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Rehabilitation of Right Hemisphere Disorder in the Chronic Phase of Recovery

47.8 Acknowledgments

The author acknowledges Dr. Robert Mayo and Dr. Margaret Blake for their ongoing mentorship and contribution to her professional development.

Suggested Readings

[1] Lehman Blake M, Frymark T, Venedictov R. An evidence-based systematic re-

view on communication treatments for individuals with right hemisphere brain damage. Am J Speech Lang Pathol. 2013; 22(1):146–160

[2] Minga J. Discourse production and right hemisphere disorder. Perspect ASHA

Spec Interest Groups.. 2016; 1(2):96–106

[3] Spreng RN, McKinnon MC, Mar RA, Levine B. The Toronto Empathy Question-

naire: scale development and initial validation of a factor-analytic solution to multiple empathy measures. J Pers Assess. 2009; 91(1):62–71

References

[1] Bickerton WL, Samson D, Williamson J, Humphreys GW. Separating forms of

neglect using the Apples Test: validation and functional prediction in chronic and acute stroke. Neuropsychology. 2011; 25(5):567–580

[2] Helm-Estabrooks N. Cognitive-Linguistic Quick Test. San Antonio, TX: Psy-

chological Corporation; 2001

[3] Mart in I, McDonald S. Weak coherence, no theory of mind, or executive dys-

function? Solving the puzzle of pragmatic language disorders. Brain Lang. 2003; 85(3):451–466

[4] Tompkins CA. Right Hemisphere Communication Disorders: Theory and Ma-

nagement. San Diego, CA: Singular Publishing Group; 1994

[5] Cicerone KD, Langenbahn DM, Braden C, et al. Evidence-based cognitive reha-

bilitation: updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil. 2011; 92(4):519–530

179

Reading as Intervention for a Skilled Nursing Facility Resident with Dementia

48 Reading as Intervention for a Skilled Nursing Facility Resident with Dementia

Susan Ostrowski

48.1 Introduction

Reading impairment may evolve early in the progression of dementia. However, the true incidence of reading impairment is unknown. Accessible reading material can be of significant benefit to people living with dementia in numerous functional and therapeutic ways.

48.2 Clinical History and Description

EB was an 87-year-old former homemaker and community volunteer. Her husband was deceased, her daughter lived nearby, and her son lived out of state. She was diagnosed with Alzheimer’s disease (AD), chronic heart failure, and diabetes. For the last 10 years, EB lived independently near her daughter. Three months ago, EB was admitted to a skilled nursing facility (SNF) due to increased diﬃculty with self-care and failure to thrive. EB was subsequently referred for speech pathology evaluation as a component of the multidisciplinary team by the nursing staﬀ primarily related to decreased cognitive functioning as well as anxious wandering, occasional agitation, and possible depression.

48.3 Clinical Testing

To determine whether speech pathology services were clinically justifiable for EB and to identify EB’s needs and strengths, formal and informal cognitive and language assessment was performed. The evaluation was initiated by spending quiet, one-on-one time with EB in relaxed conversation to acquire a sense of what is important and meaningful. Referring to her new living environment, EB stated: “I’m not sure how it all works here” and “I would like to know where I’m supposed to be.” EB discussed meaningful activities in her past including a sewing circle, reading, and volunteer work. She also added that she “missed being with friends.”

EB’s family and the SNF staﬀ were also interviewed. EB’s children said they were happy with their mother’s care, but would like to “be able to communicate better” with her. In the past, EB followed a schedule, she liked being with people, and enjoyed reading, although “she hasn’t read in a long time.” EB’s daughter reported that her mother “has pretty much lost her ability to read.” She added that EB “always wears her eye glasses” and “has never worn hearing aids.” The date of EB’s last vision or hearing evaluation was unknown.

The nursing staﬀ reported that every day, for about an hour prior to dinner, EB wandered anxiously and asked the same questions repeatedly. She also occasionally raised her voice in agitation when the staﬀ attempted to direct her away from the

exit or to an activity. The recreation staﬀ reported that EB was invited to three recreation activities a day, but she only attended about two activities a week. The staﬀ added that “EB is afraid that if she goes to an activity, she will miss her children’s visits,” and when they encourage EB to socialize and converse with other residents “it’s never successful.”

