In Study 3 another 119 examinees (38 clinical and 81
nonclinical) were tested. On the basis of scores earned by nonclinical examinees
during the research studies, two sets of normal cut-off scores (ages 18±69 and 70±
89) were established for all tasks, cognitive domains, and overall cognitive
performance.

1.3. Purpose of present study

The purpose of the present study was to further elucidate the status of cognitive
abilities in a group of individuals whose aphasia ranged from mild to severe levels.
To accomplish this, eight CLQT tasks (four linguistic and four nonlinguistic) were
used to (1) test the relationships between linguistic and nonlinguistic task
performance, and the relationships between nonlinguistic performance and
age, education, and time post onset of aphasia, and (2) examine group and
individual pro®les of spared and impaired cognitive functions vis-a-vis overall
performance on the sets of linguistic and nonlinguistic tasks and on the individual
tasks.

2. Methods

2.1. Subjects

Subjects were 13 right-handed, left hemisphere stroke patients (®ve females

and eight males) from various settings across the United States (e.g., rehabilitation
176 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186

and extended care facilities, own home). Eleven of the 13 had right hemiplegia
that forced them to use their non-preferred left hand for graphomotor activities.
They ranged in age from 46±77 years (mean ˆ 62 years, S:D: ˆ 10:6) and in
education from 8 to 22 years (mean ˆ 14 years, S:D: ˆ 4). Time post onset at
time of testing ranged from 2 to 118 months (mean ˆ 34 months, S:D: ˆ 38).

2.2. CLQT tasks

Four linguistic and four nonlinguistic CLQT tasks were administered in one
session. All administration and scoring methods, and test materials were stan-
dardized. All tasks had time limits except for personal facts (see below). As a
group these tasks were chosen to assess the ®ve primary domains of cognition,
i.e., attention, memory, executive, language, and visuospatial skills. The tasks
were as follows.

2.3. Linguistic tasks

2.3.1. Personal facts

This task primarily assesses episodic memory, word retrieval and verbal
language production. Clinicians ask four questions relating to the examinee's date
and place of birth, current age and address. One point is given for each correct
element given from memory.

2.3.2. Confrontation naming

This task primarily assesses semantic conceptual knowledge, word retrieval
and production. Ten common, pictured items are presented one-at-a-time for
naming. A 3-point scoring system allows for full, partial or no credit depending on
correctness of responses.

2.3.3. Story retelling and paragraph comprehension

The purposes of this task are to assess immediate/working memory for verbally
presented facts embedded in a story narrative and auditory comprehension of
three key elements of the story. A short story is read aloud and patients are asked
to repeat the story verbatim. A check-list of the story's 18 information units allows
clinicians to quickly record the items accurately recalled. Story retelling is
followed by three pairs of ``yes''/``no'' questions to probe auditory comprehen-
sion. Raw scores are converted to a 10-point scale based on normative data.

2.3.4. Generative naming

This task primarily assesses executive functions, working memory and verbal
language skills related to semantic and phonological knowledge. Examinees are
given 1 minute to list as many animals as possible and 1 minute to list words
(excluding proper nouns) beginning with the letter ``m.'' Total raw scores for both
lists are converted to a 9-point system based on normative data.
 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186 177

2.4. Nonlinguistic cognitive tasks

2.4.1. Symbol cancellation

The purpose of this task is to test visual attention, scanning, discrimination,
inhibition, and response shifting within four quadrants of space. In this paper and
pen task, 36 abstract symbols are arranged in a pseudo-random fashion with the
target stimulus appearing three times in each quadrant of space to allow for
assessment of visual ®eld de®cits and visual neglect. Foils bear resemblance to the
target to increase visual attention demands. The task is to cross out target symbols.
One point is given for each correct symbol cancelled and one point is subtracted
for each incorrect symbol cancelled.

2.4.2. Alternating symbol trails

The primary purpose of this task is to assess the executive functions of
planning, working memory, and mental ¯exibility without placing demands on
the language system, but the task also calls upon visual attention and perception.
Two learning trials involving the single concepts of size and shape are used in
preparation for the test item which involves drawing a single line to connect a
total of 11 circles and triangles in an alternating fashion according to size and
shape beginning with the smallest circle. The maximum possible score is 10
points.

2.4.3. Memory for designs

The purpose of this task is to test immediate/working visual memory and
attention without language demands. Three target abstract designs are presented
one-at-a-time for memorization. They must then be identi®ed immediately from
arrays of six that include four foils similar to the targets. The highest possible
score is six points.

