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9/26/16
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Cognitive-LinguisticProcessesinAphasia
CognitiveandlinguisticProcessesinAphasia• Attention• Memory– Shorttermmemory–Workingmemory
• Executivefunctions• Cognitiveimpairmentsinaphasia
Language CognitionPlaysarole
Relatedto
Cognition
language
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Attention
• “Cognitiveprocessthatconcentratesmentaleffortonanexternalstimulusorinternalthought/representation”(Ashcraft&Radvansky,2010)
• Overlapswithotheraspectsofcognition
• Ifattentionisweakenedthenlanguageoperationsbecomelessefficient
• Needattentiontofocusoncommunicationpartner’sspeech,particularlywhensurroundedbycompetingstimuli
• Arousal–– Basiclevelofattention– Physiologicalstate– Generalreadinesstoact/receive– Necessaryforintentionalcommunicationtooccur– Supportsvigilance
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• Vigilance– Attentionsustainedoverlongperiodsoftime– Necessarytoholdaconversation– Criticalforlanguageproductionandcomprehension
• Intention--- Attention– Iintend tocarryonaconversationwithyousoIneedtoattendtowhatyousay.
Arousal
Vigilance
Intention Attention
Crosson (2012)p.169,Fig8-1
AttentionandAphasia
Symptomsofaphasiaareduetoimpairmentsinattentionmechanisms(Hula&McNeil)
Impairedlinguistic&attentionmechanismscontributetosymptomspresentinaphasia(Crosson)
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• 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• But…notalwaysthecase
usablealgebra.landmark.edu
• DeclarativeMemory– Semanticmemory:sharedknowledge
• E.g.,knowledgethatcreamandsugarareoftenaddedtocoffee
– Episodicmemory:personalknowledge• E.g.,knowledgethatmyStarbuck’sorderisGrandePikecoffeewiththreeSplendas andhalf-n-half
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MemoryandAphasia
• Impairedonsimplespantasksthatinvolvewordlistrecall– Normal:7digits,5words– Aphasia:1-3digits/words– Digits>words>nonwords
• Language-basedapproachtoSTM…– ->phonologicalandsemanticinformationsupportwordlistretention
• STMdeficitsoncomprehension– PhonologicalSTMdeficithasfewconsequences– SemanticSTMdeficitnegativelyaffectssentencecomprehensionandproduction
• AdultswithaphasiapresentwithaWMdeficit– ->contributestotheirlanguageprocessingimpairments
• Acrosstheseveritycontinuum– AdultswithmildaphasiapresentwithimpairedWMandverbalmemoryabilities(e.g.,Ronnberg etal.,1996;Ween etal.,1996)
• DiscoursecomprehensionisWMdemanding
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• Clinicalimplicationsforverbalmemoryimpairments…consequencesforfunctionalcommunication– c/ooflanguagedifficultyinday-to-dayconversation
ExecutiveFunctions
“littlepersonintheheadtodirectbehavior”(Andrewes,2001)
• Elementsofexecutivefunctioninclude– Initiation– Goalmaintenance/taskpersistence– Organization– Awareness,self-monitoring,flexibility
Norman&Shallice (1986)
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• 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
• Cognitiveimpairmentsinmemory,attention,andexecutivefunctionscanaffectfunctionalcommunication
• Negativeeffectsonrehabprocess– Lesslikelytobenefitfrombehavioraltreatment– Slowerrecovery– Poorerfunctionaloutcomes
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• Assessmentofcognitivedisordersandcommunicationimpairments
(1) Interview,observation,informalassessment(2) Standardizedtestsofcognitiveprocesses(3) Standardizedtestsoflanguageand
communication(4) Non-standardizedtestsoflanguageand
communication
• 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)
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GeneralCognitiveFunctionTests
Instrument Reference
Halstead-Reitan NeuropsychologyTestBattery
Reitan &Wolfson (2004)
NeuropsychologicalAssessmentBattery Stern&White(2003)
RossInformationProcessingAssessment- 2
Ross-Swain(1996)
CognitiveDomainBatteries
• Usefulforevaluatinganumberofskillswithinonedomain
• Providedetailedinformation• Informativeforidentifyingspecifictreatmentgoals
Attention
• Unstructuredmethods– interviewandobservational
• Structuredmethods– scales,standardizedtests
• Potentialchallenge–Mostattentionmeasuresaremultifaceted
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• Attentionimpairmentsaretypicalinmosttypesofbraindamage
• Criticismsofmethodsforassessingattentioninaphasia– Theyuselinguisticstimulisomaybeconfounded&invalid(Murray)
– But…linguisticstimulishouldbeusedtoprovideinsightregardinginfluencesofoneprocessonanother(McNeil&Hula)
• Attentiontestbatteries– BriefTestofAttention(Schretlen,1997)– TestofEverydayAttention(Robertsonetal.,1994)
• Ecologicaloutcomemeasures– RatingScaleofAttentionalBehaviour (Ponsford &Kinsella,1991)
– CognitiveFailuresQuestionnaire(Broadbentetal.,1982)
Ponsford&Kinsella(1991).Theuseofaratingscaleofattentionalbehaviour.NeuropsychologicalRehabilitation,1,241-257.
