PURPOSE PURPOSE CASE #1: JOHN HISTORY AND BACKGROUND 1/9/2015 DISCLOSURES MANAGING THE ATYPICAL ADULT CLIENT: A REVIEW OF TWO UNUSUAL CASES

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1 MANAGING THE ATYPICAL ADULT CLIENT: A REVIEW OF TWO UNUSUAL CASES Ellen I. Hamby, Ph.D., CCC-SLP Clinical Associate Professor Carrie E. Mills, Ph.D., CCC-SLP Clinical Assistant Professor DISCLOSURES Carrie Mills and Ellen Hamby are employed by the University of Tennessee Health Science Center. They have no other relevant financial disclosures. PURPOSE To present two unusual cases with cognitive-communication disorders and to discuss our thought process as we: Review their history and background Review the results of our assessment Discuss our treatment techniques and their outcomes PURPOSE Why are these cases unusual? They were not what we expected in the way they presented or in the way they progressed. These patients had diagnoses/presentations that were not specifically represented in the literature. CASE #1: JOHN HISTORY AND BACKGROUND 1

2 REFERRAL INFORMATION 43 year-old male (at the time of the initial referral) Referred by his primary care physician for evaluation and treatment of speech and swallowing subsequent to stroke syndrome approximately nine months prior CASE HISTORY INFORMATION Stroke location: upper portion of the basilar artery, resulting in a diagnosis of top of the basilar syndrome CASE HISTORY INFORMATION Weak voice and difficulty finding words Memory problems Strangling on foods, especially liquids 20 previous speech therapy visits with emphasis on comprehension and expression of single words PRE-EVALUATION HYPOTHESIS Presumed location of John s stroke in the brainstem and adjacent subcortical areas should result in: Dysarthria Dysphagia Voice problems Word retrieval and cognitive issues Possible oculomotor problems BOSTON NAMING TEST EVALUATION RESULTS Correctly named 39/60 pictured items 59 th percentile 2

3 ORAL MECHANISM EXAMINIATION Masked facies Fixed gaze/lack of eye contact Limited upper lip mobility Slight deviation of the tongue to the left at rest Normal range of tongue movements Abnormally fast and indistinct diadochokinetic rates PERCEPTUAL EVALUATION OF SPEECH CHARACTERISTICS Reduced loudness Reduced stress Monopitch Rapid rate of speech Imprecise consonants WESTERN APHASIA BATTERY-R SPONTANEOUS SPEECH SUBTEST Information Content: 7 (moderately severe impairment in communication content) Fluency, Grammatical Competence, and Paraphasias: 4 ( halting, telegraphic speech; mostly single words; paraphasias; occasional propositional phrases; severe word finding difficulties ) ROSS INFORMATION PROCESSING ASSESSMENT-2 Subtest Percentile Severity Rating Immediate Memory 9 Profound Recent Memory 84 Moderate Temporal Orientation (Recent Memory) 50 Severe Temporal Orientation (Remote Memory) 50 Severe Spatial Orientation 91 Mild Orientation to Environment 50 Severe Recall of General Information 37 Severe Problem Solving and General Information 16 Profound Organization 16 Profound Auditory Processing and Reasoning 37 Severe FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING Moderately severe oropharyngeal dysphagia, characterized by decreased BOT strength and HLE Penetration and silent aspiration of thin liquids RIVERMEAD BEHAVIORAL MEMORY TEST-II 6/24 Severely impaired 3

4 IMPRESSIONS Severe word retrieval deficits on confrontation and generative naming tasks Severe deficits in all aspects of memory, problem solving and abstract reasoning, and organization Spontaneous speech that was sparse, lacking in grammatical structure, poorly organized, and consisting primarily of content words IMPRESSIONS Lack of affect Severely delayed responses to all tasks Lack of initiation Moderately severe oropharyngeal dysphagia Mild-moderate hypokinetic dysarthria FUNCTIONAL IMPACT Inability to work Inability to live independently Inability to communicate effectively with his family and friends Inability to consume a regular diet Social isolation QUESTION Which of these areas has the greatest impact on his functional skills? TARGETED AREAS TREATMENT PROCEDURES AND RESULTS Dysphagia Word retrieval Memory, problem solving and abstract reasoning, and organization Initiation 4

