Cognitive Linguistic Disorders

Definition

  • A cognitive-linguistic impairment is often the result of a right brain injury.

  • Does not directly affect the language area of the brain

  • Can affect attention, memory, problem solving and interpretive language,

    • Affect communicative abilities.

  • Evaluation of cognitive-linguistic impairments involves tasks of short-term and long-term memory, divided, sustained, and selective attention, social language skills, and abstract reasoning.

https://www.stonybrookmedicine.edu/patientcare/speechhearing/speechlanguage/cognitive_linguistic_impairments

Mild Cognitive Impairment

  • MCI is described as an stage of cognitive impairment that is often a transitional phase from cognitive changes in normal ageing to those typically found in dementia

  • does not interfere with independence in everyday activities

  • Clinical Criteria for Diagnosing Mild NCD

    • a modest decline from previous levels of performance in one or more cognitive domains, including complex attention, executive function, learning and memory, language, perceptual motor, or social cognition (preferably documented by standardized testing or clinical assessment);

    • cognitive deficits do not interfere with the ability to independently perform everyday activities (although some may require greater effort or use of compensatory strategies),

    • cognitive deficits do not occur exclusively in the context of delirium, and

    • cognitive deficits are not better explained by other mental disorders, such as major depressive disorder or schizophrenia

https://www.asha.org/practice-portal/clinical-topics/dementia/

A syndrome resulting from acquired brain disease

Diagnostic Criteria

  • A significant decline from previous levels of performance in one or more cognitive domains, including complex attention, executive function, learning and memory, language, perceptual motor, or social cognition (preferably documented by standardized testing or clinical assessment);

  • Cognitive deficits interfere with independence in everyday activities;

  • Cognitive deficits do not occur exclusively in the context of delirium; and

  • Cognitive deficits are not better explained by other mental disorders, such as major depressive disorder or schizophrenia

Behavioral problems

  • Paranoia, hallucinations, and repetitiousness may also develop as a result of the neuropathology and may interfere with communication.


**The symptoms associated with dementia continue to progress in severity until death **

Signs and Symptoms of Dementia

Attention

  • Easily distracted

  • Difficulty attending, unless input is restricted/simplified

  • Decreased information-processing speed—thinking/processing takes longer than usual

Learning and Memory

  • Episodic memory deficits, including difficulty remembering autobiographical events, situations, and experiences

  • Short-term/working memory deficits—rapid forgetting of information recently seen or heard

  • Difficulty recalling names of family and friends

  • Difficulty acquiring and remembering new information (e.g., appointments or events, new routines) without specific supports or strategies

Reasoning and Executive Functioning

  • Difficulty setting goals and planning, including reliance on others to plan activities and/or make decisions

  • Poor judgment and impaired reasoning and problem-solving abilities (e.g., making decisions without regard to safety)

  • Difficulty multitasking and handling complex tasks—need to focus on one task at a time

  • Difficulty responding to feedback

  • Poor self-monitoring and ability to correct own errors

  • Lack of inhibition

  • Lack of mental flexibility

Perceptual Abilities

  • Difficulty completing previously familiar activities or navigating in familiar environments

  • Inability to recognize familiar people, common objects, sounds, and so forth

  • Inability to find objects in direct view, independent of visual acuity

  • Other visuo-perceptual difficulties, such as trouble with depth perception and sensitivity to light

Language

  • Less concise (empty) discourse with fewer ideas

  • Economy of utterances (using fewer words) and stereotypy of speech

  • Repetitious/perseverative language (e.g., asking the same question repeatedly)

  • Word-finding difficulties signaled by long latencies, paraphasia's, and word substitutions

  • In people who are bilingual, errors in selecting and maintaining appropriate language during conversation

  • In people who are bilingual, regression to primary language

  • Tangential language

  • Circumlocution

  • Grammatical errors, including omission or incorrect use of articles, prepositions, auxiliary verbs, and so forth

  • Use of jargon and loss of meaningful speech

  • Impaired ability to compose meaningful written language

  • Difficulty following and maintaining conversation

  • Language comprehension deficits

  • Difficulty following multistep commands

  • Reading comprehension difficulties with complex materials

Behavioral and Psychosocial

  • Anger and aggression

  • Anxiety or agitation

  • Forgetfulness and confusion

  • Repetitive actions

  • New suspicions

  • Wandering and getting lost

  • Trouble sleeping

  • Mood fluctuations, including agitation and crying

  • Negative reaction to questioning

  • Loss of initiative and motivation

How Does a Person with Dementia See the World?

An acquired brain injury—usually secondary to stroke or TBI—that causes impairments in language and other cognitive domains that affect communication.

Syntax, grammar, phonological processing, and word retrieval typically are not affected. However, RHD can affect

  • semantic processing of words;

  • discourse processing -including narratives

  • prosody

  • pragmatics

  • RHD can also cause impairments in other cognitive domains

    • Attention, memory, and executive functioning

    • Impairments can include

    • Anosagnosia (reduced awareness of deficits)

    • Visual Neglect (aspects of visual stimulus are ignored)

        • both of which can significantly affect spoken and written language.