2.4.4. Mazes
This task was designed to assess executive functions, speci®cally those
involved in planning a course of action, rejecting/inhibiting incorrect choices,
and correcting mistakes when made. Other skills assessed are attention and visual
perception. Two mazes of two levels of dif®culty are used. The object of both is to
trace a continuous line through the maze ``alleys'' without entering any dead-ends
or crossing any line. The highest possible score for each maze is four (correct
solution) for a total of eight points. Even with a correct solution, one point is
subtracted each time the examinee's line travels at least halfway up an incorrect
path but is self-corrected.

2.5. Administration time

Five of the eight tasks have established time limits and total time for testing
was approximately 22 minutes. All were administered in the following temporal
178 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186

order: personal facts, symbol cancellation, confrontation naming, story retelling,

symbol trails, generative naming, design memory, mazes. (Note: A nonverbal
clock drawing/setting task was administered between confrontation naming and
story retelling but the scores on this task were not used for this study).

3. Results

Individual data for linguistic and nonlinguistic task performance, education,

age, and time post onset at time of testing as well as correlation values obtained
are presented in Table 1.

3.1. Overall performance on the linguistic tasks

The highest possible score for the four linguistic tasks was 37 points. Scores for
the 13 aphasic subjects ranged from 0 to 26 points with a mean of 10.5 points
(S:D: ˆ 11). Based on data collected from nonclinical subjects used for CLQT
standardization, the normal cut-off score for the four tasks was 29 for those 18±69
years of age and 27 for those 70±89 years. Thus, no aphasic patient earned an
overall linguistic score at or above normal cut-off, and the severity of their
language de®cits ranged from severely to mildly impaired.

Table 1
Individual data for linguistic and nonlinguistic task scores, education, age, and time post onset for 13
right-handed aphasic stroke patients

Subject Gender Linguistic Nonlinguistic Years of Age Months post

no. score score education onset

1 F 25 24 14 54 4
2 M 6 11 12 71 15
3 M 21 19 12 53 2
4 F 22 28 12 65 3
5 M 1 30 22 86 18
6 M 26 33 12 64 72
7 M 21 18 8 77 102
8 M 12 27 12 50 118
9 M 2 19 14 53 32
10 F 0 12 14 77 18
11 M 0 30 22 68 22
12 F 0 24 12 55 17
13 F 0 34 12 46 14
Mean 10.46 23.77 13.69 61.62 33.62
S.D. 10.91 7.51 3.99 10.36 38.42
Range 26.00 23.00 14 31.00 116.00
Correlations: linguistic score  nonlinguistic score, r ˆ 0:08; nonlinguistic score  years of
education, r ˆ 0:32; nonlinguistic score  age, r ˆ 0:42; nonlinguistic score  months post onset,
r ˆ 0:09.
 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186 179

3.2. Overall performance on nonlinguistic tasks

The highest possible score for the four nonlinguistic tasks was 36 points.
Scores for the 13 aphasic subjects ranged from 11 to 34 points with a mean of 23.8
points (S:D: ˆ 7:5). Based on data collected from nonclinical subjects for CLQT
standardization, the normal cut-off score for the four tasks was 32 for those 18±69
years of age and 24 for those 70±89 years. Two aphasic subjects (6 and 13) earned
scores above the normal cut-off (see Table 1). Note that subject 6 earned an overall
nonlinguistic score of 26 (only three points below normal cut-off), indicating mild
impairment in linguistic processing. While no other aphasic subject earned an
overall linguistic score at or above normal cut-off, two subjects (5 and 11) missed
by just two points. Note also, that subject 13, who scored above the cut-off on the
nonlinguistic tasks, earned a linguistic score of zero.

3.3. Correlations

A correlation computed between performance scores on the four linguistic and

four nonlinguistic cognitive scores was nonsigni®cant (r ˆ 0:08). In other words,
performance on tasks involving attentional, executive, memory, and visuospatial
processes could not be predicted on the basis of performance on the linguistic
tasks. Likewise, correlations between nonlinguistic scores and years of education
(r ˆ 0:32), age (r ˆ 0:42) and months post onset at time of testing (r ˆ 0:09)
were nonsigni®cant.

