Sex differences in post-stroke aphasia rates are caused by age. A meta-analysis and database query

Meta-analysis and systematic review of the relationship between sex and the risk or incidence of poststroke aphasia and its types

OBJECTIVE

To analyse and discuss the association of gender differences with the risk and incidence of poststroke aphasia (PSA) and its types, and to provide evidence-based guidance for the prevention and treatment of poststroke aphasia in clinical practice.

DATA SOURCES

Embase, PubMed, Cochrane Library and Web of Science were searched from January 1, 2002, to December 1, 2023.

STUDY SELECTION

Including the total number of strokes, aphasia, the number of different sexes or the number of PSA corresponding to different sex.

DATA EXTRACTION

Studies with missing data, aphasia caused by nonstroke and noncompliance with the requirements of literature types were excluded.

DATA SYNTHESIS

36 papers were included, from 19 countries. The analysis of 168,259 patients with stroke and 31,058 patients with PSA showed that the risk of PSA was 1.23 times higher in female than in male (OR = 1.23, 95% CI = 1.19-1.29, P < 0.001), with a prevalence of PSA of 31% in men and 36% in women, and an overall prevalence of 34% (P < 0.001). Analysis of the risk of the different types of aphasia in 1,048 patients with PSA showed a high risk in females for global, broca and Wenicke aphasia, and a high risk in males for anomic, conductive and transcortical aphasia, which was not statistically significant by meta-analysis. The incidence of global aphasia (males vs. females, 29% vs. 32%) and broca aphasia (17% vs 19%) were higher in females, and anomic aphasia (19% vs 14%) was higher in males, which was statistically significant (P < 0.05).

CONCLUSIONS

There are gender differences in the incidence and types of PSA. The risk of PSA in female is higher than that in male.

The role of gender in cognitive outcomes from stroke

OBJECTIVE

Stroke can cause cognitive impairment, which can lead to challenges returning to day-to-day activities. Knowing what factors are associated with cognitive impairment post-stroke can be useful for predicting outcomes and guiding rehabilitation. One such factor is gender: previous studies are inconclusive as to whether gender influences cognitive outcomes post-stroke. Accounting for key variables, we examined whether there are gender differences in cognitive outcomes after stroke.

METHOD

We analyzed data from neuropsychological assessments of 237 individuals tested in the chronic epoch (≥ 3 months) following ischemic stroke. Using ANCOVA and linear mixed modeling, we examined gender as a predictor of cognition as measured by general cognitive ability (g), Full-Scale IQ, and 18 cognitive tests, controlling for age at stroke onset, education, premorbid intelligence, and lesion volume.

RESULTS

There were no significant gender differences in overall cognitive outcomes as measured by g (p = .887) or Full-Scale IQ (p = .801). There were some significant gender differences on specific cognitive tests, with women outperforming men on scores from the Rey Auditory Verbal Learning Test (ps < .01) and men outperforming women on the Wechsler Adult Intelligence Scale Arithmetic and Information subtests (ps < .01).

CONCLUSIONS

Our findings indicate that men and women have similar overall cognitive outcomes after stroke, when demographic and lesion factors are accounted for. Although men and women differed in their performance on some individual cognitive tests, neither gender performed systematically better or worse. However, for learning, working memory, and verbal knowledge/comprehension, gender may be an important predictor of outcome post-stroke.

Bayesian stroke modeling details sex biases in the white matter substrates of aphasia

Ischemic cerebrovascular events often lead to aphasia. Previous work provided hints that such strokes may affect women and men in distinct ways. Women tend to suffer strokes with more disabling language impairment, even if the lesion size is comparable to men. In 1401 patients, we isolate data-led representations of anatomical lesion patterns and hand-tailor a Bayesian analytical solution to carefully model the degree of sex divergence in predicting language outcomes ~3 months after stroke. We locate lesion-outcome effects in the left-dominant language network that highlight the ventral pathway as a core lesion focus across different tests of language performance. We provide detailed evidence for sex-specific brain-behavior associations in the domain-general networks associated with cortico-subcortical pathways, with unique contributions of the fornix in women and cingular fiber bundles in men. Our collective findings suggest diverging white matter substrates in how stroke causes language deficits in women and men. Clinically acknowledging such sex disparities has the potential to improve personalized treatment for stroke patients worldwide.

