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Aphasia:Cognitive-linguisticProcesses,Assessment&Treatment
HeatherHarrisWright,PhDCCC-SLPEastCarolinaUniversity
1.CognitiveandlinguisticProcessesinAphasia
• Attention• Memory– Shorttermmemory–Workingmemory
• Executivefunctions• Cognitiveimpairmentsinaphasia
Language CognitionPlaysarole
Relatedto
Cognition
language
Attention
• “Cognitiveprocessthatconcentratesmentaleffortonanexternalstimulusorinternalthought/representation”(Ashcraft&Radvansky,2010)
• Overlapswithotheraspectsofcognition
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• Ifattentionisweakenedthenlanguageoperationsbecomelessefficient
• Needattentiontofocusoncommunicationpartner’sspeech,particularlywhensurroundedbycompetingstimuli
• Arousal–– Basiclevelofattention– Physiologicalstate– Generalreadinesstoact/receive– Necessaryforintentionalcommunicationtooccur– Supportsvigilance
• Vigilance– Attentionsustainedoverlongperiodsoftime– Necessarytoholdaconversation– Criticalforlanguageproductionandcomprehension
• Intention--- Attention– Iintend tocarryonaconversationwithyousoIneedtoattendtowhatyousay.
Arousal
Vigilance
Intention Attention
Crosson (2012)p.169,Fig8-1
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AttentionandAphasia
Symptomsofaphasiaareduetoimpairmentsinattentionmechanisms(Hula&McNeil)
Impairedlinguistic&attentionmechanismscontributetosymptomspresentinaphasia(Crosson)
• Adultswithaphasiahavemoredifficultywithdividedattentiontasksà– Attentionallocationinefficiency
• Damagetoadiffusely-representedattentionalnetwork(frontalandposteriorregions)• Greatestdecrementswhenlinguisticprocessingdemandsarecompetingforverbalattentionalresources• Attentionimpairmentsnegativelyaffectspokenlanguageabilitiesinmildaphasia
Murrayetal.,1997,1998
Memory
• Retentionbeyondthe“life”ofthestimulus(Davis,2012)
• Linkinginformationfromdifferentpartsofasentence,differentpartsofaconversation,differentpartsofastory,etc…requiressometypeofmemory– Shorttermmemory–Workingmemory– Episodic&semanticmemory
MemorySystems
STM
PhonologicalSTM
Lex/semSTM
WM LTM
Declarative
Semantic Episodic
Procedural
Martin&Slevc (2012)p.184,Fig9-1
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• Short-termmemory– Staticstore
• Workingmemory– Activememory– Limitedcapacity– “workspace”forcognitiveactivity(Baddeley,2009)
• WMandlanguagecomprehension– DiscoursecomprehensionisWMdemanding– LanguagecomprehensionbreakdownsoccurwhenWMcapacityis“exhausted”bysimultaneouslyholdingandprocessinginformation
usablealgebra.landmark.edu
• DeclarativeMemory– Semanticmemory:sharedknowledge• E.g.,knowledgethatcreamandsugarareoftenaddedtocoffee
– Episodicmemory:personalknowledge• E.g.,knowledgeofyourpreferredStarbuck’sorder
MemoryandAphasia
• Impairedonsimplespantasksthatinvolvewordlistrecall– Normal:7digits,5words– Aphasia:1-3digits/words– Digits>words>nonwords
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• Language-basedapproachtoSTM…– ->phonologicalandsemanticinformationsupportwordlistretention
• STMdeficitsoncomprehension– PhonologicalSTMdeficithasfewconsequences– SemanticSTMdeficitnegativelyaffectssentencecomprehensionandproduction
• AdultswithaphasiapresentwithaWMdeficit– ->contributestotheirlanguageprocessingimpairments
• Acrosstheseveritycontinuum– AdultswithmildaphasiapresentwithimpairedWMandverbalmemoryabilities(e.g.,Ronnberg etal.,1996;Ween etal.,1996)
• DiscoursecomprehensionisWMdemanding
• Clinicalimplicationsforverbalmemoryimpairments…consequencesforfunctionalcommunication– c/ooflanguagedifficultyinday-to-dayconversation
ExecutiveFunctions
“littlepersonintheheadtodirectbehavior”(Andrewes,2001)
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• Elementsofexecutivefunctioninclude– Initiation– Goalmaintenance/taskpersistence– Organization– Awareness,self-monitoring,flexibility
Norman&Shallice (1986)
• Frontallobeplaysaroleinexecutivefunctions• PatientswithleftfrontallesionsmorelikelytohaveimpairedEF– Affectsprognosisandrecovery– Affectsappropriatenessofcertaintreatments– Affectsprescribedamountoftreatment• TypicallypatientswithimpairedEFtakelongertoreachtreatmentcriterionlevels
• Impairedcognitiveflexibility– Resistanttousingalternativemodestocommunicate
– Affectsfunctionalcommunication
CognitiveProcessesandAphasia
• Adultswithaphasiamaypresentwith– limitedWMcapacity– impairedattention-controlprocesses– impairedinhibitorymechanisms– impairedcognitiveflexibilityandexecutivefunctions