Interactions between EB and staﬀ were observed. Multiple

miscommunications and incidences of confusion were noted.

s memory as well as problem-solving ability and language

EB’

ere formally evaluated via the Cognitive Linguistic Quick Test

w (CLQT) and a spaced retrieval (SR) screen. Cumulatively, these tools suggested significant working memory and problem-solving deficits. She retained and recalled new information (maximum 2–3 elements) with appropriate visual scaﬀolding, SR practice, and vanishing cues.

In addition, informal cognitive/language assessments were conducted in low- and high-stimulation environments. EB demonstrated functional verbal expression in both environments. However, in high-stimulation environments, decreased language comprehension and increased requests for repetition were observed.

Hearing screening included an outer ear exam, as well as spoken word/sentence identification tasks, with speechreading and without, in noisy and in quiet settings. This screening revealed bilateral, moderate cerumen impaction and diﬃculty perceiving speech in noise without visual cues. Under ideal listening conditions during social conversation, EB displayed rudimentary, functional speech perception, but poor auditory processing of lengthy speech input.

Vision and reading screenings were performed with and without eyeglasses and included the Arizona Battery for Communication Disorders of Dementia (ABCD) visual field screen, color identification screen, reading signs in the environment, and an oral reading screen. Although no apparent diﬀerence in visual perception was noted with and without glasses, EB chose to wear her glasses throughout the evaluation. No visual field neglect or deficit in color perception was noted. EB’s ability to notice and read signage was inconsistent. EB showed limited comprehension of common schedule aids in her current environment (e.g., calendars, recreation schedules, weekly menus, etc.), but she could read and comprehend an analog clock.

EB was unable to fluently read and comprehend typical book and newspaper material. However, when presented with print adaptations such as high-contrast, extra white space, large font, nonserif, evenly weighted typeface, EB showed intact letter identification and good decoding skills. With adapted, accessible print, EB read aloud slowly but fluently with functional comprehension. EB’s written language comprehension proved to be functional and commensurate with her oral language comprehension. EB reported that adult books for leisure reading would be enjoyable to her.

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Reading as Intervention for a Skilled Nursing Facility Resident with Dementia

48.4 Questions and Answers for the Reader

1. What information was obtained from EB and her personal history that would influence the focus of therapy? a) EB’s wandering and agitation is most likely due to her

need for physical exercise.

b) In the past, EB has derived security and comfort from

scheduling her day. Reading, working in groups, and helping others have provided fulfilment and purpose in her life.

c) EB has not had to adapt to many new situations in her life

and, therefore, may be struggling to adjust to her longterm care residence.

d) EB enjoyed living independently and exercising control

over her life. Reliance upon others for care may be the source of her distress and depression.

Answer: b is correct. Personality traits present before the disease process often persist, even in the presence of cognitive decline. In the past, EB enjoyed significant organization to her days. Presently, she may feel unsettled without that sense of structure. EB was sociable and community oriented. At this time, without conversation and personal contact with others, she may feel lost and anxious.

a is incorrect. Although exercise may benefit EB, neither EB nor her family mentioned physical exercise as important to EB in her past.

c is incorrect. This statement is too broad and universal to be helpful in determining the focus of an individualized plan for EB.

d is incorrect. Similar to c, this statement is too broad and universal to be helpful in constructing an individualized therapy plan with meaningful, practical goals unique to EB’s needs and strengths.

2. What goals would be clinically justifiable and functional for

EB? a) Use of a typical workbook to improve language skills and

participation in cognitive games (e.g., concentration, trivia) would be eﬀective therapy goals to improve EB’s memory and word finding and to enable her to better communicate her wants and needs.

b) No goals are appropriate for EB at this time due to the

progressive nature of her disease.

c) Engineering situations in which EB may engage in the

types of activities that she enjoyed in the past (socializing, participating in groups, reading) to lessen EB’s probable feelings of social isolation, disorientation, and restlessness.

d) Given EB’s signs of anxiety and depression, completion of

the Cohen–Mansfield Agitation Inventory and the Geriatric Depression Scale is warranted to provide objective information in support of pharmacological treatment of EB’s anxiety and distress.

