Interventions for Cognitive and Perceptual Deficits

Cognition

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

6 Areas of Cognition

1. Memory

2. Orientation

3. Perseveration

4. Executive functions

5. Attention

6. Alertness

Perception

Interpretation or reasoning of stimuli

True or False: If a client has an impairment in one area of cognition then their overall cognition will be impaired.

True

What are cognitive-perceptual impairments an important predictor of?

Recovery outcomes and prognosis

3 Treatment Approaches for Cognitive-Perceptual Impairments

1. Functional approach

2. Adaptation of the environment

3. Remedial approach

Functional Approach

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

What type of clients would benefit from use of the functional approach for cognitive-perceptual impairments?

Clients with poor learning potential and awareness

Adaptation of the Environment

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

Remedial Approach

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

3 Questions to Consider When Selecting a Treatment Approach

1. Does the patient have the potential to learn?

2. Is the patient aware of errors during task performance?

3. (If yes) Does the patient have the potential to seek solutions?

2 Types of Assessments

1. Paper tests

2. Performance-based tests

Paper Tests

- Contrived, not the real world

- Non-functional

- Low ecological validity

Example of Paper Test

Trail making task

Performance based tests

Will provide client with some tangible information about self

Are neurobehavioral deficits better assessed with paper or performance-based tests?

Performance-based test

Which type of assessment is preferred; paper or performance-based tests?

Performance-based test (preferred)

Assessment Considerations

- Environment (e.g. quiet room, free of distractions)

- Rapport with the client to optimize performance & motivate client

Low-Level Cognitive Skills

Memory

Initiation of activity

Arousal

Simple command following (1-2 step commands)

Orientation

Attention

Recognition

(MIA SOAR)

High-Level Cognitive Skills

Planning

Insight

Multi-step command following (e.g. brush teeth)

Mental flexibility

Problem solving

New learning (e.g. new setting)

Abstraction (abstract thinking)

Generalization of new learning

Safety/judgement (e.g. awareness)

(PIMP NAGS)

Arnadottir OT-ADL Neurobehavioral Evaluation (A-ONE)

Lowenstein OT Cognitive Assessment (LOTCA)

Multiple Errands Test (MET)

Executive Function Performance Test (EFPT)

Kettle Test

What are these assessments used for?

cognitive assessments

Arnadottir OT-ADL Neurobehavioral Evaluation (A-ONE Assessment)

Occupation-based tool to assess impact of neurological impairment on activities of daily living

Is the A-ONE assessment an example of a paper or performance-based test?

Performance based-test

What is the A-ONE assessment used to indicate?

Level of assistance needed

What 3 factors does the A-ONE assessment consider?

1. Sensory stimuli

2. Central nervous system processes

3. Behavior responses in analysis of neurobehavior

What does the A-ONE assessment require before administration?

Training (5-day course)

Lowenstein Occupational Therapy Cognitive Assessment (LOTCA)

Assessment of orientation, awareness, thinking, operations, visual perception, spatial perception, praxis, visuomotor organization, and perception

Is the LOTCA assessment an example of a paper or performance-based test?

Paper test

Is the LOTCA assessment standardized or non-standardized?

Standardized

What population is the LOTCA assessment used with?

Stroke

Dementia

Traumatic brain injury

Central nervous system dysfunction

Intellectual disability

18-69 year-olds

Multiple Errands Test (MET)

Assesses executive function through the use of real-world tasks using specific parameters

Is the MET assessment an example of a paper or performance-based test?

Performance-based test (met)

What 4 tasks are typically observed during the MET assessment?

1. Picking up an envelope

2. Using a telephone

3. Posting a letter

4. Writing down items

What are 2 appropriate settings for the MET assessment to be administered in?

1. Hospital

2. Community

How is the MET assessment completed?

By measuring the number of rule breaks or omission; free

Executive Function Performance Test (EFPT)

Determines which executive functions are impaired, an individual's capacity for functioning independently, and amount of assistance needed to complete tasks

Is the EFPT assessment an example of a paper or performance-based test?

Performance-based test (EFPT)

What 4 tasks are typically observed during the EFPT assessment?

1. Simple cooking

2. Telephone use

3. Medication management

4. Bill payment

How is the client graded in the EFPT assessment?

On the amount of cueing needed to perform tasks

True or False: The EFPT assessment is occupation-based.

True

Does the EFPT assessment focus on low or high-level cognitive skills?

High-level cognitive skills

What is the EFPT assessment used to make recommendations about?

Next level of care

Kettle Test

Performance based tool used to screen for cognitive functional performance through the use of a Kettle

What 5 areas of cognition are assessed in the Kettle Test (LAWCE)?

1. Attention

2. Working memory

3. Cognition

4. Executive functioning

5. Life participation

2 Treatment Considerations

1. Environment

2. Generalization

How can environmental influences affect a client in treatment?

Affects how the client performs an activity

Example of Environmental Influence on Treatment

Cluttered environment can cause disorientation and confusion while an organized environment can reduce distractions and increase attention

What should the occupational therapist analyze prior to treatment?

