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Cognitive-LinguisticProcessesin
Aphasia
CognitiveandlinguisticProcessesin
Aphasia
• Attention
• Memory
– Shorttermmemory
– Workingmemory
• Executivefunctions
• Cognitiveimpairmentsinaphasia
Playsarole
Language
Cognition
Relatedto
Cognition
language
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Attention
• “Cognitiveprocessthatconcentratesmental
effortonanexternalstimulusorinternal
thought/representation”(Ashcraft&Radvansky,
2010)
• Overlapswithotheraspectsofcognition
• Ifattentionisweakenedthenlanguage
operationsbecomelessefficient
• Needattentiontofocusoncommunication
partner’sspeech,particularlywhen
surroundedbycompetingstimuli
• Arousal–
– Basiclevelofattention
– Physiologicalstate
– Generalreadinesstoact/receive
– Necessaryforintentionalcommunicationtooccur
– Supportsvigilance
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• Vigilance
– Attentionsustainedoverlongperiodsoftime
– Necessarytoholdaconversation
– Criticalforlanguageproductionand
comprehension
• Intention--- Attention
– Iintend tocarryonaconversationwithyousoI
needtoattendtowhatyousay.
Intention
Attention
Vigilance
Arousal
Crosson (2012)
p.169,Fig8-1
AttentionandAphasia
Symptomsofaphasiaare
duetoimpairmentsin
attentionmechanisms
(Hula&McNeil)
Impairedlinguistic&
attentionmechanisms
contributetosymptoms
presentinaphasia(Crosson)
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• Adultswithaphasiahavemoredifficultywith
dividedattentiontasksà
– Attentionallocationinefficiency
• Damagetoadiffusely-represented
attentionalnetwork(frontalandposterior
regions)
• Greatestdecrementswhenlinguistic
processingdemandsarecompetingfor
verbalattentionalresources
• Attentionimpairmentsnegativelyaffect
spokenlanguageabilitiesinmildaphasia
Murrayetal.,1997,1998
Memory
• Retentionbeyondthe“life”ofthestimulus
(Davis,2012)
• Linkinginformationfromdifferentpartsofa
sentence,differentpartsofaconversation,
differentpartsofastory,etc…requiressome
typeofmemory
– Shorttermmemory
– Workingmemory
– Episodic&semanticmemory
Memory
Systems
STM
Phonological
STM
WM
Lex/sem
STM
LTM
Declarative
Semantic
Procedural
Episodic
Martin&Slevc (2012)p.184,Fig9-1
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• Short-termmemory
– Staticstore
• Workingmemory
– Activememory
– Limitedcapacity
– “workspace”forcognitiveactivity(Baddeley,2009)
• WMandlanguagecomprehension
– DiscoursecomprehensionisWMdemanding
– Languagecomprehensionbreakdownsoccur
whenWMcapacityis“exhausted”by
simultaneouslyholdingandprocessing
information
• But…notalwaysthecase
usablealgebra.landmark.edu
• DeclarativeMemory
– Semanticmemory:sharedknowledge
• E.g.,knowledgethatcreamandsugarareoftenadded
tocoffee
– Episodicmemory:personalknowledge
• E.g.,knowledgethatmyStarbuck’sorderisGrandePike
coffeewiththreeSplendas andhalf-n-half
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MemoryandAphasia
• Impairedonsimplespantasksthatinvolveword
listrecall
– Normal:7digits,5words
– Aphasia:1-3digits/words
– Digits>words>nonwords
• Language-basedapproachtoSTM…
– ->phonologicalandsemanticinformationsupport
wordlistretention
• STMdeficitsoncomprehension
– PhonologicalSTMdeficithasfewconsequences
– SemanticSTMdeficitnegativelyaffectssentence
comprehensionandproduction
• AdultswithaphasiapresentwithaWMdeficit
– ->contributestotheirlanguageprocessing
impairments
• Acrosstheseveritycontinuum
– Adultswithmildaphasiapresentwithimpaired
WMandverbalmemoryabilities(e.g.,Ronnberg etal.,
1996;Ween etal.,1996)
• DiscoursecomprehensionisWMdemanding
