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Communication Disorders Across the Life Span: Adults J.B. Orange, PhD Associate Professor JBOrange@uwo.ca X88921 Faculty of Health Sciences School of Communication Sciences and Disorders. Outline. Overview of common speech, voice, language, and cognitive-communication disorders in adults

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  1. Communication Disorders Across the Life Span: AdultsJ.B. Orange, PhDAssociate ProfessorJBOrange@uwo.caX88921Faculty of Health SciencesSchool of Communication Sciences and Disorders

  2. Outline • Overview of common speech, voice, language, and cognitive-communication disorders in adults • Assessment - screening • Referrals

  3. Speech(production and perception) • Medium of oral communication that employs a linguistic code • Communication through vocal symbols • Complex, dynamic neuromuscular processes of sound production • articulation • resonance • phonation • respiration • prosody (e.g., pitch, speech rate, stress, etc.)

  4. Voice • Sounds produced in air above vocal chords as chords vibrate • Use of vocal folds and associated muscular, skeletal, cartilage, and nerve tissue • Source of sound energy • Linked with respiratory, resonatory and speech systems

  5. Resonance • Vibration of the air in the cavities above, below, in front of, and behind the sound source • Nasal vs vocal

  6. Swallowing • To pass substances through the oral cavity and pharynx and into the esophagus • Complex, coordinated motor sequences of multiple muscle systems • Initiated voluntarily but almost always completed reflexively • Distinct from feeding • 4 phases

  7. Hearing • The sense through which spoken language or non-speech sounds (i.e., via sound pressure waves) are received, transmitted and processed • Ears, auditory nerve and cerebral cortex

  8. Language • a shared set of symbols used to represent concepts or ideas • symbols governed by set of rules: • phonology (sound positions and combinations) • grammar (The boy randed to the store.) • syntax (to store the boy the ran) • semantics (define “car”) • pragmatics (multiple interpretations of words, phrases, clauses, or sentences - contextual influence, e.g., “run”, “cold shoulder”)

  9. Communication 1. exchange of concepts or ideas between two entities • dynamic role exchange between speaker and listener 2. mechanism whereby we establish, maintain and change relationships • consists of multiple forms • socially motivated and mediated = interactional • agenda driven = transactional (e.g., ordering food in a restaurant)

  10. Cognition • processes of gaining knowledge, organizing information (new or old), and using what has been learned • includes, but is not limited to: • memory systems and processes • attention systems and processes • judgment • reasoning - decision making • insightfulness • other systems and processes

  11. Input/Understanding auditory comprehension reading comprehension nonverbal senses of smell, touch and taste Output/Expression spoken written nonverbal (e.g., gaze, facial expression, posture, proximity, touch, gestures, pantomime, finger spelling, sign language, etc.) Speech, Language, Hearing and Communication

  12. Speech and voice based on integration of five systems: respiratory phonatory (vocal folds) resonatory (coupling of pharyngeal, oral, and/or nasal cavities) articulatory prosodic (duration, rate, rhythm, intensity, pitch, and sound stress) Speech and Voice Disorders

  13. disruption in one or more of systems that produce speech and voice often referred to as motor speech disorder results from weakness, slowness, lack of coordination, and altered tone of muscles that support speech and voice several types including flaccid, spastic, ataxic, hypokinetic, hyperkinetic and mixed Dysarthria

  14. Dysarthria (cont’d) • individuals normally understand spoken language, can read and write (provided there are no physical or sensory impairments of arms, hands or eyes) • generally, no language problems • do not normally have trouble with word finding • mild to severe unintelligibility • if severe, anarthria (total inability to speak)

  15. Problem articulation speech rate Symptoms imprecise or unclear sounds and syllables rapid, slow, or irregular speaking rate Common Speech and Voice Symptoms in Dysarthria

  16. vocal quality loudness prosody hypernasal, breathy, hoarse, strained-strangled; intermittent voicing or aphonia (no voice) too loud, too soft, intermittent bursts of loudness, monoloud monopitch, in-appropriate changes in pitch, sound, syllable or word stress problems

