Cognitive-Communication Disorders

An OverviewJody E. Rice, M.S., CCC-SLP

Disorders Review

Introduction

• What do these have in common?– Traumatic brain injury– Right hemisphere syndrome/dysfunction– Dementia

Introduction

• Is a cognitive-communication disorder the same as an aphasia?

• Is a cognitive-communication the same as a dysarthria? – An apraxia?

Why is the SLP involved?• Cognition and communication are intrinsically and

reciprocally related in both development and function

• Cognitive-communication disorders encompass any aspect of communication affected by disruption of cognition

• Areas of function affected by cognitive impairments include behavioral self-regulation, social interaction, ADLs, learning and academic performance and vocational performance.

ASHA 2004 Knowledge and Skills Document

Narrative Discourse Sample

Bang, bang, twang, bang, as a bullet knocks the cup of hot coffee away from the lips of our trusty ol’ [Bill]. Yes, old and weak he was but, is always trying, and to no prevail. It wasn’t his real name, we think, but if people only knew, the horrifying secret of this calm yet not so docile old guy! The fact, that he had a few years on the others in the train was to be determined at some other event of event at hand. We think

Narrative Discourse Sample, cont.

Though it was always, [Bill] this, and [Bill] that, every time he turned around, the echo prevailed; [Bill] was a feeble old, chap though he had this seemingly strike one against him, he continued. Don’t worry; we wonder how, just the same as you. Great minds think alike, or not, or there about.

International Classification of Functioning, Disability, and Health 2001

• Functioning & Disability– Body structures and Functions– Activity and Participation

• Contextual Factors– Environmental Factors– Personal Factors

Cognitive-Linguistic Model Cherney 2004

EXECUTIVE FUNCTION Sensory Reception Orientation

Organization

Attention

PerceptionMemory

Problem Solving

Reasoning

Effective Communication SkillsPragmatics & Discourse

Sensory Reception

• Passive process

• Reception of tactile, olfactory, gustatory, visual, auditory, proprioceptive, and kinesthetic information

Attention

• Alertness and Arousal– Level of vigilance vs. active direction of attention

toward a target• Types of Attention (Sohlberg and Mateer)

– Focused (short focus)– Sustained (focus for a period of time)– Selective (Paying attention w/distractions– Alternating (switching activites back & fourth)– Divided (multitasking)

Perception

• Active process• Provides structure to the environment• Integrates sensory information; Detects

salient features and patterns in sensory stimuli

• Olfactory & gustatory information processes subcortically; other sensory information processed cortically

Memory• Encoding

– Linking information to the context– Phonological loop vs. visuospatial sketchpad

• Storage– Integrating new information with current store; requires

reorganization of memory• Retrieval

– Activating memory from storage for immediate use– Context during learning should be same during retrieval– Explicit (declarative)(ride bike or smell) vs. Implicit (procedural)

• Retrospective (past events) & prospective (future events)

Organization

• Sorting

• Categorizing

• Sequencing

• Prioritizing

• Analysis/Synthesis

Reasoning/Problem-Solving

• Abstract thinking; ability to draw inferences and conclusions

• Deductive/Inductive; divergent(central concept then branch off)/convergent(what does cat dog elaphant have in commen?)

• Problem-solving requires convergent and divergent thinking, especially divergent thinking

• Judgment: predicting consequences, forming opinions

Executive Functioning(mom of the brain)

• Associated with all aspects of cognitive functioning• “CEO”; Supervisory capacity to direct actions• More apparent in novel, unstructured situations• Setting goals; planning and directing goal-oriented activity• Awareness of strengths and limitations• Initiating and inhibiting behavior• Monitoring activity• Evaluating results• Taking another person’s perspective• Applying learned skills to context

TRAUMATIC BRAIN INJURY (TBI)

Head Injury

• A traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes (BIAA)– Acquired brain injury (ABI)– Examples of causes of head injury

• Closed vs. Open head injury

Statistics

• 1.4 million sustain BI each year• Leading causes: falls (28%); MVA (20%)• Males 1.5 times more likely to sustain BI• Age groups: 0-4 y.o.; 15-19 y.o.• At least 3.17 million Americans currently have

a long-term need to help to perform ADLsBIAA

Neuropathology

• Primary damage– Contusions(bruise on frontal or temporal lobe) vs.

diffuse axonal injury(not a focused area)

