SLHS 430 Exam 2

executive functioning impairments

(abstract thinking, reasoning, problem solving, inhibition, self- monitoring, goal-directed tasks, complex tasks) • Socially inappropriate_ behaviors • Reduced social-pragmatic skills e.g., difficulty initiating conversation/questions • Slowed processing speed

dysphagia

(swallowing disorder) - approx. 27%

possible conditions following TBI

Paralysis • Difficulty coordinating balance and walking • Difficulty controlling bowel and bladder functions • Impaired vision/Hearing/Taste/Smell/ Touch • Changes in sexual behaviors • Changes in personality • Fatigue • Depression • Medical complications • Physical injuries

ischemic brain damage

• A condition that occurs when there isn't enough blood flow__ to the brain: • This leads to cerebral hypoxia, which leads to death of brain tissue (necrosis) • Damage can be focal or global •focal ischemia :confined to a specific region of the brain •global ischemia: encompasses wide areas of brain tissue

types/causes of dementia

• Alzheimer's disease (approximately 70%) • Vascular dementia - (Strokes and TIA's) • Parkinson's disease • Frontotemporal dementia (FTD) • Normal-Pressure hydrocephalus (NPH) • Dementia with Lewy Bodies • Delirium/Depression • Other, less common causes

Primary Progressive Aphasia

• Diagnosed by: progressive aphasia in the absence of other cognitive or behavioral changes • Neuropathology: --Fluent PPA: pathology in parietal lobe and anterior perisylvian areas • NonfluentPPA:pathologyininferiorfrontallobeand anterior temporal lobe (R>L) • Aphasia precedes other behavioral changes by at least 2 years

diagnosis of delirium

• Disturbance in consciousness impairing awareness of the environment • Reduced ability to focus, sustain, or shift attention • Cognitive or perceptual disturbance not attributable to dementia • Acute to subacute onset (hours, days) • Diurnal fluctuations • Clinical/laboratory evidence related the disturbance to a general medical condition (e.g., UTI)

nonfluent aggramatic aphasia (PPA-G)

• Effortful, halting speech with inconsistent sound errors ("apraxia of speech") • Agrammatic language production (difficulty producing complete, grammatical sentences) • Relatively spared comprehension for words and simple sentences (complex sentences could be impaired) • Spared object knowledge. • Similar to Broca's aphasia

initial practical approach to compensation

• Housing: One level, < 3steps; few, large furniture; low bed or floor mattress; burglar alarm turned on at all times • Healthy finger foods and microwave • Electric stove preferred; with controlled access to fusebox • Telephone with large numbers and letters • Orientation cues:______calendar, names and pictures of patient and loved ones

increased intracranial pressure

• Increased Intracranial Pressure: increased pressure inside the cranial vault. • Consequence of: Cerebral edema, traumatic hydrocephalus, hemorrhage • The most _deadly consequence_of brain injury • Pressure is generated by accumulations of fluid (blood, CSF, water) within the skull. • The pressure build-up compresses and displaces brain tissues • Neurologic impairment increases as the pressure increases. • Tomonitorintracranialpressureapressuretransduceris inserted into the CSF through a hole in the skull.

middle stages

• More difficulty in the _____ • The patient probably still is aware of the consequences of AD, may be angry, depressed • Family has to do more-- e.g., bathing, dressing, patient may be incontinent, etc.

VD summary

• There is a relationship between vascular disease and the pathological processes seen in dementing diseases, such as AD • Vascular dementia is a broad that encompasses both dementia due to multiple focal infarcts and dementia due to the interaction of stroke and the type of pathologic processes in AD

Lewy body disease

• Thought to be the 2nd leading cause of dementia after AD • Neuropathology --Intracellular: Protein deposits called "lewy bodies" inside cell bodies --Lewy bodies present in frontal lobe, temporal lobe, and basal ganglia

traumatic hydrocephalus

• Traumatic Hydrocephalus: Swelling of brain tissues (esp. in midbrain regions) sometimes compresses the passages through which CSF moves between the ventricles • The trapped CSF exerts pressure on the walls of the ventricles increases, causing: • expansion of the ventricles • compression of brain structures • and elevation in intracranial pressure

angular acceleration injuries

• occur from blows that strike the head off-center and propel it at an angle from the direction of the blow and rotate it away from the blow • Forces generated are rotational rather than linear • The brain's inertia causes it to remain at rest for a few milliseconds after the skull begins to move, generating twisting and shearing forces which are concentrated in axial structures (midbrain, basal ganglia, brainstem, and cerebellum).

if intracranial pressure is too high

patient may be hyperventilated • Increased blood oxygen causes cerebral arteries to constrict, decreases cerebral blood volume, and provides temporary reduction in intracranial pressure • Steroids (anti-inflammatory) can help to reduce swelling • Body temp may be lowered (hypothermia) to diminish ___________________ • Diuretics can help the body excrete excess fluid • If these treatments are unsuccessful, the patient may be put into a drug induced coma to decrease cerebral metabolism and constrict cerebral blood vessels. • If these less invasive measures fail to decrease swelling, surgery may be indicated

VD location sites affected

patients may show heterogeneous symptoms based on site 1. brain stem affected = speech motor control problems 2. perisylvian language regions = language formulation and comprehension problems 3. frontal lobes affected = lack of bh initiative

how are VD and AD similar?