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• Clinicalimplicationsforverbalmemory
impairments…consequencesforfunctional
communication
– c/ooflanguagedifficultyin
day-to-dayconversation
ExecutiveFunctions
“littlepersonintheheadtodirect
behavior”(Andrewes,2001)
• Elementsofexecutivefunctioninclude
– Initiation
– Goalmaintenance/taskpersistence
– Organization
– Awareness,self-monitoring,flexibility
Norman&Shallice (1986)
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• Frontallobeplaysaroleinexecutivefunctions
• Patientswithleftfrontallesionsmorelikelyto
haveimpairedEF
– Affectsprognosisandrecovery
– Affectsappropriatenessofcertaintreatments
– Affectsprescribedamountoftreatment
• TypicallypatientswithimpairedEFtakelongertoreach
treatmentcriterionlevels
• Impairedcognitiveflexibility
– Resistanttousingalternativemodesto
communicate
– Affectsfunctionalcommunication
CognitiveProcessesandAphasia
• Adultswithaphasiamaypresentwith
– limitedWMcapacity
– impairedattention-controlprocesses
– impairedinhibitorymechanisms
– impairedcognitiveflexibilityandexecutive
functions
Affectslanguagecomprehension &
production,andfunctionalcommunication
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Evidence-BasedMethodsfor
treatingCognitive-Linguistic
ImpairmentsinAphasia
EvaluatingCognitive-Linguisticabilities
• Attention
• Memory
• Executivefunctions
• Cognitiveimpairmentsinmemory,attention,
andexecutivefunctionscanaffectfunctional
communication
• Negativeeffectsonrehabprocess
– Lesslikelytobenefitfrombehavioraltreatment
– Slowerrecovery
– Poorerfunctionaloutcomes
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• Assessmentofcognitivedisordersand
communicationimpairments
(1) Interview,observation,informalassessment
(2) Standardizedtestsofcognitiveprocesses
(3) Standardizedtestsoflanguageand
communication
(4) Non-standardizedtestsoflanguageand
communication
• Duringtheinterview
– Compareinformationobtained
• Whenpossible,observepatientin
informal/unstructuredenvironment
– Seehowcognitivedeficitsimpactin“non-pristine”
environment
ScreeningsforCognitiveDisorders
Instrument
Reference
Addendbrooke’s CognitiveExamination Hodges(2004)
Cognistat
Kiernanetal.(1995)
Cognitive-LinguisticQuickTest
Helm-Estabrooks (2001)
FrontalBehavioralInventory
Kertesz etal.,(1997)
Mini-mentalStateExamination
Folstein etal.(2001)
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GeneralCognitiveFunctionTests
Instrument
Reference
Halstead-Reitan NeuropsychologyTest
Battery
Reitan &Wolfson (2004)
NeuropsychologicalAssessmentBattery Stern&White(2003)
RossInformationProcessing
Assessment- 2
Ross-Swain(1996)
CognitiveDomainBatteries
• Usefulforevaluatinganumberofskillswithin
onedomain
• Providedetailedinformation
• Informativeforidentifyingspecifictreatment
goals
Attention
• Unstructuredmethods– interviewand
observational
• Structuredmethods– scales,standardized
tests
• Potentialchallenge
– Mostattentionmeasuresaremultifaceted
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• Attentionimpairmentsaretypicalinmost
typesofbraindamage
• Criticismsofmethodsforassessingattention
inaphasia
– Theyuselinguisticstimulisomaybeconfounded
&invalid(Murray)
– But…linguisticstimulishouldbeusedtoprovide
insightregardinginfluencesofoneprocesson
another(McNeil&Hula)
• Attentiontestbatteries
– BriefTestofAttention(Schretlen,1997)
– TestofEverydayAttention(Robertsonetal.,1994)
• Ecologicaloutcomemeasures
– RatingScaleofAttentionalBehaviour (Ponsford &
Kinsella,1991)
– CognitiveFailuresQuestionnaire(Broadbentetal.,
1982)
Ponsford &Kinsella(1991).Theuseofaratingscaleofattentionalbehaviour.