• Secondary damage– Occur as a result of primary damage (hemorrhage,

bleading on brain, preasure, adema(swelling))

Figure 2.  The most common types of nonpenetrating traumatic brain injury are diffuse axonal injury, contusion, and subdural hemorrhage. The most common locations for diffuse axonal injury (pink) are the corticomedullary (gray matter-white matter) junction (particularly frontotemporal), internal capsule, deep gray matter, upper brainstem, and corpus callosum. The most common locations for contusions (blue) are the superficial gray matter of the inferior, lateral and anterior aspects of the frontal and temporal lobes, with the occipital poles or cerebellum less often involved. The most common locations for subdural hemorrhage (purple) are the frontal and parietal convexities.

Dr. R. Hughes, Neuropsychologist, VAMC 2008 Presentation

Outcomes

• Depth and duration of coma – GCS 13-15 mild 9-12 moderate ≤ 8 severe

GCS score of 8 or less for 6 hours or more tend to have a poorer outcome• Age• Secondary medical complications• Behavioral & Psychological factors

(mild)mTBI

• Common Symptoms:– Fatigue– Headaches; Visual disturbances – Memory loss; Poor attention/concentration – Slowness in thinking– Irritability-emotional disturbances– Seizures– Getting lost or confused

BI in the Military

• Continuum of care from time of injury• Services at James H. Quillen Mountain Home

VAMC• Blasts/explosions as a primary source of BI

(IED, landmine, grenade)– Matter is literally transformed from a gas to a

solid wall of pressure traveling about 1300 mph.

• http://uk.truveo.com/IED-Attack-On-Humvee-In-Iraq-Humvee-Roll-Over/id/502692489

PTSDPTSD Re-experiencingRe-experiencing

AvoidanceAvoidance Social withdrawal Social withdrawal

Memory gapsMemory gapsApathyApathy

MildMild TBITBIResidualResidual

Difficulty with decisionsDifficulty with decisionsMental slownessMental slowness

ConcentrationConcentrationHeadachesHeadaches

DizzyDizzyAppetite changesAppetite changes

FatigueFatigueSadnessSadness

ArousalArousal

Sensitive to noiseSensitive to noise ConcentrationConcentration

InsomniaInsomniaIrritabilityIrritability

DepressionDepression

COGNITIVE-LINGUISTIC ASSESSMENT/ TREATMENT

Assessment• No single assessment battery effective• Review of records; thorough case history• Behavioral observations• Information from family/significant others• Standardized testing

– Component cognitive processes– Basic language function + verbal integration and reasoning

• Environmental Needs Assessment(what do they do on daily basis)

• Evaluation of Everyday Performance– Checklists/rating scales for cognitive-comm:– Discourse comprehension and production

Cognitive-Linguistic Model Cherney 2004

EXECUTIVE FUNCTION Sensory Reception Orientation

Organization

Attention

PerceptionMemory

Problem Solving

Reasoning

Effective Communication SkillsPragmatics & Discourse

Testing Component Cognitive Processes

• Standardized Semi-Comprehensive Assessments– Brief Test of Head Injury– Scales of Cognitive Ability for Traumatic Brain

Injury– Cognitive Linguistic Quick Test– Ross Information Processing Assessment

• Tests of Specific Cognitive Processes(specific test like attention or memory)

Testing Basic Language Function & Verbal Integration/Reasoning

• Basic Language Function– Subtests of aphasia batteries

• Verbal Integration & Reasoning– Detroit Tests of Learning Aptitude– Right hemisphere language tasks– Other high-level language tasks

Evaluation of Everyday Performance

• Checklists/Rating scales

• Pragmatics/Discourse

• Environmental Needs Assessment/Ecological Inventory

Forms of Intervention

• Facilitation• Process-specific training• Functional approach• Skills training• Compensations(by pass)

INTERVENTION – A CONSIDERATION

• Tailor treatment approach to stage of recovery• Early

– Sensory stimulation

• Middle– Retraining of cognitive components

• Late– Functional integration of components; compensatory

strategies

Right Hemisphere Dysfunction

Dichotomies of Cerebral Hemispheres

LEFTVerbalLinguisticExpressionSymbolic/propositionalLogical/analyticFocal/discreteSegmental

RIGHTNonverbalVisual/kinestheticPerceptionVisual/imaginativeHolistic/syntheticDiffuseSpatial/global

• http://www.youtube.com/watch?v=ZVO2dcTUZRQ

Clinical Syndromes

• Visuoperceptual– Hemispatial neglect (attentional disorder)– Anosognosia (denial of illness)

• minimize deficit; attribute limbs to another; hatred of limb; exaggerate strength

– Environmental Agnosia (loss of environmental familiarity; inability to become topographically oriented)

– Prosopagnosia (failure to recognize familiar faces)

Clinical Syndromes, cont.

