Weeks 9-11 Flashcards
T/F damage is RH is often overlooked with respect to language and communicative competence
True
Symptoms tend to be more subtle with respect to communication
Mess obvious stroke symptoms → physicians (and families) are less likely to refer to SLP for cognitive-communication impairments
Extralinguistic impairments
Occurs with RH syndrome
Impairments in:
Pragmatics
Conversation cohesion
Linking sentences
Integrating verbal with nonverbal info
Understanding main idea
Standard aphasia batteries for linguistics won’t detect RH extralinguistic impairments
Linguistic impairments
Occurs with LH damage
Impairments in language structure
Why is RH syndrome difficult to study or underdiagnosed
No specific “communication areas” → Might be large networks involved in RH communicative functions
No clear patterns for categorization
Pragmatic and cognitive competence on spectrum
Normal declines in communication with aging
RH damage %
~50% with RHD have impaired verbal communication
~80% with RHD in rehab units have cognitive and/or communication impairments
Types of cognitive impairments with RHD
Attention
Visuospatial perception
Learning
Memory
SLPs look at cognition/attention to help figure out comprehension breakdown
T/F - RHD will affect pragmatic competence and discourse level communication MORE THAN word- and sentence- level processes
TRUE
Types of communication impairments with RHD
figurative/nonliteral language
Inference
discourse/pragmatics
RHD is often diagnosed as…
cognitive -communicative disorder/impairment
Or
Cognitive-linguistic impairment/disorder
T/F
RHD can respond appropriately to indiect questions in naturalistic contexts
TRUE
T/F
RHD can directly and indirectly make requests, but often do not justify or provide explanation for request
TRUE
T/F
Fewer formulaic expression produced following RHD when compared with individual with LHD
TRUE
How does RHD have difficulty with inferencing
When situation requires elaborative inferences
When situation has multiple potential interpretations
Difficulty with understanding nad interpreting humor, sarcasm, and emotions when different from their own emotion
Suppression-deficit hypothesis
What is suppression-deficit hypothesis
With RHD, can generate several interpretations, but reduced ability to suppress/inhibit less-likely interapations
E.g. cookie theft picture description task - may talk about the bushes rather than the action of the picture
What are the discourse-level impairments in RHD
name 7
Egocentric
tangential/off-topic/irrelevant content
Difficulty maintaining conversation and linking utternances to overall topic
Disorganized narratives
Theory of mind breakdown: Reduced ability to ID/repair conversation breakdowns
Reduced ability to judge appropriateness of conversation
confabulations : when people say something untrue but not aware it’s untrue
How to assess RHD
Informally test because most RHD tests are not sensitive enough to detect subtle changes in higher-level discourse
Informal test include: narrative, biography, conversation, story-retell, picture description —> responses will be “off” or irrelevant
Many RHD impairments are due to inability
False
Most impairments are due to inefficient processing NOT inability
Do well with straightforward tasks → taxiing system reveals inefficient processing
RHD treatment
Understudied
Target metaphor comprehension → emphasizing use of context
Use contextual clues to facilitate comprehension
Patient uses self-cueing (internal) rather than clinician-cueing (external)
What is aprosodia
RH injury; not aware of it
Difficulty in comprehension or use of prosody to signal linguistic boundaries, meaning of convey emotion
Treatment for aprosodia
Focus on use of prosody to express emotion
Motoric aspects of prosody
Both found to be successful with generalization
Left neglect vs left visual cut
Left neglect → doesn’t’ recognize left side needs attention
Left visual cut → Visual field is cut
How does RHD affect attention
Attention: ability to focus on a stimulus and filter our other stimuli
Inability to focus on one thing
Reduced sustained attention and topic maintenance
Reduced alternating attention
Reduced divided attention b/e multiple tasks
Reduced selective attention
How does reduced selective attention affect communication
Irrelevant content
Inability to shift topics appropriately
May also perseverate on one topic
RHD: Nonlinguistic impairments: neglect
Failure to report, respond, orient, attend to stimuli on the left side of body despite within functional limit of motor/sensory function
Occurs in 80% of RHD patients
Attentional impairment → attention is on right side only
Assessments for neglect
scanning /canceling tasks → line bisetion task
Drawing → draw a clock at 10 o’clock
reading/writing
Types of neglect
Personal Peripersonal Extrapersonal Viewer-centered object-centered
Personal → neglects the left half of body → not shaving left side of face
Peripersonal → neglects half of space within arm’s length such as not eating food on left side of plate or not finding remote on left side of bed
Extrapersonal → neglect half of space beyond arm’s reach, not noticing a window or tv or visitor
Viewer-centered: neglects left side of space defined by patient’s midline; left side will move as patient turns head
Object-centered: neglects left side of an object, regardless of where it is placed; neglecting left side of photo even if the entire photo is place in right visual field
Treatments for neglect
Scanning tasks have limited generalization
External stimulation→ left-neck vibrations → reduced severity several days post tx
Presenting stimuli spanning the midline
Voluntary movement of attention by having patient ID items on left and right sides of pages
