lang dis adult final review

MMSE & Montreal Cognitive Assessment (MoCA)

• Used for RHD, TBI, dementia

• Small insight on presentation; 10 min bedside (below 26/30 on MoCA = impairment)

Cognitive Linguistic Quick Test (CLQT)

• Used for RHD & TBI

• Assesses cognitive-communication; ~20-30 mins 

WAB-R

• Preferred for severe patients & identifying aphasia subtypes

BDAE

• Used for mild-moderate aphasia 

• Cookie theft, BNT, mild–mod aphasia

Glasgow Coma Scale (GCS)

Measures level of consciousness and arousal (alert, oriented, responding to pain)

Rancho Los Amigos Scale

Measures recovery stages after TBI, coma, post-traumatic amnesia 

Testable for aphasia at RLA IV

Global Deterioration Scale (GDS)

Measures stages of cognitive function as dementia progresses

Pre-dementia: GDS 1–3. Dementia: GDS 4–7

Pre-dementia: GDS 1–3

1: no cognitive decline

2: age-associated memory impairment – Losing items, forgetting names

3: mild cognitive impairment (MCI) – Getting lost, poor work performance, word retrieval difficulties, losing items, decreased concentration

Dementia: GDS 4–7

4: mild dementia – More memory deficits (recent events, personal history), concentration deficits, EF deficits (finances, travel, complex tasks); Denial, flat affect and withdrawal are common

5: moderate dementia – Requires assistance with ADLs; Continued memory loss (address/phone #, family member names), disorientation to time & place, concentration/attention deficits are significant

6: moderately severe dementia – Requires consistent assistance with ADLs; Disorientation to place/time/situation, significant memory deficits (ex. forget primary caregiver name), poor attention, delusions, anxiety, agitation, sleep disturbances

7: severe dementia – Requires maximal assistance with ADLs (feeding, toileting); Gradually becomes nonverbal with decreased interaction with people in the environment; Decreased sensory/motor skills – systems shut down

Most common cause of dementia (60–70% of all cases)

Alzheimer’s Disease

Direct Dementia Tx - therapy activities with the patient

• Reminiscence Therapy: assist individuals in accessing LTM (long term memory) of people and places from their past through use of sensory stimuli. Objects provide concrete focus for reminiscing

• Reality Orientation Therapy: increase a patient’s understanding of their surroundings and sense of control through meaningful stimulation/repetition of time-place-person orientation

  • Two approaches

    • Structured activities/simulations in a classroom style 

    • 24-hour therapy in which professionals orient patients on all occasions they interact with them during ADLs (activities of daily living) (name, date, time, location, etc)

• Spaced Retrieval Therapy: facilitate recall of information in people with dementia through exposure to memory targets and then recall after time. Gradually increase interval between presentation and recall

Indirect Dementia Tx - environmental manipulation, caregiver training

• Supported Conversation Therapy: provide communication strategy training to family/caregiver (ex. education on dementia and its impacts on communication, education on verbal and nonverbal communication strategies)

• Simulated Presence Therapy: uses audio/video recordings of family/caregiver to increase comfort and cooperation during ADLs. Ideal for patients with moderate-severe dementia

Compensatory strategies:

Grouping/chunking, acrostics, mnemonics, association, visualization, memory books

Primary Progressive Aphasia (PPA):

focal dementia that primarily affects S&L skills in early stages of disease (caused by Alzheimer’s (AD) or Frontotemporal Lobar Degeneration (FTLD)

SFA (Semantic Feature Analysis):

• Improves semantic organization and word retrieval by forming connections between target word and associated words and concepts. Uses map/web as a visual aid.

PCA (Phonological Components Analysis):

• Goal is to improve linguistic organization and word retrieval by analyzing the sound components (first phoneme, last phoneme, rhyme, etc) of the target word. Uses map/web as a visual aid.

VNeST (Verb Networking Strengthening Treatment):

• Goal is to increase output of SVO sentences and strengthen semantic associations by using target verbs to generate related sets of subjects and objects.

CART (Copy and Recall Treatment):

• Treats writing/spelling at the single-word level via intensive repetition

• Goal is to strengthen orthographic representations of words as well as graphomotor patterns.

Aphasia Scripts:

• Practiced functional scripts for daily communication

Patients with RHD have _____________

difficulty with reading/writing, abstract language, inferences, relevancy, turn-taking, and emotional aprosodia

Time course for RHD stroke

Hyperacute: up to 12 hrs post onset

Acute: 12 hrs to 1–2 weeks

Subacute: 1–2 weeks to 6 months

Chronic: >6 months

L hemisphere damage vs R hemisphere damage

L hemisphere damage → language deficits; R hemisphere damage → cognitive deficits 

Communication deficits in RHD

Higher level language skills (discourse), pragmatics, prosody, communication of affect

Cognitive deficits in RHD

Perception, orientation, attention, working memory, executive function (organization, reasoning/problem-solving, planning, self-awareness) 

Left hemispatial neglect

• Lack of attention to left side of the patient’s words (80% w/RHD have neglect; can see left but do not attend to it)

• Egocentric: neglect left of whole image; Allocentric: neglect left of object

Left visual field cut/hemianopia

Visual field cut caused by damage to optic tract (CN II) (can’t see left visual field)

Anosognosia

Denial/lack of awareness of deficits (very common)

Prosopagnosia

“face blindness”

Retrograde amnesia vs Anterograde amnesia

Retrograde amnesia - memory loss for events before the injury (retrieval)

