Transcript CommunicationDisordersAdultsDrOrange

Communication Disorders
Across the Life Span: Adults
J.B. Orange, PhD
Associate Professor
[email protected]
X88921
Faculty of Health Sciences
School of Communication Sciences and Disorders
Outline

Overview of common speech, voice,
language, and cognitive-communication
disorders in adults

Assessment - screening

Referrals
Speech
(production and perception)



Medium of oral communication that employs
a linguistic code
Communication through vocal symbols
Complex, dynamic neuromuscular processes
of sound production





articulation
resonance
phonation
respiration
prosody (e.g., pitch, speech rate, stress, etc.)
Voice

Sounds produced in air above vocal chords
as chords vibrate

Use of vocal folds and associated muscular,
skeletal, cartilage, and nerve tissue

Source of sound energy

Linked with respiratory, resonatory and
speech systems
Resonance

Vibration of the air in the cavities above, below,
in front of, and behind the sound source

Nasal vs vocal
Swallowing

To pass substances through the oral cavity and
pharynx and into the esophagus

Complex, coordinated motor sequences of multiple
muscle systems

Initiated voluntarily but almost always completed
reflexively

Distinct from feeding

4 phases
Hearing

The sense through which spoken language or
non-speech sounds (i.e., via sound pressure
waves) are received, transmitted and
processed

Ears, auditory nerve and cerebral cortex
Language

a shared set of symbols used to represent concepts
or ideas

symbols governed by set of rules:
 phonology (sound positions and combinations)
 grammar (The boy randed to the store.)
 syntax (to store the boy the ran)
 semantics (define “car”)
 pragmatics (multiple interpretations of words, phrases,
clauses, or sentences - contextual influence, e.g., “run”,
“cold shoulder”)
Communication
1. exchange of concepts or ideas between two entities
 dynamic role exchange between speaker and
listener
2. mechanism whereby we establish, maintain and
change relationships

consists of multiple forms
 socially motivated and mediated = interactional
 agenda driven = transactional (e.g., ordering food
in a restaurant)
Cognition

processes of gaining knowledge, organizing
information (new or old), and using what has been
learned

includes, but is not limited to:
 memory systems and processes
 attention systems and processes
 judgment
 reasoning - decision making
 insightfulness
 other systems and processes
Communication Disorders
Hearing
Speech
Language
Conductive Loss
Voice (phonation)
Preschool Children
Specific Language Impairment
Pervasive Developmental Disorder
Sensorineural
Articulation
School Aged Children
Language Learning Disability
Retrocochlear and Central
Resonance
Adult and Older Adult
Aphasia
Dementia
Functional
Fluency
Motor Speech
Swallowing
Speech, Language, Hearing and
Communication
Input/Understanding
 auditory
comprehension
 reading
comprehension
 nonverbal
 senses of smell,
touch and taste
Output/Expression
 spoken
 written
 nonverbal (e.g., gaze,
facial expression,
posture, proximity,
touch, gestures,
pantomime, finger
spelling, sign
language, etc.)
Speech and Voice Disorders
Speech and voice based on integration of five
systems:
1.
2.
3.
4.
5.
respiratory
phonatory (vocal folds)
resonatory (coupling of pharyngeal, oral,
and/or nasal cavities)
articulatory
prosodic (duration, rate, rhythm, intensity,
pitch, and sound stress)
Dysarthria

disruption in one or more of systems that
produce speech and voice

often referred to as motor speech disorder

results from weakness, slowness, lack of
coordination, and altered tone of muscles
that support speech and voice

several types including flaccid, spastic,
ataxic, hypokinetic, hyperkinetic and mixed
Dysarthria (cont’d)

individuals normally understand spoken language,
can read and write (provided there are no physical
or sensory impairments of arms, hands or eyes)
 generally, no language problems

do not normally have trouble with word finding

mild to severe unintelligibility

if severe, anarthria (total inability to speak)
Common Speech and Voice Symptoms
in Dysarthria
Problem

articulation

speech rate
Symptoms

imprecise or unclear
sounds and syllables

rapid, slow, or irregular
speaking rate

vocal quality

hypernasal, breathy, hoarse,
strained-strangled; intermittent
voicing or aphonia (no voice)

