A Presentation to the Mississippi Speech-Language- Association - 2018

Cognitive Communication Disorders: A Clinician’s Guide

Scott S. Rubin, Ph.D. Associate Professor LSU Health Sciences Center New Orleans & Adjunct Professor Department of Psychology Tulane University

Disclosure Statement: † Speaker is receiving both travel support and honorarium from conference organization. ‡There are no other disclosures to be made 2018

Cognitive Communication Disorders: A Clinician’s Guide

OUTLINE 1. Hemispheric and system specific cognitive functions related to communication disorders. 2. Evaluation techniques for cognitive disorders. 3. Functional treatment issues/tasks focused on targeted cognitive communication deficits and patient needs.

Getting right into it.. What a great area of cortex! Gotta love it. • Pre-frontal lobe (cortex) IS the center of our Executive System. Just think about impacts on communication! Functions include: − Thought – i.e., the highest levels of thought! • 1 The voice in your head… or voices… that you use to think consciously: Of course – the internal voice(s) do involve language.

• Continued - Thought − We “verbally mediate” (consciously) what we are processing and thus what we do. − Prior to the inner voice, we have higher levels of pre-conscious thought: Language of the mind. − An unbelievable amount of activation; processing, planning, analyses, use of a wide variety of pre-conscious systems (centers), and integration of information. Far more than you can imagine.

Source art above: mylifeingodsgarden.com/2017/06/17/voices-in-my-head/

• continued – Thought

• Integration of information − Not just knowing a fact, but how different facts and concepts interact • Sorry students, but academic and clinical faculty see that some students do well memorizing terms and their individual concepts, however sometimes they can’t put it all together, see how various systems, functions, and/or disorders interact – to form the big picture. Result is difficulty applying segmented knowledge to clinical settings.

− Art above: https://www.thegreatcourses.com/courses/philosophy-of-mind-brains-consciousness-and-thinking-machines.html

• Morals (to whatever extent you and/or others may have them): − Associated with “judgement” and “actions” - what’s the right or wrong thing to do (though some people have lack of certain morals so severe that the don’t even think as an action as right of wrong – they just do without remorse) − Impact of - Environment? Levels of sanity? The web?? And… ?? − Pre-frontal cortex may help us maintain our moral values by evaluating and possibly refrain from IMMEDIATELY acting upon deep feelings of Emotion, Violence, Lust, and or Sexual impulses (but to a point – with everyone having their own “point”) − I’m assuming a number of us have experience the interruptions that deficits in this area can cause in the clinical setting (at least I have)

A Art: http://theceme.org/dr-richard- turnbull-the-market-and-morality/

• Judgment Not necessarily from just the moral perspective, but also more concrete. Should I wear a horizontally striped shirt with vertically lined pants and red checkered clown shoes? • Decision making − Involves analyses of the functions above (morals and judgements) − Decisions are made – sometimes they end up good ones – sometimes not

− After this presentation, you can decide if you made the right decision attending! BTW, next slide requires some “ATTENTION” Art from: when-making-decisions/

• Executive system important in “directing attention” toward what we’re supposed to be attending to, sustaining that attention and/or switching attention − Involved in Orientation, Shifting, Focused, Alternating, and Sustained Attention • Relates to notion of Test-Operate-Test-Exit (T.O.T.E - principle that’s been around a long time) • Memory (are many types of memory, but there are 1 of 2 main multi- sensory areas) Where all sensory, language/lexical, and conceptual information integrates to form “what we know”. In the frontal and parietal (angular and supramarginal gyri) lobes this knowledge is readily available for processing by the executive system. The frontal and parietal amulti-modal areas constntly communicate. The frontal area makes this information readily available to rest of executive system.

• Personality

− A lot of things impact our personalities, but the essence of our

personality likely lies primarily in the pre-frontal lobe. Personalities are hard to change – either your own or that of others. *We all have different personalities. Well, possible non-scientific exception, might be a “couple” who’ve together 27-30+ years, who might glomb/lump into one personality; which may, or may not be annoying • LIMBIC System - Brain areas important in cognition that definitely affect communication (for better or worse – if deficits – usually worse) − Structurally, includes various cortical locations and subcortical nuclei (Cingulate Gyrus pictured above) Includes below: Mammillary Bodies: Memory, internal compass, and along with other limbic structures (some below) – contribute to sexual desires, fantasies, daydreams, mental arousal, and neurovascular response of sexual function. Amygdaloid Nucleus: Fear, anxiety, extreme anger and rage.. Creates “arrest” (unable to run from grotesque monsters in a bad dream) or “flight” (including behaviors, bearing teeth, running from perceived danger) − With other structures, generates pleasure and the opposite. Also, involved in producing external discharge (from sexual pleasure)

