Communication Disorders Communication Disorders Across the Life Span: AdultsAcross the Life Span: Adults

J.B. Orange, PhDAssociate ProfessorJBOrange@uwo.ca

X88921

Faculty of Health SciencesSchool of Communication Sciences and Disorders

OutlineOutline

Overview of common speech, voice, language, and cognitive-communication disorders in adults

Assessment - screening

Referrals

SpeechSpeech (production and perception)(production and perception)

Medium of oral communication that employs a linguistic code

Communication through vocal symbols Complex, dynamic neuromuscular processes

of sound production articulation resonance phonation respiration prosody (e.g., pitch, speech rate, stress, etc.)

VoiceVoice

Sounds produced in air above vocal chords as chords vibrate

Use of vocal folds and associated muscular, skeletal, cartilage, and nerve tissue

Source of sound energy

Linked with respiratory, resonatory and speech systems

ResonanceResonance

Vibration of the air in the cavities above, below, in front of, and behind the sound source

Nasal vs vocal

SwallowingSwallowing

To pass substances through the oral cavity and pharynx and into the esophagus

Complex, coordinated motor sequences of multiple muscle systems

Initiated voluntarily but almost always completed reflexively

Distinct from feeding

4 phases

HearingHearing

The sense through which spoken language or non-speech sounds (i.e., via sound pressure waves) are received, transmitted and processed

Ears, auditory nerve and cerebral cortex

LanguageLanguage

a shared set of symbols used to represent concepts or ideas

symbols governed by set of rules: phonology (sound positions and combinations) grammar (The boy randed to the store.) syntax (to store the boy the ran) semantics (define “car”) pragmatics (multiple interpretations of words, phrases,

clauses, or sentences - contextual influence, e.g., “run”, “cold shoulder”)

CommunicationCommunication

1. exchange of concepts or ideas between two entities dynamic role exchange between speaker and

listener

2. mechanism whereby we establish, maintain and change relationships

consists of multiple forms socially motivated and mediated = interactional agenda driven = transactional (e.g., ordering food

in a restaurant)

CognitionCognition processes of gaining knowledge, organizing

information (new or old), and using what has been learned

includes, but is not limited to: memory systems and processes attention systems and processes judgment reasoning - decision making insightfulness other systems and processes

Functional

Retrocochlear and Central

Sensorineural

Conductive Loss

Hearing

M otor Speech

Fluency

Resonance

Articulation

Voice (phonation)

Speech

Adult and Older AdultAphasia

Dem entia

School Aged ChildrenLanguage Learning D isability

Preschool ChildrenSpecific Language Im pairm ent

Pervasive Developm ental D isorder

Language Sw allow ing

Com m unication D isorders

Speech, Language, Hearing and Speech, Language, Hearing and CommunicationCommunication

Input/Understanding auditory

comprehension reading

comprehension nonverbal senses of smell,

touch and taste

Output/Expression spoken written nonverbal (e.g., gaze,

facial expression, posture, proximity, touch, gestures, pantomime, finger spelling, sign language, etc.)

Speech and Voice DisordersSpeech and Voice Disorders

Speech and voice based on integration of five systems:

1. respiratory2. phonatory (vocal folds)3. resonatory (coupling of pharyngeal, oral,

and/or nasal cavities)4. articulatory5. prosodic (duration, rate, rhythm, intensity,

pitch, and sound stress)

DysarthriaDysarthria

disruption in one or more of systems that produce speech and voice

often referred to as motor speech disorder

results from weakness, slowness, lack of coordination, and altered tone of muscles that support speech and voice

several types including flaccid, spastic, ataxic, hypokinetic, hyperkinetic and mixed

DysarthriaDysarthria (cont’d) (cont’d)

individuals normally understand spoken language, can read and write (provided there are no physical or sensory impairments of arms, hands or eyes)

generally, no language problems

do not normally have trouble with word finding

mild to severe unintelligibility

if severe, anarthria (total inability to speak)

Common Speech and Voice Symptoms Common Speech and Voice Symptoms in Dysarthriain Dysarthria

Problem

articulation

speech rate

Symptoms

imprecise or unclear sounds and syllables

rapid, slow, or irregular speaking rate

vocal quality

loudness

prosody

hypernasal, breathy, hoarse, strained-strangled; intermittent voicing or aphonia (no voice)

too loud, too soft, intermittent bursts of loudness, monoloud

monopitch, in-appropriate changes in pitch, sound, syllable or word stress problems