Affectslanguagecomprehension &production,andfunctionalcommunication
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Evidence-BasedMethodsfortreatingCognitive-LinguisticImpairmentsinAphasia
EvaluatingCognitive-Linguisticabilities
• Attention• Memory• Executivefunctions• Discourse
• Cognitiveimpairmentsinmemory,attention,andexecutivefunctionscanaffectfunctionalcommunication
• Negativeeffectsonrehabprocess– Lesslikelytobenefitfrombehavioraltreatment– Slowerrecovery– Poorerfunctionaloutcomes
• Assessmentofcognitivedisordersandcommunicationimpairments
(1) Interview,observation,informalassessment(2) Standardizedtestsofcognitiveprocesses(3) Standardizedtestsoflanguageand
communication(4) Non-standardizedtestsoflanguageand
communication
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• Duringtheinterview– Compareinformationobtained
• Whenpossible,observepatientininformal/unstructuredenvironment– Seehowcognitivedeficitsimpactin“non-pristine”environment
ScreeningsforCognitiveDisorders
Instrument Reference
Addendbrooke’s CognitiveExamination Hodges(2004)
Cognistat Kiernanetal.(1995)
Cognitive-LinguisticQuickTest Helm-Estabrooks (2001)
FrontalBehavioralInventory Kertesz etal.,(1997)
Mini-mentalStateExamination Folstein etal.(2001)
GeneralCognitiveFunctionTests
Instrument Reference
Halstead-Reitan NeuropsychologyTestBattery
Reitan &Wolfson (2004)
NeuropsychologicalAssessmentBattery Stern&White(2003)
RossInformationProcessingAssessment- 2
Ross-Swain(1996)
CognitiveDomainBatteries
• Usefulforevaluatinganumberofskillswithinonedomain
• Providedetailedinformation• Informativeforidentifyingspecifictreatmentgoals
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Attention
• Unstructuredmethods– interviewandobservational
• Structuredmethods– scales,standardizedtests
• Potentialchallenge–Mostattentionmeasuresaremultifaceted
• Attentionimpairmentsaretypicalinmosttypesofbraindamage
• Criticismsofmethodsforassessingattentioninaphasia– Theyuselinguisticstimulisomaybeconfounded&invalid(Murray)
– But…linguisticstimulishouldbeusedtoprovideinsightregardinginfluencesofoneprocessonanother(McNeil&Hula)
• Attentiontestbatteries– BriefTestofAttention(Schretlen,1997)– TestofEverydayAttention(Robertsonetal.,1994)
Memory
• WechslerMemoryScale-IIIorIV(Wechsler,1997;2009)
– Episodicmemory–Workingmemory– Nonverbal&verbalmemory
• Rivermead BehavioralMemoryTest-III(Wilsonetal.,2008)– Everydaymemoryactivities
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• Verbalworkingmemory– Tompkinsetal.(1994)Auditory-verbalworkingmemorytest
2-sentences SetYousiton achair True
Trainscanfly False
3-sentences SetSugarissweet True
Floridaisnext toOhio False
Horsesruninthesky False
4-sentences SetTwelveequalsonedozed True
Bicyclesareslowerthancars
False
Abookcanplay False
Featherscantickle True
5-sentences SetCarrots candance False
Fishswiminwater True
Yousleep onabed True
Youeatbreakfastatnight False
People haveeyes True
SamplestimulifromTompkinsetal’s A/VWMTest
ExecutiveFunctions
Function Test ReferencePlanning Mazesubtest (CLQT) Helm-Estabrooks
(2001)
TowerTests E.g., Simon(1975)
Organization WisconsinCard SortingTest Grant&Berg (1993)
Inhibition STROOP Golden (2002)
CogFlexibility Comprehensive TrailMaking Reynolds(2002)
STROOP Golden (2002)
ProblemSolving TONI-3 Brownetal. (1997)
RavensProgressive Matrices Raven(1998)
EvaluatingCognitiveProcesses
• Adultswithaphasiamaypresentwithconcomitantcognitivedeficitsthatnegativelyaffect– Languageabilities– Rehabilitation– Functionaloutcomes
Discourse• Languageprocessingatthediscourselevelisadynamic
process• Requiresabilitytostructurelanguagetoconveyintended
information– takesintoaccounttheperspectiveoftheinterlocutor– isappropriatetothecommunicativesituation
• Successfuldiscourseprocessingrequires…• cognitiveprocesses,comprehension&production
abilities
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Whatweneedtoconsiderwithdiscourse
• Discoursetypes– Itmatters
• Discourseprocesses– Microlinguistic processes– Macrolinguisticprocesses
MicrolinguisticProcesses• Linguisticunitsofdiscourseincludelexicalandsyntactic
features
MacrolinguisticProcesses
• Interrelatednessofdiscourseunits– coherence,cohesion,andaccuracy&completenessofconveyingstoriesandprocedures
TreatingCognitive-LinguisticImpairmentsinAphasia
• Attention– Restorativeapproaches• Re-establishcognitivefunctions