Training patient to activity manipulate object in space
RHD impairments in higher-level processing
50% of RHD patient in rehab
Effects on communication like:
organizing/sequencing,
reasoning (implied meaning and theory of mind),
problem solving (reduced ability to repair conversation)
RHD treatment for cognitive deficits
No specific protocol but can use other strategies like treatment for RH TBI
Compensatory strategies are too specific and RHD may have difficulty with abstract thinking, reason so don’t know when to use strategy appropriately
More beneficial to train habitual use (using it all of the time) of strategy to facilitate overcoming deficits
What is anosognosia
Lack of awareness of deficits or reduced awareness of deficits
Co-occurs with neglect
May need increase of supervision
Diagnosis criteria for major neurocognitive disorder (dementia)
Significant cognitive decline
Substantial impairment in cognitive performance
Cognitive deficits interfere with independence in everyday activities
Must specify: with or without behavioral disturbance
Diagnosis criteria for mild neurocognitive disorder (dementia)
modest cognitive decline
modest impairment in cognitive performance
Cognitive deficits do not interfere with independence in everyday activities
Must specify: with or without behavioral disturbance
What is mild cognitive impairment
Used for people who do not meet criteria for neurocognitive disorder (dementia)
T/F: dementia is due to sudden/acute onset
False
More likely due to gradual onset of symptoms at a time rather than sudden/acute onset
Dementia progressively gets worse
Describe short term memory
Involves encoding processes, temporary storage of limited capacity
Describe long term memory
Retrieval processes, permanent storage of unlimited capacity
Long term memory - declarative
Explicit
Person’s knowledge base, conscious awareness
Type of memories that go away
Long term memory - nondeclarative
Implicit
Person’s knowledge of skills and action patterns. Unconscious awareness
More likely to maintain and remember
t/f
Postmortem examination for definitive diagnosis
TRUE
t/f
When diagnosing dementia, physicians look for neural changes in combination with cognitive/behavioral changes
TRUE
Describe CT of dementia
Wide sulci
cortical atrophy
Enlarged ventricles
Huntington’s Disease atrohpy
More atrophy in deeper parts of brain
fMRI of dementia
Reduced blood flow in areas involved in memory and cognitive like hippocampus
PET for dementia
Reduced glucose metabolism in areas associated with memory and cognition
Postmortem studies of dementia
Required for definitive diagnosis
Reduction in brain volume
Decrease in neurons
Where do neural changes occur for - parkinson’s disease
Lewy body dementia
frontotemporal
PD = substantia nigra
Lewy body = Lewy bodies in coritcal and subcortial regions
Frontotemporal = pick bodies
Why is it good to diagnosis dementia before onset of symptoms
Stop disease progression
Minimize disease severity
Reverse disease symptoms
Greatest cause of dementia
Alzheimer’s Disease
60-70% of all dementia cases
Anti-inflammatory meds protective against AD
Hallmarks of AD
Memory loss is hallmark of AD
Early disease: working memory is intact but see semantic memory loss secondary to imparied storage or retrieval
Progressive disease: loss of recent past first
Retain childhood memories for longer time
Procedural memory and formulaic language preserved
Alzhiemers Disease: effects on Language and Communication
Word find issues
Comprehension of formulaic expressions like idioms are poor but production of conversational formulaic language preserved
Use of vague terms like thing or stuff
Discourse decent on surface level like good syntax and phonology but difficult maintain topics and conversation cohesion
Late stage: ambiguous speech and incoherent mumblings and repetition
AD can occur with/without behavioral disturbance (non-communicative behaviors)
90% of patients have behavioral disturbance
Personality changes
Delusions
Manic mood
Sleep disturbances
Sundowning
Pacing/wandering
Describe Vascular Dementia
Differeiented based on artecioscerotic changes in blood supply to brain
2nd most common cause
Abrupt onset of cognitive symptoms in a fluctuating but progressive course
Early: memory loss, personality changes, excessive dysfunction
Deficits depend on where in the brain the affected blood vessels are located
Frontotemporal dementia: primary progressive aphasia
Gradual loss of language function in the context of relatively well-preserved memory until the advanced stages
Fluent or nonfluent
Gradual onset and decline in language-specifc functions
Acute awareness of deficits unlike other types of dementia
Primary effects left frontal and temporal lobe language areas
Lewy body dementia
build up for protein deposits neurons
Similar to PD → tremors, rigid
Worse than AD → verbal fluency impairment and psychomotor slowing
Similar to AD → episodic memory impairment and language disturbance
Dementia can be secondary to these diseases
PD
Huntington’s disease (onset younger in adulthood)
HIV
Dementia evaluation - what is used
Additional cognitive batteries are useful when evaluating for dementia
Screening tools good for assessing range of cognitive abilities but age and culture may affect scoring
Mental status rating scales provide stages of disability
Mini Mental Status Exam (MMSE) looks at orientation, memory, visual-spatial, repetition; low score = most severe
Cognitive Batteries like Ross Information Processing Assessment - 2 (RIPA)
Memory assessments like Wechsler Memory Scale-III
t/f BDAE and WAB can be used to evaluate language and communication in dementia
TRUE
When evaluating dementia- describe daily functional status
Has there been a change in functioning?