patients show problems with recent memory, abstract thinking, reasoning, and problem solving

pick behavior

poor decision making emotional blunting hyperorality compulsion to explore environment changes in dietary preference and sexual behavior auditory and visual agnosia repetitive behaviors

incidence of MCI

prevalance = 16%

best way to treat dementia

prevent it!!! Healthy diet Regular exercise Controlling risk factors (high cholesterol levels, chances of head injury, high blood pressure, etc.) Sustained intellectual activities

primary brain damage in TBI

primary consequences: result of forces exerted on the brain at the time of the injury • Mechanical effects of compression, stretching, shearing, abrasion, and lacerations of the brain and the meninges. • Damage depends on size and nature of impact: -- Contusions(bruises) --Lacerations (tearing of brain tissues) --Axonal injury (tearing, stretching, & twisting of axons) -- Tearing of blood vessels • All of these can lead to bleeding (hemorrhages) and accumulations of blood (hematoma)

early PPA

problems with speech and language then, on average, 5 years later they experience impairments in other functions eventually, almost all patients become mute and unable to understand spoken or written language

intervention of dementia

progressive nature of irreversible demential rules our restoration of lost abilities as a practical clinical objective for most persons with dementia focus is on lessoning advancing effects of the disease on the life of the person as well as their caregivers and family

once patient is medically stable...

rehabilitation begins. Sometimes (most of the time) therapy begins in the ICU! • Requires collaboration of many professionals: • TEAM APPROACH: physicians, nurses, neuropsychologists, clinical psychologists, social worker, vocational counselors, SLP, OT, PT, RT and person with the TBI and their family.

brain atrophy

shrinking of cortical tissue --severe in hippocampus ventricles grow larger as a result

open (penetrating) head injury

skills is fractured and meninges are torn --missiles --sharp objects --blunt instruments --falls if head hits sharp object hair, skin, and bone fragments are carried into the brain by the projectile, where they become sites for potential bacterial infections high mortality with penetrating injuries --high velocity = almost always fatal --low velocity = 20-40% fatal --to brainstem = usually fatal

PPA

slowly worsening aphasia not due to stroke, trauma, tumor, or infection --must exist with no sig memory, bh, intellectual, or visual impairments at least for 2 years NOT alzheimer's --PPA still take care of themselves/are employed

non acceleration head injury and fractures

some have skull fractures fractures at base of skull are more serious any skull fracture is dangerous if the meninges beneath fracture is torn

use of tDSC (transcrianial direct current stimulation)

spelling --after treatment, gains are 35% for tCDS + lang therapy --20% for lang therapy alone

Parkinson's Disease

subcortical dementia degenerative disease affecting nuclei in the midbrain (basal ganglia) and brain stem degeneration of dopaminergic neurons in the basal ganglia --idiopathis = cause is unknown

decomprssive craniectomy

surgical procedure that removes a section of the skull to relieve pressure on the brain

most common treatment for epidural hemorrhage

surgical removal since it is located just beneath the skulls

The duration of posttraumatic amnesia

the time following coma during which the patient is unable to store new information and experiences in memory is inversely related to the patient's eventual level of recovery from TBI

rehab goal

to help individuals regain the most independent level of functioning as possible • Question to consider: Is this goal fully independent or simply less dependent on family/caregivers?

compensations

tools and techniques (external aids) adapted to and used by the individual to allow functioning in spite of disabilities

awareness model

top to bottom anticipatory : what they plan to change emergent : do they realize what they are doing? intellectual : do they know they have it?

environmental modifications

u A schedule of routine activities u Items used in an activity are kept together e.g., coffee pot, filters, and coffee are kept on the same shelf u Checklist for complex procedures posted where the procedure is to be accomplished. u e.g., the steps to wash the clothes next to the washer

Montessori Based Treatment

u Based on philosophy and educational methods of Maria Montessori. u Designed to maintain and enhance physical, cognitive, and social activities. u Activities are designed to capitalize on the preserved procedural (implicit) memory abilities of PWD. u Use everyday stimuli and activity to facilitate action, memory, and communication. u Person-centered approach; meaningful engagement in daily activities is highlighted.

external memory aids

u Help PWD compensate for impaired memory u Electronic organizers with built-in alarms for appointments u Pocket-sized checklists for things to do u Written cues: Notes, labels, lists, signs u Organizational cues: planners, medication boxes

cognitive and lang simulation for dementia treatment examples

u Picture and object description u Story recall u Category naming u Problem solving u Word association u Famous name recall

intervene individuals who

u Show intent to communicate u Demonstrate cognitive-linguistic strengths around which to structure a treatment program u Respond to cues u Follow simple directions u Exhibit recent/significant change in status

memory book or wallet

u The functioning of PWD can be improved by capitalizing on spared recognition/long-term memory (Bourgeois, 1990; 1993) u May contain personal information, photos of family members, printed sentences relating to the person's daily life, or other personal materials. u Provide cues and context to recall information u Provide a source of topics for conversational partners

behavior disturbances

wantering physical combativeness arguments refusing medicine dangerous memory lapses (leaving stove on) delusions disruption of sleep-wake cycle incontinence (BR)

list of dementia symptoms

ØMemory loss ØDifficulty communicating ØInability to learn or remember new information ØDifficulty with planning and organizing ØDifficulty with coordination and motor functions ØPersonality changes ØInability to reason ØInappropriate behavior ØParanoia ØAgitation ØHallucinations

MCI cognitive-linguistic deficits

• "Nun Study" • Linguistic analysis of written autobiographies of approx. 200 Roman Catholic nuns aged 75-103 (writing done decades earlier) • Study found that sisters whose text had lower idea density and grammatical complexity were more likely to develop AD later in life • Various language deficits have been seen in: • Naming and word retrieval, verbal fluency, language comprehension, discourse processing, and the ability to define words

