Introduction to Communication Disorders: A Lifespan Evidence-Based Perspective 5th Edition

CHAPTER 6: Adult Language Impairments Introduction to Communication Disorders: A Lifespan Evidence-Based Perspective 5th Edition Owens, Farinella, & Metz Developed by Sarah A. Dachtyl, Ph.D., CCC/SLP Chapter Learning Goals Differentiate between aphasia, right hemisphere brain damage, traumatic brain injury, and dementia List the concomitant or accompanying deficits that occur with aphasia Explain the different types of aphasia and stroke Outline Language Development Through the Lifespan The Nervous System Aphasia Right Hemisphere Brain Damage Traumatic Brain Injury Dementia Language Development Through the Lifespan Unless there is neuropathology, adults continue to refine communication skills Use Adults are skilled conversationalists Competent communicators sense their role and adjust language and speech The number of communicative intentions increases Changes in writing and reading are not dramatic Narratives improve into middle age and senior years, decreasing after the late seventies Language Development Through the Lifespan Content Adults use between 30,000 and 60,000 words Specialized vocabularies develop Some words fade from language and others are added Multiple definitions and figurative meanings are expanded Seniors experience some deficits in accuracy and speed of word retrieval and naming Language Development Through the Lifespan Form Continue to acquire prefixes, morphophonemic contrasts, and some irregular verbs Conversations are more cohesive Written language more complex than spoken language Complex sentence production declines with advanced age, related to word retrieval Decline in oral/written language comprehension, understanding complex syntax, and inferencing The Nervous System Brain, spinal cord, and associated nerves and sense organs Neuron: Basic unit of the nervous system Cell body, axon, dendrites A nerve is a collection of neurons Electrochemical impulses generally pass between the axon of one neuron to the dendrites of another across the synapse The Nervous System Central Nervous System The Brain Cerebrum, cerebellum, brainstem Cerebrum is divided into right and left hemispheres Sensory and motor functions of the cerebrum are mostly contralateral Each hemisphere consists of white fibrous connective tracts running below the surface Covered by gray cortex of cell bodies approximately .25 inch thick The Nervous System Central Nervous System The Brain The cortex is wrinkled due to gyri and sulci Four lobes: Temporal, parietal, frontal, occipital Generalized areas of the brain are responsible for particular operations Left hemisphere is dominant for speech and language in 98% of individuals The Nervous System Central Nervous System The Brain The cerebellum consists of right and left cerebellar hemispheres and a central vermis The cerebellum coordinates the control of fine, complex motor activities, maintains muscle tone, and participates in motor learning The cerebellum also has considerable influence on language processing and higher-level cognitive and affective functions The Nervous System Central Nervous System Language Processing Nonlinguistic and paralinguistic information is processed in the right hemisphere Most linguistic information is processed in the left hemisphere Incoming auditory information is held in working memory in Broca’s area Incoming linguistic processing occur in Wernicke’s area Broca’s area sends programming information to the motor cortex Aphasia “Without language” Aphasic population is very diverse Not the result of a motor speech impairment, dementia, or deterioration of intelligence ~1 million Americans have aphasia Problems in auditory comprehension and word retrieval are common to all aphasias Memory may also be impaired Apahsia May affect listening, speaking, reading, and/or writing May also affect math, gesturing, telling time, counting money, or interpreting environmental sounds Expressive deficits: Reduced vocabulary, omission or addition of words, stereotypic utterances, delayed and reduced output of speech or hyperfluent speech, and word substitutions Aphasia Severity may range from few intelligible words and little comprehension to very subtle deficits Severity is related to cause, location, extent, and age of brain injury; also age and general health of the client Several patterns of behavior exist that allow categorization into types or syndromes Aphasia Most individuals with aphasia also have attention and other cognitive deficits Association between attention, language, and other cognitive domains Language is a complex process performed by many different areas in the brain Some areas are important, as in the frontal and temporal regions of the left hemisphere Aphasia – Concomitant Deficits Hemiparesis Hemiplegia Hemisensory impairment Hemianopsia Dysphagia Agnosia Agrammatism Agraphia Alexia Anomia Jargon Neologism Paraphasia Verbal stereotype Aphasia Types of Aphasia Fluent Aphasias Word substitutions, neologisms, verbose verbal output Often posterior lesions in the left hemisphere Wernicke’s Aphasia Fluent or hyperfluent