• Cerebellum – Very cool trivia:10% of the brain’s volume, it contains over 50% of the total number of neurons in the brain. (ties emotion to movement) “Cognitive functions. Although the cerebellum is most understood in terms of its contributions to motor control, it is also involved in certain cognitive functions, such as language. Thus, like the basal ganglia, the cerebellum is historically considered as part of the motor system, but its functions extend beyond motor control in ways that are not yet well understood.” James Knierim, Ph.D., Department of Neuroscience, The Johns Hopkins University

− Cerebellar involvement in various linguistic processes. Lexical retrieval, syntax, , reading, writing, metalinguistic skills. De Smet, Paquier, Verhoeven, Mariën (2013), The cerebellum: Its role in language and related cognitive and affective functions, Brain and Language (Issue 3)

• continued - Cerebellum • Cerebellar role in cognitive and behavioral–affective modulation. Cerebellar-induced syndromes: cerebellar cognitive affective syndrome(1) and the posterior fossa syndrome(2). Mechanisms involved in linguistic and cognitive processing. − 1. Cognitive affective syndrome: Includes following areas of deficit: impairment of executive functions such as planning, set- shifting, verbal fluency, abstract reasoning and working memory; difficulties with spatial cognition including visual-spatial organization and memory; personality change with blunting of affect or disinhibited and inappropriate behaviour; and language deficits including agrammatism and dysprosodia. − 2. Posterior fossa syndrome: Due to tumor - seen in children, it includes deficits including - Neuropsychological, Neurological, and Language and Speech. Source of1&2- https://www.ncbi.nlm.nih.gov/pubmed/9577385 • Continued - Posterior Fossa Tumor – Cavity between skull and cerebellum/brainstem • Note: 60% to 70% of pediatric brain tumors originate in the posterior fossa • Basal Ganglia (BG nuclei) – − Relays limbic information throughout brain − Involved in cortical loops: BG – pre-frontal association – cortical limbic − Through these loops, “…involved in selecting and enabling various cognitive, executive, or emotional programs that are stored in these other cortical areas.” James Knierim, Ph.D., Dept of Neuroscience, The Johns Hopkins University

Illustration from https://www.neuroscientificallychallenged.com/2- minute-neuroscience-videos/

• Parietal Lobe − Mentioned before as 1 of 2 multimodal integration (with pre-frontal) • “Location-Location-Location” – structurally located alongside sensory, visual, and auditory centers

• Important in understanding words (meaning), not so in Wernicke’s area. − Along with Frontal lobe, helps direct attention to new stimuli − Spatial reasoning (topographagnosia - can get lost in an apartment) – understanding maps − Responsible for assessing facial expressions to judge emotions (facial recognition – Temporal) − And – of course primary and secondary somatosensory processing continued - Parietal Lobe - Interesting deficits possible − Nonlinguistic Deficits • Left side neglect (visual or attentional) − Possible - strange ideas per left side of body) usually when hemiparetic on left • May think it’s another person “the dead one”; “the baby", “Burt” • May ask to have the person taken from the room; from their bed) and more strange thoughts about the left side • Lack knowledge of their deficits; physical and behavioral − Term is “anosognosia” (also see in some Wernicke’s aphasia Pts) • Visuospatial deficits that may result in “constructional apraxia” − Kohs blocks, drawing (if drawing themselves – maybe drawing 3 limbs, with 2 on one side), etc.

• Temporal Lobe − Auditory • Primary auditory processing and basic analyses.. Putting the auditory picture together • Right Hem: environmental/non-verbal sounds − If damage = Auditory Agnosia (dangerous) − Memory - Forming visual memory • Hippocampus (within temporal lobe) – forming, storing, and organizing new memories, part of limbic system for emotion − Speech • Language Comprehension − Left Hemisphere: Basic analyses and Wernicke’s for word processing – but integration into our “knowledge” happens when impulses pass into the Angular Gyrus (inf. parietal) • If signal doesn’t get into Wernicke’s area from primary auditory cortex, result = Pure Word Deafness (auditory verbal agnosia) • Temporal Lobe − Emotional Responses • Within this lobe – amygdala (talked about before under limbic system) • Mentioned hippocampus – also in temporal lobe. − – associated with occipital lobe • Inferior temporal many visual memories – includes different types of categories (including faces – just below) − Facial Recognition • See all features of face but can’t recognize as particular person (can be as bad as confusing a cat face with human) • Per the amazing Geschwind, isolated segments of inferior gyrus have centers for specific types of visual stimuli (small manipulable object, large stationary objects, etc) Traumatic Brain Injury and Non-Dominant Hemisphere Disorders - need to consider Extralinguistic Discourse Impairments • Also Dementia on some level. • Extralinguistic Defined - “the aspect of communication that transcends individual phonemes, words or sentences…can be considered the glue by which people link together the bits & pieces of language to create representations of events, objects, beliefs, personalities & experiences” (Myers, 1997)

