Perceptual Screening

Red flags of Tactile perceptual disorders

-Unable to identify familiar objects by touch alone (i.e., astereognosis) -Unable to discriminate between different types of materials by touch alone (i.e., ahylognosia) -Unable to discriminate between different forms and shapes by touch alone (i.e., amorphagnosia) -Unable to determine whether one has been touched by 1 or 2 points (i.e., 2-point discrimination disorder) -Unable to identify letters written on hand (i.e., agraphesthesia) -Unable to feel sensation on involved side if simultaneously touched on the uninvolved side (i.e., extinc- tion of simultaneous stimulation).

Depth Perception Dysfunction

(i.e., impaired stereopsis) is an inability to determine whether objects in the environment are near or far in relation to each other and in relation to the patient. -Seat the patient in the therapy room (or a room within the home or care setting). Ask him or her to identify which objects in the room are closest, farthest, and at mid-range. -Place the patient in front of a window. Ask him or her to identify which objects are closest to the building, which are farthest, and which are at mid-range. -Depth perception impairment may be indicated if the patient is unable to accurately determine which objects are closest, farthest, and at mid-range.

Red flags of Visual spatial perceptual disorders

-Confuses right and left (i.e., right-left discrimination disorder) -Difficulty distinguishing objects in the foreground from objects in the background (i.e., figure-ground discrimination dysfunction) -Unable to recognize familiar forms when they are viewed from an unfamiliar visual perspective (i.e., form-constancy dysfunction) -Confuses concepts regarding positions in space—in/out, up/down, behind/in front of (i.e., position in space dysfunction) -Frequently loses sense of direction and becomes lost (i.e., topographical disorientation) -Misjudges the distances of objects in relation to self and the environment (i.e., depth perception dys- function).

Red flags of Language perceptual disorders: Expressive Aphasia

-Difficulty expressing oneself through spoken language. Speech is characterized by nonfluent, telegraphic sentences. Substitutes inappropriate words for specific target words (i.e., Broca's aphasia). -Unable to express the names of people or objects (i.e., anomia) -Mixes up the sequence of words in spoken or written language (i.e., agrammatism) -Unable to write; demonstrates scribbling when asked to write (i.e., agraphia) -Difficulty writing; writing characterized by reversal of letters, flipped letters, incorrect sequence of letters (i.e., dysgraphia) -Difficulty using the language and symbols of mathematics (i.e., acalculia) -Difficulty calculating mathematical problems; written math is characterized by number reversal, flipped numbers, and disarranged sequence of numbers (i.e., dyscalculia).

Red flags of Language perceptual disorders: Receptive Aphasia

-Unable to comprehend spoken language despite intact auditory anatomy (i.e., Wernicke's aphasia) -Unable to read, despite intact visual anatomy (i.e., alexia) -Unable to break words down into letters—reverses letters, flips letters, mixes up sequence of letters (i.e., dyslexia) -Unable to comprehend familiar gestures and symbols (i.e., asymbolia) -Unable to interpret the emotional tone of conversations (i.e., aprosodia).

red flags of visual perceptual disorders

-Unable to recognize objects and familiar people by sight alone, despite intact visual anatomy (i.e., visual agnosia, prosopagnosia) -Distorts the physical properties of objects and people (i.e., metamorphopsia) -Unable to interpret a visual stimulus as a whole (i.e., simultanagnosia) -Unable to remember the names of colors (i.e., color anomia) -Unable to remember the color of familiar objects (i.e., color agnosia).

Red flags of Motor Perceptual Disorders

-Unable to understand the motor demands of a specific task, for example, the patient does not understand that a shirt is a clothing item that should be placed on the torso and UE using a specific motor sequence (i.e., ideational apraxia). -Understands the motor demands for a specific task but is unable to access the motor plan for that specific task; the motor plan may be lost due to neurological damage. The patient understands that a shirt is an article of clothing to be worn on the torso and UE but does not know how to don the shirt (i.e., ideomotor apraxia). -Accesses an inappropriate motor plan for a specific motor task. For example, the patient understands that a shirt is an article of clothing to be worn on the torso and UE but accesses the motor plan for donning pants, so the patient attempts to place his or her legs through the shirt sleeves (i.e., ideomotor apraxia). -Unable to dress due to an ideational apraxia, an ideomotor apraxia, or a body-schema-perceptual dis- order (i.e., dressing apraxia). -Unable to construct 2- and 3-dimensional objects (i.e., 2- and 3-dimensional constructional apraxia).

