1. Cognitive-Communication Disorders
An Overview
Jody E. Rice, M.S., CCC-SLP

2. Disorders Review

3. Introduction What do these have in common? Traumatic brain injury
Right hemisphere syndrome/dysfunction
Dementia

4. Introduction
Is a cognitive-communication disorder the same as an aphasia?
Is a cognitive-communication the same as a dysarthria?
An apraxia?

5. Why is the SLP involved?
Cognition and communication are intrinsically and reciprocally related in both development and function
Cognitive-communication disorders encompass any aspect of communication affected by disruption of cognition
Areas of function affected by cognitive impairments include behavioral self-regulation, social interaction, ADLs, learning and academic performance and vocational performance.
ASHA 2004 Knowledge and Skills Document
Communication can mean social interaction.

6. Narrative Discourse Sample
Bang, bang, twang, bang, as a bullet knocks the cup of hot coffee away from the lips of our trusty ol’ [Bill]. Yes, old and weak he was but, is always trying, and to no prevail. It wasn’t his real name, we think, but if people only knew, the horrifying secret of this calm yet not so docile old guy! The fact, that he had a few years on the others in the train was to be determined at some other event of event at hand. We think

7. Narrative Discourse Sample, cont.
Though it was always, [Bill] this, and [Bill] that, every time he turned around, the echo prevailed; [Bill] was a feeble old, chap though he had this seemingly strike one against him, he continued. Don’t worry; we wonder how, just the same as you. Great minds think alike, or not, or there about.
Fluent, tangents, lack of cohesion, good vocabulary,
Aphasic patients can talk better than they can communicate….cognitive patients talk better than they can communicate.

8. International Classification of Functioning, Disability, and Health 2001
Body structures and Functions
Activity and Participation
Contextual Factors
Environmental Factors
Personal Factors
2001, WHO issued statement “health is the complete physical, mental, and social functioning of a person and not merely the absence of disease.”
ICF was developed, and in 2001 ASHA adopted this model as the framework for the field of speech pathology as outlined in Scope of Practice

9. Cognitive-Linguistic Model Cherney 2004
EXECUTIVE FUNCTION
Sensory Reception
Orientation
Organization
Attention
Problem Solving
Memory
Cognitive-communication disorders involve any disorder of communication affected by impaired cognition.
The communication characteristics are different than those we tend to see in disorders of primary language impairment, or aphasia.
Aphasia can affect comprehension, expression, reading, writing. Although people with cognitive-communication disorders can have primary language impairment, their deficits tend to be in more high-level language functioning & verbal integration/reasoning. They may perform very well on standard aphasia tests, giving the false impression that their communication skills are better than they actually are. Aphasics communicate better than they can talk, but cog impaired persons talk better than they communicate.
GO OVER MODEL
Exec Function: CEO; Supervisory capacity to determine strengths, develop goals, direct actions. Apparent in novel, unstructured situations. Important are to consider especially if pt does well on cognitive batteries administered.
GOING INTO DISCOURSE SLIDE
Perception
Reasoning
Effective Communication Skills
Pragmatics & Discourse

10. Sensory Reception Passive process
Reception of tactile, olfactory, gustatory, visual, auditory, proprioceptive, and kinesthetic information

11. Attention Alertness and Arousal
Level of vigilance vs. active direction of attention toward a target
Types of Attention (Sohlberg and Mateer)
Focused (short focus)
Sustained (focus for a period of time)
Selective (Paying attention w/distractions
Alternating (switching activites back & fourth)
Divided (multitasking)

12. Perception Active process Provides structure to the environment
Integrates sensory information; Detects salient features and patterns in sensory stimuli
Olfactory & gustatory information processes subcortically; other sensory information processed cortically

13. Memory Encoding Storage Retrieval
Linking information to the context
Phonological loop vs. visuospatial sketchpad
Storage
Integrating new information with current store; requires reorganization of memory
Retrieval
Activating memory from storage for immediate use
Context during learning should be same during retrieval
Explicit (declarative)(ride bike or smell) vs. Implicit (procedural)
Retrospective (past events) & prospective (future events)