speech Poor auditory and visual comprehension Verbal paraphasia or unintended words, neologisms Sentences formed by strings of jargon Mild-severe impairment in naming and imitative speech Aphasia Types of Aphasia Fluent Aphasias Anomic Aphasia Characterized by naming difficulties Severe anomia in speech and writing Fluent spontaneous speech marred by word retrieval difficulties Mild to moderate auditory comprehension problems Damage is generally at the convergence of the parieto-temporal-occipital cortices Memory difficulties are evident Aphasia Types of Aphasia Fluent Aphasias Conduction Aphasia Anomia Only mild impairment of auditory comprehension Extremely poor repetitive or imitative speech Paraphasia or inappropriate use of words formed by the addition of sound and incorrect ordering of sounds or by substituting related words Self-correction attempts because of good auditory comprehension Damage may be between where language is formulated and speech is programmed Aphasia Types of Aphasia Fluent Aphasias Transcortical Sensory Aphasia Unimpaired ability to repeat or imitate words, phrases, and sentences Verbal paraphasia or word substitution Lack of nouns and severe anomia Poor auditory comprehension Brain damage seems to isolate language areas from other areas of cortical control Aphasia Types of Aphasia Fluent Aphasias Subcortical Aphasia Lesions occur deep in the brain without involvement of the cortex Fluent expressive speech Paraphasia and neologisms Repetition unaffected Auditory and reading comprehension relatively unaffected Cognitive deficits and reduced vigilance Aphasia Types of Aphasia Nonfluent Aphasia Slow, labored speech, struggle to retrieve words/form sentences Site of lesion often in or near the frontal lobe Broca’s Aphasia Short sentences with agrammatism Anomia Problems with imitation Slow, labored speech and writing Articulation and phonological errors Aphasia Types of Aphasia Nonfluent Aphasia Transcortical Motor Aphasia Impaired speech, especially in conversation Good verbal imitative abilities Mildly impaired auditory comprehension May have difficulty initiating speech or writing Severely impaired speech is characteristic of damage to the motor cortex, although the areas that are affected may go well below the surface of the brain Aphasia Types of Aphasia Nonfluent Aphasias Global, or Mixed Aphasia Profound language impairments in all modalities Limited spontaneous expressive ability of a few words or stereotypes Imitative speech and naming affected Auditory and visual comprehension limited to single words or short phrases Associated with a large, deep lesion involving both anterior speech and posterior language areas of the left hemisphere Aphasia Additional Types of Aphasia Some aphasias may affect primarily one modality Alexia with agraphia Alexia without agraphia Pure agraphia Pure word deafness Crossed aphasia Aphasia Causes of Aphasia Onset of aphasia is rapid Most common cause is stroke or cerebrovascular accident Strokes affect half a million Americans annually As a result of stroke, approximately 100,000 people become aphasic each year Strokes are of two basic types: Ischemic and hemorrhagic Aphasia Causes of Aphasia Ischemic Stroke Blockage (occlusion) of the arteries transporting blood to the brain Cerebral arteriosclerosis Embolism Thrombosis Transient ischemic attack Aphasia Causes of Aphasia Hemorrhagic stroke Weakened arterial walls burst under pressure Aneurysm Arteriovenous malformation Patterns of recovery differ with the type of stroke Ischemic: Noticeable improvement in the first weeks but slows after 3 months Hemorrhagic: Most rapid recovery is at the end of the first month and into the second Aphasia Causes of Aphasia Injury to the left hemisphere language areas produces aphasia in most people Aphasia-like symptoms may be noted with head injury, neural infections, degenerative neurological disorders, and tumors Primary progressive aphasia: A degenerative disorder of language with preservation of other mental functions and activities of daily life Progresses from primarily a motor speech disorder to a near-total inability to speak Aphasia Lifespan Issues Most victims of stroke are middle age and beyond Risk of stroke increases with Smoking, alcohol use, poor diet, lack of exercise, high blood pressure, high cholesterol, diabetes, obesity, previous strokes First signs Loss of consciousness, headache, weak/immobile limbs, slurred speech One-third will die from stroke or soon after For those who survive, there may be a period of unconsciousness and disorientation As chronic effects settle in, begin to focus on physical and language complications Aphasia Lifespan Issues Families are often frightened and confused Following acute care, may need rehabilitative care, outpatient rehab, or nursing home care Most individuals receive services for at least the first several months May exhibit perseveration, disinhibition, and emotional problems Course and extent of recovery is difficult to predict The most frequent linguistic gains are in comprehension Aphasia Lifespan Issues Maximum spontaneous recovery occurs in the first 3 months