MRCP PACES Examination of Speech
  • Language allows communication and elaboration of thoughts and experiences by linking them to words
  • Speech is the oral production of language
  • Perisylvian region of the left hemisphere in 95 – 99% of right-handed and 60 – 70% of left-handed people
    • Posterior pole: Wernicke’s area, transforms sensory inputs into their lexical representations (gives meaning)
    • Anterior pole: Broca’s area, transforms lexical representations into their articulatory sequences
      • Also involved in the construction of meaning-appropriate syntax (grammar)
  • Speech deficits
    • Dysphonia: inability to properly formulate sound from the larynx
      • Patients characteristically have a bovine cough (lacking the sharp, explosive onset)
    • Dysarthria: inability to shape noise into recognisable words
      • May have slurred and slow pronunciation
      • Especially evident on speaking words with many consonants (such as university, Episcopal, constitution or “West Register Street”)
      • Bulbar speech – nasal speech which lacks tonal modulation
      • Pseudobulbar (Donald Duck) – monotonous, slurred, high-pitched speech (sounds forced)
      • Cerebellar – staccato, scanning speech
    • Dysphasia: inability to understand or generate language
      • Wernicke’s (sensory / receptive) dysphasia: cannot understand and execute a simple three-stage command, e.g. “when I clap my hand, touch your right ear with your left index finger
      • Broca’s (motor / expressive) dysphasia: slower word production and word-finding difficulties
      • Conductive dysphasia: loss of repetition, with preserved comprehension and expression.
  • Expression
    • Fluency: maintains appropriate output volume, phrase length and melody (prosody)
      • Paraphasia: when a patient uses a word which approximates the desired one phonetically (for example, “plentil” for “pencil”). Occurs in damage to anterior language areas
      • Semantic paraphasia: when a patient offers an incorrect but legitimate word instead of the desired one (for example, “pen” for “pencil”). Occurs in semantic memory impairment
  • Naming (anomia is the single most common defect in aphasic patients)
    • Circumlocutious description of the object
    • Paraphasia
    • Mild anomia: naming parts of objects (for example watch, watch face, watch strap, hands, and crown) is more sensitive
    • Most anomias are retrieval-based (anomia, but can point object out if the examiner asks him to)
    • Two-way anomia implies comprehension deficit
  • Comprehension
    • Simple: “can a dog fly?” or “point to the source of light”
    • Complex syntax: “if a tiger is eaten by a lion, which animal stays alive?” or “if I take my shoes and socks off, then put my socks on, what am I wearing?”
    • Execute a three-stage command: “when I clap my hand, touch your right ear with your left hand”
  • Repetition: repeat “no ifs, ands or buts”
  • Reading
    • Ask the patient to read aloud from a bedside newspaper or magazine
    • Ask the patient to summarise what he has just read to test reading comprehension
    • In patients with an expressive dysphasia, ask them to read and execute “close your eyes”
  • Writing
    • Screen for the presence of dysgraphia (acquired deficit in spelling or grammar of written language)
    • Ask the patient to write a few sentences, and inspect them for spelling and grammar
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