management of extra-linguistic cognitive deficits in ... · • stroke-related cognitive and...
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Management of Extra-Linguistic Cognitive Deficits in Individuals
Aphasia
Laura Murray
Speech and Hearing Sciences
Indiana University, Bloomington, IN
Attention (Hula & McNeil, 2008; Posner & Rothbart, 2007; Raz, 2006)
• “Everyone knows what attention is.” (William James]
w A capacity-limited system consisting of one or more pools of processing resources that can be flexibly and simultaneously allocated to one or more tasks (Kahneman, 1973; Navon & Gopher, 1979)
w Response selection creates bottleneck that causes processing to switch from a parallel to serial system (Pashler, 1994)
w Attention problems when: § Insufficient attentional resources available § Sufficient resources but inappropriate allocation § Sufficient resources, appropriate allocation, but slow allocation § Combination of more than one of the above
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Neural Correlates of Attention (Filley, 2002; Raz, 2006; Stuss et al., 2006; Yantis, 2008)
• Focal/right hemisphere attention network § Posterior parietal and prefrontal cortex § Cingulate gyrus, particularly anterior portion § Subcortical structures and pathways § Posterior/scanning & selection vs. anterior/complex
Diffuse, bilateral attention network contributes to arousal, and sustained and focused attention • Thalamus and its cortical connections • Frontal lobes • Cerebellum (Highnman & Bleile, 2011; Steinlin, 2007)
Neurotransmitters (Bales et al., 2009; Mahoney et al., 2010; Raz, 2006)
Norepinephrine Acetycholine Dopamine
Memory
• Memory (Davachi & Dobbins, 2008; Sander et al., 2007)
w Complex, temporally extended cognitive functions that transforms thoughts and perception into a robust registry
• Working Memory (Baddeley, 2012; Martin & Reilly, 2012; Logie, 2011):
w Currently active arena for concurrent mental computation and temporary storage § limited-capacity sensory buffers that temporarily store incoming
information
§ a domain-free, executive/controlled attention component that directs which information to process
• Encoding & Retrieval processes (Davachi & Dobbins, 2008; Ellis & Hunt, 1993; Gamino & Chapman, 2009)
§ A set of functions that enable getting information in and out of long term memory
§ Variable depths vs. all/none phenomenon
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Long Term Memory
• Declarative/Explicit (Antonucci & Reilly, 2008; Winocur & Moscovitch, 2011)
w Episodic/autobiographical memory § Prospective memory (Knight et al., 2006)
w Semantic/factual memory w Lexical/word form memory
• Nondeclarative/Implicit (Henke, 2010; Reber, 2013)
w Procedural or habitual memory, priming, conditioning
• Anterograde vs. Retrograde (Markowitsch, 1998; Vakil, 2005)
w Anterograde: encoded subsequent to brain damage w Retrograde: encoded prior to brain damage
• Verbal vs. Nonverbal Memory
Neural Correlates of Memory (Highnman & Bleile, 2011; Reber, 2013; Winocur & Moscovitch, 2011)
• Frontal lobe areas § Broca’s, L. SMA, L. premotor § R. premotor, inf. parietal § anterior cingulate § dorsolateral prefrontal
• Temporal lobe • Hippocampus/mesial temp. • Temporal cortex
• Neurotransmitters • Dopamine • Acetylcholine • Glutamate • Serotonin
• Basal ganglia § caudate nucleus, putamen
• Cerebellum • Other subcortical structures and connections
§ thalamus, mammillary bodies, and amygdala
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Executive Functioning (EF)
• Complex, interrelated, supervisory processes for generating, choosing, organizing, and regulating goal-directed, adaptive, and nonautomatic behaviors (Alvarez & Emory, 2006; Aron, 2008; Burgess et al., 2006; Stuss, 2011; Wood & Liossi, 2007; Toplak et al., 2013) w Multidimensional construct
§ numerous executive subprocesses that act in concert and coordinate basic cognitive processes • Include metacognitive abilities
§ Perhaps “self-determination” or “general intelligence”
• Allow for: w flexible adaption to situational and environmental changes w independent participation in daily activities and
relationships
Prominent EF Abilities
• Planning/organization • Self-regulation and monitoring • Cognitive flexibility/set shifting • Initiation • Inhibition • Reasoning and problem solving • EF Challenges
w Theoretical models are not yet well specified
w Currently no consensus over (Burgess et al., 2006; Chan et al., 2008; Constantinidou et al., 2012; Mueller & Dollaghan, 2013):
§ vernacular
§ which skills are executive functions
§ which, if any, executive functions are mutually exclusive
w Implications for assessing and treating EFs
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EF Neural Correlates
• Frontal lobes (Kreuger et al., 2011; Lovstad et al., 2012; Mitchell, 2008; Rosen &
Viskontas, 2008; Stuss, 2011) § Dorsolateral cortex § Orbitofrontal cortex § Medial cortex § Frontal poles
• Other brain regions (Alvarez & Emory, 2006; Mueller & Dollaghan, 2013) § Cerebellum (Highnman & Bleile, 2011; Paquier & Marien, 2005)
§ Subcortical structures (Montoya et al., 2006)
• Corticostriatal and -thalamic circuits and white matter pathways (Bastos-Leite et al., 2007; Delano-Wood et al., 2009; Vataja et al., 2005)