5 LONG TERM GOAL #1 To improve John s ability to swallow thin liquids without compensatory strategies and without penetration or aspiration as measured by a FEES LONG TERM GOAL #2 To improve John s functional communication through improving memory and word retrieval and through increasing the amount and variety of his verbal expression as measured by criterion referenced assessments TREATMENT TECHNIQUES FOR DYSPHAGIA Seen 1x weekly for 4 months Regular diet with nectarthickened liquids Chin tuck with use of a straw TREATMENT TECHNIQUES FOR DYSPHAGIA Oral motor base of tongue (BOT) strengthening exercises (tongue depressor push and tongue in cheek push) Masako maneuver Effortful swallow Home exercises RESULTS Severity of dysphagia decreased from moderately severe to mild Diet upgraded to thin liquids Chin tuck with use of a straw still recommended TREATMENT TECHNIQUES FOR FUNCTIONAL COMMUNICATION Seen 2x weekly for 2 years Independently verbalizing 3 responses during a conversational exchange with the clinician Verbally expressing 5 complete ideas about a pictured object 5

6 TREATMENT TECHNIQUES FOR FUNCTIONAL COMMUNICATION Spontaneously initiating conversation 2 times Verbally expressing 3 complete ideas in response to an open-ended question Recalling and discussing one event that occurred between sessions RESULTS AND OBSERVATIONS Slow, steady progress on all short-term goals Visual cues required to prompt the need to respond (rather than the content of a response) RESULTS AND OBSERVATIONS Lack of initiation remained a significant hindrance to John s functional communication abilities Behavior resembling that of a patient with a frontal lobe lesion rather than John s more posterior lesion ADDITIONAL OBSERVATIONS Constant complaint of sleepiness and fatigue SOME DIGGING. Thrombus in the basilar tip had compromised blood flow to both posterior cerebral arteries and resulted in large infarcts in both thalami as well as in the midbrain Major characteristic of such lesions is persistent somnolence NEW HYPOTHESIS Somnolence and reduced wakefulness of John s brain played a larger role in his functional abilities than did his specific areas of deficit 6

7 NEW TREATMENT DIRECTION Target functional communication through tasks that required alertness and wakefulness of the brain for longer and longer periods of time John s neurologist concurred QUESTION Since wakefulness of the brain was not a measurable objective, and since John s two hours with us were not a significant portion of his needed wakeful/alert time, how could we target this? NEW LONG TERM GOALS To improve John s reasoning and problem solving skills necessary for independent living as measured by criterion referenced tasks To improve communication/social skills appropriate for obtaining employment and participating in community functions REMEMBER Those were our goals, but our underlying idea was to wake up John s brain and to encourage alertness for longer and longer periods of time QUESTION What tasks would best do this? And, at the same time, what tasks would result in more independence? PREVIOUS OBSERVATION The types of tasks that seemed to engage John the most were those that were speeded, those that required reasoning and problem solving, those that involved a bit of competition 7

8 TREATMENT TASKS Solving deductive reasoning puzzles Answering questions requiring reading maps, bus schedules, recipes, bank statements, and medicine Planning and implementing a daily schedule Recording that schedule on an ipad or planner TREATMENT TASKS Engaging in appropriate turn-taking in conversational discourse Practicing responses to interview questions Preparing a resume Looking for suitable apartments Looking for suitable jobs TREATMENT TASKS Performing speeded tasks on the ipad and on paper Setting his alarm and getting up on a daily basis Planning and preparing his own meals Requesting specific meals for his family to prepare TREATMENT STRATEGY Establish a set of effective cues to remind and encourage John to implement these tasks and similar homework assignments outside of the treatment session Transfer the brain wakefulness to the home environment TREATMENT STRATEGY Most effective cues for John were auditory reminders (alarm), and, to a lesser degree, visual reminders RESULTS AND OBSERVATIONS Significant improvement on each task as well as improvement on measures of functional independence Significant improvement in alertness and initiation on daily tasks around the home Significant improvement in test results 8