3.4. Profiles of spared and impaired abilities

In addition to analyzing group data for linguistic and nonlinguistic tasks, scores
earned by aphasic individuals on each CLQT task were examined vis-a-vis the cut-
off scores established for normal performance on that task for age groups 18±69 and
70±89 years. The scores earned by each individual were also measured against the
normal cut-off scores for the four linguistic and four nonlinguistic tasks combined
for the two age groups. As mentioned above, of the possible 37 total points for the
linguistic tasks, the normal cut-off is 29 for the 18±69 years group, and 27 for the
70±89 years group for a difference of two points. In contrast, of the possible 36 total
points for nonlinguistic tasks, the normal cut-off is 32 for the younger group and 24
for the older group for a difference of eight points. These scores re¯ect the well-
studied observation that nonlinguistic skills are more vulnerable to the effects of old
age than are linguistic skills. By examining individual performance pro®les,
therefore, each patient could be measured against the normal cut-scores for his
or her age group. This information is displayed in Table 2.

3.5. Overall linguistic and nonlinguistic scores for individuals

When overall scores earned by aphasic individuals for four linguistic tasks
were compared with the overall linguistic cut-off scores for normal performance,
 180
N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186
Table 2
Individual aphasia subject scores on CLQT linguistic and nonlinguistic tasks and deviation from normal cut-off scores for age

Subject no. Linguistic tasks Nonlinguistic tasks Overall Difference Overall Difference
linguistic in score nonlinguistic in score
Personal Confrontation Story Generative Symbol Symbol Design Mazes score score
facts naming retelling naming cancellation trails memory

1 8a 10a 5 2 12a 6 6a 0 25 5 24 8
2 1 2 2 1 0 2 5a 4a 6 21 11 13
3 7 9 3 2 4 7 4 4 21 8 19 13
4 7 9 4 2 12a 7 5a 5a 22 7 28 4
5 0 0 1 0 12a 9a 5a 4 1 29 30 2
6 8a 9 6a 3 10 10a 5a 8a 26 3 33a ‡1
7 7 10a 3 3 10a 4 4a 0 21 6 18 6
8 0 9 3 1 12a 4 3 7.5a 12 17 27 5
9 0 2 0 0 11a 2 2 4 2 27 19 13
10 0 0 0 0 7 3 2 0 0 27 12 12
11 0 0 0 0 12a 9a 5a 4 0 29 30 2
12 0 0 0 0 11a 1 5a 7a 0 29 24 8
13 0 0 0 0 12a 9a 5a 8a 0 29 34a ‡2
(
) Age cut-off scores 8±8 10±10 6±5 5±4 11±10 9±6 5±4 7±4 29±27 32±24
(
) Cut-off scores for normal task performance based on nonclinical subjects for two age groups: 18±69 years and 70±89 years (see CLQT manual).
a
Score is at or above normal cut-off.
 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186 181

it was found that the difference scores ranged from 29 to 3, with a mean
difference of 18.2 points. Two individual earned scores at cut-off for relating
personal facts and confrontation naming. One person earned a normal cut-off
score for story retelling, but none achieved a normal cut-off score for generative
naming, which was clearly the most dif®cult task for the group.
When overall scores earned by aphasic individuals for the four nonlinguistic
were compared with the overall nonlinguistic cut-off scores for normal perfor-
mance, it was found that the differences ranged from 13 to ‡2 points with a
mean difference of 6.4 points. Two patients (6 and 13) exceeded normal cut-off
scores for overall nonlinguistic task performance, as we mentioned earlier. Note
that patient 6 had mild aphasia with an overall linguistic score just three points
below normal cut-off while patient 13 had severe aphasia earning an overall
linguistic score of zero. Closer examination of individuals with very severe
aphasia (patients 5, 9, 10, 11, 12) showed great variability on nonlinguistic
task performance. Two of these patients (5 and 2) earned good nonlinguistic
scores (two points below normal cut-off for their age), two patients (9 and 10)
had notable nonlinguistic impairment, while one patient (12) showed moderate
nonlinguistic impairment.

