Introduction
The following exercise is a case study of a man (‘Robert’) of 76 years of age who was studied by Saldert et al. (Reference Saldert, Ferm and Bloch2014). Thirteen years prior to this study, Robert received a diagnosis of Parkinson's disease (PD). PD is a neurodegenerative disorder which is characterised clinically by resting tremor, bradykinesia, rigidity and postural instability. The condition is caused by a loss of neurones in the substantia nigra of the brain (Nussbaum and Ellis, Reference Nussbaum and Ellis2003). A recent meta-analysis of worldwide data shows a rising prevalence of the disorder with age: a prevalence of 41 cases per 100,000 population rises to 1,903 cases per 100,000 in individuals over 80 years (Pringsheim et al., Reference Pringsheim, Jette, Frolkis and Steeves2014). The main communication disorder associated with Parkinson's disease is dysarthria. However, individuals with the disease can also experience swallowing, language and cognitive problems, even in the absence of dementia. The case study is presented in five sections: primer on Parkinson's disease; client history and communication status; focus on word-finding difficulties; focus on conversational repair; and the role of the conversation partner.
Primer on Parkinson's disease
Parkinson's disease is a progressive, neurological disorder which has significant implications for a client's motor, cognitive and language functions. The cardinal signs of PD are the motor symptoms of rest tremor, bradykinesia, rigidity and loss of postural reflexes. However, there are also significant secondary motor symptoms such as dysarthria, dysphagia, sialorrhoea, micrographia and festination, and non-motor symptoms including cognitive deficits, sleep disorders and sensory problems (Jankovic, Reference Jankovic2008). Although the risk of PD is greater in older subjects, 5.4% of patients in one community-based prevalence study were found to have disease onset below the age of 50 years (Wickremaratchi et al., Reference Wickremaratchi, Perera, O'Loghlen, Sastry, Morgan, Jones, Edwards, Robertson, Butler, Morris and Ben-Shlomo2009). The main histopathological finding in PD is the loss of dopaminergic neurones from the substantia nigra associated with the presence of Lewy bodies (an abnormal aggregate of a protein called alpha-synuclein). For symptoms to occur, it is estimated that at least 50% of these nigral neurones must degenerate, although in most cases there is more than 80% reduction of these cells at autopsy (Mackenzie, Reference Mackenzie2001).
Parkinson's disease is a significant condition for the speech-language pathologist who must assess and treat the speech, language and swallowing problems associated with the disorder. Dysarthria, sialorrhoea and dysphagia have been reported in 51%, 37% and 18% of a sample of 419 patients with moderate PD, respectively (Perez-Lloret et al., Reference Perez-Lloret, Nègre-Pagès, Ojero-Senard, Damier, Destée, Tison, Merello and Rascol2012). The most common form of dysarthria in patients with PD is hypokinetic dysarthria. The features of this dysarthria are hypophonia, reduced stress and intonation patterns, abnormal voice qualities, distorted consonantal sounds, and abnormally rapid or slow speaking rates (Adams and Dykstra, Reference Adams, Dykstra and McNeil2009). Alongside dysarthria, there are also language impairments in PD, particularly in the domain of pragmatics. Reported pragmatic deficits include impairments of the comprehension of speech acts, irony and metaphor (Holtgraves and McNamara, Reference Holtgraves and McNamara2010; Monetta and Pell, Reference Monetta and Pell2007; Monetta et al., Reference Monetta, Grindrod and Pell2009). At least some of these impairments appear to be related to cognitive deficits in PD in areas such as theory of mind and verbal working memory (Monetta and Pell, Reference Monetta and Pell2007; Monetta et al., Reference Monetta, Grindrod and Pell2009).
Unit 32.1 Primer on Parkinson's disease
(1) Each of the following statements is a description of one of the terms used above. Match each statement to the term to which it relates:
A term used to describe reduced vocal intensity.
A term used to describe slowness of movement.
A term used to describe a progressive reduction in amplitude during writing.
A term used to describe a brainstem nucleus in the extrapyramidal system.
