Pedretti Ch. 26 - Assessment of Cognitive Dysfunction Flashcards
Cognitive rehabilitation
Cognitive rehabilitation can be described as the process of improving function and quality of life for individuals with cognitive impairments
In terms of maintaining this focus , goals should be as follows:
Evaluations/assessments should be focused on clients performing relevant occupations.
Simultaneously, OT should document what impairments in client factors and performance skills that are interfering with performance
Goals should be related to improving performance in areas of occupation
Interventions should consist of primarily graded relevant occupations being performed in natural contexts
Outcomes of OT intervention should document improved performance in areas of occupation
Client-centered approach
A common theme for this area of practice is using a client-centered approach and should focus on what the client actually wants as opposed to what the therapist thinks the client wants
Are interventions for people with cognitive dysfunction are easy or difficult to generalize to real-world settings and situations?
Interventions for people with cognitive dysfunction are notoriously difficult to generalize to real-world settings and situations
Dynamic Interaction Approach
Views cognition as a product of the interaction among the person, activity, and environment
Therefore, performance of a skill can be promoted by changing either the demands of the activity, the environment in which the activity is carried out, or the person’s use of particular strategies to facilitate skill performance
Dynamic Interaction Approach: constructs associated with this model
Structural capacity or physical limits in the ability to process and interpret information
Personal context or characteristics of the person, such as coping style, beliefs, values, and lifestyle
Self-awareness or understanding your own strengths and limitations, as well as metacognitive skills such as the ability to judge demands of tasks, such as attention, visual processing, memory, organization, and problem solving
The activity itself with respect to its demands, meaningfulness, and how familiar the activity is
Environmental factors such as the social, physical, and cultural aspects
Optimal performance is observed when there is a match between all three variables (person, activity, environment)
Multicontext Treatment Approach
Using the Dynamic Interactional Model, the Multicontext Treatment Approach was developed
Combining both remedial and compensatory strategies, this approach focuses on teaching a particular strategy to perform a task and practicing this strategy across different activities, situations, and environments over time
Multicontext Treatment Approach: components of the theory
Awareness training or structures experiences should be used in conjunction with self-monitoring techniques so that clients may redefine their knowledge of the strengths and weaknesses
Use a personal context strategy. The choice of treatment activities is based on the client’s interests and goals. Particular emphasis is on relevance and purpose of the activities.
Processing strategies are practiced during a variety of functional activities and situations. These processing strategies are defined as strategies that help a client control cognitive and perceptual symptoms such as disorganization, distractibility, impulsivity, inability to shift attention, attention to only one side of the environment, or a tendency to overly focus on one part of an activity
Activity analysis is used to choose tasks that systematically place increased demands on the ability to generalize strategies that enhance performance
Transfer of learning occurs gradually and systematically as the client practice the same strategy during activities that gradually differ in physical appearance and complexity
Interventions occur in multiple environments to promote generalization of learning
Quadraphonic Approach
Developed for use with those who are cognitively impaired after a brain injury. The approach is described as including both a micro perspective (a focus on remediation of subskills such as attention, memory, etc.) and a macro perspective (a focus on functional skills such as ADLs).
Quadraphonic Approach supports the use of remediation and compensatory strategies and incorporates four theories:
Teaching-learning theory is used to describe how clients use cues to increase cognitive awareness and control
Information-processing theory describes how an individual perceives and reacts to the environment. Three successful processing strategies are described, including detection of a stimulus, discrimination and analysis of the stimulus, and selection and determination of a response
Biomechanical theory is used to explain the client’s movement, with an emphasis on integration of the CNS, musculoskeletal system, and perceptual-motor skills
NDT is concerned with quality of movement
Quadraphonic Approach - macro perspective
The macro perspective involves the use of narrative and functional analysis to explain behavior based on the following four characteristics:
- Lifestyle status or personal characteristics related to performing everyday activities
- Life stage status such as childhood, adolescence, adulthood, and marriage
- Health status such as the presence of premorbid conditions
- Disadvantage status or the degree of functional restrictions resulting from impairment
Cognitive Retraining Model
Is used for adolescents and adults with neurologic and neuropsychologic dysfunction
Based on neuropsychologic, cognitive, and neurobiologic rationales, this model focuses on cognitive training by enhancing clients’ remaining skills and teaching cognitive strategies, learning strategies, or procedural strategies
Neurofunctional Approach
This approach is applied to those with sever cognitive impairments secondary to brain injuries
Focuses on training clients in highly compensatory strategies (not expecting generalization) and specific task training
