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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?