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-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 513- 529-2502
Email constaf@muohio.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 336-334-4475
Email chooper@uncg.edu
Wendy Ellmo, M.S., CCC-SLP, BCNCD
Center for Head Injuries
Cognitive Rehabilitation Department
2048 Oaktree Road
Edison, NJ. 08820
Tel 732-906-2640 ext. 42721
Fax 732-906-9241
Email wellmo@msn.com
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 301-897-7354
Email dpaul@asha.org
Stacie Raymer, Ph.D. (ASHA Chair)
110 Child Study Center
Old Dominion University
Norfolk, VA 23529
Tel 757-683-4522
Fax 757-683-5593
Email sraymer@odu.edu
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 313-745-9763
Fax 313-745-9854
Email rhanks@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 215-456-5926
Email thart@einstein.edu
Angelle Sander, Ph.D.
The Institute for Rehabilitation and Research
Brain Injury Research Center
2455 South Braeswood
Houston, TX 77030
Tel 713 383 5644
Fax 713 668 3695
Email asander@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 601-364-3558
Email nakase@aol.com
Jeffrey Wertheimer, Ph.D.
Brooks Rehabilitation Center
3901 University Blvd., South
Jacksonville, Florida 32216
Tel 904-858-7296
Fax 904-858-7255
Email Jeffrey.wertheimer@Brookshealth.org
Past Division 40 Committee Members
Kenneth Adams
Linas Bieliauskas
Robert Bornstein
Gerald Goldstein
Byron Rourke
Jill Fischer
Sharon Brown
Joseph Ricker
Doug Johnson-Greene
Sanford Pederson
Steven Putnam
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 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-A175373B86939A48/0/19110_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.
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 JohnsonGreene, Ph.D.
- http://www.asha.org/NR/rdonlyres/7D6D3FD5-9197429E-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.
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-A5154FA69CE6A708/0/23026_2.pdf
Encourages referral and collaboration between
speech-language pathologists and clinical
neuropsychogists and informs referral sources about
the roles of both professions.
Survey of Perceived Roles and
Collaborations for Neuropsychologists
and Speech-Language Pathologists
in 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 preassessment 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)
Visuospatial
Sketchpad
Central Executive
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, visuospatial 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 Store
Declarative
(Explicit)
Semantic
Episodic
Non-Declarative
(Implicit)
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 (primingpreserved learning even when they cannot
recall the learning episode)
– Preserved learning of procedural skills and
perceptual skills in amnestic patients
Table 1. Testing Tasks and Their Relationship to Components of the Theoretical Memory Model
SHORT-TERM STORE
LONG-TERM STORE
Working Memory
Testing Task
Visual
Phonological
Central Executive
+
+
Declarative
Memory
List Learning Memory
Supraspan Lists
(>than 9 words per list)
Immediate Recall (IR)
Delayed Recall (DR)
+
+
Recognition (Rec)
+
+
Forced Choice (FC)
+
+
Subspan Lists
(<than 7 words per list;
typically single
presentation)
Immediate Recall
+
+
Delayed Recall
+
+
Recognition
+
+
Paragraph Memory
Immediate Recall
+
+
Delayed Recall
+
+
Recognition
+
+
Paired Associates Learning
Immediate Recall
+
+
Delayed Recall
+
+
Recognition
+
+
Non-declarative
Memory
SHORT-TERM STORE
LONG-TERM STORE
Working Memory
Testing Task
Visual
Phonological
Central Executive
+
+
Declarative
Memory
Non-declarative
Memory
Digit Span Task or Serial
Recall Task - Backward
(verbal)
Immediate Recall
Picture Recall
Immediate Recall
+
+
Delayed Recall
+
+
Recognition
+
+
Figure Recall
Immediate Recall
+
+
Delayed Recall
+
+
Recognition
+
+
Digit Span Task or Serial
Recall Task - Backward
(visual)
Immediate Recall
+
+
Procedural Memory
+
Visual-Auditory Learning
Immediate Recall
Delayed Recall
+
+
+
+
+
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 TestImmediate 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 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
16
14
12
10
8
6
4
2
0
Trial 1
Trial 2
Trial 3
Trial 4
Trial 5
List B
Immediate
Recall
Delayed
Recall
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