speech language pathology with adults in healthcare

SLPs evaluate, diagnose, and treat disorders of:

1. Speech
2. Language
3. Cognition
4. Voice
5. Swallowing
6. Assess AAc need

Diagnoses SLPs treat

1. CVA
2. Parkinson's
3. MS
4. ALS/PLS
5. Guillain-Barre Syndrome
6. Myasthenia Gravis
7. Head and Neck cancer
8. Dementia
9. TBI/concussion
10. S/P drug overdoses
11. Functional neurological disorders
12. Bell's palsy/ramsey hunt
13. PSP, MSA, SCA, Huntingtons

Example of treatment diagnoses

1. Aphasia/dysphasia
2. Dysphagia
3. Dysphonia/aphonia
4. Hypophonia
5. Facial weakness
6. Dysprosody
7. Dysfluency
8. Dyscalculia
9. Executive dysfunction
10. Head and neck cancer
11. Dysgraphia

Speech/language areas of brain

Broca's area, primary motor cortex, supramarginal gyrus, angular gyrus, wernicke's area, primary auditory area

Motor speech disorders

dysarthria and apraxia

Dysarthria types

1. Spastic
2. Ataxic
3. Flaccid
4. Hypokinetic
5. Hyperkinetic
6. Mixed

Aphasia types

1. Brocas
2. Transcortical motor
3. Wernicke's
4. Conduction
5. Transcortical and sensory
6. Anomic
7. Global
8. Transcortical mixed

Dysarthria

Generalized weakness and incoordination of muscles used for speech that affects respiration, phonation, articulation, and resonation

Dysarthria symptoms

Decreased ability to produce clear, understandable speech (due to disturbances in muscular control of articulatoria), usually occurs after a stroke, brain injury, neurological disease

Treatment of dysarthria

Teaching compensatory strategies to improve speech intelligibility (primary goal), restorative treatment

Tips for PTs and other listeners for patients with dysarthria

1. Reduce distractions and background noise
2. Let the speaker know when you have difficulty understanding them
3. Repeat only the part of the message that you understood so that the speaker does not have to repeat the whole thing
4. Allow time for the patient to express themselves whether it be via verbal speech or AAC

Apraxia

A neurogenic speech production disorder resulting from impairment of the capacity to program the position of speech muscles, messages from the brain to the mouth are disrupted, can occur w/o significant weakness, slowness, or incoordination of these muscles

Apraxia incidence

Co-occurrence with other disorders: 13% "pure", 65% AOS and aphasia, 14% AOS and dysarthria

Aphasia

An acquired language disorder caused by brain damage, characterized by an impairment of language modalities: speaking, listening, reading, writing
Does not affect intelligence

Relationship between language and cognition

Language plays a role and is related to cognition, language is not all of cognition

Characteristics of receptive aphasia

Misunderstand what others say, especially when they speak fast or in long sentences
- find it hard to understand speech with background noises
- requires extra time to understand spoken language
- difficulty following simple and/or complex commands
- difficulty understanding and responding to questions

Characteristics of expressive aphasia

Difficulty producing language
- experience difficulty coming up with the words they want to say
- substitute the intended word with another word that may be related in meaning to the target or unrelated
- switch sounds within words
- use made-up words
- have difficulty putting words together to form sentences
- string together made-up words and real words fluently but without making sense

Brocas

1. Non-fluent, effortful, slow, halting, monotonous
2. Strong auditory comprehension
3. Agrammatic speech
4. Impaired repetition, naming
5. Misarticulated sounds
6. Poor oral reading and comprehension

Wernickes

1. Fluent, effortless, circumlocutions, empty speech
2. Poor auditory comprehension
3. Intact grammar
4. Severe word finding
5. Speech with semantic paraphasias and neologisms
6. Impaired turn-taking, repetition, reading comprehension

Primary progressive aphasia (ppa)

Aphasia of insidious onset with gradual progression and prolonged course without evidence on non-language-based impairments