Neuropathology of Alzheimer's

• (1) Plaques and (2) tangles primarily in the frontal lobes, temporal lobes, hippocampus, and adjacent areas • (3) Atrophy • Denser distribution of neuropathologic changes = more severe dementia

prevalence of TBI

• 1.4 million US residents receive medical attention for TBI each year • The incidence of TBI in the U.S. is about 4 times the incidence of breast cancer and about 34 times the number of new cases of HIV/AIDS • About one in four persons with TBI are hospitalized. • Of those hospitalized, about 1 in 6 die from their injuries. • Of those who survive, about 1 in 3 are left with permanent disabilities. • Most TBI (about 90% in the U.S.) are _closed-head injuries caused by falls, motor-vehicle accidents, and assaults. • Leading cause of neurological disability in persons under age 50

blood-brain barrier

• A semi-permeable diffusion barrier, which regulates movement of substances from the blood into the brain • Brain injury disrupts this regulation • Normally excluded substances include: • Proteins,neurostransmitter chemicals • Contributes to cerebral edema

subdural hematoma

• Accumulation of blood beneath the dura and above the arachnoid • Twice as common and twice as deadly as epidural hematomas • MVA are their most common cause, and about half are associated with skull fractures • Most SDH are the result of venous bleeding, not arterial bleeding

changes in learning and memory with normal aging

• Aging affects learning and retrieval of information more than the "fund of knowledge" (memories) • Slower speeds of information processing which may result in slower learning rate and greater need for repetition of new information • Not all types of learning and memories are equally vulnerable • Episodic > Working Memory > semantic memory > procedural memory

role of SLP

• Assess language skills • determine strengths • weakness • abilities for compensatory strategies • Maintain and facilitate communication strengths • Education and help family & caregivers to facilitate communication, be aware of safety issues, maximize quality of life

MCI treatment

• Better outcomes when treatment implemented early because patients with MCI continue to _retain abilities__in learning and applying strategies for maintaining function 4 Key Elements to Cognitive-Communicative Tx in MCI 1. Repetition-based focus on cognitive domains 2. Provide direct training of strategies and functional skills 3. Empower clients with education regarding healthy aging and brain habits 4. Provide goal-oriented social opportunities that support cognitive engagement

neuropathology of MCI

• Biomarkers seem to reflect AD pathology • Amyloid plaques and tau deposits can be seen in the CSF of some patients with MCI • PET scans are being develop which may be able to measure amyloid deposits in brain • Hippocampusatrophyseen in pts with MCI • Degree of hippocampal atrophy coincides with severity of cognitive decline

plaques

• Bits of pieces degenerating neurons that clump together and have an amyloid protein core. • May be by-product or a cause of neuronal death • Extracellular • Appear first in frontal, temporal, and occipital lobes

semantic variant of PPA (PPA-S)

• Both of the core features must be present: 1. impaired naming of objects (more than actions) 2. Impaired single word comprehension • Additionally: 1. impaired object knowledge for low frequency/familiarity items 2. Spared repetition 3. Spared grammar and motor speech

major tests for cognitive comm eval

• Brief Test of Head Injury (BTHI) • Ross Information Processing Assessment (RIPA-2) • Scales of Cognitive Ability for Traumatic Brain Injury (SCATBI) • Woodcock-Johnson Psychoeducational Battery • Woodcock Johnson Tests of Cognitive Ability • Woodcock-Johnson Test of Achievement • Peabody Individual Achievement Test • Textbook pp 488-490

agitation

• Can be seen intensely on inpatient or outpatient • Can be manifested in many of different ways: -spitting, biting, cursing, pulling at lines (inpatient) -short temper, lability, physical outbursts(outpatient) • Family education important throughout this process! Is family contributing to agitation? • As agitation decreases, work on cognitive communication can begin (& continue) in depth

subarachnoid hematoma

• Caused by rupture of pia vessels within the pia vessels within the subarachnoid space • Common consequence of TBI • Often associated with subdural hemorrhages • Rapid accumulation of blood from massive SAH cause severe headache, rapid neurologic deterioration, and often death • Slowly accumulating blood in SA space not as serious • Pts with slowly developing SAH can go years w/o overt symptoms

SLP evaluates what in TBI pts

• Cognition (Attention, Orientation, Memory, Executive functions) • Behavioral management (e.g., agitation, social skills) • Language comprehension & production • Higher-level communication (pragmatic deficits, extralinguistic deficits) • Speech disorders (dysarthria) • Swallowing disorders (dysphagia) • Counseling & education

middle stages of CC in AD

• Communication impairments become more obvious • More frequent word-retrieval failures and individual's success in repairing them declines • Sentence fragments and ungrammatical sentences begin to appear • More passive conversationalists: allow others to pick the topic, tone, and content of conversations • Comprehension of nonliteral material is grossly impaired.

Logopenic variant of PPA

• Core features: 1. Impaired word retrieval in conversation and naming tasks 2. Impaired repetition of sentences and phrases • Additionally: 1. speech sound substitution errors in conversation and naming tasks 2. spared single word comprehension and object knowledge 3. No difficulty producing grammatical sentences.

irreversible and progressive dementia causes

• Cortical dementias: -- Alzheimer's disease -- Pick's disease (Frontal Lobe Dementia) • Subcortical Dementias: --Parkinson's disease --Huntington's disease • Mixed dementias: --Vascular dementia -- Lewy Body Dementia

dementia describes ....

• Dementia describes a group of symptoms affecting *intellectual and social abilities* severely enough to interfere with daily functioning (work, social activities, and relationships) --affects several areas of mental function • An acquired and persistent syndrome consisting of a decline in memory and other cognitive functions • Dementia is used as an umbrella term to group all diseases in which there is some form of memory loss.

dementia is not....

• Dementia is not a specific disease. • Dementia is not part of normal aging. -not caused by delirium (transient confused state), schizophrenia, or major depression

early stages of CC in AD

• Difficulty remembering recent (new) events • Phonology, syntax, articulation and voice quality are well preserved • Mild word-retrieval problems and subtle comprehension difficulties may appear. • But client usually can recognize these difficulties and repair • Functional reading comprehension (e.g., magazines, • Adequate conversationalists: observe conversational conventions such as turn-taking and eye contact.

