CHAPTER 13 The memory subsystems described in Chapters 5 and 9 support language processing, verbal learning, and human communication in different ways. Impairment of each subsystem has consequences for the integrity of language processing and functional communication. Thus, assessment of language disorders should include an evaluation of short-term and long-term memory and other cognitive control processes (e.g., attention and executive functions). Additionally, the close association of memory and language processing indicates a need to develop treatment approaches that address both language and memory abilities. This need may seem obvious in the rehabilitation of communication disorders associated with traumatic brain injury and degenerative memory disorders (e.g., semantic dementia), as the memory disorders clearly instigates the communication disorder. Acquired aphasia, on the other hand, might seem to be primarily a language disorder and less obviously related to memory abilities. However, the memory disorder present in aphasia is not one of long-term memory or encoding new memories. Rather, it is a disturbance of short-term memory (STM) processes that are intrinsic to language processing. Recent approaches to treatment of adult-onset and developmental language disorders focus on improving short-term memory abilities to improve language function. Specific language impairments following traumatic brain injury do occur, but are not common and are associated with more focal injuries. One language disorder that is quite common following a head injury is anomia (Heilman, Safran, & Geshwind, 1971), and the severity of this symptom is directly related to the severity of the injury (Levin, Grossman, & Kelly, 1976). Memory disorders following TBI are quite common and occur in conjunction with impairments to other cognitive processes such as attention and executive functioning. The nature of the memory disorder is a difficulty in encoding new information into long-term memory (Coelho, DeRuyter, & Stein, 1996; Ylvisaker, Szekeres, & Feeney, 2008). Curtiss, Vanderploeg, Spencer, and Salazar (2001) used cluster analyses to examine memory encoding and the involvement of short- and long-term memory processes in TBI. They identified impairments of three memory processes in this population: memory consolidation, retention of memories and retrieval of memories. Furthermore, they determined that those individuals with retrieval difficulties also demonstrated “memory control” problems (perseveration of responses). It has been hypothesized that the memory encoding difficulty may be related to impairments of the hippocampal system, which has been associated with consolidation of new memories (Nadel & Moscovitch, 1997). An impaired ability to encode new memories does not affect language processing directly, but does disrupt verbal learning ability. It also can affect functional communication in several ways. The inability to learn new verbal information will make any effort to return to school or job training a challenge at best. It will also affect activities of daily living that require remembering specific sets of verbal information for a short period. For example, someone might be given directions somewhere or they might have new instructions for medicine regimen). The language in these instructions is not new, but the assembly of known words is new and must be encoded, understood, and retrieved in the short term. In addition to difficulties with specific tasks of daily living that involve language, memory retrieval impairment will make conversational interactions difficult. If there are breakdowns in functional communication, there is a risk that the person with TBI will become socially withdrawn (Ylvisaker et al., 2008), which in turn impact communication further. Rehabilitation approaches emphasize compensatory strategies to help the individual cope with these memory difficulties. Memory disorders are just one of several cognitive abilities that are impaired after head injury. Other disorders that may affect functional communication include disorders of attention and executive functions. Assessment of memory disorders and associated communication impairments should include standardized tests of memory (Butters & Delis, 1995), standardized assessments of language and communication (Turkstra, Coelho, & Ylvisaker, 2005), as well as non-standardized assessment of language and communication (Coelho, Ylvisaker, & Turkstra, 2005). Typically, standardized memory scales are included in a neuropsychological evaluation. Nonetheless, speech-language pathologists should be familiar with these tests and the interpretation of the test results. The most widely used memory scale is the Wechsler Memory Scale—Revised (WMS-R, Wechsler, 1987). It includes 13 subtests assessing many aspects of memory including short-term digit span, immediate recall of verbal and nonverbal material, delayed recall, visual memory, and verbal learning. Williams (1991) developed the Memory Assessment Scales, which are similar to the WMS-R, but include some additional tasks that measure cued recall, recognition, memory