• Neurotransmitters (Bales et al., 2009; Halbauer et al., 2009)
§ Dopamine, norepinephrine, serotonin
Cognitive and Linguistic Neural Correlates
• Some neural structures, neurotransmitters, and circuits appear to support both cognitive and linguistic functions (Alexander, 2006; Baldo et al., 2012; Kesner, 2009; Klingberg, 2010; Meyer et al., 2014; Murray, 2004)
w e.g., Broca’s area and arcuate fasciculus/sup. long. fasciculus
w e.g., left posterior temporal-parietal cortex
w e.g., acetycholine
• Therefore, brain damage that disrupts language structures/circuits/neurochemistry likely to also negatively affect some cognitive functions and vice versa
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Attention Deficits in Aphasia
• Deficits possible in all attention functions (Murray, 2012]
w Linguistic and nonlinguistic attention tasks § ⇓ information processing speed (Visser-Keizer et al., 2002; Winkens et al., 2009)
• Negatively affects performance in presence of time pressure
§ Sustained attention (Barker-Collo et al., 2010; Gerritsen et al., 2003; Laures, 2005)
§ Attention Switching (Frankel et al., 2007; Ziegler et al., 2001; Murray, 2012)
§ Focused and divided attention (Hunting-Pompon et al., 2011; Kalbe et al., 2005; Murray, 2012)
• Right neglect (Barker Collo et al., 2010; Wee & Hopman, 2008)
w 15-65% of left-hemisphere brain-damaged patients w May affect one or several modalities
• Physiological differences (Kramer et al., 2008; Laures-Gore et al., 2007)
§ e.g., ⇓ b.p., ⇑ cortisol, slower and smaller ERPs, ⇑ neural activation
Memory Deficits in Aphasia
• Verbal and nonverbal STM (Baldo et al., 2012; Fucetola et al., 2009; Hoffman et al., 2011; Laures-Gore et al., 2011; Martin et al., 2012; Potagas et al., 2011)
• Working memory (Christensen & Wright, 2010; DeDe et al. 2014; Ivanova, 2009; Mayer & Murray, 2012; Potogas et al., 2011; Seniow et al., 2009; Soares-Ishigaki et al., 2012; Sung et al., 2009)
• Encoding/learning (Valilla-Rohter & Kiran, 2013)
• Verbal and nonverbal declarative memory (Bartha & Benke, 2002; Beeson et al.,1993; Vukovic et al., 2008; Yasuda et al., 2000)
• Procedural memory? • One of the most frequently reported cognitive changes
following left stroke (Visser-Keizer et al., 2002)
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EF Disorders in Aphasia
• Most common cognitive deficit in acute stroke (Bour et al., 2011; Lesniak et al., 2008; Nys et al., 2007) w About 50% acute stroke cases and 19-75% of all stroke
survivors display EF disorders
w Particularly poor outcome if co-occur with depression (Bour et al., 2011)
• Deficits in several executive functions (Cocchini et al., 2010; Fucetola et al., 2009; Lesnicak et al., 2008; Murray, 2014; Nicholas et al., 2005, 2011; Nys et al., 2007; Penn et al., 2010; Vukovic, 2008; Zinn et al., 2007)
• Limited data require substantiation w Explore extent of individual differences
w In stroke population, EF deficits show least recovery compared to other cognitive domains (Rasquin et al., 2013)
Cognitive Deficits Negatively Affect: Communication
• Phonological and lexical/semantic processing w Word discrimination/rhyming judgment (Martin et al., 2012)
w Semantic judgment/association (Ansaldo et al., 2004; Jefferies & Lambon Ralph, 2006; Martin et al., 2012; Murray et al., 1997, 2004)
w Word-to-picture matching (Anderson, 1996)
w Word retrieval (Jefferies & Lambon Ralph, 2006; Murray, 2012)
• Morphosyntactic processing w Grammaticality judgment (Dick et al., 2001; Giovannetti et al., 2008;
Murray et al., 1997, 2006)
w Sentence comprehension (Meyer et al., 2014; Sung et al., 2009; Tomic et al., 2009; Wright et al., 2007)
w Sentence and discourse production (Haarmann et al., 1997; Kok et al., 2008; Martin & Allen, 2008; Murray, 2012; Murray et al., 1997)
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Cognitive Deficits Negatively Affect: Communication
• Pragmatics and discourse skills w Spoken discourse informativeness, efficiency, and global
coherence (Alexander, 2006; Murray, 2012; Murray et al., 1998; Penn et al., 2010; Radanovic et al., 2003; Ramsberger, 2005; Rogalski et al., 2010)
w Discourse and reading comprehension (Caspari et al.,1998; Connor et al., 2001; Kalbe et al., 2005; Martin & Allen, 2008; Yasuda et al., 2000)
w Awareness and monitoring of language output accuracy (Marshall et al., 1998 )
w Expressive and receptive social communication/problem solving (Ramsberger, 2005)
• General language/communication skills (Coleman et al., 2011; Fridricksson et al., 2006; Murray, 2012; Nys et al., 2005)
Consequences of Cognitive Deficits
• Ability to profit from treatment (Brownsett et al., 2014; Fillingham et al., 2005, 2006; Murray et al., 2004; Purdy & Dietz, 2010; Lambon Ralph et al., 2010; Lesniak et al., 2008; Nicholas et al., 2011; Nys et al., 2005; Sandt-Koenderman et al., 2008; Seniow et al., 2009; Yeung & Law, 2010)
w Difficulty acquiring new skills/strategies/device use (Evans et al., 2003; Nicholas et al., 2011; Purdy & Koch, 2006)
w Limited generalization effects (Murray et al., 2004; Yeung & Law, 2010)
w Limited maintenance of treatment effects (Fish et al., 2009;
Yeung & Law, 2010) w ⇓ compliance/motivation for treatment or compensatory
strategy use
w Need more extensive/intensive treatment?