  17. Apraxia of Speech (AOS) • motor speech disorder • difficulty initiating and sequencing speech movements (difficulty programming muscle movements) • not as a result of: • listening (comprehension) problems • reflex problems • muscle strength or tone (e.g., paralysis or paresis) • cognitive or psychiatric problems

  18. AOS(cont’d) • characterized by: • sound substitutions and additions (e.g., “take” for “cake”) • transposition of syllables (e.g., “terbut” for “butter”) • difficulty initiating speech (physical groping to produce sounds) • impaired prosody

  19. Aetiology of Dysarthria and AOS: Selected Examples • cerebral vascular accidents (CVA) = stroke = “brain attack” • head trauma • brain tumors • progressive neurological diseases (e.g., Parkinson’s disease, amyotrophic lateral sclerosis (ALS), and multiple sclerosis (MS), etc.) • negative side effects of psychotropic drugs (e.g., tardive dyskinesia) • brain infections (e.g., encephalitis)

  20. Organic carcinoma contact ulcers trauma polyps tumors nodules web cysts Non-organic – Functional stress and anxiety conversion reaction – emotional distress other psychosocial factors Aetiology of Voice Disorders: Selected Examples

  21. Voice Disorders (cont’d) • laryngeal cancer common cause of voice disorder • peak age occurrence between 60-70 years old • several studies link laryngeal cancer to excessive and prolonged cigarette smoking and alcohol consumption • laryngeal cancer treated by radiation therapy, chemotherapy, and in more advanced cases, surgery

  22. Voice Disorders (cont’d) • complete removal of larynx (i.e., total laryngectomy) requires new airway • permanent tracheostomy (i.e., stoma) created just above sternum • person breathes through stoma • nose and mouth completely separated from airway to lungs

  23. Voice Disorders (cont’d) • after total laryngectomy, laryngectomee is unable to phonate (i.e., produce a voice) Several alternatives: • artificial larynx – electrolarynx (extra- or intra-oral) • device that generates a vibration while the resident articulates (i.e., moves, lips, tongue, soft palate)

  24. Voice Disorders (cont’d) • esophageal speech • breathing air into upper segment of esophagus then expelling it to generate vibratory tone • less common Rx option

  25. Voice Disorders (cont’d) • surgically created voice - tracheoesophageal puncture (TEP) • small opening made between trachea and esophagus • one-way valve prosthesis inserted in opening • air drawn through valve into esophagus where PE segment vibrates

  26. Language Disorders - Aphasia • acquired language disorder that affects: • spoken and written language • listening and reading comprehension • nonverbal communication • damage to cortical and/or subcortial regions known to support language functioning • different types and severity: • depend on region(s) and amount involved

  27. Aetiology of Aphasia: Selected Examples • cerebrovascular accident (CVA = stroke = “brain attack”) • traumatic brain injury (TBI) • neoplasm • infectious diseases • other (e.g., exposure to toxins, etc.)

  28. Neural Basis of Aphasia • L and R cerebral hemispheres involved in language processing • for many people L cerebral hemisphere controls almost all language processes • focal damage to L hemisphere results in aphasia • R hemisphere contributes (but to lesser extent) to language functioning • R hemisphere damage does not usually result in aphasia

  29. Broca’s Aphasia • slow, laboured speech • few spoken words; mostly nouns and verbs • spoken and written grammar are impaired • word finding problems • listening and reading comprehension skills impaired but better than spoken language • person is aware of his/her language problems • AOS and R hemiplegia or hemiparesis can accompany

  30. Wernicke’s Aphasia • excessive amount of spoken language • word-finding problems • content often lacks meaning • significant listening and reading comprehension difficulties • well formed and normal speech (i.e., pitch, rate, rhythm, etc.) • person exhibits little awareness of his/her language problems

  31. Global Aphasia • limited functional language and communication • may repeat a few common every day words or clichés or non-words spontaneously or in response to questions • poor listening and reading comprehension • may understand simple gestures or pantomime, vocal inflection, facial expression and environmental sounds • may be able to copy own name; writing usually non-functional

  32. Anomia in Aphasia Variety of word-finding errors: • jargon - unacceptable sequencing of real and/or nonwords (i.e., neologism = “slammazer”) • vague/nonspecific words (e.g., “thing” for “pen”) • phonemic paraphasia - word close in sound to intended word (e.g., “pit” for “sit”)

  33. semantic paraphasia - word closely related in meaning to intended word (e.g., “salt” for “pepper”) • verbal paraphasia – real word unrelated to intended word (e.g., “cup” for “brother”)

  34. Aphasia Recovery Degree and speed of recovery of language varies depending on: • spontaneous recovery • language Rx from SLP • severity at onset • aetiology • site and extent of brain damage • type of aphasia • other factors (L1 vs L2, sex, education level, age, etc.)