14. Organization Sorting Categorizing Sequencing Prioritizing
Analysis/Synthesis

15. Reasoning/Problem-Solving
Abstract thinking; ability to draw inferences and conclusions
Deductive/Inductive; divergent(central concept then branch off)/convergent(what does cat dog elaphant have in commen?)
Problem-solving requires convergent and divergent thinking, especially divergent thinking
Judgment: predicting consequences, forming opinions

16. Executive Functioning (mom of the brain)
Associated with all aspects of cognitive functioning
“CEO”; Supervisory capacity to direct actions
More apparent in novel, unstructured situations
Setting goals; planning and directing goal-oriented activity
Awareness of strengths and limitations
Initiating and inhibiting behavior
Monitoring activity
Evaluating results
Taking another person’s perspective
Applying learned skills to context
Hard to find this type of problem in a clinical setting.
There is a disconnect from knowing and doing. Roll play is important.

17. TRAUMATIC BRAIN INJURY (TBI)

18. Head Injury
A traumatic insult to the brain capable of producing physical, intellectual, emotional, social, and vocational changes (BIAA)
Acquired brain injury (ABI)
Examples of causes of head injury
Closed vs. Open head injury
Car accidents are closed head injury, blunt force trauma, explosions.

19. Statistics 1.4 million sustain BI each year
Leading causes: falls (28%); MVA (20%)
Males 1.5 times more likely to sustain BI
Age groups: 0-4 y.o.; y.o.
At least 3.17 million Americans currently have a long-term need to help to perform ADLs
BIAA

20. Neuropathology Primary damage Secondary damage
Contusions(bruise on frontal or temporal lobe) vs. diffuse axonal injury(not a focused area)
Secondary damage
Occur as a result of primary damage (hemorrhage, bleading on brain, preasure, adema(swelling))

21. Figure 2.  The most common types of nonpenetrating traumatic brain injury are diffuse axonal injury, contusion, and subdural hemorrhage. The most common locations for diffuse axonal injury (pink) are the corticomedullary (gray matter-white matter) junction (particularly frontotemporal), internal capsule, deep gray matter, upper brainstem, and corpus callosum. The most common locations for contusions (blue) are the superficial gray matter of the inferior, lateral and anterior aspects of the frontal and temporal lobes, with the occipital poles or cerebellum less often involved. The most common locations for subdural hemorrhage (purple) are the frontal and parietal convexities.
Dr. R. Hughes, Neuropsychologist, VAMC 2008 Presentation

22. Outcomes Depth and duration of coma – GCS 13-15 mild 9-12 moderate
≤ 8 severe
GCS score of 8 or less for 6 hours or more
tend to have a poorer outcome
Age
Secondary medical complications
Behavioral & Psychological factors
Glasgow coma scale

23. (mild)mTBI Common Symptoms: Fatigue Headaches; Visual disturbances
Memory loss; Poor attention/concentration
Slowness in thinking
Irritability-emotional disturbances
Seizures
Getting lost or confused
Called a silent epidemic

24. BI in the Military Continuum of care from time of injury
Services at James H. Quillen Mountain Home VAMC
Blasts/explosions as a primary source of BI (IED, landmine, grenade)
Matter is literally transformed from a gas to a solid wall of pressure traveling about 1300 mph.

26. Difficulty with decisions
PTSD
Re-experiencing
Avoidance
Social withdrawal
Memory gaps
Apathy
Arousal
Sensitive to noise
Concentration
Insomnia
Irritability
Mild
TBI
Residual
Difficulty with decisions
Mental slowness
Concentration
Headaches
Dizzy
Appetite changes
Fatigue
Sadness
Depression

