Memory University 2013: When It's More Than Just Memory!
6/13/2013
When Speech Fails
Assisting Individuals with Neurodegenerative
Diseases Communicate Effectively
Rachelle Bates, MA, CCC‐SLP
Indiana University Health
Neurorehabilitation and Robotics Department
Memory University
June 13, 2013
Why is this Important?
 The number of people aged 60+ has doubled since 1980
 Within the next 5 years for the first time in history, the number of adults aged 65+ will outnumber children under the age of 5 years
 As of 2011 an estimated 5.1 million Americans are affected by some form of dementia
 Researchers predict that by 2050, 11 to 16 million Americans aged 65+ will have a diagnosis of dementia unless a cure or prevention is found
We NEED to equip ourselves with knowledge regarding cognitive, cognitive‐
communication changes, and neurobiological changes that occur in both the “normal aging” population and “pathological” aging population
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
What Do You Do?
 Speech Language‐Pathologist (SLP) or Speech Therapist
 Requires a Masters degree
 Assess and treat individuals throughout lifespan
 Speech Disorders (Apraxia, Dysarthria, Stuttering, Voice)
 Language Disorders (Aphasia)
 Medical Conditions (Neurodegenerative diagnoses, Head and Neck Cancers, Right Hemisphere Brain Injuries, Stroke, TBI, Cerebral palsy)
 Areas treated and assessed
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Voice
Language
Speech
Swallowing
Cognitive‐linguistic functioning
What Populations We Will Discuss
Normal Aging
Related Dementias
• Mild Cognitive Impairment, Alzheimer’s Disease, Vascular Dementia, Dementia with Lewy Bodies
Frontotemporal Dementias
• Behavioral variant FTD, Primary progressive aphasia, FTD movement disorders
Parkinson’s Disease
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Normal Aging
Important to know “normal” before we look at what is “not normal”
The brain undergoes “normal” neurological changes including
 Loss of myelination
 Neuron shrinkage
 Reductions in dendritic branching resulting in decreased brain volume
 These changes start around the age of 30 years
Effects of neurological aging differ from person to person
 Different theories as to why the cognitive changes occur
 We will review these theories briefly
Theories for Cognitive Changes
Resource Capacity Theory
 Suggests that brain loses capacity to complete tasks resulting in a higher cognitive demand for cognitive and linguistic skills attributing to the cognitive decline Speed of Processing Theory
 A slowing of cognitive and perceptual processing appears during middle age and continues through older years
Inhibition Theory
 Implies that the brain’s ability to filter irrelevant information, competing activities, or distractions changes as we age
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
“Normal Aging” Language Changes
More occurrences of “Tip‐of‐the‐tongue”
Difficulty learning new information
Increased use of interjections
Increased revisions
More repetitions
Declined use of cohesive references with pronouns
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Dementias
 Mild Cognitive Impairment 
A slight yet noticeable decline in cognitive abilities.  Alzheimer’s Disease
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Type of dementia that causes problems with memory, thinking, and behavior. Starts slowly and worsens with time eventually impacting daily life activities.
 Vascular dementia
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Decline in thinking skills caused by conditions (usually stroke) that block or reduce blood flow to the brain. Sometimes sudden onset (after stroke) and sometimes mild onset (as in with multiple TIAs).  Dementia with Lewy Bodies
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Type of progressive dementia leading to decline in thinking, reasoning, and independent function due to abnormal microscopic deposits that damage brain cells over time.