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Consequences of Cognitive Deficits
• ADL problems (Cao et al., 2007; Wee & Hopman, 2008)
• Poor functional, social and vocational outcomes (Aben et al., 2008; Hachioui et al., 2014; Hoofien et al., 2004; Lesniak et al., 2008; Leung et al., 2010; Tanaka et al., 2014; Visser-Keizer et al., 2002)
• Psychosocial well being problems (Aben et al., 2008)
• Increased risk of subsequent decline and dementia (Oksala et al., 2009; Sachdev et al., 2009)
• Caregiver burden (Choi-Kwon et al., 2005; Watanabe et al., 2000)
New Directions in Aphasia Assessment
• Moving beyond language w Understanding and assessing the influence of concomitant
cognitive deficits
w Whose responsibility?
• Moving beyond impairments w Most cognitive assessment and treatment methods focus on
the structural level of WHO model § Cannot assume a direct relationship among model levels (Birkett & Sperry,
2012; Chaytor & Schmitter-Edgecombe, 2003; Irwin et al., 2002)
§ Negative consequences: • Under- or over-estimate how well patients function in their daily
environments • Poor generalization of treatment effects
§ Must assess at all levels of WHO model (Simmons-Mackie et al., 2005)
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Need for Formal Screening/Testing
• Stroke-related cognitive and perceptual deficits can go undetected without formal screening/testing! w Edwards et al. (2006) w Fure et al. (2006) w Planton et al. (2012)
• Do not use the Mini-Mental State Examination (MMSE) to screen for cognitive problems in individuals with aphasia (Golper et al., 1987; Osher et al., 2008)
w Overestimates presence and severity of cognitive problems
• Cognitive screening tests do no always screen all cognitive domains in an equal manner
Need for Formal Screening
• Screening only suggests presence/absence of cognitive problem!!! w Additional testing necessary to identify specific
cognitive function strengths/weaknesses
• However… many health professionals rely solely on cognitive screening tools, particularly to identify/monitor EF deficits (Koh et al., 2009; Korner-Bitensky et al., 2011; Poulin et al., 2013)
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The Ideal Assessment
• Case history • Observations and interviews
w Primary dx procedure in acute settings (Constantinidou et al., 2012) • Formal tests
§ Test batteries
§ Tests of specific cognitive functions
§ Tests from the research literature
• Indirect Assessment § Strategy use
§ Conditions that ⇑ or ⇓ extra-linguistic demands
§ Sense of effort and self-awareness measures
Observations and Interviews
• Observations should precede formal testing w Formal testing context can mask EF deficits (Birkett & Sperry,
2012)
w Utilize information from other team members (Constantinidou et al., 2012)
§ e.g., +ive and -ive strategies clients observed using by team members in their hospital room, PT gym, waiting room, etc.
