7th March 2016

Pearson Clinical Webinar: Regaining Independence Post-stroke

Regaining independence post-stroke: The impact of executive functioning and language skills on activities of daily living (ADLs) after a neurological event. Presented by: Bridget Barnett E: [email protected] Consultant Occupational Therapist and Angela Kinsella-Ritter E: [email protected] Consultant Speech Pathologist 9th March 2016

A Multi-Disciplinary Approach • Today’s webinar will highlight how OTs, Speech Pathologists and Psychologists can work together to support clients in regaining functional independence post-CVA. • Through the use of case study examples, this webinar will provide a brief overview of the BADs, WAB-R,CLQT and Pyramids and Palm Trees to illustrate ways in which they can be used clinically to: • gain a clearer picture of clients’ abilities • explore the influences of cognitive skills and language on one another • the impact this has on an adult's functional performance and • to guide intervention planning.

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Pearson Clinical Webinar: Regaining Independence Post-stroke

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Goals of Assessment •

To determine the presence of impairment – Severity and type of impairment – Determine the individual’s strengths and weaknesses

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To identify exacerbating factors – Vision and hearing – Agnosias (recognition deficits) in various modalities – Deficits in proprioception or praxis – Affective (mood) disorders – Effects of medication

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To identify intervention goals

Treatment Considerations Timing • During spontaneous recovery period or wait? • Vignolo (1964): treatment is only really effective if it begins when physiologic recovery is most rapid • Poeck et al (1989): time post-onset does not affect recovery of language, but it does affect response to treatment • Generally, delaying treatment has not been conclusively demonstrated to have any effects on eventual outcome; but it might impact on the patient and their family Candidacy • Some patients have very mild impairments and recover spontaneously • Some are so severely impaired that they may note necessarily benefit from intervention • Some refuse, lack motivation, can’t travel

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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7th March 2016

Pearson Clinical Webinar: Regaining Independence Post-stroke

Treatment Planning • Analyse and interpret the assessment results • Discuss with client (where possible) as well as with the family • Set long and short term goals • Consider type of task, stimuli selected, modality of material, type of facilitation given, duration and intensity of therapy (Byng and Black 1995) What person

closing the gap

can do

What person

needs to do wants to do

cannot do does do

Components of Language Function Cognitive Recognition, understanding, memory, attention, reasoning ability

Linguistic Auditory comprehension, language production (form and content)

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

Communicative/ Pragmatic Turntaking, topic initiation and maintenance, repairs, speech acts produced, nonverbal aspects

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Behavioural Assessment of the Dysexecutive Syndrome (BADS) Utility in clinical practice

Overview of the BADS •

A test battery aimed at predicting everyday

problems arising from Dysexecutive Syndrome (frontal lobe impairment) •

Authors: Barbara A. Wilson, Nick Alderman,

Paul W. Burgess, Hazel Emslie, Jonathan J. Evans •

Published in 1996

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Administration time approx 40 mins

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Age range: 16-87 years

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Six subtests + DEX questionnaire

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© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Problems in assessing the Dysexecutive Syndrome Traditional neuropsych tests don’t always reflect real life demands of problem solving, planning and organising, setting priorities and adapting behaviour •

Tests might be sensitive to frontal lobe damage but may not reflect everyday situations, making functional correlations difficult •

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What does the BADS assess? Subtests tap into executive functions including: •

The ability to initiate behaviour

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Inhibition of competing actions or stimuli

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Selecting relevant task goals

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Planning and organising a means to solve complex problems

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Shifting problem-solving strategies flexibly

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Monitoring and evaluating behaviour

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© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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BADS Subtests •

Rule Shift Cards Test

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Action Program Test

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Key Search Test

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Temporal Judgement Test

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Zoo Map Test

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Modified Six Elements Test

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The Dysexecutive Questionnaire (DEX) A 20-item questionnaire. The items sample the range of problems commonly associated with the Dysexecutive Syndrome in four areas: emotional or personality changes, motivational changes, behavioural changes, and cognitive changes • Each item is rated on a 5 point scale representing problem severity. • Two forms; a self-report and a carer/ relative report •

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© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Case study 1 – “Harry” • • • • • • • • • • •