Broadbent,Cooper,FitGerald,&Parkes (1982).Thecognitivefailuresquestionnaire(CFQ)anditscorrelates.BritishJournalofClinicalPsychology,21,1-16.
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Memory
• WechslerMemoryScale-IIIorIV(Wechsler,1997;2009)
– Episodicmemory–Workingmemory– Nonverbal&verbalmemory
• Rivermead BehavioralMemoryTest-III(Wilsonetal.,2008)– Everydaymemoryactivities
• TempleAssessmentofLanguageandShortTermMemoryinAphasia(Martinetal,2010)
– Part1.Singleandmultiplewordprocessingtaskswithintervalconditions
– Part2.Spanmeasureswithlanguagevariations
• Martin,N.,Kohen,F.P.,&Kalinyak-Fliszar,M.(2010).Aprocessingapproachtotheassessmentoflanguageandverbalshort-termmemoryabilitiesinaphasia.ClinicalAphasiologyConference,Charleston,SC.
• Kalinyak-Fliszar,M.,Kohen,F.,&Martin,N.(2011).Remediationoflanguageprocessinginaphasia:Improvingactivationandmaintenanceoflinguisticrepresentationsin(verbal)short-termmemory.Aphasiology,25(10),1095–1131.
• Verbalworkingmemory– Tompkinsetal.(1994)Auditory-verbalworkingmemorytest
2-sentences SetYousiton achair TrueTrainscanfly False
3-sentences SetSugarissweet TrueFloridaisnext toOhio FalseHorsesruninthesky False
4-sentences SetTwelveequalsonedozed TrueBicyclesareslowerthancars
False
Abookcanplay FalseFeatherscantickle True
5-sentences SetCarrots candance FalseFishswiminwater TrueYousleep onabed TrueYoueatbreakfastatnight FalsePeople haveeyes True
SamplestimulifromTompkinsetal’s A/VWMTest
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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
TreatmentofCognitive-LinguisticDeficitsinAphasia
• 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
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• Language-specificapproach– Attentiondeficitsassociatedwithlanguageprocessingrequiretreatmentsthatarelanguage-based
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
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3. Automatizeattentionalrecruitmentforlanguage– Goaloftreatment– Attendedprocessingleadstoautomatic
processingwithpractice(Carr&Hinckley,2012)– Extensiverepetitionoflanguagetaskstomake
languageprocessesmoreautomatic– Feedback:languagetasksnotattentionalcontrol
4. EngageattentionalmechanismsinRH– Withasimpletask(picturenaming)move
stimuluspresentationinlefthemispace5. Exploitlinguisticdevicesknowntofocus
attention– Alternatesubjectselectionforsentence
production– Sentencefocusstructure– Anaphoricreference
ExamplefromSkarakis-Doyle(2005)AppendixB,p.363
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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)
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• Takehomemessage–Manipulatetreatmentstimuli– Indirecteffectsonothercognitive&linguisticabilities
Alittlebitmore…
• STMandWMaremodifiable• Indirect,positiveeffectsonothercognitive-linguisticprocesses
CaseExamples
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Thankyou!
Questions?