Anterograde amnesia - memory loss for events after the injury (encoding)

RHD Assessment

Line bisection, star cancellation task, figure copy

Focused attention

consistently responding to simple stimuli (most basic type)

Sustained attention

maintain attention overtime, usually w/ increasingly complex stimuli 

Selective attention

attending to relevant stimuli despite distractors

Alternating attention

alternating attention between tasks

How to Treat Attention

Restorative 

• Attention Process Training (APT) - hierarchical drill-based (visual and auditory drills) program with multiple difficulty levels (type and rate of stimuli) to improve different types of attention

Compensatory

• Metacognitive strategies - self-rating performance and feedback

How to Treat Executive Function 

Metacognitive strategies

• Goal Management Training: identify a goal and go through the process/steps to complete that goal (ex: paying bills, grocery shopping  )

includes *self-monitoring, reasoning/working memory, planning, organization

How to Treat Prosody

Restorative:

– Motoric-imitative approach: hierarchical treatment of saying sentences expressing different emotions

– Cognitive-linguistic approach: using emotional labels, a descriptive of vocal changes, and pictures of faces

Compensatory:

– Stating emotional state before making a statement (ex. I am angry)

How to Treat Memory

Restorative

– Stimulation Approach: restore memory through repetitive drills → listen to words, sentences, stories and ask to recall them immediately and delayed

Compensatory 

– External aids: memory books (typically for dementia) + electronic aids (setting reminders on phones), internal aids (mnemonics/strategies)

– TEACH-M: combined restorative/compensatory approach

List 3 memory operations

1. Encoding  2. Storage  3. Retrieval

Time-dependent memory:

– Sensory memory (encoding): visual and auditory memory; held for up to ~2–3 secs

– Short-term/working memory: limited to 3–5 items at a time → chunking expands this capacity; held for a few mins

– Long-term: permanent, unlimited storage

Atkinson & Shiffrin Model of Memory:

– Broke memory into STM and LTM

– Sensory stores: related to encoding

– STM: limited capacity store for info; place to rehearse new info from sensory buffers

– LTM: once items are rehearsed, stored in long-term 

– Probability of encoding STM into LTM is related to time information is in encoding STM AND amount of interference encountered

Baddeley’s Model of Working Memory:

– Phonological loop - phonological store (what we hear) and articulatory processes

– Visuospatial sketchpad: temporary storage of visual and spatial information that helps w/ navigation, completing visual puzzles/mazes

– Episodic buffer: integrates info from phonological loop, visuospatial sketchpad, LTM

2 Types of LTM → content-dependent:

– Declarative/explicit: facts or events; learned information 

– Implicit/non-declarative: procedural memory, learning how to do something

Ranchos Levels I–III:

– Reduced arousal and alertness, reduced visual and auditory processing; no memory for daily events

– Limited and inconsistent responses, delayed responses, perseverative responses

– I: coma  II: vegetative state  III: minimally conscious state

Rancho Levels IV–VI:

– Reduced attention, inhibitory and excitatory process deficits, reduced thought organization, hard time with new learning and recall

– Disinhibited, tangential (not focused), impulsive, confabulations common, severe pragmatic deficits

** can test for aphasia at level IV

Rancho Levels VII–VIII:

– Slower processing, executive dysfunction

– If no left side damage, semantics, phonology and syntax are intact; Disorganized language, difficulties comprehending abstract things

Rancho Levels IX–X:

– Aware of impairments, can anticipate potential problems and correct them with strategies

– Can use memory devices and shift back and forth between tasks; May be easily irritable

Primary causes of TBI

• Penetrating brain injuries: skull is fractured, meninges are torn

• Nonpenetrating brain injuries: skull and meninges remain intact

• Nonacceleration (fixed head), acceleration (moving head), traumatic hemorrhage

Secondary causes of TBI

Cerebral edema, traumatic hydrocephalus, elevated intracranial pressure, ischemic brain damage, alterations in blood-brain barrier

Prognostic indicators of TBI

Injury factors → strong predictors (ex. duration of coma)

Patient factors → weak predictors (ex. age, motivation, support system)

Common locations of TBIs:

Anterior and ventral surface of frontal lobe

Anterior and ventral surface of temporal lobe

Recovery: CVA vs TBI

CVA: greatest late acute/subacute and tapers off in chronic; no characteristic recovery pattern

TBI: stairstep pattern; characteristic recovery stages

SCATBI (The Scales of Cognitive Ability for Traumatic Brain Injury)

A comprehensive cognitive test for TBI; 30-120 mins

Practice Case

Michael is a 42 y/o male, 3 months post-MVA. MoCA Score: 11/30

• Visuospatial/Executive (0/5): Trail making 0/1 (abandons task), Cube copy 0/1 (doesn’t draw L side), Clock draw 0/3 (missing L side)

• Naming (3/3): Intact

• Attention (2/6): Digit span forward 1/1, Digit span backward 0/1, Vigilance 0/1, Serial 7s 1/3

• Language (2/3): Sentence repetition 1/2, Verbal fluency 1/1

• Delayed Recall (1/5): Free recall 1/5; category cues improve recall; recognizes items on multiple choice

• Orientation (2/6): Oriented to person and place; incorrect for time

• RLAS Level: IV–VI – Lacks insight (“I know how to count”), agitated, confused, oriented to person/place but not time

• Deficit areas: Visual neglect, attention (abandons tasks), working memory, anosognosia, orientation

• Appropriate treatments: Attention Process Training, visuospatial scanning, reality orientation therapy, external memory aids