Communication Disorders in Adults Midterm

Neurogenic communication disorder

A problem with communication as a result of damage to the brain or other part of the nervous system

Where do SLPs treat adult disorders?

• hospitals

  • acute care facilities ex: intensive care

  • rehabilitation facilities

  • outpatient rehabilitation facilities

• skilled nursing facilities

• home health care

• home and community

Cognition

Ability to process thought

Speech

Sounds the mouth makes to produce words

Language

Words, symbol set used to communicate meaning; usually verbal, written, or signed

Receptive or expressive

Deficits in language

Does not imply deficits in cognition

e.g., A person may be able to think clearly, but not be able to put those thoughts into words

Deficits in cognition

Does not imply deficits in language

e.g., A person may only be able to produce disordered thoughts, but every disordered thought may be perfectly organized into language and produced verbally via speech

Healthy aging

Normal changes that occur with aging, ex: wrinkles, hearing loss; speech and voice remain overall typical

What remains intact for healthy aging?

• Orientation

• sustained attention

• divided attention for basic tasks

• long term memory

• procedural memory

• executive functions for ADLs

• processing functional verbal language

• overall comprehension

What usually declines for healthy aging?

Slight non-pathological decline:

• selective attention

• divided attention for complex tasks

• short-term memory

• working memory

• processing of verbal language slows, though remain entirely functional

• reading slows, though remains entirely functional

• word finding of proper names and confrontational naming

Pathological aging

Changes that occur due to a particular disease or disability

Communication

Fundamental to an older persons’ quality of life to:

• express themselves

• maintain social connections

• function independently

• learn new things

• adapt to changes

Potential barriers to communication for the elderly

• physical isolation

• sensory losses

• diminished power/influence

• retirement, lack of purpose

• lack of transportation

• health issues

• gradual reduction of support systems

Etiology

Underlying medical cause of a symptom of deficit

Etiologies of neurogenic communication disorders

• stroke

• TBI

• tumors

• surgical trauma

• degenerative disorders

• infectious diseases

Idiopathic etiology

Deficits of symptoms that are of an unknown or obscure origin

Damage to the CNS or PNS

Results in communication, cognition, language, and behavior deficits; determined by site and severity

Stroke

Known as a cerebrovascular accident (CVA), occurs when brain tissue is permanently destroyed or temporarily does not function due to decreased or absent blood supply to affected brain tissue

• 3rd leading cause of death in US

• can occur w/in any area of the brain of brain stem

• factors that increase likelihood of strokes

  • tobacco use, physical inactivity, A-Fib, HTN (hypertension), CAD (coronary artery disease)

Anoxia

Complete lack of oxygen to a cell

Hypoxia

Partial, insufficient loss of oxygen to a cell

What are the 2 types of strokes?

1. Ischemic

2. Hemorrhagic

Ischemic stroke

Blockage in the arterial system, occurs when a blood vessel in the brain is occluded. 3 types of ischemic strokes:

1. thrombotic

2. embolic

3. transient ischemic attack (TIA)

Ischemic core/infarct

Location of the focal damage to tissue w/in the brain following the stroke

Ischemic penumbra

Area of tissue that, although it has lost the appropriate level of blood supply to function, still receives enough collateral blood flow from other vessels to stay alive

• Surrounds the ischemic core

• damage to the penumbra can be reversed w/in 2 to 4 hours of medical attention

Thrombotic stroke

An occlusion of blood vessels w/in the brain, usually due to atherosclerosis, occurs when:

• a thrombus forms

• interrupts flow w/in the brain

Embolic stroke

Occurs when:

• embolus lodges w/in a blood vessel inside the brain

  • A mass traveling through the circulatory system, lodges in a blood vessel in the brain

• cuts off blood circulation to a part of the brain

Transient ischemic attack

TIA, or mini-stroke

small ischemia in the brain that resolves itself w/in 24 hours

• does not cause permanent deficits unless TIAs are recurring

• may be a warning sign of a larger oncoming stroke

Hemorrhagic stroke

Compromised artery resulting in bleeding, occurs when:

• a blood vessel w/in the brain ruptures

• blood spills into the brain

• deprives a part of the brain of blood flow

Typical causes of hemorrhagic stroke

• high blood pressure aka hypertension (HTN)

• engaging in high periods of physical activity

• have a history of hemorrhagic stroke

• experience alcohol abuse

• onset symptoms:

  • severe headache

  • nausea

  • vomiting

3 mechanisms of damage due to hemorrhagic stroke

1. blood supply to a portion of the brain has been interrupted due to a burst/broken blood vessel

2. blood spilling out into the brain tissue where it does not belong causes damage

3. intracranial pressure increases due to the continued release of blood into the brain or between the surface of the brain and the cranium

Aneurysm

Weakness in the wall of the artery results in abnormal stretching or ballooning out of the wall of a blood vessel, symptoms include:

• severe headache

• nausea

• vomiting

• blurred vision

• sensitivity to light

• seizures

• loss of consciousness

Traumatic brain injury

Serious and life-threatening brain damage,

• result of an external and forceful event (not due to disease, stroke, seizure, surgery)

• common causes: falls, motor vehicle accidents (MVA), violent assault, being struck by an object

• immediate impact ranges from mild concussion to coma to death

• language + cognitive deficits are varied and complex

  • depends on what areas of the brain were damaged and to what extent

• common in children ages 4 yrs and under to sustain a TBI

Opioid-related brain injury

• Anoxic/hypoxic brain injury

  • severity depends on extent and length of oxygen deprivation

  • damage is diffuse

• toxic brain injury

  • damage to the brain induced by high levels of toxins in the body

  • common in opioid abuse and CO2 poisoning

Brain tumors

Neoplasm, abnormal growth of cells in the brain, serves no purpose to the body

• the name of brain tumors reflect the types of cells they are composed of primary or secondary tumors

Infection

• Can damage CNS and PNS

• may be viral, fungal, bacterial, parasitic

• examples: encephalitis, HIV/AIDS, Creutzfeldt-Jakob disease (mad cow)

• impacts cognition, motor, and language

  • depends on site, nature, and damage of infection

Seizures

Sudden, often periodic, abnormal levels of electrical discharge occurring in the brain, caused by:

• stroke

• TBI

• tumor

• surgical trauma

• infections

• epilepsy

Nervous system

• central nervous system: brain and spinal cord

• peripheral nervous system: cranial and spiral nerves

What are the three gross divisions of the brain?

Cerebrum, brainstem, cerebellum

Cerebrum

The major portion of the brain that’s filled with ridges and valleys; houses our consciousness, language, cognition, organizes body movements, and other complex cognitive functions

• cerebral cortex

• subcortex structures: basal ganglia, limbic system, thalamus

Longitudinal fissure

• runs from the front to the back along the brain

• divides the brain into left and right halves

Corpus callosum

• connects the right and left hemispheres through white matter

• located at the base of the cerebral hemispheres

Cerebral cortex

The surface tissue and most superficial layer of the cerebrum made up of gray matter (cell bodies); is divided into 4 lobes

Grooves and bulges in cortex

• sulci: small

• fissures: large

• bulges: gyri

Cerebral lobes

Frontal, parietal, temporal, occipital

Frontal lobe

Anterior aspect of both hemispheres, contains:

• primary motor cortex

• Broca’s area

• prefrontal cortex

Primary motor cortex (motor strip)

• posterior gyrus of frontal lobe just anterior to the central sulcus

• left primary motor cortex send motor plans to speech muscles

• damage near base of motor strip often creates apraxia of speech

Broca’s area

• inferior frontal gyrus

• one hemisphere, located in the left frontal lobe

• damage results in Broca’s aphasia

  • expressive language impairment

Pre-frontal cortex

Critical for executive functioning and personality

Parietal lobe

Primary sensory cortex (sensory strip)