Impaired executive function

• Difficulty with planning, initiating, sequencing, monitoring or stopping complex behaviors. • Occurs early to midcourse • Contributes to loss of instrumental activities of ADLs such as shopping, meal preparation, driving and managing finances.

cognitive behavioral disturbances

• Disoriented to time, person, situation, & place • Confused & agitated • Agitation is a common problem for confused & disoriented patients. • Attention impairments • Memory impairments • Pretraumatic memory loss: loss of memory for the events immediately preceding injury • Posttraumatic memory loss: loss of memory for the events immediately following injury • Chronic memory impairment

early stages of recovery (RLAS)

• Early Stage (Levels 1-3): • Bed-bound, usually in an ICU • Comatose or semi-comatose stages • Pt begins to respond to environmental stimuli minimally or inconsistently • At the end of this stage, pt selectively responses to stimuli (e.g., localizing sounds, tracking visual stimuli) and follows simple spoken commands (e.g., open your eyes) • Pts require intensive, full-time support.

awareness-enhancing interventions

• Education: Patient and family! • Clinician-delivered feedback: timely, consistent and respectful. • Experiential feedback (planned feedback):patient discovers own errors in real-life situations • Behavior therapy • Counseling, support, psychotherapy • Strengths/weakness list: make a list together • Self-Rating of task and performance: patient and SLP rate independently and discuss. • Visual feedback: video patient and have them ID their behaviors (HIPAA-need video release form!)

Declarative Long-Term Memory (explicit)

• Episodic = autobiographical memory encoded in a temporal/spatial context • Semantic = general knowledge • Lexical = knowledge of words • Assess via conscious recall of specific facts and events ***uses hippocampus for learning

normal aging

• Even healthy older adults experience mild decline in some areas of cognition • With increasing, humans slow down physically and psychologically • Mild normal atrophy: brain weight declines by about10% • Loss of neurons, particularly in hippocampous • Declining levels of neurotransmitters • Slower at perceiving, processing, and reacting to information, particularly when the situation requires rapid processing of complex information • Main deficits are in executive functions, working memory, and declarative learning but often only revealed on examination and do not affect activities of daily living

causes of TBI

• Falls • Motor vehicle accidents • Violence (gunshot wounds, domestic violence, child abuse) • Sports injuries • Explosive blasts

primary signs of LBD

• Fluctuating cognitive signs and symptoms • At least one of: • Visual and/or auditory hallucinations with paranoid delusions • Mild extra pyramidal features --E.g., uncontrolled muscle movements or contractions (legs, hands, face), breathing difficulties, drooling • Repeated unexplained falls • Clouding of consciousness • Memory characteristics • Proceduralmemoryandlearningdeficitswhenbasalganglia is involved, declarative memory deficits when neocortex is involved

symptoms of MCI

• Forgetting recent events or conversations • Overwhelmed during decisions making or on completing complex cognitive tasks • Difficulty performing more _____________at a time • Difficulty solving problems • Having a difficult time finding your way around previously learned environments • Pooterm-77r ______________ • Family or friends observe memory loss or other cognitive symptoms • Concerns of memory lapses/loss • Co-occurring depression, irritability, apathy or personality change

staging severity of dementia

• Global Deterioration Scale (GDS; Reisberg et al., 982): • An observation scale of 7 stages based on functional deficits • Stages 1-3: Pre-dementia stages • Stages 4-7: Dementia stages • Beginning stage 5, individual can no longer survive without assistance

diagnosing AD

• History, mental status evaluation, physical examination, limited laboratory testing, and in many cases, neuroimaging, more extensive neuropsychological testing and a depression screen. • An MRI finding of bilateral hippocampal atrophy suggests AD, but is not specific or sensitive • Laboratory testing (bloodwork) to rule out other medical issues • SLPs do not diagnose dementia, but we can diagnosis cognitive- communicative impairment. More on this later. --definite Dx can only be made upon postmortem exam of brain --probable AD Dx is made my exclusion

why is awareness important

• Impaired Self-Awareness: Lack accurate info about themselves and nature and magnitude of their impairments. "I don't forget to take my medications, my mom/wife/husband just didn't give them to me." • They are puzzled (angry?) when given feedback about their behaviors or their functional limitations. "What do you mean I forgot my medications?" • They are cautiously willing or indifferent when asked to work with new info about themselves and their limitations. "Ok, I guess I will set an alarm to take my medications, even though I don't need one." • Denial and Awareness (to impairments) are not the same!

memory deficits in AD

• Impaired episodic memory (remembering recent events) • Impaired working memory (verbal & visuospatial span tasks) • Semantic memory not always affected (impaired in severe pts) • Motor procedural (implicit) memory may be spared • Long-term (distant, e.g., childhood memories) memory remains preserved in early stages. • Phonology and syntax are relatively preserved in early stages

sensory stimulation therapy

• Intervention with comatose or semi-comatose patients consists primarily of sensory stimulation. • Purpose: to increase the patient's responsiveness to the environment and to facilitate the patient's return to consciousness. • Pt is repeatedly exposed to auditory, visual, tactile, olfactory, and taste stimuli for about 10- to 15- minute intervals of stimulation each day.

tangles

• Intracellular deposits that occur when the neurofibrils become twisted via abnormal phosphorylation of tau protein • Intracellular • Interfere with axonal transport • Typically develop first in entorhinal cortex, hippocampus, & basal forebrain

cognition and communication in AD

• Language is less affected than cognition, memory, and intellect in early stages • Communication activities that require greater mental effort are affected first and most dramatically. • Language processes that require little effort (grammar, social conversations) are usually preserved until the very late stages of AD.

management of PPA

• Language therapy may slow the rate of decline in some language tasks. • Might be augmented by tDCS (but results are still preliminary) • Both impairment specific treatments and compensatory strategies are beneficial. • Participation in aphasia/PPA community groups is recommended.

late stages of recovery (RLAS)

• Late Stage (Levels 7 and above): • At the beginning of this stage, pts have an adequate (sometimes fragile) orientation to important aspects of life. • Pt becomes increasingly independent and adept at compensating for his or her residual impairments. • Intervention focuses on refining skills needed for effective participation in everyday life.