Answer: c is correct. A justifiable, functional therapy approach for EB should focus on making modifications to foster EB’s participation in the types of activities she enjoyed in her past.

a is incorrect. Although language exercises and memory games are common in traditional speech therapy, no scientific

evidence exists that isolated language or memory activities improve recall or communication skills in people with dementia. A plan of care must use evidence-based interventions aimed at improved safety, communication, independence, and quality of life (e.g., a communication book to recall family visits, comprehending the dinner menu, speaking on the phone, using the nurse’s call button, remembering to use a walker, remembering the steps for safe transfers, comprehending the activity calendar, using the TV remote, managing mealtime items, using a life storybook to increase socialization, using simulated presence therapy to decrease agitation, actively participating in activities of daily living, accepting medication, etc.).

b is incorrect. Therapy for memory-challenged seniors need not be restorative. Therapy is justified when the goal is to improve function, often via memory aids, environmental modifications, care partner training, and use of adapted materials.

d is incorrect. Although standardized assessments can provide helpful information in some cases, these scales are not of primary importance for EB’s plan of care at this time. Given that EB is of no danger to herself or to others, the first priority is to determine EB’s response to evidence-based therapy techniques and strategies to increase her comfort and engagement with the people, materials, and activities in her current environment.

3. How can SR and errorless learning (EL) be used to benefit EB

in a functional way? a) To assist with recall and retrieval of a daily schedule. b) To assist with recall and retrieval of her eyeglasses. c) To assist her to remember the day of the week. d) To assist her to remember the name of the facility.

Answer: a is correct. For EB, a daily schedule is an excellent visual orientation aid that could reduce confusion and anxiety.

ted by her independent use of the

However, its eﬃcacy is a aid. SR and EL will enhance EB’s cued recall, and possibly free recall, of this visual aid throughout the day.

b is incorrect. Although remembering to wear her eyeglasses is a functional goal, EB has shown no forgetfulness in this area. Wearing her glasses is in her procedural memory and does not need to be addressed in therapy.

c is incorrect. Recalling the day of the week is not a functional goal because it will not aﬀect EB’s behavior, activity level, engagement, or emotions.

d is incorrect. Although recall of the name of the facility is often a goal of therapy, EB’s recall of the name of the facility will not likely aﬀect her behavior, activity level, engagement, or emotions.

ﬀec

48.5 Description of Disorder and Recommended Treatment

Formal and informal assessment results confirmed that EB was functioning with vision and hearing limitations, moderate deficits in working memory and short-term memory, and a severe deficit in executive functioning. With regard to language, reading, and sustained attention, EB demonstrated functional skills for her age and environment. A significant component of EB’s anxiety and agitation was not inherent to her AD diagnosis. As with many people living with dementia, much of EB’s frustra-

181

Reading as Intervention for a Skilled Nursing Facility Resident with Dementia

tion and restlessness was due to the limitations of her environment and inadequate communication by her care partners. Hearing loss and decreased vision may also contribute to EB’s social isolation, disassociation, loss of control, and disorientation.

Broadly, the goals of intervention for people living with dementia are to decrease disability, maximize functional abilities, and contribute to the design of a system of care to allow the individual to live symptom free as much as possible in the least restric tive environment. The justification for speech therapy (three t imes per week for 4 weeks) for EB was as follows:

There is reasonable expectation that therapeutic intervention in the form of environmental modifications, communicationpartner training, visual memory aids, and meaningful activities with adapted materials will result in attainment of measurable, functional objectives for EB.

The objectives for EB are as follows:

●

Increased attendance in recreation activities.

●

More positive social interactions with peers.

●

Less anxious wandering.

●

Less agitated verbal exchanges.

A plan of care was designed to work collaboratively with EB, family members, and care professionals. The plan of care included the recommendations and treatment strategies below.

●

Audition recommendations: Treatment for bilateral cerumen impaction and audiological evaluation was recommended. The impact of background noise on speech perception, confusion, and frustration level was discussed with family and staﬀ. A quiet environment was created, with EB’s consent, during care and during visits and involved turning TV/radio oﬀ, shutting the door, silencing pagers/phones, and refraining from side conversations with other individuals when with EB.

●

Vision-related recommendations: Complete optometric evaluation was recommended. In addition, increased task lighting and ambient lighting was recommended in EB’s room.

●

Communication compensatory strategies: To minimize the frustration of miscommunication, the following communication recommendations for EB’s conversational partner were suggested:

○

Maintain eye contact during discourse.