for proper names, and list-learning. This latter task allows for observation of learning strategies and error types that occur (Butters & Delis, 1995). This kind of information is directly relevant to the development of a rehabilitation protocol for the person with cognitive impairments following head injury. Fostering the development of efficient learning strategies is an important goal in cognitive rehabilitation. Thus, it is important to know what strategies, good or bad, the person with TBI is using to learn new information. Other tests of verbal learning include the Rey Auditory Verbal Learning Test (Rey, 1941, 1964) and the California Verbal Learning Test (CVLT; Delis, Kramer, Kaplan, & Ober, 1987). The typical procedure used in a verbal learning test is to first present a list of unrelated words five times and ask for immediate recall of the list after each presentation. These are the learning trials. They are followed by a second list of unrelated words presented one at a time. This is the interference task. Following this, the examinee is asked to recall the first list. Assessment of learning is gauged by number of items recalled after the interference task, but also the CVLT includes measures of strategies used by the examinee and errors that occurred during the list-learning task. Assessment of language and memory function after traumatic brain injury can be challenging for the speech and language pathologist because standardized language and communication tests are not necessarily designed with this population in mind. Moreover, even those tests that assess functional communication do not address the functional language and communication needs outside the clinical setting. Nonetheless, standardized tests provide a starting point to evaluate the client’s functional communication abilities relative to normative data or some standard of typical communication behavior (Turkstra et al., 2005). These measures can also serve to identify starting points in treatment. In response to a growing need for guidelines to the assessment of language and communication abilities after TBI, the Academy of Neurological Communication Disorders and Sciences Practice Guidelines Group (ANCDS) developed a set of guidelines for speech-language pathologists (Turkstra et al., 2005). The committee evaluated 84 tests recommended by speech-language pathologists in a survey on assessment and an additional 40 tests recommended by publishers. After an initial screening, tests that did not include traumatic brain injury as a target population were eliminated, leaving 31 tests for the next stage of the evaluation, which considered the reliability and validity criteria of the tests. The criteria established by the Agency for Health Care Policy Research (www.ahrq.gov.clinic.epc; reported by Turkstra et al., 2005) were met by only 7 of the 31 tests. These included: 1. American Speech-Language-Hearing Association Functional Assessment of Communication Skills in Adults (ASHA-FACS) 2. Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) 3. Communication Activities of Daily Living, Second Edition (CADL-2; Holland, Frattali, & Fromm, 1999) 4. Functional Independence Measure (FIM), Uniform Data Set for Medical Rehabilitation 5. Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, 2001) 6. Test of Language Competence—Expanded (Wiig & Secord, 1989) Turkstra et al. (2005) note some important themes that are shared by these measures. In the context of the International Classification of Functioning, Disability and Health (ICF) Model, some of these tests address impairment level and activity/participation levels of function. They also note that these measures are not designed specifically for cognitive communication impairments associated with traumatic brain injury. Although they can be adapted for use with this population, there is still a need for assessment measures designed specifically for this population. As noted above, standardized assessments of language and communication disorders provide only a starting point of understanding the communication needs of someone with a traumatic brain injury. The eventual development of a comprehensive standardized battery to address the needs of this population will be a welcome advance in rehabilitation medicine. Until that is accomplished, nonstandardized assessment procedures can be used to fill in the assessment gaps not addressed by current standardized communication measures. It is important to note, however, that nonstandardized tests will always have a place in assessment of communication abilities associated with TBI. In particular, they are necessary to assess communication functions and abilities in real-world contexts, which vary across individuals. Thus, nonstandardized observations should be used to document (1) performance in real-world settings, (2) demands of those real-world settings, (3) competencies of the client’s communication partners, and (4) changes in these circumstances (Coelho et al., 2005). A nonstandardized assessment approach that is commonly used in rehabilitation of people with head injury is discourse analysis. This is a valuable