Global Deterioration Scale

• Level 1. No cognitive decline • Level 2. Age Assoc Memory Impairment --Forgetting names, misplacing objects, no deficits in employment situation • Level 3. Mild Cognitive Impairment • Co-workers aware of decline, word finding difficulty evident to intimates, losing valuable objects, concentration deficit • Level 4. Mild Dementia • Decreased knowledge of current & recent events, forgetting some of personal history, difficulty managing personal finances 21 • Level5.ModerateDementia • Unabletorecallfamiliaraddressornamesoffamilymemberssuchas grandchildren, not oriented to time or place • Level6.ModeratelySevereDementia • Forgettingnameofspouseorveryfamiliarcaregiver,unawareofyear or season, occasionally incontinent, delusional, sleep disturbance • Level7. SevereDementia • Lossofabilitytospeak,walk,andfeedself,incontinent,brainno longer controls bod

dementia causes

• Many causes of dementia symptoms exist. • Alzheimer's disease is the most common cause of a progressive dementia -Dementia results from impaired functioning of multiple brain systems in both cortical and sub-cortical areas that are associated with short- term memory (i.e. learning) and other higher cognitive functions. -Generally this is due to structural brain damage that is often progressive and relatively irreversible

Glaslow Coma Scale

• Measures levels of consciousness • Based on a 15 point scale for estimating and categorizing the outcomes of brain injury on the basis of overall social capability or dependence on others. • The test assess the patient's motor response, verbal response and eye opening response. • Then based on the total score obtained, the severity of brain injury is determined.

pharmalogical therapy

• Medications are sometimes used to reduce patients' agitated behavior • Sedative or antipsychotic drugs to reduce agitation • Stimulant drugs to improve a lethargic patient's alertness and attention and to facilitate rehabilitation • Antidepressant medications

MCI assessment includes what tasks?

• Memory • listlearning,paragraphrecall • _Working memory_ • Verbalfluency,verbalmathskills • Executive Function • Problemsolving,planning,inhibition/initiation • Processing speed

Middle stages of recovery (RLAS)

• Middle Stage (Levels 4-6): • Pts are alert and increasingly active but are confused, disoriented, and agitated. • At the end of this stage, pts are often oriented and less confused, and their behavior in familiar environments generally is goal-directed. • Most have difficulty organizing and executing complex tasks. • Pts require moderate but systematically decreasing levels of support.

treatment of PPA

• No cure or drug for PPA as of now • No proven medical interventions to reduce rate of decline of language • Mostly behavioral management/treatment (speech therapy) • Even temporary improvement or stabilization can improve quality of life.

medical management of AD

• No medical treatment prevents or cures AD • Tranquilizers to control combativeness or aggression • Antidepressants to lessen depression • Monitoring diet and fluid intake to prevent dehydration and malnutrition • Medications to improve cognition and functioning (Donepezil/Aricept, Namenda)

acceleration head injury

• Occur when the unrestrained head is struck by a moving object or the moving head strikes a stationary object. • Also referred to as "moving-head trauma" • Very common in motor vehicle accidents • Generally more severe brain trauma than non-acceleration injuries

secondary damage in TBI

• Often more devastating than primary consequences • Cerebral edema (brain swelling) • Increased intracranial pressure, causing herniation (shifted brain areas) • Ischemic brain damage • Hypoxia - lack of oxygen to brain • Alterations to Blood-Brain Barrier • Read text book for these terms

incidence of dementia

• One of the most rapidly growing clinical populations • Dementia usually begins in late life • Its incidence increases rapidly with age. • Approximately 2% of 65-year-olds are likely to be affected by dementia • ~20% of 80-year-olds are likely to be affected by dementia.

orientation

• Orientation becomes the focus of intervention as a pt's confusion and agitation diminish and as the pt begins to respond to caregivers and environmental conditions. • Environmental prompts: • signs, notes, appointment calendars etc. • Orientation drills: • The clinician provides instruction, prompts, and cues to help the patient understand who they are, what has happened to them, where they are. • The clinician helps the pt identify the current hour, day, and year. **can be passive or active training. Active training usually takes place after passive

changes in personality in normal aging

• Personality remains relatively throughout the lifespan, although changes may occur in responses to major or traumatic life events, etc. • Personality changes that are noticeable have meaning and signal potential clinical significance

Neuroplasticity and cognitive reserve of MCI

• Possible factors to explain why some convert to dementia and other do not • Individuals with higher level of cognitive reserve have reduced rate of developing dementia • Neuroplasticity plays an important role in brain wellness and successful aging processes

semantic dimentia

• Progressive loss of semantic knowledge while other aspects of cognition are spared • E.g.,lossofmemoryforwordswithlargelysparedgrammar, syntax, and fluency • Neuropathology: bilateral pathology of temporal lobes (left > right), but may also affect frontal lobe • Onset: 50-65 years of age • Duration: roughly 8 years

early stages management

• Providing information and support to family members is a large part of our role • Memory Compensation • reminders, notebooks, etc. • Disorientation/Confusion • calendars, maps, reminders • Denial, anger, questions • Some planning, but mostly anxiety, grief, anger

late stages of CC in AD

• Reading becomes nonfunctional • Writingisnonfunctional • Comprehension of spoken materials is limited to simple familiar phrases and words. • Speech consists primarily of single words and sentence fragments, which are often bizarre, devoid of meaning, and repeated in robot-like fashion. • Syntax breaks down and stereotypic utterances (e.g., great day in the morning...great day in the morning) begin to occur. • Neologisms (e.g., "Take it down the cranbibby") • Unaware of errors, no attempt to repair • Some patients become mute or echolalic • See Table 12-1

rehab

• Rehab process is different for everyone. Rehab should be individualized to each TBI survivor's needs. No two brain injuries are alike. The person with TBI and their family are an important part of the team. • Rehab involves natural healing of the body and the brain's relearning.