  35. Cognitive-Communication Disorders: Dementia • Syndrome of acquired, progressive, persistent decline in 3 of 5 spheres of mental activity:   1. memory 2.language and communication 3. personality 4. visuospatial skills 5. cognition(e.g., reasoning, abstraction, judgement, etc.)

  36. DSM IV A. Multiple cognitive deficits including both: 1. memory impairment 2. one (or more) of the following:a. aphasia b. apraxia c. agnosia d. disturbance in executive functioning(e.g., planning, organizing, sequencing, abstracting, etc.) • Cognitive deficits in A1 and A2 each:1. cause significant impairment in social or occupational functioning 2. represent significant decline from previous functioning

  37. Epidemiology and Demographics: Prevalence(CSHA I Working Group, 1994, CMAJ) • 252,600 (8% of 65+) (% distribution: community = institutions) • 2 ♀: 1 ♂ • 2.4% 65-74 yrs • 34.5% 85+ yrs • 161,000 DAT (64% of total dementias) • 19% VaD • Mixed = DAT + VaD = rising % • 592,000 cases by 2021 (65 yrs + = 23-24% total pop) • # cases will triple by 2031

  38. Incidence(CSHA II Working Group, 2000, Neurology) • 60,150 new cases dementia/yr • 39,000 cases of DAT/yr

  39. DAT/AD EoAD DS-DAT VaD Mixed (DAT + VaD) Lewy body disease FTLD (FLD + semantic dementia) PPA FTLD Pick’s Pick’s Complex Dementia with motor neurone disease Parkinson’s, ALS, MS, HC, etc. AIDS dementia CJD Examples of Types of Dementia

  40. Dementia (cont’d) • previously thought of as irreversible = non-treatable, although this is changing • prevalence increases dramatically with age • DAT more common among those with low education • subgroups of DAT (e.g., age of onset, family history, frontal lobe signs, head trauma, maternal age, level of formal education, etc.)

  41. Speech, Language and Communication Profiles in DAT

  42. dysarthria pitch changes volume control speaking rate apraxias none none no problems normal limb praxis problems early; verbal and oral apraxias may appear later Speech

  43. Language and Communication Language and communication problems prominent in DAT • subtle onset; prominent with progression Profiles vary by clinical stage • markers of onset and progression Language and communication of utmost concern to caregivers Heterogeneity (i.e., broad range of skills) within each stage

  44. normal aging confusion or delirium stroke-based aphasia psychiatric disorders (e.g., schizophrenia) depression R hemisphere dysfunction other focal neurological disorders and syndromes traumatic brain injury (e.g., motor vehicle accident - MVA) Language and communication profile in DAT differs from those associated with:

  45. DifficultiesPrevalence (%) word finding ……… 84 naming objects …… 82 letter writing ……… 80 comprehend instructions ……… 76 sustain conversation …… 71 complete ideas …… 64 repeat ideas ……… 64 reading comprehension …… 64 DifficultiesPrevalence (%) meaningless sentences ………… 60 decreased talkativeness …… 58 inappropriate talk … 54 repeat words ……… 45 interprets literally …… 33 recognizes humor … 32 increased talkativeness ……… 16 (n = 99; Bayles & Tomoeda, 1991) Prevalence of Language and Communication Symptoms in DAT

  46. naming & vocabulary spokenoutput repetition listeningcomprehension writing errors appear early; related words used then words become increasingly less related subtle changes early; reduced meaning with progression; sentences less elaborate and tangential; grammar and syntax OK until late stage intact problems apparent in middle stage; Wh questions difficult; prosody and nonverbal important semantically empty by middle stage Language

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