Cognition in acute care

level 1 functional cognition

autonomic actions

level 2 functional cognition

postural actions

level 3 functional cognition

manual actions

level 4 functional cognition

goal directed action

level 5 functional cognition

exploratory actions

level 6 functional cognition

planned actions

arousal

involuntary responsiveness to the world, demonstrated by reflex and generalized responses to both internal and external stimuli

- reticular activation system

awareness

individual's ability to receive and process sensory information and use that information to relate in an intentional way to the outside world. required for voluntary responses

- higher cortical areas

coma

- no arousal / eye opening

- no behavioral signs of awareness

- impaired spontaneous breathing

- impaired brainstem reflexes

- no vocalization

brainstem reflexes

- pupillary reactivity

- spontaneous eye position and movement

- vestibule-oculocephalic reflex (eye movement opposite head movement)

- corneal reflexes

- cough

- gag

vegetative state

aka unresponsive wakefulness syndrome

- arousal / spontaneous or stimulus induced eye opening

- no behavioral signs of awareness

- preserved spontaneous breathing

- preserved brainstem reflexes

- no purposeful behavior

- no language production or comprehension

- may grimace to pain and localize to sound inconsistently

- atypical visual fixation, response to threat, inappropriate single words

minimally conscious state

- arousal and spontaneous eye opening

- fluctuating but reproducible behavioral signs of awareness

- follows verbal commands

- environmentally contingent smiling or crying

- object localization and manipulation

- sustained visual fixation and visual pursuit

- intentional but unreliable communication

emergence from disorders of consciousness

- functional communication as evidenced by verbal or gestural yes/no responses

AND/OR

- functional use of two or more objects (hairbrush, cup..etc)

DOC/emergence from DOC OT role

assess consciousness

set realistic goals

provide stimulation

maintain physical function

DOC assessment

- richmond agitation and sedation scale (RASS)

- Coma recovery scale - revised

Richmond agitation and sedation scale (RASS)

used to describe a hospitalized patient's level of alertness or agitation

also used in the scoring of CAM-ICU (delirium)

Coma recovery scale - revised

used to asses DOC (mostly coma)

- 23 items / 6 subscales (auditory, visual, motor, oral motor, communication, arousal functions)

start with higher scoring items and go down

response goals

based on response type

- no response, generalized response, localized response

no response

no discernible or volitional response to stimuli

generalized response

response is automatic, reflexive, or non-purposeful

- eye opening, changes in breathing or heart rate, changes in flexion or extension, non-specific vocalization

localized response

response reflects person's ability to regulate incoming sensory info and voluntarily control the response to the stimulation. responses are not reflexive and occur in the relationship to the area stimulated

- turning head toward sound, tracking visual stimuli, movement or looking down to the area stimulated, following simple commands

positive responses

- blinking

- calming effect

- crying

- withdraw or localization to stimuli

- eye opening, increased arousal

- increased movement, increased muscle tone

- respiratory rate increased then decreased

- swallowing

- grimaces

- following commands

- vocal utterance

negative responses

- absence of any response

- agitation

- bite reflex or tightly pursed lips

- flushing

- increased salivation

- seizure activity

- abnormal posturing

- sudden decrease in arousal

- sustained increase in heart rate, respiration rate, intercranial pressure

tolerance goals

base goal based on level of tolerance exhibited by the person for a given intervention

risk management / prevention goals

goals focused on prevention of physical complications

caregiver focused goals

goals related to education and training of caregiver's within a person's support system

visual interventions

mirror, familiar pictures, scenery changes

auditory interventions

pre-recorded voices of family members, music

olfactory interventions

family member perfume, cologne, laundry detergent, different smells

proprioceptive / vestibular interventions

ROM, position changes, hand over hand assist for simple motor tasks

tactile interventions

alternating smooth and rough textures, familiar stuffed animals or blankets

physical interventions

ROM, orthotics, upright positioning, bed positioning

postural actions

providing person with opportunities to sit unsupported, promote protective and righting responses

manual actions

naming objects, using objects purposefully, participating in self care tasks, increased ability to sustain participation (attention)

goal directed actions

pt starts to initiate tasks, expresses needs, minimal to no problem solving, may be able to learn a new task (initiation, improved processing time, working memory)

exploratory actions

person can think outside themselves, understands the effects of their actions

planned actions

planning ahead, predicting errors, self correcting errors, basically indepedent

manual actions interventions

- Setting out all ADL supplies and have pt name and choose correct objects to complete self care tasks

- Starting with 1 self care task and moving towards a few self care tasks at a time (sustained attention, cognitive endurance)

- Forward chaining and Backward chaining may be appropriate at this stage

Goal directed actions interventions

- Have the patient start to interact with others, asking unit secretaries for directions or facetiming with family members

- Can try to teach pt simple 1-2 new tasks to assess and challenge their ability for new learning; example: playing a new card game

exploratory interventions

- Challenge and assess the patient's ability to problem solve

- Try the game "heads-up"- mobile app that involves explaining words from different categories and trying to have another person guess the word and visa versa

- Playing a higher-level card game, I like SPIT

higher level cognitive interventions in acture care

- dual tasking

- human clock

- word scramble with post it notes

- human simon game

Performance assessment of self care skills

Subcategory IADL medication management

0- dependent

3- independent

Delirium

disturbance in attention and awareness

- develops over short period of time, represents a change from baseline, and tends to fluctuate during the day

caused by medical reason but not explained by another preexisting, evolving, or established disorder

types of delirium

hyperactive and hypoactive

delirium effects on healthcare system

- prolonged hospitalization

- prolonged post acute stays

- increased mortality

- increased risk for readmission

- increased costs

delirium effects on patient

- mortality increases 11% for every additional 48 hours of active delirium

- higher risk of re-intubation or prolonged medical ventilation

- prolonged cognitive dysfunction

- functional decline

delirium risk factors

hospitalized individuals 65+

- 30% of older patients experience it during hospitalization, mostly in ICU

- older adults who had surgical intervention

- mechanical ventilation

- baseline dementia

- sub-acute or palliative care

non-modifiable delirium risk factors

- 65+

- brain disease

- multiple medical problems

- organ failure

- advanced cancer

- limb fracture

- infection

modifiable delirium risk factors

-immobilization

-catheters

- untreated pain or pain medications

- multiple medications

- visual or hearing impairments

- sleep deprivation

- sudden withdraw of substance or alcohol

- frailty / malnutrition

delirium diagnostic criteria

- disturbance of consciousness with reduced ability to focus, sustain, or shift attention

- change in cognition

- develops over a short period of time

Confusion assessment method for the ICU (CAM-ICU)

4 steps:

- acute onset or fluctuating course

- inattention

- disorganized thinking

- altered level of consciousness

delirium prevention

- Ample light during the day and darkness at night

- Minimize sleep interruptions

- Keep clocks /calendars up to date and easily visible

- Ensure sensory aids are available (glasses, hearing aids, etc.)

- Behavioral activation - have patient up in a chair, participating in time appropriate self care, engaging in ambulation if safe

- Attempt to engage in cognitively stimulating activities (puzzles, reading, etc.)

- Re-orient frequently with regards to domains of person, place, time, and nature of stay in hospital

- Attempt to keep familiar objects in the room or have family / friends visit frequently

delirium intervention

- positioning (upright so they can socialize and complete daily tasks)

- cognitive stimulation

- basic activities of daily living

- family participation