Assessment of Mild Cognitive Communication Disorders Using Patient Reported Measures

Published in the June 2024 ISHA Voice. 

By Miriam Carroll-Alfano, a member of the Medical Practice Issues Committee

 Assessment of persons with mild cognitive communication disorders can often be challenging.  Screening tools, which are often used to provide a quick diagnosis, lack the sensitivity and specificity to identify difficulties in persons with mild disorders.  These patients can also perform well on standardized assessments, yet they will report having difficulty in many aspects of their daily life. In situations such as these, patient reported measures are a valuable tool that speech-language pathologists should consider using to gather information and help determine treatment goals for persons with mild cognitive communication disorders.

Background and Important Considerations

Mild cognitive communication disorders have a variety of causes including stroke, mild traumatic brain injury, cancer and its treatments (chemotherapy and radiation), infections (Covid-19, West Nile Virus), neurological disorders (Parkinson’s Disease, Multiple Sclerosis), and others.  When assessing persons with cognitive communication disorders, it is important that we consider the complexity of the brain and how it is affected when disorders occur. Sohlberg, Hamilton, and Turkstra (2023) identify 3 fundamental principles that we must consider when working with this population.  These include:

Cognitive domains are complex and multifactorial, with multiple components and subcomponents.

Cognitive domains interact and overlap with one another. For example, it is difficult to isolate memory from attention.

Cognition is affected by contextual factors including psychological, physical, and environmental factors. (Sohlberg, Hamilton, & Turkstra, 2023). 

Psychological factors impacting cognition can include motivation, engagement, depression, and anxiety.  Depression and anxiety have been shown to have negative impacts on memory and executive functioning (Kizilbash et al., 2002; Lindert et al., 2021; & Shelton & Kirwin, 2013).  Physical factors such as fatigue and pain can impact a person’s cognitive abilities and be a barrier for treatment and return to daily activities (Abd-Elfattah et al., 2015; Carroll et al., 2004; Hicks, Larkin, & Purdy, 2011).  Environmental factors such as family support, noise, and lighting can also impact cognitive abilities.  Gathering information about these factors and their effect on a person’s cognitive communication abilities can be challenging during assessments.

When working with persons with any disorder, the World Health Organization International Classification of Functioning, Disability and Health (ICF) framework helps us to plan person-centered goals (ASHA, 2024; WHO, 2024)). For a person who has a mild cognitive communication disorder, we consider their impairments (working memory, divided attention, word retrieval difficulties, etc.) and their activities and participation (difficulty remembering tasks for work or school, unable to remember if medications were taken, frustration during conversations, etc.).  We also want to consider environmental and personal factors that may help (family support, motivation) or hinder (headaches, fatigue, sensitivity to noise) the person during recovery.   Assessment of persons with cognitive communication disorders can occur at different steps along the continuum of care, from the inpatient hospital to outpatient services at home or clinics.  Persons with mild cognitive communication disorders may not be aware of the difficulties they are having early on, particularly if they are in a hospital or inpatient rehabilitation center, because their cognitive demands are relatively low.  When the person returns home and tries to return to their everyday activities where their cognitive demands are higher (household tasks, self-care, managing finances, driving, work, school, etc.), they or their family members start to recognize the difficulties they are having. 

Assessment of Cognitive Communication Disorders

Assessment for persons with mild cognitive communication disorders begins with a review of the persons case history and an interview.  A comprehensive interview is important because it will guide your assessment and you may obtain information that you cannot get from the medical records and standardized and non-standardized assessments.  Asking open ended questions relating to their personal, medical, social, work/school/volunteer activities, as well as what they identify as difficulties are helpful. The person may be able to identify specific areas in which they are having difficulty, but some may not be able to identify them specifically and say, “I’m not myself” or “I can’t think like I used to before my illness”.  Following the interview, our assessment typically continues with administration of standardized assessments or portions of standardized assessments.  Standardized assessments can help us to identify specific areas of impairment in attention, memory, executive functioning, problem solving, language, and more.  This provides us with another piece of information that we can use when setting treatment goals; however, sometimes persons with mild cognitive communication disorders perform fairly well on these tests which can make it difficult to identify treatment goals.

