Cueing order for logopenic PPA at home

Last updated 12 September 2026

They are looking at the coffee cup. They know it is a cup. The word will not come, and after about five seconds you badly want to fill the silence. What you say next, and in what order you say it, is worth getting right.

In logopenic variant primary progressive aphasia, meaning is intact and the sound form of the word is what fails. That one fact sets the whole cueing order. Sound and letter cues go first. Meaning cues go last, or not at all.

What logopenic PPA is, and why the order follows from it

Primary progressive aphasia (PPA) is a condition in which language declines first, while memory and other thinking stay relatively intact early on. It has three recognised variants. The logopenic variant, written lvPPA, is the one where the breakdown sits in phonology, the sound structure of words.

Practically, that means the person knows exactly what a cup is. They could tell you they drink coffee from it and who gave it to them. What they cannot do reliably is assemble the sounds k-uh-p and get them out at speed. Sound errors are common ("cuv" for "cup"). Repeating a long sentence back to you is hard, because phonological short-term memory, the system that holds a string of sounds for a few seconds, is part of what is affected. Single-word understanding is usually fine. Understanding long sentences is where the trouble shows up.

So a first-sound cue hands them the missing piece. A first-letter cue does the same thing through a second route. A meaning cue ("you drink coffee out of it") hands them something they already have, and it adds one more sentence for a strained memory system to hold. In the semantic variant the reverse is true, which is why the variant changes the practice.

One honest note about published order. The cueing cascade from Maya Henry's lab, used in the 2019 treatment study, runs semantic self-cue first, then orthographic (write the word or its first letter), then phonemic (say the first sound), then oral reading, then repetition. That order was built to serve both the semantic and the logopenic variant with one protocol. For a logopenic person the orthographic and phonemic steps are the ones doing the work, and clinicians commonly reorder them. Ask your speech-language pathologist whether they want the first sound or the first letter offered first. Either is defensible. What matters more is that the order never changes from day to day.

The six steps, with a real word

1. Their own attempt, untimed. Show the photo. Say nothing. Count to ten in your head. Ten seconds is far longer than it feels, and the effort of trying is part of what makes the word stick. Tactus Therapy puts it bluntly in its cueing guidance: therapists are often too quick to provide help. Do not say "come on, you know this one."

2. First sound. Give the sound, not the syllable. "Kuh," not "cuh-up". Say it once, then stop talking and let them finish it. In our house the recording is a family voice, because a familiar voice is easier to follow than a synthetic one.

3. First letter. Show the letter and point at it. Say nothing else. A letter on the screen sometimes unlocks the sound when a spoken cue did not, and written words are a durable route in: Meyer et al. 2018 found their orthographic condition (read and copy the written word) produced longer-lasting effects than their phonological condition (listen and repeat), across variants.

4. The written word. Show cup and let them read it aloud. Reading aloud is a step most people get through even on a bad day. It is step four in Henry's published protocol for the same reason.

5. Hear it. You say the word, slowly, in an ordinary adult voice. They repeat it. Any version counts. "Cuv" for "cup" is a success and should be treated as one out loud.

6. Say it together. Both of you say it, slowly, twice. This is the floor. Nobody finishes a card having failed to say the word.

If you use a personal memory cue at all ("this is the mug Sarah gave you"), put it at the end or leave it off. It is warm and it is often worth saying. As a retrieval cue for a logopenic person, it is the weakest one you have.

When to move on

• Move down a step when they ask for help, when they have visibly stopped searching, or when their face changes. Their jaw is the signal, not the clock.
• Skip straight to "say it together" the moment they tense up. Say the word, say it with them, move on. That is not giving up, it is the point of the errorless floor.
• Move on from the card after the last step, with no comment. It is just the next word.
• Do not drill the same word five times in a row. Cycle through the set and come back to it. Spaced practice beat massed practice at one week and one month in Middleton et al. 2016.
• Keep it to about fifteen minutes. Daily home practice of under fifteen minutes was the active ingredient in Henry et al. 2019. Doubling clinician sessions on top of it added nothing.
• Stop for the day on frustration. A five-minute session is data, not failure. Write down that it was short and why.
• Watch the cue level over weeks. A word that used to come unaided and now needs the written form is worth flagging to the speech-language pathologist. Cue level tends to move before accuracy does.