Red Flags of Body schema perceptual disorders

-Unable to understand the spatial relationships between his or her own fingers; unable to identify thumb and 1st, 2nd, 3rd, and 4th fingers (i.e., finger agnosia) -Demonstrates inattention to 1 side of body or environment (i.e., unilateral neglect) -Unable to recognize paralyzed limbs as belonging to his or her own body (i.e., anosognosia) -Unable to feel sensation on involved side if simultaneously touched on the uninvolved side (i.e., extinction of simultaneous stimulation).

visual agnosia

-an umbrella term for the inability to identify and recognize familiar objects and people despite intact visual anatomical structures. Lesions that cause visual agnosias are often located in the right hemisphere occipital lobe or posterior multimodal association area. -Show the patient several familiar items 1 at a time (e.g., pencil, eyeglasses, hairbrush, keys, wristwatch). -Ask the patient to identify the object. It is important to discriminate between visual agnosia and aphasia. If the patient is experiencing word-finding difficulties, offer the patient a choice of 3 answers. Ask the patient to indicate the correct choice by nodding his or her head "yes." - Visual agnosia may be indicated if the patient is unable to name half of the presented items.

metamorphopsia

-involves a visual distortion of the physical properties of objects so that objects appear bigger, smaller, heavier, or lighter than they really are. Select 2 of the following: -Present the patient with a puzzle of simple shapes with differing sizes. Ask the patient to insert the correctly sized shape into its corresponding cut-out space. Determine whether the patient has diffi- culty matching the correctly sized shape to its corresponding cut-out space. -Present the patient with several objects (e.g., mug, full grocery bag, thick hardcover book, bag of cotton balls). Ask the patient to estimate each object's size and weight by observation alone. -Present the patient with several different-sized drinking glasses, each filled with water. Ask the patient to order the glasses from those holding the most to least water. -Metamorphopsia may be indicated if the patient is unable to accurately place the puzzle pieces into their matching cut-out spaces, if the patient is unable to accurately estimate the size and weight of the presented objects, or if the patient is unable to accurately order the drinking glasses.

ideational apraxia

-involves an inability to cognitively understand the motor demands of a task involving multiple, sequential steps. For example, a patient may not understand that a shirt is an article of clothing to be worn on the torso and UE.

2 and 3 dimensional constructional apraxia

-involves an inability to copy or build 2- and 3-dimensional designs. For example, a patient who is an architect would have difficulty drafting 2-dimensional blue- prints. A patient who is a plumber would have difficulty reassembling a kitchen faucet once taken apart. Patients with constructional apraxia due to a right hemisphere lesion draw objects or put models together in a spatially disorganized way. Patients with constructional apraxia due to a left hemisphere lesion draw objects that lack detail. When building 3-dimensional models, the models are spatially organized, but pieces are often left out. To determine whether constructional apraxia is present, choose 1 of the 3 screen- ing procedures listed below. -Instruct the patient to construct a 3-dimensional block design (using 3-dimensional blocks) by copying a 2-dimensional colored block design (shown on paper). Constructional apraxia may be indicated if the patient incorrectly constructs the 3-dimensional block design. -Present the patient with a large bolt onto which is screwed a specific sequence of different-sized nuts and washers. Present the patient with a duplicate bolt and several sizes of nuts and washers. In- struct the patient to use the hardware to assemble an exact replica of the model bolt with its specific sequence of nuts and washers. Constructional apraxia may be indicated if the patient is unable to construct an exact duplicate of the model bolt. -Instruct the patient to construct a house (or car, person) using Legos (or similar toy construction pieces) based on a 3-dimensional model provided by the therapist. -Constructional apraxia may be indicated if the patient is unable to accurately construct a duplicate of the model provided by the therapist.

finger agnosia

-is an impaired perception of the relationship of the fingers to each other. Patients with finger agnosia have difficulty identifying and localizing their own fingers. -Instruct the patient to carry out the following commands: - Show me your thumbs. Show me your index fingers. Show me your ring fingers. - Touch your ring finger to your thumb (on the patient's involved side or bilaterally). - Touch your index fingers together. - Touch your little finger to your thumb (on the patient's involved side or bilaterally). -Finger agnosia may be indicated if the patient is unable to demonstrate half of the above commands.