80 years old Admitted for inpatient rehab following right CVA Lives at home with daughter Independent with showering, dressing, toileting Has an IDC that will be required upon discharge Manages own medication Prepares light meals Drives an automatic car Previously managed finances independently Shows limited awareness of current abilities MMSE score 24/30

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Case study 1 – “Harry” Rule Shift Cards •Numerous

errors in both versions •Difficulty processing the test instructions; did not seek clarification when instructions not understood Action Program Test •“Why would you want me to do that?” 18 Clinical utility of the BADS

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Case study 1 – “Harry” Key Search Test •Unable to conceptualise square as a field •Took 7 minutes •Evidence of attempt to cover all ground but ineffective

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Case study 1 – “Harry” Temporal Judgement •Initially stated it was “impossible” to estimate •Correctly answered question “how long do most dogs live for” •Unable to estimate question about window cleaning •Reported 10 minutes for time needed to blow up a balloon •Reported 30 minutes for dental check-up but stated “it depends how many teeth you have” 20 Clinical utility of the BADS

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Case study 1 – “Harry” Zoo Map •Difficulty conceptualising task •When prompted, stated that he needed to “visit places” •Lack of scanning/searching skills when visually locating places on map •Distracted by certain details, e.g. perseverated on cafe •Stated “there are too many restrictions” •Did not attempt to draw on either version map 21 Clinical utility of the BADS

Case study 1 – “Harry” • • •

Age corrected standardised score – 24 “Impaired” range Assessment highlighted depth of impairment and shed light on issues managing IDC, e.g. • Planning ahead • Prospective memory • Managing multiple cognitive demands • Comprehending instructions • Insight/error recognition • Strategy generation

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© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Conclusion •

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•

•

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BADS can detect subtle cognitive impairments that may be missed on MMSE and less complex tasks BADS allows qualitative data gathering e.g. impulsivity, flexibility of thought, self monitoring BADS can highlight strengths as well as weaknesses BADS can provide insight into potentially useful strategies BADS can increase client/carer awareness

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Cognitive Linguistic Quick Test (CLQT)

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Overview of the CLQT •

The purpose of the CLQT is to assess the relative status of five cognitive domains in adults with known or suspected neurological dysfunction.

•

Author: Nancy Helm-Estabrooks

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Published in 2001

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Administration time approx 15 to 30 mins

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Age range: 18-89 years

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© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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CLQT Tasks & Cognitive Domains

Total Composite Severity Rating

• CLQT is criterion-referenced • Severity ratings for two age categories (ages 18-69 and 70-89) • Severity ratings are mild, moderate, several and WNL for each of the 5 cognitive domains • A total Composite Severity Rating and a Clock Drawing Severity Rating serve as a neurocognitive screener

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Personal Facts

Symbol Cancellation

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Symbol Cancellation Task Results

Confrontation Naming

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Clock Drawing

Story Retelling

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Auditory Comprehension

Symbol Trails –Trial Items

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Symbol Trails

Generative Naming

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Design Memory

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Pearson Clinical Webinar: Regaining Independence Post-stroke

Mazes

Design Generation

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Case Study: CVA with extensive left hemisphere lesion and small right hemisphere lesion • •

•

•

64 year old, right handed man with a doctorate degree Referred for an evaluation 11 months post left-hemisphere stroke which resulted in a
Dense right hemiplegia and aphasia He had received extensive rehabilitation and is still under the care of a speech-language pathologist (who requested a second opinion re therapy planning Assessments included:
CLQT
Boston Diagnostic Aphasia Examination, 3rd Ed (BDAE-III)
Boston Assessment of Severe Aphasia, 2nd Ed (BASA-II)
A comprehensive neuropsychological test
MRI Scan
Informal Assessment

CLQT Examiner’s Manual, p. 87

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Summary Scoring Worksheet

Summary Scoring Worksheet

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Summary Scoring Worksheet

Design Generation Task Results

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Symbol Cancellation Task Results

CLQT Results • • •

• •

•

Moderate overall impairment Severely impaired language skills Moderately impaired attention and executive functions Mildly impaired visuospatial skills The Memory Severity Rating (MSR) was interpreted with caution as the client was unable to produce verbal responses Although the MSR was in the severe range, his score (5 points out of a possible 6) for the nonverbal task of Design Memory was at the normal Criterion Cut Score for his age (5 points)

