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)