RHD results in a collection of symptoms that vary in severity and in domains affected, depending on the site and extent of injury to the underlying neural substrate.

Language

RHD does not typically affect word retrieval, syntax, and/or repetition, as seen in aphasia. However, if the left hemisphere language centers are also damaged (e.g., in TBI), RHD symptoms can co-occur with classic aphasia symptoms.

Language deficits typically affected by RHD include the following:

  • Discourse comprehension deficits marked by

    • difficulty understanding abstract language, figurative language, lexical ambiguities, or information that can be interpreted in multiple ways

    • difficulty making inferences and understanding the global meanings of discourse such as topic, gist, and big picture

    • difficulty understanding jokes, irony, and sarcasm; and

    • difficulty understanding others' emotions.

  • Discourse production deficits marked by

    • verbosity

    • egocentric, tangential comments and digressions from the topic

    • focus on irrelevant details

    • disorganized thoughts

    • impulsive, poorly organized responses

  • Pragmatic communication deficits, including reduced eye contact, poor turn taking, and decreased conversation initiation.

  • Semantic processing deficits, particularly at higher levels of functioning such as understanding the metaphorical meaning of words (e.g., “a sea of grief” and “roller coaster of emotions”).

  • Aprosodia—reduction or absence of normal variations in pitch, loudness, intonation, and rhythm of speech to express meaning or emotion.

  • Flat affect—severely reduced emotional expressiveness; individual may speak in a monotonous voice (Aprosodia) and have diminished facial expressions

Other Cognitive Impairments

Cognitive impairments are not exclusive to RHD. For example, memory deficits are often associated with any injury to the brain, including stroke and TBI

Cognitive deficits typically associated with RHD that can affect communication include

  • reduced sustained attention

  • reduced selective attention (easily distracted)

  • reduced attention to detail

  • unilateral visual neglect—typically, the left side

  • decreased or no awareness of deficits (anosognosia)

  • reduced reasoning and judgment

  • difficulty with sequencing and problem solving

  • impaired executive functioning skills

  • reduced inhibition

  • reduced recognition of facial expression

Other Deficits

Other deficits that may be associated with RHD include

  • emotional disorders such as emotional lability (e.g., crying or inappropriate laughing), difficulty interpreting and conveying emotions, and reduced empathy

  • dysphagia

  • dysarthria

  • hemiparesis/hemiplegia

TBI Severity

Severity of TBI is based on the extent and nature of the injury, duration of loss of consciousness, posttraumatic amnesia (PTA; loss of memory for events immediately following injury), and extent of confusion at initial assessment during the acute phase of the injury

Levels of severity

  • Concussion/Mild TBI—loss of consciousness for up to 30 minutes; or confused or disoriented state lasting less than 24 hours; or memory loss lasting less than 24 hours. Excludes penetrating TBI. Results of a computed tomography (CT) scan, if obtained, are normal.

  • Moderate TBI—loss of consciousness for more than 30 minutes, but less than 24 hours; or confused or disoriented state lasting more than 24 hours; or memory loss lasting more than 24 hours but less than 7 days; or meets criteria for concussion/mild TBI but with an abnormal CT. Excludes penetrating TBI. A structural brain imaging study may be normal or abnormal.

  • Severe TBI—loss of consciousness for more than 24 hours; or confused or disoriented state lasting more than 24 hours; or memory loss lasting more than 7 days. Excludes penetrating TBI. A structural brain imaging study may be normal but usually is abnormal.

  • Penetrating TBI—open head injury; scalp, skull, and dura mater (outer layer of meninges) are penetrated. Caused by high-velocity projectiles, objects of lower velocity such as knives, or bone fragments from a skull fracture that are driven into the brain.

https://www.asha.org/practice-portal/clinical-topics/traumatic-brain-injury-in-adults/

**TBI is a form of nondegenerative acquired brain injury, resulting from an external physical force to the head or other mechanisms of displacement of the brain within the skull.

**Focal or Widespread damage to the Brain

**Damage due to Primary or Secondary Damage

Common Characteristics

  • Changes in levels of consciousness

  • Memory disturbances

  • Confusion associated with deficits in orientation

  • Neurological signs, such as brain injury observable on neuroimaging, new onset or worsening of seizure disorder, visual field deficits, and hemiparesis

Pediatrics

The functional impact of TBI in children can be different than in adults—deficits may not be immediately apparent because the pediatric brain is still developing. TBI in children is a chronic disease process rather than a one-time event, because symptoms may change and unfold over time

  • Mild TBI (mTBI) — loss of consciousness for less than 30 minutes, an initial Glasgow Coma Scale (GCS) or Pediatric GCS of 13–15 after 30 minutes of injury onset, and PTA for not greater than 24 hours (CDC, 2015; McCrory et al., 2013; Ontario Neurotrauma Foundation, 2013).

    • Uncomplicated — mTBI where there are no overt neuroimaging findings.

    • Complicated — mTBI where there are intracranial abnormalities (e.g., bruising or a collection of blood in the brain) seen on CT scan or MRI.

  • Moderate TBI — loss of consciousness and/or PTA for 1–24 hours and a GCS of 9–12 (CDC, 2015).

