Lecture 10 - Assessment & Management of PPA & End of Life Care

R.A.I.S.E Framework for PPA Assessment:

What are assessment suggestions for general PPA Diagnosis?

• Can start w/ screeners

• Standard aphasia batteries may be used, but classifications (e.g., Broca’s aphasia) should not be used

• Western Aphasia Battery-Revised

• Boston Diagnostic Aphasia Exam

• Comprehensive Aphasia Test

What other cognitive domains should be assessed?

• Extralinguistic cognitive domains!

  • Visuospatial processing & visual memory: complex figure copy & recall

  • Emotional processing: Emotional Evaluation subtest of the Awareness of Social Inference Test

• Cognitive decline will not begin after 2 years!

What is a specific standardized test for PPA subtypes?

• Sydney Language Battery

What factors should you consider when formulating a diagnosis vs. suspicion?

• What is the neurological evidence?

• Consider the patient’s symptoms

• Do they meet the criteria for PPA?

When neuro referral is needed…

• Suspected primary progressive aphasia

When neuro evidence exists before SLP testing…

• “_____ type PRIMARY PROGRESSIVE APHASIA”

(PPA Subtyping - Assessment Suggestions) Picture description:

• svPPA

• lvPPA

• nfvPPA

svPPA:

• fluent with high frequency nouns, pronouns & verbs; normal speech rate; prominent word finding difficulties

lvPPA:

• intermediate speech rate between svPPA & nfvPPA; fewer syntactic errors than nfvPPA; word finding difficulties NOT as severe as svPPA; phonemic paraphasias

nfvPPA:

• nonfluent, agrammatic, & slow; frequent speech distortions

On aphasia batteries, what would svPPA present with?

• difficulty w/ naming subtests; poor performance on auditory comprehension tests

On aphasia batteries, what would lvPPA present with?

• difficulty w/ naming subtests; impaired repetition

On aphasia batteries, what would lvPPA present with?

• difficulty w/ naming subtests; impaired repetition

On aphasia batteries, what would nfvPPA present with?

• distortions in naming subtests; impaired repetition may be observed, but due to apraxia of speech &/or grammatical processing impairment; poor performance on subtests assessing grammatical processing impairment; poor performance on subtests assessing grammatical processing

(Goal Management for PPA) STGs:

1. We want to “compensate for progression of language loss (not stimulate the language system to regain skills).”

2. We also want to start early. “Begin compensatory treatment as soon as possible. Be proactive so the person w/ PPA can learn to use communication strategies & tools.”

3. Finally, we want to “include primary communication partners in all aspects of training, w/ outreach to multiple partners.”

(Goal Management for PPA) LTGs:

1. Decrease frustration & increase communication

2. Enhance overall understanding in the functional communication setting

3. E.g.: “PWA will be able to express pain related to illness or mood”

4. E/g/: PWA will increase independence & safety

How do you differentially diagnose at more severe stages?

• Look at functional assessments

• stage of PPA matters a lot (mild to more severe stages) At mild, easier to differentially diagnose bc it’s consistent w/ subtypes. In more severe stages, patient may present w/ difficulties we’re not aware of, making it more challenging to box patient into specific subtypes

• If this is the case, more functional assessment measures. Obtain strong case history, if you take naming, repetition, if it is logopenic type, repetition would be the weakest component early on → this helps tell you based on how patient is performing what their diagnosis was more consistent w/ early on & where they were at initially

Impairment-Based Approach:

• Enhancing verbal expression or auditory comprehension by direct training of highly significant lexical terms

Participation-Based Approach:

• Enhancing life participation by providing access to & training the use of supportive resources

Lexical Retrieval Treatment:

• Goal: Developing personally relevant mini lexicons:

  • Training using cueing hierarchies

Lexical Retrieval Treatment:

• Personally relevant mini lexicons →

  • Training using cueing hierarchies

  • Semantic Feature Analysis (SFA)

  • Pairing cues - spoken + written

• Research shows that there is long-lasting gains from such tc in svPPA, nfvPPA, & lvPPA

Video-Implemented Script Training for Aphasia (VISTA):

• Repeated practice talking about important topics using “scripted” content developed collaboratively w/ the clinician

• Largely homework-based (unison speech production w/ video)

• Practice using scripts in conversation

Other Direct Interventions:

• Spaced Retrieval Training

• Vanishing Cues

• Direct Verbal Instructions

What are participation-based/indirect interventions?

• Communication Partner Training

• Use of AAC & other nonverbal communication (Voice banking)

Montessori-Based Interventions (MI):

• Montessori activities involve everyday practical tasks & engage the learning-by-doing system, thus relying on implicit memory (usually spared) rather than explicit or declarative memory

Reading Roundtable:

• Montessori-based group activity; aimed at increasing positive engagement & verbal discussion

• Capitalizes on relatively spared oral reading skills in many PWD

• Specifically developed stories, designed & adapted w/ ease of communicative access:

  • Stories have a supportive sensory format (e.g., large font, high-contrast printing),

  • Accompanying questions to spark discussion

• Positively engages residents & fosters reminiscence

• Participate in conversation (e.g., turn taking, listening, making on-topic statements)

Overview of End-of-Life Care:

• Palliative care & hospice: a continuum of health care services for persons with serious illness from the time of diagnosis of a medical condition through death & bereavement care

• In palliative care, the goal is to adjust day-to-day activities in response to the continuous progression of the condition to enhance well-being, promote client autonomy, & involve clients & care partners in the process of clinical decision making

• Hospice is a type of palliative care & is implemented as patients approach the end of life (EoL)

Who are the care members of the interdisciplinary team?

• Patients, Family, & Friends

• Medical & Nursing Staff

• SLP, OT, PT, SW, Music/Art therapists, Counselors

• Chaplains, Other religious/spiritual leaders

1. vague, reading an item

2. kipnic - logopenic

3. nonfluent variant PPA

• logopenic variant

  • nonfluent can occur with sentence repetition, however, they will still be able to recall some words this is different from logopenic where they will not be able to recall any

The role of the SLP in palliative care:

1. Consultation with patients, families, & members of the hospice team regarding choices in the areas of communication, cognition, & swallowing function

2. Consultation regarding strategies & tools in the area of communication to support the patient’s active participation in decision making, to maintain social closeness, & to assist the patient in fulfillment of end-of-life goals

3. Assistance in optimizing function related to dysphagia symptoms to improve patient comfort & eating satisfaction & to support positive mealtime interactions w/ family members

4. Collaborative consultation w/ members of the interdisciplinary team to provide & receive input related to overall care

What could we improve & how?

• Learning how to manage our emotional responses related to death & dying

• Expanding our views to consider death & dying a part of the human experience

• Arrange time for self-care practices to maintain our own mental & physical health