• first gyrus of parietal lobes

• receives tactile + proprioceptive (somatic) information

• left sensory cortex receives sensory info from the right side of the body

• right sensory cortex receives sensory info from left side of the body

Temporal lobe

• inferior to lateral sulcus

• hearing center

  • located in upper half of anterior two thirds of temporal lobe

• left primary auditory cortex

  • auditory comprehension of verbal language

• right primary auditory cortex

  • comprehension of environmental sounds and music

Wernicke’s Area

• posterior part of superior temporal lobe

• important for attaching meaning to sensory input

• damage results in Wernicke’s aphasia

  • receptive language impairment

Hippocampi (“seahorse”) of limbic system

• located in the inferior and medial sections of temporal lobes

• moves experiences from short-term memory into long-term memory

• needed to learn new information

Occipital lobe

The most posterior sections of the cerebrum that are dedicated to receiving and processing neural impulses related to vision

Primary visual cortex

• located on the most posterior section of the occipital lobe

• receives visual information from the eyes

• each visual cortex receives and processes information from the contralateral visual field

• transmits visual information anteriorly to visual association (parieto-occipital) area for processing

Subcortex

• Responsible for function usually beneath the level of awareness

  • refines motor plans

  • regulates heartbeat, breathing, arousal, and sleep/wake cycle

  • coordinates viscera and digestive system

Primary structures of the subcortex

1. basal ganglia - motor control/inhibition

2. limbic system - memory + emotional control

3. thalamus - sensory relay station

4. cerebellum - fine-tuning motor output

5. brain stem - home of the CN

Basal ganglia

Group of subcortical structures located within the cerebral hemispheres on either side of the thalamus; plays a role in initiation of movement, muscle tone maintenance, and inhibition of extraneous movements

Includes substructures such as:

• caudate nucleus, putamen, globus pallidus

Limbic system

A number of subcortical structures responsible for sense of pleasure, mating, and feeding behaviors, fight-or flight response, emotions, emotional memory, and sense of motivation. Some structures include:

• hippocampi

  • medial temporal lobe

  • LTM (storage)

• amygdala - emotional control center

  • emotions and memory

Thalamus

• sits on top of the brain stem, under the cerebral hemispheres

• functions as a sensory relay station

• receives afferent sensory information being transmitted from the body (except olfaction) and directs it to the appropriate part of the brain for processing

• receives the motor plans the cerebellum has checked for errors and sends the refined plans for motor execution

Cerebellum

• known as “little brain”

• Divided into 2 hemispheres

  • hemispheres connected by the vermis

  • vermis receives info about the body from projections through the pons

• attached to the pons via peduncles

  • superior, middle, and inferior peduncles

• works as an error control device, detect and correct errors in motor plans

• makes sure body movements are coordinated and free of errors

• monitors the intent of motor plans and compares them to what the body is actually doing

  • if an error occurs, the cerebellum alters the force, timing, and sequencing of muscle contractions

  • ataxia

Brainstem

Structure that connects the spinal cord to the brain

What are the 3 main divisions of the brain?

1. midbrain - houses substantia nigra

2. pons - attaches cerebellum to the rest of CNS

3. medulla - many motor fibers decussate here to other side of the body

   1. lesion w/in the CNS above medulla often creates contralateral hemispheres/hemiplegia

   2. lesion along spinal cord below medulla creates ipsilateral hemispheres/hemiplegia

   3. reticular formation

Spinal cord

Bundle of white and gray matter in the spinal column

• transmits sensory (afferent) information from the body to the brain and motor (efferent) info from the brain to the body

• begins at the medulla

• spinal cord breaks up into loose strands of nerves called the cauda equina

White matter

Region of fiber tracts (myelinated axons), tracts that connect parts of nervous system

Gray matter

Cell bodies

Peripheral nervous system

Carries sensory and motor info to and from the body and CNS , spinal and cranial nerves

Spinal nerves

Controls the trunk, arms, and legs of the body, connects the spinal cord to muscles, organs, or glands

• 31 pairs of spinal nerves originate w/in the gray matter of the spinal cord and course out of vertebral column into soft tissues