Assessment and intervention begin as soon as the client’s condition permits The earlier the treatment, the better the rate of recovery Loss of language ability changes social roles and can lead to social isolation May become more dependent on others Aphasia Assessment for Aphasia Occurs in multiple phases as client recovers Medical history Interview with client and family Oral peripheral exam Hearing testing Direct speech and language testing Counseling is ongoing Aphasia Assessment for Aphasia Formal testing postponed until patient is stable Address Overall communication skills Expressive language Receptive language All modalities across all aspects of language Standardized tests are available Observation/interpretation of client behavior Aphasia Intervention Goal: Aid recovery and provide compensatory strategies Determined by assessment and client/family needs Cross-modality generalization Conversational techniques “Bridging” between cerebral hemispheres Multimodality stimulation AAC Neural plasticity Involve family members Right Hemisphere Brain Damage Group of deficits resulting from right cerebral hemisphere injury 50-78% of individuals with RHBD exhibit one or more communication impairments; many do not receive treatment Communication disorders are not strictly language-based Paralinguistic information processed in the RH Right Hemisphere Brain Damage Characteristics Neglect of information from the left side Unrealistic denial of illness or limb involvement Impaired judgment and self-monitoring Lack of motivation Inattention Deficits may be subtle but can have a great effect on everyday life Right Hemisphere Brain Damage Characteristics Attentional deficits Lack of response to information coming from the left side of the body Visuospatial deficits Poor visual discrimination and poor scanning and tracking Communication deficits Linguistic vs. paralinguistic deficits Facial expression, body language, and prosody are all nonverbal means of conveying intent Right Hemisphere Brain Damage Characteristics Poor auditory and visual comprehension of complex information Limited word discrimination and visual word recognition RH is important for activation of distant word and sentence meanings An individual with RHBD is slower in suppressing incorrect meanings Topic maintenance, appreciation of the communication situation, and determination of listener needs are affected areas of pragmatics Right Hemisphere Brain Damage Characteristics Expressive language is egocentric and tangential Verbosity or paucity of speech Contextual cues may be missed or ignored Misinterpretation of intended meaning Poor judgment in determining important information Difficulty with naming, repetition, writing Difficulty comprehending and producing emotional language Aprosodia Right Hemisphere Brain Damage Assessment Visual scanning and tracking Auditory and visual comprehension Direction following Response to emotion Naming and describing Writing Observation is essential for pragmatics Portions of aphasia batteries, standardized measures for RHBD, and nonstandardized measures can be used Right Hemisphere Brain Damage Intervention Little is known about effective treatments Begin with visual and auditory recognition Expressive aprosodia: Imitate a sentence in unison with SLP or use cognitive-linguistic treatment Semantic intervention approach for nonliteral language Contextual pre-stimulation Assistance in responding appropriately Time restraints Sequencing and explaining actions Important nonlinguistic markers are targeted Traumatic Brain Injury Disruption in normal functioning caused by a blow or jolt to the head or penetrating injury Leading causes Falls Motor vehicle accidents Blows to the head (sports) Assaults 1.4 million people sustain TBI annually Males are twice as likely to sustain a TBI At least 5.3 million Americans currently have a long-term need for help as a result of TBI Traumatic Brain Injury TBI is a diffuse injury to the brain and may result from: Bruising and laceration of the brain from coming into contact with the rough inner surface of the skull Secondary edema, which can lead to increased pressure Infection Hypoxia Intracranial pressure from tissue swelling Infarction Hematoma Traumatic Brain Injury Aphasia-like symptoms are rare, but linguistic impairments related to cognitive damage are not May have sensory, motor, behavioral, and affective disabilities Epilepsy, hemisensory impairment, and hemiparesis or hemiplegia may occur Traumatic Brain Injury Characteristics Inability to resume interests and daily living tasks Affects orientation, memory, attention, reasoning/problem solving, and executive function Language may be affected in ¾ individuals with TBI The two most commonly reported symptoms are anomia and impaired comprehension The most disturbed language area is pragmatics Inability to inhibit behavior, errors of judgment, rambling speech and incoherence, poor turn-taking skills, poor affective language abilities, and inappropriate laughter and swearing Traumatic Brain Injury Characteristics Speech, voice, and swallowing difficulties About 1/3 of individuals with TBI have