Apraxia of SpeechApraxia of Speech ( (AOSAOS))

motor speech disorder

difficulty initiating and sequencing speech movements (difficulty programming muscle movements)

not as a result of: listening (comprehension) problems reflex problems muscle strength or tone (e.g., paralysis or paresis) cognitive or psychiatric problems

AOSAOS (cont’d)(cont’d)

characterized by: sound substitutions and additions (e.g., “take” for

“cake”)

transposition of syllables (e.g., “terbut” for “butter”)

difficulty initiating speech (physical groping to produce sounds)

impaired prosody

Aetiology of Dysarthria and AOS: Selected Aetiology of Dysarthria and AOS: Selected ExamplesExamples

cerebral vascular accidents (CVA) = stroke = “brain attack”

head trauma

brain tumors

progressive neurological diseases (e.g., Parkinson’s disease, amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS), etc.)

negative side effects of psychotropic drugs (e.g., tardive dyskinesia)

brain infections (e.g., encephalitis)

Aetiology of Voice Disorders: Selected Aetiology of Voice Disorders: Selected ExamplesExamples

Organic

carcinoma contact ulcers trauma polyps tumors nodules web cysts

Non-organic – Functional

stress and anxiety conversion reaction –

emotional distress other psychosocial factors

Voice DisordersVoice Disorders (cont’d) (cont’d)

laryngeal cancer common cause of voice disorder

peak age occurrence between 60-70 years old

several studies link laryngeal cancer to excessive and prolonged cigarette smoking and alcohol consumption

laryngeal cancer treated by radiation therapy, chemotherapy, and in more advanced cases, surgery

Voice DisordersVoice Disorders (cont’d) (cont’d)

complete removal of larynx (i.e., total laryngectomy) requires new airway

permanent tracheostomy (i.e., stoma) created just above sternum

person breathes through stoma

nose and mouth completely separated from airway to lungs

Voice DisordersVoice Disorders (cont’d) (cont’d)

after total laryngectomy, laryngectomee is unable to phonate (i.e., produce a voice)

Several alternatives:

1. artificial larynx – electrolarynx (extra- or intra-oral)

device that generates a vibration while the resident articulates (i.e., moves, lips, tongue, soft palate)

Voice DisordersVoice Disorders (cont’d) (cont’d)

2. esophageal speech breathing air into upper segment of

esophagus then expelling it to generate vibratory tone

less common Rx option

Voice DisordersVoice Disorders (cont’d) (cont’d)

3. surgically created voice - tracheoesophageal puncture (TEP)

small opening made between trachea and esophagus

one-way valve prosthesis inserted in opening

air drawn through valve into esophagus where PE segment vibrates

Language Disorders - AphasiaLanguage Disorders - Aphasia

acquired language disorder that affects: spoken and written language listening and reading comprehension nonverbal communication

damage to cortical and/or subcortial regions known to support language functioning

different types and severity: depend on region(s) and amount involved

Aetiology of Aphasia: Selected Aetiology of Aphasia: Selected ExamplesExamples

cerebrovascular accident (CVA = stroke = “brain attack”)

traumatic brain injury (TBI)

neoplasm

infectious diseases

other (e.g., exposure to toxins, etc.)

Neural Basis of AphasiaNeural Basis of Aphasia

L and R cerebral hemispheres involved in language processing

for many people L cerebral hemisphere controls almost all language processes

focal damage to L hemisphere results in aphasia

R hemisphere contributes (but to lesser extent) to language functioning

R hemisphere damage does not usually result in aphasia

Broca’s AphasiaBroca’s Aphasia

slow, laboured speech

few spoken words; mostly nouns and verbs

spoken and written grammar are impaired

word finding problems

listening and reading comprehension skills impaired but better than spoken language

person is aware of his/her language problems

AOS and R hemiplegia or hemiparesis can accompany

Wernicke’s AphasiaWernicke’s Aphasia

excessive amount of spoken language

word-finding problems

content often lacks meaning

significant listening and reading comprehension difficulties

well formed and normal speech (i.e., pitch, rate, rhythm, etc.)