Dressing Apraxia

-involves an inability to dress oneself due to body-schema disorder or apraxia. With a body-schema disorder, the patient's understanding of his or her body in space has become so distorted that dressing becomes extraordinarily difficult. For example, a patient with an attentional neglect syndrome (e.g., unilateral neglect, anosognosia) may dress only half of his or her body. With an apraxia, the patient -Does not cognitively understand the demands of the task (i.e., ideational apraxia), -Has lost the appropriate motor plan for a specific task (i.e., ideomotor apraxia), or -Maintains the appropriate motor plan for a specific task but can no longer access it (i.e., ideomotor apraxia). -For example, a patient with an ideomotor apraxia who understands that pants are to be worn on the LE may be unable to access the appropriate motor plan for donning pants and instead attempt to place his or her arms through the legs of the pants. -Observe the patient during morning ADLs. Apraxia may be indicated if the patient has difficulty dressing; for example, the patient may inappropriately attempt to place the pants on his or her torso or may dress only half of his or her body. Apraxia also may be indicated if the patient inappropriately uses the tools of grooming, for example, the patient uses his or her toothbrush to brush his or her hair. -Place objects in front of the patient and ask him or her to show you what one does with the object. Say to the patient, "Show me what to do with this object." -Choose at least 4 of the following: a toothbrush, a comb, a folded letter and envelope, an article of clothing (slippers, a large shirt), a key, a wristwatch, a pen, a phone. -Apraxia may be indicated if the patient is unable to demonstrate the appropriate motor plan for 3 of the 4 presented objects.

Topographical Disorientation

-involves difficulty comprehending the relationship of 1 location to another. -Ask the patient to find his or her way around the treatment facility using verbal directions or a written or pictorial map (provided by the therapist). Select 1 of the following: -Ask the patient to find his or her way back from the occupational therapy treatment setting to his or her hospital room (or room in care setting). Ask the patient to find his or her way from the occupational therapy treatment setting to the dining room, cafeteria, lobby, gift shop, and so forth. -If the treatment setting is large and confusing, ask the patient to find his or her way around only 1 hospital floor or unit. For example, ask him or her to find the way from his or her hospital room to the nurses' station, to the elevators, and back. -Topographical disorientation may be indicated if the patient commonly becomes lost while trying to navigate the treatment setting using directions or a written or pictorial map.

Position-in-space dysfunction

-involves difficulty using concepts relating to positions, such as up/down, in/out, and behind/in front. -Instruct the patient to follow at least 2 of the following directions using the above terms: - Place the key on top of the box. Place the box inside the drawer. -Take the pot from underneath the sink, and place it on the table. Put the bag of rice inside the pot. - Place the comb in front of the (small freestanding) mirror, and place the hairbrush behind the mirror. - Put the bar of soap on top of the sink, and place the hairbrush inside the medicine cabinet. - Place the soup can on the top shelf of the cabinet, and put the cereal box on the bottom shelf. -Position-in-space dysfunction may be indicated if the patient demonstrates difficulty with 1 of 2 of these commands.

ideomotor apraxia

-involves the loss of the kinesthetic memory of motor patterns; in other words, the motor plan for a specific task may be lost. Or the motor plan may be intact, but the patient cannot access the appropriate motor plan and may implement an inappropriate motor plan for a specific task. For ex- ample, a patient may cognitively understand that a toothbrush is used for brushing one's teeth but may access an inappropriate motor plan for using a toothbrush and instead use the toothbrush to brush his or her hair. Sometimes a patient with an ideomotor apraxia cannot access a specific motor plan on command but can access it automatically when presented with a visual cue, such as being offered a comb. Note. It is difficult to distinguish between an ideational and ideomotor apraxia. Screening methods for the apraxias are the same. -Apraxia can be detected by observing the patient carrying out motor sequences. Give the patient at least 4 of the following verbal commands: - Wave goodbye. - Blow a kiss. - Snap your fingers. - Touch your left knee. - Touch your right ear. - Cross your legs. - Raise your arm above your head. - Fold your arms across your chest. -Apraxia may be indicated if the patient has difficulty implementing the appropriate motor plan for 3 of 4 of these motor tasks.

