Cognitive Lecture 4 Flashcards
There is _______ as a typical brain injury
No such thing
Brain injury can occur_____
at any age with no uniform set of sx’s characteristic of all TBIs
Commonly seen consequences of brain injury
Cognitive deficits
Perceptual deficits
Physical deficits
Behavioral/emotional deficits
Cognitive Deficits
Attention deficits
Memory disorders
Language impairments
Impaired abstraction & judgment capabilities (inflexibility)
Decreased speed, accuracy, consistency
Defective reasoning processes
Greater susceptibility to internal/external stressors
Internal stressors:
Internal drives, etc.
External stressors:
Things you don’t have control over; supervisors, etc.
Perceptual Deficits
Decreased acuity or or increased sensitivity in vision, hearing, or touch
Vestibular deficits
Spatial disorientation
Disorders of taste and smell
Vestibular Deficits
Balance/equilibrium
Controlled by cerebellum, semicircular canals, great toe, vision, EPS)
Spatial Disorientation
Goes back to proprioception; where you’re at in space
Disorders of Taste/Smell
Anosmia
Loss of appetite because food doesn’t taste good anymore
Physical Deficits
Disorders of ataxia (cerebellum has to be involved in ataxic dysarthria), spasticity, tremor Musculoskeletal disorders (pain/discomfort in bones, joints, muscles, surrounding tissues; can be acute, chronic, focal, diffuse; PT involved)
Emotional & Behavioral Deficits
Irritability, impatience, poor frustration tolerance, dependence (high dependence on SLP, other therapists; you want pt to have some degree of independence though)
Denial of disability (put them in situation where they won’t be able to do activity so they can see that they can’t)
Emotional lability
Neuropsych involved here (not at Ranchos IV–won’t help)
Prior to Direct Assessment…
Obtain as much info as possible (chart check)
Review type & severity of brain injury
Date of onset
Identify cerebral areas affected
Investigate medical history
Pre-trauma personality & pre-morbid status
Recent CT scans & MRIs
Additional neuromedical variables (extended coma, cerebral hemorrhage, etc)
Glasgow Coma Scale
Not over time but a point in time
Speech/Language Characteristics Resulting from TBI often Resemble:
Aspects of aphasia
Prominent aphasia-like sx’s in TBI
anomia, circumlocution, paraphasia, perseveration Also dysarthria (especially spastic) and dysphagia
The primary objection to making a diagnosis of aphasia…
the pragmatic (proxemics) & language behaviors associated with a true aphasia differs from those associated with TBI
CVA in Aphasia vs. TBI:
Aphasia: results in mild to severe language deficits while retaining most social & pragmatic functions
TBI in Aphasia vs. TBI:
Essentially normal receptive/expressive language; communication difficulties are related to cognitive deficit components
Assessment Areas:
General cognitive/intellectual abilities Language functions Visuospatial, visuomotor, & visuo-constructional abilities Attention & concentration Learning & memory abilities (both verbal & nonverbal modalities) Motor functioning Higher cognitive functioning Emotional functioning
Speech/Language Batteries Useful for TBI
Assessment of Intelligibility of Dysarthric Speech
BDAE & MTDDA
Boston Naming Test
BTHI, EOWPVT & ROWPVT
PPVT
Scales of Cognitive Ability for TBI or SCATBI
Token Test, WAB, RIPA (pediatric, adult, geriatric)
Hard Neurological Signs Definition
Give clear evidence of neurological dysfunction
Soft Neurological Signs
Correlated with but do not confirm neurlogic dysfunction
Not unusual for any child under 8y b/c they reflect immature CNS
More often present in children w/ developmental disabilities & those w/ TBI than typically developing children
Hard & Soft Neurological Signs
Difficult to interpret without additional info from comprehensive eval
Diagnosis shouldn’t be solely based on presence or absence of 1+ neurological signs
Kids must be at least 2 SD below in 1 area or 1.5 SD below in 2 areas: cognition, communication (receptive & expressive), social-emotional, motor skills (fine & gross), self-help/adaptive skills
Hard Neurological Signs Include but Aren’t Limited to…
Abnormal infantile reflexes in non-infants (Babinski, rooting, etc.)
Disrupted motor function in 1+ areas (unilateral paralysis or paresis)
Disrupted sensory function in 1+ areas (loss of vision)
Dysarthria (slurred speech) not due to medications or physical injury
Apraxia of speech or limbs; aphasia
Soft Neurological Signs Include but Aren’t Limited to…
Hyperkinetic motor overflow (constant extremities movement)
Impulsivity (responding prior to thinking or being given all info)
Distractability internally (daydreaming) & externally (env’tal sights & sounds)
Inattention or difficulty focusing on 1’s work
Heavy use of concrete thinking based on stimulus thinking (bus is yellow w/ wheels as opposed to vehicle or mode of transport)
Slowed processing speed
Simultaneous movement of opposite limbs or digits that are unintended based on task
Uncoordinated movement; slow motor movement
Immature grasp of writing instrument/ difficulty drawing
Late milestone development
Flow of Assessment
Chart Check First!!!