  • Severe TBI — loss of consciousness for more than 24 hours and PTA for more than 7 days with a GCS of 3–8 (CDC, 2015).

Concussion, a form of mTBI, is an injury to the brain characterized by the physical and cognitive sequelae of TBI.

Concussion typically occurs as a result of a blow, bump, or jolt to the head, face, neck, or body that may or may not involve loss of consciousness

Concussion has received more attention in recent years, particularly with respect to sports injuries.

https://www.asha.org/practice-portal/clinical-topics/pediatric-traumatic-brain-injury/#collapse_3

Signs and Symptoms of TBI

*Adult and Pediatric Symptoms*

Physical

  • Changes in bowel and bladder function

  • Changes in level of consciousness, ranging from brief loss of consciousness to coma

  • Dizziness

  • Fatigue

  • Headaches

  • Impaired movement, balance, and/or coordination

  • Motor speed and programing deficits (dyspraxia/apraxia)

  • Nausea

  • Pain

  • Reduced muscle strength (paresis/paralysis)

  • Seizures

  • Vomiting

Sensory–Perceptual

Auditory and Vestibular

  • Auditory dysfunction from injury to the outer ear, middle ear, inner ear, and/or temporal lobe, resulting in

Visual

  • Changes in perception of color, shape, size, depth, and distance

  • Changes in visual acuity

  • Blurred vision

  • Double vision (diplopia)

  • Problems with visual convergence and accommodation

  • Sensitivity to light

  • Visual field deficits/visual neglect

Other Sensory–Perceptual

  • Gustatory—loss of taste

  • Olfactory—inability to recognize smells

  • Tactile—sensitivity or defensiveness to touch; changes in perception of pain, pressure, and/or temperature

https://www.asha.org/practice-portal/clinical-topics/traumatic-brain-injury-in-adults/#collapse_3

Cognitive

Attention

  • Deficits in shifting attention between tasks

  • Difficulty with selective attention

  • Impaired sustained attention (e.g., for task completion)

  • Reduced attention span

Executive Functioning

  • Difficulty with the following:

Information Processing

  • Increased response latencies

  • Reduced processing speed (e.g., of rapid speech and/or complex language), resulting in confusion

Memory and Learning

  • Deficits in short-term memory that negatively affect new learning

  • Deficits in working memory that negatively affect following directions and task completion

  • Difficulty remembering to perform a planned action (prospective memory) such as remembering to take medication

  • Difficulty retrieving information from memory

  • Post-traumatic amnesia marked by impaired memory of events that happened shortly before the injury (retrograde)

Metacognition

  • Lack of insight for monitoring one's strengths, weaknesses, functional abilities, problem situations, and so forth

  • Reduced awareness of deficits (anosagnosia)

Other Cognitive Deficits

  • Deficits in orientation to self, situation, location, and/or time

  • Impaired spatial cognition that can affect ability to navigate and ambulate

https://www.asha.org/practice-portal/clinical-topics/traumatic-brain-injury-in-adults/#collapse_3

Language

Pragmatic/Social Communication

  • Conversational turns marked by verbosity

  • Difficulty initiating conversation and maintaining topic

  • Difficulty taking turns in conversation

  • Difficulty inhibiting inappropriate language or behavior

  • Impaired ability to use nonverbal communication effectively (e.g., tone of voice, facial expression, body language)

  • Impaired social cognition skills (e.g., regulating emotion; expressing emotion and perceiving emotion of others; ability to take the perspective of others and to modify language accordingly)

  • Inability to interpret others' nonverbal communication

  • Tendency to be tangential

Spoken Language

  • Anomia or word retrieval deficits

  • Decreased ability to formulate organized discourse or conversation

  • Difficulty following directions

  • Difficulty formulating fluent speech

  • Difficulty making inferences

  • Difficulty understanding abstract language/concepts

  • Difficulty making inferences

  • Tendency to perseverate in verbal responses

  • Tendency to use tangential speech

  • Use of incoherent or confabulatory speech

Written Language

  • Difficulty comprehending written text, particularly with respect to complex syntax and figurative language

  • Difficulty planning, organizing, writing, and editing written products

Speech

  • Apraxia of speech (motor programming)

  • Aprosodia/dysposodia, marked by deficits in intonation, pitch, stress, and rate

  • Dysarthria characterized by reduced respiratory support, articulatory imprecision, and/or vowel distortions

  • Hypernasality secondary to paresis or paralysis of velopharyngeal muscles involved in speech

https://www.asha.org/practice-portal/clinical-topics/traumatic-brain-injury-in-adults/#collapse_3

Voice

  • Aphonia/dysphonia resulting from intubation, tracheostomy, or use of mechanical ventilator

  • Laryngeal hyper/hypofunction marked by

  • Neurogenic phonatory abnormalities resulting from injury to sensory or motor innervations to the vocal folds

  • Psychogenic phonatory abnormalities (e.g., related to post-traumatic stress disorder)

Dysphagia

  • Swallowing problems secondary to oral and/or pharyngeal sensory disorders and/or motor deficits (e.g., weakness or paralysis of oropharyngeal musculature, oral apraxia)