Speech and Language Therapy for Acquired Central Dysgraphia in Neurological Patients: A Systematic Review to Describe and Identify Trainings for Clinical Practice

PURPOSE

Acquired central dysgraphia is a heterogeneous neurological disorder that usually co-occurs with other language disorders. Written language training is relevant to improve everyday skills and as a compensatory strategy to support limited oral communication. A systematic evaluation of existing writing treatments is thus needed.

METHOD

We performed a systematic review of speech and language therapies for acquired dysgraphia in studies of neurological diseases (PROSPERO: CRD42018084221), following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist with a search on several databases for articles written in English and published until August 31, 2021. Only methodological well-designed studies were included. Further assessment of methodological quality was conducted by means of a modified version of the Downs and Black checklist.

RESULTS

Eleven studies of 43 patients in total were included. For each study, we collected data on type of population, type of impairment, experimental design, type of treatment, and measured outcomes. The studies had a medium level of assessed methodological quality. An informative description of treatments and linkages to deficits is reported.

CONCLUSIONS

Although there is a need for further experimental evidence, most treatments showed good applicability and improvement of written skills in patients with dysgraphia. Lexical treatments appear to be more frequently adopted and more flexible in improving dysgraphia and communication, especially when a multimodal approach is used. Finally, the reported description of treatment modalities for dysgraphia in relation to patients' deficits may be important for providing tailored therapies in clinical management.

Men Are at Higher Risk of Screening Positive for Vascular Cognitive Impairment Compared to Women after Stroke and Transient Ischemic Attack

While women have greater incidence of dementia, men have higher prevalence of vascular risk factors. This study examined sex differences in risk of screening positive for cognitive impairment after stroke. Ischemic stroke/TIA patients (N = 5969) participated in this prospective, multi-centered study, which screened for cognitive impairment using a validated brief screen. Men showed a higher risk of screening positive for cognitive impairment after adjusting for age, education, stroke severity, and vascular risk factors, suggesting that other factors may be contributing to increased risk among men (OR = 1.34, CI 95% [1.16, 1.55], p < 0.001). The effect of sex on cognitive impairment after stroke warrants further attention.

Production of time reference in Turkish Broca's aphasia: The effect of morphological complexity

In PWA (people with aphasia) difficulties with sentences that refer to the past compared to non-past time reference have been shown for many languages, including Turkish. However, the impact of morphological complexity on past time reference ability in production has not yet been reported for Turkish-speaking PWA. Turkish, where verb forms have complex inflectional paradigms and exhibit overt and non-overt morphology, facilitates the examination of the effects of morphological complexity. The current study has two objectives: 1) to investigate whether the morphological complexity of the verb form affects time reference production of Turkish-speaking PWA and 2) to provide analysis for the error patterns discovered. Seventeen Turkish individuals with Broca's aphasia who were matched in age with a control group of 17 neurologically intact Turkish individuals were tested with a picture sentence completion task. Test conditions were present progressive, simple past, past perfect, past progressive, and future tense. The task required the participants to complete each sentence frame with a verb. Our findings show that Turkish-speaking PWA were more successful in producing verb forms referring to non-past than verb forms referring to the past time reference. The current study supports previous findings that past is more difficult than non-past time reference for Turkish-speaking PWA. In terms of morphological complexity, we find that PWA were more impaired when producing morphologically complex verb forms rather than morphologically simple forms. We argue that these impairments lie in the realization of overt morphology.

Structural disconnections associated with language impairments in chronic post-stroke aphasia using disconnectome maps