○

Introduce a topic before asking about it or elaborating on it.

○

Do not shift topics frequently.

○

Ask yes/no questions and oﬀer binary choices rather than open-ended questions.

○

Do not ask direct questions about recent events.

○

Use one-idea sentences.

○

Do not speak quickly.

○

Give EB quiet time to process what was said and to formulate her response.

○

Be comfortable with silence.

●

Daily schedule cue card (▶ Fig. 48.1, blank and ▶ Fig. 48.2, completed).

●

Given EB’s past reliance on a daily schedule, EB collaboratively designed a highly readable daily schedule form with place of residence and date printed on the top. EB communicated where she would like the schedule to be kept for easy access (i.e., in the bag on her walker). The importance of filling in the schedule every day with such items as meals, therapy, recreation activities, favorite TV programs, doctor appointments,

and especially family/friend visits was emphasized. Necessary print considerations were implemented to make the schedule readable for EB (i.e., using black ink, print letter formation not cursive, not block letters, large size font, and no print distractions). By observing staﬀ’s use of the form, the eﬃcacy of the written daily schedule to decrease EB’s feelings of disorientation and her anxiety about missing family visits was assessed as well as increased attendance at recreation activities. The nursing staﬀ reviewed the schedule with EB in the morning and after her afternoon nap. Evidence-based memory interventions (e.g., SR and EL) were implemented to increase EB’s recall of the daily schedule and its location.

●

Independent, solo reading of adapted material: Given EB’s past interest in reading and present ability to read, evidencebased, dementia-care Montessori principles (use of meaningful activities, preserved abilities, adapted materials, and prepared environment) were implemented to facilitate independent reading with the goal of reduced boredom, restlessness, and anxiety. Books with print adaptations (such as wide margins, nonserif, evenly weighted typeface, bold print, large font, short sentences with simple syntax, and supportive images) were identified; EB discussed her preference of books with nursing and recreation staﬀ.

Environmental factors were also optimized to enhance EB’s independent reading experience including the following:

●

Bright lighting above and behind.

●

Quiet environment.

●

Use of a tabletop book stand.

●

Optimal back, shoulder, arm, neck and head positioning and support.

●

Reading to enhance family communication: Family members were introduced to interactive reading with adapted books as a means of enhanced communication with EB. These recommendations included the following:

○

Allow EB to explore the book at her own pace, in her own way, which may not be sequential.

○

Follow her lead.

○

Avoid a teacher–student dynamic.

○

Accept periods of silence as she reads and formulates her ideas.

○

Use gentle comments more than direct questions.

●

Accessible reading material created by the family: EB’s family was educated regarding the creation of personalized, accessible reading material for their mother (e.g., adapted online articles, high interest books, life storybooks).

●

Reading with a friend (▶ Fig. 48.3): Typically, conversations with peer residents were unsuccessful for EB due to auditory, speech, and memory issues. Adapted books were implemented as an eﬀective means of fostering EB’s communication with peers. EB and a peer partner remained engaged with the book and with each other for a prolonged period of time without relying on staﬀ intervention. The burden of understanding each other’s speech and remembering what was said was lifted by the tangible, visual support provided by accessible reading material. To reduce EB’s frequent late afternoon agitation, the staﬀ encouraged EB to read an adapted book with another resident (i.e., reading with a friend). The environmental and interaction recommendations (treatments Nos. 5 and 6) to optimize the reading experience

182

Reading as Intervention for a Skilled Nursing Facility Resident with Dementia

Fig. 48.1 Daily schedule cue card blank.

were reinforced. “Reading with a friend” was added as an afternoon activity on EB’s daily schedule form and added to EB’s nursing care plan.

●

Reading2Connect groups ( ▶ Fig. 48.4): Given EB’s past experience with committees and social groups, EB, with the speech pathologist, attended one of the weekly recreation department Reading2Connect groups. The speech-language pathologist modeled and reviewed the optimal reading environmental and interaction recommendations (▶ Fig. 48.5 and

▶ Fig. 48.6) to foster EB’s comfort level and engagement with

the group. In addition, the weekly Reading2Connect group was also included in EB’s daily schedule.

48.6 Outcome

By the end of therapy, visual memory aids, environmental adaptions, and communication strategies were implemented. Recreation staﬀ reported that EB’s activity attendance had increased from twice a week before therapy to twice a day.