Broca's aphasia

-is an expressive-language disorder in which patients can understand what is spoken to them but cannot express their ideas in an understandable way. Broca's aphasia always results from a left hemisphere lesion in the brain region referred to as Broca's area. Often, patients speak in nonfluent sentences that do not make sense. Patients may even speak gibberish. Sentences tend to be telegraphic, that is, preserving only the essential content words: "Vacation . . . New York." Patients often demonstrate semantic or paraphasic sentences in which they substitute a related or unrelated word for the desired target word: mother is used for wife; dinner is used for breakfast. Because patients can comprehend what is being asked of them, they can sometimes write their answers or point to a desired object or picture of a desired need (e.g., bathroom). -Ask the patient to answer the following simple questions: -What is your name? -When is your birthday? -How old are you? -Where do you live? -If the patient is unable to answer the questions using clear, fluent speech that makes sense, Broca's aphasia may be indicated. To determine that the patient understood the question (and that comprehension is intact), allow the patient to attempt to answer the questions in writing; by shaking his or her head no/yes; or by choosing 1 of 3 verbal, written, or pictorial answers provided by the therapist.

Anosognosia

-is an extensive neglect syndrome involving failure to recognize one's paralyzed limbs as one's own. It results from lesions of the right hemisphere. Right hemisphere dis-orders involve a distortion of the physical environment and one's own body. Although patients with unilateral neglect can be taught to enhance their awareness of the left (or sometimes right) side of their body and environment, patients with anosognosia cannot be taught in the same way. Anosognosia is ac-companied by a strange affective dissociation.Patients show extraordinary indifference to their affected limb(s), often asking others to help them remove their affected limb(s) from their wheelchair lap tray or bed as though those limbs were not part of their body. Anosognosia often is a transient state of the patient with acute cerebrovascular accident. Anosog-nosia will usually resolve as the patient recovers. To determine whether a patient has anosognosia, ask the patient to perform 3 of the following tasks: -Ask the patient to show you his or her affected UE (ask him or her to show you the left or right arm). If the patient cannot do this, or if the patient can show you only his or her unaffected UE, anosognosia may be indicated. -Take the patient's affected UE and shake hands with that limb. Ask the patient whose hand you are shaking. If the patient cannot recognize that you are shaking hands with his or her affected UE, anosognosia may be indicated. -Ask the patient to tap the affected leg with his or her unaffected hand (e.g., "Tap your left leg with your right hand."). If the patient cannot tap his or her affected leg or can tap only his or her unaffected leg, anosognosia may be indicated. -Show the patient a large coin, such as a quarter. Tell the patient that you are going to put the coin somewhere on his or her body. Place the coin on the patient's unaffected thigh and ask him or her to find it. Then repeat the procedure with the affected lower extremity (LE). If the patient cannot find the coin placed on the affected LE, anosognosia may be indicated.

Right-Left Discrimination Dysfunction

-is an inability to accurately use the concepts of right and left. -Ask the patient to point to his or her own right and left body parts. For example, - Point to your left elbow. - Point to your right knee. - Point to your right shoulder. - Point to your left foot. -Ask the patient to follow your right-left commands as you give him or her directions to walk around the treatment environment. For example, - Go to the back of the room and open the left door of the closet. - Go to the desk and open the top drawer on the right. - Walk down the hall and open the first door on your right. - Open the window at the far left of the room. -Right-left discrimination impairment may be indicated if the patient confuses right and left 3 of 4 times when pointing to right and left body parts. It may also be indicated if the patient confuses directions 3 of 4 times when responding to right-left commands to walk around the treatment environment.

Figure- ground discrimination dysfunction

-is an inability to distinguish objects in the foreground from objects in the background. -Ask the patient to pick out forks from a kitchen drawer (or table tray) with disorganized, multiple utensils (all having a silver color). -Or, ask the patient to find the white toothbrush, bar of white soap, and white washcloth as he or she sits against the background of a white bathroom sink. -Figure-ground discrimination impairment may be indicated if the patient is unable to pick out more than half of the forks from the other utensils or is unable to easily find the white toothbrush, soap, and washcloth against the white background of the bathroom sink.