  • Risk of aspiration while eating related to impact of cognitive impairment (e.g., poor memory, reduced insight, limited attention, impulsivity, and agitation)

Neurobehavioral

  • Affective changes, including over-emotional or over-reactive affect or flat (i.e., emotionless) affect

  • Agitation and/or combativeness

  • Anxiety disorder

  • Depression

  • Difficulty identifying emotions in others (alexithymia)

  • Emotional lability and mood changes or mood swings

  • Excessive drowsiness and changes in sleep patterns, including difficulty falling or staying asleep (insomnia), excessive sleepiness (hypersomnia)

  • Feeling of disorientation or fogginess

  • Increased state of sensory sensitivity accompanied by exaggerated response to perceived threats (hypervigilance)

  • Impulsivity

  • Irritability and reduced frustration tolerance

  • Lack of initiation (e.g., for making choices, talking, moving)

  • Stress disorders

https://www.asha.org/practice-portal/clinical-topics/traumatic-brain-injury-in-adults/#collapse_3

https://www.peakstatesclinics.com/TBI_files/tbi-symptom-table.png

Pediatric Considerations for Signs and Symptoms of TBI

Infants and toddlers may lack the communication or developmental skills to overtly report the signs and symptoms of TBI noted above. Clinicians and families need to be aware of the following signs that may be initially observed after TBI for this age group:

  • Changes in the ability to pay attention

  • Changes in eating or nursing habits

  • Changes in play (e.g., loss of interest in favorite toys/activities)

  • Changes in sleeping habits

  • Irritability, persistent crying, and inability to be consoled

  • Lethargy

  • Loss of acquired language

  • Loss of new skills, such as toilet training

  • Sensitivity to light and/or noise

  • Unsteady walking, loss of balance

In cases of abusive head trauma such as shaken baby syndrome, sometimes there are no apparent external physical signs to indicate a TBI.

**Signs and symptoms may co-occur with other existing developmental conditions such as attention-deficit/hyperactivity disorder, learning disabilities, autism spectrum disorder, intellectual disability, childhood apraxia of speech, childhood fluency disorders, late language emergence, spoken language disorders, written language disorders, and social communication disorders.

https://www.asha.org/practice-portal/clinical-topics/pediatric-traumatic-brain-injury/#collapse_3


Traumatic Brain Injury

Adult Brain VS Child Brain

Etiologies

Dementia

Alzheimer's disease is the most common cause of dementia, accounting for approximately 70% of all cases

The remaining cases are accounted for by vascular dementia, Lewy body dementia, Parkinson's disease, frontotemporal dementia, and mixed dementia types

Most dementias are the result of neuropathology stemming from (a) diffuse degeneration in cortical and/or subcortical structures and neural pathways and/or (b) chemical changes that affect neural functioning.

Structural changes include neurofibrillary tangles and neurotic plaques—both commonly associated with Alzheimer's disease—and loss of neural pathways (connections between neurons) responsible for memory and new learning.

Chemical changes include (a) cholinergic deficits within the subcortical structures as in Alzheimer's disease or (b) chemical imbalances associated with metabolic disorders.

http://www.purerecoveryca.com/wp-content/uploads/2020/03/Brain-Diagram.jpg

TBI Causes-Pediatrics

Causes of pediatric TBI are varied and appear to differ by age. The Centers for Disease Control and Prevention (CDC) identified the following leading causes of TBI in children and adolescents ages 0 to 14:

  • Falls (50.2%)

  • Struck by/against events (24.8%)

  • Motor vehicle accidents (6.8%)

  • Assault (2.9%)

  • Unknown/other (15.3%)

Falls and assault (e.g., shaken baby syndrome or other physical abuse) are the most common mechanisms of TBI in infants, toddlers, and preschoolers. TBI secondary to velocity injury (e.g., motor vehicle or bicycle accidents, sports injuries) occurs more often in elementary school children and adolescents


TBI Causes-Adult

  • Falls and motor vehicle crashes were reported to be the first and second leading causes of all TBI-related hospitalizations (52% and 20%, respectively).

  • Falls accounted for almost half (48%) of all TBI-related emergency department visits and 81% of TBI-related emergency department visits by persons aged 65 and older.

  • Collision-related events (being struck by or against an object) accounted for about 17% of all TBI-related emergency department visits in the United States in 2014.

  • Intentional self-harm was the leading cause of TBI-related deaths (33%) in 2014


Case History

Dementia

  • Medical status and medical history

  • Review of auditory, visual, motor, cognitive, and emotional status

  • Demographic information (e.g., educational level, marital status, occupation)

  • Current living arrangements and available supports

  • Language(s) spoken

Interview with Individual

  • Report of cognitive changes (e.g., memory loss, forgetfulness, disorientation, getting lost)

  • Impact of changes on functional communication and life participation

  • Contexts of concern (e.g., social interactions, work activities)

  • Language(s) used in contexts of concern

  • Goals for continued functional communication and life participation

Interview with Family/caregivers

  • Observations of cognitive changes

  • Impact of changes on individual's functional communication and ability to participate fully in everyday activities

  • Impact of changes on individual's safety and safety awareness

  • Contexts of concern (e.g., social interactions, family discussions and decision making)

https://www.asha.org/practice-portal/clinical-topics/dementia/#collapse_5


Right Hemisphere Disorder

  • Relevant medical history (history of previous strokes or other neurological disorders)

  • Patient interview (educational, social, and occupational history)

  • Input from family members or others close to the patient, to identify changes

  • Impact of deficits on ADLs and overall daily functioning

  • Input from other medical professionals (e.g., physical and occupational therapists, neurologist, neuropsychologist, social worker, etc.)

