Communication in FTD Daisy Sapolsky, MS, CCC-SLP Speech-Language Pathologist MGH Department of Speech, Language and Swallowing Disorders & Reading Disabilities

Communication in FTD

Daisy Sapolsky, MS, CCC-SLPSpeech-Language PathologistMGH Department of Speech, Language and Swallowing Disorders & Reading DisabilitiesMGH Frontotemporal Disorders Unit

Topics

Subtypes of FTD

Communication challenges

Compensatory strategies

MGH FTD Unit and Progressive Communication Disorders Program

Terms

AphasiaAn acquired communication disorder that

impairs a person's ability to process language, but does not affect intelligence.

Can have impairment in one or more areas:speakingunderstanding others readingwriting/spelling

http://www.aphasia.org/

Terms

Primary Progressive Aphasia (Mesulam, 1982)A language disorder (“aphasia”) that

worsens over time (“progressive”), and is the most prominent problem the person experiences (“primary”)

Subtypes of FTD

Frontotemporal Dementia (FTD)

Primary Progressive Aphasia (PPA) Behavioral Variant (bvFTD)

Progressive Nonfluent Aphasia (PNFA)

Semantic Dementia (SD)

Logopenic Progressive Aphasia (LPA)

Progressive nonfluent aphasia (PNFA)

agrammatism nonfluent speech, may be telegraphic

hesitant, effortful, pauses, hesitations, fillers (e.g., umm)

difficulty with verbs and functor words (e.g., the, for, an, to)

knowing what you want to say, but can’t think of the word or can’t get the word out

comprehension is (typically) intact there may be difficulty in comprehension of

complex syntactic forms


impaired reading and writing difficulty with forming grammatically correct sentences

difficulty with reading complex sentences; comprehension of single words usually intact

or, writing may be significantly better than speech in some patients

spelling difficulty

yes/no confusion

pronoun confusion


picture description: “Umm, you know, the umm, the family for uh

the picnic...umm...maybe the Cape...you know, the umm, like sailing and fishing and umm the ah, uh, girl is umm, the umm, the sandcastles, and umm the picnic man’s reading a book and umm the lady is uh, wine, and you know, like summertime, summertime.”

Picnic scene picture

Western Aphasia Battery-Revised (Kertesz, A., 2007)

Subtypes of FTD


Primary Progressive Aphasia (PPA) Behavioral Variant (Beh)




Semantic dementia (SD)

loss of knowledge of the meanings of words lower frequency/uncommon words most affected “What is a ___?”

use of vague/general words (e.g., stuff, thing) speech content has an empty quality

lack of detail, common/vague words

but, speech is fluent and grammatical

Semantic dementia (SD)

picture description: “There’s a guy and a dog and this, and then

there’s a girl and another dog, and something. And, they’re eating. This is the...I should know that because I always do it...I always know that usually.”

Subtypes of FTD







intermittent word-finding hesitationsimpaired namingphonemic paraphasias (saying words or

nonwords that share some sounds with the correct word) “octible” for octopus “rackel” for racquet “glow” for globe


picture description: It looks like a family is, has a hou, uh, I

think it’s a house or a friend’s place, on the leck lake...Uh, and uh, there’s somebody who’s uh finishing, uh, fishing...Uh some friends are in the boat, in the so, sailboat, sail, sailboat...They uh, the mother is putting some, I’d like to think it’s wing uh wine...

Subtypes of FTD






Behavioral variant FTD (bvFTD)

As patients may do well in testing, they are often not thought to have a primary speech/language disorder.

