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

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

ASHA Representatives (2005)

Fofi Constantinidou, Ph.D., CCC-SLPAssociate Professor &Director of Graduate StudiesDirector of NeuroCognitive Disorders LaboratoryDepartment of Speech Pathology & AudiologyMiami University2 Bachelor HallOxford, OH 45056Tel 513- 529-2507 Fax 513- 529-2502Email constaf@muohio.edu

Wendy Ellmo, M.S., CCC-SLP, BCNCDCenter for Head InjuriesCognitive Rehabilitation Department2048 Oaktree RoadEdison, NJ. 08820Tel 732-906-2640 ext. 42721Fax 732-906-9241Email wellmo@msn.com

Stacie Raymer, Ph.D. (ASHA Chair)110 Child Study CenterOld Dominion UniversityNorfolk, VA 23529Tel 757-683-4522Fax 757-683-5593Email 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-GreensboroDepartment of Communication Sciences and Disorders 300 Ferguson Building, P. O. Box 26170 Greensboro, NC 27402-6170 Tel 336- 334-5184 Fax 336-334-4475Email chooper@uncg.edu

Diane R. Paul, Ph.D., CCC-SLP (Ex Officio)DirectorClinical Issues in Speech-Language PathologyAmerican Speech-Language-Hearing Association10801 Rockville PikeRockville, MD 20852Tel 301-897-5700 ext. 4297Fax 301-897-7354Email dpaul@asha.org

Division 40 Representatives (2005)

Robin Hanks, Ph.D., ABPP (Committee Chair) Chief, Rehabilitation Psychology & NeuropsychologyRehabilitation Institute of Michigan261 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 2131200 West Tabor RoadPhiladelphia, PA 19141Tel 215-456-6544Fax 215-456-5926Email thart@einstein.edu

Angelle Sander, Ph.D.The Institute for Rehabilitation and ResearchBrain Injury Research Center2455 South BraeswoodHouston, TX 77030Tel 713 383 5644Fax 713 668 3695Email asander@bcm.tmc.edu

Risa Nakase-Richardson, Ph.DNeuropsychology DepartmentMethodist Rehabilitation Center1350 E. Woodrow WilsonJackson, MS 39216Tel 601-364-3448Fax 601-364-3558Email nakase@aol.com

Jeffrey Wertheimer, Ph.D.Brooks Rehabilitation Center3901 University Blvd., SouthJacksonville, Florida 32216Tel 904-858-7296Fax 904-858-7255Email Jeffrey.wertheimer@Brookshealth.org

Past Division 40 Committee MembersKenneth Adams Sharon Brown

Linas Bieliauskas Joseph Ricker

Robert Bornstein Doug Johnson-Greene

Gerald Goldstein Sanford Pederson

Byron Rourke Steven Putnam

Jill Fischer

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

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

“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 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.”

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 Documents2. 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.pdfProvides general guidelines for interdisciplinaryteams for the clinical management of people withbrain injury, with the ultimate goal to improve the quality of service for individuals affected by communication and cognitive disorders.

Joint Committee Documents4. 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.pdfPublished 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 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 aboutthe roles of both professions.

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

• 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 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 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 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.

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

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)

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• 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 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

• 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

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

• 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

Theoretical Model

Early Stage Models

• Encoding

• Storage

• Retrieval

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

• 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

• 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

• 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• 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

Model of Working Memory

(Baddeley & Hitch, 1974)

Central Executive VisuospatialSketchpad

Phonological Loop

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, 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

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

Long-term Memory StoreDeclarative (Explicit)

Non-Declarative (Implicit)

Semantic Episodic Skills & Habits

Priming

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, 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

++ Recognition

Paired Associates Learning

++ Immediate Recall

++ Delayed Recall

++ Recognition

++ Immediate Recall

++ Delayed Recall 

++ Recognition

Paragraph Memory

++ Delayed Recall

++ Delayed Recall (DR)

++ Recognition (Rec)

++ Forced Choice (FC)

Subspan Lists (<than 7 words per list; typically single presentation)

++ Immediate Recall 

Supraspan Lists (>than 9 words per list)

++ Immediate Recall (IR)

List Learning Memory

Non-declarative Memory

Declarative MemoryCentral ExecutivePhonologicalVisual

Working MemoryTesting Task

LONG-TERM STORESHORT-TERM STORE

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

Visual-Auditory Learning

+++ Immediate Recall 

++ Delayed Recall 

++ Immediate Recall

++ Delayed Recall

++ Recognition

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

+Procedural Memory

++ Immediate Recall

++ Delayed Recall

++ Recognition

Figure Recall

++ Immediate Recall

++ Immediate Recall

Picture Recall

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

Non-declarative Memory

Declarative MemoryCentral ExecutivePhonologicalVisual

Working MemoryTesting Task

LONG-TERM STORESHORT-TERM STORE

Case Study

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

Neuroimaging Findings

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

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• 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

Test ResultsCVLT-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

0

2

4

6

8

10

12

14

16

Trial 1 Trial 2 Trial 3 Trial 4 Trial 5 List B ImmediateRecall

DelayedRecall

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

• Distractibility

• Motor restlessness

• Impulsive responding

• Reduced awareness of errors

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• 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

• 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• 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 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