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Memory Assessment on an Interdisciplinary Team: Roles and Collaborations Between Neuropsychology and Speech-Language Pathology. Angelle M. Sander, Ph.D. Assistant Professor Department of Physical Medicine & Rehabilitation Baylor College of Medicine Presented at Monthly Meeting of the

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slide1

Memory Assessment on an Interdisciplinary Team: Roles and Collaborations Between Neuropsychology and Speech-Language Pathology

Angelle M. Sander, Ph.D.

Assistant Professor

Department of Physical Medicine & Rehabilitation

Baylor College of Medicine

Presented at Monthly Meeting of the

Houston Neuropsychological Society

January 2006

slide2

Joint Committee on Interprofessional Relations Between Division 40 (Clinical Neuropsychology) of the American Psychological Association (APA) and the American Speech-Language-Hearing Association (ASHA)

slide3

ASHARepresentatives(2005)

Fofi Constantinidou, Ph.D., CCC-SLP

Associate Professor &

Director of Graduate Studies

Director of NeuroCognitive Disorders Laboratory

Department of Speech Pathology & Audiology

Miami University

2 Bachelor Hall

Oxford, OH 45056

Tel 513- 529-2507

Fax 513- 529-2502

Email constaf@muohio.edu

Wendy Ellmo, M.S., CCC-SLP, BCNCD

Center for Head Injuries

Cognitive Rehabilitation Department

2048 Oaktree Road

Edison, NJ. 08820

Tel 732-906-2640 ext. 42721

Fax 732-906-9241

Email wellmo@msn.com

Stacie Raymer, Ph.D. (ASHA Chair)

110 Child Study Center

Old Dominion University

Norfolk, VA 23529

Tel 757-683-4522

Fax 757-683-5593

Email sraymer@odu.edu

Celia R. Hooper, Ph.D., CCC-SLP (Monitoring Vice

President)

ASHA Vice President for Professional Practices in

Speech-Language Pathology (2003-2005)

Professor and Department Head, UNC-Greensboro

Department of Communication Sciences and Disorders

300 Ferguson Building, P. O. Box 26170

Greensboro, NC 27402-6170

Tel 336- 334-5184

Fax 336-334-4475

Email chooper@uncg.edu

Diane R. Paul, Ph.D., CCC-SLP (Ex Officio)

Director

Clinical Issues in Speech-Language Pathology

American Speech-Language-Hearing Association

10801 Rockville Pike

Rockville, MD 20852

Tel 301-897-5700 ext. 4297

Fax 301-897-7354

Email dpaul@asha.org

slide4

Division 40 Representatives (2005)

Robin Hanks, Ph.D., ABPP (Committee Chair)

Chief, Rehabilitation Psychology & Neuropsychology

Rehabilitation Institute of Michigan

261 Mack Boulevard

Detroit, Michigan 48201

Tel 313-745-9763

Fax 313-745-9854

Email rhanks@dmc.org

Tessa Hart, Ph.D.

Moss Rehabilitation Research Institute (MRRI)

Korman Suite 213

1200 West Tabor Road

Philadelphia, PA 19141

Tel 215-456-6544

Fax 215-456-5926

Email thart@einstein.edu

Angelle Sander, Ph.D.

The Institute for Rehabilitation and Research

Brain Injury Research Center

2455 South Braeswood

Houston, TX 77030

Tel 713 383 5644

Fax 713 668 3695

Email asander@bcm.tmc.edu

Risa Nakase-Richardson, Ph.D

Neuropsychology Department

Methodist Rehabilitation Center

1350 E. Woodrow Wilson

Jackson, MS 39216

Tel 601-364-3448

Fax 601-364-3558

Email nakase@aol.com

Jeffrey Wertheimer, Ph.D.