Contextual and metacognitive factors are specifically considered during intervention planning
This approach does not target the underlying cause of the functional limitation but focuses directly on retraining the skill itself
Task-Oriented Approach (TOA)
Summary points include: Role performance (social participation): identify past roles and whether they can be maintained or need to be changed; determine how future roles will be balanced
Occupational performance tasks (areas of occupation)
Task selection and analysis: what client factors, performance skills and patterns, and/or contexts and activity demands limit or enhance occupational performance
Person (client factors, performance skills and patterns): cognitive – orientation, attention span, memory, problem solving, sequencing, calculations, learning, and generalization; psychosocial; and sensorimotor
Environment (context and activity demands): including physical, socioeconomic, and cultural
Task-oriented Approach - intervention approach
Intervention points include:
Help patients adjust to their role and limitations
Create an environment that used the common challenges of everyday life
Practice functional tasks or close simulations to find effective strategies
Remediate a client factor (impairment)
Adapt the environment, modify the task, or use assistive technology
When choosing assessments, emphasis should be placed on ___
When choosing assessments, emphasis should be placed on ecologic validity of an instrument
Ecologic validity refers to the degree to which the cognitive demands of the test theoretically resemble the cognitive demands in the everyday environment
First step in choosing assessment
A client-centered approach should be utilized and can use the COPM as a starting point
(Could also just use an informal interview)
Clinical context (acute care setting, outpatient, etc.) should be considered
OT uses observation skills to determine which cognitive deficits are interfering with performance
Ecologic validity of standardized measures of cognitive impairment
Traditionally, those working with cognitively impaired patients have used standardized measures of cognitive impairment as the primary outcome measure to document the effectiveness of intervention, but these tend to have low ecologic validity as opposed to those that use relevant occupations in naturalistic contexts
Clinical programs should focus on:
Clinical programs should focus on measures of activity, participation, and quality of life as a key outcome
Why is it important to use self-report or caregiver report measures
The rationale for this is that comparing self-reports with observed performance provides the OT with critical info on awareness of the severity of impairment and functional status; comparing self-reports and caregiver reports is helpful in getting s snapshot of how clients perform in their own environment; and it is important that clients and caregivers see benefit from the OT services provided
Different terms related to limited self-awareness are used
Different terms related to limited self-awareness are used: lack of insight, lack of/impaired self-awareness or unawareness, anosognosia and denial
Non-impaired self-awareness
capacity to perceive the self in relatively objective terms, while maintaining a sense of subjectivity
Impaired self-awareness/anosgnosia (terms used interchangeably)
Impaired self-awareness/anosgnosia (terms used interchangeably): clinical phenomenon in which a person does not appear to be aware of impaired neurological or neuropsychological function (obvious to clinician and other individuals) (neurologically based)
- Lack of awareness is specific to individual deficits and can’t be accounted for by hyperarousal or widespread cognitive impairment
- Some authors use the term anosgnosia to describe unawareness of physical deficits only (anosognosia for hemiplegia)
Psychologic denial
a subconscious process that spares the patient the psychological pain of accepting the serious consequences of a brain injury and its unwanted effects on their life (psychologic method of coping)
Pyramid Model of Self-Awareness - three interdependent types of awareness
Intellectual awareness, emergent awareness, and anticipatory awareness
Intellectual awareness
The ability to understand at some level that a function is impaired
- Lowest level: aware that one is having difficultly performing certain activities
- Higher level: recognize commonalities between difficult activities and implications of the deficits
Emergent awareness
The ability to recognize a problem when it is actually happening
- Intellectual awareness is a prerequisite –must know one is experiencing a problem when it occurs
- Included in monitoring of performance during the actual tasks
Anticipatory awareness
ability to anticipate that a problem will occur as the result of a particular impairment in advance of actions
Categorization of Compensatory Strategies (according to way implementation is triggered)
Anticipatory compensation, recognition compensation, situational compensation, external compensation
Anticipatory compensation
Anticipatory compensation: implementation of a compensatory technique by anticipating that a problem will occur (applied only when needed)
Recognition compensation
strategies that are triggered and implemented because a person recognizes that a problem is occurring (applied only when needed)
Situational compensation
Situational compensation: strategies that can be triggered by a specific type of circumstance where an impairment may affect function. These strategies are taught to be used consistently every time that a particular event occurs
- Intellectual awareness is necessary to use strategy –must be aware of deficit to integrate a strategy for overcoming it
External compensation
External compensation: triggered via an external agent or involves an environmental modification. Examples include alarm clock, post-it notes, etc.
