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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?