• Think – EXTRALINGUISTICS

“…beyond the bounds of language.” (??) https://en.oxforddictionaries.com/definition/extralinguistic According to Meyers (and others) extralinguistic functions include: 1) Narrative Discourse 2) Generation of Alternate Meanings 3) Sensitivity to Communicative Events 4) Prosody

Now, let’s have a little discussion

-- Activity (9.3 min) Groups of 3 (if we have that many here)

• TO BE DISCLOSED AT CONFERENCE

• Traumatic Brain Injury– Elements of a Definition − “… sudden trauma causes damage to the brain. …head suddenly and violently hits an object [closed], or an object pierces the skull [open] and enters the brain tissue.” (National Institutes of Health) Open versus closed head injury − TBI “… is caused by a blow or jolt to the head or a penetrating head injury that disrupts the normal function of the brain.” (Centers for Disease Control and Prevention) Of course – When we have a diagnosis – we also need to isolate deficit functions and severity levels -

−

• Traumatic Brain Injury

• Diagnosis per DSM-5 (APA): − A complex diagnosis that has distinctions between levels of severity. They include: − Mild Neurocognitive Disorder(^) • “The cognitive deficits do not interfere with independence in everyday activities (but greater effort, compensatory strategies, or accommodation may be required).” − Major Neurocognitive Disorder (^) • “The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living).” (^) Source: https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/882- notes.pdf NOTE: The 2 above are just elements within a larger groups of symptoms/signs for Mild and Major

• https://news.rutgers.edu/memory-decline-after-head-injury-may-be- prevented-slowing-brain-cell-growth/20170915#.WtI0z0xFx2E

• Traumatic Brain Injury − ASHA describes a Cognitive Communication Disorder. Focus now referring to disorders pertaining more to closed head injury – affecting entire brain (which I am focusing on here). − In cases of open head wound (meninges torn), the damage from a knife or bullet will likely be more specific. Depending of region damaged, could have any type of deficits (including aphasia).

Some areas to consider when planning Tx - It’s all about improving our Pts’ Quality of life! If we aren’t – what the heck are we doing this for?

Rank Need (Response Scale = 1-10) Degee met Degree importance 1 Finding paid employment 3.82 7.23 2 Fulfilling my need for intimacy 3.85 7.23 3 Increasing my income 4.14 8.10 4 Caring for my children 4.26 4.86 5 Improving job skills 4.66 7.42 6 Participating in sports and recreation 4.91 7.19 7 Increasing my educational qualifications 4.95 6.04 8 Obtaining personal care/attendant services 5.00 5.36 9 Finding places and opportunities to socialize 5.23 7.42 10 Feeling part of my community 5.34 6.99 Quality of Life and Adaptation for Traumatic Brain Injury Survivors: Assessment of the Disability Centrality Model (2015), Mackenzie, et. al., Journal o f Rehabilitation

Mild TBI Symptoms (NIH ) Any of the following - Headache Fatigue or lethargy Confusion Change in sleep patterns Lightheadedness Behavioral or mood changes Trouble with Dizziness any of Ringing in ears memory Bad in mouth concentration attention thinking

Moderate or Severe - same symptoms – mild plus

Vomiting/nausea Weakness or numbness in Convulsion or seizures extremities Inability to awaken from sleep Increased Slurred speech confusion Loss of coordination restlessness agitation

Divisions of symptoms by system (DoD/VA)

PHYSICAL Headache Spasticity Vomiting Aphasia [sic] Nausea Dysphagia Weakness Dysarthria Paresis/plegia Apraxia (and more) COGNITIVE Attention Reasoning Concentration Judgment Memory Executive control Speed of processing Self awareness New learning Language Planning Abstract thinking BEHAVIORAL/ Depression Irritability EMOTIONAL Anxiety Impulsivity Agitation Aggression • Right (Non -Dominant) Hemisphere Disorder (RHD) aka Right Hemisphere Syndrome, Non-Dominant Hemisphere Disorder - Right hemisphere stroke may be less common than in left. • Nonlinguistic – Possible Deficits. − As stated in last session -. − Topographagnosia. − Left side neglect • (visual or attentional). − Visuospatial deficits and “constructional apraxia”. − Personality & Control. • “Linguistic” – Possible Deficits. • Various types of naming and word fluency. • High-level comprehension. • Writing (agraphia). • Oral reading. But what are the sources of these deficits?