However, the hallmark changes in behavior and personality directly affect daily communication and functioning, and therefore can result in a communication disorder.


apathetic variant flat affect, emotional blunting

not expressing emotion, not understanding or reading someone else’s emotion

withdrawal, loss of interest (apathy)not engaging in conversation or previously

enjoyed activities lack of initiation

only speaks when spoken to


disinhibited variant saying inappropriate things or in an inappropriate

way inappropriate increase in talking

press of speech

not reading social cues that someone is not interested in the conversation or is ready to stop the conversation

compulsive behaviors

Topics

Subtypes of FTD




Common communication challenges

knowing what you want to say but the words won’t come out → frustration

able to express basic wants and needs, but difficulty with higher-level conversation “I miss the discourse.”

feeling rushed and pressured to get your thoughts out may result in withdrawing from social situations one patient said she doesn’t want to make people

wait for her to come up with words

Common communication challenges

communicating the problem to friends and family, people at work

carrying out routines and activities difficulty reading and writing may mean the

loss of previously enjoyed and practical activities

adjusting to new communication style “I used to be a fast talker.”

Topics

Subtypes of FTD




Example compensatory strategies

key words and semantic cueing patient provides key words instead of attempting to

say full sentences patient describes the concept/word using semantic

features 5 w’s template

helps patient organize thoughts visual guide

multiple-choice questions partner asks multiple-choice or yes/no questions


visual materials use a newspaper headline, photo, or other visual

material as conversation topic

elaboration help patient elaborate on previous response

gesture (e.g., past, future, yes/no, size, shape)


pre-written “scripts” write brief scripts to be used in specific situations practicing may reduce the pressure of the moment can be used to read from or to show to the partner

Please pump $20 worth of gas. How was your vacation to Paris? I need to find a dress to wear to a wedding. I need to return these shoes because they didn’t fit.


communication book primary or supplementary communication update topics/formats as needed

point to pictures/words: people (family members, friends) places (shops, restaurants) food activities emotions time/date


slow down – both patient and partner patient has more time to think of words and

organize thoughts allows patient time to process what is being said to

him/her relieves the pressure of a fast-paced conversation


Identify barriers to functioning in the home or workplace and be creative in brainstorming solutions e.g., a patient with non-fluent speech allows calls to

go to voicemail, enabling her to take time to formulate a response, write a script, or send an e-mail response


Identify activities, hobbies, and volunteer opportunities that have low demand on language (arts, music, gardening).

Discuss when a job or responsibility is no longer manageable. Create an action plan to leave the situation.


Prompt the patient to use any means of expression gesturing, writing, drawing, pointing to pictures or

words, facial expression

Refer to an AAC (Augmentative & Alternative Communication) center

For apraxia of speech, try traditional motor speech strategies


Some patients have reported success! From an e-mail:

Script for a phone conversation for friends, a business, and doctors - I practice the script until I can speak decently.

Gestures, facial expression, and body language...two-thumbs-up, wave, and five high slap...and dance around with my body.

Syllable attack is very helpful. I break down the long word into syllables and practice them slowly. Then I quicken my speed until I can pronounce the word properly...

They (strategies) are helpful. It takes a long time to practice a script on the phone but it pays off. The reward is speaking more normally...not perfect!

Strategies: Behavioral variant

Set up situations and routines that allow the patient to respond to others, instead of needing to initiate communication themselves

Brainstorm ways to engage the patient in activities and communication

Strategies: Behavioral variant

Break down tasks into manageable steps that are not overwhelming (e.g., setting the table)daily calendar/schedule to provide a list of

activities and to-do itemsdo this together so that the patient has input

phone message template

Topics

Subtypes of FTD




MGH Progressive Communication Disorders Program

goals of the evaluation: identify strengths and weaknesses in speech/language abilities, compensations already

in use, communication partners, and what is/isn’t working in daily life develop functional goals:

to maintain and enhance communication; and to prepare for future decline

goals of the therapy program: teach/practice compensatory strategies to facilitate communication in everyday

situations educate the patient/partner about the diagnosis and implications for communication brainstorm suggestions for modifying the environment to facilitate communication troubleshoot barriers to communication and participation provide check-ins and ongoing support

program structure: individual sessions that vary in frequency and duration for patient and partner “tune-up” sessions to review strategies and determine if another round of therapy is

warranted group therapy to practice strategies within a comfortable setting and to meet others

Documents

Communication in FTD Daisy Sapolsky, MS, CCC-SLP Speech-Language Pathologist MGH Department of Speech, Language and Swallowing Disorders & Reading Disabilities