Rehab: Cognition

Cognition Concepts I need to know

Understand the impact of impaired cognition on function

• Cognition Terms and Dysfunction commonly seen in OT

Understand functional cognition.

Cognitive assessments to measure cognitive function based on performance deficits.

Screening vs. Performance based

Understand the various types of intervention approaches in cognitive rehab

Cognition: How a person thinks: acquiring, processing, and analyzing information then reacting to that information......a crucial process to function (OT in Acute Care, 2017)

Common Terminology

• Level of consciousness (alert, lethargic)

• Metacognition

• Attention

• Memory

• Executive Functioning

• Safety Judgement

Acute Changes (temporary symptoms) 

• Altered Mental status 

• Medication side effects

• Encephalopathy 

• Delirium 

 Cognitive Disorder

• TBI

• Stroke 

• Multiple sclerosis

• Dementia

• Mental health disorder

Functional Cognition- OT

“the use of cognitive processes in the context of performing everyday activities.” 

• Can only be understood and fully facilitated within the context of occupational performance.

• Functional cognition vs. cognition (neuropsych, SLP, neurology)

• Focus on context and environment, rather than discrete tasks (sets OT aside from SLP and others)

• Quantifies a skill level, rather than estimation of cognitive abilities for ADL & IADL

Performance Skills/ Client Factors

Alertness: State of awareness and alertness

Orientation: Person, place, time, self, and others

Executive functions: Judgement, concept formation,, metacognition, cognitive flexibility, insight, sequencing, planning

Attention: Sustained, selected, divided

Memory: Long-term, short-term, working memory,

Perception: Discrimination of senses (touch, smell, motor)

Thoughts: Awareness of reality, control of thought, logical

Temperament: Agreeableness, self-control, initiates, terminates

Alertness + Levels of consciousness 

• Alert: awake and participates with no efforts to maintain alertness

• Lethargic: Drowsy, requires loud verbal stimulation to stay awake, responds slowly, may need to be sitting to be awake

• Obtunded: Requires constant tactile or motor stimulation to obtain and maintain arousal. Often confused when stimulated

• Stupor: Minimally arousable, eye opening, withdrawing or pushing with noxious stimuli (cold washcloth, pinching, etc.)

• Coma: does not respond with any type of stimulus including noxious stim. May exhibit reflexive responses. 

Attention 

• Most important function

• Types: Sustained, selective, alternating, divided 

• Prerequisite for higher order cognitive status 

• Working memory- relies on attention process 

• Recovery from 1-3 months after neurologic injury, but can also persist in some form-linked to long-term functional dysfunction

Assessments: Clinician Observation-Documentation of deficits

• How long attended (seconds, minutes)

• Redirection

Standardized Assessments

• Test of Everyday Attention (Adult & Children)

• Moss Attention Rating Scale (done by observation, scored)

Awareness- Management of Limitations 

• Self-awareness 

• Insight

• Unawareness/ anosognosia

• Psychological denial 

• Poor initiation. Planning and self regulation 

Memory 

• Attention → Encoding → Storage → Retrieve

• Thalamus, frontal lobe, language and visual systems, hippocampus (storage) 

Assessments: Quick screenings

Standardized: 

• Rivermead Behavioral Memory Test 

• The Contextual Memory Test 

• Comprehensive Assessment of Prospective Memory 

• Self-Questionnaires 

Executive Function

• To perform tasks using a collection of performance skills as a complex process, not just specific cognitive skills in isolation 

• Working memory, flexible thinking, self-awareness (Inhibitory Control) 

• Paying attention

• Organizing, planning, and prioritizing

• Starting tasks and staying focused on them to completion

• Understanding different points of view

• Regulating emotions

• Self-monitoring (keeping track of what you’re doing)

Safety 

• Safety and Judgment should be during the evaluation process.

• Ability to recognize errors

• Poor insight

• Memory impairments

• Attention to environmental hazards

• Orientation

Intervention Approaches

• Top Down: Focus on specific problem, uses strategies and adaptations to improve function. In OT-think compensatory

• Bottom Up: Assessment of underlying deficits, working on deficits to improve function. In OT- think remedial

• Decision Making Tree 

• Task-Specific Training: Chaining activities linking phases, breaking down an activity into steps. Using cues to link the phases. Highly studied in cognitive and motor interventions. (Bottom Up Approach)

• Task/habit training: OT training a client in a specific task, working on the same task in the same way using same techniques until the client demonstrates consistent mastery (does not always transfer to other activities)

  • Identifies and area of dysfunction

  • Designs a procedure that allows the client to accomplish ADL and IADL tasks

  • Facilitates the clients practice of the procedure until they can do it automatically

  • Cognitive retraining-context dependent

- Strategy training: Learning strategies to overcome challenges. Transfer occurs to new activities or situations.

• Metacognitive-global strategy for any context

• Domain-Specific: compensatory, similar tasks (i.e using sticky notes)

• Environmental Modifications/Assistive Technology

• Top-down approach

-Indirect Intervention- caregiver education, training (teachers, caregivers, parents)

Direction following- Cueing 

• Documents the number of steps a client can follow.

• Types: Verbal, Visual, Tactile

• Directions should be provided without interference of others

In order from least to greatest deficit:

• Verbal (reminder, assist to initiate)

• Visual (demonstration)

• Tactile (hand over hand or a tactile cue to initiate)

• Verbal and Visual

• Verbal and Tactile

• Verbal, Visual, and Tactile