Extralinguistic Disorders are the heart of the problem in both TBI and RHD! Defined - “the aspect of communication that transcends individual phonemes, words or sentences…can be considered the glue by which people link together the bits & pieces of language to create representations of events, objects, beliefs, personalities & experiences” (Myers, 1997)

Extra/Macro Linguistic Defects (TBI & RHD) Reduced number of core concepts Reduced accuracy of core concepts Reduced number of accurate inferences Problems with meaning and/or relationships Tend to use literal interpretations for figurative language Tend to focus on irrelevant or insignificant details & fail to synthesize information in narrative or conversational discourse Reduced specificity – increases the listeners’ burden; decreased presupposition skills & decreased social awareness Reduced efficiency – in exchange of overall information

Extrainguistics • Comprehension: − Have difficulty w/ inferential aspects of narratives − Have difficulty altering initial assumptions − May not respond to the emotion attached to the incoming information − May miss the main point / theme of the incoming information • Production: − See errors in cohesion (related to logical sequences of info) − Use of fewer complex propositions − Have less integration of others info into their own narratives

Extralinguistic Impairments • Listing behaviors: Difficulty putting an entire theme together but identify individual elements

What’s happening here?

• Reduced sensitivity to alternate meanings − Reduced recognition of figurative & metaphoric meanings & indirect requests (figurative meaning – “kick the bucket”), (indirect request – “Do you have the time?”)

− Reduced ability to interpret humor, irony and/or sarcasm (difficulty using facial, situational or prosodic cues, difficulty perceiving incongruities). Often see use of crude or inappropriate humor) − Reduced capacity to revise original interpretations Nonlinguistic Impairments • Include: − Neglect − Attentional Deficits − Visuospatial Deficits − Confusion − Memory − Other • What could be effect of these impairments on communication? Confabulation Is your patient “lying”? Well, maybe – but that’s not confabulation! − It’s Brain’s way of making of situations (Pts’ current circumstances) – the brain craves normalcy (see last page). − How does a brain incorporate some of misperceptions and confusion? The brain wants to answer-away the agnosia, thinking their body’s left side is another person, hemineglect, visuospatial problems, etc? − The brain makes up situations, surroundings, events that help it function as normal as possible. Confabulations are NOT intentional lies… the individual believes they’re true – because the brain tells them it is! The brain is telling you what you’re seeing, thinking, experiencing, and feeling, right now.

Image from: https://www.ranorex.com/why- test-automation/

EVALUATION of cognitive & cognitive- linguistic communication disorders (note – given limited time – I will only be covering a few of the major exams used today – there are so many) Many of the tests used in Traumatic Brain Injury (TBI) and Right-Hemisphere Injury (Syndrome) (RHI) can be used interchangeably; due to similarity in deficits

Are a lot of tests out there – so must limit number talking about

Ross Information Processing Assessment

• RIPA-2 or RIPA-G − RIPA-2 (now standardized); RIPA-G (geriatric) standardized − Materials needed: Picture book & test protocol. − Areas of Assessment: Memory, Orientation, Recall, Reasoning, Aud Processing (comprehension), Problem solving. Has Supplemental tests − Immediate Memory; Recent Memory; Temporal Orientation; Spatial Orientation; Orientation to Environment; Recall of General Info − Problem solving and Abstract Reasoning; Organization of Info; Auditory Processing and Comprehension; Problem Solving and Concrete Reasoning − Supplemental Subtests • Naming Common Objects • Functional Oral Reading

Scales of Cognitive Ability For Traumatic Brain Injury (SCATBI) • Perception and Discrimination • Orientation • Organization • Recall • Reasoning

Weakness: Time consuming to administer the entire test; however, you are able to administer only select portions of the test. It does not have to be administered in its entirety. A few of the sections may be somewhat outdated expensive Strength: Valid and Reliable Addresses specific cognitive deficits found in the population it was intended to assess Compact and easy to set-up and clean-up Clear directions on how to score, administer, and interpret. Source: https://health.utah.edu/occupational-recreational-therapies/docs/evaluations- reviews/scatbi.pdf Communication Activities of Daily Living – 3 (CADL-3) Standardized – Good functional test for all neuro disorders Fun to give – need to be very comfortable with test and you must ham-it-up! Areas of Assessment:1) Social Interaction, 2) Divergent Communication, 3) Contextual Communication, 4) Sequential Relationships, 5) Nonverbal Communication, 6) Reading, Writing, and Using Numbers, 7) Humor/Metaphor/Absurdity Per the areas above - you see how great it is for TBI and RHD?? Super for planning functional Tx!

A comparison of two assessments of high level cognitive communication disorders in mild traumatic brain injury, Blyth et al., 2012, Brain Injury

• Two screening measures in the acute care setting • Cognitive Linguistic Quick Test (CLQT) − Tasks more complex than Cognistat; better for high-level deficits? • Cognistat - Often used, may miss high-level deficits Subtests included in Language Domain Score

−

(£) =not in other test

continued - CLQT versus Cognistat − In the end, CLQT identified 16 impaired and Cognistat just 1 (all mildly impaired) − I know which I’m using!!