means of gaining insight into a client’s functional language abilities, as performance on single word and sentence processing measures may seem unimpaired. A survey by Coelho et al. (2005) indicated that speech-language pathologists working with individuals with TBI used two types of discourse analysis in their assessments of communication ability, monologic and conversational. Memory impairments potentially could affect either type of discourse, because maintaining a theme across sentences in a story or in the context of a conversation requires encoding information and maintaining it in working memory. Results of the survey indicated that typical measures obtained from monologic discourse samples included cohesion of meaning across sentences, grammatical complexity of sentences, thematic unity, accuracy of information content, productivity and efficiency of narrative, lexical selection, and propositional content. Some consistent observations reported by participants in the survey were that individuals with TBI are less verbal overall, and their narratives less efficient and coherent. In particular, the content of narratives was not always accurate or well organized. In the survey of conversational discourse studies in TBI a consistent finding was difficulty in initiation of and maintenance of conversation topics. Additionally, content errors and word finding episodes were reported. Memory disorders associated with TBI as well as some executive function impairments can account for these difficulties. Coelho et al. (2005; see also Ylvisaker, Szekeres, & Feeney, 2008) emphasize the need for dynamic, ongoing assessment to identify factors that will influence performance, including strategies used by the client, potential ways to modify a task, context effects, and environmental supports. The goal of a dynamic assessment is to determine how these factors can be modified to optimize a person’s communication abilities and develop an effective intervention plan. Consistent with the dynamic assessment approach, Ylvisaker and colleagues have developed a protocol that they term “contextualized hypothesis testing” (Ylvisaker & Feeney, 1998; Ylvisaker et al., 2008). This approach emphasizes the need for ongoing assessment of abilities and environmental factors in rehabilitation of communication impairments in TBI. There are a multitude of factors that can affect communication ability and success in functional communication environments. These ever-changing factors include those relating to a person’s cognitive abilities and those relating to his/her real-life circumstances. A key motivation for using an ongoing hypothesis testing strategy is that there are multiple factors that may or may not be contributing to the communication success or failure of individuals with TBI. These include the memory disorder, speed of processing, language ability, knowledge base, and executive function abilities (e.g., attention, orientation, working memory self-monitoring). The combination of spared and impaired abilities in TBI will vary from person to person and will change over the course of recovery. It is critical to keep abreast of changes in a person’s overall cognitive/language profile in order to adjust the rehabilitation program accordingly. For the speech-language pathologist working in a setting that provides service for individuals with TBI, the benefits of using the contextual hypothesis testing approach will be enhanced by collaboration with other professionals who work with the client’s cognitive/emotional abilities and/or the client’s environment. Such collaboration provides more information to form and test hypotheses about approaches to rehabilitation that will be most beneficial to the client. It is also recommended that a portion of the hypotheses testing be carried out in contexts that at least simulate environmental settings that will be encountered by the client with TBI (Coelho et al., 2005; Ylvisaker & Feeney, 1998). For good reasons, clinical settings are different from the real-life environment in many ways. They control for distractions and variables that confound diagnoses of language disorders and, in so doing, enable optimal performance of someone with TBI (or other impairment) on diagnostic and treatment activities. This is an important approach to the overall assessment of someone’s language and cognitive abilities after brain injury, of course. However, the clinical environment does not reflect the real world in which the client will be faced with numerous and frequently changing variables that will challenge his/her functional communication every day. Therefore, it is important that clinicians find ways to assess a client’s performance in his/her real life environment or in a setting that simulates the kinds of challenges the client will face outside the clinic. It should be apparent from the review of approaches to assessment of functional communication in TBI that there are a multitude of cognitive, social, and behavioral abilities and factors to be considered in this disorder. Given the idea that assessment and rehabilitation of TBI continuously yield