Mild Cognitive Impairment (MCI)
Language Changes with MCI
 Lots of debate regarding accurate assessment and diagnosis of MCI
 Language changes very similar to “normal aging” language changes including:
Slowed speed and accuracy of word retrieval
Difficulty learning new information
 Increased use of interjections, revisions, and repetitions
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HOWEVER some researchers suggest that language changes often occur before the subjective complaint of memory impairment (Fleming, 2013)
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Mild Cognitive Impairment
Role of SLP
Holistically assess patient’s needs
Educate public
Provide patient with means to enhance communication
Train compensatory strategies
Alzheimer’s Disease (AD)
Language Changes with AD
 Reduced information content
 Tendency to digress
 Word finding problems
 Eventually severe enough that daily life activities are affected
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Volunteer for Picture Description
Alzheimer’s Disease
Assessing Discourse as early marker for AD
 Chapman et al. (1995) investigated the characteristics of discourse having participants describe three Norman Rockwell pictures
 They found that persons even in early stages AD had compromised conciseness and coherence in describing the picture
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Alzheimer’s Disease
Role of SLP
Holistically assess patient’s needs
Maintain current meaningful cognitive‐linguistic function through use of memory books, visual reminders
Provide patient with means to enhance communication
Train caregivers
Vascular Dementia
Language Changes with vascular dementia
 Difficulty finding the right words
 Difficulty understanding speech
 Declined ability to pay attention
 Diagnosis typically meets three criteria:
1. Diagnosis confirmed by neurocognitive testing
2. Brain imaging evidence 3. No evidence that factors other than vascular changes are attributing to cognitive decline
(www.alz.org)
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Vascular Dementia
Role of SLP
Holistically assess patient’s needs
Train caregivers
Provide patient with means to enhance communication
Train compensatory strategies
Intervention with Dementias
 Facilitating Orientation
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Calendars, Bulletin Boards, Clocks with Large Faces, Photos, Memory Books, Name tags
 Sustaining Attention
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Relevant to patient, Work within patient’s span capacity, Use stimuli with emotional connotations
 Functional
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Shopping, Cooking, Reminiscing, Sports
 Meet Patient Where They are at Their Disease Progression
 Avoid “search” questions, Allow more response time, Use visual aids
 Keep Engaged!
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Reduces stress, anxiety, aggression
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Frontotemporal Dementias
Three described categories
 Behavioral variant frontotemporal dementia (bvFTD)
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Greatest toll on personality and behavior
May begin with subtle changes and easily mistaken for depression
 Primary Progressive Aphasia (PPA)
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Semantic Dementia
Logopenic Progressive Aphasia
Nonfluent Aphasia
 FTD Movement Disorders
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Corticobasal degeneration
Progressive supranuclear palsy (PSP)
Behavioral variant FTD (bvFTD)
Language changes with bvFTD
 Language changes are not typical with this particular type of FTD
 May talk less due to increased apathy and lack of initiation
 Others may experience disinhibition and be “social inappropriate”
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Primary Progressive Aphasia (PPA)
Variants of PPA
 Semantic Variant or Semantic Dementia (SV‐PPA)
 Logopenic Variant or Logopenic Progressive Aphasia (LV‐PPA)
 Nonfluent or agrammatic variant or progressive nonfluent aphasia (NFV‐PPA)
Semantic Variant PPA (SV-PPA)
Language of SV‐PPA
 Grammatically correct language
 Loss of word and object meaning
 Language comprehension impaired
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Logopenic Variant PPA (LV-PPA)
Language of LV‐PPA
 Decreased speech fluency
 Word finding errors
 Frequent pauses in conversation
 Grammatical, yet simple speech
 Impaired sentence production
Nonfluent Variant PPA (NFV-PPA)
Language of NFV‐PPA
 Halting, agrammatic speech
 Reduced phrase length
 Paucity of function words
 Impaired sentence production as well as deficits in verb naming relative to noun naming
 Intact word comprehension
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Primary Progressive Aphasia
Role of SLP
Holistically assess patient’s needs
Educate patient and caregivers of likely future of speech characteristics given progression of disease
Train caregivers of functional communication
Consider
alternative means of communication for long‐term picture
Augmentative and Alternative
Communication
What is It and Why is it Important?
