Transcript Chapter 8: Adult Aphasia and Other Cognitive

Chapter 8:
Adult Aphasia and Other
Cognitive-Based Dysfunctions
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.1
Focus Questions
•
•
•
•
•
What is aphasia?
How is aphasia classified?
What are the defining characteristics of
aphasia syndromes?
How is aphasia identified and treated?
What are right hemisphere dysfunction,
traumatic brain injury, and dementia?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.2
Introduction
• Language and cognitive disorders associated
with acquired neurological injury:
– Aphasia: difficulties in expressing, understanding,
reading, or writing oral and written language
– Right Hemisphere Damage: memory impairment,
attention and impulsivity problems, and visual
dysfunction
– Traumatic Brain Injury: cognitive impairment
caused by brain damage from injury
– Dementia: loss of linguistic and cognitive ability
due to a progressive brain disease
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.3
Case Study #1: Joe
• 48-year old carpenter who suffered a stroke
in the left frontal lobe two weeks ago
• He can understand other’s speech and can
communicate, though labored; also
weakness on his right side
• History of coronary artery disease, high-blood
pressure, and smoking habit put him at risk
for another stroke
• Primary wage earner for his family, so now
worried that his family will now be in financial
difficulty
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.4
Case Study #1 Questions
• What psychosocial issues do you see in
this case that will need to be considered
by the rehabilitation team working with
Joe?
• What strategies might be used to optimize
Joe’s recovery and ultimate return to
work?
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.5
Case Study #2: Maria
• 68-year old bilingual who emigrated from
Mexico to Texas in early 1990’s and cares
for her four grandchildren after school
• Suffered a stroke in the right hemisphere
three weeks ago – now vision problems,
weakness of left arm and leg, and difficulty
retrieving words (especially in English)
• Begins her outpatient rehabilitation
therapies next week
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.6
Case Study #2 Questions
• If you were not competent in Spanish, are
you able to evaluate Maria? What
challenges might you face?
• How would you determine if therapy
should be conducted in English, Spanish,
or both?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.7
Case Study #3: Mable
• 72-year old woman who lives alone in
Florida, but two adult children both live within
15 minutes
• Mable is having increasing periods of
forgetfulness (locked herself out of her
house, got lost going to usual beauty salon,
etc.)
• Daughter is very concerned and wants Mable
to see the family physician, but son says that
the forgetfulness is expected at his mother’s
age
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.8
Case Study #3 Questions
• Why is it important for Mable to have a
complete physical with her physician?
• How might the family dynamics in this
scenario influence Mable’s outcome?
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.9
I. What is Aphasia?
• Literally means “without language”
• Definition:
– A disturbance in the adult language system
after the language has been established or
learned
– Results from neurological injury to the
language-dominant hemisphere of the brain
– Includes disturbances of receptive and/or
expressive abilities for both spoken and/or
written language
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.10
Additional Considerations
• Aphasia is not developmental, it is
acquired following a neurological injury
• A person with aphasia usually has intact
psychosocial skills;