information relevant to the evolving needs and circumstances of someone with TBI as he/she recovers, treatment strategies will need to be dynamic and consider all cognitive, executive, and social functions. For example, treatment does not involve just working on memory or just working on attention. Treatment must address these fundamental functions and in the context of real-life settings that the client will face. Thus, the first and most important consideration in fashioning a rehabilitation program for someone with TBI is that it will be very individualized. This is not to say that it will be totally unique, although parts of it may be. Rather, techniques and strategies to foster redevelopment or establishment of fundamental cognitive skills and functional/social communication abilities should be based on general approaches to cognitive rehabilitation and the unique needs, abilities, and disabilities of the client. This approach, which, by necessity, will involve the client’s input, is reflected in a program of rehabilitation developed by Kennedy & Coelho (2005) that aims to develop self-monitoring and self-control of memory and learning in TBI. They emphasize the importance of a person with TBI learning to self-monitor the accuracy of his/her memory performance, be it retrieval of long- or short-term memories. This means that whatever specific memory retraining strategies are employed in a rehabilitation program, they need to be accompanied by additional training in monitoring the outcomes of memory “exercises.” This will enable the client to be more aware of when he/she needs to review something to be remembered or to ask for additional information or repetition of information. One means of promoting independent self-monitoring of memory functions is the use of a diary or memory notebook. A number of studies indicate the usefulness of this approach (Kreutzer, Wehman, Condor, & Morrison, 1989; Sohlberg & Mateer, 1989). Training to use a memory notebook is sometimes conducted in two stages (Sohlberg & Mateer, 1989; Squires, Hunkin, & Parkin, 1997). In the first stage, the client learns novel paired associates and uses the notebook to look up the responses. This helps to establish a habit of looking up information in the notebook. In the second stage, this new behavior is applied to looking up information in the notebook about everyday events (Squires et al., 1997). Apart from the larger strategy of improving self-monitoring of memory abilities, there are the tasks and strategies used in the clinic to foster direct improvement in memory ability and/or to develop compensatory strategies that will compensate for memory limitations. Memory drills designed to stimulate immediate and short-term recall of information are somewhat effective, but effects of these exercises do not generalize to new environments or other tasks. Verbal elaboration is a technique used to promote improved encoding of information, and visual imagery is sometimes used to help this process. These approaches may be effective in the short-term, but it has been observed that spontaneous use of the strategies is rare and transfer to real-world situations is difficult (Mateer, Kerns, & Eso, 1996). One approach that has been shown to effectively foster learning in the context of memory encoding difficulties is the use of errorless learning strategies. This approach minimizes or eliminates any opportunity for errors to occur during learning. Errorless learning is best understood as a set of task manipulations that can be incorporated into most treatments for memory impairments. Drawing from several sources in the literature on errorless learning (Baddeley, Wilson, & Watts, 1995; Evans, Wilson, Schuri, et al., 2000; Wilson, Baddeley, Evans, & Shiel, 1994). Sohlberg, Ehlhardt, & Kennedy (2005) summarized the following practices that are effective in reducing or eliminating errors: The effects of errorless learning are believed to be mediated by implicit memory, knowledge that is learned without conscious recollection of what has been learned (Anderson & Craik, 2006; Baddeley & Wilson, 1994; Page, Wilson, Shiel, et al., 2006). The prevention of error in the learning process minimizes any priming of erroneous response by implicit memory, thus maximizing accurate encoding of the input. In contrast, explicit memory involves awareness and recollection of what is learned and the ability to adequately encode new memories. Errorful learning is exploited in tasks that involve overt evaluation of responses (e.g., trial and error learning; Sohlberg et al., 2005). This type of learning engages explicit memory processes, as correct and incorrect responses are integrated with long-term memories. Whereas explicit memory processes in TBI are impaired, implicit memory encoding remains viable (Baddeley & Wilson, 1994). This finding is supported by numerous studies of errorless learning for acquired memory disorders associated with various etiologies (e.g., TBI: Dou, Man, Ou, et al., 2006; Landis, Hanten, Levin, et al., 2006; amnesia: Baddeley & Wilson, 1994; Evans et al., 2000; Alzheimer’s disease: Clare, Wilson, Breen, & Hodges, 