NeuropsychologicalRehabilitation,1,241-257.
Broadbent,Cooper,FitGerald,&Parkes (1982).Thecognitivefailures
questionnaire(CFQ)anditscorrelates.BritishJournalofClinicalPsychology,21,116.
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Memory
• WechslerMemoryScale-IIIorIV(Wechsler,1997;
2009)
– Episodicmemory
– Workingmemory
– Nonverbal&verbalmemory
• Rivermead BehavioralMemoryTest-III(Wilson
etal.,2008)
– Everydaymemoryactivities
• TempleAssessmentofLanguageandShort
TermMemoryinAphasia(Martinetal,2010)
– Part1.Singleandmultiplewordprocessingtasks
withintervalconditions
– Part2.Spanmeasureswithlanguagevariations
• Martin,N.,Kohen,F.P.,&Kalinyak-Fliszar,M.(2010).Aprocessingapproachtothe
assessmentoflanguageandverbalshort-termmemoryabilitiesinaphasia.Clinical
AphasiologyConference,Charleston,SC.
• Kalinyak-Fliszar,M.,Kohen,F.,&Martin,N.(2011).Remediationoflanguage
processinginaphasia:Improvingactivationandmaintenanceoflinguistic
representationsin(verbal)short-termmemory.Aphasiology,25(10),1095–1131.
• Verbalworkingmemory
– Tompkinsetal.(1994)Auditory-verbalworking
memorytest
2-sentences Set
Yousiton achair
Trainscanfly
4-sentences Set
Twelveequalsonedozed
Bicyclesareslowerthan
cars
Abookcanplay
Featherscantickle
True
False
True
False
False
True
3-sentences Set
Sugarissweet
Floridaisnext toOhio
Horsesruninthesky
5-sentences Set
Carrots candance
Fishswimin water
Yousleep onabed
Youeatbreakfastatnight
People haveeyes
True
False
False
False
True
True
False
True
SamplestimulifromTompkinsetal’s A/VWMTest
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ExecutiveFunctions
Function
Planning
Test
Mazesubtest (CLQT)
Reference
Helm-Estabrooks
(2001)
TowerTests
E.g., Simon(1975)
Organization
WisconsinCard SortingTest
Grant&Berg (1993)
Inhibition
STROOP
Golden (2002)
CogFlexibility
Comprehensive TrailMaking
Reynolds(2002)
STROOP
Golden (2002)
TONI-3
Brownetal. (1997)
ProblemSolving
RavensProgressive Matrices Raven(1998)
EvaluatingCognitiveProcesses
• Adultswithaphasiamaypresentwith
concomitantcognitivedeficitsthatnegatively
affect
– Languageabilities
– Rehabilitation
– Functionaloutcomes
TreatmentofCognitive-Linguistic
DeficitsinAphasia
• Attention
– Restorativeapproaches
• Re-establishcognitivefunctions
– Compensatory(specific-skills)approaches
• Re-learningfunctionallyimportantactivities
• Memory
– Directtreatments
– Indirecttreatments
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Attention
• Commerciallyavailableattentiontraining
programs
– AttentionProcessTraining(Sohlberg &Mateer,1986)
– APT-II(Sohlberg etal.,2001)
• APTis
– Theoreticallymotivated
– Hierarchicallyorganized
• FollowingtrainingwithAPTpatientsimproved
onstandardizedattentionmeasures
– Patientsearlypoststroke(Barker-Collo etal.,
2009)
– PatientswithABI(Sohlberg &Mateer,1987;
Sohlberg etal.,2000)
– PatientwithmildTBI[usingAPT-II](Palmer&
Raskin,2000)
• APTwithAphasia
– Coelho(2005)usedAPT-IIwitha50y.o.woman
withaphasia
• ImprovedonreadingmeasuresbutnotonWAB
– Sinotte &Coelho(2007)replicatedthestudywith
a60y.o.womanwithmildaphasia
• Noremarkablechangeonmeasures
