Language and CognitionColombo, June 2011

Day 10Cognitive communication disorders

Traumatic brain injury / right hemisphere syndrome

Disorders of language

• Affect phonology, morphology, syntax, semantics– Broca’s aphasia, Wernicke’s aphasia etc

• Pragmatics?– Requires linguistic knowledge AND access to

other cognitive systems– Memory, attention, Theory of Mind, executive

functions etc

Cognitive disorders

• Affect cognitive systems other than language

• Pragmatics; Theory of Mind, executive function, attention, memory etc

• Syntax is OK– Also semantics, morphology, phonology

• BUT there may be issues with performance

Primary brain injury

• Sudden physical damage to the brain• Closed head injury: caused by the head forcefully hitting

an object such as the dashboard of a car • Penetrating head injury: caused by something passing

through the skull and piercing the brain, as in a gunshot wound

• major causes: motor vehicle accidents, falls, sports injuries, violent crimes, and child abuse

• Damage can be: – Focal, most often at the point where the head hits an object or

where an object enters the brain– Diffuse, when the impact of the injury causes the brain to move

back and forth against the inside of the bony skull– Coup / contre-coup– Axonal shearing

Coup / contre-coup injuries

Axonal shearing

• Results in:– Cell

miscommunication– Neurotoxicity– Microinflammation

Force

Force

Secondary brain injury

• Intracranial hematoma• Cerebral edema• Raised intracranial pressure• Infection (e.g. encephalopathy)• Seizures; Epilepsy• Results of metabolic changes: fever, low or high

blood pressure, low sodium, anemia, too much or too little carbon dioxide, abnormal blood coagulation, cardiac changes, lung changes, and nutritional changes

Assessing TBI

• For someone to have a TBI, one of the following has occurred.– Documented loss of consciousness– Amnesia for the event

• Anterograde Amnesia: Loss of memory after the injury• Retrograde Amnesia: Loss of memory before the injury

– The presence of a skull fracture, post-traumatic seizure, or a CT scan (computerized tomography) or MRI (magnetic resonance imaging) associated with trauma

– A Glasgow Coma Scale (GCS) score of less than 15 during the first 24 hours

Glasgow Coma ScaleEye Opening E

spontaneous 4

to speech 3

to pain 2

no response 1

Best Motor Response M

To Verbal Command:  

obeys 6

To Painful Stimulus:  

localizes pain 5

flexion-withdrawal 4

flexion-abnormal 3

extension 2

no response 1

Best Verbal Response V

oriented and converses 5

disoriented and converses 4

inappropriate words 3

incomprehensible sounds 2

no response 1

E + M + V = 3 to 15• Greater than or equal to 12 = Minor injury • 9 -11 = Moderate injury • Less than or equal to 8 = Severe injury

8 is the critical score • 90% less than or equal to 8 are in coma • Less than or equal to 8 at 6 hours - 50% die Coma is defined as: (1) not opening eyes, (2) not obeying commands, and (3) not uttering understandable words.

Cognitive Communication Deficits

• Focal injuries to speech/language regions of the brain disorders of language

• More diffuse damage, or damage to other areas of the brain disorders of communication – often indirect – e.g. communication impairment is a result of impairment to systems underpinning memory, attention etc

• May be specific difficulties following/participating in a conversation, formulating/expressing ideas, reading, writing, and/or completing mathematical tasks

http://lifecenter.ric.org/content/282/?topic=1&subtopic=294

Cognitive Communication Deficits

• Typically, cognitive communication disorders present with some combination of the following:– Attentional deficits– Reduced concentration during activities– Disorientation for time, place, person and/or situation– Memory impairments problems learning new information– Reduced ability to solve problems; the person may be unable

to begin (initiate) or may act too quickly (impulsive) without first organizing information and identifying the best solutions

– Problems interpreting (making sense of) sensory information– Reduced insight or awareness of problems– Cognitive and pragmatic problems impact overall

communicative ability

Right hemisphere syndrome

• Causes: as for aphasia, except that damage is to the non-dominant hemisphere (= RHS in most people)

• Cognitive / Communicative effects specific to RHS:– Difficulty attending to people and items on the person’s left side– Reduced pragmatic skills

• Establishing / maintaining eye contact• Initiating / maintaining a topic• Turn-taking• Interpreting and using facial / prosodic affect appropriately• Understanding and using other aspects of nonverbal communication

(gestures, body language)• Understanding known vs novel information

– Reduced structure and cohesiveness of narrative / discourse – Problems interpreting complex / indirect language such as

humor and/or metaphor

Example narrative (cookie theft)

“Well, this is a scene in a house. It looks like a fine spring day. The window is open. I guess it’s not Minnesota, or the flies & mosquitoes would be flying in. Outside I see a tree & another window. Looks like the neighbors have their windows closed. There’s a woman near the window wearing what appears to be an inexpensive pair of shoes. She’s holding something that looks like a plate. On the counter there, there’s a hat and two caps that look like they would fit on a child’s head…”

Example from Prof. M. Rouse, Biola University, CA

Example Narrative

• Picture description (T.S.)