  • Cultural and linguistic backgrounds

Self-Report

  • Functional communication struggles and successes

  • Communication difficulties and impact on individual and his or her family/caregivers

  • Contexts of concern (e.g., social interactions, work activities)

  • Language(s) used in contexts of concern

  • Goals and preferences of the individual

https://www.asha.org/practice-portal/clinical-topics/right-hemisphere-damage/#collapse_5

Traumatic Brain Injury

Adult

  • SLPs and audiologists do not diagnose TBI.

  • Nature and onset of TBI and related hospitalizations

  • Medical status—current and prior to injury

  • Current medications

  • Review of auditory, visual, motor, and cognitive status

  • Review of emotional and mental status

  • Educational and occupational background

  • Reported areas of concern (e.g., memory, speaking, swallowing) and contexts of concern (e.g., social interactions, work activities)

  • Language(s) used in contexts of concern

  • Impact of current condition on the individual and their family/caregivers

  • Goals and priorities of the individual and their family/caregivers

https://www.asha.org/practice-portal/clinical-topics/traumatic-brain-injury-in-adults/#collapse_5

Pediatric

  • Medical status prior to injury (e.g., surgeries, prior TBI)

  • Psychiatric and psychosocial history prior to injury

  • Nature and onset of TBI and related hospitalizations

  • Current medical status, including medications

  • Developmental milestones

  • History of hearing or vision problems

  • Speech and language status prior to injury, including history of speech and language services

  • Concerns regarding current communication status and context of concern (e.g., daily routines, school activities, social interactions)

  • Impact of current condition on individual and their family/caregivers

  • Goals and priorities of the individual and their family/ caregivers

https://www.asha.org/practice-portal/clinical-topics/pediatric-traumatic-brain-injury/#collapse_5

Assessment

Screening

Screening is conducted in the language(s) used by the person, with sensitivity to cultural and linguistic diversity.

An Oral Motor Sensory Examination should be conducted with all screenings to examine oral anatomy and physiology.

Dementia Screening

Prior to screening for cognitive-communication disorders, it is important to consider the impact of sensory impairment (hearing and vision), depression, and current medications on cognitive functioning.

Tasks:

  • Auditory Comprehension

      • Story recall/retell

  • Cognition

      • Episodic memory assessment

      • Orientation

          • Awareness of person, place, time, circumstance/situation (AAO x 1,2,3,4)

Screening tools:

Cognitive Linguistic Quick Test-Plus (CLQT+)

Mini Mental Status Exam (MMSE)

The Saint Louis University Mental Status Examination (SLUMS)

The Montreal Cognitive Assessment (MoCA)


Right Hemisphere Damage

Standardized and non-standardized methods are used to screen

  • Oral motor functions

  • Speech production skills

  • Comprehension and production of spoken and written language

  • Pragmatic competence & discourse-level communication

(more than word and sentence level processes)

Tasks may include:

  • Narratives

  • Conversation

  • Story-retell

  • Picture description

Other cognitive skills such as attention, memory, and executive function as they relate to communication, swallowing, unilateral visual neglect, and hearing.


Nonlinguistic Impairments

  • Attention

  • Left side visual neglect

Tasks for nonlinguistic impairments may include:

  • Scanning/canceling tasks

  • Line bisection

  • Drawing

  • Reading/writing


Traumatic Brain Injury

Standardized and non-standardized methods are used to screen

speech, language, cognitive-communication, and swallowing deficits

Tasks may include:

  • Orientation screening

      • Awareness of person, place, time, circumstance/situation (AAO x 1,2,3,4)

  • Discourse screening

      • Monologues

      • Conversations

(ASHA, 2021) (Bridges, 2021) (Shipley, 2016)

Standardized/Norm-Referenced Tests

Assessment Age Range Administration

Time (minutes)

Cognitive Linguistic Quick Test-Plus (CLQT+)

Assesses strengths and weaknesses in five cognitive 18;0-89;11 15-30

domains, including an optional administration path

for patients with aphasia

Functional Assessment of Verbal Reasoning and

Executive Strategies (FAVRES)

Assesses verbal reasoning, complex comprehension, 18;0-79;11 60

discourse, and executive functioning during performance (15 per task)

on a set of challenging functional tasks. Standardized on

adults with acquired brain injuries as well as a sample of

non-injured controls

Ross Information Processing Assessment-Geriatric,

Second Edition (RIPA-G:2)

A comprehensive, norm-referenced, assessment battery 55 and up 30

designed to identify, describe, and quantify cognitive-

linguistic deficits in the geriatric population

Scales of Cognitive Ability for Traumatic Brain Injury

(SCATBI)

Assesses cognitive and linguistic abilities of adolescent Adolescents 30-120

and adult patients with head injuries to adults

(Shipley, 2016)

Areas and Skills Assessed

LANGUAGE

  • Phonology

  • Morphology

  • Syntax

  • Pragmatics

  • Semantics

Right Hemisphere Brain Damage (RHD) (asha.org)

EXECUTIVE FUNCTION

  • Insight

  • Judgment

  • Reasoning

  • Problem solving

SPATIAL ORIENTATION

  • Spatial Orientation

  • Memory

  • Attention

  • Visuo-Spatial skills

  • Metacognition

  • Social Interactions

Data/Statistics



  • Normative Data Depends on Standardized Tests


RHD/DEMEMTIA/TBI

  • The incidence of RHD has been reported most frequently following strokes.