Inconsistent findings have been reported about the impact of structural disconnections on language function in post-stroke aphasia. This study investigated patterns of structural disconnections associated with chronic language impairments using disconnectome maps. Seventy-six individuals with post-stroke aphasia underwent a battery of language assessments and a structural MRI scan. Support-vector regression disconnectome-symptom mapping analyses were performed to examine the correlations between disconnectome maps, representing the probability of disconnection at each white matter voxel and different language scores. To further understand whether significant disconnections were primarily representing focal damage or a more extended network of seemingly preserved but disconnected areas beyond the lesion site, results were qualitatively compared to support-vector regression lesion-symptom mapping analyses. Part of the left white matter perisylvian network was similarly disconnected in 90% of the individuals with aphasia. Surrounding this common left perisylvian disconnectome, specific structural disconnections in the left fronto-temporo-parietal network were significantly associated with aphasia severity and with lower performance in auditory comprehension, syntactic comprehension, syntactic production, repetition and naming tasks. Auditory comprehension, repetition and syntactic processing deficits were related to disconnections in areas that overlapped with and extended beyond lesion sites significant in SVR-LSM analyses. In contrast, overall language abilities as measured by aphasia severity and naming seemed to be mostly explained by focal damage at the level of the insular and central opercular cortices, given the high overlap between SVR-DSM and SVR-LSM results for these scores. While focal damage seems to be sufficient to explain broad measures of language performance, the structural disconnections between language areas provide additional information on the neural basis of specific and persistent language impairments at the chronic stage beyond lesion volume. Leveraging routinely available clinical data, disconnectome mapping furthers our understanding of anatomical connectivity constraints that may limit the recovery of some language abilities in chronic post-stroke aphasia.

Predictors of Therapy Response in Chronic Aphasia: Building a Foundation for Personalized Aphasia Therapy

Chronic aphasia, a devastating impairment of language, affects up to a third of stroke survivors. Speech and language therapy has consistently been shown to improve language function in prior clinical trials, but few clinicially applicable predictors of individual therapy response have been identified to date. Consequently, clinicians struggle substantially with prognostication in the clinical management of aphasia. A rising prevalence of aphasia, in particular in younger populations, has emphasized the increasing demand for a personalized approach to aphasia therapy, that is, therapy aimed at maximizing language recovery of each individual with reference to evidence-based clinical recommendations. In this narrative review, we discuss the current state of the literature with respect to commonly studied predictors of therapy response in aphasia. In particular, we focus our discussion on biographical, neuropsychological, and neurobiological predictors, and emphasize limitations of the literature, summarize consistent findings, and consider how the research field can better support the development of personalized aphasia therapy. In conclusion, a review of the literature indicates that future research efforts should aim to recruit larger samples of people with aphasia, including by establishing multisite aphasia research centers.

Combining electroacupuncture and transcranial direct current stimulation as an adjuvant therapy enhances spontaneous conversation and naming in subacute vascular aphasia: A retrospective analysis

OBJECTIVE

Emerging evidence shows the effectiveness of speech and language therapy (SLT); however, precise therapeutic parameters remain unclear. Evidence for the use of adjunctive transcranial direct current stimulation (tDCS) to treat post-stroke aphasia (PSA) is promising; however, the utility of combining tDCS and electroacupuncture (EA) has not yet been analyzed. This study assessed the therapeutic consequences of EA and tDCS coupled with SLT in subacute PSA patients who were also undergoing hyperbaric oxygen therapy (HBOT).

METHODS

A retrospective analysis was conducted on subacute (< 6 months) PSA patients who were divided into three groups: patients who received EA plus tDCS (acupuncture group), patients who underwent tDCS (tDCS group), and patients who experienced conventional therapy (HBOT + SLT). All subjects underwent 21 days of treatment and also received conventional treatment. The aphasia battery of Chinese (ABC) was used to score pre- and post-intervention status.

RESULTS

The analysis comprised 238 patients. Cerebral infarction was the most frequent stroke type (137 [57.6%]), while motor (66 [27.7%]) and global aphasia (60 [25.2%]) were the most common types of aphasia. After 21 days of intervention, the ABC scores of all patients were improved. The acupuncture group had the highest ABC scores, but only repetition, naming, and spontaneous speech were statistically improved (P < 0.01). Post-hoc tests revealed significant improvement in word retrieval in the acupuncture and tDCS groups (P < 0.01, P = 0.037), while the acupuncture group had additional significant improvement in spontaneous conversation (P < 0.01).

CONCLUSION

Combining acupuncture and tDCS as an adjuvant therapy for subacute PSA led to significant spontaneous speech and word retrieval improvements. Future prospective, multi-ethnic, multi-center trials are warranted.

Does acupuncture therapy improve language function of patients with aphasia following ischemic stroke? A systematic review and meta-analysis

BACKGROUND

Aphasia is one of the most common complications in patients with ischemic stroke. Studies have shown that acupuncture can improve the symptoms of aphasia patients. However, the effect of acupuncture on language function in patients with ischemic stroke is still controversial.