According to recreation staﬀ,EB“seemed to respect the author- ity of print” and most of the time willingly attended activities that were written on her daily schedule. EB also reported enjoying reading. However, staﬀ observed that EB rarely read independently. Family and staﬀ concluded that EB read and enjoyed books most when reading interactively with a family member or another resident. One staﬀ member reported, “She lights right up when we invite her to read with another resident.”

Nursing reported that EB consented to and enjoyed the scheduled reading with a friend four to five afternoons a week. Staﬀ also reported that per iods of afternoon wandering and agi- tated verbal exchanges decreased from about approximately 1 hour a day, 7 days a week, to approximately 15 minutes, about three times a week. Companionship reading appeared to be an eﬀective nonpharmacological strategy to address EB’s agitation, repeated questions, high confusion, and restlessness. In addition, EB’s family reported that their awareness of environmental factors, use of communication strategies, and the adapted reading material made conversations with their mother more successful, substantial, and relaxed.

183

Reading as Intervention for a Skilled Nursing Facility Resident with Dementia

Fig. 48.2 Daily schedule cue card completed.

Fig. 48.3 Reading with a friend.

184

Reading as Intervention for a Skilled Nursing Facility Resident with Dementia

Fig. 48.4 Reading2Connect group.

Fig. 48.5 Environmental recommendations.

185

Reading as Intervention for a Skilled Nursing Facility Resident with Dementia

Fig. 48.6 Interaction recommendations.

48.7 Key Points

●

Cognitive/language therapy for people living with dementia should be functional, focusing on optimizing visual and auditory reception, educating communication partners, and modifying the environment to circumvent deficits and capitalize on the individual’s spared abilities.

●

Diﬃcult behaviors exhibited by persons living with dementia are not random. They are a form of communication, and may more accurately be referred to as responsive behaviors. These

Suggested Readings

[1] Bourgeois M. Memory Books and Other Graphic Cuing Systems. Baltimore,

MD: Health Professions Press; 2007

[2] Dixon PS, Ostrowski S. Making reading easier for people with dementia.

vertical bar Advance Senior Care. 2016. Available at: http://www.iadvanceseniorcare.com/article/memory-care/making-reading-easier-people-dementia

[3] Kitwood T. Dementia Reconsidered: The Person Comes First. Philadelphia,

PA: Open University Press; 1999

[4] Basting AD. Forget Memory. Baltimore, MD: The Johns Hopkins University

Press; 2009

behaviors are generally related to physical discomfort or pain, inadequate communication by care partners, and/or suboptimal environmental factors.

●

Cognitive/language assessment of people with dementia is a dynamic and highly individualized process, occurring throughout the duration of therapy and involves the examination of the eﬃcacy of interventions.

186

Assessment in a Bilingual Female Post-CVA

49 Speech-Language and Dysphagia Assessment in a Bilingual Female Post Cerebrovascular Accident

Luis F. Riquelme

49.1 Introduction

This case describes the speech-language/dysphagia assessment and intervention following a left hemisphere cerebrovascular accident (CVA) in an 81-year-old bilingual (Spanish/English) woman. This patient initially presented equal language impairment in both her native, Spanish, and second language, English. Patients like these can benefit immensely from assessment and treatment by a bilingual speech-language pathologist (SLP), who is able to accept responses in either language, as well as provide stimuli in either language.

49.2 Clinical History and Description

AS, an 81-year-old woman, presented to the emergency room at a local acute care hospital with a past medical history of diabetes mellitus, hypertension, and hyperlipidemia. Initial computed tomography of the brain revealed no evidence of acute intracranial hemorrhage, mass eﬀect, or midline shift. A focal area of diminished attenuation in the right basal ganglia compatible with lacunar infarct was noted. Given that AS arrived at the emergency room with signs/symptoms of stroke, she underwent and failed dysphagia screening (i.e., she coughed upon being given 3 ounces of water to drink without interruption) and was temporarily kept NPO (nil per os). According to AS’s daughter, AS was fully bilingual (Spanish/English) prior to this incident, but her native/primary language was Spanish. AS was a retired seamstress. In addition, AS was also employed as a home health aide for a short period of time. AS was originally from Honduras and had lived in the United States for more than 20 years.