  • Frequency of right hemisphere strokes ranging from 42% to 49%

  • Approximately 50%–78% of individuals with RHD exhibit one or more cognitive deficits that affect communication

  • Worldwide, an estimated 50 million people are living with dementia

  • These numbers are projected to reach 82 million by the year 2030 and 152 million by 2050, with the majority of individuals coming from low- and middle-income countries

  • Globally, the annual number of new cases of dementia is 9.9 million

  • Within the United States, approximately 5.7 million people are living with dementia

  • Alzheimer's disease accounts for approximately 60%–70% of these cases, followed by vascular dementias

  • The total number of individuals living with Alzheimer's dementia is projected to be 13.8 million by 2050

  • Each year, the number of new cases of TBI in the Unites States is approximately 2.8 million Incidence rates include approximately 2.5 million TBI-related emergency department visits

  • 288,000 TBI-related hospitalizations, and 57,000 TBI-related deaths.

  • 5.3 million individuals are living with a TBI-related disability in the United States. This represents a prevalence of approximately 2% of the U.S. population



Non-Standarized Assessment


Cognitive Screening Assessment:

5 Domains:

-Memory

-Fluency

-Attention

-Language

-Visuospatial

(ASHA, Cognition 2021)

Behaviors Clinician Should Assess:

-Maintaining eye contact

-Decreased interruptions

-Excessive clarification

-Supressed thoughts

Informal Assessments:

-Narrative Production

-Semantic Verbal Fluency Test

-Retelling Events

-Picture Observations

Clinicians may observe hardships in

-Engaging in conversation

-Cognitive abilities

-Responding at proper times/manner

-Fluid speech

-Decision making and rationalizing

-Memory

Differential Diagnosis


Aphasia Signs Vs. Cognitive-Linguistic Disorders

Aphasia patients...

-Use speech jargon

-Difficulty articulating thoughts and words

-Semantic paraphasia's

-Making up words

-Single words are less difficult than full sentences

(ASHA, Aphasia 2021)

Cognistic-Linguistic Disorders

CLD patients...

-Lose attention during conversation

-Do not include enough details in communication

-Struggle to stay on topic

-Misunderstood gesturing

Cultural Considerations Vs. Cognistic-Linguistic Disorders

Cultural Differences may have different outlooks and should not be confused with Cognistic-Linguistic Disorders

-Eye contact during communication

-Taking turns while talking

-Gesturing and body language

-Explaining topics differently

(ASHA, Cultural Diversity 2021)


Assessment Summary

Dementia

  • Level of Dementia

    • Early Dementia

    • Intermediate Dementia

    • Advanced Dementia

  • The Presences of Diseases or Condition associated with progressive dementia

    • Alzheimer's disease

    • Creutzfeldt-Jakob disease

    • Frontotemporal Dementia (Pick's disease)

    • Huntington's disease

    • Lewy Body disease

    • Mixed dementia

    • Parkinson's disease dementia

    • Posterior cortical atrophy

    • Vascular dementia (multi-infarct)

  • Onset

  • Type of memory loss

    • short-term, working, long-term, procedural, eposodic, declarative, etc.

  • Word-finding problems

  • Attention deficits

  • Intact or not intact

    • automatic speech

    • articulation

    • phonological skills

    • syntactic skills

    • mechanics of writing and reading

  • Orientation or lack thereof

  • Reasoning and judgement difficulties

  • Any presence of anxiety, depression, agitation, and apathy

  • Cognition deficits

  • Physical debilitating markers present

  • Swallowing or feeding concerns

  • Other behavioral markers present

Right Hemisphere

  • Cause for the Right Hemisphere Damage (RHD)

  • Outcomes from the RHD

    • Perceptual, logic and problem-solving, memory, pragmatic, organizational, orientation, prosodic, language, reading and writing and personal insight deficits

  • Attention deficiencies or reduction of

    • Sustained

    • Joint

    • Alternating

    • Divided

    • Selective

  • Maintaining factors

  • Family/caregiver support

  • Age and gender

  • Visuospatial, visuomotor, and visuoconstructional abilities

  • Presence of Anosognosia

  • Prognosis

TBI

  • Cause of TBI

  • Nature of TBI

    • cerebral system involved

  • Severity of TBI

  • the presence of additional neuromedical variables (e.g., extended coma, cerebral hemorhage)

  • Age and gender

  • Pretrauma status

    • any period of unconsciousness

    • Coma status

  • Attention deficits

  • Signs of Impaired Memory, Language, reasoning

  • Disorienation to time, place and self

  • Anomia

  • Behavioral concerns

    • restlessness, irritability, distractibility, high frustration, anxiety, aggression concerns, poor control of emotion

  • Reduced ability to read, write, draw

  • Physical limitations

  • Inconsistency with responses

  • Disorders of smell and taste

  • Lack of judgement, self-care

  • Visuospatial, visuomotor, and visuoconstructional abilities

Shipley and McAFee (2016)

Treatment

Treatment Approaches

Requires analysis of the context, recognition of limitations, and then application of a learned strategy. May rely on attention ability.

