Cognitive dysfunction in Neurological Rehabilitation

Cognition

mental actions of knowing, thinking, learning, judging, and processing of information

Perception

interpretation of reasoning of stimuli

Neurobehavior

any behavioral response resulting from CNS processing and includes praxis, attention, memory, spatial relations, sequencing, and problem solving

Functional approach

use of repetitive practice during functional activities; compensatory. skills may not generalize to other activities

Adaptation of the environment

changing aspects of the task or environment when compensation is not possible; used with clients who have poor learning potential

Remedial approach

restoration of function or skill; used acute stages, short-term benefits in later stages

Questions to ask self when selecting treatment

1) Does the patient have the potential to learn?

2) Is the patient aware of errors during task performance? If yes, does patient have potential to seek solutions to those errors?

assessment and evaluation of cognition

• paper tests → non-functional, low ecological validity

• performance based tests

Assessment considerations

quiet room, free of distractions, rapport with the client to optimize performance and motivate client.

Skills assessed for low-level cognition

arousal, attention, orientation, recognition, simple command following, memory, initiation of activity

Skills assessed for high-level cognition

insight, following multi-step commands, mental flexibility, planning, problem solving, abstraction, new learning, generalization of new learning, safety/judgment

Arnadottir OT-ADL Neurobehavioral evaluation

Occupation-based tool to assess impact of neurological impairment on ADL. Used to indicate level of assist needed. Considers sensory stimuli, CNS process, and behavior responses in analysis of neurobehavior. Requires specific training to administer

Lowenstein Occupational Therapy Cognitive Assessment (LOTCHA)

Standardized assessment; orientation awareness, thinking operations, visual perception, spatial perception, praxis, visuomotor, organization, and perception. Used with stroke, dementia, TBI, CNA dysfunction, intellectual disabilities, 18-69 y/o. Cost $300-500 depending on the version purchased.

Multiple errands test

Assesses executive function through the use of real-world tasks using specific parameters, appropriate for hospital or community setting, assessment completed by measuring the number of rule breaks or omissions. Cost-free

Executive function performance test

Occupation based assessment. Assesses executive function and capacity for functioning independently. Four tasks: simple cooking, telephone use, medication management, bill payment. Client is graded on the amount of cueing needed. Cost-free

Kettle Test

performance based tool to screen cognitive functional performance. Assesses attention and working memory, cognition, executive functioning, and life participation. Cost-free

Treatment considerations for cognition

Environment, Generalization

Near transfer

1-2 components of the task are changed from the original practiced task

Intermediate transfer

3-6 components are changed from the original practiced task

Far transfer

tasks are conceptually similar but share only one similarity

Very far transfer

tasks are very different

Activity processing

therapist discusses purpose of activity with client, emphasizes purpose of activity in rehabilitation process

Behavior modification

use of prompting, shaping, and contigent reinforcement

Group therapy

clients receive feedback from their peers

What is ideational praxis caused by?

Damage to prefrontal and premotor cortex in either hemisphere, L inferior parietal lobe and corpus callosum

Interventions for apraxia

Strategy training → initiation, execution, control

Errorless completion and training of details

Intervention for perserveration

Bring perseveration to conscious level in attempt to inhibit, redirect attention, assist patient to initiate a new task or movement, engage in tasks that are repetitive to promote task participation.

Intervention for organization and sequencing

step by step instruction, use visual or auditory supports, organize environment and declutter

intervention for memory

restorative approaches, strategy training, non electronic memory aid, electronic memory aid, memory notebooks and diaries

Selective attention

ability to focus on a stimulus and screen irrelevant stimuli

Sustained attention

ability to maintain attention over a period of time

Alternating attention

ability to shift focus from one stimulus to another

Interventions for attention

• use checklists

• use checklists

• avoid overstimulation

• self-manage efforts and emotional responses during tasks

• mixed results on the success of remediation

Interventions for executive functions

environmental modifications, compensatory strategies, task specific training, training in metacognitive strategies

Skill-task-habit training

development of new skills or tasks to develop habits and improve occupational performance

Strategy training

focused on acquisition, application, and adaptation

memory strategies

metacognitive

Task and/or Environmental Modification training

• changing the task to decrease cognitive demand

• using cognitive exercises to remediate or improve specific areas

• general or nonspecific > specific > explicit