The Aphasia Hierarchy

So you get an aphasic patient and wonder where do I start?

When I did my medical internship the honest truth is that school did not prepare me for what I was about to experience. I was lucky to have a wonderful supervisor with 20+ years experience that knew the diagnosis well.

I wanted to share with other students, CF’s, and new SLP’s the tips I learned along the way.

When I perform an evaluation on a patient that I suspect would have aphasia I looked at 4 different areas:

  1. Auditory comprehension
  2. Verbal expression
  3. Reading comprehension
  4. Written expression

You come to the conclusion that your patient is having auditory comprehension deficits but how do you break down the areas to target? They can’t respond to simple directions, what do you do next? What if your patient can’t tell you their name, what area do you assess next? What if they can’t read their own name or write it? How do you determine what they can do and where to start treatment?

There was something my supervisor engrained in my soul… “you need to find where they break down in order to determine where to begin treatment”.

Sounds simple right?

But when you’re a student and the most aphasia experience you have gotten is a youtube video in neuro class and lecture after lecture about memorizing the different lesion areas and aphasia types, it doesn’t always come as common sense.

Here are the hierarchy’s that I use…

Auditory comprehension:

  1. Personal y/n questions
  2. non-personal y/n questions
  3. 1-step directions
  4. multi-step directions
  5. ID pix/object by name or function
  6. Comprehend simple—>running discourse

Tip: When working on identifying pictures/objects start with visual field 1-2 and increase as appropriate

Verbal expresson:

  1. Pre-speech tasks (includes throat clearing/coughing/humming/laughing)
  2. Vowels—>consonant-vowel sequences (start with visual sounds)
  3. Automatic language/auto rote tasks (counting/days of the week/months of the year)
  4. Sentence completion (up and _, black and _, the cow says _)
  5. Confrontational naming (body parts, picture cards)
  6. Generate sentences when given a target word
  7. Provide a definition when given a word
  8. Provide a description when given a word
  9. Perform category naming tasks
  10. Participate in simple—>running discourse

Reading comprehension:

  1. Matching shapes/letters/objects to the same
  2. Identify shapes/letters/objects
  3. Read personal information
  4. Read words—>phrases—>sentences—>paragraphs
  5. Perform functional reading tasks

Tip: Once you’ve identified the patient can match shapes/letters/objects, increase the visual field from 2-3 and so on. For reading words/phrases etc, you can start with matching. Start with matching two words/phrases and increase the visual field.

Written expression:

  1. Draw lines/shapes/letters
  2. Write name
  3. Write personal information
  4. Write words—>phrases—>sentences—>short message—>paragraph
  5. Perform functional writing tasks

Tip: Provide visual and tactile cues as needed. Think trace/copy/write. If your patient can’t draw a line on their own, can they copy it? If not, can they trace it? Provide hand over hand assistance if needed.

I usually start somewhere in the middle and work my way forward or backward to determine where the breakdown occurs.

In my goal bank I have an aphasia area with goals to coincide with what I have written here.

Hope this helps!

🖤 SlpYogi

2 thoughts on “The Aphasia Hierarchy

  1. I’m currently in my last externship in acute rehab with geriatric patients and after working with children the last year and a half it’s been tough transitioning. This hierarchy is so helpful, though! Thank you!!


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