Transcript
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