Approaches to Therapy in Progressive Aphasia

Cathleen Taylor

Speech PathologistWar Memorial Hospital9369 0212taylorc@sesiahs.health.nsw.gov.au

progressive non- fluent aphasia (PNFA)

Frontotemporal lobar degeneration (FTLD)

frontotemporal dementia (FTD),

semantic dementia.

Semantic Dementia

•Semantic components of language are affected. (Hodges, 1999)

•Fluent (Mesulam, 1982)

Progressive Non Fluent Aphasia (PNFA)

Phonological (sounds) and syntactic components (sentence order and structure) of language are affected. (Hodges, 2001)

Non fluent

Anomia

Phonemic paraphasias(sound errors in speech e.g. 'gat' for 'cat')

Agrammatism

Hesitant, effortful speech

Loss of fluency

(Neary et al 1998)

apple

Semantic System

Phonological input lexicon

Visual representation

Graphemic input lexicon

Sound to letterconversion

Letter to sound conversion

GraphemicOutputlexicon

Phonological Output lexicon

/æp l/

Single word processingmodel Adapted fromKay, Lesser & Coltheart (1996) Aphasiology,10,159-215.

Case History 154 yo maleUniversity graduate level education, lawyerDriving, surfing , all personal ADLsNo reported changes to behaviour or personality2 yr h/o deterioration of speech and language skills.

Package

Speech Sample: Case 1

Symptoms: case 1Effortful, groping speech productionAnomia, (circumlocutes)Phonological errorsInitial sound and whole word repetitionsResults in overall slowed speech rate ~110-150 SPM ( norm 160 -190)Syntactical errorsHigh level comprehension difficulties, eg logicogrammatical relations

Case History 258 yo maleGraduate and post graduate level education, now retiredDriving, golf, all personal ADLsSome reported changes to behaviour2 yr h/o deterioration of speech and language skills

Speech Sample: Case 2

21st january04.wav 21st january06.wav21st january08.wav

Symptoms: case 2“Stuttering”: speech rate ~120-150SPM with ~10% syllables stuttered.AnomiaPhonemic errorsSyntactical errorsHigh level comprehension difficulties, eglogico grammatical relations

Case History 348 yo femaleNESB with 20+yr ho of fluent English ( verbal and literate)All personal ADLs, some cooking, cleaning etc but with some home help, using public transport independentlyLabile5-6yr h/o speech and language deterioration

Symptoms: case 3

severe oral apraxiaunable to perform oral mmts to commandunable to consistently phonate - non verbal

Mild oro pharyngeal dysphagia…MBS resultsUsing written language, and sms to communicate.

AssessmentComprehensive communication Ax can assist DxAx should identify level of breakdown in language processing and therefore guide different approaches to Tx (Hillis and Carramazza, 1994)Individuals with progressive language impairments are under referred for speech pathology services.(Taylor et al, in print)

Treatment

•Intervention is relevant

•Evidence in literature for effectiveness of intervention

•Full disclosure to individual and significant other.

•Collaborative decision making and goal setting.

TherapiesImpairment Based InterventionsSemantic RxNaming/word retrieval RxWord finding strategiesFluency RxNumerous others

Participation Facilitation InterventionsTeaching total communication techniquesAlternative and Augmentative Communication: life books, portfolios, memory wallets, communication books, ID cards, lists,maps

Treatment case 1 & 2

Fluency RxWord retrieval

Fluency Rxrate of speechSmooth contactsRespirationEffective pausingStress patterns

diplomatic

Word Retrieval Rx

Treatment case 3

Appropriate AAC-pen & paper, SMS, electronic voice output, picture baseResponsive vs generative; issue of adynamiaDysphagia mx

Review

Communication needs changeOngoing Dysphagia Mx53% of individuals described were reviewed (Taylor et al in press)

Education/ SupportEducation programs; individual and group: enhancing communicationAustralia specific information, web, printedAustralian Aphasia Association

Enhancing Communication

Supporting Partners of People with Aphasia in Relationships & Conversation(Lock, Wilkinson & Bryan, 2001)

Errors of meaning

Four weeks ago….