Orientation->automatics->following directions->organization->math->auditory processing->memory->functional problem solving->multifactor problem solving-> deductive/inductive reasoning->divergent thinking/abstract reasoning->convergent thinking/drawing conclusions->reading passages
Orientation in Assessment:
name, where they are, season
Automatics in Assessment:
Things you automatically know without thinking about; ability to count from 1-20, ABCs, days of week (DOW), months of year (MOY)
(Can also check for dysarthria during DOW & MOY)
MOY starting at July; count by 2s, 3s, 4s, etc.
Following Directions in Assessment:
start simple and move to more complex
Organization in Assessment
Sequencing Categorization (rapid naming, convergent/ divergent naming, similarities & differences, which 1 doesn't belong & why)
Math in Assessment
word problems
Divergent Thinking/Abstract Reasoning in Assessment
verbal absurdities, humor, etc.
Levels of Consciousness
Alert, lethargic, apathetic, aggressive, fluctuating
Alert level of consciousness
Fully awake & appropriate responsive to internal/external stimuli; still may have cognitive deficits
Lethargic level of consciousness
Not fully awake; may drift in/out of awareness when not being stimulated
May appear sleepy or confused with poor arousal or energy
Apathetic level of consciousness
Lacks motivation or initiation for goal-directed behaviors or volitional activities; shows diminished concern for things that were previous interests; loss of enthusiasm
Aggressive level of consciousness
Irritability & tendency for dis-inhibited verbal/nonverbal impulsivity; often temporary as pt recovers
Fluctuating level of consciousness
variations in levels of awareness, energy, behaviors
Recovery Issues
Your role will change based on your setting
Will have to adapt evals & tx’s to fit the needs of the pts
3 Stages of Recovery
Early, middle, late
Early Stage of Recovery Goals
Acute stage will require max therapeutic support
Determine if pt can…
comprehend commands & ?s, make needs known
Are cog. skills adequate for communication
Is there need for coma management techniques?
Presence of dysphagia?
Family education needs?
Role(s) of family in therapy
Staff education re: pt’s needs
Middle Stage of Recovery Goals
Client may appear more “normal”
Is client ready to return to community w/ support or independently?
Determine…
Type/level of cog-comm breakdown
Any compensatory strategies
Best methods family can use to help client
What about: caring for kids, independent fx’ing, finances management, societal expectations
?s may arise about client’s competency
Note delayed response times (latency periods), perseveration, failure to note errors, difficulty following instructions
Late-Stage of Recovery Goals
Discharge: focus no longer on formal testing but on real-life situations
(See chart)
Focus more on rehab & home-based situations
Pediatric Recovery Issues
Recover from brain injury differently
Some may “seem” to recover back to premorbid fx’ing levels but higher cognition must be assessed
Difficulties may not be obvious immediately; think about executive fx
Ongoing limitations w/ learning/memory can make it difficult to maintain age/grade level progress in school; slowed processing can affect socialization w/ age-matched peers
Brain injury recovery takes much longer than other medical conditions; most recovery takes place during 1st 6 mos; fx’al gains can be made after 6 mos, but are much slower
Slow/steady becomes normal
Recovery due to plasticity
Processes of Recovery “Positives” Microscopically
Brain cells may produce new dendrite branches for new connections w/ other cells
Previous cell connections may be strengthened or altered to change on how info is processed
Axon terminals may change amt of neurotransmitters released, making connections more effective
Axons may produce sprouts to re-establish synaptic connections
Processes of Recovery “Negatives” Microscopically
Recovery only involves the cells that were undamaged in injury
W/ a few exceptions, only cells w/in area of injury can help w/ recovery
Cells from undamaged areas of brain generally don’t take over functions for other damaged areas
Cell growth involving axons & dendrites takes place @ roughly 1/1000 or .001 meters per day; this accts for the slow rate of brain recovery after an injury
Predictors of Recovery
In general, 3 main variables:
- Physical aspects of the injury
- Premorbid functioning
- Support network & available resources
Physical aspects of injury in predicting recovery
Type of injury, severity of injury, extent of injury (diffuse vs. localized)
Premorbid functioning in predicting recovery
people w/ healthy brains & adequate intelligence prior to injury will do better than those w/ developmental disabilities
Support network & available resources in predicting recovery
Supportive families & resources that allow for more therapy or education assistance after leaving hospital will generally recover better than those that do not
Patterns of Recovery:
Every case will differ, but some patterns are:
Kids w/ more severe injuries less likely to improve over 1st 2 yrs following injury than those w/ less severe injury
Kids will progress thru stages of recovery similarly but progression may vary & plateau; recovery of skills can take days, wks, mos, & yrs
Kids may go thru multiple periods of rapid gain followed by days or wks of little recovery
Rates of recovery vary secondary to…
medical complications, fatigue, pain, attention deficits, motor limitations, frontal lobe dysfunction
Yankauer Suctioning
Trach-Nose-Mouth
Never go reverse
Mouth always has to be end point because of bacteria