Rancho Los Amigos Scale

• Scaling Baseline Behaviors: • Widely used scales that provide categories to which clinicians can assign brain-injured patients based on the patients' cognitive and behavioral characteristics and independence level. • Assessing Recovery Stages: • Clinicians assume that the time-course of individual patient's recovery follows RLAS levels. • Some pts. may stay in a particular stage for a awhile, some move through stages quickly. • See Box 11-1 in the textbook

what memory functions remain stable with age?

• Semantic memory - Facts and general knowledge about the world, esp. if the information is used frequently. • Procedural memory - Acquisition and performance of learned motor/cognitive skills (e.g., how to play a new sport; rules to play a game).

causes of dementia

• Some dementias are reversible (temporary) • Depression • Nutritional deficiencies • Drug overdoes or side effects • Poisoning with toxic substances (mercury, lead) • Reversible dementias tend to occur in younger persons • Tumor

cerebral edema

• Swelling in the brain • Edema almost always surrounds the primary site of brain injury, but can occur throughout the brain, especially following diffuse injuries. • Cerebral edema is a contributor to increased intracranial pressure_ • It usually becomes significant within 4 to 6 hours post injury and peaks in 24 to 36 hours.

agnosia

• The inability to recognize or identify objects despite intact sensory function • Typically occurs later in the course of illness • Can be visual or tactile

Nondeclarative Long-Term Memory (procedural)

• Unintentional, nonconscious use of previously acquired information • Expressed in changes in performance rather than conscious recollection • Pts with dementia have normal priming > suggesting that impairment is in the conscious access to LTM information • Examples: riding a bike, tying your shoes, walking

changes in hearing and vision with normal aging

• Unrecognized hearing loss can be misinterpreted as impaired auditory comprehension • Unrecognized loss of visual perception can be misinterpreted as multiple types of cognitive deficits • So, need to carefully consider these issues when giving assessments and make appropriate referrals as needed

compensation/accommodations

• Use external aids or modify environment to lessen the negative effects of impairments on ADLs. e.g., use of appointment book for impaired memory; taking rest breaks often for impaired attention

late stages

• Usually in a nursing home • Caregiver may feel guilt over placement • Counseling of the family at this stage very important • If at home, hospice may be involved

AD is not

• Vascular Dementia • Lewy Body Disease • Dementia with Parkinson's Disease • Other degenerative cognitive syndromes • Pick's disease • Primary Progressive Aphasia • Frontotemporal dementia • Creutzfeld-Jacob Disease

changes in language with normal aging

• Word learning and grammar _______ • Word knowledge is intact and may increase • Confrontation naming (word-finding) and generative naming may decline but does ___________with communication • Language comprehension may be affected if information is complex and presented rapidly • Main effects on language are secondary to slower processing and poorer attention

cognitive communicative rehab

• Work to improve impaired cognitive-communicative skills through process-specific drills: • Attention • Memory • Executive functions (abstract thinking/reasoning, problem solving, planning, self-monitoring etc.) • Language skills (comprehension, speaking, reading, writing) • Extralinguistic skills (verbosity, tangential speech, organization etc.) • Pragmatics (eye contact, turn taking, initiating questions, keep the conversation going, adjusting vocal loudness etc.)

what memory functions decrease with age?

• Working memory - Holding and manipulating information in the mind, (e.g., adding lists of numbers "in head"). • Episodic memory - Personal events and experiences (e.g., Where did I park my car?) • Prospective memory - The ability to remember to remember to perform an action in the future (e.g., remembering an appointment).

who is at risk for TBI?

• Young males between age 15-25 • Experience TBI at twice the rate of same age female peers • Motor vehicle accidents (MVA) most common cause • Toddlers and elderly • Less likely than young males • Falls most common cause of TBI • Substance Abuse • Approx. 50% of pts admitted to hospital with TBI are intoxicated •TBI causes resulting from intoxication :#1MVA,#2falls, #3 assaults -drivers more likely to be intoxicated sports players --boxing/football --motorcycling/biking/rock climbing

Dementia symptoms

- emerge slowly, worsen over time and restrict ability to function. -alter behavior and personality -may include physical impairments like movement disorders and sensory disturbances -hard to differentiate depression from dementia since it can sometimes affect memory and cognition

PPA-G

-Agrammatic variant atrophy in regions of the left frontal lobe

SLP and dementia

-Assess cog-comm skills to determine strengths and weaknesses, abilities for compensatory strategies -Maintain and facilitate cognitive/communicative strengths -Educate and help family & caregivers to facilitate communication, be aware of safety issues, maximize quality of life.

Frontotemporal Dementia

-Cognitive impairment associated with a variety of disorders that are characterized by frontotemporal lobe degeneration • Distinction made between individuals who present early on with progressive behavioral changes and those with progressive changes in language function • *Behavioral Variant (Pick) pts will have language impairments later on

causes of vascular dementia

-dysfunction of neurovasular unit and mech regulating blood flow -hypertension/heart disease/multiple strokes history -can follow heart attacks with brain ischemia, hematomas, or autoimmune diseases

vascular dementia diagnostic criteria

-memory impairment -aphasia/apraxia/agnosia/ or impaired exec functioning -decline in social or occupational functioning -focal neurologic signs present + symptoms of cerebrovascular disease that is related to these signs -deficits not related to delirium

vasular dementia

-mixed (rarely occurs alone, commonly seen with AD) -20% of dementias worldwide -2nd most common cause of dementia -used to be called "multi-infarct dementia" (not only cause, so name changed)

PD prevalence

1% of US adults more common in men ages 50-65

treatment considerations

1. Appropriate & realistic therapy goals: • Based on pt's capacity & needs • Attention or memory deficits? • Functional needs? • What is important to the patient and family? 2. Stages of Recovery : goals need to be appropriate to each stage of recovery 3. Individual differences: tailor each patients strengths, weaknesses, and interests etc. e.g., interests in baseball card collection, cooking etc.