 AAC is an alternative way for individuals to communicate needs and wants
 Low‐tech options and high‐tech options available
 AAC is important because Joint Commission standards are changing for healthcare providers
 AAC has also been known to reduce stress and improve overall healthcare for patients
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Low-Tech AAC
Examples
High Tech AAC
Examples
Accent 1200 with NuEye
Tobii I‐Series
DynaVox EyeMax
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Video Examples of AAC
http://www.youtube.com/watch?v=QtAIC3fohQI&feature=player
_detailpage#t=160s
http://www.youtube.com/watch?feature=player_embedded&v=
MPRBAICBdFo
FTD Movement Disorders
Types of FTD Movement Disorders
 Corticobasal Degeneration (CBD)
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Progressive neurological perceptual‐motor syndrome
Progressive apraxia, rigidity, and dystonia
Cortical sensory loss
Asymmetrical hand clumsiness is a typical early symptom
 Progressive Supranuclear Palsy (PSP)
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Progressive degenerative disease caused by atrophy of thalamus, globus pallidus, pontine tegmentum, and midbrain
Parkinsonian signs (i.e. stiffness, frequent falls, rigidity)
Gait impairment
Early sign is difficulty looking down and increased ability to move eyes right and left as disease progresses
Pseudobulbar signs
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
FTD Movement Disorders
Language and speech of CBD and PSP
 Limited research in our field
 Motor speech disorders prominent in both diseases
 Dysarthria prominent in CBD and also documented in PSP
 Progressive aphasia present in more than half of patients with CBD in one case‐study of 13 participants
 Many patients with CBD or PSP also have progressive nonfluent aphasia (PNFA) and or apraxia of speech (AOS)
FTD Movement Disorders
Role of SLP
Holistically assess patient’s needs
Educate patient and caregivers of PNFA and AOS speech characteristics
Train caregivers of functional communication
Consider
alternative means of communication for long‐term picture
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Parkinson’s Disease (PD)
Language and speech changes with PD
 Hypokinetic dysarthria  Evident changes in prosody, voice, and articulation
 Monopitch, monoloudness
 Reduced stress
 Some individuals with Parkinson’s Disease may also experience Parkinson’s Disease Dementia (PDD) which affects problem solving, planning, memory, social and daily functioning, and behavior Parkinson’s Disease
Role of SLP
Holistically assess patient’s needs
Train patient for improving speech prosody, rate, and volume
Monitor for any changes in cognition
Educate caregivers of need to encourage trained speech in all environments
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Memory University 2013: When It's More Than Just Memory!
6/13/2013
Video of LSVT Patient
Pre‐ and Post‐ Treatment
http://www.youtube.com/watch?v=gNIdxYjGVV8&feature=player
_detailpage
References
Alzheimer’s Association (2013). Alzheimer’s Disease. Retrieved from http://www.alz.org/alzheimers_disease_1973.asp Chapman, S. B., Ulatowska, H. K., King, K., Johnson J. K. McIntire, D. D. (1995). Discourse in Early Alzheimer’s Disease Versus Normal Advanced Aging. American Journal of Speech‐Language Pathology, 4, 124‐129. Fleming, V. B. (2013). Normal Cognitive Aging and Mild Cognitive Impairment: Drawing the Fine Line. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 23, 5‐13. Fried‐Oken, M., Rowland, C., & Gibbons, C. (2010). Providing Augmentative and Alternative Communication Treatment to Persons With Progressive Nonfluent Aphasia. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 20, 21‐25. Henry, M. (2010). Treatment for Progressive Impairments of Language. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 20, 13‐20. Hopper, T., Bourgeois, M., Pimentel, J., Qualls, C. D., Hickey, E., Frymark, T., & Schooling, T. (2013).
An Evidenced‐Based Systemic Review on Cognitive Interventions for Individuals With Dementia. American Journal of Speech‐Language Pathology, 22, 126‐145. Ogar, J. M. (2010). Primary Progressive Aphasia and Its Three Variants. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 20, 5‐12. Ripich, D. N., & Horner, J. (2004). The Neurodegenerative Dementias: Diagnoses and Interventions. The ASHA Leader. Retrieved from: http://www.asha.org/Publications/leader/2004/040427/f040427a.htm Snowden, J. S., Neary, D., & Mann, D. M. A. (2002). Frontotemporal dementia. British Journal of Psychiatry, 180, 140‐143. Spencer, K., Sanchez, J., McAllen, A., Weir, P. (2010). Speech and Cognitive‐Linguistic Function in Parkinson’s Disease. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 20, 31‐38. Strand, E. A. (2010). Corticobasal Ganglionic Degeneration and Progressive Supranuclear Palsy: Clinical and Speech‐Language Characteristics. Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders, 20, 45‐49. University of California, San Francisco (2008). Speech and Language. Retrieved from http://memory.ucsf.edu/ftd/overview/biology/language/single Voyzey, G. A. (2012). Cognitive Strategies for Individuals with Parkinson’s Disease. Perspectives on Gerontology, 17, 60‐68. 18
Memory University 2013: When It's More Than Just Memory!
6/13/2013
Questions?
Rachelle Bates, MA, CCC‐SLP
Speech‐Language Pathologist
Indiana University Health
Neurorehabilitation and Robotics Department
Neuroscience Center, Suite 1078
317.963.7050 (p) 317.963.7055 (f)
[email protected]
“To affect the quality of the day, that is the highest of arts.”
‐Henry David Thoreau
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