Brooks Rehabilitation Center

3901 University Blvd., South

Jacksonville, Florida 32216

Tel 904-858-7296

Fax 904-858-7255

Email Jeffrey.wertheimer@Brookshealth.org

past division 40 committee members
Past Division 40 Committee Members

Kenneth Adams Sharon Brown

Linas Bieliauskas Joseph Ricker

Robert Bornstein Doug Johnson-Greene

Gerald Goldstein Sanford Pederson

Byron Rourke Steven Putnam

Jill Fischer

joint committee
Joint Committee
  • Established in 1989
  • Mission:
      • improve the clinical care of patients with congenital or acquired brain impairment by identifying and promoting assessment and rehabilitation practices that are both compatible with current neuropsychology knowledge and of demonstrable functional benefit to patients and their families
      • foster communication and collaborative work between speech-language pathologists and clinical neuropsychologists for the benefit of both professions
slide7

Joint Committee Documents

  • 1. Interdisciplinary Approaches to Brain
  • Damage
    • - 1989 Position Statement
    • - http://www.asha.org/NR/rdonlyres/4A1C60E7-
    • BC87-49A0-84F4-0E2AA9DED99E/0/
    • 19051_1.pdf
interdisciplinary approaches to brain damage
Interdisciplinary Approaches to Brain Damage

“Neuropsychology is the scientific study of the relationship between brain function and behavior. As such, neuropsychology, in the generic sense, is an interdisciplinary knowledge area embracing many contributing disciplines and professions. Therefore, it is appropriate that the knowledge base of neuropsychology not be regarded as proprietary by any given discipline or profession.”

interdisciplinary approaches to brain damage9
Interdisciplinary Approaches to Brain Damage

“It is acknowledged that this knowledge base may be applied for the betterment of human welfare by different disciplines and professions with different training emphases. It is assumed that such practice will include techniques andprocedures included in discipline-specific training and exclude those for which competence has not been established through such training criteria.”

interdisciplinary approaches to brain damage10
Interdisciplinary Approaches to Brain Damage

“Individual practice may also be limited by laws or even ethical considerations in a given instance.It is also recognized that clinical practice with individuals who demonstrate impairment of the central nervous system is frequently an interdisciplinary effort which employs the particular strengths and expertise of various professions and disciplines.”

“…mutual respect and cooperation between disciplines and professions is an ongoing necessity.”

joint committee documents
Joint Committee Documents

2. Guidelines for the Structure and Function of an Interdisciplinary Team for Persons With Brain Injury

- 2003 Technical Report by Diane R. Paul,

Ph.D., & Joseph H. Ricker, Ph.D.

- http://www.asha.org/NR/rdonlyres/

34D07350-A6C0-43DD-A175-

373B86939A48/0/19110_1.pdf

Provides general guidelines for interdisciplinary

teams for the clinical management of people with

brain injury, with the ultimate goal to improve the

quality of service for individuals affected by

communication and cognitive disorders.

joint committee documents12
Joint Committee Documents

4. Rehabilitation of Children and Adults With Cognitive-Communication Disorders After Brain Injury

- 2002 Technical Report by Mark Ylvisaker,

Ph.D., Robin Hanks, Ph.D., & Doug Johnson-

Greene, Ph.D.

- http://www.asha.org/NR/rdonlyres/7D6D3FD5-9197-

429E-9CA7-BB31E9C95B26/0/21939_4.pdf

Published in Journal of Head Trauma Rehabilitation.

(2002). 17(3), 191-209.

The report outlines two paradigms for cognitive

Rehabilitation: a traditional discrete approach, and an

alternative contextualized approach.

joint committee documents13
Joint Committee Documents

3. Evaluating and Treating Communication and Cognitive Disorders: Approaches to Referral and Collaboration for Speech-Language Pathology and Clinical Neuropsychology (2003)

- http://www.asha.org/NR/rdonlyres/

E868544A-0C78-4F90-A515-

4FA69CE6A708/0/23026_2.pdf

Encourages referral and collaboration between

speech-language pathologists and clinical

neuropsychogists and informs referral sources about

the roles of both professions.