3.6. Task specific scores for individuals

Table 2 indicates that the scores earned on a particular task by an individual

patient was at or above the normal cut-off for his or her age. Not surprisingly,
given that these patients had the language disorder of aphasia, the best perfor-
mances were seen on nonlinguistic tasks. The easiest tasks for these aphasic
patients were tasks of symbol cancellation and design memory with nine or 69%
of individuals earning scores at or above normal cut-off for their age. The next
easiest task was mazes with six patients (46%) earning normal or above normal
scores, followed by symbol trails (four subjects or 31%). Two patients (15%)
earned normal cut-off scores for personal facts and confrontation naming, one
(8%) for story retelling and none (0%) for generative naming.
The pattern of task dif®culty for the 13 aphasia patients is displayed in Table 3.
The four easiest tasks, all of which were nonlinguistic, must be completed within
prescribed time frames. The two easiest tasks were symbol cancellation and
design memory with nine patients (69%) performing at or above normal cut-off.
One of the two, symbol cancellation, calls upon visual attention, scanning and
discrimination. It also requires the ability to inhibit stimulus ``pull'' to symbols
similar to the target and response shifting within four quadrants of space. The
other easiest task, design memory, calls upon immediate/working visual memory
and attention for dif®cult-to-encode visual stimuli.
Six out of 13 patients (46%) performed at or above normal cut-off on mazes
which (in addition to visuospatial skills), requires executive skills of planning and
foresight. Symbol trails was the most dif®cult of the nonlinguistic tasks with 4/13
(31%) of patients reaching or surpassing normal cut-off scores. This demanding
182 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186

Table 3
Pattern of task difficulty for 13 individuals with aphasia

CLQT tasks Number/earning scores at

or above normal cut-off (%)

Easiest Symbol cancellation and design memory 9 (69%)

Mazes 6 (46%)
Symbol trail 4 (31%)
Personal facts and confrontation naming 2 (15%)
Story retelling 1 (8%)
Hardest Generative naming 0 (0%)

task requires working memory, attention, and visuospatial skills as well as the
executive abilities of mental ¯exibility in planning and shifting responses.
All of the linguistic tasks were dif®cult for the aphasic patients although two
individuals (1 and 6) were able to answer the four personal fact questions
pertaining to name, date of birth, age and current address. One of these individuals
(1) also named all 10 pictured objects correctly (10 is the normal cut-off for both
age groups). One other person (7) achieved this score for confrontation naming.
Story retelling which calls upon memory as well as language comprehension and
production was dif®cult for most individuals with only one patient (6) scoring at
cut-off. No patient was able to earn a normal cut-off score for generative naming,
which not only calls upon language skills related to semantic and phonological
knowledge, but requires some executive skills and working memory so as not to
repeat previously listed items.

4. Discussion

There is a growing realization among aphasia therapists that aspects of

cognition, other than language, may account for the variability in response that
some patients with the same aphasia severity level have to the same treatment
protocols. Furthermore, it may be that higher level cognitive skills, i.e., those that
allow us to plan intentional activities while ¯exibly adjusting our goal-directed
strategies in keeping with situational changes (so-called executive functions),
may account for differences that some patients of equal aphasia severity show in
their functional communication skills.
Treatment planning would be made easier if clinicians could assume a direct
relation between linguistic and nonlinguistic cognitive skills; having some
con®dence that mildly aphasic patients will have mild problems in the areas
of attention, memory, executive functions and visuospatial skills, and that these
problems will increase as the aphasia severity increases. Instead, we have
mounting evidence that it is impossible to predict the status of nonlinguistic
cognitive skills on the basis of language skills. Helm-Estabrooks et al. (1995)
 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186 183

