Cognitive Communication Initial Goal Areas

Here are some potential goals areas to focus on for a patient with cognitive communication deficits:

• Increase deficit awareness
• Increase executive functioning
• Increase planning and decision making skills
• Decrease impulsivity
• Decrease verbosity and tangential speech
• Increase awareness of nonverbal cues and body language in communication interactions
• Increase attention
• Increase working memory
• Increase short-term/long-term memory
• Increase initiation of tasks/conversations

Cognitive Communication Resources

For the client/family:

http://www.asha.org/public/speech/disorders/TBI/

• This webpage is a great resource for a client or family member who has recently suffered from a traumatic brain injury (TBI). It provides general information in easy-to-understand language about what a TBI is and what symptoms and deficits it might cause. It also helps clients and family members prepare for what assessment and treatment may look like depending on their particular set of strengths and weaknesses.

http://www.biausa.org/living-with-brain-injury.htm

• This website has a lot of information for the client or caregiver who wants to learn more about the brain and what happens when different parts of the brain are damaged due to a stroke, TBI or other neurodegenerative diseases. It gives a brief education about the lobes of the brain and what they are responsible for as well as what kinds of symptoms and deficits are associated with damage in each of these areas. There is even a helpful and informative video at the bottom of the page, which explains the brain anatomy and functioning. All of this would help a client and their family understand what it is like to suffer from a brain injury.

Papa, J. (2013). Patient & family education flash book: Communication after stroke or TBI. Youngsville, NC: Lash & Associates Publishing/Training Inc.

• This book is a wonderful resource for patients and family members who want to improve their communication skills post-TBI or stroke. It has worksheets and information about brain anatomy, the different types of attention and memory, how executive functioning works and tips for better communication, all written in terms that are easy to follow and understand. This book comes on a flashdrive so that materials are easily accessible for clients and family members.

For the SLP:

Kimbarow, M.L. (2011). Cognitive communication disorders. San Diego, CA: Plural Publishing Inc.

• This textbook is a great resource for an SLP who wants to learn more about cognitive communication impairments, assessment of these types of disorders and potential treatments for these types of communication problems. It focuses on education about right hemisphere damage, dementia, traumatic brain injury and the communication difficulties that can accompany these types of conditions. It also provides information about associated attention, executive functioning and planning deficits associated with each of the previously mentioned diagnoses.

http://www.asha.org/Publications/leader/2011/110215/Cognitive-Communication–Research-and-Resources.htm

• This article from the Leader magazine provides a number of links to helpful resources for the SLP working with a cognitive communication client. It has links to different research articles related to the main etiologies responsible for cognitive communication deficits, and it provides links to other websites who focus on research and remediation of these kinds of communication impairments.

Click to access TESCognitiveCommunicationDisordersFromTBI.pdf

&

Click to access TESCognitiveCommunicationDisordersfromRightHemisphereBrainDamage.pdf

•  These two articles have treatment efficacy summaries for remediation of cognitive communication deficits resulting from right hemisphere damage or TBI. Both articles suggest that remediation of problem solving, pragmatics, attention and memory problems can be remediated in 73% and 83% of patients. This gives hope and encouragement to patients and SLPs alike, knowing that the services given and received can effect change in the functioning of the client’s cognitive communication skills.

Cognitive Communication Assessment

Formal Tests:

• Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES)
• California Verbal Learning Test (CVLT)
• Cognitive Linguistic Quick Test (CLQT)
• Mini Inventory of Right Brain Injury (MIRBI)
• Montreal Cognitive Assessment (MoCA)
• Brief Test of Head Injury (BTHI)
• Test of Everyday Attention (TEA) or Test of Everyday Attention for Children (TEA-CH)
• Woodcock Johnson Test of Cognitive Abilities (WJ)
• Detroit Test of Learning Aptitude

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Informal Assessment Tools:

• Clock drawing – to assess perseverations, attention, planning, etc.
• Assess deficit awareness during conversation and interview

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Interview Questions:

• What was your injury like?
• Were you unconscious? For how long?
• What do you think you struggle with? What do you think you do well?
• What was your occupation?
• What would you like to be able to do again?
• What are your hobbies and interests?
• What kinds of things are you involved in outside of the home?