3 variants of ppa

Semantic, nonfluent/agrammatic, logopenci

Communicating with people with aphasia

1. Get the persons attention before speaking
2. Keep your voice at a normal level, do not speak loudly unless the person asks you to do so
3. Simplify your sentence
4. Reduce rate of speech
5. Give the individual time to speak
6. If they have the expressive language ability, ask
them to repeat what you said if you know they have
impaired auditory comprehension (receptive)
7. Don't assume they comprehend even when they
appear to be (i.e. nodding)
8. Repeat your instructions in the same manner (don't
re-phrase)
9. Gesture and use visuals and pictures; demonstrate
what you want
10. Remember that their "yes's" may not mean "yes" and
their "no's" may not mean "no"
11. Educate caregivers on the patient's HEP
12. Use their AAC
13. Ask the SLP

Right Hemisphere Strokes

Visual Processing - scanning, inattention to the
Left
Unilateral neglect of the left side
Lack of insight
Impaired Time concepts
Higher level language skills
Problems with depth perception
Memory and attention issues
Impulsivity
Difficulty thinking ahead or understanding
consequences

Nine Core Executive Functions

Attention and focus
Organization
Task initiation
Planning and prioritizing
Self monitoring
Working memory
Flexible thinking
Emotional control
Impulse control

Attention and focus

Directing your energy toward a task and completing in a timely manner

Organization

Being able to find what you need because you are well organized

Task initiation

Starting something in a timely manner and not procrastinating

Planning and prioritizing

Carrying out tasks in a smooth manner

Self-monitoring

Monitoring your progress and making changes

Working memory

Holding information in your mind while carrying out a task

Flexible thinking

Not being rigid in your thinking

Emotional control

Being able to calm yourself

Impulse control

Not being distracted

Attention

1. Selective/focused
2. Sustained/vigilance
3. Alternating
4. Divided

Selective/focused attention

Suppressing distracters to stay on task

Sustained/vigilance attention

Remembering to hold phone number in memory long enough to write it down

Alternating attention

Ability to shift focus between tasks that require different cognitive requirements, commonly difficult for patients with TBIs

Divided attention

Typing on a commuter while singing a song, major challenge for patients with TBIs

Dementia treatment

Restorative and compensatory treatment
- memory exercises
- cognitive stimulation
- compensatory strategies
- pt/family/caregiver education and training

Vocal changes d/t aging

Softer/weaker (hypophonia), hoarseness, breathiness, shakiness, alteration in pitch

Dysphagia (swallowing disorders)

Difficulty with swallowing, 30-75% of nursing home residents

Dysphagia causes

Many causes, often a side effect of medications, weak or deconditioned patients, COPD or acute onset

Phases of swallowing

Oral predatory phase, oral phase, pharyngeal phase, esophageal phase

Oral phase of swallowing

Tongue propels food posteriorly until swallowing reflex is triggered

Pharyngeal phase of swallowing

Begins when swallow reflex is triggered, airway closure occurs during this time

Esophageal phase of swallowing

Esophageal peristalsis carries the bolus through the esophagus into the stomach

Bedside eval for dysphagia

Oral motor movements, brief voice assessment, secretion management, volitional swallow, trials of food/liquid consistencies, cough and throat clearing

Instrumental exams for dysphagia

Includes VFSS or modified barium swallow studies, fiberoptic endoscopic evaluation of swallowing (FEES)

Aspiration

Entry of material into the airway below the level of the vocal cords, can result in serious medical complications, silent aspiration

Signs and symptoms of aspiration

Coughing before, during or after a swallow
Multiple swallows per bolus
Food remaining in the mouth after
swallowing
Wet gurgly vocal quality
Nasal regurgitation of food/liquid
Frequent throat clearing
Choking
Complaints of food sticking or lump in
throat
Undesired weight loss
Drooling
Fatigue when eating/drinking
Effortful chewing/swallowing
Inability to handle own secretions

Swallowing treatment

Diet texture analysis and modification
Training of compensatory swallowing strategies
Laryngeal elevation/excursion and strengthening exercises
Base of tongue exercises
Lingual, facial, labial exercises
NMES