Form-Constancy Dysfunction

-is an inability to recognize subtle variations in form or changes in form such as a size variation of the same object. -Determine whether the patient is able to identify a familiar object when turned on its side or placed one (do not allow the patient o manipulate the objects with his or her hands): a plate turned upside down, a fork placed on its side, a pair of scissors opened fully, a doorknob placed on the table in front of the patient. -Determine whether the patient is able to categorize a group of shapes having varying sizes. Give the patient several different sizes of triangles, squares, and rectangles all having the same color. -Instruct the patient to sort the shapes into categories. Can the patient sort all of the triangles, squares, and rectangles into separate groups even if the shapes are of varying sizes? -Form-constancy dysfunction may be indicated if the patient is unable to identify these familiar objects when they are placed in odd positions. It may also be indicated if the patient makes several errors when attempting to sort shapes of varying sizes.

Color Anomia

-is an inability to remember the names of colors. Color anomia differs from color agnosia in that patients with color anomia may forget the names of colors but would still recognize that a banana is not blue. -Show the patient 6 flash cards, each having 1 distinct, simple color (e.g., red, blue, yellow, green, orange, purple). Ask the patient to name the color. -For patients with expressive aphasia, offer the patient 3 choices for each card. -Tell the patient to indicate the correct answer by nodding "yes." -Color anomia may be indicated if the patient is unable to accurately identify 3 of the 6 colors shown on the flash cards.

Asymbolia

-is difficulty comprehending gestures and symbols. It is often caused by left hemisphere lesions; however, it can result from right hemisphere lesions as well. -Demonstrate the following gestures and symbols to the patient and ask him or her to tell you what they mean. If the patient has word-finding difficulties, offer the patient a choice of 3 verbal, written, or pictorial options. - Wave hello/goodbye. - Shake your head no/yes. - Point to your watch and gesture "What time is it?" - Shiver to demonstrate that you are cold; chatter your teeth. - Gesture with your hand for the patient to come forward. -Asymbolia may be indicated if the patient is unable to understand 3 or more of the 5 gestures.

Wernicke's aphasia

-is difficulty comprehending the literal meaning of language. Wernicke's aphasia always results from a left hemisphere lesion in the brain region referred to as Wernicke's area. -Determine whether the patient can understand the spoken word. -Ask the patient simple questions, for example, - What is your name? - When is your birthday? - How old are you? - Where do you live? -A patient with Wernicke's aphasia will not be able to understand the questions and will offer an- swers that do not make sense. However, the patient's verbal responses, while not appropriately answering the questions, will nevertheless be fluent; in other words, the patient's sentences are clear rather than meaningless gibberish as may be seen in expressive aphasia.

Dyslexia

-is the impaired ability to read. Dyslexia is a language problem in which the ability to break down written language into its most basic units—letters—is impaired. The patient may perceive letters as reversed or sequentially mixed up. Some words in a sentence may be overlooked or left out. If the patient uses glasses to read, make sure that he or she is screened with glasses on. It is also important to be certain that the patient is not illiterate and does not have visual field cuts or visual-perceptual problems that would interfere with reading. -Rule out a possible previous history of dyslexia before screening. -Ask the patient to read a simple paragraph, for example, -The barnyard has 5 different kinds of animals. There are pigs, goats, cows, sheep, and chickens. A barn cat keeps the mice away. A herding dog keeps the sheep in the pasture. At noon, the farmer's wife milks the cows. At dinnertime, the family sits down together for an evening meal. -Dyslexia is indicated if the patient has difficulty reading the paragraph because of an inability to break down words into letters. In other words, the patient will reverse letters or mix up the sequence of letters within words.