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Deficit Areas	Behaviors to look for
Attention	Not paying attention, disengaged, irrelevant stimuli, incomplete work, careless mistakes, fidgety
Memory	STM loss, forgetting to do assignments,LTM loss
New learning/ strategic learning	Inability to apply new info, unable to remember new names, can’t get “big picture,” inconsistent performance
Processing speed	Difficulty transitioning, can’t keep up, slow test-taker, takes a long time to respond, looks lost
Initiation	Can’t get started on things, a “follower,” needs constant reminders
Planning	Needs to be told step-by-step what to do, gives up quickly, long-term projects are difficult, time management issues
Organization	Tangential speech, messy
Mental flexibility	Can’t think of another way to think about something, can’t take another’s perspective, can’t switch gears
Judgment	Cutting class, can’t take another’s perspective, makes unsafe decisions, sexual promiscuity, recklessness
Social skills/ pragmatics	Can’t keep or make friends, acting younger than their age, says inappropriate things, blurts out, fighting
Word retrieval	Nonspecific language, filler words, writing is sparse
Self-regulation/ impulsivity	Makes poor choices, blurts out, can’t regulate behaviors
Sensory processing	Averse to sounds/noises, slow auditory processing, picky about food texture, unaware of personal space, fidgety

(Class notes, SPAUD 501)

Cognitive Communication – In General

Most Common Etiologies

• Alzheimer’s disease
• Brain tumors
• Stroke
• Traumatic brain injury (TBI)

Potential Consequences/Impact of Cognitive-Communication Impairment Can Include:

• Reduced awareness and ability to initiate and effectively communicate needs

• Reduced awareness of impairment and its degree (i.e., loss of ability to assess one’s own communication effectiveness)

• Reduced memory, judgment, and ability to initiate and effectively exchange routine information

• Difficulty performing personal lifestyle management activities effectively (i.e., pay bills)

• Reduced ability to anticipate potential consequences, with reasonable judgment and problem solving

• Reduced social communication skills and/or ability to manage emotions, often causing loss of relationships

• Disruption of ability to fulfill educational or vocational roles, including potential loss of employment

• At risk for injury due to inability to communicate in an emergency and/or anticipate the consequences of own actions

http://www.asha.org/slp/cognitive-referral/

Leading causes of TBI:

1. Motor vehicle crashes
2. Falls
3. Assault
4. Struck by or against something

At-risk groups:

• Young adults, particularly males
• Under 5
• Over 65

(Class notes, SPAUD 501)

Motor Speech Disorders Initial Goal Areas

Dysarthria

1. Increase labial, velar, and lingual strength
2. Decrease nasality
3. Increase confidence in speech abilities
4. Increase intelligibility

Apraxia

1. Increase intelligibility
2. Increase confidence in speaking abilities
3. Decrease irregularity in prosody
4. Increase regular pacing of speech
5. Increase utterance length

Motor Speech Disorders Resources

For Client/Family:

http://www.asha.org/public/speech/disorders/ApraxiaAdults/

• This website from ASHA provides a lot of general information about apraxia of speech. It outlines what it is, what symptoms often occur with it and how it is assessed and treated. This would be a great resource for a person who has recently been diagnosed with apraxia of speech and/or their family members and caregivers.

http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/CommunicationChallenges/Steps-to-Improve-Communication-for-Survivors-with-Dysarthria_UCM_310083_Article.jsp

• This webpage is a great resource for someone who is living with chronic dysarthria. It provides tips for communication to compensate or go around deficits associated with dysarthria. All of these tips could be applied to all communication interactions but they would be beneficial for those who have dysarthria. Environmental, speaker and listener variables are considered in the suggestions.

http://www.mayoclinic.org/diseases-conditions/dysarthria/basics/causes/con-20035008

• This webpage from the Mayo Clinic provides a comprehensive list of the causes of dysarthria, which can range from a traumatic brain injury to a degenerative disease like ALS. This may help clients to understand why they are having neuromuscular weakness, as it may be caused by a variety of things. It would be beneficial if this list was discussed with an SLP or doctor to help the client understand their specific diagnosis.