Definition of Memory

1. Stored representations 2.Processes of encoding, consolidation, and retrieval through which knowledge is acquired and manipulated 3. Quasi-modularsystem • i.e.,differenttypesofmemoryareassociatedwithdifferentbrainregions,butthe systems are interrelated

goals of intervention

1. To minimize the disruptive effects of the dementia on the person with dementia and to support caregivers and family members 2. To ensure the safety of the person with dementia and to keep her/him healthy 3. To provide support and direction for the person with dementia/caregivers/family members Collaboration is required across disciplines: medicine, nursing, SLP, OT, recreational therapy, social work, person with dementia, caregiver, family members etc.

closed head injury

1. acceleration closed head injury 2. non acceleration closed head injury

MCI diagnostic criteria

1. concern regarding change in cognition compared to ___ 2. impairment in one or more cognitive domains 3. preservation of independence in functional abilities 4. not demented

% MCI converts to dementia

10-15% depending on type of dementia people can also "convert" back to normal cognitive function

mutism

3% Pt can comprehend but does not speak. Pt can communicate nonverbally.

dysarthria

30 % speech disorder result of weakness or incoordination in muscles of the respiratory, phonatory, resonatory, or articulatory systems.

avg onset age of PPA

60 (gradual onset) man affected 2x as often half of individuals with PPA have family member with dementia (indicates genetic component)

AD and cell death

AD disrupts how electrical charges travel within cells and the activity of neurotransmitters - resulting in death begin years before onset of symptoms

risk factors of MCI

AGE!!!! APOE carrier status - those with ApoE4 variant have greater risk of developing MCI that will progress to AD Diabetes, hyperlipidemia, smoking, depression, high blood pressure, high cholesterol, lack of exercise, high alcohol consumption, infrequent social participation

severity of TBI

Based on the initial length of loss of consciousness and post- traumatic memory loss.

Alzheimer's disease

CORTICAL • Progressive neurologic disorder that results in memory loss, personality changes, global cognitive dysfunction, and functional impairments. • AD is the fastest-growing and most expensive clinical population in the US (Bayles, 1987). • About 4 million adults in the United States have AD. • AD affects about 5-10% of the over-65 population and 15%-30% of the over-80 population in the United States. • The most common cause of irreversible dementia, affecting up to 70% of those diagnosed with dementia (ASHA) *cause unknown beside inherited forms

intracerebral hemotoma

Caused by rupture of blood vessels within the brain substance develop in subcortical white matter , BG, and brain stem. most commonly seen in combination with diffuse axonal injury A pattern of multiple small intracerebral hemorrhages sometimes occurs in combination with DAI (diffuse axonal injury) • This combination often leads to coma and death

accommodation

Changes in the shared environment of the individual which allow functioning in spite of disabilities.

SLP specific assessments for MCI

Cognitive Linguistic Quick Test (CLQT) • Subtests: orientation, paragraph recall, word fluency, naming, cancellation tasks, trail tasks, design memory, clock drawing, design generation • Provides scores for each subtests, as well as composite scores for five cognitive domains • Attention • Memory • Executive Function • Language • Visual Spatial Skills

duration of coma

Deeper and longer-lasting unconsciousness (coma) is associated with poorer eventual recovery

LBD and Parkinson's Disease

LB present in many PD patients demential is present in 10-20% of PD both demented and non-demented PD patients appear to have impairments on procedural learning tasks

PPA-L

Logopenic variant atrophy in left temporal and parietal lobes

severe tBI (less than 10%)

Loss of consciousness for 6 hours or longer • Extensive axonal damage throughout the brain and brainstem • Hemorrhages common and life-threatening • Ischemic changes common in first few days after injury • Blood loss or altered autoregulation of blood pressure can add to brain ischemia • Hypoxia from can further diminished brain's oxygen supply • neiroplasticity_ contributes very little to recovery due to diffuse axonal damage throughout the brain

moderte TBI

Loss of consciousness from 15 min to a few hours, followed by a few days or weeks of confusion. • Diffuse axonal damage spread throughout the brain and brainstem • Lacerations and contusions on the surface of the brain destroy brain tissue • Lacerated and torn blood vessels created hematomas • Neuroplasticity contributes to moderate amount of physiological recovery in these patients

hypoxia

Normal blood oxygen levels 90% or above • Can occur as a secondary consequence of TBI as well as a primary consequence in Acquired Brain Injury • Dysautonomia • Drug overdose • Strangulation • Birthing, etc. • We won't go into much detail on this

mild TBI

Pt initially loses consciousness for 15 min or less any memory loss about the trauma event pt may feel dazed, disoriented or confused Aka "concussions"

restoration

Repetitive exercises and activities designed to restore or improve damaged abilities

PPA-S

Semantic variant of PPA atrophy in left anterior and ventral temporal lobe

concussion

a traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. • Do not necessarily have to lose consciousness

source of SDH

aceration of cortical blood vessels caused by abrasions and contusions on the brain surface

what sets VD apart from AD?

acute/abrupt onset of VD symptoms that result in neurologic signs relative to site and size of lesions fluctuating severity of symptoms history of hypertension and stroke

AD risk factors

age (doubles every decade after the age of 60) family history (4x more likely) ApoE E4 allele (increased 1-2x risk) Mild cognitive impairment

what acceleration injury creates the most severe brain injury?

angular acceleration and rotation of cranial contents within the skull

arterial v. venous bleeding

arterial =massive hemorrhage, rapid progression, death in 85% of cases venuos = slow oozing of blood, slow progression of symptoms, less dramatic, death in 15% of cases

