Cognitive Communication (Spencer) > Right Hemisphere Damage > Flashcards

Right Hemisphere Damage Flashcards

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1
Q

RHD Symptom Overview

A

Cognitive: anosognosia, hemispatial neglect, attention/memory deficits, visual function deficits
Linguistic (usually minor)
Extralinguistic: pragmatics (nonverbal comm, inferences, humor, etc.), prosody, discourse and conversation

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2
Q

RHD Overview

A

Right hemisphere language capacities and deficits have been a focus of study for only the last 20 years.
Researchers are just beginning to develop explanatory models, predictors of recovery, and lesion localization information.
The RHD population is markedly HETEROGENOUS (which further complicates research efforts)

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3
Q

Cognitive deficits

A

anosognosia

other aspects of executive functioning (planning, organizing, reasoning, problem solving…)

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4
Q

Anosognosia

A

Complex family of related disorders

Impaired awareness of deficits or reduced insight into how those deficits affect daily function.

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5
Q

Attention deficits

A

Right hemisphere appears to play a particular role in attention.
Arousal and orienting toward a stimulus (may be hypoaroused)
Vigilance and sustained attention
Possibly selective, divided, alternating attention.

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6
Q

Hemispatial neglect

A

constellation of disorders of spatial exploration and attention that manifests primarily in a directional bias for perception, attention, and/or action.
Difficulty disengaging attention from ipsilesional space and orienting to, acknowledging, or responding to stimuli that are primarily in contralesional space.
Often co-occurs with anosognosia
Negative ramifications for recovery of independence.

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7
Q

Does neglect only occur in the visual modality?

A

No

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8
Q

What are the most common lesion sites for neglect?

A

parietal lobe

temporal lobe

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9
Q

Can it occur after a left brain stroke?

A

Yes
Doesn’t last as long
Not as severe
Not as common

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10
Q

Memory

A

Episodic memory difficulties
Can have trouble with recall tasks (story, word list, paired-associates) -difficulties have been attributed to attention problems.

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11
Q

Working memory

A

adults with RHD often demonstrate limitations in verbal working memory.

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12
Q

Visual perceptual/visual spatial

A

May produce drawings that are spatially incomplete/disorganized
Topographical difficulty (map reading, describing how to get from one place to another)
May be exacerbated by co-occurring neglect, field cuts.

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13
Q

What kind of participation restrictions might result from these cognitive difficulties?

A
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14
Q

Linguistic deficits

A

Pure linguistic deficits are NOT a major source of RHD communication impairment.
May make errors on expressive and receptive language tasks such as naming, verbal fluency, following commands, but usually mild in severity.
Visuospatial deficits, neglect and attention/working memory impairments have been cited as possible contaminating factors in some studies investigating linguistic disorders.

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15
Q

Deficits in reading

A

May see reading comprehension impairments primarily for information requiring integration and inference revision.
Reading requires encoding and processing of visuospatial information, so may see impairment (scanning a line of print, looking up and down page to find info…
Neglect dyslexia

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16
Q

Writing deficits

A

spatial agraphias

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17
Q

Emotional and nonverbal communication deficits

A

may have reduced ability to comprehend/express emotional content as conveyed in facial expression, discourse, body language, gesture
May show decreased nonverbal animation or extreme animation.

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18
Q

Literal interpretation in RHD

A

More common to choose related NONLITERAL interpretation than literal.
Metacognitive demands of common assessment may obscure retained abilities.
Visuoperceptual skills can confound performance
May do fine day to day with familiar expressions.

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19
Q

Sensitivity to listener’s needs/situation

A

possible problems with presupposition and theory of mind

May have difficulty taking the listener’s perspective

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20
Q

Humor

A

May have deficits appreciating humor

May tell crude/disinhibited jokes

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21
Q

Inferences

A

May have difficulty gleaning information that is not explicitly provided.
Clients with RHD appear to have more difficulties with inferencing when they have to revise their initial inference.

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22
Q

Prosody

A

Difficulty producing/interpreting pitch, loudness, duration cues.
Speech may be flat, monotonous or hypermelodic
May demonstrate difficulty interpreting prosody (e.g. judging intonation, emotional or syntactic markers)

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23
Q

Discourse production

A

Contrasting findings: diminished content, verbose, tangential, excessive detail, lack of coherence.

