Download Communication in FTD

Communication in FTD
Daisy Sapolsky, MS, CCC-SLP
Speech-Language Pathologist
MGH Department of Speech, Language and Swallowing Disorders & Reading Disabilities
MGH Frontotemporal Disorders Unit
Topics

Subtypes of FTD

Communication challenges

Compensatory strategies

MGH FTD Unit and Progressive
Communication Disorders Program
Terms

Aphasia
 An acquired communication disorder that
impairs a person's ability to process
language, but does not affect intelligence.
 Can have impairment in one or more areas:
speaking
 understanding others
 reading
 writing/spelling

http://www.aphasia.org/
Terms

Primary Progressive Aphasia (Mesulam, 1982)
 A language disorder (“aphasia”) that
worsens over time (“progressive”), and is
the most prominent problem the person
experiences (“primary”)
Subtypes of FTD
Frontotemporal Dementia (FTD)
Primary Progressive Aphasia (PPA)
Behavioral Variant (bvFTD)
Progressive Nonfluent Aphasia (PNFA)
Semantic Dementia (SD)
Logopenic Progressive Aphasia (LPA)
Progressive nonfluent aphasia (PNFA)


agrammatism
nonfluent speech, may be telegraphic

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hesitant, effortful, pauses, hesitations, fillers (e.g.,
umm)
difficulty with verbs and functor words (e.g., the, for,
an, to)

knowing what you want to say, but can’t think
of the word or can’t get the word out

comprehension is (typically) intact

there may be difficulty in comprehension of
complex syntactic forms
Progressive nonfluent aphasia (PNFA)

impaired reading and writing

difficulty with forming grammatically correct sentences

difficulty with reading complex sentences; comprehension of
single words usually intact

or, writing may be significantly better than speech in some
patients

spelling difficulty

yes/no confusion

pronoun confusion
Progressive nonfluent aphasia (PNFA)

picture description:

“Umm, you know, the umm, the family for uh
the picnic...umm...maybe the Cape...you
know, the umm, like sailing and fishing and
umm the ah, uh, girl is umm, the umm, the
sandcastles, and umm the picnic man’s
reading a book and umm the lady is uh,
wine, and you know, like summertime,
summertime.”
Picnic scene picture
Western Aphasia Battery-Revised (Kertesz, A., 2007)
Subtypes of FTD
Frontotemporal Dementia (FTD)
Primary Progressive Aphasia (PPA)
Behavioral Variant (Beh)
Progressive Nonfluent Aphasia (PNFA)
Semantic Dementia (SD)
Logopenic Progressive Aphasia (LPA)
Semantic dementia (SD)

loss of knowledge of the meanings of words


lower frequency/uncommon words most affected
“What is a ___?”

use of vague/general words (e.g., stuff, thing)
 speech content has an empty quality


lack of detail, common/vague words
but, speech is fluent and grammatical
Semantic dementia (SD)

picture description:

“There’s a guy and a dog and this, and then
there’s a girl and another dog, and
something. And, they’re eating. This is
the...I should know that because I always do
it...I always know that usually.”
Subtypes of FTD
Frontotemporal Dementia (FTD)
Primary Progressive Aphasia (PPA)
Behavioral Variant (bvFTD)
Progressive Nonfluent Aphasia (PNFA)
Semantic Dementia (SD)
Logopenic Progressive Aphasia (LPA)
Logopenic Progressive Aphasia (LPA)
intermittent word-finding hesitations
 impaired naming
 phonemic paraphasias (saying words or
nonwords that share some sounds with
the correct word)

“octible” for octopus
 “rackel” for racquet
 “glow” for globe

Logopenic Progressive Aphasia (LPA)

picture description:

It looks like a family is, has a hou, uh, I
think it’s a house or a friend’s place, on the
leck lake...Uh, and uh, there’s somebody
who’s uh finishing, uh, fishing...Uh some
friends are in the boat, in the so, sailboat,
sail, sailboat...They uh, the mother is
putting some, I’d like to think it’s wing uh
wine...
Subtypes of FTD
Frontotemporal Dementia (FTD)
Primary Progressive Aphasia (PPA)
Behavioral Variant (bvFTD)
Progressive Nonfluent Aphasia (PNFA)
Semantic Dementia (SD)
Logopenic Progressive Aphasia (LPA)
Behavioral variant FTD (bvFTD)

As patients may do well in testing, they are
often not thought to have a primary
speech/language disorder.

