cognitive

Cognitive/communicative Impairments
Associated with
Right Hemisphere Damage, Traumatic Brain Injury, and Dementia

Primary Sources: Tompkins (1995), Halper, Cherney & Burns (1996), Hartley (1995)

What is cognition?

Cognitive processes

•perception
•attention
•orientation
•memory
•executive functions

Do the right & left hemispheres perform different cognitive functions?

Cognitive Process	Left hemisphere	Right hemisphere
Auditory	temporal	pitch and melody
Auditory comprehension	phonology, morphology, semantics, syntax	pragmatics, including emotional content
Visual or tactile	reading (especially phonetic decoding), writing, sign language	reading, especially visually picturable nouns and sight words facial recognition
Calculation	arithmetic	spatial processing
Memory	verbal memory	visual memory, working memory
Attention	allocation of attentional resources for subconscious processing	spatial distribution of attention, vigilance
Other	praxis	recognition of facial expressions, body image and perception of body in space

What kinds of behaviors do patients with RHD exhibit?

Cognitive deficits

Attention

•Hemispatial neglect

•excluding detail from left side during drawing from memory
•making errors of omission when choices are on left side
•omitting letters on the left side of words
•dressing or grooming only right side of the body
•bumping into structures on the left side of the body

•impaired selective attention
•impaired vigilance

Visuoperception

•simultanagnosia (failure to recognize the gestalt in a visual display)
•achromatopsia (loss of color vision)
•topographical disorientation (environmental agnosia)
•failure to recognize familiar or famous faces

Visuomotor

•constructional impairments

•drawing
•assembling

•dressing disturbance

•left neglect
•garment disorientation

Affect & Emotions

•anosognosia (unawareness or denial of deficits)
•aprosodia
•impaired auditory comprehension of affect
•impaired ability to recognize or produce facial expressions
•voice recognition impairments

Memory

•impaired working memory
•impaired visual memory

Other

•Capgras' syndrome
•acute confusion
•impairments in executive function

•Difficulty with planning and problem-solving
•Difficulty initiating activity
•Distractibility
•Impaired ability to use feedback
•Perseveration

Communication Symptoms

Use

•Prosody

•Too much or too little
•May have difficulty interpreting emotional prosody

•Emotional and nonverbal communication

•Insensitivity to emotional stimuli
•Reduced nonverbal animation

•Speech acts

•Difficulty interpreting indirect requests
•Difficulty judging the appropriateness of actions

•Figurative and implied meanings

•Tendency to take utterances literally
•May be complicated by metalinguistic tasks

•Sensitivity to listener needs and situation (Code mismatches)
•Humor (may be related to many interpretation deficits)
•Inferences

Discourse and Conversation

•May understand less in discourse than would be predicted by sentence-level comprehension
•May perform better when attentional demands are reduced
•Language comprehension may be more variable than non-brain damaged
•Word-finding

•Often make visually related errors
•May have difficulty assigning categories

•Reading & Writing

•Neglect dyslexia
•Spatial agraphias
•Inappropriately large left margins

•Dysarthria

What kind of behaviors do patients with TBI exhibit?

Cognitive deficits

Attention

•decreased arousal / alertness
•impaired selective attention
•reduced ability to divide and/or shift attention
•impaired vigilance

Visuoperception

•difficulty perceiving complex visual information
•decreased scanning ability
•spatial disorientation (environmental agnosia)

Affect & Emotions

•tendency to be self-focused
•decreased empathy
•difficulty perceiving or expressing emotions (too much, too little, inappropriate)
•disinhibition

Memory

•impaired working memory
•prone to learning interference
•reduced ability to organize information for storage
•reduced ability to use memory strategies

Executive function

•decreased use of organizational strategies
•difficulty with integrating information
•reduced initiative and motivation
•poor problem solving
•reduced self-monitoring
•poor judgment
•impaired sequencing

Communication Symptoms

Content

•word-finding problems
•difficulty with abstract meanings, idioms, or proverbs
•confabulation
•use of nonspecific references

Form

•impaired auditory comprehension
•paraphasias if concomitant aphasia
•dysarthria and/or apraxia

Use

•Prosody

•flat affect
•slowed initiation of speech and overall rate
•may have difficulty interpreting emotional prosody

•Emotional and nonverbal communication

•reduced ability to comprehend or express emotional information
•inappropriate nonverbals (eye contact, facial expressions, touching, personal space)
•inappropriate laughter

•Speech acts

•tangential speech, inability to be concise
•poor topic maintenance or perseveration
•reduced ability to identify main ideas
•inability to code switch or judge context
•limited use of clarification strategies
•stereotyped responses
•decreased comprehension of indirect requests and humor

What kind of behaviors do patients with dementia exhibit?

Cognitive deficits

Attention

•decreased arousal / alertness
•impaired selective attention
•disorientation for time

Visuoperception

•may have difficulty identifying complex visual displays
•spatial disorientation

Affect & Emotions

•may exhibit emotional lability
•disinhibition

Memory

•impaired working memory
•impaired semantic memory
•poor episodic memory

Motor

•restlessness
•incontinence
•rigidity and nonambulatory in final stages

Executive function

•reduced initiative and motivation
•reduced self-monitoring
•poor judgment
•impaired sequencing

Communication Symptoms

Content

•decreased vocabulary
•repetitious
•reduced overall output, muteness in late stages
•empty speech

Form

•intact until late stages
•dysarthria in some subcortical dementias

Use

•Prosody

•flat affect
•slowed initiation of speech and overall rate

•Emotional and nonverbal communication

•reduced ability to comprehend or express emotional information
•inappropriate nonverbals (eye contact, facial expressions, touching, personal space)
•inappropriate laughter

•Speech acts

•overall diminished comprehension
•poor topic maintenance or perseveration
•reduced ability to identify main ideas
•reduced ability to code switch or judge context
•stereotyped responses
•decreased comprehension of indirect requests and humor
•may maintain reflexive use of social phrases

Cognitive Process	Aphasia	RHD	TBI	Dementia
Auditory processing	Difficulty with temporal processing	Difficulty with pitch and melody	Difficulty with figure/ground
Auditory comprehension	phonology, morphology, semantics, syntax	pragmatics, including emotional content, impairments in voice recognition	any combination	all aspects eventually affected
Visual or spatial processing	reading, writing, sign language impairments	visuospatial neglect, geographical disorientation, facial recognition deficits	any combination	geographical disorientation, facial recognition deficits
Memory	verbal memory	visual memory	verbal & visual memory, STM, retrograde and anterograde amnesia	verbal & visual memory, STM, retrograde and anterograde amnesia
Attention	Impaired allocation of working memory resources	Impaired spatial attention, impaired vigilance	Impaired selective and sustained attention	Impaired selective attention
Executive functions	perseveration	impulsivity, anosagnosia	impulsivity, impaired judgment	impaired judgment, personality changes
Other	apraxia	disrupted body image	adynamia, disinhibition	ambulation, incontinence