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Goals of Communicative Assessment • To assess potential for future recovery (prognosis) • To monitor change – e.g. spontaneous recovery, treatment efficacy • To evaluate maintenance of treatment gains • To define factors that facilitate comprehension, production and use of language • To establish a working relationship with client and significant others

Goals of Communicative Assessment To determine the presence of aphasia*, and severity and type of aphasia, and to profile the client’s strengths and weaknesses

• Organised, goal directed evaluation of the components of communication • Evaluation of person’s QOL • Evaluation of communicative interactions within family/social unit • Their role in society • Carried out to determine how strengths fortified and weaknesses modified Chapey 2008 *Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write.

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Assessment of Communicative Functioning • Not language per se – performance, pragmatics, communication skills in everyday life CALDs • reading timetables and menus • going to the doctor and shopping • making a phone call • writing a shopping list

Aphasia Recovery Spontaneous recovery: decelerating curve • Maximum recovery 1-3m • Flattening out 6-7m • Little/no spontaneous recovery after 1yr – plateau Basso 1992 Benson and Ardila 1996 in Chapey 2008 Prognosis: TBI better than stroke, haemorrhagic better than infarction Lesser and Milroy 1993

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Neural Mechanisms for Recovery • Reduction of cerebral oedema/improvement of local circulation: Spontaneous recovery • Brain plasticity: cortical reorganisation to engage pre-existing but functionally depressed pathways. Called upon when dominant system fails • Lesion size = negative influence on recovery

Aphasia Treatment Efficacy: does aphasia treatment result in a significant improvement on one or more tests of language functioning? Yes, provided that: • Treatment is delivered by qualified professionals • Content, intensity, duration and timing of treatment are appropriate • Sensitive and reliable measures are used to track changes Effectiveness: does aphasia treatment result in meaningful improvements in communicative functioning in daily life?

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Therapy Approaches and Models • Approaches that assume the brain can relearn what has been lost/skills can be re-accessed • Approaches that assume lost language functions not recoverable. • Therapy aimed at compensatory strategies • WHO International classification of Functioning, Disability and Health (2002) • Body functions and structures i.e. impairments of brain • Activity i.e. ability to make a phone call, read a menu • Participation i.e. pursuit and enjoyment of real life goals e.g. volunteering/getting a job

Western Aphasia Battery Revised (WAB-R)

Author: Andrew Kertesz | Published: 2007

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Western Aphasia Battery-Revised Purpose: a screening and diagnostic test battery for evaluating language function in adults with acquired neurological disorders Age Range: 18 to 89 years Administration Time:
Bedside Screening: 15 minutes
Diagnostic assessment: 30-45 minutes
Reading, writing, praxis, construction: 45-60 minutes Scores: Research-based criterion scores; Aphasia Quotient, Language Quotient, Cortical Quotient

Applications •

Determine the presence, severity, and type of aphasia

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Obtain a baseline of patient abilities

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Document changes in abilities over time

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Guide treatment and management recommendations

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Infer the location and etiology of the lesion causing aphasia

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Bedside Screening: a quick look at functioning in 15 minutes

Bedside Screening: Areas Tested • • • • • • • • •

Spontaneous Speech: Content Spontaneous Speech: Fluency Auditory Verbal Comprehension: Yes/No Questions Sequential Commands Repetition Object Naming Reading Writing Apraxia

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Bedside Screening: Scores Bedside Aphasia Score
Content, Fluency, Auditory Verbal Comprehension, Sequential Commands, Repetition, and Object Naming Bedside Language Score
Content, Fluency, Auditory Verbal Comprehension, Sequential Commands, Repetition, Object Naming, Reading, Writing Bedside Aphasia Classification
Global, Broca’s Isolation, Transcortical Motor, Wernicke’s Transcortical Sensory, Conduction, Anomic

