question 4
What approaches might you use to manage these deficits? Memory
Assessment -Screening: MOCA, MMSE, SLUMS, RBANS *RBANS is great in that it offers four parallel forms: A, B, C, D to make it ideal for measuring change over time, and identifies abnormal cognitive decline in older adults -Comprehensive Assessments: -RBMT-3: Rivermead Behavioral Memory Test *Assesses everyday memory problems in people with acquired brain injury and to monitor their change over time *14 subtests assessing aspects of visual, verbal, recall, recognition, immediate, and delayed everyday memory Treatment: Two primary approaches 1. Restorative -Based on neuroanatomical and neuro physical models of learning Examples: Semantic organization, rehearsal techniques, chunking/organization, rhyming strategies 2. Compensatory -Based on the assumption that certain functions cannot be restored or recovered completely Examples: Environmental modifications, external memory aids Spaced Retrieval Training -SRT is a shaping paradigm for facilitating recall of information or procedures -Features built-in, errorless learning -SRT can be used to train: Compensatory strategies Using a calendar or schedule, Learning a safety strategy or a safe swallowing strategy OR Meaningful information: Room number, Address, Face-name associations
What approaches might you use to manage these deficits? EF
Assessment: -Ideally want a combination of tests or subtests of impairment-based and participation-based measures Impairment-Based Tests 1. Wisconsin Card Sorting Test (WCST) -128 cards containing varying shapes and colors -Examiner's feedback is used to determine the sorting strategy (color, shape, etc.) -Sorting criterion changes without the patient's knowledge -Assess abstract reasoning and cognitive shifting 2. Trail Making Test -Cognitive flexibility and shifting 3. Tower Test -Assess planning, rule adherence, and flexibility Participation-Based Tests 1. Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES) -4 tasks -Assesses different executive functions in everyday tasks -Assesses planning, organization, inhibition, reasoning, sequencing, and prioritizing 2. Behavior Rating Inventory of Executive Function - Adults (BRIEF-A) -Self-report, 75-item questionnaire -Rating of executive functioning in everyday environment Treatment: 1. PIE: Plan, implement, evaluate -Learning protocol = errorless learning, massed practice, intensive practice -E.g., using an electronic calendar to schedule daily tasks 2. Problem-Solving Therapy: SWAPS Stop! Is there a problem? What is the problem? Alternatives and options to solve the problem Pick and plan the chosen option Satisfied with the outcome of the plan 3. Environmental Supports -Modification of task demands: Remove stimuli that may elicit inappropriate behavior, Provide breaks, Allow extra time to complete tasks -Organize physical space/ Designated area for items -Cueing and promoting
What is a cognitive-communication disorder?
-According to ASHA, A cognitive communication disorder is difficulty with any aspect of communication as a result of a disruption to cognitive processes such as attention, memory, and executive function. -Communication is a complex skill which requires cognitive and lang skills to interplay together in order to communication to be successful and effortless -Therefore, problems in language skills (comprehension, expression, semantics, syntax, pragmatics) can rsult from impaired cognitive skills (attention, memory, EF) -examples of cognitive communication disorders we discussed in class are RHD, TBI, Dementia
How do the different types of cognitive-communication disturbances relate to specific impairments in attention, memory, language, executive function, and how would you explain the observed symptoms? TBI
-An acquired injury to the brain due to any applied force that results in widespread damage to cortical and subcortical structures -attention: primarily problems with concentration and processing speed -memory: deficits storing and retrieving factual information (as opposed to procedural memory) -EF: planning, organizing, monitoring errors, emotional regulation, decision making
Describe the symptoms/characteristics of the communication problems that are included within this umbrella term
-Attention: always defined in relation to a stimulus *limited capacity resource *Types: 1. Sustained: the ability to focus on one task for a continuous amount of time 2. Selective: selecting from stimuli and focusing on the one you want while filtering out distractions 3. Alternating: shifting focus between two stimuli/tasks 4. Divided: ability to react to two stimuli/tasks simultaneously *relative to communication, impaired attention will impact our ability to attend to our communication partner without attending to distracting stimuli, therefore impacting our ability to form an effective response -Memory: any retention of information beyond the life of an external stimulus *Formed via encoding, consolidation, storage -Encoding: repetition, rehearsal, meaningful organization for learning new information -Consolidation: strengthening encoded information and transferring to permanent storage -Storage: pertaining info in memory for future use *Types: 1. Immediate: brief impression after stimulus ends (roughly 2 seconds) 2. STM/WM: when IM has been brought to consciousness, temporarily store/work with the info. About 20 seconds 3. LTM: involves both declarative (knowing facts) and nondeclarative memory (motor/cognitive skills) -relative to communication, impaired memory will impact our ability to temporarily store the information our partner has said, in order to respond appropriately, will also impact of course word finding abilities and ability to remember necessary info to respond EF: Higher level, more goal-directed than other cognitive functions *Initiation, problem solving, planning, mental flexibility, judgment, inhibition, reasoning, meta-cogntion, self-regulation *`Dorsolateral PFC and its connections very responsible for executive functions
What tools might you use to address the cognitive- communication impairment and its impact on an individual's activity and life participation outcomes?