Dynamic Comprehensive Model of Awareness
Dynamic relationship among knowledge, beliefs, task demands, context of a situation based on concept of metacognition
- Differentiates between metacognitive knowledge, declarative knowledge, beliefs about abilities before performing task, online monitoring and regulation of performance of a task
3 Level Model of Self-Awareness
Self-awareness of the injury-related deficits themselves such as cognitive, emotional and physical impairments
Awareness of functional implications of deficits for independent living
The ability to set realistic goals; ability to predict one’s future state and prognosis
Self-awareness
It is recommended to evaluate self-awareness using standardized test to guide choices of intervention
- Can also determine how motivated one is to participate in rehabilitation process –must be aware and concerned about deficit
Assessment measures to determine person’s level of self-awareness:
questionnaires (self or clinician rated), interviews, rating scales, functional observations, comparisons of self-ratings and ratings based on objective measures of function or cognitive constructs
Individuals with brain injuries or cognitive deterioration typically do what
Individuals with brain injuries or cognitive deterioration typically underestimate level of cognitive impairment and overestimate level of function
Important to end session with comparison of actual performance and predicted performance to increase awareness
Important to remember that cues are used to facilitate insight and encourage client to solve problems by developing new strategies to overcome deficit areas
Attention Deficits Having an Impact on Daily Function
One of the most important and basic functions of the human brain, is the basis for other cognitive processes (memory, executive function, etc.)
Ex: Can’t hold working memory down if your attention is not fully there
Attention
voluntary control over more automatic brain systems to be able to select and manipulate sensory and stored information briefly/for sustained periods
Arousal
State of responsiveness to sensory stimulation or excitability (dependent on widely distributed neural network)
Decrease in responsivity to visual, auditory, tactile cues during task performance, needs noxious/extreme sensory stimuli for a behavioral response
Selective attention
Processing and filtering relevant information in the presence of irrelevant stimuli
Ex: attending to a therapist’s instructions and cues in a crowded therapy clinic
Sustained attention
Supports tasks that require vigilance and maintaining attention over time
Ex: Attending to long conversations, instructions, class lessons, etc.
Attentional switching or alternating attention
Switching attention flexibly from one concept to another (related to cognitive flexibility)
Ex: Cooking → take care of crying child → cooking
Divided attention
Dividing attention between two or more tasks simultaneously
Ex: Text and carry a conversation at the same time
Distractibility
Inability to block out environmental/internal stimuli when one is trying to concentrate on performing a task
Ex: can’t attend to therapy session because of being distracted by watching someone else’s session
Field-dependent behavior
Distracted by and acting on an irrelevant impulse that interferes with performance of an activity and takes over goal-directed activity
Ex: during oral care, person is distracted by the light switch and stops oral care to turn on/off the light switch (i.e. not relevant to the task at hand)
Unilateral neglect (a lateralized attention deficit)
For people with CVA/stroke
Impaired attention results in:
Impaired attention results in increased rates of off-task behavior in comparison to controls
Those with impairments in attention are less attentive than control with and without distractions
Study: Relationship between attention impairment and error awareness
People with TBI have lower sustained attention and error awareness in comparison with a control group
The degree of error awareness was strongly correlated with sustained attention capacity, even when the injury severity was controlled
Error feedback significantly reduces errors
TBI leads to sustained attention and error awareness
Posner and Peterson: there are 3 main functionally and anatomically distinct attentional control subsystems
Orienting system, executive system, alerting to sustained attention system
- Orienting system
- Orienting system: selection of relevant sensory information
Posterior brain areas: superior parietal lobe and temporoparietal junction and frontal eye fields)
Brings attention to a specific location in space → perceptual awareness
Reflects involuntary orienting or automatic processing
System performance is determined by reaction time in response to stimuli detection
- Executive system
- Executive system: selection and exercising control over lower-level cognitive functions and resolving conflicts
Structures: anterior cingulate, lateral prefrontal cortex, basal ganglia
Prominent in detective signals for focal or conscious attention
System breakdown → difficulty managing tasks with divided attention, screening out interfering stimuli, responding to novelty
- Alerting or sustained attention system
- Alerting or sustain attention system: achieving and maintaining sensitivity to incoming stimuli.