Justifies need for therapy to improve interaction in social environments
Test: CADL or ASHA FCMs (NOMS)
Activities of Daily Living Instrumental Activities of Daily Living
T/F: ASHA NOMS level 1 - individual ability is independent
NOMS tests functional level for dementia
False
Level 1 is most severe - unable to speak in meaningful or familiar way
Dementia behavioral treatment - 3 strategies of Memory Treatment
Internal, external, environmental
Describe internal strategies for memory treatment for dementia
Internal:
mild/normal aging declines → WOPR, mnemonic devices and visual association
Spaced retrieval → recall info over time; relies on preservation of reading and procedural memory
But these might be difficult for someone with dementia to know when to use strategies
Describe external strategies for memory treatment
External:
Compensation → used when we know we won’t be changing person’s cognitive ability
Environmental cues like written reminders, calendars
Written information/pictures in “memory wallet”
People with dementia benefit from external strategies
Describe environmental strategies for memory treatment
Environmental:
Combo of internal and external strategies
Special care units → reduced environmental complexity, low stimulating environment
Social groups
t/f
TBI is 30% of all injury-related deaths
And falls are the leading cause of TBIs
TRUE
Mostly kids and older adults over 65
Define TBI
Craniocerebral injury from blow from an external mechanical force causing temporary or permanent impairments in brain function
The external force is what distinguishes TBI from stroke or infection
What is coup-contrcoup
Contusions on opposite sides of head
Coup = 1st point of impact Contrecoup = 2nd point of impact
Closed head injury associated with acceleration-deceleration movement
About 50% of all TBIs
TBI: Primary damage vs secondary damage
Primary:
Immediate effects
Coup-contrecoup (primary/focal-secondary/diffuse) or penetrating wound (focal)
Vascular injury
Secondary:
Affected post trauma
Ischemia
Increase in intracranial pressure
What is glasgow coma scale
15 point scale based on eye opening and verbal and motor responses
The lower the score the more severe
Verbal also incorporates cognitive
Motor also incorporates attention
Describe loss of consciousness severity
0-30 min = mild
30-<24 hrs = moderate
24hrs + = severe
Most qualitative with unclear boundaries
TBI prognosis
MRI/CT dhow depth of lesion associated with poorer outcomes (brain stem is most severe)
GCS = lower the score, the poorer the outcome
Duration of coma: severe disability “uniquely” with coma < 2weeks;
positive recovery “unlikely” with coma >4weeks
Basically, the lower the score, the deeper the damage and damage occurring both sides of brain = poorer outcoes
t/f
The cause of the TBI does not predict outcome
TRUE
When compared with less dependent TBI patients, more dependent TBI patients at admission to rehab _____, _____, etc. at discharge
More dependent:
- Make more progress
- Remain more dependent
- Slower rate of recovery
Less dependent = Shorter distance to go = less progress
End goal for TBI rehabilitation
Community reintegration
t/f
Common to all TBI survivors = reduced ability to pursue pre-injury career and leisure activities
True
Secondary cognitive impairment: attn, memory, organizing, communication, reasoning. Inhibition
Cognitive and communicative symptoms most likely the cause preventing patient to return to pre-injury QoL
Describe coma
State of unconsciousness, eyes closed, pt does not wake
Results of persistent, severe diffuse injury to both cortex and subcortical regions like brainstem
TBI cognitive impairments may affect:
Orientation (frontal lobe implications) → AAO
attention/concentration (thalamo-frontal pathways)
Memory - LTM, STM, working
Executive function
Anosognosia
Behavioral like immature, egocentric, irritable and impulsive
Communication → issue with lang. USE
What is AAO
Awake alert orientation
Cognitive rating for TBI
1 = person 2 = person and place 3 = person place time 4 = person place time situation
What is minimally conscious state
Often transitional state reflecting improvement in consciousness
Behavioral evidence of self or environments
Ability to follow simple commands unlike PVS can’t follow commands
Act of engaging in a response
Intentional movements (not reflexive)
assessments for cognitive-comm impairment in TBI
Standardized tests paired with Naturalistic informal testing (ST should not occur in isolation)
SLP scope: cognitive processes related to communicative behavior and language
Guideline developed by Academy of Neurologic Comm dis and Sciences (ANCDS)
Interventions (with evidence) for cognitive-comm impairments in TBI
Attention training → stimulus-drill approaches make best generalizations
External memory aids → not effective for mod-severe memory impairments (better for mild)
Instructing people with acquired memory impairments; evidence that structuring introduction of and use of procedures improves strategy learning
Self-monitoring → training strategies help to generalize
Behavioral intervention → traditional contingency management and positive behavior interventions (or both together) are valid EBP options
Treating TBI - what’s important!
The roles of family/caregivers and educating on nature of TBI and educating them on strategies to use