loudness

too loud, too soft, intermittent
bursts of loudness, monoloud

monopitch, in-appropriate changes
in pitch, sound, syllable or word
stress problems

prosody
Apraxia of Speech (AOS)

motor speech disorder

difficulty initiating and sequencing speech movements
(difficulty programming muscle movements)

not as a result of:

listening (comprehension) problems

reflex problems

muscle strength or tone (e.g., paralysis or paresis)

cognitive or psychiatric problems
AOS (cont’d)

characterized by:

sound substitutions and additions (e.g., “take” for
“cake”)

transposition of syllables (e.g., “terbut” for “butter”)

difficulty initiating speech (physical groping to
produce sounds)

impaired prosody
Aetiology of Dysarthria and AOS: Selected
Examples

cerebral vascular accidents (CVA) = stroke = “brain attack”

head trauma

brain tumors

progressive neurological diseases (e.g., Parkinson’s disease,
amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS),
etc.)

negative side effects of psychotropic drugs (e.g., tardive
dyskinesia)

brain infections (e.g., encephalitis)
Aetiology of Voice Disorders: Selected
Examples
Organic








carcinoma
contact ulcers
trauma
polyps
tumors
nodules
web
cysts
Non-organic – Functional



stress and anxiety
conversion reaction –
emotional distress
other psychosocial factors
Voice Disorders (cont’d)

laryngeal cancer common cause of voice disorder

peak age occurrence between 60-70 years old

several studies link laryngeal cancer to excessive and
prolonged cigarette smoking and alcohol consumption

laryngeal cancer treated by radiation therapy,
chemotherapy, and in more advanced cases, surgery
Voice Disorders (cont’d)

complete removal of larynx (i.e., total
laryngectomy) requires new airway

permanent tracheostomy (i.e., stoma) created
just above sternum

person breathes through stoma

nose and mouth completely separated from
airway to lungs
Voice Disorders (cont’d)

after total laryngectomy, laryngectomee is
unable to phonate (i.e., produce a voice)
Several alternatives:
1. artificial larynx – electrolarynx (extra- or intraoral)

device that generates a vibration
while the resident articulates (i.e.,
moves, lips, tongue, soft palate)
Voice Disorders (cont’d)
2.
esophageal speech

breathing air into upper segment of
esophagus then expelling it to generate
vibratory tone

less common Rx option
Voice Disorders (cont’d)
3.
surgically created voice - tracheoesophageal
puncture (TEP)
 small opening made between trachea and
esophagus

one-way valve prosthesis inserted in opening

air drawn through valve into esophagus
where PE segment vibrates
Language Disorders - Aphasia
 acquired language disorder that affects:
 spoken and written language
 listening and reading comprehension
 nonverbal communication
 damage to cortical and/or subcortial regions
known to support language functioning
 different types and severity:
 depend on region(s) and amount involved
Aetiology of Aphasia: Selected
Examples

cerebrovascular accident (CVA = stroke = “brain
attack”)

traumatic brain injury (TBI)

neoplasm

infectious diseases

other (e.g., exposure to toxins, etc.)
Neural Basis of Aphasia

L and R cerebral hemispheres involved in language
processing

for many people L cerebral hemisphere controls
almost all language processes

focal damage to L hemisphere results in aphasia

R hemisphere contributes (but to lesser extent) to
language functioning

R hemisphere damage does not usually result in
aphasia
Broca’s Aphasia

slow, laboured speech

few spoken words; mostly nouns and verbs

spoken and written grammar are impaired

word finding problems

listening and reading comprehension skills impaired but better
than spoken language

person is aware of his/her language problems

AOS and R hemiplegia or hemiparesis can accompany
Wernicke’s Aphasia
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excessive amount of spoken language

word-finding problems

content often lacks meaning

significant listening and reading comprehension difficulties

well formed and normal speech (i.e., pitch, rate, rhythm, etc.)