slide14
Survey of Perceived Roles and Collaborations for Neuropsychologists and Speech-Language Pathologistsin Rehabilitation
  • Surveys e-mailed to:
    • 1,351 SLPs in ASAH Division 2 (Neurophysiology and Neurogenic Speech and Language Disorders): 311 returned (23.2%)
    • 340 NPs who held joint membership in APA Divisions 40 (Clinical Neuropsychology) and 22 (Rehabilitation Psychology): 77 returned (22.9%)
highlights from survey
Highlights from Survey
  • While 88% of NPs practice in settings where an SLP is present, only 60% of SLPs practice in settings where a NP is present.
  • Many SLPs (46%) view NPs role as consultation only; Few NPs (14%) view SLPs role as consultation only.
  • Only 29% of SLPs view NPs as assessing language, while 100% of NPs view SLPs as assessing language.
highlights from survey16
Highlights from Survey
  • 86% of each discipline viewed the other as assessing cognition.
  • The majority of NPs (>90%) viewed SLPs as treating language and cognition, while only 27% of SLPs viewed NPs as treating cognition and <1% perceived them as treating language.
highlights from survey17
Highlights from Survey
  • Primary means of collaboration reported by both disciplines was informal consultation.
  • Most frequent collaborations reported were sharing assessment results and educating patients and families (still only 42% of SLPs and 51% of NPs reported often or always).
  • Least frequent collaborations were pre-assessment discussions and orienting medical staff.
highlights from survey18
Highlights from Survey
  • 59% of SLPs refer to NP for assessment; 37% of NPs refer to SLP for assessment.
  • While 63% of NPs report referring to SLPs for treatment, only 23% of SLPs refer to NPs for treatment.
slide19

Impaired memory is a frequently observed occurrence among patients in rehabilitation- both inpatient and outpatient.

slide20

Diagnoses Commonly Seen on Rehabilitation Unit

  • Stroke
  • Traumatic Brain Injury
  • Anoxia
  • Multiple Sclerosis
  • Cerebral Tumors
  • Dementia (concommitant with deconditioning, orthopedic injuries, etc.)
  • Encephalitis (e.g., Herpes Simplex)
slide21

Other Conditions Resulting in Memory Impairment

  • Epilepsy
  • Metabolic abnormalities (e.g., NA levels)
  • Nutritional disorders (e.g., B12 deficiency)
  • Hematologic Conditions (e.g., chronic anemia)
neuroanatomy of memory
Neuroanatomy of Memory
  • Temporal lobe and hippocampus important for storage of new memories and retrieval of existing memories
  • Frontal lobe and subcortical structures important for encoding and retrieving through their role in “executive” or “supervisory” functions (e.g., attention, organization, temporal memory)
  • Memory can be impacted by lesions anywhere in the brain (e.g., language issues impacting verbal memory; parietal lobe lesions impacting visual memory.
neuroanatomy of memory23
Neuroanatomy of Memory
  • Modality specificity
    • Left hemisphere verbal memory]
    • Right hemisphere visual memory

This only holds true with relatively circumscribed lesions. Furthermore, most visual memory tests include materials that can be verbalized.

memory assessment is an important part of the rehab process
Memory Assessment is an Important Part of the Rehab Process
  • To guide implementation of treatment goals by the team (e.g., learning of strategies; assimilating safety practices)
  • To guide development of compensatory strategies
  • To guide discussions with patients and their family members regarding challenges after discharge
  • To serve as an anchor point for future changes
slide25

Memory is assessed by multiple disciplines, in a variety of ways, both formally and informally, raising the potential for disparate messages to be communicated to patients, family members, and other rehabilitation staff.