OBJECTIVE

This study aimed to critically assess the efficacy and safety of acupuncture for aphasia following ischemic stroke.

METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, China National Knowledge Infrastructure, Wanfang Digital Periodicals, and Chinese Science and Technology Periodicals database were searched. All randomized controlled trials (RCTs) that met the criteria were included.

RESULTS

Meta-analyses showed that mean difference in change of auditory comprehension score (MD = 7.71, 95% CI: 1.83 to 13.59, P = 0.01), spontaneous speech (MD = 2.77, 95% CI: 0.59 to 4.95, P = 0.01), repetition score (MD = 14.48, 95% CI: 11.04 to 17.91, P <  0.00001) and naming score (MD = 14.60, 95% CI: 11.33 to 17.88, P <  0.00001) measured by WAB scale were statistically significant. Subgroup analyses demonstrated that there were statistically significant mean differences in four items of WAB scale in patients with sub-acute stroke, and no statistically significant differences in patients with acute stroke.

CONCLUSION

The present study suggests that acupuncture may improve the language function of patients with aphasia following ischemic stroke, especially during the sub-acute phase. However, due to insufficient sample sizes and information on the safety, more high-quality RCTs are still needed.

Sex Differences in the Long-Term Consequences of Stroke

Stroke is the fifth leading cause of death and as healthcare intervention improves, the number of stroke survivors has also increased. Furthermore, there exists a subgroup of younger adults, who suffer stroke and survive. Given the overall improved survival rate, bettering our understanding of long-term stroke outcomes is critical. In this review we will explore the causes and challenges of known long-term consequences of stroke and if present, their corresponding sex differences in both old and young survivors. We have separated these long-term post-stroke consequences into three categories: mobility and muscle weakness, memory and cognitive deficits, and mental health and mood. Lastly, we discuss the potential of common preclinical stroke models to contribute to our understanding of long-term outcomes following stroke.

The economic burden of stroke: a systematic review of cost of illness studies

Stroke is one of the leading causes of morbidity and mortality worldwide. As the number of stroke cases is rising from one year to another, policymakers require data on the amount spent on stroke to enforce better financing policies for prevention, hospital care, outpatient rehabilitation services and social services. We aimed to systematically assess the economic burden of stroke at global level. Cost of stroke studies were retrieved from five databases. We retrieved the average cost per patient, where specified, or estimated it using a top-down approach. Resulting costs were grouped in two main categories: per patient per year and per patient lifetime. We extracted information from forty-six cost of illness studies. Per patient per year costs are larger in high income countries and in studies conducted from the payer perspective. The highest average per patient per year cost by country was reported in the United States ($59,900), followed by Sweden ($52,725) and Spain ($41,950). The highest per patient lifetime costs were reported in Australia ($232,100) for all identified definitions of stroke. Existing literature regarding the economic burden of stroke is concentrated in high-income settings, with very few studies conducted in South America and Africa. Published manuscripts on this topic highlight substantial methodological heterogeneity, rendering comparisons difficult or impossible, even within the same country or among studies with similar costing perspectives.

Machine learning-based multimodal prediction of language outcomes in chronic aphasia

Recent studies have combined multiple neuroimaging modalities to gain further understanding of the neurobiological substrates of aphasia. Following this line of work, the current study uses machine learning approaches to predict aphasia severity and specific language measures based on a multimodal neuroimaging dataset. A total of 116 individuals with chronic left-hemisphere stroke were included in the study. Neuroimaging data included task-based functional magnetic resonance imaging (fMRI), diffusion-based fractional anisotropy (FA)-values, cerebral blood flow (CBF), and lesion-load data. The Western Aphasia Battery was used to measure aphasia severity and specific language functions. As a primary analysis, we constructed support vector regression (SVR) models predicting language measures based on (i) each neuroimaging modality separately, (ii) lesion volume alone, and (iii) a combination of all modalities. Prediction accuracy across models was subsequently statistically compared. Prediction accuracy across modalities and language measures varied substantially (predicted vs. empirical correlation range: r = .00-.67). The multimodal prediction model yielded the most accurate prediction in all cases (r = .53-.67). Statistical superiority in favor of the multimodal model was achieved in 28/30 model comparisons (p-value range: <.001-.046). Our results indicate that different neuroimaging modalities carry complementary information that can be integrated to more accurately depict how brain damage and remaining functionality of intact brain tissue translate into language function in aphasia.