• no direct role in speech except for phrenic nerve

Cranial nerves

Innervates the muscles of the head, face, and neck; connects the muscles and structures of the head, face, and neck to the CNS

• 12 paired nerves

• all either motor, sensory, or mixed motor-sensory

CN I Optic Nerve

Conducts sensory signals from eyes/retina

• optic chiasm - the point where the left and right optic nerves come together and medial fibers decussate

• optic radiations

CN V Trigeminal Nerve

Mixed motor-sensory nerve, splits into 3 branches:

• ophthalmic: sensory

  • sensory info from upper face, forehead, scalp to CNS

• maxillary: sensory

  • sensory info from teeth, upper lip, buccal, nasal cavities, sides of face to CNS

• mandibular: motor-sensory

  • sensory info from lower teeth, lower gums, bottom lips, portions of tongue to CNS

  • motor info to muscles for mastication

CN VII Facial Nerve

• Mixed motor-sensory nerve

  • motor info to the face

  • sensory (taste) info from anterior 2/3 of tongue

• Has four branches

  • temporal, zygomatic

    • motor info to muscles of the upper face

    • bilaterally innervated

  • buccal, mandibular

    • motor info to muscles of the lower face

    • unilaterally innervated

Bilateral innervation

Receives motor plans from both contralateral and ipsilateral hemispheres, protective redundancy allows body part to still function if one cerebral hemisphere is damaged

Unilateral innervation

Receive motor plans from the contralateral hemisphere of motor movement, no protective redundancy

CN IX Glossopharyngeal Nerve

Sensory and motor functions:

• sensory (taste) from posterior 1/3 of tongue

• motor to muscles of pharynx for swallowing and parotid gland for saliva

CN X Vagus Nerve

Also known as “the wanderer”, both sensory and motor functions:

• innervates muscles of the soft palate, pharynx, and larynx through various branches

• important for speech/voice

Pharyngeal branch

Innervates portions of pharynx for swallowing and elevates velum for non-nasal sounds

Superior laryngeal nerve (SNL)

• intrinsic branch - sends afferent info from inside larynx to CNS

• extrinsic branch - innervates cricothyroid muscle

Recurrent laryngeal nerve (RLN)

• right RLN = passes under right subclavian artery

• left RLN = passes under arch of aorta

  • both recur into neck/larynx and innervate muscles for adduction and abduction of vocal cords

CN XI Accessory Nerve

Only motor function:

• cranial component works as an accessory of the vagus nerve

• spinal component innervates muscles of the neck/shoulders

  • sternocleidomastoid - bilateral innervation cerebral cortex

  • trapezius - unilateral innervation

CN XII Hypoglossal Nerve

Motor functions

• innervates all intrinsic muscles of the tongue

  • fine motor movements of tongue

• innervates most extrinsic muscles of the tongue

  • gross motor movements of tongue

Ataxia

Manifests as poorly controlled and poorly coordinated movement that is lacking in smoothness; complex movements are often disintegrated and broken down and executed in their component parts

Cerebral hemispheres

Each hemisphere is responsible for different cognitive and motor functions

Vascular System

Made up of the vessels that carry blood and lymph fluid through the body:

• Aorta - Common carotid artery

  • internal carotid - majority of blood goes to the brain

    • anterior cerebral artery

    • middle cerebral artery

  • external carotid

• Vertebral artery

  • posterior cerebral artery

Deficits associated with ACA lesions

• Paralysis

  • contralateral hemiplegia of leg only

• cognitive + emotional changes

• apraxia of gait

• incontinence of bowl + bladder

Deficits associated with MCA lesions

• contralateral hemiplegia

• hemianopsia

  • visual field cut

• aphasia

• apraxia

• upper motor dysarthria

Deficits associated with PCA lesions

• hemianopsia

• visual agnosia

  • difficulty with labeling or identifying objects

Deficits associated with Vertebrobasilar system

• Brainstem blood supply

  • Dysarthria

  • Dysphagia

  • Locked in syndrome (LIS)