Brief Test of Head Injury • Good for patients with limited sustained attention and who are ‘lower’ level. • Cognitive-linguistic tool, for acute and rehabilitation patients − Tests: 1) Orientation/Attention 2) Following Commands 3) Linguistic Organization 4) Reading Comprehension 5) Naming 6) Memory 7) Visual-Spatial Skills

Functional Independence Measure (FIM) • A functional measure of disability – often used. − Track changes over time • Has 2 subscales • Motor subscale has item like − Eating, Bathing, Toileting, Transferring to bed/chair, stairs, as just a few examples (are 13 items) • Cognitive subscale (of more interest to me) − 1. Comprehension, 2. Expression − 3. Social interaction, 4. Problem solving − 5. Memory (there are only 5 items) • Each item scored 1-7: examples – (Max score = 35) 1 - Total assistance with helper 4 - Minimal assistance with helper 5 - Supervision or setup with helper 7 - Complete independence with no helper

American Speech Language Hearing Association Functional Assessment of Communication Skills for Adults (ASHA FACS) Revised in 2017 • Used to obtain self-reports of abilities in variety of communication situations, tasks having both client & family or friend fill it out, can compare clients of skills with other’s perceptions = awareness of abilities/disabilities • Four Domains: Social Communication, Communication of Basic Needs, Reading/Writing/Number Concepts, and Daily Planning.

• Test of Nonverbal Intelligence – Third

Edition (TONI -4) Age-based standard scores (M=100, SD=15) − Name tells what it measures. − Good to use with TBI Pts. − Similar to the Raven’s Colour Progrssice Matrices (used in WAB) – but black and white. − What common TBI deficits could interfere with this type of task?? If you haven’t used yet – take it yourself first!! That is IF you want to know your nonverbal IQ

Awareness Questionnaire (AQ)

To find out Pt’s knowledge of their own deficits. Good for TBI & RHD Uses 3 forms: • One form completed by the patient • One by family member/significant other (the above have 17 questions each) • One by a clinician familiar with the person with TBI (18 questions) − Examines abilities of patient to perform various tasks after the injury as compared to before the injury are rated on a five point scale ranging from "much worse" to "much better." - continued - Awareness Questionnaire

Range of Scores:1 = much worse, 2= little worse, 3= about the same, 4 little better, 5 = much better

Example Items: • Q. 14. How good are you at planning things now as compared to before your injury? • Q. 15. How well organized are you now as compared to before your injury? • Q. 16. How well can you keep your feelings in control now as compared to before your injury? • Q. 17. How well adjusted emotionally are you now as compared to before your injury?

Agitated Behavior Scale (ABS) Scale developed to assess the nature and extent of agitation during the acute phase of recovery. − Obtained through observation Possible Scores: • 1 = absent: behavior not present. • 2 = present to a slight degree: behavior present but does not prevent the conduct of other, contextually appropriate behavior. • 3 = present to a moderate degree: individual needs to be redirected from an agitated to an appropriate behavior, but benefits from such cueing. • 4 = present to an extreme degree: individual not able to engage in appropriate behavior due to the interference of the agitated behavior, even when external cueing or redirection is provided. ABS continued - continued ABS – Actual items for Observation • 1. Short attention span, easy distractibility, inability to concentrate. • 2. Impulsive, impatient, low tolerance for or frustration. • 3. Uncooperative, resistant to care, demanding. • 4. Violent and or threatening violence toward people or property. • 5. Explosive and/or unpredictable anger. • 6. Rocking, rubbing, moaning or other self-stimulating behavior. • 7. Pulling at tubes, restraints, etc. • 8. Wandering from treatment areas. • 9. Restlessness, pacing, excessive movement. • 10. Repetitive behaviors, motor and/or verbal. • 11. Rapid, loud or excessive talking. • 12. Sudden changes of mood. • 13. Easily initiated or excessive crying and/or laughter. • 14. Self-abusiveness, physical and/or verbal. _____ Total Score (worst possible = 56; me = 16??) The Total Score is calculated by adding all (each item scored (Best 1- Worst 4) Satisfaction With Life Scale (SWLS) Measures what it says! Hope to see scores raise with time. We should all be doing 1 or more QOL measures with our Pts (and friends) Scale - 1 = strongly disagree , 2 = disagree, 3 = slightly disagree, 4 = neither agree nor disagree, 5 = slightly agree, 6 = agree, 7 = strongly agree • 1. In most ways my life is close to my ideal. • 2. The conditions of my life are excellent. • 3. I am satisfied with my life. • 4. So far I have gotten the important things I want in life. • 5. If I could live my life over, I would change almost nothing. continued SWLS