Pick disease

behavioral variant of FTD pick bodies in the cortex, later atrophy of frontal and temporal lobes

traumatic hemorrhage

bleeding in the brain that leads to accumulations of blood called hematomas. There are four major categories of hemorrhage • epidural hematoma • subdural hematoma • subarachnoid hematoma • intracerebral hematoma

epidural hematoma

blood between dura mater and skull --bleeding into posterior inferior epidural space can cause compression of brainstem --bleeding into frontal and superior epidural spaces is less serious bc farther away from vital structures 20-30% mortality rate severity caused is related to location

where are shearing forces greatest fro angular acceleration injuries?

boundaries between gray and white matter

herniation

brain tissues pushed against cranial partitions or through openings in the skull due to increased

coup injuries

bruises and abrasions on the surface of the brain where it strikes the skull "blow"

rapid acceleration and deceleration of the head

causes abrasions and lacerations of cortical tissues --abrasions tend to concentrate on the bottom surface of the surface of the frontal lobes and anterior temporal lobes as brain moves: --scrapes against bony parts of the floor of the cranial vault leads to widespread damage and common to traits among many TBI pts (coupled with they indy deficits due to site of impact)

diffuse axonal injury

damage to nerve cell axons diffusely scattered throughout the brain substance --caused my stretching, tearing, twisting or brain tissue -common after BI -assumed to be responsible for many of the diffuse cog and bh impairments following BI

TBI definition

damage to the brain caused by external forces forces generated when a moving object strikes head or when the moving head strikes a stationary object

pick language

develop nonfluent aphasia later in disease course

acute SDH

develops within a few hours and almost always within a week of injury

PD symptoms

disturbances in movement (muscle rigidity, tremor, slowness, loss of balance, difficulty initiating movement) motor speech impairments at early stages (hyperkinetic dysarthria) --weak voice --language remains preserved until later stages higher level cognitive functions impaired in early stages slowly progressive deterioration of motor and mental functions later stages some patients become demented, showing impaired orientation, attention, language, and loss of ability to function in ADLs.

GPA model

for executive functioning Goal Plan Anticipate helps w problem solving

vascular lesions/infarcts tend to...

get demented even though people rarely have severe memory loss from stroke

TBI results in...

impaired cognitive abilities and/or physical functioning, and sometimes disturbs behavioral or emotional functioning

pick cognition

impairments in exec function and attention (typical of frontal lobe path) --functional memory and visuospatial abilities spared until later

apraxia

inability to carry out motor activities despite intact motor function -contributes to loss of ADLs ex: self feeling/dressing/toiletting

VD symptoms pattern

incidents followed by stepwise deterioration and progression of symptoms slow accumulation of neurologic events produce diffuse cerebral involvement show differences in personality and intellect in later stages depression, irritability, and emotional lability appear early

if patient survives open (penetrating) injury...

infection, bleeding, increased intracranial pressure become threats to survival have secondary consequences adults who survive make good recoveries but almost always have lingering physical, cognitive, or linguistic deficits --focal damage = loss of functions served by damaged brain tissue

aphasia in dementia

initially fluent aphasia -can initiate and maintain convo -impaired comprehension -intact grammar and syntax but vague speech (paraphaisias, circumlocution, nonspecific phrases) -mutism or echolalia

contrecoup injuries

injury to the surface of the brain on the opposite side from the blow that first started the head moving "counter-blow"

people with early stage dementia

intensely aware of their impairments and willingly participate in therapy concern - maintaining independent functioning as long as possible

increasing pressure and displacement of brain tissue of SDH

leads to coma and death within a few hours

2 forms of acceleration injuries

linear angular depends on direction from which the head is struck

AD timeline

loss of STM is early later in states, pt are totally dependent on others for ADL

warning signs of AD

memory loss affecting daily life challenges in planning/problem solving difficulty completing familiar tasks confusion with time or place trouble understanding images/spatial relationships new problems in speaking/writing misplacing things decreased or poor judgement changes in mood and personality

mTBI

mild TBI = concussion • "A blow or force to the head that causes loss of consciousness lasting less than 30 minutes or an alteration in consciousness" • Symptoms (these and more!): • -Headaches • -Visual disturbances • -Memory loss • -Poor attention/concentration • -Sleep disturbances • -Dizziness/loss of balance • -Irritability-emotional disturbances • -Feelings of depression • -Seizures

picks disease effects

more woman age 50s lats 3-27 years

Closed (Non-Penetrating) Head Injury

most common cause of TBI meninges intact, no foreign entry into brain 2 classifications 1. non acceleration 2. acceleration

impaired cognitive skills

most pervasive in TBI

Diagnosis of Dementia

multiple cog deficits --memory impairment --aphasia, apraxia, agnosia, abstract thinking/exec. function impairment in one or more of the following --impairment in social or occupational function --gradual onset and progressive worsening --symptoms not explained by another disorder

cause of PPA

neurodegeneration of brain tissue important for speech and language (LH)

diagnosing PPA

no totally reliable testing brain imaging may show L sided brain areas affected but attire these tests can be normal with PPA individuals

linear acceleration injuries

occur when the head is struck by an outside force which is applied on a linear path (ie: straight line) that passes through the center axis of the head coup and countercoup injuries are salient characteristics of linear injuries

nonacceleration head injuries

occur when the restrained head is struck by a moving object (e.g., the victim is lying on a hard surface or sitting with his or her head against an stationary surface when the head is struck). • Also referred to as "fixed-head trauma" • Generally _less_ damage than acceleration injuries (Blows to movable head are approximately 20 times more damaging to a fixed head) • Primary consequence = Deformation of the skull • Impression trauma & ellipsoidal deformation

frontal lobes and TBI

often damaged important for execute functions --organizing info --planning --decision making --problem solving --bh --emotion --self monitoring --inhibition --higher level cog processes

TBI may be result of either...

open or closed head injury

persons with later stages dementia

patient loses insight into deteriorating skills, direct intervention is not effective. Concern is to maintain communication to the extent possible by helping caregivers to adapt to the declining patient skills and behavior.