§ Remember that the client and his/her family or caregivers are team members**(Dawson et al., 2009)
• e.g., Research supports value of client involvement in goal setting
w Essential to identifying influential contextual factors § The Environment and Communication Assessment Toolkit
(Brush et al., 2012)
• Includes questionnaires to evaluate public and personal spaces
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General Cognition Test Batteries
• Cognitive-Linguistic Quick Test (Helm-Estabrooks, 2001)
w Ages 18-89 w English and Spanish versions
• Repeatable Battery for the Assessment of Neuropsychological Status Update (Randolph, 2012)
w Ages 12-90 w Has parallel forms
• Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN; Milman & Holland, 2012)
w Ages 18 – 91
Patient-Reported Measures of General Cognitive Functioning
• e.g., BOSS (Burden of Stroke Scale) Cognitive Domain scale (Doyle et al., 2004)
• Avoid using patient-reported measures that combine cognitive and communicative items/responses (Hula et al., 2010)
• An important indication of the effects of cognitive deficits on everyday functioning (Schmitter-Edgecombe et al., 2011)
w Self-report of IADLs was a unique predictor of observation measures (taken while participants completed IADLs)
w Sensitive to the effects of healthy cognitive aging
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Attention Tests
• Test Batteries w Test of Everyday Attention (Robertson et al., 1994)
§ Also available - TEACH (Manley et al., 1999)
w Behavioral Inattention Test (Wilson et al., 1987)
§ Visual neglect
• Tests of Specific Attention Functions w Color Trails Test (D’Elia et al., 1996)
w Test of Visual Field Attention (Williams, 1994)
w Test of Variables of Attention – 8 (Greenberg et al., 2011)
§ Ages 4 – 80+
Attention Tests
• Observational/Rating Scales w Rating Scale of Attentional Behavior (Ponsford &
Kinsella, 1991)
w Mental Slowness Observation Test and Questionnaire (Winkens et al., 2009)
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Neglect Testing
• Tests w BIT, Test of Visual Field Attention w Kicking Test (Grossi et al., 2001)
• Research recommends assessing: w With multiple tests/tasks
§ Patients often perform within normal limits on one neglect task (Arene & Hillis, 2008; Shiraishi et al., 2008)
w On more than one occasion § Variability even within a day reported, particularly for mild
to moderate neglect (Hamilton et al., 2008)
Memory Tests
• Test Batteries w Wechsler Memory Scales - IV (Wechsler, 2009)
§ STM, LTM, working memory
§ Adult (16-69 yrs) and Older Adult (65-90 yrs) batteries
§ Difficult for SLPs to obtain
w Rivermead Behavioral Memory Test – III (Wilson et al., 2008) § Variety of memory functions in ages 16 - 96 § Functional tasks and 4 parallel forms
w Test of Memory and Learning – Senior Edition (Reynolds & Voress, 2012)
§ Variety of memory functions in ages 55 - 89
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Tests of Specific Memory Functions
• STM/WM Tests w Repetition span subtests
§ forward and backward span, immediate recall tasks
w Matching listening/pointing span tests
§ PALPA subtest 13 (PALPA, Kay et al., 1992)
• Tests with demands on executive component of WM
w NIH Toolbox List Sorting Working Memory Test (NIH, 2012; Tulsky et al., 2014)
w Test of Everyday Attention subtests (TEA; Robertson et al., 1994)
• Language tests with ⇑ STM demands w Revised Token Test (McNeil & Prescott, 1978)
Tests of Specific Memory Functions
• Tests of other specific memory functions w Rey Complex Figure Test (Meyers & Meyers, 1995) w Continuous Visual Memory Test (Trahan & Larrabee, 1988)
w Location Learning Test (Bucks et al., 2000) w Cambridge Test of Prospective Memory (Wilson et al., 2005)
w Doors and People (Baddeley et al., 1994) • Patient-reported measures
w Working Memory Questionnaire (Vallat-Azouvi et al., 2012)
• Observation w Does the patient remember task instructions? w Is patient displaying spontaneous use of encoding/retrieval
strategies?
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Executive Function Tests
• Test Batteries
w Behavioral Assessment of the Dysexecutive Syndrome (Wilson et al., 1996)
§ Ages 16-87
§ BADS-C (Wilson et al., 2004) • Ages 8-16
w Delis-Kaplan Executive Function System (Delis et al., 2001) § Suitable (ages 8-89 years)
Tests of More Specific EFs
• Planning tests w Porteus Maze Test (Porteus, 1965)
w NAB Mazes Test (Stern & White, 2009)
w Tower tests
§ Tower of Hanoi
§ Tower of LondonDx – 2 (Cullbertson & Zillmer, 2012)
• Problem solving/reasoning tests w Progressive Matrices (Raven, 1998)
w Test of Nonverbal Intelligence - 4 (Brown et al., 2010)
w Comprehensive Test of Nonverbal Intelligence - 2
w Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES; MacDonald, 2005)
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Tests of More Specific EFs
• Card sorting tests w Modified Wisconsin Card Sorting Test (Schretlen, 2011)/
Wisconsin Card Sorting Test (WCST; Heaton et al., 1993)
• Fluency tests w Ruff Figural Fluency Test (Ruff, 1996)