No…. four days ago

Semantic paraphasias

Solution: Perhaps let errors go. Clarify by giving a choice of two or a verifying question.

Word finding difficulties

Solution =Give more timeBinary choiceClarify with questions

I saw…oh you know….that one….who goes there….ohhh…

Getting stuck on the same ideaThe taxi comes at 4

The taxi comes at 4

That’s fine.

Don’t forget Roger’s

coming to dinner.

Solution: Pause. Introduce new content in a way that doesn’t require response.

Preventing problems From Occurring

Prepare the environmentGain attention before beginning-a gentle touch, an “alerter”

Dealing with problems can stop conversation.

You can choose not to deal with problems!

References and Bibliography:Access Economics. (2005). Dementia Estimates and Projections: Australian States and

Territories. Access Economics Pty Ltd. for Alzheimer’s Australia.

Brodaty, H. (2006). Dementia in Australia Now. Plenary session address at The Hammond Care Group’s 6th Biennial International Dementia Conference, Sydney, Australia 29-30 June 2006.

Croot, K. Communication Disruptions in Dementia of the Alzheimer Type and Primary Progressive Aphasia: Impairment-, and Activity/Participation-based Interventions. Speech Pathology Australia Neurology Focus day, Sydney, November 09, 2002

Croot, K., & Nickels, L. (in press). Impairment and Activity/Participation directed Interventions in progressive language impairment: Clinical and Theoretical issues. Aphasiology, accepted for publication August 20th, 2007.

Duffy, J.R. & Petersen, R.C. (1992). Primary progressive aphasia. Aphasiology,6(1) 1-15.

Garrard P.; Hodges J. R. Semantic dementia: implications for the neural basis of language and meaning Aphasiology, Volume 13, Number 8, 1 August 1999 , pp. 609-623(15)

Graham,K.S., Patterson, K.H & Hodges, J.R. (1999). Relearning and subsequent forgetting of semantic category exemplars in a case of semantic dementia. Neuropsychology, 13(3), 359-380.

McNeil, M.R., Small, S.L., Masterton, R.J. & Fossett, T.R.D. (1995). Behavioural and pharmacological treatment of lexical-semantic defictis in a single patient with primary progressive aphasia. American Journal of Speech-Language Pathology, 4, 76-87

Murray, L (1998). Longitudinal treatment of primary progressive aphasia: A case study. [Peer Reviewed Journal] Aphasiology. Vol 12(7-8) Jul-Aug 1998, 651-672. Taylor & Francis, United Kingdom

Ratnavalli E. Brayne C. Dawson K. Hodges JR. The prevalence of frontotemporal dementia.[see comment]. [Journal Article] Neurology. 58(11):1615-21, 2002 Jun 1

Neary D, Snowden JS, Gustafson L, Passant U, Stuss D, Black S, et al . Frontotemporal lobar degeneration: a consensus on clinical diagnostic criteria. Neurology 1998;51:1546-54.

Rogers & Alarcon (1999). Characteristics and management of primary progressive aphasia. ASHA Special Interest Division Neurophysiology and Neurogenic Speech and Language Disorders, 9(4), 12-26

Schneider, S.L., Thompson, C.K., & Luring, B. (1996). Effects of verbal plus gestural matrix on sentence production in a patient with primary progressive aphasia. Aphasiology, 10(3), 297-317.

References and Bibliography:

Schwartz MF, Marin OS, Saffran EM. Dissociations of language function in dementia: a case study. Brain Lang 1979; 7: 277–306

Snowden JS, Neary D, Mann DMA. Fronto-Temporal Lobar Degeneration. Fronto-Temporal Dementia, Progressive Aphasia, Semantic Dementia. London: Churchill Livingstone, 1996.

Taylor, C., Kingma, R., Croot, K. & Nickels, L. (in press). Speech pathology services for primary progressive aphasia: Exploring an emerging area of practice. Aphasiology, accepted for publication August 20th, 2007.

Westbury & Bub (1997) Primary Progressive Aphasia: A review of 112 cases. Brain and Language, 60(3) 381-406