– Compensatory(specific-skills)approaches• Re-learningfunctionallyimportantactivities
• Memory– Directtreatments– Indirecttreatments
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Attention
• Commerciallyavailableattentiontrainingprograms– AttentionProcessTraining(Sohlberg &Mateer,1986)
– APT-II(Sohlberg etal.,2001)
• APTis– Theoreticallymotivated– Hierarchicallyorganized
• FollowingtrainingwithAPTpatientsimprovedonstandardizedattentionmeasures– Patientsearlypoststroke(Barker-Collo etal.,2009)
– PatientswithABI(Sohlberg &Mateer,1987;Sohlberg etal.,2000)
– PatientwithmildTBI[usingAPT-II](Palmer&Raskin,2000)
• APTwithAphasia– Coelho(2005)usedAPT-IIwitha50y.o.womanwithaphasia• ImprovedonreadingmeasuresbutnotonWAB
– Sinotte &Coelho(2007)replicatedthestudywitha60y.o.womanwithmildaphasia• Noremarkablechangeonmeasures
–Murrayetal.(2006)usedAPT-IIwitha57y.o.manwithconductionaphasia• Nosignificantimprovements
• Language-specificapproach– Attentiondeficitsassociatedwithlanguageprocessingrequiretreatmentsthatarelanguage-based
Peach,Nathan,&Beck,2017(SeminarsinSpeech&Language)
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Principles forLanguage-SpecificAttentionalTraining(Peach,2012)1.Trainattentionalfocus&resourcemanagement2.Increaseattentionaldemands3.Automatizeattentionalrecruitmentforlanguagea.practiceb. focusc.feedback
4. Engageundamagedattentionalmechanisms5.Incorporatelinguisticdevicestofocus attention
Peach(2012),p.265,Table12-4
1. Trainattentionalfocus&resourcemanagementforlanguage(Hula&McNeil,2008)
– Makesuretasksarelanguage-based2. Increaseattentionaldemands(Murrayetal.,
1998)– Increasecomplexityoflanguage-basedtasks
acrossintervention– Requirementsofthetask
3. Automatizeattentionalrecruitmentforlanguage– Goaloftreatment– Attendedprocessingleadstoautomatic
processingwithpractice(Carr&Hinckley,2012)– Extensiverepetitionoflanguagetaskstomake
languageprocessesmoreautomatic– Feedback:languagetasksnotattentionalcontrol
4. EngageattentionalmechanismsinRH– Withasimpletask(picturenaming)move
stimuluspresentationinlefthemispace5. Exploitlinguisticdevicesknowntofocus
attention– Alternatesubjectselectionforsentence
production– Sentencefocusstructure– Anaphoricreference
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ExamplefromSkarakis-Doyle(2005)AppendixB,p.363
Memory
• Theoretically…– TreatingSTM/WMimpairmentsshouldremediatetheseimpairmentsand indirectlyimprovecognitiveandlinguisticskills
• Because…– Overlapinneurophysiologicalcircuitry
STM/WMCapacityTreatment
• Francisetal.(2003)– Sentencerepetitiontreatment– Improved:• A/VMemorySpan• Sentencerepetition• Auditorycomprehension• “catchingon”fasterathome• Decreasedanxietyaboutmemoryproblems
• Koenig-Brubin &Studer-Eichenberger (2007)– Sentencerepetitiontreatment– Improved:• Sentencerepetition• A/Vspan• Sentencelengthindiscourseproductionincreased
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• Takehomemessage…– STM/WMdeficitsrespondtotreatmentswithincreasingrepetitionanddelay
–Why?• Increasingamountofinformation“stored”• Increasingtimefor“storing”and“rehearsing”
WM/CESTreatment
• Mayer&Murray(2002)–Multiplesentencetasks– grammaticalityjudgment&semanticcategoryforfinalword
– Improved:• A/VWMspan• Readingrates• Readingcomprehension
• Vallat etal.(2005)– Spokenmanipulationtasks(e.g.,namingfromoralspelling,odd/evennumberoflettersinwords)
– Improved• Spanlength• Mathproblemsolvingskills• ADLs(reading,writing,participationinsocialactivities)
• Takehomemessage–Manipulatetreatmentstimuli– Indirecteffectsonothercognitive&linguisticabilities
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Alittlebitmore…
• STMandWMaremodifiable• Indirect,positiveeffectsonothercognitive-linguisticprocesses
SeminarsinSpeech&Language• 2017• Vol38,Issue1• CognitiveApproachestoAphasiaTreatment
• Takehomemessage…– TherapyforlanguagedisordersshouldbedesignedtoincorporateSTM
– Severityofimpairmentmayaffectthedegreetowhichtreatmentshouldsimulatereal-lifeconversationalsituations• StartwithmorestructuredlanguagetaskswithincreasingSTM&EFdemands• ProgresstomorenaturalspeakingcontextsthatinvolveSTM&EFdemands (e.g.,sharingrecipedetails)
DiscourseProcessingTreatmentStep Activity ActivityDescription
Step1 Viewstimuluswithcomprehensionquestions
PWAviewsthesequentialpictureandclinicianprobesforlevelofunderstandingbyaskingspecificcomprehensionquestionsthatarepairedwiththepicture.