w Test of Verbal Conceptualization and Fluency (Reynolds & Horton, 2007) § Ages 8-89
w Calibrated Ideational Fluency Assessment (Schrelten & Vannorsdall, 2011) § Ages 18 - >90
• Clock drawing (Freedman et al., 1994)
w CLOX (Royall et al., 1998)
w Various scoring protocols
Executive Function Tests
• Documenting awareness issues w VATA-L: Visual-Analogue Test Assessing Anosognosia
for Language Impairment (Cocchini et al., 2010)
§ Caregivers and patients rate how well patient can carry out daily language production and/or comprehension tasks
• Estimating pre-morbid intelligence w Useful for prognosticating
w Typically use oral word reading (e.g., NART; ANART)
§ Pronounce 50 words varying in irregularity and difficulty
w Lexical Orthographic Familiarity Test (Leritz et al., 2008)
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Functional/Naturalistic EF Tests
• Relate to ICF levels of personal activities and/or society participation (Poulin et al., 2013; WHO, 1998)
w Photocopy test (Crepeau et al., 1997)
w Multiple Errands Test (Aitken et al., 1993; Birkett & Sperry, 2012; Rand et al., 2009; Morrison et al., 2013)
§ Various versions including virtual reality version
w Cooking task (Chevignard et al., 2008; 2010)
• Still underused by clinicians (Constantindou et al., 2012)
Confounding Variables
• Inadequate norms for the elderly and ethnocultural minorities w Quality of translated verbal test materials of “unacceptably
poor quality” (Bender et al., 2010, p. 227)
w Must acknowledge interaction between cultural background of client and structured, time-limited testing environment (Agranovich et al., 2011; Ardila, 2005; Bender et al., 2010)
w Check research literature for extended norms and new test protocols
• Inadequate norms for people with aphasia (Murray, 2012; Murray et al., 2015; Poulin et al., 2013)
• Excessive linguistic demands + use nonstandard administration (e.g., Laures-Gore et al., 2011)
- informative but negates use of norms
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Confounding Variables
• Ecological and content validity (Birkett & Sperry, 2012; Burgess et al., 2006; Mueller & Dollaghan, 2013; Pickens et al., 2010; Poulin et al., 2013) w Implications in terms of ICF activity and participation levels? w Tests often assess more than target function w Structure of EF tests’ format may support EF deficits (i.e.,
underestimate deficit)
• Some tests (partic. EF tests) report or have established (Mueller & Dollaghan, 2013; Poulin et al., 2013):
§ Test-retest reliability or responsiveness
§ Floor and/or ceiling effects
§ Inter-rater reliability, particularly for functional/naturalistic tests § Norms that consider educational differences
• Cost, but can utilize test protocols in the empirical literature w e.g., Temple Assessment of Language and Short-Term Memory in
Aphasia (TALSA; Martin et al., 2010)
Indirect Assessment
• Observe cognitive skills when assessing communication • Assess communication under conditions with low vs. high
cognitive demands w Quiet vs. noisy (auditory and/or visual distracters) w Increase memory demands w Novel/unstructured vs. routine/structured tasks, stimuli, environments,
etc.
• Sense of effort or self-awareness measures (Markova & Berrios, 2006)
w Compare pre- and post-task completion predictions § Performance accuracy/speed § Task difficulty § May be used before/after each item, a subtest, test, etc.
w Compare on- vs. off-line ratings/self-corrections w Compare patient and caregiver ratings
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Important EBP Resources
• www.ancds.org w Links to systematic, evidence-based reviews of
treatments for a variety of neurogenic communication disorders
• www.asha.org/members/slp/topics/ebp/evidence_guidelines.htm w Information to descriptions and levels of evidence-
based practice
• www.psychbite.com w psychBite - evidence-based practice resource for
cognitive disorders treatments
Treatment Study Design Issues
• Randomized Clinical Trials (RCTs) as gold standard? § Drug treatment research “yes” § Behavioral treatment research “no” (Barrett et al., 2006; Galante
et al., 2011; Miller et al., 2011; Togher et al., 2009; Tucker & Reed, 2008; Whyte et al., 2009)
• Require large n samples of homogeneous patients • Procedural issues
u Difficult to administer double-blind protocol
u Appropriate activities for control group?
• Outcome issues u Poor generalization power
u Poor transfer to clinical practice
u Difficult to identify factors/processes that contribute to treatment’s effectiveness
§ Not well-suited to chronic conditions influenced by environmental and social factors
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Attention Treatment
• Attention training recommendations and guidelines (Cappa et al., 2003; Cicerone et al., 2011; Michel & Mateer, 2006; Sohlberg et al., 2003; Zoccolotti et al., 2011)
w Mild, post-acute TBI cases most responsive
w Utilize complex training tasks in concert with metacognitive/strategy training
w Intensive training with optimal session length of 1 hour
w Individualize tasks, stimuli, etc.