– Must be careful not to confuse language
deficits in of an individual with aphasia for a
more general psychological disturbance
• Aphasia is a language-based dysfunction,
not a motor-based dysfunction, although
the two sometimes coexist
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.11
II. How is Aphasia Classified?
•
Aphasia types should be grouped or
classified (taxonomy), but some debate
over how to do this
1. Categorization by cause and location of
the brain damage
2. Categorization based on the language
characteristics
-fluent vs. non-fluent speech
-receptive vs. expressive deficits
-motor vs. sensory deficits
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.12
Behavioral Symptoms
• Most professionals classify aphasia types based
on distinct behaviors:
–
–
–
–
–
Fluency of expression
Language comprehension
Naming
Repetition
Additional considerations:
• Motor output: Are the motor systems involved with speech
affected? This indicates a concomitant motor-speech
disorder
• Reading and writing: To what extent is reading and writing
affected? This usually reflects the overall impact of aphasia
on language more generally
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Communication Sciences and Disorders: An Introduction
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8.13
Fluency
• Expression of thoughts using a smooth,
uninterrupted flow and rate of speech
• Fluent aphasia: spontaneous speech flow
with adequate phrase length
– Generally reveals posterior brain damage
(temporal/parietal regions)
• Non-fluent aphasia: diminished phrase
length, slowed or labored speech
production, grammatical errors
– Generally reveals anterior brain damage
(frontal lobe)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.14
Language Comprehension
• Ability to understand spoken messages
• Influenced by:
– Amount of information
– Frequency of word usage
– Personal relevance of information
– Part of speech
• Based on this ability, aphasia can be
classified as predominantly receptive or
predominantly expressive
Justice
Communication Sciences and Disorders: An Introduction
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8.15
Repetition
• Ability to accurately reproduce verbal
stimuli
• In order to display this ability, one must:
– Receive and process incoming stimulus
– Convey the information to regions of brain
that formulate and plan motor sequence for
speech
– Articulate to reproduce the initial stimulus
• Repetition skills can subcategorize a more
general classification
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Communication Sciences and Disorders: An Introduction
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8.16
Naming
• Ability to retrieve and produce a targeted
word
• Anomia: disturbance in the ability to name
• Most pervasive and most persistent deficit
• Paraphasias (patterns of speech errors):
– Phonemic: substitution or transposition of the
targeted phoneme (non-fluent, expressive,
motor aphasia group)
– Semantic: error is related or in the same
category but is incorrect (fluent, receptive,
sensory aphasia group)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.17
Reading and Writing
• Written language disturbances usually
parallel spoken language impairments
– Non-fluent speakers will also be non-fluent in
writing and reading
– Individuals with auditory comprehension
problems also have problems comprehending
written information
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.18
Aphasia Syndromes
• More refined labeling of the aphasias
facilitates communication across
professional disciplines
• Described based on the defining, salient
characteristics
• Aphasia syndromes include:
-Broca’s
-transcortical motor
-global
-Wernicke’s
-conduction
-transcortical sensory
-anomic
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Communication Sciences and Disorders: An Introduction
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8.19
Broca’s Aphasia
• Location of damage: frontal lobe, specifically
Broca’s area
• Non-fluent, expressive, motor
• Slowed, labored, telegraphic speech; short
phrases, agrammatical speech
• Expressive problems are hallmark of this
type, but also receptive deficits
• Repetition and naming difficulties range from
mild to severe
• Reading is slowed and laborious, writing is
effortful and oversized (macrographia)
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Communication Sciences and Disorders: An Introduction
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8.20
Transcortical Motor Aphasia
• Location of damage: frontal lobe, typically
superior and anterior portions
• Non-fluent, expressive, motor
• Characteristics are the same as Broca’s
aphasia except these clients show far
better repetition skills
• Also show strong performance in oral
reading
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.21
Global Aphasia
• Location of damage: large region of brain
or multiple sites of injury
• Non-fluent, both receptive and
expressive, and both motor and sensory
• Severe problems communicating
• Often non-verbal with limited gestures
• Reading and writing deficits
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Communication Sciences and Disorders: An Introduction
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8.22
Wernicke’s Aphasia
• Location of damage: temporal lobe, possible
parietal also, specifically Wernicke’s area
• Fluent, receptive, sensory
• Spontaneous speech with normal prosody,
sometimes even logorrhea, but meaningful
content is limited
• Semantic paraphasias, neologisms, jargon
• Poor auditory comprehension, repetition, and
naming (use circumlocution), writing is fluent
but message is unclear (like verbal)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.23
Transcortical Sensory Aphasia
• Location of damage: border of the
temporal and occipital lobes or the parietal
lobe (superior region)
• Fluent, receptive, sensory
• Characteristics are the same as
Wernicke’s aphasia except these clients
show far better repetition skills
– Sometimes even frequent verbal repetitions of
random auditory stimuli (echolalia)
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.24
Conduction Aphasia
• Location of damage: temporal-parietal
region, usually a connector pathway called
arcuate fasciculus
• Fluent, mild deficits in expression or
reception
• Inabilities to repeat verbal stimuli or read
aloud – receive and process stimuli but
cannot transfer this to the verbal output
area
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.25
Anomic Aphasia
• Location of damage: no specific area
• Fluent and meaningful
• Word retrieval deficits in both spoken and
written language
• Most pervasive and most common
aphasia profile
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.26
Aphasia - Causes
• Results from neurological damage or brain
injury
– Stroke: most common cause – blood supply
providing nutrients and oxygen to the brain is
interrupted (when language area of the brain
is affected, aphasia can happen)
– Infectious diseases
– Tumors
– Exposure to toxins or poisons
– Hydrocephalus
– Nutritional or metabolic disorders
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.27
Aphasia
Prevalence and Incidence
• National Stroke Association:
– Stroke occurs every 45 seconds in the U.S.