found this to be true for 32 patients representing a range of aphasia severity

excluding global aphasia. Similarly, Van Mourik et al. (1992) studied only
patients with global aphasia and found that not only were cognitive test scores
unrelated to auditory comprehension but that three subgroups of globally aphasic
patients could be identi®ed; those with relatively spared nonlinguistic cognitive
skills, those with variable patterns of de®cits, and those who could not respond at
all to testing. One of the measures used in their study was the Raven's progressive
matrices, used earlier by Basso et al. (1973) who found that virtually no relation
existed between Raven's scores and a test of auditory comprehension and naming
in a larger group of patients with a wider range of aphasia severity.
To the mounting evidence that it is impossible to predict the status of other
aspects of cognition on the basis of language test scores, we can add the results of
the present study. Scores earned on a group of four linguistic tasks taken from the
newly published CLQT 2001 by 13 individuals were not signi®cantly correlated
with scores earned on a group of four CLQT nonlinguistic tasks chosen to brie¯y
assess visual attention and memory, executive functions, and visuospatial skills.
Examination of individual pro®les of task performance underscored the poor
relation between linguistic and nonlinguistic task performances. For example, of
the two patients earning the overall nonlinguistic scores that were above the normal
cut-off for their age, one had mild language de®cits (three points below normal cut-
off) and one had severe de®cits (29 points below normal cut-off). Among all six
patients with severe linguistic de®cits, three had relatively spared nonlinguistic
skills, earning nonlinguistic scores near or above normal cut-off, two had notably
impaired nonlinguistic skills, and one demonstrated moderate impairment.
It would appear that second to language, executive functions are the cognitive
skills most vulnerable to the effects of brain damage associated with aphasia. The
results of the present study showed that the greater the task-demands for executive
skills the more dif®cult the task for the group in general. This was true in both the
nonlinguistic and linguistic domains with the ability to create trails between
symbols according to progressive size and alternating shape the most dif®cult
nonlinguistic task, and generative naming the most dif®cult linguistic task. Even
so, four patients (two with severe aphasia) achieved normal cut-off scores on
symbol trails. No one, however, was able to achieve normal cut-off for generative
naming.
The importance of executive functions to treatment response is underscored by
the results of the Hinckley et al. (2001) study in which they found that the lower the
scores on the Raven's and Wisconsin card sort test, the longer it took patients to
achieve performance criterion for ``context-based'' therapy. Furthermore, scores
earned by patients receiving this type of treatment on the Raven's and the
Wisconsin were signi®cantly related to the ability to perform the functional task
6 months after treatment. These investigators concluded their discussion on these
results with the following statement. ``Furthermore, if con®rmed and replicated,
aspects of executive function and cognitive status may become important con-
tributors to clinical decision-making about treatment type and amount.''
184 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186

In the present study, visual discrimination and attention skills were most spared
with 9/13 achieving scores at or above normal cut-off for symbol cancellation.
Interestingly, 2/4 patients with low symbol cancellation scores were two of the
three individuals over 70 years of age. Because, the CLQT normal cut-off scores
are adjusted for age, this suggests that visual attention may be particularly
sensitive to the effects of brain damage in the elderly.
The relation between attentional skills and aphasia has been a topic of growing
interest. For a review of this literature see Murray (1999). Given that various
attentional mechanisms may be impaired in the presence of aphasia and in¯uence
language performance, some clinical researchers have designed treatment pro-
tocols to directly or indirectly treat forms of attention. For example, Strum and
Willmes (1991) used a computerized treatment protocol to train accurate response
to single and multiple nonlinguistic stimuli presented in auditory and visual
modalities. Subjects improved in speed and accuracy of the attentional tasks but
showed little concurrent improvement on tasks used to measure other cognitive
functions (e.g., Raven's matrices).
In contrast, the study of two severely aphasic patients, for whom repeated baseline
measures were obtained before beginning a nonlinguistic attention treatment
program, Helm-Estabrooks, Connor and Albert (2000) found that Raven coloured
progressive matrices scores did improve with attention training. At the same time,
modest gains occurred in auditory comprehension test scores of these two subjects.
Crosson (2000) and his colleagues are currently engaged in the study of the
effects of attention treatments on remediation of aphasic naming disorders.
Crosson was referring to attention vis-a-vis aphasia rehabilitation when he
pointed out, ``there is a considerable need for research'' (p. 392), but the same
may be said of other domains of cognition and their importance to treatment of
aphasia. Indeed, it would appear that this is an area ripe for careful investigation as
we rightfully move away from the conceptualization of language as being
separate from cognition and accept that language is one aspect of cognition.
If aphasia therapists are to consider their patients' overall neuropsychological
pro®les in developing or adopting appropriate treatment approaches, then they
must be prepared to at least screen these abilities. The CLQT tasks used in the
present study appear to be useful for a brief, standardized assessment of all
domains of cognition. More in-depth testing with domain-speci®c tests probably
will be required if notable attention, memory, executive, and visuospatial de®cits
are identi®ed. Certainly, there is much to be learned about the relation between
aspects of cognition and aphasia treatment outcomes. Fortunately, it would appear
that some clinical investigators are now pursuing this line of research.

Acknowledgments

Some of the data used in this study were standardization data of the CLQT.
Copyright # 2000 by The Psychological Corporation. Used by permission. All
 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186 185

rights reserved. Dr. Helm-Estabrooks' work was supported, in part, by a grant

from the McDonnell Foundation.