A term used to describe the ability to attribute mental states to other minds.
(2) The substantia nigra contains dopaminergic neurones, i.e. neurones that produce dopamine. State what dopamine is, and describe its function in the central nervous system.
(3) Below is a list of features of hypokinetic dysarthria in Parkinson's disease. Assign each feature to one of the following speech production subsystems: articulation; resonation; phonation; respiration; and prosody
(4) Which of the following utterances may prove to be difficult for the client with PD to understand? Justify your response(s).
Client history and communication status
Robert is 76 years old and is a former medical doctor. He is a native Swedish speaker. His wife Sonja is 73 years old and is a former audiologist. It has been 13 years since Robert was diagnosed with PD. He is at Stage IV of the Hoehn and Yahr (Reference Hoehn and Yahr1967) scale of clinical disability: ‘Fully developed, severely disabling disease; the patient is still able to walk and stand unassisted but is markedly incapacitated’ (433). Robert has not been diagnosed with dementia. However, he has dysarthria. His comprehensibility in contextual speech is 75%. Degree of comprehensibility was measured by calculating the percentage of correctly perceived words by a native rater out of 100 words which were uttered by Robert in the context of a video-recorded conversation. Both phonological and semantic aspects of word fluency were impaired in Robert. When asked to produce as many words as possible beginning with the letters F, A and S during one minute for each letter, Robert produced 28 words (norm 42.3 +/− 10.6). When asked to name as many animals and activities as possible during one minute, Robert named just 9 (norm for animals: 20.9 +/− 7.7; norm for activities 18.1 +/− 6.0). The Token Test (De Renzi and Vignolo, Reference De Renzi and Vignolo1962) was used to measure auditory verbal comprehension. Robert achieved a score of 175, which was well below the cut-off point of 253/261.
Unit 32.2 Client history and communication status
(1) Given the advanced nature of Robert's neurological condition, which of the following should feature in the SLP management of the client?
(2) Robert's comprehensibility was assessed. Comprehensibility is not the same as intelligibility. How might the difference between these notions be characterised?
(3) Robert's comprehensibility is likely to exceed his intelligibility. Explain why this is likely to be the case.
(4) Both phonological and semantic aspects of word fluency are impaired in Robert. Which group of cognitive skills are likely to be disrupted to produce this finding?
Focus on word-finding difficulties
Conversation between Robert and Sonja was video-recorded in their home. Thirty minutes of transcribed natural interaction were obtained. The transcription included non-vocal features such as gestures and body movements as well as talk. All instances of repair were recorded. There were 11 instances in total. Some were related to comprehension problems caused by Robert's dysarthria, while other instances of repair were related to the meaning of words. Although Sonja tended to dominate the interaction with Robert, there were several occasions where they both participated as listeners and speakers in the exchange. The topic of conversation in the following exchange is a visit to a church that Robert has undertaken along with other people at his day care centre. Just prior to the start of the extract shown below, Sonja has asked if there was any singing during the visit. It has been established that there were two girls singing and a man playing the organ. After a pause of 1.4 seconds, Robert continues to tell Sonja about the visit (underlining = emphasis; (xxx) = unintelligible sequence):
R: (and then it was) (0.6) it was some priest who (2.5) read a chapter from (1.2) eh the bible (1.6) and well (x) there were no (1.0) purposes or influ- or something that should be influenced fluenced or so but it was like what was part of their work (xxx) (0.8) help and encourage (1.4) be considerate to (0.9) elderly persons and such who are living on those pension schemes (1.1)
S: ((subtle nod)) mm
R: but it was a moment of =
S: = an ho- an hour or what?
R: yes
S: yes
R: it is a moment of (different) (1.8)
S: no but you are participating in the singing of hymns
R: yes
Unit 32.3 Focus on word-finding difficulties
(1) Robert makes extensive use of pauses in his initial turn in the above exchange. Describe three features of these pauses which indicate that they are related to a word search.