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For SLP:

Haynes, W.O. & Pindzola, R.H. (2012). Motor Speech Disorders, Dysphagia, and the Oral Exam. In Haynes, W.O. & Pindzola, R.H. (8th Ed.), Diagnosis and evaluation in speech pathology. (pp. 239-266). Upper Saddle River, NJ: Pearson Education Inc.

• Table 9.4 in this chapter outlines the differences between dysarthria and apraxia, clearly distinguishing that one is a neuromuscular weakness while the other is a motor planning issue. This would be a beneficial diagnostic tool for an SLP to use when evaluating a patient with potential motor speech problems. It would help to tease apart the motor speech issues that the patient may present with in combination with the language issues that often arise as well.

• Pages 251 and 252 also provide thorough descriptions of the different types of dysarthria. As the different types present with a number of different symptoms, it is important that the SLP understand which type of dysarthria they are presenting with so that treatment can be more effective for their specific needs.

http://ajslp.pubs.asha.org/article.aspx?articleid=1782728&resultClick=3

• This research article centered around the treatment of acquired apraxia of speech.  It suggests that the frequency and intensity of treatment of apraxia of speech does not affect the outcomes of speech therapy; however, avoiding blocks of treatment time or inconsistent therapy will assist the client in maintaining skills learned in therapy and generalizing those skills to conversational speech. This is important for speech pathologists to know, as recommendations for amount of therapy are crucial decisions to make when assessing a new patient.

http://www.asha.org/uploadedFiles/slp/healthcare/AATMotorSpeech.pdf#search=%22motor%22

• This motor speech disorder assessment template form will be beneficial for speech-language pathologists who need a resource when informally assessing patients for potential speech and intelligibility problems. It gives a comprehensive guide for assessing oral mechanisms and structures and oral motor movements. It also assesses respiration, phonation, diadochokinetic rates, and impairment rating scales. At the end of the form, a prognosis checklist, family care plan and treatment plan are provided.

Motor Speech Disorders Assessment

For Dysarthria:

Formal Tests:

1. Oral Speech Mechanism Screening Examination (OSMSE)
2. Quick Assessment for Dysarthria
3. Frenchay Dysarthria Assessment (FDA)
4. Assessment of Intelligibility of Dysarthric Speech (AIDS)

Informal Assessments:

1. Speech sample from conversation or reading
2. Assess physical features of speech, such as lips, tongue, and jaws through informal oral motor test

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For Apraxia:

Formal Tests:

1. Apraxia Batter for Adults (ABA)
2. Test of Oral and Limb Apraxia
3. Quick Assessment of Apraxia of Speech

*Complete aphasia testing as well if that is an area of concern*

Informal Assessments:

1. Speech sample from conversation or reading
2. Assess physical features of speech, such as lips, tongue, and jaws through informal oral motor test

 

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Interview Questions:

• When did these concerns start?
• Do you notice more weakness on one side or the other? Both sides?
• Are their words or phrases that are easier/harder for you to say?
• Do other people have a difficult time understanding you?

