Memory%20Assessment%20on%20an%20Interdisciplinary%20Team:%20Roles%20and%20Collaborations%20Between%20Neuropsychology%20and%20Speech-Language%20Pathology

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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
• Houston Neuropsychological Society
• January 2006

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Joint Committee on Interprofessional Relations
Between Division 40 (Clinical Neuropsychology) of
the American Psychological Association (APA) and
the American Speech-Language-Hearing Association
(ASHA)
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ASHA Representatives (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 [phone] Email
constaf_at_muohio.edu Wendy Ellmo, M.S., CCC-SLP,
BCNCD Center for Head Injuries Cognitive
Rehabilitation Department 2048 Oaktree
Road Edison, NJ. 08820 Tel [phone] ext.
42721 Fax [phone] Email wellmo_at_msn.com Staci
e Raymer, Ph.D. (ASHA Chair) 110 Child Study
Center Old Dominion University Norfolk, VA
23529 Tel [phone] Fax [phone] Email
sraymer_at_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 [phone] Email
chooper_at_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 [phone] Email
dpaul_at_asha.org
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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 [phone] Fax [phone]
Email rhanks_at_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 [phone] Email
thart_at_einstein.edu Angelle Sander, Ph.D. The
Institute for Rehabilitation and Research Brain
Injury Research Center 2455 South
Braeswood Houston, TX 77030 Tel [phone] Fax
713 668 3695 Email asander_at_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 [phone] Email
nakase_at_aol.com Jeffrey Wertheimer, Ph.D. Brooks
Rehabilitation Center 3901 University Blvd.,
South Jacksonville, Florida 32216 Tel
904-858-7296 Fax [phone] Email
Jeffrey.wertheimer_at_Brookshealth.org
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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

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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

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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
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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.

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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 and
  procedures included in discipline-specific
  training and exclude those for which competence
  has not been established through such training
  criteria.

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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.

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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.

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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/7D6D3FD5-9
  197-
• 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.

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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.

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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)

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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.

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Highlights from Survey

• 86 of each discipline viewed the other as
  assessing cognition.
• The majority of NPs (gt90) viewed SLPs as
  treating language and cognition, while only 27
  of SLPs viewed NPs as treating cognition and lt1
  perceived them as treating language.

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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.

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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.

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

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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)

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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.

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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.

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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

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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.
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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

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Theoretical Model
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Early Stage Models

• Encoding
• Storage
• Retrieval

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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)

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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

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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)

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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

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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

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Model of Working Memory (Baddeley Hitch, 1974)
Phonological Loop
Central Executive
VisuospatialSketchpad
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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)

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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

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Model of Long-Term Memory (Tulving, 1985 Squire,
1992)
Long-term Memory Store
Declarative (Explicit)
Non-Declarative (Implicit)
Skills Habits
Semantic
Episodic
Priming
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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.

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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

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Table 1. Testing Tasks and Their Relationship to
Components of the Theoretical Memory Model
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(No Transcript)
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Case Study
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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

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

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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
• Couldnt repeat a more complex sentence with 3
  ideas
• Recalled 2 of 3 words after a 10-minute delay

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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

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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
• Forward6 Backward3

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Behavioral Observations

• Distractibility
• Motor restlessness
• Impulsive responding
• Reduced awareness of errors

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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)

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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

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Discussion Points

• Memory was sufficient for functional
  communication skills.
• Use of screening measures alone (e.g., RIPA-II)
  would have overestimated the patients memory
  abilities.
• Use of raw scores and percentiles alone would
  have underestimated functional problems
  (importance of qualitative analysis and
  behavioral observations)

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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)

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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