1999; Clare, Wilson, Carter, et al., 2000; schizophrenia: O’Carroll, Russell, Lawrie, & Johnstone, 1999; herpes encephalitis: Parkin, Hunkin, & Squires, 1998; semantic dementia: Jokel, Cupit, Rochon, & Graham, 2007). Semantic memory disorders associated with neurological degenerative disease affect long-term memory (LTM). LTM is also known as declarative memory and consists of semantic memory (knowledge of the world) and episodic memory (memory for personal experiences). LTM supports language processing indirectly as the conceptual knowledge base that is communicated and understood via language. Long-term declarative memory is contrasted with procedural memory, which supports skill learning and regulation of the execution of cognitive and motor skills. Whereas procedural memories are established via implicit learning, long-term declarative memories are formed via explicit learning. In the domain of language ability, Ullman, Corkin, Coppola, et al., (1997) proposed a model relating declarative memory to the mental lexicon, which stores word-specific knowledge, and procedural memory to the mental grammar, which supports rule-governed assembly of lexical representations into sentences. Impairment of procedural memory has been observed in Parkinson’s disease and Huntington’s chorea. This is most apparent in regulation of motor movements, but disturbances of grammatical abilities have also been observed (Ullman, et al., 1997). Other degenerative neurological diseases such as frontal-temporal lobar disease (FTD) and Alzheimer’s disease (AD) lead to degradation of the declarative memories (including semantic and episodic memories). The most prominent symptom of language disturbance in the temporal variant of FTD (also known as semantic dementia, SD) is anomia, which becomes more severe as the conceptual knowledge associated with words of a language deteriorates (Hodges, Patterson, Oxbury, & Funnel, 1992). Comprehension of words also becomes increasingly impaired as the disease progresses. Thus, in semantic dementia, the type of declarative memory that is vulnerable to the disease is factual memory about the world (semantic memory). Concepts that are expressed via language are degrading. In contrast, episodic memory, which is impaired in AD, is relatively preserved in SD. Semantic memories are also affected in AD, but differ in subtle ways from the impairment in SD. Evidence indicates that the nature of the semantic deficit in AD is a gradual degradation of distinguishing features among semantic concepts. This erosion makes it difficult to distinguish differences among related concepts (Garrard, Lambon Ralph, Patterson, et al., 2005; for review, Altmann & McClung, 2008). The difference in semantic impairment of SD and AD is evident in the types of errors that are made in picture naming. Errors produced by individuals with SD tend to be visual in nature (e.g., orange → ball, nail → pointed), indicating a loss of the concept itself. The picture naming errors of individuals with AD tend to be semantic coordinates (tiger → lion) or superordinates (tiger → apple) indicating a fuzziness about the features that distinguish members of a category (Altmann & McClung, 2008). Despite the severe loss of conceptual meanings of words, other language abilities remain functional well into the course of the progressive dementia. Repetition is spared, as are abilities to distinguish words and non-words. Syntactic processing remains stable, even comprehension of thematic roles (Breedin & Saffran, 1999; Kempler, Curtis, & Jackson, 1987). Reading is characterized by progressive surface dyslexia (inability to read irregularly spelled words), and impaired comprehension as the lexical-semantic links break down. Reilly and Peele (2008) note that the relative preservation of nonsemantic domains of language makes it difficult to discern the presence of language impairment in casual conversation. However, a closer examination of the content of conversational speech and narratives typically reveals an overuse of closed class words, semantically “light” verbs (e.g., go vs. fly), and a paucity of nouns (e.g., Bird, Lambon Ralph, Patterson, & Hodges, 2000). It is important to emphasize a distinction between the semantic impairment in stroke-related aphasia and that in semantic dementia. In aphasia, the difficulty is one of accessing semantics from words. Whereas in semantic dementia, semantic memories are degrading progressively, in aphasia, the difficulty lies in accessing semantics from lexical (word) representations (Antonucci & Reilly, 2008; Jefferies & Lambon Ralph, 2006; Martin, 2005). Thus, in aphasia, a word’s meaning may be accessible on one task but not another, or accessibility might vary because of the memory load of the task (Martin, 2005, 2008). In semantic dementia, once the conceptual representations have degraded, there can be no connection with the words that were once used to express them. A study by Lambon Ralph, Graham, Patterson, and Hodges (1999) provides evidence of the conceptual nature of the anomia in semantic dementia. They found a strong positive correlation between the quality