Attention, Memory, Eval, Intervention TBI

Spatial attention

ability to detect and allocate attention to different parts of space

A client with right hemispheric TBI consistently

fails to attend to items on the left side of the plate during

meals or misses people approaching from the left during hallway mobility. Which attentional process is affected?

spatial attention

Selective attention

- ability to maintain a consistent behavioral set through activation and inhibition of responses

- requires selection of target stimuli from among background stimuli

A client is unable to complete a medication management

task in a busy therapy gym due to distraction from surrounding conversations and equipment noise. Which attentional process is affected?

Selective attention

Sustained attention

ability to maintain a consistent response set during continuous or repetitive activity over time

A client begins a grooming task appropriately but

loses focus midway through and requires repeated cues to

complete the activity. Which attentional process is affected?

sustained attention

Alternating attention

- ability to switch response sets in response to environmental cues

- allows two activities with distinct response requirements to be performed in sequence

A client struggles to switch between following a recipe and responding to verbal questions during a cooking task. Which attentional process is affected?

Alternating attention

Divided attention

capacity to divide attention to respond to two or more task occurring during the same time period

A client is unable to safely walk while simultaneously engaging in

conversation, resulting in slowed gait or loss of balance. Which attentional process is affected?

divided attention

Test of Everyday Attention (TEA)

- standardized, noncomputerized test

- uses familiar, everyday materials and assesses attention in ecological valid contexts

- assess: visual Selective Attention and Speed, Attentional Switching, Sustained Attention, Auditory-Verbal Working Memory

Direct attention training

- bottom up; repetitive, structured tasks designed to stress a specific type of attention

- often progresses from simple-complex with controlled variables

- restores or strengthens attentional capacity, not teaching compensation

A client completes paper-and-pencil cancellation

tasks that progressively increase visual complexity to

target selective attention. Along with computer-based tasks requiring the client to respond to target stimuli while ignoring distractors. Which training does this describe?

direct attention training

Metacognitive strategy training

- top down; focuses on awareness, self monitoring, and strategy use

- explicit teaching of thinking about thinking

- emphasis on error awareness, prediction, and self correction

- teaching the client to use self-talk (e.g., "Stop - check continue") during multi- step ADLs

Before a cooking task, the client is asked:

"What parts of this task will be hardest for your attention?"

"What strategy will you use if you get distracted?" and

Post-task reflection:

"Where did your attention break down?"

"What would you do differently next time?"

Which training does this describe?

metacognitive

Dual task training

- performing two task simultaneously

- used to assess and treat divided attention and real world safety

- deficits are often invisible at rest but emerge during functional mobility and IADLs

Walking in the hallway while answering functional questions (e.g.,

scheduling, directions).

Carrying groceries while scanning for room numbers.

Preparing a meal while responding to environmental interruptions (timer, therapist questions). Which training does this describe?

Dual task training

Selective attention: pencil and paper task

- Letter or symbol cancellation worksheets where the client:

- Circles only the target letter (e.g., "A") while ignoring distractors

- Complexity increases by adding similar-looking letters or reducing spacing

- Crossing out numbers divisible by 3 while ignoring others

Sustained attention: pencil and paper task

- Long-duration cancellation tasks completed over several minutes without breaks

- Repetitive sequencing tasks (e.g., connecting alternating numbers and letters for extended periods)

Alternating attention: pencil and paper task

Worksheets that require switching rules:

- First line: circle vowels

- Second line: underline consonants

- Rules alternate every line or every minute

Divided attention: pencil and paper task

Completing a worksheet while simultaneously listening for and responding to a target word

spoken by the therapist

Sustained attention: computer based task

- Vigilance tasks where the client presses a

key when a target stimulus appears over

time

- Continuous Performance Test-type

activities

Selective attention: computer based task

Responding only to specific visual or

auditory stimuli while ignoring distractors

(e.g., respond to a red square but not blue)

Alternating attention: computer based task

Computer tasks requiring frequent rule

shifts (e.g., respond to shape/respond to

color/respond to number)

Divided attention: computer based task

Tracking a moving object on the screen

while responding to auditory cues

Attention process training

systematically targets 5 attention domains using graded tasks

- Sustained attention: Listening for a target word in a recorded passage and marking each occurrence