Why you never say "wrong"

Two reasons, one about feelings and one about results.

The feelings reason is that naming under pressure is genuinely stressful. Anxiety affects between 27% and 46% of people with PPA depending on variant, and a 2020 study in Folia Phoniatrica et Logopaedica measured physiological stress responses during word retrieval tasks in people with aphasia. The semantic-variant consensus review says it plainly: when practice becomes stressful, it may not be desirable to continue. Pressure makes word finding worse in the moment, so every correction costs you the next three words as well.

The results reason is that error correction buys you nothing. Nunn and Middleton's 2023 scoping review found errorless and errorful practice broadly comparable on naming outcomes, with retrieval practice (an attempt before the answer, spaced over time) more durable than either, and repeated concerns in the literature that errorful methods damage motivation and preference. Jokel and Anderson 2012 found errorless learning outperformed errorful learning in semantic dementia. So you get the same learning without the cost.

In practice this means a wrong word gets exactly the same calm response as a right one. You say the target word warmly, they repeat it, you move on. The trial is recorded as "got it at the written word", never as a failure. If something goes wrong in a conversation, blame yourself out loud ("I'm not following well today"), which is straight out of Supported Conversation for Adults with Aphasia. And drop test questions, the ones you already know the answer to, everywhere except the practice slot.

What the research says

• Henry et al. 2019 (Journal of Speech, Language, and Hearing Research), 18 people with semantic and logopenic PPA. One clinician session a week plus daily home practice of under 15 minutes produced large gains on trained words, mean effect size d = 7.2, still above baseline at 12 months despite measurable cognitive decline over the same year. Gains on untrained words were small, d = 1.06. Doubling the clinician sessions did not help. PMC6802912
• The same study found no difference in response between the semantic and logopenic participants on one shared protocol. What changes with variant is which cue steps carry the load and which words you choose, rather than the whole approach.
• Meyer et al. 2018 (Aphasiology): the orthographic condition, reading and copying the written word, gave more durable effects than the phonological condition across variants. In the same study, gains on words the person could still name at the start lasted up to 15 months, while gains on words already lost faded by 8 months. PMC6066454
• A 2025 logopenic-variant teletherapy study trained phonological short-term memory with immediate and five-second-delayed repetition of words of increasing syllable length, three 45-minute sessions a week for five weeks. Gains on trained items held at 3 months, with little transfer to naming. PMC12756969
• Grasso et al. 2024, modified VISTA script training across all three variants (n = 13): 30-minute sessions twice weekly for 8 weeks plus home practice three days a week with a personalised video. Logopenic and nonfluent participants improved most, which the authors attribute to scripts lowering the demands associated with word retrieval. Gains held at 3 and 6 months, and participant satisfaction was 4.7 to 4.9 out of 5. PMC11482574
• Grasso et al. 2017 found that word sets trained by a caregiver did as well as word sets trained by a clinician in logopenic PPA, when the caregiver followed the clinician's protocol. A family member can run this. Following the fixed order is the part that matters.
• Rogalski et al. 2025, the Communication Bridge-2 randomised trial, 95 people across all three variants. The arm that trained the person and their partner together, using personal photos and personal goals, beat the drill-only arm on goal attainment, 66.7% of goals improved against 49.1%. Word retrieval improved similarly in both arms from 30 minutes a day, five days a week. PMC11947768
• The honest caveat. Roheger et al.'s 2024 Cochrane review rates the randomised evidence for behavioural PPA treatment as very low certainty, because the trials are small. The effect on practised words is consistent across studies. How much any one person will get from it is not something anyone can promise. Cochrane CD015067

What to ask the speech-language pathologist

• Which variant, how confident are you, and what would change your mind?
• What cue order do you want us to use? Should the first letter come before the first sound?
• Which 20 to 30 words, and how many of them should be words they can still say?
• How long should we wait before offering the first cue?
• What would you actually want to see in a weekly summary from home?