of conceptual definitions of objects and the ability to name the words. An early symptom that is a hallmark of Alzheimer’s disease is episodic memory loss (Bayles, 1991), but there also can be difficulties in language processing (Kempler, Curtiss, & Jackson, 1987; Martin & Fedio, 1983) and working memory processes (Bayles, 2003). In contrast, the most prominent early symptom of semantic dementia is anomia and difficulty comprehending words (Reilly & Peele, 2008). Error types in naming are typically semantic paraphasias, often visually related to the target in some way. Another common symptom of semantic dementia is prosopagnosia (inability to recognize faces) and associative visual agnosia (impaired object recognition). These disturbances reflect the degrading conceptual representations that support the language system. An important part of the assessment process in the case of semantic memory loss is the case history, including an interview with the primary caregiver (Bayles, 1991). Because of the progressive nature of this disorder, observations of changes in language and memory abilities observed by significant others are important to the diagnosis of semantic dementia. Hopper and Bayles (2008) provide a comprehensive list of formal tests that are appropriate for evaluating language and cognitive skills in dementia (Alzheimer’s or semantic dementia). Effective screening measures include the story-retelling subtest on the Arizona Battery for Communication Disorders of Dementia (Bayles & Tomoeda, 1993) and the FAS Verbal Fluency Test (Borkowski, Benton, & Spreen, 1967). The story retelling test requires the person to listen to a story and retell it immediately after hearing it and then again 5 minutes after hearing it. Bayles and Tomoeda (1993) found that people with moderate Alzheimer’s disease (and dementia typical of this disorder) were unable to remember anything about the story after 5 minutes. Another screening test that is often used in this population is the Mini-mental State Examination (Folstein, Folstein, & McHugh, 1975). The test contains 11 items that focus on general cognitive abilities such as memory, orientation, and attention and more specific abilities such as language, calculation, and visual-spatial processing. Assessment of verbal fluency is another means of detecting word retrieval difficulties. Several language batteries have verbal fluency subtests, including the Arizona Battery for Communication Disorders of Dementia (Bayles & Tomoeda, 1993) and the Boston Diagnostic Aphasia Examination (Goodglass, Kaplan, & Barresi, 2000). The semantic verbal fluency task involves naming as many members of particular semantic category (e.g., animals) as one can in a specified period of time (e.g., 30 seconds or 1 minute). There are also letter fluency tasks that require naming words that begin with a particular letter. Word generation tasks tend to be difficult for people with dementia and consequently they are a sensitive measure of anomia at early stages of the illness. A more comprehensive evaluation of the language and memory abilities can be achieved with the full Arizona Battery for Communication Disorders of Dementia (Bayles & Tomoeda, 1993) and the Functional Linguistic Communication Inventory (Bayles & Tomoeda, 1994). Part of a complete evaluation of language and cognitive abilities associated with degenerative neurological disease is an assessment of severity of the language and cognitive impairments. This information will help determine the level of functional care that a person with dementia needs and will help in determining goals for any kind of intervention to improve or maintain functional communication abilities. Hopper and Bayles (2008) recommend two scales that are used to document the progression of impairment to functional abilities: Global Deterioration Scale (Reisberg, Ferris, deLeon, & Crook, 1982) and a follow up to that test, the Functional Assessment Staging Scale (Reisberg, Ferris, & Franssen, 1985). Each of these use observation as the measure and include detailed descriptions of functional behaviors and impairments that are typically present at a particular stage of disease progression. When considering rehabilitation priorities for language impairment related to degenerative neurological disease, it may at first seem counterintuitive to provide language intervention that aims to improve language ability. Indeed, it is only in the last decade or so that clinicians and researchers have considered treatment approaches for people with semantic memory deficits that do more than compensate for the lost memories. Memory aids are still highly recommended to help the person with dementia to cope in his/her environment independently or with assistance from significant others for as long as is possible. Bourgeois and colleagues, for example, have demonstrated the usefulness of a memory aid (memory wallet) to enhance conversational skills of patients with AD (Bourgeois, 1990; Bourgeois & Mason, 1996). This kind of training, as might be expected, involves training of caregivers to work with the person with dementia (e.g., Hickey, Bourgeois, & Olswang, 