Cognition and Neuro Behaviors Post-Brain Injury

Cognition in practice

Why should we care?

• Cognitive rehabilitation (remediation) vs. compensation for cognition following brain injury:

  • Improves problem-solving and executive function

  • Potentially reduces the cost of rehabilitation and lifestyle support following TBI

• Impacts how we deliver feedback to the patient

Cognitive skills hierarchy

Damage to temporal lobe

• Explicit memory (declarative memory)

• Implicit memory deficits (procedural memory)

Explicit memory deficits (declarative)

• Retention and retrieval of facts, event, or steps to complete a task

• Prospective Memory ability to remember to follow up and anticipate upcoming events, dates, deadlines, etc.

• Explicit memory is notably affected during brain injury

Implicit memory deficits (procedural)

• “It’s like riding a bike!”

• Learned through movement or perception

• Accessing implicit memory for learning can be affected due to perceptual and motor disorders as a result of the brain injury

• Often utilize procedural memory tasks for remediation

Post-traumatic amnesia (PTA)

• Amnesia can occur when there is damage to the medial temporal lobes and the hippocampus

• Retrograde Amnesia

  • Loss of the ability to recall events that occurred immediately before the head injury

• Anterograde Amnesia

  • New events in the immediate memory cannot be transferred into long-term memory; therefore, inability to form new memory (50 First Dates)

• Can be retrograde, anterograde, or mixed/transient (unable to remember time and place but remember self)

PTA Recovery

• Duration of PTA is an indicator of cognitive and functional deficits

  • 80% of patients with PTA lasting < 2 weeks had good recovery

  • Classification of TBI due to memory deficits:

    • Mild TBI: < 24 hours

    • Moderate: 1-7 days

    • Severe: 1- 4 weeks

    • Very severe: > 4 weeks

Damage to prefrontal cortex

• Working Memory (attention) deficits

  • Holding on to small amounts of information and applying it to a cognitive task

  • Important for learning and the first step in forming memories

  • Without attention memories cannot be formed

  • Affected by level of consciousness, arousal, awareness, and motivation

• Executive Function deficits

  • Restraint: judgment, foresight, delay of gratification, inhibiting inappropriate behavior, and self-governance

  • Initiative: curiosity, drive, creativity, mental flexibility, and personality

  • Order: planning, abstract reasoning, sequencing, and organization

EF impact on behavior

• Emotional control

• Inhibition

• Shifting

• Self-monitoring

Emotional control

the ability to identify and regulate your emotions and respond in a socially tolerable and flexible way and also have a certain level of control over spontaneous reactions

Inhibition

involves being able to control one's attention, behavior, thoughts, and/or emotions to override a strong internal predisposition or external lure, and instead do what's more appropriate or needed

Shifting

involves conscious (not unconscious) change in attention

Self-monitoring

reflects how we understand our behaviors and how we adjust to make changes for the future. Self-monitoring behaviors can include both work-checking behaviors (reviewing mistakes, fixing errors, etc.)

Executive dysfunctions and behavior manifestations

• Agitation and aggression are a result of poor executive function skills, especially decreased ability for self-monitoring skills

• Inability to establish healthy coping strategies

• Important to identify antecedents that trigger maladaptive behaviors

• Constantly observing for physical and verbal signs of behavior disruption

• Implement healthy coping strategies for the individual

What is behavior?

• Actions that are made by a person in conjunction with their environment

• Response of the person to various stimuli or input

• Neurological Behaviors are those that occur in response to a neurological injury that are dependent on severity of injury, injury location, and psychosocial variables of the individual

We all have behaviors

Etiology of neurological behaviors

• Biological/biochemistry

  • Cellular level (dopamine, serotonin, melatonin, norepinephrine)

• Neuropathology

  • frontal and temporal damage; unable to

    process limbic system information,

    cerebellum cognitive-emotional

    regulation)

• Neurobehavioral

  • Emotional regulation, Aggression, impulsivity, social withdrawal, compulsive behaviors, disorientation