purpose
Purpose
  • To provide some guidelines to improve clarity and consistency with regard to the communication of memory impairments
    • Presentation of a theoretical model based in cognitive neuroscience
    • Discussion of some frequently used memory measures and their relation to the model
    • Presentation of a case to illustrate assessment issues and treatment implications
early stage models
Early Stage Models
  • Encoding
  • Storage
  • Retrieval
encoding
Encoding
  • Early processing of material to be learned
  • Involves strategies such as rehearsal and organization
  • Quality determines how well info is stored and later retrieved (e.g., depth of encoding, organization of material)
storage
Storage
  • Holding of information in the memory system for future use
  • Short-term store temporary unless transferred to long-term store
  • Encoding processes occur during short-term storage
  • Long-term store considered to be permanent unless disrupted by pathological process
retrieval
Retrieval
  • Pulling information from storage (long-term store) in order to use it
  • Delayed recall on memory tests
  • May be facilitated by presentation of information in recognition formats (e.g., multiple-choice; yes-no)
interaction between encoding storage and retrieval
Interaction Between Encoding, Storage, and Retrieval
  • Quality of encoding impacts storage and retrieval
  • Information is better recalled under conditions that are similar to when it was learned (context-dependent memory)
  • Repeated retrieval of information can increase the probability of it being retrieved at a later time
systems models of memory
Systems Models of Memory
  • Evolved from concerns that stage models were simplistic and could not explain complexities of memory process
  • Breakdowns can occur in one component of the system, while others are preserved (e.g., severe amnestics can have preserved digit span and recall of recent items, but be unable to learn new material
  • Memory is comprised of a set of interrelated systems and subsystems
slide34

Model of Working Memory

(Baddeley & Hitch, 1974)

Phonological Loop

VisuospatialSketchpad

Central Executive

model of working memory baddeley hitch 1974
Model of Working Memory(Baddeley & Hitch, 1974)
  • Two “slave systems” serve long-term memory: phonological loop and visuo-spatial sketchpad.
  • The systems temporarily store information, as well as perform operations (such as rehearsal) that would maintain information and eventually transfer it to long-term memory; also holds information that has been temporarily pulled from long-term store (e.g., multiplication tables)
model of working memory baddeley hitch 197436
Model of Working Memory(Baddeley & Hitch, 1974)
  • Central executive:
    • Interfaces between phonological loop, visuo-spatial sketchpad, and long-term memory
    • Traditional “frontal lobe functions”
    • Allocates attention to different processes; chooses and carries out different activities, such as organization
slide37

Model of Long-Term Memory (Tulving, 1985; Squire, 1992)

Long-term Memory Store

Declarative (Explicit)

Non-Declarative (Implicit)

Skills & Habits

Semantic

Episodic

Priming

long term memory tulving 1985 squire 1992
Long-Term Memory(Tulving, 1985; Squire, 1992)
  • Declarative Memory
    • Semantic: knowledge of facts (e.g., multiplication tables, historical facts)
    • Episodic: knowledge regarding personal experiences (e.g., college graduation; what you had for breakfast)
    • Episodic memory is most typically disrupted by damage to the brain, while semantic is typically relatively preserved.
long term memory tulving 1985 squire 199239
Long-Term Memory(Tulving, 1985; Squire, 1992)
  • Non-Declarative
    • Implicit memory in amnestic patients (priming- preserved learning even when they cannot recall the learning episode)
    • Preserved learning of procedural skills and perceptual skills in amnestic patients
slide40

SHORT-TERM STORE

LONG-TERM STORE

Testing Task

Working Memory

Declarative

Memory

Non-declarative Memory

Visual

Phonological

Central Executive

List Learning Memory

Supraspan Lists

(>than 9 words per list)

Immediate Recall (IR)

+

+

Delayed Recall (DR)

+

+

Recognition (Rec)

+

+

Forced Choice (FC)

+

+

Subspan Lists

(<than 7 words per list;

typically single

presentation)

Immediate Recall 

+

+

Delayed Recall 

+

+

Recognition

+

+

Paragraph Memory

Immediate Recall

+

+

Delayed Recall

+

+

Recognition

+

+

Paired Associates Learning

Immediate Recall

+

+

Delayed Recall

+

+

Recognition

+

+

Table 1. Testing Tasks and Their Relationship to Components of the Theoretical Memory Model

slide41

SHORT-TERM STORE

LONG-TERM STORE

Testing Task

Working Memory

Declarative

Memory

Non-declarative Memory

Visual

Phonological

Central Executive

Digit Span Task or Serial Recall Task - Backward (verbal)