2004). Although the goal is not to improve language and memory function per se, memory aids have an important impact on quality of life for the person with dementia and his/her significant others. As our understanding of the exact nature of language impairment in semantic dementia improves, there has been an increasing focus on developing methods to improve language function in SD and AD by capitalizing on residual language abilities. Graham, Patterson, Pratt, and Hodges (2001) reported a seminal case study of DM, a 59-year-old male surgeon. Following a 2-year history of word-finding difficulties, the source of DM’s anomia was determined to be semantic dementia. There were two central questions addressed in this study: (1) Would repeated practice on a set of vocabulary words provide short-term access to those words and (2) would it help to maintain access to that vocabulary from day to day. Several factors suggested this approach might be successful with DM. He had already made a list of words he could not reliably remember or produce. Also, he was highly motivated and expressed a willingness to practice every day. Three sets of words were created. Words in Set 1 were practiced regularly for 2 weeks, and then words from Set 2 were practiced for 2 weeks. Performance improved with practice but dropped when practice was stopped. The third set of words was not practiced at all, but some improvement was noted in that set as well. It was concluded that relearning of names was possible in semantic dementia, but continued exposure and practice was needed. Graham et al. (2001) assessed DM’s abilities after 2 years. DM continued to show improvement and maintenance of category fluency (naming members of categories). However, they also note that although he could name the objects, he could not provide semantic information about them. Also, his performance declined on The Pyramids and Palm Trees Test (Howard & Patterson, 1992), a nonverbal semantic tests of conceptual knowledge. They concluded that although the continued practice of object names supported retrieval of those names, it did not reverse the degradation of the semantic system. Evidence that intensive practice can help to maintain access to words in semantic dementia comes from a treatment case study reported by Jokel, Rochon, and Leonard (2006) of a person with semantic dementia, AK, who was severely anomic. Their treatment protocol, like the approach used by Graham et al. (2001), involved intensive practice of objects that AK could once name. The training protocol included three groups of stimuli: words that AK understood but could not name, words that she could not understand or name, and words that she understood and could name. Immediately following treatment, there was improvement on words that AK could and could not understand before training. At a follow-up evaluation 1 month after therapy, these improvements remained only for those words that she could understand prior to therapy. Additionally, Jokel et al. (2006) provide evidence that the words AK understood and could name prior to treatment were less vulnerable to loss compared to untreated words that she knew and could name prior to treatment. These two studies indicate the importance of residual comprehension of vocabulary to the success of a program to improve retrieval of word names. Although it is possible to stimulate short-term retrieval of vocabulary with intensive practice even for names whose meaning is not well retained, relearning in this context is short-lived compared to a context in which knowledge of the concept remains. Related findings by other researchers support this (e.g., Snowden, Griffiths, & Neary, 1999; Snowden & Neary, 2002). In an extensive review of treatments for word retrieval in semantic dementia, Henry, Beeson, and Rapcsak (2008) note that all evidence suggests that the ability to relearn vocabulary will be directly related to the residual semantic knowledge for those words. Consistent with this finding, it has been suggested that training vocabulary in SD should focus on a finite set of words that are relevant to the individual rather than focus on retraining lost vocabulary (Reilly, Martin, & Grossman, 2005). Henry et al. (2008) also suggest that drawing on relatively spared episodic memories in SD may enhance the effects of repeated practice of vocabulary.
Management of communication deficits associated with memory disorders
Encoding new memories following traumatic brain injury (TBI)
Nature of the impact on language and communication
Assessment
Standardized memory scales
Standardized tests of cognitive-based communication disorders
Nonstandardized assessment of cognitive-communication impairment
Approaches to rehabilitation
Semantic memory disorders
Nature of the impact on language and communication
Assessment
Approaches to rehabilitation
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Management of acquired language disorders associated with attentional impairment
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Attention: architecture and process
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