Patients with vision, hearing or language impairment

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Adapting administration of the Westmead Post-Traumatic Amnesia (PTA) Scale for patients with communication, vision, hearing or language impairment.

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Patients with verbal communication impairment

Select the scenario most relevant to the patient, then follow the instructions for adapting the test.

Patients who:

Patients who can consistently and accurately indicate yes or no with gestures

Yes/no gestures may include head shaking, eye blinking, sounds or other suitable action.

Present 3 options for all questions and ask the patient to indicate yes or no to each of the options, as per the examples below.

Example 1

Assessor: How old are you? Are you 19 years old?

Patient: Gestures “no”

Assessor: How old are you? Are you 20 years old?

Patient: Gestures “yes”

Assessor: How old are you? Are you 21 years old?

Patient: Gestures “no”

Example 2

Assessor: What day of the week is it? Is it Thursday?

Patient: Gestures “no”

Assessor: What day of the week is it? Is it Friday?

Patient: Gestures “no”

Assessor: What day of the week is it? Is it Saturday?

Patient: Gestures “yes”

Q1. How old are you?
Q3. What month are we in?
Q4. What time of day is it (morning, afternoon or night)?
Q5. What day of the week is it?
Q6. What year are we in?
Q9. What is my name?

Follow the process for giving 3 options, with the options presented in sequential order. Vary the position of the correct answer for each question.

Q2. What is your date of birth?

Choose one of 2 options:

  • Option 1: present 3 options for their date of birth and have the patient gesture “yes” or “no” to each in turn. The dates should be similar to the correct date of birth.
  • Option 2: ask the question in 3 parts, using the 3-options examples for day, then month and then year.
Example for date of birth 19 Nov 1994

Assessor: “What is your date of birth? Were you born on the 18th of the month?”

Patient: Gestures “yes” or “no”

Assessor: repeat with the 19th and then the 20th of the month.

Then repeat for month (Sept, Oct, Nov) and for year (1994, 1995, 1996).

The patient needs to get all 3 parts of their date of birth correct to score one point.

Q7. What is the name of this place?

This question is asked in 2 parts, again using 3 options with gestures “yes” or “no” after each option is presented.

Assessor: “What is the name of this place? ls it your home, a hotel or a hospital?”

If the patient gestures “yes” to “hospital”, then follow with: “What is the name of this hospital: Nepean Hospital, or Westmead Hospital, or Liverpool Hospital?”

The patient must get both parts correct to score one point.

Q8. Have you seen my face before?

This question is already in a yes/no format.

Q10, 11 and 12. What were the 3 pictures selected yesterday?

Using an A4 sheet of all 9 picture cards, point to each picture and ask “ls this one of the pictures l asked you to remember: yes or no?”

Patient: gestures “yes” or “no” to each picture in turn

Score one point for each card that is correct.

Patients who use writing or a communication device to indicate choice

Devices may include a keyboard, an alphabet board or other augmentative communication device.

Ask questions verbally, and the patient responds by writing down the answers on paper; typing using a keyboard; or via another communication device. Seek guidance from a speech pathologist on what tools to use.

If the patient’s writing is too hard to read or using a communication device is not reliable, consider using either the “yes/no” procedure or the “arm gesture/eye gaze” procedure.

Patients who use arm movements or eye gaze to indicate choice

Options may include use of limb or eye gaze to indicate choice.

Ask questions verbally, and the patient indicates an answer by pointing or eye-gazing at their answer from a choice of 3 presented on a whiteboard, a large sheet of paper, a large screen (tablet/computer monitor) or a series of large flash cards.

The size of the print on the whiteboard, paper or cards used is determined by the degree of accuracy of movement or visual scanning the patient has control over.

You can have the questions ready to go or write them as you go through the test. If using flash cards, prepare them before each session.

For the picture cards, present all 9 cards in front of the patient (either on a table or on a screen) and ask them to point to or pick up the 3 pictures they needed to remember from the day before. Alternatively, give the patient all the cards, and let them select which 3 were the target cards.

Patients with vision impairment

Select the scenario most relevant to the patient, then follow the instructions to adapt the test.

Patients with:

Patients with severe visual acuity impairment

If the person usually wears glasses for reading, they should wear these for the assessment and follow the standard procedure.

For patients unable to see the picture cards, the assessor’s face or photograph due to severe visual impairment, use the following modifications to administer the test.

Q8. Have you seen my face before?

There is no suitable adaptation for the facial recognition item, so this question is eliminated from the test, and the maximum PTA score becomes 11.

Q9. What is my name?

If the usual assessor is completing the test, ask the patient if they remember your name.

If the usual assessor is not available, ask the patient to give the name of the assessor from the previous day. Rehearsal on the previous day will have included the assessor's name.

Q10, 11 and 12. What were the 3 pictures selected yesterday?

Select 3 cards and name these for the patient.

Ask the patient to repeat the names of the 3 objects and remember them for the following day.

On the following day, either:

  • ask the patient to recall what the 3 objects were; or
  • name all 9 items from an A4 card, and ask the patient to indicate yes or no to identify the 3 items they were required to remember.

Patients with visual neglect or visual field deficits

No specific adaptations to the standard procedure are needed; however, present test materials and rehearse within the intact visual or perceptual field. Confirm the patient correctly recognises the item before continuing with further testing. If there is severe neglect, seek advice from a neuropsychologist.

Patients with visual agnosia

In these rare cases, consult a neuropsychologist early to determine whether suitable adaptations are possible.

Patients with hearing impairment

For patients with profound hearing impairment, administer the test using written communication.

  • Establish if the patient has appropriate literacy and reading capacity; and consult with a speech pathologist if necessary.
  • Write each question on a whiteboard, a piece of paper or a computer/tablet screen and ask the patient to read it and provide an answer, either verbally or by another method.
  • Use the picture cards and deliver all instructions and rehearsal via written communication.
  • Confirm the patient understands the task, by asking them to write the names of the 3 pictures or point to the 3 cards. Use the same process to ask about the assessor’s face/photograph and name.

A patient who is fluent in sign language can complete the test with a trained sign language interpreter.

Patients with language impairment

For patients who present with expressive and/or receptive dysphasia, consult with a speech pathologist to clarify the best way to communicate with them. If there is no reliable way for the patient to correctly and consistently answer yes/no questions, it is not appropriate to test them.

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