– Murrayetal.(2006)usedAPT-IIwitha57y.o.man
withconductionaphasia
• Nosignificantimprovements
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• Language-specificapproach
– Attentiondeficitsassociatedwithlanguage
processingrequiretreatmentsthatarelanguagebased
Principles forLanguage-SpecificAttentionalTraining
(Peach,2012)
1.Trainattentionalfocus&resourcemanagement
2.Increaseattentionaldemands
3.Automatizeattentionalrecruitmentforlanguage
a.practice
b. focus
c.feedback
4. Engageundamagedattentionalmechanisms
5.Incorporatelinguisticdevicestofocus attention
Peach(2012),p.265,Table12-4
1. Trainattentionalfocus&resource
managementforlanguage(Hula&McNeil,2008)
– Makesuretasksarelanguage-based
2. Increaseattentionaldemands(Murrayetal.,
1998)
– Increasecomplexityoflanguage-basedtasks
acrossintervention
– Requirementsofthetask
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3. Automatizeattentionalrecruitmentfor
language
– Goaloftreatment
– Attendedprocessingleadstoautomatic
processingwithpractice(Carr&Hinckley,2012)
– Extensiverepetitionoflanguagetaskstomake
languageprocessesmoreautomatic
– Feedback:languagetasksnotattentionalcontrol
4. EngageattentionalmechanismsinRH
– Withasimpletask(picturenaming)move
stimuluspresentationinlefthemispace
5. Exploitlinguisticdevicesknowntofocus
attention
– Alternatesubjectselectionforsentence
production
– Sentencefocusstructure
– Anaphoricreference
ExamplefromSkarakis-Doyle
(2005)AppendixB,p.363
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Memory
• Theoretically…
– TreatingSTM/WMimpairmentsshouldremediate
theseimpairmentsand indirectlyimprove
cognitiveandlinguisticskills
• Because…
– Overlapinneurophysiologicalcircuitry
STM/WMCapacityTreatment
• Francisetal.(2003)
– Sentencerepetitiontreatment
– Improved:
• A/VMemorySpan
• Sentencerepetition
• Auditorycomprehension
• “catchingon”fasterathome
• Decreasedanxietyaboutmemoryproblems
• Koenig-Brubin &Studer-Eichenberger (2007)
– Sentencerepetitiontreatment
– Improved:
• Sentencerepetition
• A/Vspan
• Sentencelengthindiscourseproductionincreased
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• Takehomemessage…
– STM/WMdeficitsrespondtotreatmentswith
increasingrepetitionanddelay
– Why?
• Increasingamountofinformation“stored”
• Increasingtimefor“storing”and“rehearsing”
WM/CESTreatment
• Mayer&Murray(2002)
– Multiplesentencetasks– grammaticality
judgment&semanticcategoryforfinalword
– Improved:
• A/VWMspan
• Readingrates
• Readingcomprehension
• Vallat etal.(2005)
– Spokenmanipulationtasks(e.g.,namingfromoral
spelling,odd/evennumberoflettersinwords)
– Improved
• Spanlength
• Mathproblemsolvingskills
• ADLs(reading,writing,participationinsocialactivities)
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• Takehomemessage
– Manipulatetreatmentstimuli
– Indirecteffectsonothercognitive&linguistic
abilities
Alittlebitmore…
• STMandWMaremodifiable
• Indirect,positiveeffectsonothercognitivelinguisticprocesses
CaseExamples
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Thankyou!
Questions?
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