- Selective attention: Completing tasks with increasing background noise or visual clutter

- Alternating attention: Switching between addition and subtraction problems when cued

- Divided attention: Writing numbers while simultaneously listening for specific words

- Focused attention: Responding only to target stimuli under time pressure

Functional and contextualized interventions

- use of real world functional tasks to target attention

- ex. include cooking, community mobility, and IADL simulations

T or F: orientation does not equal intact memory

True

Posttraumatic Amnesia (PTA)

- a period of confusion and inability to form new episodic memories following TBI

- the duration is one of the most accurate indicators of injury severity and outcome

Client repeatedly asks why they are hospitalized and cannot

retain answers day to day. What is this an example of?

posttraumatic amnesia

Memory eval

- orientation

- short delay recall

- long delay recall

- carry over

Short term memory is evaluated

through immediate and brief delay recall

Long term memory is evaluated

through delayed recall and carryover across days

Working memory is evaluated

-during task execution and multistep activities

- observing multistep task performance; dual task demands; immediate recall during activity

Working memory deficit presents

difficulty holding and manipulating information over short periods

Working memory intervention

-task simplification

-external cueing

-reducing cognitive load

Verbal memory deficit

difficulty recalling spoken information

Verbal memory eval

delayed recall of verbal instructions at 30 seconds and 30 minutes; standardized verbal memory tests

Verbal memory intervention

- external memory aids

- repetition

- errorless learning for key info

Visual memory eval

recall of pictures, object locations, or visual sequences after delay

Visual memory intervention

- environmental consistency

- visual cues

- repeated exposure

Client cannot remember where kitchen items were placed after a short delay. Which memory is affected?

Visual memory

Episodic memory deficit

inability to recall recent personal experiences or events

Episodic memory eval

interview about recent events; observation of carryover across days

Episodic memory intervention

-external memory supports

-spaced retrieval

-errorless learning

Client cannot recall yesterday's therapy session or family visit.

Which memory is affected?

Episodic memory

Prospective memory deficit

failure to remember to perform intended actions in the future

Prospective memory eval

assigning future actions and observing completion

Prospective memory intervention

- alarms

- paging systems

- external reminders

Client forgets to take meds at scheduled times. Which memory is affected?

prospective memory

Remote memory

-recall of long past events is typically preserved

-eval: life history interview

-ex. client accurately recalls childhood events but not recent meals

Autobiographical memory deficit

fragmented or incomplete life narrative

Autobiographical memory intervention

-external memory books

-life story work

Client struggles to recount major life milestones coherently. Which memory is affected?

Autobiographical memory

Incidental learning deficit

failure to learn routines without explicit instruction

Incidental learning eval

observation of performance across repeated exposure without cues

Client does not improve a routine unless explicitly taught each

step. which memory is affected?

Incidental learning

External aids for memory: passive systems

- checklists

- timetables

- memory books

- diaries

- daily planners or organizers

External aids for memory: active systems

- PDAs

- mobile phones

- paging systems

Errorless learning

- practitioner provides sufficient support to prevent errors, and support is gradually withdrawn as learning occurs

- superior for people with TBI who has severe memory impairments because it prevents propagation of errors

Errorless dressing activity

"Shirt first. Now pants. Good, follow me"

Overlearning

- the practice of a skill beyond the point of mastery

- increases retention and supports automatic performance, reducing reliance on declarative memory

Environmental cueing

- supports performance by reducing reliance on impaired internal memory

- cues may be visual, spatial, temporal, or embedded in the environment

Executive function deficits commonly result in

- difficulty initiating tasks

- poor planning and organization

- reduced problem solving

- decreased tolerance for complex or stimulation environments

Global (metacognitive) strategy training

recommended for executive function and emotional self regulation deficits after TBI

focuses on:

-self monitoring

-self regulation

-awareness of errors

-adjusting strategies during task performance

Goal management training

teaches self instructional strategies to reduce goal neglect

steps:

1. stop

2. define the main task

3. list steps

4. learn steps

5. do the task

6. check performance

Debriefing

happens after the client completes (or attempts) a task

sessions focus on:

- monitoring task performance

- detecting errors

- generating new strategies