Step2 TellStory Whileusingthestoryguide,thePWAwilltellastory.
Step3 Clinicianreviewsstoryandelaborates
Usingthestoryguide,theclinicianretellsthestorywhileelaboratingonorfillinginmissingdetails.
Step4 PWAretellsstory Whileviewingthestimuli,bynotthestoryguide,thePWAretellsthestory.
AllTogether!1. Whatistheguycarving?
2. Whoarethecharactersinthe
scene?
3. Howdoeshegethernameonhim?
4. Whatdoestheguydooutside?
5. Howdoesthegirlreact?
6. Whatishisreactionattheend?
Essential Elements Detail Elements Essential Actions Detail Actionsguy shirt carving her name goes to sleepgirl/girlfriend house covers himself up lifts up his shirttattoo pool chair puts it/stencil around his
stomachshows her what is written/tattoo
stomach drink goes to lay down she is happy/excitedCara/Sara tape name tattooed on his bodysun cardboard paper she hugs him
suntanblanket/towel
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NarrativeCoherence:ThematicUnits
Participant Stimuli BL F1 F2 EffectSize
P1 T 26.3 52.6 33.3 5.1=M
U 15.1 32.5 19.7 6.7=L
P2 T 37.3 52.6 53.7 0.7=S
U 36.5 42.8 47.7 0.5=S
P4 T 15.2 40.1 20.3 0.9=S
U 15.2 24.0 10.1 0.4=S
P5 T 33.0 54.1 69.0 22.4=L
U 36.7 41.1 77.9 3.6=S
Totalnumberofcorrectthematicunitsproduced(%)
AllPWAincreasedfollowingtreatment(T&U)
Beeson&Robey,2006
NarrativeProductivityStimuli Units SpeechRate(wpm) CorrectWords
BL F1 F2 BL F1 F2 BL F1 F2
P1 T 78.8 131.3 129.8 44.5 62.7 48.0 35.4 60.8 78.8
U 65.3 120.0 163.0 34.8 64.3 54.2 29.2 66.5 95.0
P2 T 86.1 127.8 124.8 48.8 72.4 63.3 51.5 85.0 71.8
U 21.5 79.2 78.2 50.4 58.5 57.5 58.3 53.2 47.2
P4 T 48.5 89.8 81.5 55.5 77.8 68.0 25.5 60.6 50.0
U 36.0 59.7 60.5 49.7 38.8 58.0 18.7 38.7 30.7
P5 T 91.6 150.2 174.6 64.7 69.0 56.8 41.4 90.8 95.0
U 80.3 152.0 165.5 69.1 55.2 65.6 40.7 83.2 95.2
• P1:increasedonallmeasuresfortreatedanduntreatedstimuli• P2:increasedonallmeasureEXCEPT,didnotincreaseproductionofcorrectwords
foruntreatedstimuli• P4:increasedonallmeasuresEXCEPT,didnotincreasespeechrateforuntreated
stimuli• P5:increasedonallmeasuresEXCEPT,didnotincreasespeechrateforuntreated
stimuli
StandardizedAssessment
• WAB-R:AQsubtestsParticipant InitialWAB-R
AQ
Follow-Up
WAB-RAQ
Change
P1 87.2 88.9 1.7points
P2 75.9 78.2 2.3points
P4 81.4 77.6 -3.8points
P5 82.5 82.9 0.4points
• Insignificantchange• Similarfindings(e.g.,Marini2011,Lafeiul &LeDorze 1997)
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CETI:FamilyMemberReports
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Thankyou!
Questions?