“This guy’s sitting in front of a window working on a computer there this guy cleaning the windows working on the scaffolding and there’s a manager coming to the door smiling at the guy working it’s five thirty in the afternoon…”

Heterogeneity of Brain Injury

Hartley, L.L. (1995). Cognitive-Communicative Abilities Following Brain Injury: A Functional Approach. San Diego: Singular Publishing Group.

Assessing cognitive communication deficits

• Multidisciplinary team:– Physician / Neurologist– Neuropsychologist– Psychiatrist– OT– PT– Vocational therapist– Social worker/Case manager– SLP– Education Specialist– Counselor

Assessing cognitive communication deficits

Areas of Cognitive Assessment & Intervention

1. Arousal2. Perception3. Information Processing4. Attention

• Sustained• Simultaneous• Alternating

5. Memory/Learning6. Initiation7. Maintenance8. Flexibility9. Goal Directed Behavior10. Organization

– Planning/Sequencing

11. Self Awareness / Self Monitoring /Self Correction

12. Problem Solving/Reasoning

Areas of Speech & Language Assessment & Intervention

1. Auditory Processing2. Verbal Expression3. Pragmatics4. Reading 5. Writing6. Oral Motor Functioning

Note: Impact of Cognition on the above areas

Hierarchy: always work in a hierarchical progression from easiest to hardest

Functional: keep goals and tasks functional when possible

W.Ellmo 1997

Assessing cognitive communication deficits

• Assessments frequently used:– The Ross Information Processing Assessment (RIPA)

– Boston Diagnostic Aphasia Examination (BDAE)

– Boston Naming Test

– Scales of Cognitive Ability of TBI (SCATBI)

– Measures of Cognitive Linguistic Abilities (MCLA)

• Non-standardized Conversational and

Structured Language Sampling

• Patient and Family Report

Goal Development• Meet with other team members

• Unstructured conversation descriptions from other team members will help to reveal other possible difficulties– PT relays instructions on a specific exercise, patient performs

exercise wrong functional comprehension difficulties– Visual neglect and other difficulties (described by the OT) may

explain your findings and alter how you treat • E.g. Severe double vision would explain why your client performed poorly on

a reading or writing assessment; poor eye contact during assessment could be attributed to a neglect

Goal Development

• Develop speech-language goals based on your findings, descriptions from other disciplines, and patient/family input– Goals should be presented to the patient and discussed, they

are an active member of the treatment (you’re not going to get anywhere without them)

– Hierarchy of goals should progress in a logical way, but also take into consideration what the patient is most concern with and their awareness of the difficulties they are having

• E.g., the patient may be very aware that they are having word finding difficulties and describes this as a concern: good place to start

• Patient may not think they are talking too much describes this as their personality: not a good place to start

– Remember goals can be changed, if you start on one and it isn’t working out (e.g. due to levels of awareness, or general lack of cooperation), choose something more relevant

Intervention

• As a therapist you will often find yourself walking the line between increasing a patient’s awareness and making them feel successful

• Develop functional activities that address needs and utilized compensatory strategies to increase abilities

• Strategies will ALWAYS need to be adjusted based on your patient’s capabilities

• Begin with increased structure and cues, and decreased complexity. Gradually decrease structure/cues and increase complexity as the patient improves

• Always take into consideration information from other disciplines

Intervention

• The ultimate goal is that the patient is independent with strategy use to maximize function

• Because each patient will be completely different in terms of their presentation and personality there is no “cookie cutter” approach to intervention

• You will be most successful by looking at each patient as an individual, and shifting your approach as necessary

Follow-up with T.S.• A year post the initial recording, after receiving therapy 2-3 times

per week.

• There’s a guy typing on the computer there’s no keyboard… his lunch is on the desk, phone next him, guy’s cleaning the windows behind him it’s 5:30, there’s a guy interrupting him coming in the door… girl cleaning the windows with one pant rolled up… the phone is facing opposite him… it’s 5:30… there’s a glass of water and a cheeseburger on the desk… a lot of garbage in the garbage can… there’s a clock to his right, the blinds are up on the window… there’s a lot of paper coming out of the calculator or printer… there’s a pencil next to the water and the hamburger… there’s a guy standing in the door with a moustache… I think the guy that’s typing is black… the girl’s smiling that’s washing the windows… there’s no keyboard where he’s typing… his lunch is on the corner of the table, the phone is facing opposite him… there’s water coming out of the bucket… the guy coming in the door has a moustache… the girl has one pant leg rolled up that’s doing the windows… the guy’s black that’s typing, or he looks black, he has an afro… the phones facing the wrong way… it’s 5:30… There’s a lot of paper on the ground… the trash is overflowing and it says gas next to the garbage can… the girl’s smiling that’s washing the windows, the blinds are up… there’s no keypad that he’s typing on… I don’t know