Cognitive-Communication Disorders Treatment

The Treatment Team

• Neurologists: Primary responsibility for medical care following brain injury/disease.
• Rehab Medicine Physicians (Physiatrists): Determine medical and rehabilitation needs.
• Physical Therapists: Retrain/gain strength and ROM; typically focus on limb functions/gross motor skills.
• Occupational Therapists: Retrain/gain muscle activity for ADLs; typically focus on fine motor skills.
• Vocational Therapists: Determine ability to return to work.
• Social Workers: Liaison between medical staff, patients, and family; coordinate care.
• Neuropsychologists: Assess cognitive function; help set cognitive plan of care.
• Clinical Psychologists: Administer and interpret tests of intelligence, cognition, and personality.
• Psychiatrists: Provide diagnosis and treatment of mental health disorders.

Treatment of Attention

• Approaches:
  • Direct training of attention.
  • Training of specific skills requiring attention.
  • Self-management of attention deficits (Compensatory).
  • Environmental modifications (Compensatory).
  • External aids (Compensatory).
  • Care partner training (Compensatory).

Direct Training of Attention

• Goal: Treat the underlying attention impairment.
• Usually through repetitive, decontextualized tasks.
• Results in improved performance on:
  • Trained tasks.
  • Tasks similar to the trained tasks.
  • Neuropsych testing.
• May not generalize to improved attention in real-world situations.

Attention Process Training-III

• Computer-based hierarchy with audio & visual stimuli:
  • Sustained attention
  • Working memory
  • Selective attention
  • Inhibitory control
  • Alternating attention
• Followed by discussion of metacognitive strategies.
  • Metacognition: Thinking about thinking
  • E.g., thinking out loud, monitoring performance, reflecting on performance

Meta-Analysis on Cognitive Rehabilitation for Attention

• No convincing effect of cognitive rehabilitation on subjective measures of attention immediately after treatment or at follow-up.
• Measures of divided attention recorded immediately after treatment may improve, but it is uncertain that these effects persisted.
• No evidence for immediate or persistent effect of cognitive rehabilitation on alertness, selective attention, and sustained attention.
• No convincing evidence for immediate or long-term effects of cognitive rehabilitation for attentional problems on functional abilities, mood, and quality of life after stroke.

Training of Functional Skills Requiring Attention

• Goal: Treat attention in the context of real-world activities of daily living.
  • E.g., reading, preparing food, bathing, dressing, driving.
• Uses neuropsychological scaffolding in training specific skills:
  • Identify the simpler component parts involved in more complex tasks.
  • Practice each one individually.
• Involve interdisciplinary team to support ADLs as needed.
  • E.g., PT, OT
• Larger gains in functioning compared to direct training approaches.

Compensatory Approaches

• Can be specific to a situation:
  • Post a list next to the bathroom mirror that includes each of the tasks they need to complete.
• Or can be general:
  • Describe each step of a task while completing it.
  • Verbally rehearse important information.
• Can use external devices:
  • Set a watch/phone to beep once an hour to remind the patient to ask themselves:
    • What am I currently doing?
    • What was I doing before this?
    • What am I supposed to be doing?
• Can modify the environment:
  • Reduce visual or auditory distractions in the home.

Notes on Treating Attention

• Patient-centered
• Based on theories of attention
• Organized in hierarchical way
• Progress towards generalization to real-world situations
• Flexible to adapt to patients’ changing needs
• Implementation of compensatory strategies should involve:
  • Adequate time for training & practice
  • Social & environmental supports
  • Maintenance program to assess outcomes

Treatment of Memory

• Approaches:
  • Attention training (Restorative)
  • Rehearsal techniques (Restorative)
  • Chunking & rhyming (Restorative)
  • Organization strategies (Restorative)
  • Self-management of memory deficits (Compensatory)
  • Environmental modifications (Compensatory)
  • External aids (Compensatory)
  • Care partner training (Compensatory)

Reminiscence Therapy

• Semi-cued conversation regarding past events
  • Goal: Increase orientation, functional communication, and trigger recall of pleasant episodic memories
• Can use tangible prompts: objects, videos, music, scents to cue the conversation
• Can be done in group settings to allow greater level of interaction and facilitation of social skills
• Event choice should be guided by patient and loved ones, and clinician should have knowledge of event

Spaced Retrieval Training

• Present new or previously known information and prompt recall over increasingly longer time intervals
  • Goal: Increase ability to recall functional information
• Example prompts
  • Face-name associations with friends and family
  • Implementation of safe swallowing and transfers
  • When to take medications
  • Important locations – e.g., bathroom and cafeteria
  • Emergency procedures – e.g., calling a nurse for help
• Can be done at the same time as other activities