person exhibits little awareness of his/her language problems
Global Aphasia

limited functional language and communication

may repeat a few common every day words or clichés
or non-words spontaneously or in response to
questions

poor listening and reading comprehension

may understand simple gestures or pantomime,
vocal inflection, facial expression and environmental
sounds

may be able to copy own name; writing usually nonfunctional
Anomia in Aphasia
Variety of word-finding errors:
1.
2.
3.
jargon - unacceptable sequencing of real
and/or nonwords (i.e., neologism =
“slammazer”)
vague/nonspecific words (e.g., “thing” for
“pen”)
phonemic paraphasia - word close in sound
to intended word (e.g., “pit” for “sit”)
4.
5.
semantic paraphasia - word closely related in
meaning to intended word (e.g., “salt” for
“pepper”)
verbal paraphasia – real word unrelated to
intended word (e.g., “cup” for “brother”)
Aphasia Recovery
Degree and speed of recovery of language varies
depending on:







spontaneous recovery
language Rx from SLP
severity at onset
aetiology
site and extent of brain damage
type of aphasia
other factors (L1 vs L2, sex, education level,
age, etc.)
Cognitive-Communication Disorders:
Dementia
Syndrome of acquired, progressive, persistent
decline in 3 of 5 spheres of mental activity:
1. memory
2. language and communication
3. personality
4. visuospatial skills
5. cognition (e.g., reasoning, abstraction, judgement, etc.)
DSM IV
A.
Multiple cognitive deficits including both:
1. memory impairment
2. one (or more) of the following:
a. aphasia
b. apraxia
c. agnosia
d. disturbance in executive functioning
(e.g., planning, organizing, sequencing, abstracting, etc.)
B.
Cognitive deficits in A1 and A2 each:
1. cause significant impairment in social or
occupational functioning
2. represent significant decline from previous
functioning
Epidemiology and Demographics: Prevalence
(CSHA I Working Group, 1994, CMAJ)
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252,600 (8% of 65+) (% distribution: community = institutions)
2 ♀: 1 ♂
2.4% 65-74 yrs
34.5% 85+ yrs
161,000 DAT (64% of total dementias)
19% VaD
Mixed = DAT + VaD = rising %
592,000 cases by 2021 (65 yrs + = 23-24% total pop)
# cases will triple by 2031
Incidence
(CSHA II Working Group, 2000, Neurology)

60,150 new cases dementia/yr

39,000 cases of DAT/yr
Examples of Types of Dementia
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DAT/AD
 EoAD
 DS-DAT
VaD
Mixed (DAT + VaD)
Lewy body disease
FTLD (FLD +
semantic dementia)






PPA
FTLD
Pick’s
Pick’s
Complex
Dementia with motor
neurone disease
 Parkinson’s, ALS,
MS, HC, etc.
AIDS dementia
CJD
Dementia (cont’d)

previously thought of as irreversible = nontreatable, although this is changing

prevalence increases dramatically with age
 DAT more common among those with low
education

subgroups of DAT (e.g., age of onset, family
history, frontal lobe signs, head trauma,
maternal age, level of formal education, etc.)
Speech, Language and
Communication Profiles in DAT
Speech
dysarthria

none
pitch changes

none
volume control

no problems
speaking rate

normal
apraxias

limb praxis problems
early; verbal and
oral apraxias may
appear later
Language and Communication
Language and communication problems prominent in DAT
 subtle onset; prominent with progression
Profiles vary by clinical stage
 markers of onset and progression
Language and communication of utmost concern to
caregivers
Heterogeneity (i.e., broad range of skills) within each stage
Language and communication profile in DAT differs from
those associated with:

normal aging

depression

confusion or
delirium

R hemisphere
dysfunction

stroke-based
aphasia

other focal neurological
disorders and
syndromes

psychiatric
disorders (e.g.,
schizophrenia)

traumatic brain injury
(e.g., motor vehicle
accident - MVA)
Prevalence of Language and
Communication Symptoms in DAT
Difficulties
Prevalence (%)
word finding ………
84
naming objects ……
82
letter writing ………
80
comprehend
instructions ………
76
sustain
conversation ……
71
complete ideas ……
64
repeat ideas ………
64
reading
comprehension …… 64
Difficulties
Prevalence (%)
meaningless
sentences ………… 60
decreased
talkativeness ……
58
inappropriate talk …
54
repeat words ………
45
interprets literally …… 33
recognizes humor …
32
increased
talkativeness ……… 16
(n = 99; Bayles & Tomoeda, 1991)
Language