w Expect primarily task-specific improvements
Direct Tx of Cognitive Disorders: Attention
• Sturm & Willmes (1991; 1997)
w Group ABA study to compare specific vs. nonspecific computerized attention training
w 22 LHD (19 aphasic), 16 RHD subjects
w Two 14 one-hr session training periods to train each subject’s two most impaired attention functions
• Murray et al. (2006)
w Single subject, multiple baseline ABA design to examine Attention Process Training-II effects
w Received 30 60-min sessions plus asked to complete 30 at-home sessions with spouse
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Direct Treatment of Cognitive Disorders: Attention
• Positive APT outcomes for language: w Coelho (2005)
w Sinotte & Coelho (2007)
w Amaddii et al. (2007)
§ APT part of cognitive tx for thalamic stroke patient • tx included internal and external memory aids and prospective memory training
§ ⇑ discourse informativeness
Direct Treatment of Cognitive Disorders: Attention
• Future Ideas w Functional skill-specific training (Wilson & Robertson, 1992)
§ Case study of relaxation + reading treatment
§ Outcomes w Computer programs/workbooks?
§ Examples • www.brainconnection.com - Bungalow software • www.mybraintrainer.com • www.Challengingourminds.com • www.cogmed.com
w Positives w Negatives
w Cognitive-motor dual task protocol (Evans et al., 2009)
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Direct Treatment of Cognitive Disorders: Memory
• General memory treatment guidelines (Ehlhardt et al., 2008)
w Avoid hyper-specificity of training conditions § Include stimulus variation and effortful processing
w Emphasize strategies § These promote effortful processing
w More practice leads to better maintenance
w Choose ecologically valid tasks § Focus on daily information and/or skills
Direct Treatment of Cognitive Disorders: Memory
• Traditional memory retraining w Task-specific learning only, unless paired with strategy
training (Cornis-Pop et al., 2012; Ehlhardt et al., 2008; Murray, 2012; Piras et al., 2011)
• Internal mnemonic strategies (Cicerone et al., 2011; Ehlhardt et al. 2008; Piras et al., 2011; Radford et al., 2012)
w ⇑ language demands § Aphasic patients typically excluded from these tx studies
w +ive outcomes in mild, stable memory disorders § Require effortful processing
§ More severely impaired less likely to acquire independent strategy use
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Memory Tx: No Delay Repetition Protocols
• Francis et al. (2003)
w Case study trained on sentence repetition tasks to improve STM/WM and in turn, auditory comprehension
• More recently, often task specific gains: w Berthier et al. (2014)
§ 40 hrs of at home sentence repetition tx (+ donepezil)
w Harris et al. (2014)
Memory Tx: Delayed Repetition Protocols
• Koenig-Bruhin & Studer-Eichenberger (2007) w Case study of chronic conduction aphasia patient trained on
sentence repetition tasks to improve STM § Compound nouns and sentences under immediate and delayed repetition
• Kalinyak-Fliszar et al. (2011)
w Single-subject design with chronic conduction aphasia patient trained on word and nonword repetition tasks § 137 sessions with three 45-60 min sessions/week
• Salis (2012)
w Single-subject ABA design involving a patient with severe transcortical motor aphasia § Listening span task in which decided if 2 lists of words were the same or
different
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Memory Tx: Working Memory Span Tasks
• Mayer & Murray (2002) w Single-subject alternating treatment design to
compare reading (MMOR) and working memory (SEW) treatments in an individual with chronic anomic aphasia § Modified multiple oral reading
§ Sequenced exercises for working memory
§ Reading rate and comprehension probes
§ 11 2-hr treatment sessions
Memory Tx: Multiple Components/Tasks
• Vallat et al. (2005) w Single subject design with an individual with chronic
conduction aphasia
w Treatment targeted the central executive and phonological buffer components: § 8 tasks with auditory stimuli
§ 3 60-min sessions per week for 6 months
• Vallat-Azouvi et al. (2014)
w Single subject design with participant with nominal conduction aphasia but ⇓ all WM components
w 3 successive training stages for each WM component § Verbal/phonological WM tasks from 2005 study § Visuospatial WM tasks from Vallat-Azouvi et al. (2009) § Executive WM tasks
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Memory Tx: Future Ideas
• Strategy training (Amaddii et al., 2014; Butler & Copeland, 2002; Cicerone, 2002; Duval et al., 2008; Levaux et al., 2009; Ponsford et al. 2014)
§ e.g., Cicerone (2002) with TBI participants • 1/2 of each session devoted to:
§ working memory N-back tasks practiced under different attention conditions
§ strategy and self-evaluation training
§ e.g., Duval et al. (2008) with left temporal lobe tumor excision client