Activity

Client's strengths and weaknesses

Why should the occupational therapist analyze the activity and the client's strengths and weaknesses?

Provide optimal environment

Generalization

Ability to perform skill or activity in multiple contexts

What are the 2 ways in which a client should practice a skill to increase generalization?

1. Across multiple tasks/contexts (e.g. sit-to-stand)

2. Across multiple environments (e.g. transfers)

What is the purpose of the continuum for transfer of learning?

to promote 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

3 Intervention Considerations

1. Activity processing

2. Behavior modification

3. Group therapy

What does the therapist discuss with the client in activity processing?

Purpose of activity

What does the therapist emphasize in the rehabilitation process of activity processing?

Purpose of activity

What does activity processing allow the therapist to assess?

Awareness

What does activity processing allow the client to do?

Engage in treatment

What does activity processing enhance?

Metacognition

Behavior Modification

Use of prompting, shaping, and contingent reinforcement

What can behavior modification improve a clients independence in?

Daily activities

Group Therapy

Clients receive feedback from their peers

What can clients learn from group therapy?

Other's mistakes

What can clients practice in group therapy?

Monitoring their own behavior

What is the most common intervention consideration used for clients with cognitive-perceptual impairments; activity processing, behavior modification, and group therapy?

Group therapy

3 Levels of Awareness for Clients to Efficiently and Effectively Participate

1. Anticipatory (recognize how problem affects performance)

2. Emergent (recognize problem during a task)

3. Intellectual (recognize they have a problem)

What is the foundational level of awareness for clients to efficiently and effectively participate; intellectual, emergent, or anticipatory?

Intellectual awareness

Interventions for Awareness

- Anticipatory compensation (e.g grocery shopping in am vs pm)

- Recognition compensation

- Situational compensation (e.g. use tape recording for memory)

- External compensation (e.g. alarms)

- Use meaningful activities (apply treatment in a meaningful way)

- Goal focused

Use prompts or cues (e.g. "how do you know this is correct?")

What level of awareness does recognition compensation require; intellectual, emergent, or anticipatory?

Emergent

What type of problem does an inability to distinguish foreground from background indicate?

Figure ground discrimination

Interventions for Figure Ground Discrimination

- Teach awareness of deficit

- Teach organization skills (e.g. simplify environment (declutter)

- Slow down to identify all details of object or stimuli before

- Use contrasts between foreground objects and background

- Task practice

Examples of Task Practice for Figure Ground Discrimination

- Sorting objects (e.g. coins)

- Routine of returning objects to their place

- Maintaining a simple environment

What should clinicians assess before implementing interventions for figure ground discrimination?

Environment

What type of problem does difficulty finding one's way in the environment indicate?

Topographical disorientation

Interventions for Topographical Disorientation

- Mazes simple to complex

- Colored dots to mark the route client has to take

- Practice directional instructions (e.g. turn right at elevator)

- Practice taking the route with a map (occasional glances)

- Draw the path (home setting)

What is the last step to practicing taking a route with a map for topographical disorientation?

Removal of map

When should clinicians take away cues for topographical disorientation?

With mastery

How should clinicians remove cues for topographical disorientation?

Gradually

What type of problem does an inability to detect stimuli indicate?

Agnosia

Does agnosia occur as a result of a defect in one sensory or motor modality?

Sensory

3 Types of Agnosia

1. Finger agnosia

2. Somatoagnosia (body scheme)

3. Tactile agnosia

True or False: There is no specific remediation for agnosia.

True (Agnosia)

Interventions for Agnosia

- Increase awareness

- Compensate by using alternate intact senses

Apraxia

Dysfunction of purposeful movement due to difficulty conceiving and planning the movement

What 3 impairments does apraxia not result from?

1. Motor

2. Sensory

3. Comprehension

Ideational Praxis

Impairment in using everyday objects and tools for their intended purpose

Example of Ideational Praxis

Using comb as toothbrush or putting socks over shoes

What do clients with ideational praxis make significant errors in?

Sequencing common multitask activities

What 2 conditions does ideational praxis rarely occur without?

1. Aphasia

2. Dementia

What does ideational praxis occur as a result of damage to?

1. Prefrontal and premotor cortex in either hemisphere

2. Left inferior parietal lobe

3. Corpus callosum

How are clients with ideational praxis evaluated?

By giving the client everyday objects and asking them to use them

Ideomotor Praxis

Inability to 'motor plan' the task even though the client understands what they wish to do

How can a clients movements with ideomotor praxis be described?

Clumsy and awkward

Example of Ideomotor Praxis

Does not know how to put on shirt but understands how it fits

How are clients with ideomotor praxis evaluated?

By requesting the client to ‘show you how they would’ or ‘pantomime’ an action without the affordances of the actual objects (e.g. “pretend to comb your hair”)

2 Interventions for Apraxia

1. Strategy training

2. Errorless completion and training of details

Strategy Training

Teaching a variety of compensatory strategies to combat impairment and improve activity performance