– 750,000 people each year
– Total number of surviving stroke victims in the
United States: 4 million
– Health care costs in this country for stroke:
$30 billion annually
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.28
Aphasia – Risk Factors
• Uncontrollable factors
– Age
– Gender
– Racial or ethnic background
– Family history
• Controllable factors
– Hypertension
– Diabetes
– Tobacco smoking
– Alcohol use
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.29
III. How is Aphasia Identified?
• Assessment of speech and language
disturbances – important component
• Assessment and treatment completed by
interdisciplinary team of professionals using a
holistic approach
• Evaluation goals will address:
– Presence or absence of aphasia
– Type or syndrome of aphasia
– Most beneficial treatment plan
– Prognosis for recovery
– Referrals to other professional as needed
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.30
Assessment of Aphasia
• Initial informal clinical assessment (survey of
speech and language performance in about 30
minutes):
– Aphasia Language Performance Scales (ALPS)
– Bedside Evaluation Screening Test (BEST)
• Extensive, comprehensive assessment (after
client becomes more medically stable):
– Choice of Aphasia battery influenced by clinician
preference, test availability and unique client
needs
• Assessment should be ongoing and
comprehensive
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.31
IV. How is Aphasia Treated?
A. Prognostic Indicators
• Factors that predict or determine which
clients will benefit from therapy
• Include:
–
–
–
–
–
–
Site, type, and size of brain injury
Time post onset (TPO)
Type and severity of aphasia
Handedness
Age
Pre-injury status
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Communication Sciences and Disorders: An Introduction
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8.32
B. Designing Treatment Plans
•
Treatment strategies: the client’s
compensatory strategies
– Self-directed
– Clinician-directed
•
•
Treatment approaches: target the specific
deficits and the underlying processes that
produce the errors
When designing treatment plan, consider
evidence-based practice (interventions that
have been studied and proven effective in a
controlled setting for a particular disorder)
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Communication Sciences and Disorders: An Introduction
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8.33
C. Determining the Setting
• Multiple environments should be used for
treatment to facilitate carryover of
improvements
– Co-treatments with occupational therapist
– Community reentry programs
– Group therapy (most beneficial for chronic
aphasia)
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.34
D. Measuring Outcomes
• Carryover of test scores to real-world
communication is the standard for
effectiveness of treatment
• Outcomes: functional communication
improvements with intervention
• Instruments to measure outcomes:
– Communication Abilities of Daily Living,
Second Edition (CADL-2)
– Functional Independence Measures (FIMS)
– ASHA Functional Assessment of
Communication Skills (ASHA-FACS)
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.35
V. Cognitive-Based Dysfunctions
• Right Hemisphere Dysfunction
• Traumatic Brain Injury
• Dementia
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.36
What is Right Hemisphere
Dysfunction (RHD)?
• Neurological damage to the right cerebral
hemisphere
• Communication profile is different than
aphasias (left hemisphere is usually
language hemisphere)
• Cognitive, perceptual or behavioral
disruptions are most prevalent, but still
language difficulties
• Cognitive-linguistic disorder
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Communication Sciences and Disorders: An Introduction
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8.37
Defining Characteristics of RHD
• Lack of insight to deficits
• Lack of attention or complete neglect of
the left side of the body
• Difficulty recognizing faces
• Compromised pragmatics
• Problems understanding and/or using
higher-level cognitive-linguistic skills
• Neuromotor compromise, resulting in
dysarthria or dysphagia
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Communication Sciences and Disorders: An Introduction
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8.38
How is RHD Identified?