Patient Reported Measures

Another tool in assessment is patient reported measures (Table 1.).  Patient reported measures are typically self-reported questionnaires.  Patient reported measures provide information directly from the patient about their functional status, quality of life, personal experiences, and behaviors that are not identified in standardized assessments.  These can be valuable tools to target activity and participation level needs, and identify functional and person-centered treatment goals.  There are a variety of evidence-based patient reported measures available that can be used with different populations.  Some measures are interprofessional and ask questions about all aspects of life including physical abilities, cognition, and behavior, while others may be more specific and just target memory or communication. Some examples of patient reported measures that can be used with persons with mild cognitive communication disorders are provided in Table 1.

            Patient reported measures can provide speech-language pathologists a wealth of information when completing assessments with persons with mild cognitive communication disorders.  They can help patients describe and quantify some of the difficulties they may be having in everyday life and fill in the gaps of information that standardized assessments may leave. They can be sent to the patient/family in advance and reviewed during the interview, or completed during the scheduled assessment time.  Patient outcome measures can also be repeated and used to assess progress over time.  Patient reported measures are a tool that should be considered by speech-language pathologists when assessing persons with mild cognitive communication disorders.

Table 1. Examples of Patient Reported Measures

References

Abd-Elfattah, H., Abdelazeim, F., & Elshennawy, S. (2015). Physical and cognitive consequences of fatigue: A review, Journal of Advanced Research, 6(3), 351-358.

American Speech-Language-Hearing Association. (2024). International classification of functioning, disability, and health (ICF), Retrieved from https://www.asha.org/slp/icf/.

  Broadbent, D.E., Cooper, P.F., FitzGerald, P., & Parkes, K.R. (1982). The Cognitive Failures Questionnaire (CFQ) and its correlates. British Journal of Clinical Psychology, 21, 1-16.

Carroll, L.J. et al., (2004). Methodological issues and research recommendations for mild traumatic brain injury, Journal of Rehabilitation Medicine, 43; 113-125.

Hicks, E., Larkins, B., and Purdy, S. (2011). Fatigue management by speech language pathologists for adults with traumatic brain injury. International, Journal of Speech Language       Pathology. 13(2):145-155.

 Hilari, K., Lamping, D. L., Smith, S. C., Northcott, S., Lamb, A. & Marshall, J. (2009). Psychometric properties of the Stroke and Aphasia Quality of Life Scale (SAQOL-39) in a generic stroke population. Clinical Rehabilitation, 23(6), 544-557. doi: 10.1177/0269215508101729

 Kizilbash, A., Vanderploeg, R., & Curtiss, G. (2002). The effects of depression and anxiety on memory performance, Archives in Clinical Neuropsychology, 17(1), 57-67.

Lindert, J., Paul, K., Lachman, M., Ritz, B., & Seeman, T. (2021). Depression, anxiety, and anger and cognitive functions: Findings from a longitudinal prospective study, Frontiers in Psychiatry, 12: 665742.

MacDonald, Sheila (2015). Cognitive Communication Checklist for Acquired Brain Injury (CCCABI) CCD Publishing; Guelph, Ontario, Canada, N1H 6J2

Shelton, D., & Kirwan, C. (2013). A possible negative influence of depression on the ability to overcome memory interference. Behavioural Brain Research, 256, 20–26. https://doi.org/10.1016/j.bbr.2013.08.016

Sohlberg, M., Hamilton, J., & Turkstra, L. (2023). Transforming cognitive rehabilitation, Guilford Press.

World Health Organization (2024). International Classification of Functioning, Disability and Health (ICF), Retrieved from https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health.

Miriam Carroll-Alfano is an Associate Professor at Midwestern University in Downers Grove and a Certified Brain Injury Specialist. She has been a speech-language pathologist for over 23 years working with patients with a variety of disorders including neurogenic communications disorders, head and neck cancer, and swallowing disorders.  She has served on the ISHA Membership Committee and is a member of the Medical Practice Issues Committee.