27. COGNITIVE-LINGUISTIC ASSESSMENT/ TREATMENT

28. Assessment No single assessment battery effective
Review of records; thorough case history
Behavioral observations
Information from family/significant others
Standardized testing
Component cognitive processes
Basic language function + verbal integration and reasoning
Environmental Needs Assessment(what do they do on daily basis)
Evaluation of Everyday Performance
Checklists/rating scales for cognitive-comm:
Discourse comprehension and production
Consider ICF framework:
Assess cognitive/linguistic processes
Assess surface symptoms/activity level
Assess in different contexts
COGNITIVE
SCATBI, CLQT, RBMT, RIPA-2, 3 words 3 shapes, trail-making, stroop, tower of london
LANGUAGE
WAB, BDAE
Test of Language Competence, Extended; The Word Test; Right Hemis
language battery; Detroit Tests of learning aptitude
RATING SCALES
Natural situation, unstructured play, role play, video
General model to provide more detailed profile of function. Can do further assessment through dx tx

29. Cognitive-Linguistic Model Cherney 2004
EXECUTIVE FUNCTION
Sensory Reception
Orientation
Organization
Attention
Problem Solving
Memory
Cognitive-communication disorders involve any disorder of communication affected by impaired cognition.
The communication characteristics are different than those we tend to see in disorders of primary language impairment, or aphasia.
Aphasia can affect comprehension, expression, reading, writing. Although people with cognitive-communication disorders can have primary language impairment, their deficits tend to be in more high-level language functioning & verbal integration/reasoning. They may perform very well on standard aphasia tests, giving the false impression that their communication skills are better than they actually are. Aphasics communicate better than they can talk, but cog impaired persons talk better than they communicate.
GO OVER MODEL
Exec Function: CEO; Supervisory capacity to determine strengths, develop goals, direct actions. Apparent in novel, unstructured situations. Important are to consider especially if pt does well on cognitive batteries administered.
GOING INTO DISCOURSE SLIDE
Perception
Reasoning
Effective Communication Skills
Pragmatics & Discourse

30. Testing Component Cognitive Processes
Standardized Semi-Comprehensive Assessments
Brief Test of Head Injury
Scales of Cognitive Ability for Traumatic Brain Injury
Cognitive Linguistic Quick Test
Ross Information Processing Assessment
Tests of Specific Cognitive Processes(specific test like attention or memory)

31. Testing Basic Language Function & Verbal Integration/Reasoning
Subtests of aphasia batteries
Verbal Integration & Reasoning
Detroit Tests of Learning Aptitude
Right hemisphere language tasks
Other high-level language tasks

32. Evaluation of Everyday Performance
Checklists/Rating scales
Pragmatics/Discourse
Environmental Needs Assessment/Ecological Inventory

33. Forms of Intervention Facilitation Process-specific training
Functional approach
Skills training
Compensations(by pass)
Facilitation – severe cases, sensory stimulation
Process-specific – probably approach SLPs are more familiar with but not well supported by evidence. Training of discrete cognitive processes in clinic setting with hopes that training will generalize to other processes and to other contexts. Problem with this approach is that there is a dissociation in cognitively impaired persons between knowing and doing. They can often perform discrete tasks well in structure but have difficulty generalizing.
Functional – functional tasks in different contexts
Skills training – vocational training – train one skill in one context
Teach compensatory strategies without attempt to improve process functioning

34. INTERVENTION – A CONSIDERATION
Tailor treatment approach to stage of recovery
Early
Sensory stimulation
Middle
Retraining of cognitive components
Late
Functional integration of components; compensatory strategies

35. Right Hemisphere Dysfunction

36. Dichotomies of Cerebral Hemispheres
LEFT Verbal Linguistic Expression Symbolic/propositional Logical/analytic Focal/discrete Segmental
RIGHT Nonverbal Visual/kinesthetic Perception Visual/imaginative Holistic/synthetic Diffuse Spatial/global

38. Clinical Syndromes Visuoperceptual
Hemispatial neglect (attentional disorder)
Anosognosia (denial of illness)
minimize deficit; attribute limbs to another; hatred of limb; exaggerate strength
Environmental Agnosia (loss of environmental familiarity; inability to become topographically oriented)
Prosopagnosia (failure to recognize familiar faces)