• Comprehensive speech-language
assessment by interdisciplinary team
• Additionally, further assessment of:
– Higher-level language skills
– Visual-perceptual performance
– Pragmatic appropriateness
• Available standardized batteries:
– Mini Inventory of Right Brain Injury (MIRBI)
– Right Hemisphere Language Battery (RHLB)
– Clinical Management of Right Hemisphere
Dysfunction-Revised (RICE-R)
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.39
How is RHD Treated?
• Initial therapy:
– Management of attention and visual
disruptions
• Further treatment:
– Higher-level cognitive-linguistic tasks
– Activities for explain abstract thoughts or
making inferences
– Pragmatics of communication interactions
– Both individual and group treatment
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.40
What is Traumatic Brain Injury?
• Neurological damage resulting from external
forces impacting upon the brain
• TBI occurs mostly from motor vehicle
accidents, falls, and acts of violence
• Leading cause of death and disability in U.S.
• Males twice as likely to suffer from TBI
• Lower SES backgrounds more likely
• Infants, adolescents, and senior citizens
more likely
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Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
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8.41
Defining Characteristics of TBI
• Open-head injuries: skull and brain have
not been penetrated – focal injuries
• Closed-head injuries: no penetration of
skull or brain, but brain jostled – diffuse
injuries
• Diverse group: cognitive impairments are
a result of the size, location, and overall
severity of the injury
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.42
How are Cognitive-Linguistic
Deficits of TBI Identified?
• Early phases of TBI:
– Glascow Coma Scale: observes eye opening,
motor behavior, and verbal responses
– Rancho Los Amigos Levels of Cognitive
Function: eight levels of cognitive functioning
• Later phases (after client improves medically) –
more extensive testing:
– Brief Test of Head Injury
– Scales of Cognitive Ability for TBI
– Ross Information Processing Assessment – 2nd
Edition
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.43
How are Cognitive-Linguistic
Deficits of TBI Treated?
• Early stages – Rancho Levels I-III:
– Stimulation treatment: activities to facilitate
arousal, altering, and attention
• Middle stages – Rancho Levels IV-VI:
– Tasks to establish basic communication
systems
• Later stages – Rancho Levels VII-VIII:
– Focus on facilitating independence
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.44
What is Dementia?
• Chronic and progressive decline in memory,
cognition, language, and personality resulting from
CNS dysfunction
• Alzheimer’s disease is the most common disorder
producing dementia
• Dementia is the most prevalent in the older
population
• DSM-IV Criteria:
–
–
–
–
Memory impairment
Cognitive skills deficits
Either aphasia, apraxia, or agnosia
Must have a gradual onset and progressive functional
decline
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.45
Characteristics of Mild Dementia
• Forgetfulness, even of basic information
and common routines
• Decreased vocabulary choices
• Reduced or verbose conversation
• Anomia
• Pragmatics and motor function are still
intact
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.46
Characteristics of Moderate
Dementia
• Disoriented to time and place
• Poor attention and memory
• Marked language difficulties (anomia,
repetition problems, “empty” conversation,
difficulty understanding humor)
• Restlessness and roaming may occur
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.47
Characteristics of Severe
Dementia
• Disorientation
• Minimal cognitive ability
• Very poor language and comprehension
skills
• Motor skills vary, but many are confined to
a wheelchair and unable to control bowel
and bladder functions
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.48
How is Dementia Identified?
• Screening of mental status:
– Mini Mental State Examination
– Mental Status Subtest of the Arizona Battery
for Communication Disorders of Dementia
• Comprehensive testing:
– Arizona Battery for Communication Disorders
of Dementia (ABCD): tests linguistic
comprehension, linguistic expression, verbal
memory, visuospatial skills, and mental status
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
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8.49
How is Dementia Treated?
• Mild to moderate cases:
– Activities to compensate for deficits
– Environmental changes to promote safety
– Education for family members
– Active support groups for caregivers
• Severe cases:
– Resources necessary are probably beyond
capabilities of the family
– Long term placement in a nursing home or
supported group environment is necessary
Justice
Communication Sciences and Disorders: An Introduction
Copyright ©2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.