Immediate Recall

+

+

Picture Recall

Immediate Recall

+

+

Delayed Recall

+

+

Recognition

+

+

Figure Recall

Immediate Recall

+

+

Delayed Recall

+

+

Recognition

+

+

Digit Span Task or Serial Recall Task - Backward (visual)  

Immediate Recall

+

+

Procedural Memory

+

Visual-Auditory Learning

Immediate Recall 

+

+

+

Delayed Recall 

+

+

background
Background
  • 58 year-old, right-handed, Hispanic female
  • 3 years of education
  • Sustained a right subcortical stroke
  • Symptom presentation: left hemiparesis and mild left inattention
  • Employment history: housewife for most of her adult life
  • Psychiatric history: none
  • Substance abuse history: none
  • Learning disability history: none
slide44

Neuroimaging Findings

Intracranial hemorrhage in the right internal capsule (part of the basal ganglia)

memory tests administered
Memory Tests Administered
  • Ross Information Processing Assessment-2
  • Digit Span (Forward and Backward) from WAIS-III
  • California Verbal Learning Test-2
  • Logical Memory I & II from WMS-III
  • Rey-Osterrieth Complex Figure Test- Immediate and Delayed Recall
test results
Test Results
  • RIPA-II
    • Within normal limits on items assessing orientation, memory for recent events (e.g., “What is the first thing you did this morning?) and memory for remotely learned information (e.g., “In what month is Christmas?”)
    • Correctly repeated 6 digits in forward sequence
    • Repeated a 15-word sentence
    • Couldn’t repeat a more complex sentence with 3 ideas
    • Recalled 2 of 3 words after a 10-minute delay
slide47

Test Results

  • CVLT-2
    • Intrusion errors on most trials
    • Benefited somewhat from semantic cueing based on category
    • Auditory recognition impaired due to a high number of false alarm errors
test results48
Test Results
  • Logical Memory
    • Within normal limits for number of details recalled for immediate and 30-minute delayed recall
    • Qualitatively, she recalled details in a piecemeal, disorganized fashion
  • Rey-Osterrieth Figure
    • Impaired (partially due to impairment of copy secondary to left neglect)
  • Digit Span
    • Forward=6; Backward=3
behavioral observations
Behavioral Observations
  • Distractibility
  • Motor restlessness
  • Impulsive responding
  • Reduced awareness of errors
conclusions
Conclusions
  • Immediate attention was within normal limits
  • Working memory impaired
  • Problems with organization and selective attention (screening out irrelevant information) resulted in impaired learning and recall)
  • May recall details, but may recall them out of sequence, resulting in errors on everyday tasks (e.g., medication management)
functional recommendations
Functional Recommendations
  • Supervision for most of each day
  • Assistance with making important decisions
  • Home safety evaluation
  • Supervision for medication management
  • Restriction from using potentially dangerous appliances
  • Cueing by family members to reduce impulsive behavior
  • Training in compensatory organizational and memory strategies
discussion points
Discussion Points
  • Memory was sufficient for functional communication skills.
  • Use of screening measures alone (e.g., RIPA-II) would have overestimated the patient’s memory abilities.
  • Use of raw scores and percentiles alone would have underestimated functional problems (importance of qualitative analysis and behavioral observations)
relation to theoretical model
Relation to Theoretical Model
  • Able to access information in the long-term store relatively well
    • Semantic (“In what month is Christmas?”_
    • Episodic (what she did yesterday or what she has for breakfast)- encoded in an organized way with personal meaning/significance
  • Impaired working memory
  • Impairment in Central Executive system (organization and selective attention) led to trouble encoding information in a way that would enhance recall)
relation to theoretical model54
Relation to Theoretical Model
  • Able to recall sentences and stories because they were organized in a manner that allowed for ease of encoding in the episodic store
  • Unable to impose organization on unstructured material, like word lists
  • Impairment in allocation of attention by Central Executive system led to false positive errors during auditory recognition memory performance