39. Clinical Syndromes, cont.
Visuomotor
Constructional disability
Neglect left half of model, errors in spatial relations, add extraneous material
Dressing disturbances
Hemispatial neglect
Body-garment disorientation

40. Clinical Syndromes, cont.
Affective and Emotional Alterations
Aprosody
Impaired affective auditory comprehension
Disturbances of emotional facial recognition
Altered emotional facial expression
Memory Disorders
Retention of complex visual patterns/ faces
Nonverbal memory

41. Clinical Syndromes, cont.
Neuropsychiatric Disorders
Visual hallucinations (r/t visual field defects)
Capgras’ Syndrome (loved ones replaced by imposters)
Secondary mania (elated and/or irritable mood lasting > 1 week)
Acute confusional states
Paranoid hallucinatory states

42. TREATMENT OF COGNITIVE-LINGUISTIC DISORDERS

43. Goal Setting Functional assessment
Identify long-term outcomes for life domains
Short-term objectives
Responses to be measured
Consistency/accuracy
Efficiency/frequency
Duration
Response mode
Independence
Traditional data keeping, etc. of percent correct may not be appropriate (error-free learning)

44. Treatment Relation to ICF 2001 framework:
Treat underlying processes
Treat surface communication symptoms
Treat in appropriate contexts
Integrative, collaborative approach

45. Treatment Principles Positive attitude – instill sense of ownership
Hierarchical organization – move from simple to the complex; “error-free” environment
Concise, clear instructions and specific feedback
Use of strategies and problem-solving; task analysis
Self-talk; promote self-monitoring
Use natural consequences
Opportunity for generalization; role-play
Focus on functional routines
Remember: dissociation between knowing and doing
Functional Routines
Book by Ylvisaker & Feeney with many different examples of routines
2 types especially pertinent to SLP: Communication and Executive Functioning

46. Attention Training Process-Specific Training; Hierarchy
Environmental Adjustments
Eliminate external distractions
Avoid clutter
One task at a time
Compensatory Strategy Training
Self-talk: Am I paying attention? What am I supposed to be doing?
Use of timer, alarm or watch
Other cognitive prosthetic devices
Breaks
Schedule more difficult tasks first

47. Memory Training Restoration vs. Compensation External Memory Aids
Rehearsal
Focus on teaching of strategies
Internal vs. external strategies
Gear treatment to type of memory deficit
External Memory Aids
Devices, notebooks
Internal Retrieval Strategies

48. Dementia

49. Types of Dementia Primary (progressive & irreversible)
Alzheimer’s Disease: senile plaques and neurofibrillar tangles
Secondary (progressive & irreversible)
Huntington’s Disease
Parkinson’s Disease
Secondary (potentially reversible)
UTI
Stress/Fatigue
Secondary (treatable but irreversible)
Alcoholic dementia

51. Deficits Associated with AD
Cognition
Language
Perception
Figure ground, position in space, visuoconstructional skills, facial agnosia
Psychomotor skills (apraxia)

52. Depiction of Retrogenesis Reisburg
Dementia Stage
GDS Level
Developmental Age
Early
4-5
4-7 years
Middle 6
2-4 years
Late 7
12-24 months
End 7+
1-12 months

53. WHAT IS BEHAVIOR?
Behavior is the action or reaction of persons or things in response to unmet physical, emotional, social, or environmental needs. Behavior is language for late stages 6 & 7

54. Speech-Pathologist’s Role
Evaluation/staging
Active tx (if appropriate)
Development and training in use of Functional Maintenance Program

55. Assessment Brief Cognitive Rating Scale (BCRS); GDS
Arizona Battery for Communication Disorders of Dementia (ABCD)
Functional Linguistic Communication Inventory (FLCI)

56. Treatment Active treatment vs. functional maintenance plans
Stage of dementia
Following directions
New learning

57. FMPs Developed by SLP Support staff trained by SLP
Approx. 2-3 week duration of tx