person exhibits little awareness of his/her language problems

Global AphasiaGlobal Aphasia

limited functional language and communication

may repeat a few common every day words or clichés or non-words spontaneously or in response to questions

poor listening and reading comprehension may understand simple gestures or pantomime,

vocal inflection, facial expression and environmental sounds

may be able to copy own name; writing usually non-functional

Anomia in AphasiaAnomia in AphasiaVariety of word-finding errors:

1. jargon - unacceptable sequencing of real and/or nonwords (i.e., neologism = “slammazer”)

2. vague/nonspecific words (e.g., “thing” for “pen”)

3. phonemic paraphasia - word close in sound to intended word (e.g., “pit” for “sit”)

4. semantic paraphasia - word closely related in meaning to intended word (e.g., “salt” for “pepper”)

5. verbal paraphasia – real word unrelated to intended word (e.g., “cup” for “brother”)

Aphasia RecoveryAphasia Recovery

Degree and speed of recovery of language varies depending on:

spontaneous recovery language Rx from SLP severity at onset aetiology site and extent of brain damage type of aphasia other factors (L1 vs L2, sex, education level,

age, etc.)

Cognitive-Communication Disorders: Cognitive-Communication Disorders: DementiaDementia

Syndrome of acquired, progressive, persistentdecline in 3 of 5 spheres of mental activity:

  1. memory2. language and communication3. personality4. visuospatial skills5. cognition (e.g., reasoning, abstraction, judgement, etc.)

DSM IVDSM IV

A. Multiple cognitive deficits including both:1. memory impairment2. one (or more) of the following:

a. aphasiab. apraxiac. agnosiad. disturbance in executive functioning(e.g., planning, organizing, sequencing, abstracting, etc.)

B. Cognitive deficits in A1 and A2 each:1. cause significant impairment in social or occupational functioning2. represent significant decline from previous

functioning

Epidemiology and DemographicsEpidemiology and Demographics: : PrPrevalenceevalence(CSHA I Working Group, 1994, (CSHA I Working Group, 1994, CMAJCMAJ))

252,600 (8% of 65+) (% distribution: community = institutions)

2 ♀: 1 ♂ 2.4% 65-74 yrs 34.5% 85+ yrs

161,000 DAT (64% of total dementias) 19% VaD Mixed = DAT + VaD = rising %

592,000 cases by 2021 (65 yrs + = 23-24% total pop) # cases will triple by 2031

IncidenceIncidence(CSHA II Working Group, 2000, (CSHA II Working Group, 2000, NeurologyNeurology))

60,150 new cases dementia/yr 39,000 cases of DAT/yr

Examples of Types of DementiaExamples of Types of Dementia

DAT/AD EoAD DS-DAT

VaD Mixed (DAT + VaD) Lewy body disease FTLD (FLD +

semantic dementia)

PPA FTLD Pick’s Pick’s Complex Dementia with motor

neurone disease Parkinson’s, ALS,

MS, HC, etc. AIDS dementia CJD

DementiaDementia (cont’d) (cont’d)

previously thought of as irreversible = non-treatable, although this is changing

prevalence increases dramatically with age DAT more common among those with low

education

subgroups of DAT (e.g., age of onset, family history, frontal lobe signs, head trauma, maternal age, level of formal education, etc.)

Speech, Language and Speech, Language and Communication Profiles in Communication Profiles in

DATDAT

SpeechSpeech

dysarthria

pitch changes

volume control

speaking rate

apraxias

none

none

no problems

normal

limb praxis problems early; verbal and oral apraxias may appear later

Language and CommunicationLanguage and Communication

Language and communication problems prominent in DAT subtle onset; prominent with progression

Profiles vary by clinical stage markers of onset and progression

Language and communication of utmost concern to caregivers

Heterogeneity (i.e., broad range of skills) within each stage

Language and communication profile in DAT differs from those associated with:

normal aging

confusion or delirium

stroke-based aphasia

psychiatric disorders (e.g., schizophrenia)

depression

R hemisphere dysfunction

other focal neurological disorders and syndromes

traumatic brain injury

(e.g., motor vehicle accident - MVA)

Prevalence of Language and Prevalence of Language and Communication Symptoms in DATCommunication Symptoms in DAT