dysarthria Psychosocial and personality changes may include disinhibition or impulsivity, poor organization and social judgment, and either withdrawal or aggressiveness Physical signs may include difficulty walking, poor coordination, and vision problems Severity related to initial levels of consciousness and post-traumatic amnesia Traumatic Brain Injury Lifespan Issues Most are young, result of vehicular accident Several stages of recovery Initially, nonresponsive and require full assistance Gradually respond to stimuli and recognize some individuals Confusion and agitation Inappropriate, incoherent, emotional language Later, can remain alert and hold short conversations Traumatic Brain Injury Lifespan Issues Oriented to person and place, not time Inappropriate, unaware, unrealistic, and uncooperative Frustration with greater understanding of limitations Can later initiate and carry out tasks May consistently behave in a socially appropriate manner, respond appropriately to others, and to plan, initiate, and complete familiar/unfamiliar tasks Periodic depression and irritability Most will have lingering deficits; generally in pragmatics Traumatic Brain Injury Assessment SLP Cognitive-communication abilities Swallowing Assessment varies with stages of recovery Few comprehensive tools Sampling essential for pragmatics Traumatic Brain Injury Intervention Cognitive rehabilitation Restorative approach Compensatory approach Early stages Orientation, sensorimotor stimulation, recognition Middle stages Reduce confusion, improve memory and goal-directed behavior Late stages Comprehension of complex information and directions, conversational and social skills Dementia Group of both pathological conditions and syndromes that result in declining of memory and at least one other cognitive ability that is significant enough to interfere with daily life Memory is the most obvious function affected Poor reasoning or judgment, impaired abstract thinking, inability to attend to relevant information, impaired communication, and personality changes Irreversible dementia is most frequently caused by Alzheimer’s disease, vascular dementia, or a combination of both Dementia Cortical Visuospatial deficits, memory problems, judgment and abstract thinking disturbances, and language deficits in naming, reading and writing, and auditory comprehension Alzheimer’s Pick’s Subcortical Deficits in memory, problem solving, language, neuromuscular control Multiple sclerosis AIDS-related encephalopathy Parkinson’s Huntington’s Dementia Alzheimer’s disease Cortical pathology Affects 13% of those over 65 50% of those over 85 The most expensive disease in the U.S. Cause unknown Genetic and environmental Nerve fibers degenerate, causing brain atrophy Presence of twisted neurofilaments and plaques Extensive damage to hippocampus and cortex Dementia Alzheimer’s disease Mild dementia Name recall difficulty, disorientation, memory loss Later: Paraphasia and delayed responding Severe stages: Vocabulary and complex sentence production reduced; pronoun confusion, topic digression, and inability to return to and shift topic; writing and reading errors Most severe: Naming errors and the use of generic words, syntactic errors, minimal comprehension, jargon, echolalia, or mutism Dementia Alzheimer’s disease Lifespan Issues Often unaware or ignores early signs No cures, but drug therapy may help Early stages: Memory loss As disease progresses, memory loss increases and vocabulary decreases Most advanced stages All intellectual functions are severely impaired Almost all reside in nursing homes Dementia Assessment Definitive diagnosis difficult early on Neuroimaging techniques may help Computer-based assessments are being developed SLP identifies changes in language performance and behavior Genetic history and health information Observation in different environments A few language tests exist Scales can be used for rating loss Aphasia assessments can be used Dementia Intervention Maintain highest level of functioning Emphasize intact abilities Cognitive training Cognitive stimulation Computer-assisted cognitive interventions, Montessori-based interventions, reminiscence therapy, errorless learning, simulated presence therapy, spaced-retrieval, and vanishing cues Family members can be trained Stem cells may someday be used Summary Aphasia, RHBD, and TBI, and dementia result in very different types of language impairment SLPs function in a multidisciplinary team Assess communication and the implication of cognitive deficits, swallowing, and associated neurological disorders Treatment planning, direct intervention, consultation, and family training and counseling Intervention usually focuses on retrieval of language skills and on compensatory strategies Online Resources ASHA website for information on adult disorders: www.asha.org National Aphasia Association: www.aphasia.org National Institute of Deafness and Other Communication Disorders: www.nidcd.nih.gov/Pages/default.aspx Professor McCaffrey’s page at Cal State University: www.csuchico.edu/~pmccaffrey/ National Institute of Neurological Disorders and Stroke: www.ninds.nih.gov