Factors Associated With Adherence to Self-Managed Aphasia Therapy Practice on a Computer-A Mixed Methods Study Alongside a Randomized Controlled Trial

Background: Aphasia is a communication disorder often acquired after a stroke. Independent use of specialist aphasia software on a home computer is a form of asynchronous tele-rehabilitation that can provide increased opportunity for practice of rehabilitation exercises. This study aimed to explore the factors associated with adherence to self-managed aphasia computer therapy practice.

Method: A mixed methods exploration of adherence was conducted alongside the Big CACTUS randomized controlled trial [ISRCTN: 68798818]. The trial evaluated the clinical effectiveness of self-managed aphasia computer therapy. This study reports secondary analysis of data from participants randomized to the computer therapy group to investigate whether any demographic, clinical or intervention variables were associated with adherence to therapy practice. A sub-sample of the same participants took part in qualitative interviews exploring the factors perceived to influence the amount of aphasia computer therapy practice undertaken. Interviews were analyzed thematically. A convergence-coding matrix was used to triangulate the two sets of findings.

Results: Data from 85 participants randomized to the computer therapy group were included in the quantitative analyses. At a clinical level, a greater length of time post-stroke was associated with higher adherence to self-managed aphasia therapy practice on a computer. At an intervention level, length of computer therapy access and therapist time supporting the participant were associated with greater adherence to computer therapy practice. Interviews with 11 patients and 12 informal carers identified a multitude of factors perceived to influence engagement with tele-rehabilitation by people with aphasia. The factors grouped around three themes: capability to use the computer therapy, having the opportunity to practice (external influences and technological issues) and motivation (beliefs, goals and intentions vs. personality, emotions, habit and reinforcement). Triangulation demonstrated convergence for the finding that participants' practiced computer-based therapy exercises more when they received increased support from a speech and language therapist.

Conclusion: Clinicians delivering asynchronous tele-rehabilitation involving self-management of aphasia therapy practice on a computer should consider the factors found to be associated with engagement when deciding which patients may be suited to this option, as well as how they can be supported to optimize the amount of practice they engage in.

Prevalence of aphasia after stroke in a hospital population in southern Brazil: a retrospective cohort study

Background: Aphasia negatively impacts quality of life. This is the first Brazilian study that investigates the prevalence of aphasia and its related factors, the results of which may underpin hospital and health service planning for this vulnerable population.Objective: To establish the prevalence of aphasia in patients after first-ever ischemic stroke (FEIS) and associated factors.Methods: This is a retrospective cohort study, based on a database held in Joinville, Brazil. All cases of FEIS admitted to one public hospital in Joinville in 2015 were selected. The diagnosis of aphasia was verified by neurologists through the language item of the National Institute of Health Stroke Scale (NIHSS).Results: Of the 350 patients with FEIS, 79 (22.6%) had aphasia. Patients with aphasia (PWA) were older, with a higher likelihood of dysarthria, more thrombolytic use, and greater stroke severity. PWA had higher mortality than patients without aphasia (24.1% versus 10.7%, p = .004) and longer hospitalization time (21.32 versus 17.46 days, p = .009). Higher NIHSS score was an independent predictor for the occurrence of aphasia on admission (OR 1.24, 95% CI 1.17-1.31, p < .001). Older age (OR 1.06, 95% CI 1.03-1.09, p < .001) and stroke severity by NIHSS (OR 1.19, 95% CI 1.12-1.25, p = <0.001) were independent predictors of death.Conclusions: PWA may need more health care during hospitalization, because of the severity of the stroke, and their frailty. Further studies are needed to assess the direct impact of aphasia on inpatients.

Gender differences in aphasia outcomes: evidence from the AphasiaBank

BACKGROUND

Stroke is one of the leading causes of death in the United States. Aphasia is a language impairment which results as a consequence of stroke. Gender differences are reported in underlying mechanisms of stroke, however, gender differences in aphasia type and severity remain unclear.

AIMS

To examine gender differences in aphasia impairment based on data from AphasiaBank, a research repository of data obtained from studies of aphasia.