WAB-R Test Battery Comprehensive Assessment
10 receptive and expressive language tasks
16 reading and writing tasks
1 apraxia task
4 nonlinguistic skills tasks Scores
Aphasia Quotient (AQ) o Spontaneous Speech | Auditory Verbal Comprehension | Repetition | Naming and Word Finding
Language Quotient (LQ) o AQ subtests + Reading and Writing Score
Cortical Quotient o AQ + LQ subtests + Apraxia Score and Constructional, Visuospatial and Calculation Scores

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Spontaneous Speech

Spontaneous Speech Scoring

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Auditory Verbal Comprehension

Auditory Verbal Comprehension

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Auditory Verbal Comprehension

Repetition

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Naming and Word Finding

Naming and Word Finding

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Naming and Word Finding

Score Summary

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Language & Cortical Quotients

Goals for Treatment •

• • •

• •

“The primary objective in treatment of aphasia is to increase communication. What the aphasic patient wants is to recover enough language to get on with his life.” (Schuell et al 1964, 333.) There may not be a complete recovery of language and communicative function Treatment may enhance recovery, but recovery will stop Identify strengths and weaknesses; use the strengths to compensate for the weaknesses; help the client with aphasia to be an effective communicator in spite of their language deficits Generalisation – recovery must not be limited to the treatment room Generalisation does not just happen – it must be planned for, worked towards, tested for

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Example – treatment planning Mr Z’s assessments show:
Strengths: o Good lexical comprehension o Good comprehension of basic sentence structure o Can draw and gesture to convey some aspects of meaning o Semantic cueing facilitates naming o Written support facilitates comprehension
Weaknesses: o Poor complex auditory sentence comprehension o Spoken confrontation naming difficulties o Difficulties in written confrontation naming when word frequency decreases o Drawings and gestures may not be recognisable outside context as tend not to be well defined • Mr Z’s wish: to talk/communicate better with family and friends

Pyramids and Palm Trees A test of semantic access from words and pictures • • • •

Authors: David Howard and Karalyn Patterson Published: 1992 Age Range: 18 to 80 years Administration Time:

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Pyramids and Palm Trees Six different versions of the test can be administered: 1. 2. 3. 4. 5. 6.

Three pictures Three written words Written word as given item, pictures as choices Picture as given item, written words as choices Spoken word as given item, two pictures as choices Spoken word as given item, written words as choices

Pyramids & Palm Trees

Here are three pictures. You have to decide which one of these two at the bottom goes with the one at the top. Is it this one or this one?

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Pyramids & Palm Trees

Here are three words. You have to decide which one of these two at the bottom goes with the one at the top. Is it this one or this one?

Pyramids and Palm Trees • The two choices – the target and the distractor - are always semantic coordinates whereas the given (top) item is usually from a different category. • The choice must always be made on the basis of some property or association that is shared by the given item and the target. • Each triad can be answered on the basis of partial information from the three stimulus items. • Because the different triads tap a variety of kinds of knowledge, clients are only able to perform with consistent accuracy if they can retrieve complete and correct semantic information from the three items in each of the triads.

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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Pearson Clinical Webinar: Regaining Independence Post-stroke

Pyramids and Palm Trees: Interpretation • Poor performance could indicate difficulty in • Item recognition • Semantics, or in the • Decision process /word retrieval • Determining the type of difficulty depends on the pattern of performance: • Score = total number of responses (+ 0.5 for refusals) • A score of 26/52 is expected by chance • A score of 33 is better than chance at p < 0.05 • 35 at p < 0.01 • 38+ at p < 0.001

Summary •

Multi-disciplinary approach
Working in a multi-disciplinary team enables clinicians easy access expertise from other allied health professional when assessing and planning intervention for your patients.

•

The assessments discussed today demonstrated that although we work in specific disciplines there is overlap in the information being sought and they highlight how each discipline supports and complements the other.

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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7th March 2016

Pearson Clinical Webinar: Regaining Independence Post-stroke

We’re here to help

Pearson Clinical Assessment Bridget Barnett Consultant Occupational Therapist [email protected]

sAngela Kinsella-Ritter Consultant Speech Pathologist [email protected]

M: 0407 259 317

M: 0408 511 110

Client Services: 1800 882 385

Client Services: 1800 882 385

www.pearsonclinical.com.au

© 2015 Pearson Clinical Assessment Presented by Bridget Barnett, OT and Angela Kinsella-Ritter, SP

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