Difficulties Prevalence (%)word finding ……… 84naming objects …… 82letter writing ……… 80comprehend instructions ……… 76sustain conversation ……71complete ideas …… 64repeat ideas ……… 64reading comprehension …… 64

Difficulties Prevalence (%)meaningless sentences ………… 60decreased talkativeness …… 58inappropriate talk … 54repeat words ……… 45interprets literally …… 33recognizes humor … 32increased talkativeness ……… 16

(n = 99; Bayles & Tomoeda, 1991)

LanguageLanguage

naming & vocabulary

spoken output

repetition

listening comprehension

writing

errors appear early; related words used then words become increasingly less related

subtle changes early; reduced meaning with progression; sentences less elaborate and tangential; grammar and syntax OK until late stage

intact

problems apparent in middle stage; Wh questions difficult; prosody and nonverbal important

semantically empty by middle stage

CommunicationCommunication

early subtle changes that can progress to mutism

short and frequent conversational turns

problems linking ideas within and between sentences

difficulty understanding humour, sarcasm, morals, gist, figurative language

turn-taking and repair preserved through to late stage

topic initiation and management problems emerge in early stage; prominent in middle stage

So What?So What?

Communication Considerations for Communication Considerations for Clinical PracticeClinical Practice

1. What is your agenda? why are you communicating why do you want to communicate with the person?

social connectedness, personhood and dignity task-agenda driven (i.e., information gathering)

2. Consider multiple options strategy may work well then not work well later –

heterogeneity

partnership (speaker and listener roles)

active listener

optimize existing skills know strengths and limitations of all

participants

raise your awareness of how, what, where and when you communicate

Elder-Speak, Patronizing Speech, Elder-Speak, Patronizing Speech, Secondary Baby TalkSecondary Baby Talk

increased loudness exaggerated intonation higher pitch slow speaking rate simplified syntax simplified content tag question closed-end questions

short directives short utterances higher # utterances per

conversational turn presumptions of poor

memory nonverbal behaviours terms of endearment,

pet names, nick names use of first name

Communication Assessment (Screening) Communication Assessment (Screening) ConsiderationsConsiderations

1. Case Hx• medical• psychiatric• neurological• educational• linguistic• social• occupational• family dynamics

Screening ConsiderationsScreening Considerations (cont’d)

2. Hearing• otoscopic examination

• pure tone screening (+ impedance, where possible)

• assistive listening devices (e.g., Pocket Talker)

• referral to audiologist where necessary

Screening ConsiderationsScreening Considerations (cont’d)

3. Language

A. Speaking• Spontaneous• Topic directed interview (“Tell me about .

• where you were born and raised

• work or jobs you did

• your family

• your health right now

• what you do each day

A. Speaking (cont’d)

Naming• confrontation (objects or pictures)• generative (animals, colours, letters F, A, S, etc.)• responsive (You get your prescription filled at

a .)

Repetition• words (e.g., nouns vs verbs)• phrases (e.g., noun vs verb) • sentences (e.g., present vs past tense – regular vs

irregular)

Listen for:word substitutionsword errorsemptiness of meaning topic digressionschanges in contentverbosity (or inhibition)grammar and syntax errors

B. Writing

Spontaneous (not rote) vs copying words phrases sentences

Copying words phrases sentences

C. Auditory Comprehension

complex vs simple language (1, 2, and 3 step commands with and without body movements)

note performance changes based on content, grammar and syntax

consider influences on performance from neurological, cognitive, psychiatric and emotional status

D. Reading Comprehension

Reading aloud vs comprehension words phrases sentences

consider influences on performance based on word class (e.g., nouns vs verbs vs prepositions), spelling (regular vs irregular; “ship” vs “yacht”), among other factors

Screening ConsiderationsScreening Considerations (cont’d)

4. Caregivers’ Perceptions

what do family members note about changes in: speech language hearing communication

ask about content (e.g., word finding problems), form (e.g., grammar and syntax) and use (e.g., appropriateness) of language and communication

SLP Referral ConsiderationsSLP Referral Considerations

Sudden or gradual onset of:

unexplained slurred or unintelligible speech, voice or language

harsh, breathy voice quality

hypernasality

SLP Referral ConsiderationsSLP Referral Considerations (cont’d) (cont’d)

word finding problems

listening or reading comprehension problems

grammar or word order problems

spoken or written language that does not make sense

withdrawal from communication