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Definition
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.
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
Signs and Symptoms of Dementia
Attention
Attention
Easily distracted
Difficulty attending, unless input is restricted/simplified
Decreased information-processing speed—thinking/processing takes longer than usual
Learning and Memory
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
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
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
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
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?
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
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
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
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
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
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
*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
Traumatic Brain Injury
Adult Brain VS Child Brain
Etiologies
Etiologies
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
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
brain tumors
brain surgery
brain infections
cerebrovascular accidents (hemorrhagic and ischemic)
seizure disorders
TBI
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
Case History
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
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
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
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
Assessment
Screening
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
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
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,
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
Assesses cognitive and linguistic abilities of adolescent Adolescents 30-120
and adult patients with head injuries to adults
(Shipley, 2016)
Areas and Skills Assessed
Areas and Skills Assessed
EXECUTIVE FUNCTION
Insight
Judgment
Reasoning
Problem solving
SPATIAL ORIENTATION
Spatial Orientation
Memory
Attention
Visuo-Spatial skills
Metacognition
Social Interactions
Data/Statistics
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
Non-Standarized Assessment
Cognitive Screening Assessment:
5 Domains:
-Memory
-Fluency
-Attention
-Language
-Visuospatial
(ASHA, Cognition 2021)
Behaviors Clinician Should Assess:
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
Differential Diagnosis
Aphasia Signs Vs. Cognitive-Linguistic Disorders
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
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 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
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
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
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
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:
Direct instruction: comprehensive instructional technique (e.g., identify targets, providing models, etc.)
Strategy-based instruction: use of various strategies to improve awareness, self-monitoring and regulation.
Metacognitive skills training
compensatory strategy training
internal aids
external aids
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
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
Visuals & other resources
Visuals & other resources
Other Resources: click for link
Right Hemisphere Brain Damage : Trifold Information PDF
Academy of Neurologic Communication Disorders and Sciences (ANCDS)
CCCABI: SLP screening and referral tool
CAM: The confusion Assessment method
Language/cognition-communication evaluation
Ranchos Los Amigos: Levels of cognitive functioning scale
Dementia and Cognitive Impairments: epidemiology, diagnosis, and treatment
Shipley and McAFee (2016)
References
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
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