  • Inability to adequately use executive function skills

• Neurocognitive

  • Language (receptive and expressive aphasia)

  • Memory

  • Problem solving/judgement

• Psychosocial variables

  • Mental health prior to TBI

  • Family – culture – dynamic

  • Education level and achievement

  • Occupational history

  • Substance abuse

  • Financial considerations

Right hemispheric lesions

• Agnosia

  • Inability to recognize the emotions or social cues of others

• Inability to initiate an appropriate emotional response

  • Flat affect

  • Stunted emotionally

  • Poor social interaction or socially inappropriate

  • Impulsive with thoughts, words, actions, etc

• They still understand everything going on around them but are limited to making an appropriate emotional connection

Left hemispheric lesions

• Aphasia

  • Frustration with the inability to communicate effectively

• Compulsiveness

  • Frustration when things are out of order or not going the way they want

  • Compounded with impaired communication

• Increased desire for independence/safety

  • Risky behavior in efforts to not rely on others

Neuroplasticity

• The brain’s ability to change and adapt in response to experiences, learning and changes

• Whatever the person DOES (or does not do)

  is what they are going to continue to do….

  • Optimal behavior is key!

Negative behaviors

• A behavior is typically considered negative when there is a RISK!

• These tend to get our attention more than positive behavior…

• Negative behaviors tend to be subjective

  • Verbal outburst

  • Verbal aggression

  • Physical aggression

  • Inappropriate sexual behavior

  • Elopements – leaving without permission or without someone knowing where they are

  • Impulsivity

  • Self-harm

Positive behaviors

• Often have no risk, so we tend to overlook these…

  • Social courtesy – consideration of others

  • Social skills

  • Problem-solving

  • Appropriate requesting

  • Self-calming or self-regulation

  • Safety awareness

  • Acceptance of feedback

• THE GOAL: Replace negative behaviors with positive behavior

  • We need to focus our attention on the positive behaviors by reinforcing them…

Behavior plan

• Structured, collaborative strategy designed to identify, understand, and manage behaviors that interfere with recovery, safety, or quality of life after a brain injury.

• Help to determine the relative frequency and intensity of the behaviors

• Both positive and negative behaviors should be measured

• Behavior intervention plan (BIP) designed to modify the environment and consequences to shape more functional behaviors.

• Are multidisciplinary collaborations that are designed to help the whole team understand behaviors and avoid over medication/sedation

What’s our role in the behavior plan?

• Skillfully observe interactions through the different environments and activity demands

• Identify and document potential triggers

• Redirect/Reinforce as appropriate

• Implement the behavior strategies that are deemed successful by the team and document their effectiveness

Guidelines for reducing behavior

Antecedent

• Document all events leading to behavior and possible to triggers:

  • Do they appear more anxious, angry, tired, etc. than usual?

  • Was there anything different about their greeting? Was it a typical greeting for this individual?

  • Consider different triggers. Environmental? Activity? Personal/psychosocial factors?

Behavior

Consequences

• Implementation of the behavior plan or strategies agreed upon by the therapy team

• Document your response (the chosen strategies) & the person’s response to those strategies:

  • The individual’s response is usually MOST negative when implementing new strategies

  • Did the behavior persist, or did extinction occur after using strategies?

  • Did additional staff have to step in due to escalation?

  • What strategy seemed to be the most effective? Be prepared to share this with the team.

Behavior plan requirements

Consequences: Strategies for shaping negative behavior

• Extinction

  • “Pivoting” from “junk” or negative behavior

  • Must use good clinical judgment to determine if negative behavior should persist

  • Plan for backup staff in near proximity for anticipated escalation of behavior

  • Redirection to another task or environment

• Positive Reinforcement

  • Praising “desired” or positive behavior

  • Modeling positive behavior

  • Praising others in close proximity for their positive participation

  • You perform the desired task in hopes of their contribution

Substitute negative behaviors

• We do NOT want to restrict experiences

• We WANT to allow real-life experiences to allow for opportunities to reinforce positive behaviors

• Be prepared and have backup!