31 - 35 Extremely satisfied 26 - 30 Satisfied 21 - 25 Slightly satisfied 20 Neutral 15 - 19 Slightly dissatisfied 10 - 14 Dissatisfied If you get a 35 – you’re surely on a lot of meds (can I have some?). 5 - 9 Extremely dissatisfied • From original studies: 98 patients with TBI six months to 5 years post-discharge from acute rehabilitation - Mean of 19.0 (middle of the road), standard deviation of 7.6 • Time post-injury was significantly associated with higher SWLS total score (better over time especially after 2 yrs post) Ref - Corrigan, Smith-Knapp & Granger (1998) • Track patient over time! Hope your Tx not making things worse

Quality of Communication Life Scale (ASHA-QCL) • Measures: − Socialization/Activity Participation, Confidence/Self Concept, Roles and Responsibilities, Overall General Well-being.

• 5 point scale – most desirable to least.

Example: my Pt with pretty much no functional communication selected “5” across the board – except – “I like myself” – He chose a “1” - BTW, he is a depressed Pt (under psych management) who suffers from a spouse who yells at him when he makes an error communicating! No – really!

Continued - Quality of Communication Life Scale

What level of comprehension is necessary to answer These questions – reliably?

• Neuro-QOL developed and evaluated by HealthMeasures along with the NIH. • Has long format and also “Short Forms” with limited items. Quite a few of these are excellent for TBI and RHD (oh, and Aphasia). All Short Forms below:

• Ability to participate in • Emotional & Behavioral social roles and activities Dyscontrol • Communication • Fatigue • Lower Extremity Function • Positive affect & well-being • Upper Extremity Function • Sleep disturbance • Cognition • Satisfaction with social roles • Anxiety and activities • Depression • Stigma • Bowel/bladder function • Pain • Sexual function • End of life concerns Some assorted “Short Forms” from the Neuro-QOL Scale • Neuro-QOL – Communication

Neuro-QOL – Short Form - Social Engagement

• Neuro -QOL – Stigma

• Neuro-QOL – Depression

What’s QOL like for anyone with depression?

- A FANTASTIC RESOURCE - The Center for Outcome Measurement in Brain Injury (COMBI)

List of tests for use with brain jury patients – Many have links to the actual protocols!! Find this resource at: www.tbims.org/combi/list.html

Session II: Neuro Disorders and Evaluation

TIME FOR A GROUP ACTIVITY

ACTIVITY PRESENTED AT CONFERENCE

Treatments for Cognitive and Cognitive-Linguistic Disorders • You clinicians know a number of the typical Tx procedures that – yes - I’m about to cover first. • BUT - HOW can you make a bit different, more functional, more interesting? Be creative with stimuli!

VS

“Carkreek Shore,” by Simon Bland Balloon Art from: https://tinyartroom.wordpress.com/2016/12/20/ 4th-grade-hot-air-balloons/ Treatment – Tasks for Memory Procedural memory • Following sequential directions Pt listens to your description/directions for a certain task − Pt (tracks) identifies how many steps are involved? After, Pt writes steps down on separate cards − Mix up the cards and the Pt resorts cards in order continued - Procedural memory Another Tx activity Sequenced Tasks – You give name of a task (no steps modeled or described by clinician) and they list the steps for task (start to finish) in a sequence, as in- depth as possible (possible errors if Pt with ideational or ideomotor apraxia) Example - Cashing a check • Get checkbook and fill out check • Take it to bank • Sign, cash it, and count the money you receive • Take to your SLP for long term “safe keeping” Depending on severity, this task could be broken down into more discreet steps

More Sequenced Tasks– Procedural Memory IMPORTANT - Can you come up with some tasks based on Pt’s interests? Related to hobbies, work , daily activities, etc. etc. = • Ride a motorcycle • Prepping for an Ole Miss game • Spin a clay bowl • Play an oboe • Cheat in Poker You give some other ideas! Other cognitive functions involved?

Episodic memory Example Tx tasks - • Word list recall (that IS episodic memory – of giving the list) • Story retell – Consider your story carefully: Is it of interest to Pt? Is it dull? Is it the right complexity? • Relaying their life events - “What’s the most fun thing you did in college?”

− What tasks can you come up with? − Other cognitive functions involved? Topographic memory Example Tx tasks include: • Order photographs by locations on a route - Requires previous pictures taken in areas. Can family member or friend take the photos? If not, will you? • Describe the route you drive home, etc. • Draw the layout of your bedroom (severe Pts) • Maybe more difficult – discuss how landmarks on routes have changed over the years (see next page) Other cognitive functions involved in these tasks?