(2) Clients who have word-finding difficulties often use a preponderance of non-specific vocabulary. Are there any instances of this type of vocabulary in the above exchange?
(3) The presence of circumlocutions is often symptomatic of word-finding difficulties on the part of a speaker. Does Robert use a circumlocution at any point in the above exchange?
Focus on conversational repair
After agreeing that he participated in the singing of hymns, Robert returns to his earlier attempt to tell Sonja what happened during the church visit. In this part of the exchange, Sonja is more proactive in her efforts to understand what Robert is attempting to communicate. To this end, she initiates a conversational repair:
R: and then what you feel about that (1.6) that you don't know (2.6) but eh (2.9) yes it is (1.0) it is (x) it is good for such (it is) that you shouldn't (1.1) understand or (x) be able to (0.8) ehm (1.1) refer to certain (1.0) things in (2.1) (and) (2.1) but you eh (0.6) may speak quite (0.9) freely on such things
S: I see so you had some discussions after or?
R: no it is not much it is just a little
S: so there are questions put to you by the priest or?
R: yes it is it is not so much but eh (there is) a lit- a little
S: I see
R: to make the time pass
S: ok yes
Unit 32.4 Focus on conversational repair
(1) Robert also makes extensive use of non-specific vocabulary in this part of the conversational exchange. Give three examples of this vocabulary.
(2) It is also difficult in this part of the exchange to assign referents to many of the terms that Robert uses. Give three examples of where this occurs in Robert's turns.
(3) Sonja is less inclined in this part of the conversation to let her lack of understanding of Robert's turns pass unacknowledged in the exchange. Accordingly, she attempts a conversational repair. How would you characterise this repair? Is it effective in establishing common ground between Robert and Sonja?
(4) Is there another way of characterising Sonja's repair strategy which differs from the characterisation that you have given in your response to (3)?
The role of the conversation partner
Speech-language pathologists attach considerable significance to the conversation partner of the person with an acquired neurogenic communication disorder. It has long been recognised that conversation partners can both facilitate and hinder communication with clients who have Parkinson's disease or other neurological disorders. To this end, considerable effort is expended in therapy in encouraging strategies which facilitate communication between clients and their partners, and in discouraging behaviours which impede effective communication. In a related study, Carlsson et al. (Reference Carlsson, Hartelius and Saldert2014) examined the communicative strategies that are used by the partners of people with advanced Parkinson's disease to overcome their difficulties with dysarthria and anomia. Robert and Sonja were one of the dyads used in this study. Sonja was observed to use six different strategies during conversation with Robert: (1) response token where the partner indicates that she is taking part in the interaction but does not intend to undertake repair work (e.g. ‘mm hm’); (2) contribution for flow where the partner contributes a comment or question in the area of the initiated topic, thereby maintaining the flow of conversation; (3) topic shift where the conversation partner shifts the topic from one that has caused problems for the person with a communication disorder; (4) open-class initiation of repair where the conversation partner does not specify which part of the client's contribution needs to be repaired (e.g. ‘what do you mean?’); (5) guess/completion/suggestion where the partner guesses what the client is trying to express by providing a target word or specific alternatives; and (6) elaboration/specification where the conversation partner attempts to narrow down, sum up or expand on the information provided by the client.
Unit 32.5 The role of the conversation partner
(1) During Robert's conversation with Sonja about his church visit, he attempts to tell her that someone played the organ. The exchange in question is shown below. Classify Sonja's contribution according to one of the six categories described above:
R: who played on eh (0.8)
S: on the organ or the piano?
(2) For the category you identified in response to (1), are there any further examples of its use in the conversational data shown in units 32.3 and 32.4?
(3) In the conversational data in units 32.3 and 32.4, are there any examples of the strategy called response token?
(4) In the conversational data in units 32.3 and 32.4, are there any examples of the strategy called topic shift?
(5) Some of these strategies are not related to the initiation of or participation in repair. Other strategies request a clarification or modification of the message by the client. Still other strategies provide the client with solutions. Classify each of the six categories above according to one of these three types of strategy.