errors appear early; related words
used then words become increasingly
less related

subtle changes early; reduced
meaning with progression; sentences
less elaborate and tangential; grammar
and syntax OK until late stage

intact
listening comprehension

problems apparent in middle stage;
Wh questions difficult; prosody and
nonverbal important
writing

semantically empty by middle stage

naming & vocabulary

spoken output

repetition


Communication

early subtle changes that can progress to mutism

short and frequent conversational turns

problems linking ideas within and between sentences

difficulty understanding humour, sarcasm, morals, gist,
figurative language

turn-taking and repair preserved through to late stage

topic initiation and management problems emerge in
early stage; prominent in middle stage
So What?
Communication Considerations for
Clinical Practice
1.
What is your agenda?

why are you communicating

why do you want to communicate with the person?

social connectedness, personhood and dignity

task-agenda driven (i.e., information gathering)
2.
Consider multiple options

strategy may work well then not work well later –
heterogeneity

partnership (speaker and listener roles)

active listener

optimize existing skills
 know strengths and limitations of all
participants

raise your awareness of how, what, where and
when you communicate
Elder-Speak, Patronizing Speech,
Secondary Baby Talk
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





increased loudness
exaggerated intonation
higher pitch
slow speaking rate
simplified syntax
simplified content
tag question
closed-end questions







short directives
short utterances
higher # utterances per
conversational turn
presumptions of poor
memory
nonverbal behaviours
terms of endearment,
pet names, nick names
use of first name
Communication Assessment (Screening)
Considerations
1.
Case Hx
•
medical
•
psychiatric
•
neurological
•
educational
•
linguistic
•
social
•
occupational
•
family dynamics
Screening Considerations (cont’d)
2.
Hearing
•
otoscopic examination
•
pure tone screening (+ impedance, where
possible)
•
assistive listening devices (e.g., Pocket
Talker)
•
referral to audiologist where necessary
Screening Considerations (cont’d)
3.
Language
A. Speaking
•
Spontaneous
•
Topic directed interview (“Tell me about
•
where you were born and raised
•
work or jobs you did
•
your family
•
your health right now
•
what you do each day
.
A. Speaking (cont’d)
Naming
•
confrontation (objects or pictures)
•
generative (animals, colours, letters F, A, S, etc.)
•
responsive (You get your prescription filled at a
Repetition
•
words (e.g., nouns vs verbs)
•
phrases (e.g., noun vs verb)
•
sentences (e.g., present vs past tense – regular vs
irregular)
.)

Listen for:
 word substitutions
 word errors
 emptiness of meaning
 topic digressions
 changes in content
 verbosity (or inhibition)
 grammar and syntax errors
B. Writing
 Spontaneous (not rote) vs copying




words
phrases
sentences
Copying
 words
 phrases
 sentences
C. Auditory Comprehension

complex vs simple language (1, 2, and 3 step
commands with and without body
movements)

note performance changes based on content,
grammar and syntax

consider influences on performance from
neurological, cognitive, psychiatric and
emotional status
D. Reading Comprehension
Reading aloud vs comprehension
 words
 phrases
 sentences

consider influences on performance based on word
class (e.g., nouns vs verbs vs prepositions), spelling
(regular vs irregular; “ship” vs “yacht”), among other
factors
Screening Considerations (cont’d)
4.
Caregivers’ Perceptions


what do family members note about changes in:

speech

language

hearing

communication
ask about content (e.g., word finding problems), form
(e.g., grammar and syntax) and use (e.g.,
appropriateness) of language and communication
SLP Referral Considerations
Sudden or gradual onset of:

unexplained slurred or unintelligible speech,
voice or language

harsh, breathy voice quality

hypernasality
SLP Referral Considerations (cont’d)

word finding problems

listening or reading comprehension problems

grammar or word order problems

spoken or written language that does not make sense

withdrawal from communication