Topographic memory Working with places on maps? Since “topographic”, include pictures of destination (and places along route)

Example MAL What other cognitive functions involved in these tasks? Semantic (conceptual) Memory Know what I mean by “Semantic Memory”? Name category to which these items belong: Present pictures? Or, which is not in different category? necklace - earrings - watch sister - mother - aunt – football How complex will your pictures be? How busy the picture? • This is not to be thought of exactly like a verbal categorization task.. So, opposite of naming items within a given category (map them out by subcategories? Draw them?)

− Remind you of direct language tasks? − Other cognitive functions involved?

Therapy in TBI and RHD Compensatory Strategies A major focus for “treatment” of TBI also very important in RHD! • Compensatory Strategies should maximize strengths and make use of what the patient CAN do. (Based on Milton & Wertz, etc)

• Example: If patient can’t use public transportation – but can read a list of directions… make cue cards for specific trips. Train patient to follow the directions in sequence. Use a map of Metro system? Compensatory Strategies • Strategies are on a continuum. As patient progresses and learns – techniques may change. External cues may become internalized. • A strategy may be difficult at first – but – patient learns and it becomes easier. • Not 100% necessary - but patient should be involved in developing the strategy (knowing how it helps) • The number of strategies used should be monitored. Too many strategies reduces effectiveness. Evaluate the effect of a new strategy on the performance of those already used. May decline!

(pre)Compensatory Strategies Prior to teaching a compensatory strategy • Self awareness: Of course – you will have been working on these. •Be able to discriminate between effective and ineffective performance •Become aware of deficits •Recognize implications of deficits • Teach value of strategies − Goal: Patient to agree that strategies are helpful in accomplishing their goals − Use videos, other Pt testimonials, self-evaluation, and talk about how people without deficits also use some of these ideas (smartphone calendars, alarms, etc)

TEACHING Compensatory Strategies • Self Discovery − Construct task that causes failure then adjust the task for success (example – a paragraph reading task with too little time versus one with adequate time) • Kind of like the kiddie tx for requests? • Modeling − SLP or Peer (or friend?) models use of the strategy (role play – use video, etc) • Verbalize the strategy as you do it. • Direct Instruction − Guide use with pictures, diagrams, written instruction, outline, flow chart, etc. • Make it concrete AND functional for the specific Pt Compensatory Strategies • What to include? • Attention and Concentration − External aids: Smartphones are AmAZinG: timers, alarm, verbal cues (T.O.T.E.) − Internal aids: self-instruction, self-monitoring • Orientation − External: pictures, memory book − Internal: selecting “anchor points” to places or points in time. − We do that!

Teaching Strategies – continued • Input control − If Auditory; Give speaker feedback… “please slow down”, “please write it down for me”. − If Visual; cover parts up and systematically look at parts. Index card with slit. • Verbal processing – comprehension − Use self questioning, “Do I understand?” − Ask for clarification or repetitions • Memory (encoding and retrieval) − Create basic scripts (external or internal) Example, Script for going to a restaurant or Biker Bar − Memory book (for little money – if not using a smartphone) For: Appointments, people met & where, dates, tasks by day, biographical information, etc. What could be FUN in the memory book?

Compensatory Strategies - continued • Learning Behaviors − Use tape recorder (no on Smartphones) − Set alarm on Smartphone for every 15 min - Pt to do “self questioning” – T.O.T.E.? • Organization − Task Organization – Lay out tasks in advance, include materials needed, steps, and time frame Do you use all the little bowls when cooking? I do! − Thought organization – construct time-line to maintain order of events

Functional Skills for Tx

Related to the following slides – need to consider Pt’s interests and what they need to be able to do!! • Functional Memory Includes: Orientation - Recalling schedules - Recalling Events - Learning new tasks Other tasks?? • Functional Reading (USE THESE – so FUNCTIONAL) − Signs, Coupons, Menus, Advertisements, Brochures, Job Applications (if appropriate), Newspapers, Magazines, Flyers, Billboards (you take the dang pictures)

Functional Skills for Tx • Money Management − Coins, paper money, casino chips, Calculations, Purchases, Credit cards, Investments What other tasks can you think of?

• Study and Testing Skills − For school or for training for new occupation − Following Schedules − Classroom behavior (can they be any better than my M.C.D. students?) − Initiating asking for help – and of whom? − Concentration (attention) – attention to what? − Study habits (time management – completion of work)

Functional Skills for Tx • Telephone Skills − Placing a call − Recording the information − Using telephone book - or more likely looking up number on Smartphone or computer? − Making emergency calls – can you just do a hotkey on their phone? Make sure they don’t call 9112 for fun! • Transportation − Planning for use of public transportation − Organizes and executes trips − Obtaining a drivers license (if physician allows) − Use of Maps (talked about before) − Problem solving - breakdowns, etc

Functional Skills for Tx • In depth examples of “skills” – For banking − Complete checks − Filling out deposit and withdrawal slips − Balancing checkbook − Managing savings record − Using Cash card − Recording transactions

• Skills for social involvement − Filling out Membership form(s) • HOG, AARP, etc.