However, the hallmark changes in behavior
and personality directly affect daily
communication and functioning, and therefore
can result in a communication disorder.
Behavioral variant FTD (bvFTD)

apathetic variant

flat affect, emotional blunting

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withdrawal, loss of interest (apathy)

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not expressing emotion, not understanding or
reading someone else’s emotion
not engaging in conversation or previously
enjoyed activities
lack of initiation

only speaks when spoken to
Behavioral variant FTD (bvFTD)

disinhibited variant


saying inappropriate things or in an inappropriate
way
inappropriate increase in talking



press of speech
not reading social cues that someone is not
interested in the conversation or is ready to stop
the conversation
compulsive behaviors
Topics

Subtypes of FTD

Communication challenges

Compensatory strategies

MGH FTD Unit and Progressive
Communication Disorders Program
Common communication challenges

knowing what you want to say but the words
won’t come out → frustration
 able to express basic wants and needs, but
difficulty with higher-level conversation


“I miss the discourse.”
feeling rushed and pressured to get your
thoughts out


may result in withdrawing from social situations
one patient said she doesn’t want to make people
wait for her to come up with words
Common communication challenges

communicating the problem to friends and
family, people at work
 carrying out routines and activities
 difficulty reading and writing may mean the
loss of previously enjoyed and practical
activities
 adjusting to new communication style

“I used to be a fast talker.”
Topics

Subtypes of FTD

Communication challenges

Compensatory strategies

MGH FTD Unit and Progressive
Communication Disorders Program
Example compensatory strategies

key words and semantic cueing
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5 w’s template
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patient provides key words instead of attempting to
say full sentences
patient describes the concept/word using semantic
features
helps patient organize thoughts
visual guide
multiple-choice questions

partner asks multiple-choice or yes/no questions
Example compensatory strategies

visual materials

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elaboration

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use a newspaper headline, photo, or other visual
material as conversation topic
help patient elaborate on previous response
gesture (e.g., past, future, yes/no, size, shape)
Example compensatory strategies

pre-written “scripts”
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write brief scripts to be used in specific situations
practicing may reduce the pressure of the moment
can be used to read from or to show to the partner
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Please pump $20 worth of gas.
How was your vacation to Paris?
I need to find a dress to wear to a wedding.
I need to return these shoes because they didn’t fit.
Example compensatory strategies

communication book


primary or supplementary communication
update topics/formats as needed
 point to pictures/words:
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people (family members, friends)
places (shops, restaurants)
food
activities
emotions
time/date
Example compensatory strategies

slow down – both patient and partner



patient has more time to think of words and
organize thoughts
allows patient time to process what is being said to
him/her
relieves the pressure of a fast-paced conversation
Example compensatory strategies

Identify barriers to functioning in the home or
workplace and be creative in brainstorming
solutions

e.g., a patient with non-fluent speech allows calls to
go to voicemail, enabling her to take time to
formulate a response, write a script, or send an email response
Example compensatory strategies

Identify activities, hobbies, and volunteer
opportunities that have low demand on
language (arts, music, gardening).

Discuss when a job or responsibility is no
longer manageable. Create an action plan to
leave the situation.
Example compensatory strategies

Prompt the patient to use any means of
expression

gesturing, writing, drawing, pointing to pictures or
words, facial expression

Refer to an AAC (Augmentative & Alternative
Communication) center

For apraxia of speech, try traditional motor
speech strategies
Example compensatory strategies

Some patients have reported success!

From an e-mail:
 Script for a phone conversation for friends, a business, and
doctors - I practice the script until I can speak decently.
 Gestures, facial expression, and body language...two-thumbs-up,
wave, and five high slap...and dance around with my body.
 Syllable attack is very helpful. I break down the long word into
syllables and practice them slowly. Then I quicken my speed until
I can pronounce the word properly...
 They (strategies) are helpful. It takes a long time to practice a
script on the phone but it pays off. The reward is speaking more
normally...not perfect!
Strategies: Behavioral variant
Set up situations and routines that allow
the patient to respond to others, instead
of needing to initiate communication
themselves
 Brainstorm ways to engage the patient in
activities and communication

Strategies: Behavioral variant

Break down tasks into manageable steps
that are not overwhelming (e.g., setting
the table)

daily calendar/schedule to provide a list of
activities and to-do items


do this together so that the patient has input
phone message template
Topics

Subtypes of FTD

Communication challenges

Compensatory strategies

MGH FTD Unit and Progressive
Communication Disorders Program
MGH Progressive Communication
Disorders Program

goals of the evaluation:


identify strengths and weaknesses in speech/language abilities, compensations already
in use, communication partners, and what is/isn’t working in daily life
develop functional goals:
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goals of the therapy program:
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to maintain and enhance communication; and
to prepare for future decline
teach/practice compensatory strategies to facilitate communication in everyday situations
educate the patient/partner about the diagnosis and implications for communication
brainstorm suggestions for modifying the environment to facilitate communication
troubleshoot barriers to communication and participation
provide check-ins and ongoing support
program structure:
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
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individual sessions that vary in frequency and duration for patient and partner
“tune-up” sessions to review strategies and determine if another round of therapy is
warranted
group therapy to practice strategies within a comfortable setting and to meet others