-Functional communication measures: CADL - Communication Activities of Daily Living *Assesses communication activities in seven areas: e.g., social interactions, nonverbal communication, etc. -Discourse analysis and spontaneous speech samples - assessing how communication is impacted in more real life situations -Quality of life scales
Outcomes
-Objective data within sessions (tracking any progress from baseline) -Pre- to post- test improvements!; Re-administer assessments -Generalization of abilities -Use subjective data & conversations with client/family/caregivers to assess changes/progress/maintenance
Describe how the WHO-ICF framework can be useful in guiding your assessment and treatment planning for a patient with a cognitive-communication disorder.
-The WHO-ICF model explains how health is the state of complete physical, mental, and social well-being and not merely the absence of disease -The WHO-ICF model looks at treating the person and their ability to FUNCTION in daily life, not just focusing on the body/structure impacts of the disorder -Shows how various components contribute to the patient's disorder. these include body function, activity, participation, environmental factors, and personal factors -The model is helpful in guiding cog-comm assessments and treatments to ensure the clinician considers how the impairment is impacting all factors in the patient's life- not just the body function
What approaches might you use to manage these deficits? Attention
Assessment: -Widely used screening tools: Mini Mental (MMSE), MOCA, SLUMS Exam -Comprehensive Assessments: 1. TEA (test of everyday attention) Assesses different types of visual and auditory attention 8 subtests: e.g., map search, telephone search, elevator counting, etc. High construct validity but limited ecological validity 2. Brief Test of Attention - assesses auditory divided attention, also taps into language comprehension and WM 3. Symbol digit modalities test - Measures visual selective attention Involves matching symbols to digits 4. Clinician Rating Scales to provide ecological validity - Moss attention rating scale Treatment: -Training in specific skills: Training attention in the context of everyday activities Example: providing scaffolding to help a patient attend to a morning routine More contextualized and very individualized -Environmental modifications, self-management strategies, external aids Example: a watch that beeps every hour to remind the patient to check their schedule and remind themselves what they are supposed to be doing Not one ideal approach, but insufficient evidence for solely direct training (decontextualized tasks, app based training) to be effective, likely want to combine two or more of these approaches
How do the different types of cognitive-communication disturbances relate to specific impairments in attention, memory, language, executive function, and how would you explain the observed symptoms? Dementia
Diagnosis: requires evidence of significant cognitive decline and cognitive decline must be severe enough to disrupt independence in ADLs -AD *earliest symptoms: episodic and WM deficits, attention and EF impairments *middle stages: more severe memory loss, personality changes, expressive language deficits. Wanderlust, disorientation and confusion *late stages: loss of motor function, may cause muteness and dysphagia
How does the type and site of brain damage relate to the resulting communication disorder?
Site of brain damage directly relates to cognitive communication disorders, as different areas of the brain often specialize in specific cognitive functions that underlie communication -attention: Bilateral superior temporal gyrus: sustained attention Right inferior frontal gyrus: attentional allocation to unexpected signals Superior frontal gyrus: selective attention and attentional control Medial frontal gyrus: selective attention and attentional control -memory: deficits are associated with medial temporal lobe, frontal cortex and hippocampus injuries -EF: Prefrontal cortex and its connections -Not to say that damage to other areas cannot result in these deficits, as all areas are connected and work together to carry out these cognitive processes
How do the different types of cognitive-communication disturbances relate to specific impairments in attention, memory, language, executive function, and how would you explain the observed symptoms? RHD
RHD -Damage to the side of the brain that is non-dominant for language -Communication problems are not language based, rather a result of impaired cognition -specific right hemisphere functions are typically affected including: music processing, visuospatial functions, prosody, higher order-linguistic abilities -Attention: impaired sustained, divided, and selective attention *They may miss relevant information within a speech signal or in the environment, may be easily distracted by irrelevant stimuli, and may struggle with topic maintanence *left neglect: reduced attention to L side -memory: WM and LTM deficits *Problems recalling street names, important dates/faces, learning new info -EF: *organization: may struggle telling a story in order or planning events *problem solving impairments *reasoning: difficulty thinking rationally and finding logical answers