Restorative Strategies: Aimed at improving or restoring function by reinforces, strengthen or restoring impaired skills

Compensatory Strategies: Teaches ways of bypassing or compensating for deficits not amenable to retraining.

External Compensatory Strategies:

  • External Aids

    • to-do lists

    • habitual note taking

    • creating checklist

    • daily planners/calendars

    • alarm/timers

    • Journals to document details

    • labeling the home environment

    • usage of photographs to represent steps of activity or task (e.g., tying shoes)

  • Using Orthographic skills if preserved

  • Smartphones or augmentative tools

Internal Compensatory Strategies:

  • Mnemonics (e.g., creating acronyms or phrases)

  • Visualization and rehearsal

  • Repetition and rehearsal of information

  • Semantic elaboration (eg., identifying and describing as many salient features as possible)

Environmental Compensatory Strategies:

  • Accomodations (e.g., changes to environment)

  • Modification (e.g., changes to nature of activity)

Click link: Using memory strategies after Brain Injury

Asha (2021), Bridges (2021)

IMPORTANT TO TRAIN WITH HABITUAL USE OF STRATEGY TO FACILITATE OVERCOMING DEFICITS

Note: No specific protocols for RBD treatment but usage of cognition can be used.

Language:

Focuses on,

(A) Narrative and conversational discourse

  • Guided inference-generating tasks in which the client labels items in scenes or stories, IDs relevant or significant items, and explains the relationship- Target is to arrive at an inference.

  • Macrostructure tasks

    • ID "big picture" of a story, picture, conversation

    • Organizing printed sentences into a narrative, placing pictures into a logical sequence

(B) Understanding and managing alternate meaning

  • Grouping words with connotative meaning

  • providing multiple meanings for homographs or homophones

  • resolving lexical ambiguities based on contextual cues

  • practice interpreting figurative language

  • generating alternative meanings to ambiguous sentences

  • adding a "next sentence" (after giving possible interpretations) to disambiguate the intended meaning

(C) Pragmatics

  • increasing appropriate use of conversational skills (e.g., eye contact, nods)

  • decreasing use of barriers to successful conversation (e.g., poor turn taking, interruptions, etc)

Other approaches target all social communication

Right Hemisphere

Neglect Treatments

  • Scanning Tasks: scan room or plate; limited generalization

  • External stimulation: left-neck vibration, prism glasses

  • Presenting stimuli spanning the midline: Call attention to turn head to pay attention to neglected side

  • Encouraging voluntary movement of attention: Work with Client to ID items on left and right side of pages/spaces

  • Training patient to actively manipulate objects in space: "remember to turn your head and look to the left..."

Prosody

Direct treatment approaches:

  • Prosodic production drills: asking the person to imitate or read printed sentence conveying differnt emotions

  • Imitation/modeling tasks using a hierarchical approach

  • Tasks to improve recognition of prosodic features

    • Judging between two targets

    • Identifying the emotion from listening to a sentence

Compensatory strategy:

  • Cuing listener to upcoming discussion by stating client's emotional state or intent prior to commencing narrative or discourse

  • Teaching Clients to ID cues other than prosody (e.g., Facial expression or body language identification.

  • Ask communication partner explicitly the intent of the message they will convey.

Metacognitive and compensatory strategies

Help the person sustain attention to a task or goal

  • Using systems, tools or strategies (e.g., graphic organizers or charts) to facilitate breaking task into smaller parts

  • Writing down thoughts and ideas that can potentially distract from the task at hand.

Asha (2021), Bridges (2021)

Augmentative and Alternative communication (AAC): Client factors to consider: communication abilities and needs, cognition, neurobehavioral, motor, sensory, and perceptual impairments.

Social communication intervention

  • Social communication intervention:

    • including sharing knowledge to communication partners

    • situational training to improve perception and ability to interpret others

    • situational coaching

    • counseling to help a client ID a sense of self

  • Communication partner training (CPT):

    • providing emotional support

    • using positive question style

    • using turn-taking

    • helping clients with TBI extend and organize their thinking.

NOTE: DO NOT neglect family and caregivers and the importance of their role. Provide education and supports.

TBI

Cognitive-communication treatment: focused on both restorative and compensatory approaches.