ONSET & COURSE
1. Do you have any difficulty with your speech? If not, has anyone else commented on a change or problem with your speech?
2. When did the speech problem begin? Did it begin suddenly or gradually? Who noticed it first, you or someone else?
3. Did you develop any other difficulties when your speech problem began? Were other problems present before your speech problem began? Did other problems develop after the sppech problem began?
4. Has the speech problem changed? Better, worse, stable, better-than-stable, fluctuating?
5. Has your speech ever returned to normal? If so, when and for how long?
ASSOCIATED DEFICITS
1. Have you had any difficulty with chewing? drooling?
2. Is it difficult to move food around in your mouth? Why?
3. Does food get stuck in your cheeks or in the roof of your mouth? Do you have to remove it with your finger or a fork?
4. Do you have trouble moving food back in your mouth to get a swallow started?
5. Do you have trouble with swallowing? Food or liquid? Do you have trouble getting a swallow started? Do you lose food or liquid out of your mouth? Does food or liquid ever get into or out of yournose when you swallow? Does food or liquid go down before you swallow and cause coughing or choking? Do you gag or choke when swallowing? Do you cough or choke wheen completing a swallow? Have you had to modify your diet because of these problems? Have you lost weight?
6. Have you had any cahnge in your emotional expression? Do you cry or laugh more easily or less easily than in the past?
7. Are you taking any medications that seem to affect your speech?
PATIENTS PERCEPTION OF THE PROBLEM:
1. What did your speech sound like when the problem began? Did anything feel different when you spoke?
2. Describe your current speech difficulty. How does it sound to you? How does it feel to speak? Is it faster or slower? Louder or slower? Less precise? Is speaking effortful?
3. Have you noticed any change in the appearance or feeling in your face or mouth?
CONSEQUENCES OF THE DISORDER:
1. Do people ever have trouble understanding you? When? What do you do if that happens?
2. Do you ever have to write to make yourself understood? Has your speech problem affected your work? Does it prevent you from doing anything?
MANAGEMENT
1. What have you done to compensate for your speech difficulty? Have you had any help for your speech? When? For how long? What was done? Did it help?
2. Do you think you need help with your speech now?
AWARENESS OF DIAGNOSIS AND PROGNOSIS:
1. What have you been told is the cause of this problem?
2. In view of this diagnosis, what is going to happen?

http://www.appstate.edu/~clarkhm/cd5673/interview.htm

Motor Speech Disorders – In General

Two main categories of motor speech disorders are:

Dysarthria:

Dysarthria is a motor speech disorder. It results from impaired movement of the muscles used for speech production, including the lips, tongue, vocal folds, and/or diaphragm. The type and severity of dysarthria depend on which area of the nervous system is affected.

http://www.asha.org/public/speech/disorders/dysarthria/#what_is_dysarthria

Some symptoms of dysarthria are:

• Slurred or choppy speech
• Unintelligibility
• Mumbly sounding speech
• Slow or rapid rate of speech
• Limited range of oral motion
• Hypernasality of speech

http://www.csuchico.edu/~pmccaffrey//syllabi/SPPA342/342unit14.html – This website has thorough descriptions of the different types of dysarthria.

Handouts from dennis43

Apraxia:

Apraxia is the inability to perform purposeful and learned movements. This can impair a person’s ability to execute communicative motions such as speech movements or gestures.

• Ideomotor apraxia is the impaired ability to program, sequence and execute purposeful movements either on command or in imitation. It is not due to a loss in strength, coordination or cognitive issues such as inattention or confusion. This includes limb and oral apraxia.

• Apraxia of Speech (AOS) is the impaired ability to program, sequence and execute purposeful speech movements. Longer words and utterances are difficult to say, although automatic phrases can be easily said. This type of apraxia often co-occurs with aphasia which makes it difficult to tease out.

Symptoms of AOS include:

1. Perceived substitutions and distortions
2. Perceived omissions and additions
3. Effortful articulation
4. Trial and error groping
5. Slow speech and dysprosody
6. Difficulty imitating
7. Excess and equal stress
8. Part-word repetitions
9. More errors on polysyllabic words
10. Inconsistent errors
11. Islands of error-free speech
12. Severe cases may be nonverbal

(Class notes, SPAUD 501)