Agrammatism

-is the inability to arrange words sequentially so that they form intelligible sentences in conversation or writing. Agrammatism usually occurs as a result of left hemisphere lesions. Patients mix up the correct sequence of words and fail to form clear, meaningful sentences. For example, a patient may write or say "Fox jumped over fence chicken house" instead of "The fox jumped over the chicken house fence." Or "Mother cake oven bake" instead of "Mother baked the cake in the oven." Articles and prepositions such as "the" and "in" are left out. The therapist can observe the patient's speech during screening procedures to determine if agrammatism is evident. -Ask the patient to write (if possible) or repeat the sentences "The fox jumped over the chicken house fence" and "Mother baked the cake in the oven." -Agrammatism may be indicated if the patient mixes up the sequence of words in these sentences, whether written or spoken.

Acalculia

-is the inability to calculate mathematical problems. Dyscalculia is difficulty calculating math problems. Both are caused by lesions occurring in the left hemisphere. Although mathematical calcu- lation is a cognitive function, it is considered to be a form of language expression involving the use of mathematical language or numeric symbols. -Ask the patient to calculate simple addition and subtraction problems on paper or to make change in a simple word problem (e.g., The apple costs 75¢. You give the store employee $1.00. Using coins, show me what change the employee will give you.). -A patient with acalculia would be unable to perform mathematical functions. -In dyscalculia, the patient reverses numbers, flips them, mixes them up sequentially, or overlooks them. For example, if you ask a patient to write the addition problem of 16 34, a patient with dyscalculia may write 19 1 43. -Ask the patient to calculate simple addition and subtraction problems on paper or to make change in a simple word problem. -A patient with dyscalculia would have difficulty performing mathematical functions as a result of reversing, flipping, overlooking, or sequentially mixing up the correct order or sequence of numbers.

Extinction of simultaneous stimulation

-is the inability to determine that one has been touched on both sides of the body; the neural sensation of the uninvolved side overrides the ability to perceive touch on the involved side (see Figure 3.1 and Video 3.1). -Touch the patient on the dorsal surface of the involved UE. -Ask the patient to indicate on what body region he or she has been touched. -Touch the patient on the dorsal surface of the uninvolved UE. -Ask the patient to indicate on what body region he or she has been touched. -Simultaneously touch the patient on the dorsal surface of both the uninvolved and involved UE. -Ask the patient to indicate on what body region he or she has been touched. -Repeat the above procedures with all extremities. -Extinction of simultaneous stimulation occurs when the patient can identify the area of stimulation on the involved extremity when touched alone but cannot identify the area of stimulation on the involved extremity when simultaneously touched on the same region on both extremities. This occurs because the neurons that carry tactile sensation from the involved side are cortically over- ridden by the neurons carrying sensation from the uninvolved side.

2 point discrimination dysfunction

-is the inability to determine whether one has been touched by 1 or 2 points. -Use an esthesiometer to determine whether the patient can identify whether he or she has been touched by 1 or 2 points. -Instruct the patient that you are going to touch his or her fingertip with 1 or 2 points—test 2-point discrimination on 1 hand at a time. Ask the patient to state whether he or she has been touched by 1 or 2 points (occlude the patient's vision). Gradually move the points of the esthesiometer closer together until the patient states that he or she is being touched by 1 point only. Note the distance between points at this time. The starting distance of the esthesiometer should begin at 4 mm and end at 2.6 mm. -Repeat with the opposite hand. -Most people can determine that they have been touched by 2 points at a minimal distance of 3 mm on the fingertip, 4 mm to 5 mm on the middle phalanx, 6 mm to 7 mm on the proximal pha- lanx, and 7 mm to 10 mm on the palm. If the patient has normal 2-point discrimination in 1 hand but not the other, the lesion is indicated in the contralateral hemisphere.

Amorphagnosia

-is the inability to discriminate between different forms by touch alone. -Instruct the patient to identify the following forms by touch alone (occlude the patient's vision): a triangle (a triangular Styrofoam form), a square (a square block), a circle (a ball or circular Styrofoam form), a rectangle (a rectangular block), and a star (a Styrofoam star). -Test for amorphagnosia in 1 hand at a time. -Alternate the sequence of presented forms for each hand. -Amorphagnosia may be indicated if the patient is unable to identify 3 of the 5 presented forms. If the patient is able to identify the forms using 1 hand but not the other, the lesion is indicated in the contralateral hemisphere.