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24
Q

Discourse comprehension

A

particular difficulties when discourse contains ambiguous or conflicting elements that make multiple interpretations possible (sarcasm, irony, and figurative expressions)
Difficulty can also arise when discourse requires a revision of an initial inference
Most difficulty: attentional demands of task are high, working memory resources are low, inferred details.
Do well when: discourse info is coherent and consistent, inferences strongly supported, explicitly stated main concepts.

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25
How might extralinguistic deficits result in participation restrictions?
--
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Extralinguistic deficits
``` emotional and nonverbal communication sensitivity to listeners needs humor inferences literality prosody ```
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Interview questions for RHD
``` Does so and so: engage in casual conversation initiate communication verbally/nonverbally communicate when TV or radio is on understand "hints" from others stays on conversation topics ```
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Comprehensive Eval of RHD includes:
``` discourse production and comprehension pragmatic behavior, conversation anosognosia/EF neglect attention, working memory possibly reading and writing ```
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Published tests for RHD
The Burns Brief Inventory of Communication and Cognition RICE-R: Rehab Institute of Chicago Evaluation of Communication Problems in RIght Hemisphere Dysfunction-REvised Right Hemisphere Language Battery, 2nd Ed Mini Inventory of Right Brain Injury
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What test is not appropriate for RHD?
Ross Information Processing Assessment-2: serious psychometric problems
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Simulation Activities
Tompkins (Table 15-11)
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What do you evaluate from a Video Retell?
narrative production, emotion conveyed in video, sustained attention, memory, EF:planning/organization
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Newspaper reading
memory (for task goal) | EF: initiation, organization, self-direction
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Eval of Discourse Production
Procedural narrative or picture description | Looking for: main concepts, supportive vs irrelevant details, inferences, how efficient and informative the message is
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Eval of Discourse Comprehension
use stimuli that require the client to draw inferences (it should be sufficiently detailed for you to determine the client's control over main ideas and details) can read to client news items, editorials, etc. and check comprehension with yes/no questions about main ideas/details, writer's opinion, etc. Discourse Comprehension Test
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Standardized Pragmatics Test
The Prutting Pragmatic Protocol: normed checklist, rate each parameter in 15 min unstructured conversation.
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Eval of Prosody
Florida Affect Battery gather information from conversation prosodic comprehension by having client perform prosodic discrimination independent of context (e.g. identify emotional tone of a neutral sentence, have client distinguish between declarative and interrogative sentences (for more severe deficits).
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Prosodic Production Eval
determine whether client is using a combination of pausing, duration, pitch, and intensity changes effectively
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Comprehension of nonverbal/emotional communication
Some published batteries (Florida Affect Battery) informally, can have client discriminate pictures of faces expressing different emotions, name the emotional expression, etc.
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Eval anosognosia/EF
anosognosia usually determined informally ("why are you here? what kinds of difficulties are you having?") though there are awareness questionnaires
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Attention Eval
informal observations during screening/interview can be informative. Can the pt: orient to a novel stimulus, sustain focus on the topic/task, shift between topics/tasks, resist distraction
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Published Attention Tests
Test of Everyday Attention | Trail Making Test
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Informal Neglect Measures
``` Line bisection Cancellation tasks Drawing Reading (should try to do 3 tasks) ```
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Published Tests for Neglect
Behavioral Inattention Test: cancellation, figure and shape copying, line bisection, representational drawing, picture scanning, card sorting, plus subtests reflecting daily life functions, such as menu reading, telephone dialing, map navigation, etc. Catherine Bergego Scale: direct observation of pt's functioning in 10 real-life situations
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Working Memory Eval
gross measure: backward digit span informal measure: arrange items by some variable (e.g., dog, mouse, elephant, horse, snail: Tell them back from smallest to largest)
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RHD Memory Eval
Visual memory: visual patterns test | Everyday memory problems: Rivermead Vehavioral Memory Test
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Eval Reading
important to remember what their reading fxn was prior to injury and if reading is a fxnl goal for client Discourse Comprehension Test
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Eval Writing
often assessed informally using individually relevant tasks (e.g., taking a phone message, writing an appointment, written discourse fro ma picture description)
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Improving Anosognosia
educate pt about deficits (review med recs together, compare ratings, watch video etc.) Exercises: (predict performance; tangible feedback "supported" failure)
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Treatment of Executive Fxn
Rely on TBI literature Metacognitive Strategy Instruction GPPDR Compensatory strategies
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Treatment of Neglect
Visual scanning treatments
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Visual Scanning Treatments