49.3 Clinical Testing

AS was admitted to the Acute Stroke Unit and seen by speechlanguage pathology early the next morning. The available clinician was a monolingual/English speaker. The initial evaluation focused on AS’s most immediate need: her ability to eat by mouth. Use of an interpreter was explored, but due to the complexity of linguistic symptomatology, the clinician chose to await full speech-language evaluation by a Spanish-speaking clinician. Results of this evaluation revealed a mild oropharyngeal dysphagia, characterized by mild bolus management delays noted clinically. Further, the initial monolingual evaluation left queries regarding possible aphasia versus apraxia of speech for further exploration by a bilingual clinician. This evaluation resulted in the following recommendations: chopped diet with neutral liquids and further speech-language assessment by a Spanish-speaking examiner. Neutral liquids are a classification used at the local institution to describe a set of liquids that do not include acidic or fatty substances. All other liquids are

allowed. This classification is thought to reduce risk for development of aspiration pneumonia given that acidic/fatty substances are thought to be more invasive for the lungs than other “neutral” substances.

A second SLP evaluation was conducted by a Spanish-speaking clinician. AS presented with poor comprehension skills (< 10%) for simple yes/no questions, following commands, and object identification in a field of two. These findings were consistent when stimuli were presented in Spanish and in English. Verbal output was unintelligible with prosodic features of both Spanish and English. Approximately 10% real words were produced within jargon; these words were judged to be low content. Again, some productions were in English and some in Spanish. Overall, AS was well related and cooperative. Results of this evaluation revealed a moderate-to-severe fluent aphasia and speech-language treatment provided by a bilingual Spanish/English clinician was recommended.

Subsequent magnetic resonance imaging of the brain without contrast, conducted 4 days postadmission, revealed acute infarct in the left temporoparietal region, with foci of diminished gradient within the infarcted region compatible with hemorrhagic components. In addition, mild chronic microvascular changes and mild cortical atrophy were noted. AS was discharged home after a 2-week admission. She was then referred for outpatient rehabilitation, including speech-language reassessment and treatment . Approximately 8 weeks post onset, AS was seen in the outpatient center and reassessed for speech-language treatment services by a bilingual Spanish-/ English-speaking clinician. Results revealed continued moderate-to-severe fluent aphasia, with improvements observed in comprehension and slightly for expression. Data from testing in Spanish revealed the following: simple yes/no questions—62% correct; common object identification in a field of two—66% correct. Verbal output continued to comprise mostly jargon with increasing use of concrete words. Jargon now included simple phrases, which increased intelligible productions to 30%. In this context, some confabulation was noted. More direct testing for output was conducted via adapted subtests of the Boston Diagnostic Aphasia Examination (BDAE; available informally in Spanish version from Spain or from Argentina). Confrontation naming: 20% correct; picture description via the cookie theft picture was similar to conversational output described. Reading was at 60% for matching labels to common objects, while writing was limited to producing AS’s name. Similar results were noted in English.

49.4 Questions and Answers for the Reader

1. What was the significance of having a speaker of the patient’s

native language conduct an assessment? (In view of the fact that patient was bilingual Spanish/English prior to the CVA.)

187

Assessment in a Bilingual Female Post-CVA

a) Testing in dominant language would have suﬃced. b) Need to compare proficiency and breakdown in both

languages concurrently. c) Important for patient to feel comfortable. d) No real need to have a bilingual examiner see patient.

Answer: b is correct. Diﬀerences in comprehension, processing, and selection for expression are significant factors in determining choice of language for treatment and overall prognosis. It is known that bilinguals possess an intermixed lexical and morphosyntactic neural organization; however, inconsistent evidence exists for cross-language transfer post CVA. Kohnert questions whether L1 and L2 are equipotent for language/communication gains.

a is incorrect. AS was bilingual prior to CVA; therefore, the interaction of both languages needs to be addressed post neurological event.

c is incorrect. The patient’s language proficiency is likely insuﬃcient for feelings of comfort. Overall communicative eﬀectiveness needs to be taken into account.

d is incorrect. The argument for testing in both languages of proficiency prior to CVA has been made.