• Triple strategy approach § Dual encoding strategy - use phonological and visuospatial buffers) § Serial processing – avoid dual-task situations § Speed reduction – slow down/emphasize quality
• Storage, manipulation, n-back, and dual-task activities + scenario analysis and real-life simulations + information sessions
w PROMPT (Raskin & Sohlberg, 2009; Sohlberg & Mateer, 2001)
Direct Tx of Cognitive Disorders: Executive Functioning
• EF treatments most successful if (Catroppa & Anderson, 2006;
Cicerone et al., 2006; Gordon et al., 2006; Schutz & Trainor, 2007): w Provided to patients who:
§ Can concentrate for > 20 min § Don’t have abulia or anosognosia
w Start with individual and move to group tx setting w Use contextualized learning
§ i.e., learning within everyday situations w Focus on training strategies - i.e., top-down approach
(Kennedy et al., 2008; Mateer, 2009; Singer & Bashir, 1999; Sohlberg & Turkstra, 2011)
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Direct Tx of Cognitive Disorders: Executive Functioning
• Limited data w Aphasia a common exclusionary criteria or fail to
specify presence/severity of aphasia (e.g., Spikeman et al., 2009)
• Awareness training (Kennedy, 1983) w Stopping strategy for individuals with Wernicke’s aphasia
• Treatment of Aphasia Perseveration (Helm-Estabrooks et al., 1987; Helm-Estabrooks & Albert, 2004)
w Strategies taught § Give no response or ask for help vs. perseverate § Sensitizing technique
Direct Tx of Cognitive Disorders: Executive Functioning
• Future Ideas w Awareness training ideas (Kennedy et al., 2008; Kortte &
Hillis, 2011; Nilsson et al., 2011; Ownsworth et al., 2006, 2008; Schmidt et al., 2012) § Psychoeducation § Prediction paradigms (Cicerone, 2002)
§ Track own performance/guided self-evaluation § Videotape review/self-advocacy videos § Role play/reversal § Peer teaching § Best outcomes when use a variety of approaches
(e.g., Ownsworth et al., 2006; Stuss, 1991)
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EF Tx: Future Ideas
w Goal Management training (Dawson et al., 2009; Grant et al., 2012; Hickey & Saunders, 2010; Krasny-Pacini et al., 2014; Kurowski et al., 2013; Levine et al., 2011; Metzler-Baddeley & Jones, 2011; Rand et al., 2009) § Target goal setting and planning/problem solving and self-regulation to
achieve these goals § Steps • Set goal/identify problem • Separate relevant and irrelevant info • Generate steps/solutions • Select/apply a solution • Monitor effectiveness of steps/solutions
§ Suitable for individual and group tx settings § Outcomes
Holistic/Alternative Approaches
• Mindfulness Meditation (Orenstein et al., 2012)
w Easy to learn
w Faster reaction times
w Patient report of ⇑ relaxed/peaceful
w ⇑ WM and emotional status in healthy adults (e.g., Zeidan et al.,
2010) and military personnel (e.g., Jha et al., 2010)
• Physical fitness training (Lorenzen & Murray, 2011)
w ⇑ cognitive and language measures
w ⇑ WM following combined aerobic and strength training in older adults (e.g., Klusmann et al., 2010; Smith et al., 2010)
29
Pharmacological Approaches
• Dopamine agonists (Berthier et al., 2011; Napolitano et al., 2005) w e.g., amantadine, dextroamphetamine, methylphenidate,
bromocriptine
§ Drawbacks in aphasia related to high rates of (e.g., Bragoni et
al., 2000): • Side effects and patients with contraindications for taking high doses
• Noradrenergic agonists (Bedard et al., 1998; Berthier et al., 2011; Malhotra et al., 2006; Sawyer et al., 2008)
w e.g., naphtoxazine, tricyclic antidepressants, clonidine, amantadine
• Noradrenergic antagonists (Beversdorf et al., 1999; 2007)
w e.g., propranolol
Pharmacological Approaches
• Cholinergic agonists (Atri, 2011; Berthier et al., 2011; Chang et al., 2011; Halbauer et al., 2009; Moretti et al., 2004; Wilkinson et al., 2010)
w e.g., bifemelane hydrochloride, donepezil, citicoline, galantamine, rivastigmine
• Modafinil/Provigil (Arciniegas & Silver, 2007; Chew & Zafonte, 2009; Krupp, 2003; Young, 2011)
• Serotonin agonists (Halbauer et al., 2009; Levine & Langa, 2011; Narushima et al., 2007; Portugal et al., 2011; Tanaka & Bachman, 2007)
w e.g., buspirone, sertraline, fluoxamine
• NMDA/glutamate antagonists (Atri, 2011; Berthier et al., 2009; Halbauer et al., 2009; Johnson et al., 2010; Lee, 2011; Paskavitz et al., 2007)
w Memantine
• Nootropic drugs (Berthier et al., 2011; Diamond et al., 2000; Penn, 2000)
w e.g., piracetam, gingko biloba
30
Indirect Treatment Approaches
• Environmental accommodations (Brush & Calkins, 2008; Catroppa & Anderson, 2006; Sander et al., 2007; Sohlberg & Turkstra, 2011)
w Avoid distracting environments and numerous response choices
w Neglect accommodations (Kerkhoff et al., 2012)
w Pacing strategies w Task demand modifications w Organizational systems/structured environment
(Michel & Mateer, 2006)
Indirect Treatment Approaches