involves consciously scanning the environment, often use stimuli compelling enough to elicit head/eye turn to L, visual anchor (vertical line in left margin), repetition to turn strategy into habit Upt to 40tx sessions, 5 hrs/wk may be needed for durable gains/generalization
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Visual scanning treatment activities
reading copying sentences, drawings describing a pictured scene or finding objects in the scene finding objects in the room
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Technological treatment of neglect
Prism Adaptation
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Treatments related to neglect
paper and pencil cancellation tasks computerized scanning tasks object searches
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Compensatory Treatments of Neglect
verbal, visual and tactile reminders to look to the left | restructuring the environment
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Compensatory Treatment of Impaired Attention
minimize distraction, highlight important parts of stimulus/activity, cover up all but small amounts of relevant information, use step-by-step checklists, train communication partners to use alerters to shift attn
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Treatment of Impaired Attention
Sustained attention: tasks where pt. must respond to the appearance of a target overtime Selective attention: visual or auditory tasks in which pt. must screen out distracters, e.g., cancellation tasks APT
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Treatment of Memory Deficits
External aids: day planners, text messages, pagers... Internal compensatory strategies Spaced retrieval with errorless learning Use instructional methods (frequency, intensity, variability etc.)
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Treatment of Memory with Family
Communication partners, increase redundancy of input; simplify and reduce Decrease rate of presentation of info; more time at critical junctures
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What underlies discourse deficits?
May be due to: attention/working memory problems, problems with inferences/multiple meanings Folks with RHD are activating too many meanings and can't quickly suppress those that don't fit with the context
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Treatment of Discourse according to Tompkins
Draw the client's focus to contextual cues Contextual cues from pictures: guided description, ask how different characters in the picture are related, ask how other visual cues (e.g., clothing, facial expressions) might add to the meaning of the picture, provide several titles and ask client to select the most appropriate, etc.
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Treatment of Discourse production
Compensatory: scripts Impairment-oriented: trouble organizing-organize pictures in a story sequence trouble with big picture- summarize a story or identify essential elements trouble with topic manipulation-have client identify main points of a newspaper article, construct a story
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Treatment of Discourse Comprehension
Compensatory: initiate "input controls" (e.g., ask someone to speak more slowly, ask Dr. to write down instructions, etc) Impairment-oriented: use a wide variety of auditory/written materials to target identification of important info; have client answer questions, etc. Have client practice identifying topic shifts, info that is contextually inappropriate etc.
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Compensatory Treatment of Prosodic Production
Teach client to state feelings explicitly | Teach others to check interpretation with client
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Impairment oriented treatment of Prosodic Production
Contrastive stress drills Disambiguation exercises Imitation treatment Cognitive Linguistic Treatment
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Compensatory Treatment of Prosodic Comprehension
asking others to be explicit about main points/attitudes
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Impairment-oriented treatment of Prosodic Comprehension
present stimuli and ask client to identify vocal emphasis, identify emotion in neutral sentences, etc. discuss how to determine mood from prosody generate lists of vocal cues/signals to help analyze prosodic contrasts, then listen to stimuli to identify the signals
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Treatment of Pragmatics/ Sensitivity to Listener
Social skills training: videotaped feedback to enhance discrimination and monitoring of targeted behaviors
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Treatment of Conversational Skills | Rambling
if ramble: id occurrence on video, self-monitoring practice, practice saying the same thing in fewer words, limit ouput to a restricted time frame
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Treatment of Conversational Skills | Socially inappropriate utterances
if use socially inappropriate topics: establish awareness, encourage self-monitoring, discuss why some topics are inappropriate
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Treatment of Conversation Skills | Turn-taking
work on relinquishing topics/turns or ending conversations appropriately; heighten awareness of signals used by others; can observe videotapes or role-play situations.
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Treatment of Conversation Skills | Communication Partners
``` Train partners to: get the attention of the client cue the topic of discussion prompt client to focus on the main ideas emphasize important information reduce rate and complexity of questions asked or information provided ```
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Variables affecting treatment of reading and writing
how handicapping abilities are in light of premorbid skills and interests, and levels of literacy needed for social, vocational, or recreational purposes
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Reading Strategies
PQRST | Cue patient to look for the who, what, where, when and why/how of a newspaper article or narrative
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Treatment of Writing/Spatial Agraphia
Can begin with graphs and lines to structure writing of functional material: name, address, phone, simple to-do list or shopping lists
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Steps in treating spatial agraphia
1. start with large-type single sentences; progress to paragraphs-can use anchor at left margin 2. Instruct patient to copy text exactly, one word at a time at first 3. encourage verbalization of words initially 4. progressively remove cues, line numerals and anchors
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