9 BOSTON NAMING TEST Raw score improved from 36 to 43 Percentile score improved from 59 th to 70 th Represents a significant improvement in word retrieval that also was reflected in conversational interactions WAB-R Information content score improved from 7 to 9 Fluency, grammatical competence, and paraphasias score improved from 4 to 9 These scores represent an improvement in John s content as well as in his fluency and grammatical structure RIPA-2 Improvement in severity ratings on 6 of 10 subtests Improvement in scores on remaining 4 subtests These scores represent an overall improvement in memory and cognitive functioning Greatest improvement was noted in problem solving and general information RIVERMEAD BEHAVIORAL MEMORY TEST-II Improvement in scores from 6/24 (severely impaired) to 13/24 (moderately impaired) CONCLUSIONS CASE #2: JANE 9

10 REFERRAL INFORMATION HISTORY AND BACKGROUND Referred to our clinic due to: Word-finding difficulties Memory Impairment Overall cognitive decline CASE HISTORY INFORMATION She reported: PTSD Anxiety disorder Dyslexia (never treated) FUNCTIONAL IMPACT Difficulty driving (wrong side of road) Problems with tasks regarding focused attention Specific to her work: Fear and anxiety block my memory Halted business OTHER FACTORS Depression, nervousness, emotional problems (for which she receives therapy), dizziness, allergies, hearing loss, tinnitus, and sleep disorders. OTHER FACTORS She is right handed, wears glasses, and does not consume alcohol or use tobacco products. 10

11 OTHER FACTORS She denies any recent surgeries or hospitalizations. Remote head injury, but no reported significant change or findings from assessment EVALUATION RESULTS MINI-MENTAL STATE EXAMINATION Administered to screen overall cognitive function to determine areas of impairment for deeper testing. MINI-MENTAL STATE EXAMINATION She achieved a raw score of 27 out of 30 possible points, which is consistent with a normal or questionably significant degree of impairment. Patients with this score may have clinically significant, but mild, deficits, which would likely affect only demanding activities of daily living. Test and Subtest ALFA 2: Counting Money ALFA 4: Solving Daily Math Problems ALFA 8: Reading Instructions Response accuracy ALFA Time in minutes Response latency: normally functioning adults 90.00% 4'11 Mean: SD= 1' % 3'52 Mean: SD = 1'34 Time: standard deviation from the mean Within +/-1 SD Within +/-1 SD % N/a Within +/-1 SD Assessment of Language-Related Functional Activities (ALFA) Independent Functioning Rating 1 High probably of independent functioning 1 High probably of independent functioning 1 High probably of independent functioning ABCD-2 Test and Subtest Summary Scores Consistent with: ABCD: Story Retelling- 4 Normal Responses Immediate ABCD: Word Learning Free Recall ABCD: Word Learning Total Recall ABCD: Word Learning Recognition ABCD: Story Retelling- Delayed 3 Mild Impairment 5 Normal Responses 5 Normal Responses 5 Normal Responses Arizona Battery for Communication Disorders of Dementia-2 nd Edition 11

12 ABCD-2 These findings support a mild impairment in non-context dependent short-term memory skills, but overall improvement with the use of context or semantic associations. RIPA-2 Test and Subtest Raw Score Standard Score 8: Problem Solving and Abstract Reasoning Percentile Rank Ratings Moderate 9: Organization Moderate 10: Auditory Processing and Retention Moderate Ross Information Processing Assessment- 2 nd Edition RIPA-2 While her scores fall within +/- 1 standard deviation from the mean, her scores must be interpreted with regard to the normed population: those with traumatic brain injury. Therefore, these findings are consistent with moderate impairment. ATTENTION PROCESSING TRAINING TEST - II Subtest Targets Hit False Positives Residual Score Mean Residual Score for Participants aged Sustained Attention 2. Complex Sustained Attention Divided 1 0 1* 22.5 Attention 5. Alternating Attention 0** 12.7 *stopped test before completing **stated that she could not complete While her sustained attention was a strength, she could not complete the divided attention task, stating that it made her too anxious and overwhelmed. She requested also that the alternating task not be attempted. COGNITIVE-LINGUISTIC QUICK TEST Subtest Raw Score Criterion Cut-Off Score Symbol Cancellation Symbol Trails 7 6 Generative Naming* 5 4 Design Memory 6 4 Mazes 4 4 Design Generation 6 5 *Perseveration noted All domains scores WNL: Attention, Memory, Executive Functions, Language, and Visuospatial Skills. Closest cut-off score was in Executive Functioning NEED FOR DYNAMIC ASSESSMENT Emphasis on behavior during assessment on various tasks Marked by inattention Memory deficits (immediate recall) Limited by therapy paradigm interview as opposed to observation of behavior 12