2. Would results be diﬀerent if the assessment had been con-

ducted using an interpreter? a) Yes, using an oﬃcial interpreter always yields more accu-

rate data.

b) Yes, using a bilingual SLP always yields more accurate

data.

c) There is minimal evidence to support large diagnostic dif-

ferences when using an interpreter.

Answer: c is correct. Clinical intuition suggests that the use of an interpreter is the “second” best alternative; however, no empirical evidence exists to support this. The SLP team at this local institution conducted a small performance-improvement project in 2012 using interpreters and native-speaking SLPs for patients of Spanish or Russian background who were referred for a speech-language evaluation post CVA. The hypothesis was that results from evaluations conducted at bedside would diﬀer when conducted by a native speaker of the patient’s native language versus when conducted with the use of an interpreter. All testing was conducted on the same day and examiners were blinded to results from the previous evaluation. Nine patients participated in the project, four Russian and five Spanish speakers. We found that the resulting impressions did not diﬀer when the assessment was conducted by an SLP in the native language of the patient versus when conducted with a nativespeaking interpreter. These results should be interpreted cautiously given the small number of participants.

a is incorrect. There is insuﬃcient research evidence available to make this statement.

b is incorrect. There is insuﬃcient evidence on this issue.

3. Knowledge of the neuroimaging results assist in reaching a

communication diagnosis. True or false? a) True. b) False.

Answer: a is correct. The fact that damage was multifocal helped explain some language-processing behaviors. Simply stated, focal damage may result in one-dimensional language

breakdown, whereas in the presence of diﬀuse damage, cognitive factors play a stronger role in neural relations with language processing.

If only considering behavioral communication factors during assessment, many clinical judgments may be questioned. While neuroimaging data are not always available, location and circumstances of the brain damage help the examiner form a stronger hypothesis for impressions and recommendations.

49.5 Description of Disorder and

Recommended Treatment

AS presented with significant moderate-to-severe fluent aphasia. Her comprehension was limited, ranging 60% to 70% for simple auditory input, yet she appeared socially appropriate, as expected with this clinical population. While her language output was mostly jargon, prosodic features from both Spanish and English were observed. An increase in concrete productions and simple phrases, mostly in Spanish, was also of note. The mild oropharyngeal dysphagia noted acutely when first examined 1 day post admission had resolved by the time of discharge from the hospital. As there were no complaints of any swallowing deficits, a dysphagia evaluation was not included in the outpatient assessment protocol.

AS’s family support, mostly from her only daughter, was excellent. Her daughter was present for approximately 80% of the sessions, supporting carryover of the treatment goals to the home. Language proficiency in one language versus the other was diﬃcult to ascertain in the context of fluent aphasia. Given that both L1 and L2 are processed in the dominant hemisphere, in overlapping areas, it was anticipated that both languages were aﬀected by her CVA.

During outpatient language therapy, an important decision had to be made regarding the choice of language to employ in treatment. Several hypotheses exist regarding language recovery post focal cerebral lesion in bilingual speakers. The most known are parallel and nonparallel recovery (where prof iciency in L1 and L2 are similar or dissimilar to levels prior to the brain injury), Ribot’s rule (proposed in 1881: L1 will be the stronger language post injury), and Pitre’s rule (proposed in 1895: the dominant language at the time of injury will be the first to recover). The following three components should be considered when making decisions regarding language of treatment decisions in bilingual patients:

●

Premorbid language history, including educational/occupational history and estimated extent of premorbid bilingualism.

●

Strengths and weaknesses in each language.

●

Environmental factors: the language that the patient selects for rehabilitation, the language of family choice, and the sociocultural language needs upon discharge.

Given that AS presented stronger skills in Spanish, with some emerging English output, treatment was conducted in Spanish with allowances for English productions. This ideal clinical scenario was possible given the availability of a bilingual SLP for treatment. Encouragingly, evidence suggests that regardless of language of treatment, the other language will also benefit. A recent systematic review of 14 st udies examining the eﬀect of

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31.08.202630 Мб0Книга_4520_Библиотеки_им_академика_М_И_Перельмана.djvu
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31.08.202630 Мб0Книга_4522_Библиотеки_им_академика_М_И_Перельмана.pdf
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31.08.202629 Мб0Книга_4529_Библиотеки_им_академика_М_И_Перельмана.pdf
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31.08.202628 Мб0Книга_4531_Библиотеки_им_академика_М_И_Перельмана.epub