Cognition

OTs Role

Eval- occupational profile. motor and cognitive assessments, collaborative goal setting

Intervention: modify (compensate, adapt), therapeutic use of occupation, education, advocacy, group interventions

Occupation/Performance Demands: supplies, space, time, number of steps, speed required, position required, sequence, prep work, sensory/perceptual

conditions, functions, and structures

basic cognition skills

attention- alertness and arousal; higher levels involve working memory, sustained concentration, vigilance, divided attention

memory- complex skills consisting of attention, encoding, storage, and retrieval

perception- hemispatial neglect, visuospatial organization, apraxia

• neglect is an attention issue not vision

Types of attention

divided- respond to 2+ events/stimuli at the same time

alternating- shift focus between tasks that demand different behavioral/cognitive skills

selective- process target info selectively and inhibit responding to nontarget info

sustained- ability to maintain attention over time, during continuous or repetitive task

focused- recognize and acknowledge specific sensory info; hear a knock→turn eyes towards noise

subsystems of attention

alerting: controls sustained attention and vigilance

orienting: responsible for selecting and prioritizing incoming sensory info

executive control: exerting volitional control over attention processes, monitoring, resolving conflict

Attention assessments

Trail making test

test of everyday attention (TEA)

attention treatment

Attention: Time pressure management

decision making ordered in 3 levels based on time pressure present

• operational: immediate decisions and actions to prevent failure

• tactical: anticipate and adapt behaviors to reduce or prevent problems when time pressure is present but manageable

• strategic: decisions made well ahead of time with no pressure

Memory

depending on location of injury, different types of memory are impacted

Long term memory hierarchy

declarative- explicit memory, conscious recall of what you did this weekend

• semantic- knowledge, definitions, facts, concepts

• episodic- context specific, personal experiences; tap into episodic to remember semantic (where did I write that fact in my notes, where was I when I studied this)

non-declaritive- does not require conscious thought to retrieve, automatic behaviors

• priming- exposure to stimulus influences later response without conscious awareness

  • read the word coffee, more likely to later identify soda rather than bread because you’ve been primed for beverages

• procedural- skill memory, implicit, know how to ride a bike without “thinking about it”

• prospective (future)- I need to remember I have a Dr appointment tmrw

• retrospective (past)- I had a Dr appointment last week

Memory assessments and interventions

contextual memory test

rivermead behavioral memory test 3rd edition

goal attainment scaling

interventions: external help (orientation notebook, visual cues, electronic devices); memory strategy training (association techniques, organizational, and elaboration)

Perception

guides decisions and actions, shapes beliefs

hemispatial neglect: most associated with right parietal lobe injury; many improve but chronic neglect impacts many occupations

• can be neglect of visual, auditory, tactile, and proprioception contralateral to injury

• assessments: bells test, behavioral inattention test, test of visual neglect

• training: visual scanning training (gold standard), stimulus location, anchoring, pacing, density, lighthouse strategy (help cue to visually scan the whole environment)

visuospatial and visual organizational skills

assessment: line bisection test, figure-ground visual perception test, body midline test, conditional visual target cancellations

training: pattern recognition (word locus, dot configurations, sequential analysis); 30-40 min, 3x /week

Apraxia

Injury to premotor strip; if someone has Broca’s aphasia also assess for apraxia because Broca’s injury often spans the area affecting praxis

• know their not right, but can’t figure out how to fix it→ frustration

assessment- Arnadottir OT-ADL neurobehavioral evaluation (A-ONE), apraxia screen of TULIA (AST)

treatment: specific gestural or strategy training is recommended for apraxia during acute rehab for L hem. stroke

• gestural: transitive to intransitive to instransitive-nonsymbolic gesture; use personally relevant stimuli

• strategy training: initiating with proper plan of action and selection of objects to activity execution to controlling own performance

  • grading instructions, assistance, and feedback

Higher level cog skills

knowing about knowing and knowing how to know, metacognition , monitoring, awareness of executive functions

Stages of Treatment for Cognition:

Frontal lobe regulation of internal and external milieu

awareness

lack of knowledge/recognition of disease/injury, consequential deficits, functional disabilities

• unawareness = anosognosia

Awareness Levels

anticipatory: anticipating any potential impact of deficits prior to situation

emergent: recognizing deficits are occurring in functional engagement; able to use compensations once recognized

• executive functions- actual doing (and anticipatory)

intellectual: key for compensation implementation (able to set a reminder)

• knowledge about + how to compensate

Awareness treatment guidelines

Executive functions

integrative cognitive processes that manage goal-directed, purposeful, and adaptive behavior; higher-order functions in non-routine situations (novel, conflicting, complex)

• oversees basic processes: attention, memory, behavior, emotion

• development of metacognition processes (self-monitoring, error awareness, insight)

common issues: fail to comprehend goal, plan, oversimplify task, recognize errors, poor execution, reject complexity of task

Goal setting for executive function

GOAL-PLAN-DO-CHECK

Goal attainment scale

patient reported outcome that involves goal selection and standardize means to measure the extent goals are met

planning

anticipation and step-by-step sequence to meet activity demands

• check traffic, get in car, drive to campus

monitoring is a common deficit in neuro- can you monitor yourself when carrying out plan and make appropriate responses

self-eval- evaluate yourself and receiving feedback, make changes as needed

assessments and intervention for executive functioning

Stages of Treatment: Executive Functioning

feedback