Ahylognosia

-is the inability to discriminate between different types of materials by touch alone. -Instruct the patient to identify the following materials by touch alone (occlude the patient's vision): a cotton ball; a piece of metal, such as a washer or large nail; a piece of cloth, such as velvet; a piece of rubber, such as a rubber band or Theraband; and a piece of wood, such as a wooden block. -Test for ahylognosia in 1 hand at a time. -Alternate the sequence of presented materials for each hand. -Ahylognosia may be indicated if the patient is unable to identify 3 of the 5 presented materials. If the patient is able to identify the materials using 1 hand but not the other, the lesion is indicated in the contralateral hemisphere.

Agraphesthesia

-is the inability to interpret letters written on the palmar surface of the hand. -Instruct the patient that you are going to write letters on his or her hand with your fingertip (occlude the patient's vision). -Write 5 letters on the patient's hand, 1 at a time (e.g., o, w, t, x, s). Ask the patient to identify each letter. Test 1 hand at a time. -Agraphesthesia may be indicated if the patient is unable to identify 3 of the 5 letters. If the patient has normal graphesthesia on 1 hand but not the other, the lesion is indicated in the contralateral hemisphere.

Anomia

-is the inability to remember and express the names of people and objects. The patient may know the person but cannot remember his or her name. Anomia differs from prosopagnosia, in which individuals do not recognize familiar faces. Lesions resulting in anomia can occur in either hemisphere. -Present the patient with several familiar objects (e.g., hairbrush, wristwatch, apple, keys, eyeglasses, pencil). Ask the patient to name an object. If the patient cannot accurately name the object as a result of anomia, allow the patient to correctly name the object by choosing 1 of 3 written or verbal answers provided by the therapist (the patient can shake his or her head no/yes in response to the choices). If the patient can accurately choose the correct name of the object using written or verbal choices, the patient has demonstrated comprehension of the therapist's question. -Present the patient with photos of famous or familiar people. Choose famous people whom the patient would likely know, or choose photos of the patient's family members. If the patient is unable to name the presented photos as a result of anomia, allow the patient a choice of 3 written or verbal answers provided by the therapist (the patient can shake his or her head no/yes in response to the choices). -If the patient can accurately choose the correct name of the person using written or verbal choices, the patient has demonstrated comprehension of the therapist's question. -Anomia may be indicated if the patient is unable to name 3 of the 5 presented familiar objects or is unable to name 3 of the 5 presented photos of famous people or family members.

Dysgraphia

-is the inability to write because the patient cannot break words into letters. Dysgraphia is the written form of dyslexia (i.e., the inability to read because the patient cannot break words into letters) and occurs as a result of left hemisphere lesions. The writing of a patient with dysgraphia contains words with reversed letters, flipped letters, and mixed-up sequences of letters. Some words may be left out of the sentence. Dysgraphia can be observed by asking the patient to write his or her name, address, and phone number. The attempts at writing by a patient with dysgraphia may appear as follows: -Mray Smht (Mary Smith)5B6 Nil raod (56-B Mill Road)jnkimgont, PA 19964 (Jenkintown, PA 19046)

Simultanagnosia

Inability to recognize and interpret an entire visual stimulus as a whole; usually due to damage to the right hemisphere. -Show the patient photographs of detailed scenes (e.g., a farm with animals or crops, a zoo, a city street, the inside of a grocery store). -Ask the patient to describe the scene in detail. -Or, take the patient to a window and ask him or her to describe the scene outside the window. -Patients with simultanagnosia may be able to identify small details from the scene but are unable to integrate all details to understand the scene as a whole. For example, when viewing a photograph, patients may see a car, a person walking, and a storefront window, but be unable to interpret all aspects of the photo as a busy city street. Often, patients with simultanagnosia confabulate in an effort to fill in parts of a scene they cannot interpret. -Simultanagnosia may be indicated if the patient is unable to understand the scene as a whole or confabulates imaginary items that don't exist.