13 SUMMARY AND IMPRESSIONS These findings support a mild cognitive-communication decline marked by deficits in: Attention Short-term memory Inconsistent findings regarding problem solving SUMMARY AND IMPRESSIONS Her relative strengths include: Visual memory Mathematical computation Context-dependent recall CONCLUSIONS Given her attention deficits, she requires working environments that have few distractions. She performs best on tasks that are easily separated into distinct activities, rather than tasks that require alternating or divided attention. RECOMMENDATIONS Target areas include: Memory Word Recall MEMORY Taught the following techniques: Verbalization: repeating several times (verbal rehearsal) MEMORY Visualization: Visualizing 3 sentence material Given 5 words, establish connection, then provide opposites (black, circle, up, north, left) 13

14 MEMORY Rhythm: Not emphasized as much (she seemed less enthusiastic about this technique) MEMORY After teaching these techniques, then introduced Spaced Retrieval: Reintroducing material after a delay of a specified (and increasing) period of time. there s an app for that! SPACED RETRIEVAL TASK: COCONUT OIL Found simple article on-line Pulled 5 facts from article that could be used in SR format (questionanswer) Created a 5 question quiz based on the 5 facts Used quiz as pre and post test COCONUT OIL TEST Benefits of Coconut Oil: Pre-Test 1. True or false (circle one): Coconut oil is unhealthy and contributes to heart disease. 2. True or false (circle one): Coconut oil helps our bodies to mount resistance to viruses but not bacteria that can cause illness. 3. Name 3 other things that coconut oil can fight that causes illness in our bodies: 4. True or false (circle one): Coconut oil improves blood-sugar control by improving insulin use within the body. 5. True or false (circle one): According to the article, increased insulin in the body helps the body to absorb fat-soluble vitamins. FACTORS CONSIDERED IN TEST DEVELOPMENT Range of response difficulty (easy to hard), varied by: Type of answer: True/false and listing FACTORS CONSIDERED IN TEST DEVELOPMENT Range of comprehension difficulty (easy to hard), varied by: Use of negative Complex sentences Correct statement except for 1 word 14

15 SPACED RETRIEVAL TASK Jane missed 2 questions on the Coconut Oil Pre-Test (#3 and #5) These 2 were used for SR, targeted at 30 seconds, 60 seconds, 2 minutes, and 4 minutes, requiring one passed trial at each level Task was to recall a list of 5 items (one easy, one hard ) EASY LIST Question: List 5 things that coconut oil helps our bodies fight that can cause illness Answer: Viruses, bacteria, yeast, fungus, and candida She required 2 trials at 30 seconds, then advanced 1 trial each at 60, 2 min, and 4 min HARD LIST Question: Name 5 ways coconut oil affects thyroid function Answer: Thyroid helps to increase metabolism, energy, endurance, digestion, and absorption of fatsoluble vitamins She required 5 trials at 30 seconds, then advanced 1 trial each at 60, 2 min, and 4 min SPACED RETRIEVAL TASK After completing the 2 tasks, I administered the post-test (same as the pre-test). How do you think she did? RESULTS RESULTS Pause for dramatic effect... Question 1 Question 2 Question 3 Question 4 Question 5 Pre-Test Correct Correct Incorrect Correct Incorrect Post- Test Correct Correct Incorrect Incorrect Correct 15

16 RESULTS What happened?!? Because I grouped items together, she had a hard time listing only part of a response She remembered that one answer was wrong by 1 word, but misremembered which question, and did not read carefully (attention) DRIVING ON THE WRONG SIDE OF THE ROAD OTHER TREATMENT TARGETS Deductive reasoning to examine process driven problem solving strategies Word finding (convergent, divergent, odd one out) QUESTIONS Where do I go from here? Where would you go from here? 16