• Visuomotor– Constructional disability

• Neglect left half of model, errors in spatial relations, add extraneous material

– Dressing disturbances• Hemispatial neglect• Body-garment disorientation

Clinical Syndromes, cont.

• Affective and Emotional Alterations– Aprosody– Impaired affective auditory comprehension– Disturbances of emotional facial recognition– Altered emotional facial expression

• Memory Disorders– Retention of complex visual patterns/ faces– Nonverbal memory

Clinical Syndromes, cont.

• Neuropsychiatric Disorders– Visual hallucinations (r/t visual field defects)– Capgras’ Syndrome (loved ones replaced by

imposters)– Secondary mania (elated and/or irritable mood

lasting > 1 week)– Acute confusional states – Paranoid hallucinatory states

TREATMENT OF COGNITIVE-LINGUISTIC DISORDERS

Goal Setting

• Functional assessment• Identify long-term outcomes for life domains• Short-term objectives• Responses to be measured

– Consistency/accuracy– Efficiency/frequency– Duration– Response mode– Independence

Treatment

• Relation to ICF 2001 framework:– Treat underlying processes– Treat surface communication symptoms– Treat in appropriate contexts

• Integrative, collaborative approach

Treatment Principles

• Positive attitude – instill sense of ownership• Hierarchical organization – move from simple to the

complex; “error-free” environment• Concise, clear instructions and specific feedback• Use of strategies and problem-solving; task analysis• Self-talk; promote self-monitoring• Use natural consequences• Opportunity for generalization; role-play• Focus on functional routines

Attention Training• Process-Specific Training; Hierarchy• Environmental Adjustments

– Eliminate external distractions– Avoid clutter– One task at a time

• Compensatory Strategy Training– Self-talk: Am I paying attention? What am I supposed to

be doing?– Use of timer, alarm or watch– Other cognitive prosthetic devices– Breaks– Schedule more difficult tasks first

Memory Training

• Restoration vs. Compensation– Rehearsal– Focus on teaching of strategies– Internal vs. external strategies– Gear treatment to type of memory deficit

• External Memory Aids – Devices, notebooks

• Internal Retrieval Strategies

Dementia

Types of Dementia

• Primary (progressive & irreversible)– Alzheimer’s Disease: senile plaques and neurofibrillar tangles

• Secondary (progressive & irreversible)– Huntington’s Disease– Parkinson’s Disease

• Secondary (potentially reversible)– UTI– Stress/Fatigue

• Secondary (treatable but irreversible)– Alcoholic dementia

• http://www.alz.org/alzheimers_disease_4719.asp

Deficits Associated with AD• Cognition

• Language

• Perception– Figure ground, position in space, visuoconstructional skills,

facial agnosia• Psychomotor skills (apraxia)

Depiction of RetrogenesisReisburg

Dementia Dementia StageStage

GDS GDS LevelLevel

Developmental Developmental AgeAge

EarlyEarly 4-54-5 4-7 years4-7 years

MiddleMiddle 66 2-4 years2-4 years

LateLate 77 12-24 months12-24 months

EndEnd 7+7+ 1-12 months1-12 months

WHAT IS BEHAVIOR?

Behavior is the action or reaction of persons or things in response to unmet physical, emotional, social, or environmental needs.

Behavior is language for late stages 6 & 7

Speech-Pathologist’s Role

• Evaluation/staging• Active tx (if appropriate)• Development and training in use of Functional

Maintenance Program

Assessment

• Brief Cognitive Rating Scale (BCRS); GDS• Arizona Battery for Communication Disorders

of Dementia (ABCD)• Functional Linguistic Communication

Inventory (FLCI)

Treatment

• Active treatment vs. functional maintenance plans

• Stage of dementia• Following directions• New learning

FMPs

• Developed by SLP• Support staff trained by SLP • Approx. 2-3 week duration of tx