Prosopagnosia

inability to recognize familiar faces -Show the patient photographs of familiar people (e.g., world leaders, celebrities, sports figures). Make sure that the famous people shown are individuals whom the patient would recognize, that is -Show the patient photographs of familiar family members. -Ask the patient to identify the names of the people in the photographs. If the patient is unable to think of the individuals' names, ask the patient what the famous people are known for. Or offer the patient a choice of 3 answers. If the patient has expressive aphasia, allow him or her to nod "yes" in response to the correct answer. -Hold a mirror in front of the patient's face. Ask the patient to identify the person reflected in the mirror. Or give the patient a photo of himself or herself and ask the patient to identify the person shown. -Prosopagnosia may be indicated if the patient is unable to identify familiar family members, famous people, or himself or herself as reflected in a mirror or photograph.

Aprosodia

is impaired comprehension of tonal inflections used in conversation. Patients have difficulty perceiving the emotional tone of someone's conversation. Aprosodia often results from a right hemi- sphere lesion. Patients can often understand the literal meaning of words but cannot interpret the words' emotional tonal inflections. To determine whether a patient is aprosodic, state a neutral sentence to the patient but change your tonal inflection to sound angry, sad, happy, or disgusted. Ask the patient to identify your emotion. If the patient has word-finding difficulties, offer him or her a choice of 3 verbal, written, or pictorial answers. - Say in an angry tone , "That cat came over the fence again last night."Ask the patient to identify your emotion. - Say in a happy ,enthused tone,"That cat came over the fence again last night."Ask the patient to identify your emotion. - Say in a sad tone,"That cat came over the fence again last night."Ask the patient to identify your emotion. -Aprosodia may be indicated if the patient is unable to identify the appropriate emotional tonal inflections in 2 of the 3 sentences.

Alexia

is the inability to comprehend the written word or the inability to read. Alexia can occur as a result of lesions to either hemisphere; more often the left hemisphere is lesioned. -Ask the patient to read a simple paragraph (with large print). If the patient uses glasses to read, make sure that he or she is screened with glasses on. It is also important to be certain that the patient is not illiterate and does not have visual field cuts or visual-perceptual problems that would interfere with reading. -An inability to read (in the absence of visual problems, visual-perceptual disorders, or illiteracy) may indicate alexia.

Astereognosis

is the inability to identify objects by touch alone. - Instruct the patient to identify the following by touch alone (occlude the patient's vision): a key, quarter or other coin, paper clip, wristwatch, and pencil. -Test for astereognosis in 1 hand at a time. -Alternate the sequence of presented objects for each hand. -Astereognosis may be indicated if the patient is unable to identify 3 of the 5 presented objects. If the patient is able to identify the objects using 1 hand but not the other, the lesion is indicated in the contralateral hemisphere.

Unilateral Neglect

is the inability to integrate and use perceptions from 1 side of the body or 1 side of the environment. The awareness of the left side of the environment is lost temporarily. Patients more often experience left neglect syndromes than right neglect syndromes; right neglect tends to resolve more quickly. Left neglect often results from a lesion to the right hemi- sphere's posterior multimodal association area. Patients with unilateral neglect can be trained to heighten their awareness of the neglected side of their body and the environment. Select 3 of the following. -Ask the patient to perform the following tasks: - Draw a clock. Note whether the patient ne- glects to insert numbers on the left side of the clock (see Figure 3.2). - Draw a human figure. Note whether the patient draws only half of the body or leaves off limbs on 1 side of the body (see Figure 3.3). -Ask the patient to read a paragraph from a book or magazine page. Note whether the patient begins each sentence at the middle of the page and ignores the words to the left of midline. -Give the patient a page on which columns of letters appear. Instruct the patient to cross out all of theHs. Note whether the patient crosses out only theHs on the right half of the page and ignores those on the left half of the page (see Figure 3.4). -Observe the patient while eating. Note whether the patient attends to both sides of the plate or ignores the food on the left half of the plate and meal tray (see Figure 3.5). -Observe the patient during the morning grooming routine. Note whether the pa- tient fails to shave one side of his face or bathe one-half of his or her body. -Observe the patient while dressing. Note whether the patient is able to dress both halves of his or her body or whether he or she dresses only 1 side (see Figure 3.6).

Agraphia

is the inability to write intelligible words and sentences. Agraphia is the written form of alexia (i.e., the inability to read) and occurs as a result of left hemisphere lesions. A patient with agraphia may attempt to write but instead only scribble. Agraphia can be observed by asking the patient to write his or her name, address, and phone number.