  • Arousal difficulties

• Cerebellar blood supply

  • Ataxic dysarthria

Wernicke’s aphasia

• Good speakers, poor communicators

• Damage to this area and surrounding:

  • occlusion of inferior/posterior branches of MCA to posterior 1/3 of superior gyrus of temporal lobe

• Characteristics:

  • Poor comprehension

  • Neologisms (jargon)

  • Semantic + phonemic paraphasias

  • Logorrhea

  • Empty speech

  • Loss of pragmatic skills

  • Minimal motor involvement of extremities

Transcortical sensory aphasia

• Transcortical sensory: L Parietal watershed

• Occlusion to anterior area between MCA and posterior cerebral artery (PCA) posterior to Wernicke’s area at the temporo-occipital-parietal area

• Characteristics:

  • Poor auditory comprehension

  • Relatively intact reception

  • Fluent speech with semantic paraphasias

  • Visual deficits

Conduction aphasia

• Conduction: L supramarginal gyrus + atcuate fasciculus

  • Supramarginal gyrus of parietal lobe, posterior to sensory cortex and above Wernicke’s area damaging arcuate fasciculus leaving Broca’s and Wernicke’s genrally okay

• Characteristics:

  • Fluent speech

  • Intact auditory comprehension

  • Repetition inordinately impaired relative to other deficits

  • Phonemic paraphasias

  • Anomia

  • Aware of errors

  • Self repair/correction attempts

Anomic aphasia

• Damage anywhere w/in the language areas

• L angular gyrus

• Characteristics:

  • Fluent speech

  • Intact receptive language

  • Disproportionately severe anomia

Crossed aphasia

Lesion to a right hemisphere that creates aphasia, the consequent contralateral hemiparesis/hemiplegia leaves R hand (usually dominant writing hand) motorically intact

Assessment of aphasia

• Case history - demographic info, medical chart

• Assess/observe communication and speech - observe residual language, compensatory strategies, connected speech

• Administer standardized test - ex: BDAE, WAB-R

• Cognitive evaluation - cognition, language, and communication are intertwined,

  • Some level of cognitive deficits almost universally present in those with aphasia

  • Attention, working memory, STM

4 primary modalities of language

1. Auditory comprehension

2. Verbal expression

3. Visual comprehension (reading)

4. Written expression (writing)

   1. and possibly non-verbal communication

Aphasia therapy

• Spontaneous recovery is up to 6 months post-onset

• therapy during aphasia will facilitate spontaneous recovery

• 3 categories of therapy approaches:

  • restorative, compensatory, social

Restorative approach

• Based on neuroplasticity

  • ability of the brain to change itself to take on new functions and to compensate for damage to another part of the brain

• Melodic Intonation therapy - uses intact melodic/prosodic processing of the right hemisphere to cue word retrieval in the left hemisphere

• Constraint-induced therapy - combats learned non-use

• Errorless learning - avoid the practicing of errors

Compensatory strategies

• Strategies that focus on helping a patient function despite their deficits

• AAC

  • low tech - gestures, draw, point to pictures on a communication board

  • high tech - programmable voice generating computers such as Lingraphica, apps for iPhones, iPads

Social approaches

• Communication partner training

  • targets changing the behavior of those in the environment of individuals with aphasia to facilitate the communication of those with aphasia

• Group therapy

  • increases hope, psycho-social emotional support, pragmatic skills, and confidence as speaker

  • may also focus on goals unaddressed by individual therapy

Aphasias

• multimodality deficit in communication, affecting language-based modalities

• acquired neurologic impairment of language

• NOT a disorder of development

• NOT due to sensory or motor disorder

  • Can a child have aphasia? Yes, through brain tumors, TBI, stroke, etc.

Expressive language deficit

• Difficulty in formulation or production of verbal, written, or gestural language

• Due to lesions at or near Broca’s area

  • lesions anywhere w/in anterior portion of left cerebral hemisphere may cause expressive deficits