A treatment consideration described for Aphasia – but awesome for TBI/RHD - “Making a good time”: The role of friendship in living successfully with aphasia, Brown et al., 2013, IJSLP • Per SLPs’ clinical work they stress the need that caregivers (spouses, etc.), family, and friends be included the therapeutic process. Although some psychological issues my complicate work in this area… the implications are apparent • Friendship should be a very important issue • Since many of pts’ friends didn’t know or understand about communication disorders, provide information and education for friends specifically. Teach friends techniques and how to optimize communication/interaction continues - • Consider group treatment and support groups! Below ALSO from “Making a good time”: The role of friendship in living successfully with aphasia, Brown et al., IJSLP • Per SLPs’ clinical work: stress the need that caregivers (spouses, etc.), family, and friends be included the therapeutic process • We have Pts that lose most of their friends after a TBI or stroke: Since many of pts’ friends didn’t know or understand about communication disorders, provide information and education for friends specifically. Teach friends techniques and how to optimize communication/interaction

CONTINUED -Referred to a study: “Making a good time”: The role of friendship in living successfully with aphasia. Another important notion • Provide pts with ways to meet one another. Have group tx, put them in touch with support groups (start one?), and provide introductions to the different associations. Also, explore interest groups in the community and encourage the pt to participate. Need to help them overcome their difficulties in social activities.  When working with TBI and RHD patients we often include their significant other (hopefully) but we should also include other important communicative partners (not all at

the same time – of course)

 How can those ‘other” persons be included in treatment? See deficits associated with TBI and think of roles they can

play

Related to communication with communicative partners The following is from - Describing conversations between individuals with traumatic brain injury (TBI) and communication partners following communication partner training: Using exchange structure analysis, Sim, et al., 2013

Treatment provided to the JOINT grp − Tx 10wks; 3.5hr wk (2.5hr wk group & 1 hr wk individual) • Groups restricted to 4-5 pairs Social communication skills training program (SCST) Goal - “…maximize communicative effectiveness by reducing the effects of cognitive communication deficits and achieve more rewarding , productive conversations.” • Used ‘Behavioral techniques’ – role-plays, video feedback, cues for self-monitoring

continued - Social communication skills training program

TBI participants’ Tx was to “…apply appropriate verbal and non-verbal behavior in social situations.” •Everyday communicative partners (ECPs) trained on providing positive feedback and scaffolding technique −Scaffolding includes: Cognitive support, emotional support, collaborative turn-taking , positive question style, helping to “…organize and extend their [partners] thinking to elaborate conversation topics…” •Homework to audio-tape home-based tasks to promote use of techniques

continued – Social Skills Training • Findings summarized: (compared to controls) − Everyday communicative Partners (ECPs) reduced their use of negative questioning in conversations and potentially increase use of helpful questions •This improved naturalness and quality of conversations − ECPs trend for increased a) information tracking information given by their partner and b) negotiating of communication breakdowns − Those with TBI may be trained to better share the “communication burden” with their ECPs − Those with TBI demonstrated increased productivity in casual conversations − ECPs able to scaffold conversations to encourage contribution of partners

continued – Social Skills Training

…BTW - The Appendices in this publication are great, with the protocols used as well as an outline and description of the treatment tasks Describing conversations between individuals with traumatic brain injury (TBI) and communication partners following communication partner training: Using exchange structure analysis, Sim, et al., 2013

They below was taken from “Knowledge translation in ABI rehabilitation: A model for consolidating and applying the evidence for cognitive-communication interventions”, MacDonald & Wiseman-Hakes, 2010 From this meta-study (above) – there’s this list the following approaches that “…appear to helpful across intervention domains…” •Individualized goals •Feedback and outcome measures •Context sensitive tx embedded in communications and environments of daily life •Self-evaluation & self-regulation techniques •Use of meta-cognitive strategies •Focus on activity and participation levels of intervention and outcome rather than impairment level drill and training

Questions/Conclusion

Contact Information: Scott Rubin [email protected] or [email protected] Address: LSUHSC, COMD, 1900 Gravier St. New Orleans, LA 70117 Office: 504 568-4350 Cell: 504 638-1590

A small plug for something very close to my heart –

David’s Apple, LLC – (501c3) Patient Advocacy Team Specializing in Stroke and Aphasia – Educational Programs for Students, Healthcare Professionals, and the Community. Also providing individual patient support during rehabilitation Please Visit Our Website - www.davidsapple.com and our Facebook Page – DavidsAppleLLC Email – [email protected] * Speaker is Co-Founder and Executive Vice President of David’s Apple. * * * Speaker receives no monetary compensation from David’s Apple LLC for any service.