Appendix A. Continuing education

1. Which of the following is a test of visual analogic thinking?

a. Wisconsin card sort test
b. Porteus mazes
c. Raven's progressive matrices
d. Cognitive linguistic quick test
e. None of the above
2. In the present study what was the correlation between linguistic and
nonlinguistic cognitive skills?
a. Highly significant
b. Non significant
c. Weakly significant
d. Significant in the negative direction
e. Not determinable
3. What skill is needed for successfully completing symbol trails?
a. Mental flexibility
b. Semantic knowledge
c. Verbal mediation
d. Episodic memory
e. All of the above
4. Nonlinguistic cognitive skills in the presence of aphasia are related to:
a. Years of education
b. Time post onset
c. Severity of aphasia
d. Linguistic skills
e. None of the above
5. What is the cognitive domain most likely to be impaired in aphasia patients?
a. Executive functions
b. Analogic thinking
c. Attention
d. Language
e. Memory

References

Basso, A., DeRenzi, E., Faglioni, P., Scotti, G., & Spinnler, H. (1973). Neuropsychological evidence for
the existence of cerebral areas critical to the performance of intelligence tasks. Brain, 96, 715±728.
186 N. Helm-Estabrooks / Journal of Communication Disorders 35 (2002) 171±186

Bayles, K.A. 2001. Understanding the neuropsychological syndrome of dementia. Seminars in

Speech and Language, 22(4), 251±259.
Chapey, R. (1994). Cognitive intervention: stimulation of cognition, memory, convergent thinking,
convergent thinking, and evaluative thinking. In R. Chapey (Ed.), Language intervention
strategies in adult aphasia (3rd ed.) (pp. 220±245). Baltimore, MD: Williams & Wilkins.
Chapey, R. (2001). Language intervention strategies in aphasia and related neurogenic communica-
tion disorders (4th ed.). Baltimore, MD: Williams & Wilkins.
Crosson, B. (2000). Systems that support language processes: attention. In S. E. Nadeau, L.
Gonzalez, J. Rothi, & B. Crosson (Eds.), Aphasia and language (pp. 372±398). New York: The
Guilford Press.
Helm-Estabrooks, N., & Albert, M. L. (1991). Manual of aphasia therapy. Austin, TX: Pro-Ed Inc.
Helm-Estabrooks, N., Bayles, K., Ramage, A., & Bryant, S. (1995). Relationship between cognitive
performance and aphasia severity, age and education: females versus males. Brain and Language,
51(1), 139±141.
Helm-Estabrooks, N. (2001). Cognitive Linguistic Quick Test. San Antonio, TX: The Psychological
Corporation.
Helm-Estabrooks, N., Connor, L. T., & Albert, A. L. (2000). Treating attention to improve auditory
comprehension in aphasia. Brain and Language, 74, 469±472.
Hinckley, J. J., Carr, T. H., & Patterson, J. P. (2001). Relationships between cognitive abilities,
treatment type and treatment time in aphasia. Paper presented at the Clinical Aphasiology
Conference, Sante Fe, NM, June.
Grant, D. A., & Berg, E. A. (1993). Wisconsin card sorting test. Tampa, FL: Psychological
Assessment Resources.
Luria, A. R. (1966). Higher cortical functions in man. New York: Basic Books.
Murray, L. L. (1999). Attention and aphasia: theory, research and clinical implications, research and
clinical implications. Aphasiology, 13(3), 91±111.
Neisser, U. (1967). Cognitive psychology. New York: Appleton Century-Crofts.
Raven, J. C., Court, J. H., & Raven, J. (1979). Manual for Raven's progressive matrices and
vocabulary scales. London: Lewis & Co.
Raven, J. C. (1995). Raven's coloured progressive matrices. San Antonio, TX: The Psychological
Corporation.
Sarno, M. T. (1998). Recovery and rehabilitation in aphasia. In M. T. Sarno (Ed.), Acquired aphasia
(3rd ed.). (pp. 595±631). New York: Academic Press.
Strum, W., & Willmes, K. (1991). Efficacy of a reaction training on various attentional and cognitive
functions in stroke patients. Neuropsychological Rehabilitation, 1, 259±280.
Van Mourik, M., Verschaene, M., Boon, P., Paquier, P. et al. (1992). Cognition in global aphasia:
indicators for therapy. Aphasiology, 6(5), 491±499.
Wechsler, D. (1997). Wechsler memory scaleÐIII. San Antonio, TX: The Psychological Corporation.