Frontoparietal regions
System impairments → short attention spans
Attention deficits usually follow brain injuries
Damage to frontal lobes, especially the white matter connecting the frontal, parietal, and stratal regions
Frontal lobe damage → tendency to drift from intended goals and increases unintended frequencies of action slips
Highest complaint from people with TBI are problems with attention and concentration rate
Tests of attention
Pen-and-paper measures or lab-type tasks:
- Paced Auditory Serial Addition Test
- Trail Making Test Part A
- Wisconsin Card Sorting Task
- There’s the question of ecological validity in difficulty generalizing results of these tests to everyday living tasks
Memory impairment
Memory impairment is one of the most common consequences of brain injury and degenerative cognitive disorders
Severity and type of memory loss vary based on which brain structures are affected
Amnesia
Anterograde amnesia: Deficit in new learning AFTER brain damage
Retrograde amnesia: difficulty recalling memories formed and stored BEFORE the onset of disease
Short-term memory (STM)
storage of limited information for a limited amount of time
Working memory
related to STM and actively manipulating information in short term storage through rehearsals
Long-term memory (LTM)
relatively permanent storing of information with unlimited capacity
Nondeclarative/implicit or procedural memory
knowing HOW to perform a skill, retaining previously learned skills, and learning new skills
Declarative/Explicit memory
Knowing that something was learned, verbally retrieving knowledge base such as facts, and remembering everyday events
Episodic memory: Autobiographic memory for contextually specific events, personally experienced events, Form of declarative LTM
Semantic memory: knowledge of general world and facts, linguistic skill, vocabulary (may be spared after injury), form of declarative LTM
Explicit and implicit memory
Explicit memory: memories of events that happened in the external world (specific event at a specific time and place)
Implicit memory: does not require conscious retrieval of the past
Prospective memory
remembering to carry out future intentions
Metamemory
awareness of own memory abilities
Steps/Stages of memory
Attention → encoding → storage → retrieval
Attention: gain access to and use incoming information, uses alertness, arousal and other attention processes like selective attention
Encoding: forming memories, initial stage of memory that analyzes the material to be remembered, correct analysis needed for proper information storage
Storage: retaining memories, transferring transient memory to a form/location of the brain for permanent retention/access
Retrieval: recalling memories, searching for or activating existing memory traces
Traditional measures of memory
Tabletop lab-style tools
Remembering a string of numbers, word list, details of a drawn figure and/or paired associate learning (ex: requiring a person to recognize or recall recently presented material)
Relation between tests/test results to everyday memory function not clear and not strong
- Functional gains do not always correlate with improvement in memory processes based on objective testing
Comprehensive evaluation
- Standardized assessments
- Nonstandardized observations
- Standardized self-reports and reports of caregivers and significant others
- Contextual Memory Test is a useful screening tool to test:
- Awareness of memory: using general questioning and predicting performance before the assessment and estimating memory capacity after performance
- Recall of 20 line-drawn aspects: immediate and delayed recall (15-20 minutes)
- Strategy use: probes the use of memory strategies and determines the ability to benefit from strategy recommended by clinician
Executive Dysfunction Having an Impact on Daily Function
Umbrella term for complex cognitive processing requiring the coordination of several subprocesses to achieve a particular goal which allow one to adapt to new situations and achieve goals
- Specific functions: decision making, problem solving, planning, task switching, modifying behavior in light of new information, self-correction, generating strategies, formulating goals, and sequencing complex actions
- Lack in consistency in literature on whether a particular function is executive
20 most commonly reported dysexecutive symptoms
Poor abstract thinking, impulsivity, confabulation, planning, euphoria, poor temporal sequencing, lack of insight, apathy, disinhibition (social), variable motivation, shallow affect, aggression, lack of concern, perseveration, restlessness, can’t inhibit responses, know-do dissociation, distractibility, poor decision making, unconcern for social rules
Studies examining ADL performance in people with frontal lobe lesions
Study 1: Demonstrated difficulties in meal preparation task, can be explained by impairment of several executive functions, generalized slowness in performance, and paucity of behavior
Study 2: Did not differ with control group on any neuropsychologic test by nonparametric testing but marked anomalies in meal preparation task
- Small action sequences could be made but large action sets could not be executed correctly, concluded that there was a big deficit in strategic planning and prospective memory
- Also, categorization and deductive reasoning ability in people with brain injury are good predictors of IADL functional performance
Lezak classifies various forms of executive disorders in a 4 part schema
- Volition and goal formulation: with self-awareness, initiation, and motivation
- Planning: with ability to conceptualize change, be objective, conceive alternatives, make choices, develop a plan, and sustain attention
- Purposive action: to implement plans for achieving goals, including productivity, self-regulation, switching, and action sequencing
- Performance effectiveness: quality control, self-correction, monitoring, and time management
Cicerone and associates: schema for executive function
4 domains based on anatomy and evolutionary development
- Executive cognitive functions (dorsolateral prefrontal cortex)
- Control and direction (planning, monitoring, activation, switching, inhibiting) of lower level functions. Working memory and inhibition mediate executive functions - Behavioral self-regulatory functions (ventral/medial prefrontal area)
- Emotional processing and behavioral self-regulation when cognitive analysis, habit, environmental cues are not sufficient to determine best adaptive response - Activation-regulating functions (medial frontal areas)
- Activation via initiative and energizing behavior. Pathology results in decrease in activation and drive (aka apathy and abulia) - Metacognitive processes (frontal poles)
- Personality, social cognition, self-awareness as reflected by accurate evaluation of one’s own abilities and behavior vs. objective evaluation or reports by significant others
Usual tests: pen-and-paper or lab-type tasks
Ex: Wisconsin Card Sorting Task, Trail Making Test, Stroop Test, etc.
Difficulty generalizing results to everyday living tasks (only a low to moderate relationship)
Standard clinical tests are too structured and rater led → fail to capture common problems of initiation, planning, self-monitoring