METHODS & PROCEDURES

The data were collected from AphasiaBank for 294 persons with aphasia (PWA) (172 men, 122 women). Baseline comparisons by gender groups were completed using independent samples t-tests and Pearson Chi square statistics. Univariate comparisons of the total Western Aphasia Battery-Revised (WAB-R) -AQ and -R subtests' scores were compared between the two groups using independent samples t-tests. Multivariate comparisons were completed by using multivariate analysis of variance (MANOVA).

OUTCOMES & RESULTS

Gender differences were observed in the severity of aphasia with men exhibiting more severe aphasia than women. Analyses of WAB-R indicated greater impairment among men based on AQ and greater impairment was observed in individual subtest performance. Men exhibited statistically significantly lower WAB-R AQs than women (67.4 versus 75.6). Lower WAB-R AQs were derived from lower scores among men on individual subtests; information content, fluency, repetition, sentence completion, responsive speech and tests of comprehension (yes/no, auditory word recognition and sequential commands).

CONCLUSIONS & IMPLICATIONS

This study offers evidence of gender differences in aphasia severity, global communication impairment and lower scores on individual subtests used to derive the WAB-R AQ. The limitations of the study with suggestions for future directions are presented.

Language beyond the language system: Dorsal visuospatial pathways support processing of demonstratives and spatial language during naturalistic fast fMRI

Spatial demonstratives are powerful linguistic tools used to establish joint attention. Identifying the meaning of semantically underspecified expressions like "this one" hinges on the integration of linguistic and visual cues, attentional orienting and pragmatic inference. This synergy between language and extralinguistic cognition is pivotal to language comprehension in general, but especially prominent in demonstratives. In this study, we aimed to elucidate which neural architectures enable this intertwining between language and extralinguistic cognition using a naturalistic fMRI paradigm. In our experiment, 28 participants listened to a specially crafted dialogical narrative with a controlled number of spatial demonstratives. A fast multiband-EPI acquisition sequence (TR = 388 m s) combined with finite impulse response (FIR) modelling of the hemodynamic response was used to capture signal changes at word-level resolution. We found that spatial demonstratives bilaterally engage a network of parietal areas, including the supramarginal gyrus, the angular gyrus, and precuneus, implicated in information integration and visuospatial processing. Moreover, demonstratives recruit frontal regions, including the right FEF, implicated in attentional orienting and reference frames shifts. Finally, using multivariate similarity analyses, we provide evidence for a general involvement of the dorsal ("where") stream in the processing of spatial expressions, as opposed to ventral pathways encoding object semantics. Overall, our results suggest that language processing relies on a distributed architecture, recruiting neural resources for perception, attention, and extra-linguistic aspects of cognition in a dynamic and context-dependent fashion.

Leukoaraiosis Is Associated With a Decline in Language Abilities in Chronic Aphasia

Background. A fraction of stroke survivors with chronic aphasia experience declines in language abilities over time, but the reason for this remains unclear. Objective. To evaluate the effect of leukoaraiosis on baseline aphasia severity and long-term changes in aphasia severity. This study directly compares the predictive capacity of leukoaraiosis severity to that of lesion damage, a factor known to account for a substantial proportion of variance in the degree of language impairment and recovery. Methods. Using a longitudinal database of behavioral and neuroimaging data from 35 individuals in the chronic stage of recovery after a single-event left-hemisphere stroke (9 females, mean stroke age = 55.8 ± 9.1 years, mean months poststroke at initial evaluation = 36.3 ± 40.8), we examined 2 lines of inquiry: (1) to what extent does leukoaraiosis severity at initial evaluation predict aphasia severity and (2) to what extent does leukoaraiosis severity at initial evaluation predict longitudinal change in aphasia severity. Participants underwent high-resolution magnetic resonance imaging for the purpose of lesion volume analysis and leukoaraiosis severity rating. Biographical information was also considered. Results. Lesion volume and time poststroke at initial assessment best predicted initial aphasia severity (adjusted R² = 0.37). Leukoaraiosis severity and initial aphasia severity significantly predicted decline in language abilities at follow-up, accounting for approximately one-third of the variance (adjusted R² = 0.33). More severe leukoaraiosis was associated with a 4.3 odds increase of decline. Conclusions. Leukoaraiosis is a significant risk factor for declining language abilities in aphasia and should be considered for better identification of individuals at risk for long-term decline, which can guide clinical decision making.