Memory Aids

• External cues to prompt recall of memory
  • Goal: Augment memory capacity of patient
• Usually contain personal and biographic information in written or picture form
• Examples
  • Memory books
  • Schedules
  • Information for orienting to surroundings
• Can be paired with reminiscence therapy & spaced retrieval training

Environmental Modifications

• Keep the person safe
  • Remove firearms and weapons from the house
  • Lock up poisonous substances
  • Use nightlights, nonslip mats, and lock doors
  • Post signs on doors identifying the room
  • Keep car keys secured
  • Have patient wear identification bracelet
• Support communication
  • Limit distractions during conversation
    • Tv/radio off, lights on, glasses on, sit close
  • Speak slower and give more time for response
  • Use shorter sentences with simple grammar
  • Avoid abstract topics
  • Check for understanding

Treatment of Executive Functions

• Approaches:
  • Restorative
  • Compensatory

Guiding Principles for Treating Executive Function

• Structure
  • Built-in organizational plan
  • Anchors: routines that are established in an individual’s life
  • Scaffolding: developing systems to maintain or re-establish anchors
  • Strategies: help transition patient to independent use of aids in the natural environment
• Systematic Instruction
  • Strategies need to be systematically trained in order to be acquired and used
  • Error control
    • Errorless learning: prioritize avoidance of errors
    • Particularly helpful in acquisition of strategies
  • Practice
    • Initially, high amounts of correct practice
    • Then spaced retrieval
    • Then self-generated
• Collaboration
  • Need strong partnership between clinician, patient, and care partners
  • Therapeutic alliance
  • Goal attainment scaling
    • Specify an overall goal and break it down into a set of component goals
    • Assign a weight for each goal according to priority
    • Specify a continuum of possible outcomes
    • Determine initial or current performance
    • Intervene for a specified period
    • Determine performance on each objective
    • Evaluate extent of attainment
• Context
  • Successive management of executive functions is related to the personal relevance of the treatment and the way the treatment uses supports from the person’s everyday life
  • Positive behavioral momentum: providing a context in which the patient can succeed
  • Training in natural environments with meaningful therapy materials are more likely to generalize
• Metacognitive Strategy Instruction
  • Metacognition: thinking about your thinking
  • Self-awareness, self-monitoring, and self-control of cognition while performing an activity
  • Doesn’t train a specific task but guides the integration of self-regulation processes

Cognitive-Communication Treatment Considerations

General Principles of Treatment

• Strengthen abilities that are capable of improving
• Reduce demands on impaired cognitive abilities and increase use of intact cognitive abilities
• Provide stimuli that evoke positive memories and positive emotion

Candidacy for Treatment

• Severity/location of brain injury
• Medical and physical status
  • E.g., ability to be alert and attentive for at least 15 minutes
• Motivation
  • Involve patient/caregiver in treatment planning
• Consider implementing treatment trial

WHO ICF Framework

• Health Condition (Disorder or disease)
• Body Functions & Structures (Impairments)
• Activity (Limitations)
• Participation (Restrictions)
• Contextual factors
  • Environmental factors
  • Personal factors

Impairment-Level Approaches

• Start in area of most impairment
• Start in area of least impairment
• Fundamental processes: identify impairments in underlying processes that contribute to linguistic, cognitive, or communicative abilities
  • E.g., work on attention to improve tasks that require executive functioning

Activity-Level Approaches

• Communication is a social phenomenon
• Purpose of intervention is to enhance communication success in everyday life
• Treatment designed to help brain-injured persons succeed in targeted daily life activities that are impaired
  • E.g., remembering medical appointments, speaking on the telephone, going back to school

General Differences Between Impairment-Level and Activity-Participation Approaches to Treatment of Brain-Injured Adults

Generalization

• The carry-over of behaviors trained in therapy to new conditions, environments, and stimuli
• Naturally maintaining contingencies: target behaviors that naturally elicit favorable consequences in a patient’s daily life
  • Need to have a good understanding of what happens in the patient’s daily life and be creative to generate carry-over
• Can vary behavior, environment, success conditions, and/or feedback

Brain Training

• Brain training programs can produce benefits, these might extend to tasks that are operationally similar to the training regime.

Summary

• Treatment of cognitive communication disorders is carried out by a diverse medical team
• SLP-based treatment can focus on impairments and/or activities
• Rehabilitation plans are personalized and motivated by patient’s and care partners’ motivations and long-term goals
• A goal of treatment is generalization of targeted behaviors outside of therapy