Steps for de-escalation

Metacognition

•“thinking about thinking”

•The awareness and regulation of one’s own cognitive processes

•Planning how to approach a task- monitoring comprehension

during the process and evaluating performance afterward.

•Planning, monitoring, evaluating, studying, problem-solving,

preparation.

•Helps learners become more confident and independent.

Choosing an intervention based on metacognitive availability

Neuro-functional approach (NFA)

• “Learning by doing” through meaningful activities (task-specific training)

• Utilize “practice tasks” that have a structured format

  • Eliminate the required use of executive function

  • Develop competency and improve self-esteem

  • Enhances performance and promotes engagement

• Goal-setting → positive feedback → motivation

Practice makes perfect

• Practice Schedules

  • Structured daily schedules

  • Consider the individual’s routine

• Blocked Practice vs. Random Practice

  • Initially blocked practice may be necessary for skill acquisition then transitioning to random practice to facilitate generalization

Trial and error learning

• The superior form of learning for people with self-monitoring capabilities

◦ Able to…

1) remember if an error has occurred

2) recognize an error

3) suppress maladaptive behaviors or behaviors

that interfere with the performance

4) replace error-full or maladaptive behavior

with a different or more optimal behavior

• Moderate to Mild TBI

Errorless learning

• Used with people who have decreased self-monitoring and memory impairments

◦ Unable to…

1) remember if an error has occurred

2) recognize an error

3) suppress maladaptive behaviors or behaviors

that interfere with performance

4) replace error-full or maladaptive behavior

with a different or more optimal behavior

Therapeutic alliance

• Emotional bond between client and therapist

• Mutual agreement on goals

• Mutual agreement on the tasks within the intervention

Evaluation, Planning, Implementation

Cognitive strategies examples

Memory & attention aides

◦ Therapy “to-do” or daily check-lists

◦ Daily calendar and orientation logs

◦ Verbal summarization

◦ Visual targets or external cues during pathfinding or activities

◦ Timers (visual timers) and/or alarms for reminders

◦ Grading environment stimuli

Executive Function

◦ Plan and organize in advance or prior to the performance

◦ Time blocking to manage “work” time, scheduling breaks,

etc.

◦ Grade activity to down or up with summary feedback

◦ Complete part of the task versus all of the task

◦ Allow the person to vocalize successes and areas of improvement or provide this for the person if they are unable to

Overlearning a task

• Acquisition of skill beyond the point of mastery

• No more performance improvements are observed with practice

• Increased ability to maintain skill and reduces performance effort

• Increased stability of learned skills and increased self-monitoring skills

  • Reduces the likelihood of regression as reinforcements are gradually removed

• Goal is to achieve optimal, automatic behavior

What’s our goal as therapists?

GENERALIZATION

Behavior change through cognitive approaches

• Therapeutic Alliance

  • patient-therapist trust each other

• Neuro-functional Approach (Task-specific Training)

  • salience will increase motivation and promote participation

• Overlearning

  • the appropriate behavior

Psychosocial & environmental factors

Improving metacognition

• Use guided self-discovery – Let them figure it out!

• Reshape intended behavior by asking probing questions that requires self-reflection of performance

• CO-OP (Cognitive Orientation to daily Occupational Performance)

Signs of metacognition

◦ Spontaneously checks work

◦ Has a good understanding of own personal strengths and weaknesses?

◦ Can easily estimate abilities

◦ Can self monitor during a task— “Am I doing ok? Do I need to change how I am doing this?”

◦ Can monitor the amount of time it is taking to do the task

◦ Can detect errors and change accordingly

Factors that impact prognosis

• Age, physical and mental condition, socioeconomic status, & social support

• Initial Glasgow Coma Scale and at the time of admission predicts disability and recovery

  • Longer the duration = poorer outcomes

• Severity of the injury; type and location of injury; other injuries and complications; prolonged time before initiation of rehab

• Duration of recovery/time spent at different Rancho Levels

• Length of post-traumatic amnesia

• Disability Rating Scale - associated with employability and school