(A) Sensory stimulation

(B) Dual-task training

(C) Computer- assisted treatment (CAT)

NOTE: Instructional or teaching techniques:

  1. Direct instruction: comprehensive instructional technique (e.g., identify targets, providing models, etc.)

  2. Strategy-based instruction: use of various strategies to improve awareness, self-monitoring and regulation.

      • Metacognitive skills training

      • compensatory strategy training

      • internal aids

      • external aids

  3. Errorless learning: technique that tries to minimize errors as the client learns a new skill

Other training

Attention training: Stimulus - drill approaches

Executive function treatment:

- self-awareness, self-monitoring, self-regulation: increasing awareness and educating on injury in giving feedback while shaping behaviors

-Problem solving and planning: self-regulatory/self-instruction techniques: practice problem solving personally relevant and problem situation

Behavioral Intervention:

-Traditional contingency management

-positive behavior interventions

Asha (2021), Bridges (2021)

Dementia

Approaches

Pharmacologic: medications

  • Can have negative side effects

  • Cholinesterase inhibitors: increase measures of cognition function

  • Targeting glutamate (effective for a few years to improve/stabilize cognition function

  • Antipsychotics, sedatives, antidepressants- targeting behaviors

VS

Behavioral:

Treatment to facilitate or maintain functional communication and improve quality of life (QoF)

Memory Treatment

  • Internal strategies

    • WOPR: write, organize, picture, and repeat

    • Mnemonic devices

    • visual association

  • Space retrieval

  • External strategies

    • environmental cues

    • written information/pictures in "memory wallet" or "memory book"

  • Environmental strategies

    • social groups

    • special care units

    • music, dolls, pet therapy

Other treatment options:

  • Assistive techonology

  • Hearing assistive technology systems (HATS)

  • Cognitive stimulation therapy (CST): group treatment for mild-mod dementia- uses theme-based, mentally stimulating activities

  • Computer-based treatment

  • Montessori For Aging and Dementia: approach focused on providing a supportive environment where the clients strength are used to engage in meaningful activities.

  • Simulated presence therapy (SimPres)- emotional-oriented appraoached aimed to reducing levels of anxiety and challenging behaviors by playing audio video recordsing of client's close relative

  • Validation therapy- accepting the values, beliefs, and reality of the person with dementia to reduce stress and promote contentment.

  • Eating and swallowing interventions

Asha (2021), Bridges (2021)

Bridges 2021

References


ASHA. (2021). Dementia. American Speech-Language-Hearing Association. Retrieved October 16, 2021, from https://www.asha.org/practice-portal/clinical-topics/dementia/

ASHA. (2021).Traumatic Brain Injury. American Speech-Language-Hearing Association. Retrieved October 16, 2021, from https://www.asha.org/practice-portal/clinical-topics/traumatic-brain-injury-in-adults/

ASHA. (2021). Right Hemisphere Damage .American Speech-Language-Hearing Association. Retrieved October 16, 2021, from https://www.asha.org/practice-portal/clinical-topics/right-hemisphere-damage/

Barman, A., Chatterjee, A., & Bhide, R. (2016). Cognitive Impairment and Rehabilitation Strategies After Traumatic Brain Injury. Indian Journal of Psychological Medicine, 38(3), 172–181. https://doi.org/10.4103/0253-7176.183086


Bridges, K. (2021,October 16). Right-Hemisphere Syndrome. [PowerPoint slides]. Communicative Sciences & Disorders, New York University. https://2nyu.speech.steinhardt.nyu.edu/ap/courses/943/sections/87597407-e7b6-4efb-967a-cefea788daf5/coursework/module/8438ebc8-72a3-4ada-be9d-8eb95d5c0db1/segment/2f47ea67-c084-414a-927a-1444c0631e41

Bridges, K. (2021,October 16). Traumatic Brain Injury. [PowerPoint slides]. Communicative Sciences & Disorders, New York University. https://2nyu.speech.steinhardt.nyu.edu/ap/courses/943/sections/87597407-e7b6-4efb-967a-cefea788daf5/coursework/module/8438ebc8-72a3-4ada-be9d-8eb95d5c0db1/segment/2f47ea67-c084-414a-927a-1444c0631e41

Bridges, K. (2021,October 16).Dementia and Primary Progressive Aphasia. [PowerPoint slides]. Communicative Sciences & Disorders, New York University. https://2nyu.speech.steinhardt.nyu.edu/ap/courses/943/sections/87597407-e7b6-4efb-967a-cefea788daf5/coursework/module/8438ebc8-72a3-4ada-be9d-8eb95d5c0db1/segment/2f47ea67-c084-414a-927a-1444c0631e41


Bridges, K. (2021) Adult Language Disorders. [PowerPoint Slides]. 2NYU. Retrieved on October 14, 2021 from https://2nyu.speech.steinhardt.nyu.edu/ap/courses/943/sections/e9071d35-07d3-49a2-a646-2d1760c32ccb/coursework/courseModule/ed4938c4-0120-4397-86bd-9cfd1965124f


Shipley, K. G., & McAfee, J. G. (2016). Assessment in speech-language pathology: A resource manual (6th ed.). Boston, MA: Cengage.


Using Memory Strategies After Brain Injury (2018). Acquired Brain Injury Outreach Service (ABIOS). Retrieved July 9, 2021, from https://www.health.qld.gov.au/__data/assets/pdf_file/0036/671877/memory_strategies_fsw.pdf