• Perseveration strategies (Corbett et al., 2008; Frankel & Penn, 2007; Moses et al., 2004) w ⇓ presentation rate w Give breaks between tasks to
help establish a new set w ⇓ semantic relatedness of targets w ⇑ word/target frequency w Minimize repetition of stimuli
during a task w Utilize extrinsic cues (e.g.,
phonemic, sentence completion) w Communication partner behaviors
31
Indirect Treatment Approaches
• External devices (Amaddii et al., 2014; de Joode et al., 2010; Shum et al., 2011; Sohlberg & Turkstra, 2011; Van de Sandt-Koenderman et al., 2007; Wild, 2013)
w Practice standard/guideline for memory disorders (Cicerone et al., 2011)
w Low tech w Specialized and main stream high tech w Specific vs. variety of settings
§
Sentence Shaper (Linebarger et al., 2004; 2007; 2008; McCall et al., 2009)
• Computer program or “prosthesis” that reduces temporal and working memory demands of real-time language processing through self-directed practice w Records and stores patient’s speech for later manipulation/ordering
and/or correction § Combine recorded segments into sentences and narratives
w Can be used for nonspecific or specific grammatical structure training w Most success with patients who have:
§ Nonfluent aphasia § Some speech § Relatively intact auditory comprehension at word level § Some self-monitoring ability § Good grammaticality judgment for simple syntactic structures
32
Sentence Shaper
• Outcomes in nonfluent patients (Allbright & Purves,
2008; Linebarger et al., 2004; 2007; 2008; McCall et al., 2009): w Narratives contain longer and ⇑ grammatical and
grammatically complex sentences w ⇑ informativeness in aided and unaided
productions in many, but not all, patients w Qualitative outcomes (Allbright & Purves, 2008)
§ Use for e-mail § Less likely to use to augment communication in
everyday life
Indirect Treatment Approaches
• Must explicitly and systematically train external device and strategy use (Ehlhardt Powell et al., 2013; Mateer, 2009; Singer & Bashir, 1999; Sohlberg et al., 2007; Sohlberg & Turkstra, 2011)
w Application § what strategy/device can do
w Acquisition § Train how to use • e.g., errorless learning
§ Extensive practice needed w Adaptation § when, where, and with
whom to use • Practice in daily contexts
33
Language Treatments That Consider Cognitive Limitations
• Patient- vs. paid/unpaid caregiver-implemented strategies (Nys et al., 2005; Rende, 2000; van Mourik et al., 1992)
w Caregiver-implemented may be more appropriate if patient (e.g., Schutz & Trainor, 2007): § Has significant concomitant cognitive issues
§ Has profound, diffuse brain damage
• Length of language treatment w Longer treatment phase may be necessary if:
§ Patient with aphasia has significant concomitant cognitive issues
Language Treatments That Consider Cognitive Limitations
• Cognitive-language treatment w Treat language in multi-task/complex environments (Davidoff &
Katz, 1985)
w Spaced retrieval in concert with anomia treatment (Fridriksson et al., 2005; Morrow & Fridriksson, 2006)
w Errorless learning (Ehlardt et al., 2008; Fillingham et al., 2006; Lloyd et al., 2009; Middleton & Schwartz, 2012; Page et al., 2006)
§ e.g., Errorless learning for anomia (Fillingham et al., 2005, 2006)
§ e.g., Mapping plus errorless learning (Wierenga et al., 2006)
w ELA-Syntax Programme (Stark, 2005)
w Depth of encoding (e.g., Rajaram et al., 2012)
w Spatial attention considerations during anomia tx § Dotson et al. (2008): Name simple line drawings 45˚ L of body midline
34
Generalization and Transfer
• Variation (Bornhofen & MacDonald, 2008; Golisz, 1998; Piras et al., 2011) w Tasks
§ Recognition vs. free recall vs. cued recall
w Stimuli (Ehlhardt et al., 2008; Jackson-Waite et al., 2003)
w Contexts w ⇓ acquisition rate but ⇑ mainten./generalization
Generalization and Transfer
• Relevance (Dawson et al., 2009; Ehlhardt et al., 2008; Horton et al., 2011; Wressle et al., 2002)
w Motivational, emotional, & functional significance § Patient-directed and/or adequate clinician explanation
• Intensity and duration (Basso, 2005; Bhogel et al., 2003; Ehlhardt et al., 2008; Piras et al., 2011; Raymer et al., 2008)
w Minimum: > 2 hrs/week
w ⇑ frequent sessions lead to ⇑ acquisition BUT: § May or may not enhance long term maintenance
§ May not be suitable for all patient populations
35
Selected References
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Selected References
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36
Selected References
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Selected References
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37
Selected References
Milman, L. & Holland, A. (2012). Scales of Cognitive and Communicative Ability for Neurorehabilitation. Austin, TX: Pro-Ed.
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Selected References
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Selected References
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