Quiz #3 Flashcards
Etiologies
- Stroke
- Trauma
- Cancer
- Seizure disorder
- Infection
- Hypoxia
- Poison
RH functions
- Processes non-linguistic & emotional elements of communication: prosody, facial expressions, body lang/gesture, visuospatial skills, music/art
- Inferencing
- Gestalt
- Interpreting emotion
- Maintaining attention
Sustained attention
How well you can maintain your attention to a task
Selective attention
Can you focus on something & tune out distractions?
Alternating attention
Doing 1 thing & then another, then go back to 1st thing
Divided attention
Can you focus on 2 things at once?
Communication deficits
Prosodic deficits (receptive & expressive)
- Trouble not sounding monotone
- Can’t perceive differences in prosody
Poor narrative cohesion/organization
-Not good storytellers or good at giving directions
Poor pragmatics
- Preoccupied w/ self
- Behaviorally passive (may not respond to things in their environment)
- Understanding & showing facial expression
Poor awareness (unaware or inattentive to physical/mental limitations)
Poor arousal
-How to maintain arousal: altering signals, repositioning the person, bright lights, increase task complexity, give them performance incentives (relaxing, food, going outside, calling family)
Inferencing deficits
- Doesn’t perceive humor, sarcasm, & non-literal language
- Perseverates on details of picture w/o grasping overall whole (gestalt)
- Misses general topic, purposes of discourse
- Cultural backgrounds; taboos
Discourse deficits
- Limited inferencing
- Difficulty paying attention
- Lack of ability to make repairs
- Pedantic style of speaking (talking monotone)
- Difficulty with turn-taking
- Difficulty with topic maintenance
Visuospatial deficits
- Simultagnosia
- Achromatopsia
- Neglect
- Prosopagnosia
- Somatophrenia
- Constructional deficits
- Topographic impairment
- Geographic disorientation
Simultagnosia
Can’t perceive more than 1 object at a time
Achromatopsia
Can’t perceive colors
Prosopagnosia
Unable to recognize faces
Somatophrenia
Don’t believe that a limb is theirs
Topographic impairment
Decreased ability to follow routine, follow maps/directions
Neuropsychiatric disorders
- Anosognosia
- Reduplicative paramnesis
- Capgras delusion
- Depression
- Hallucinations
Anosognosia
Denial of illness
Reduplicative paramnesis
Duplicate of person, body part
Capgras delusion
A delusion that a friend, spouse, or close family member (or pet) has been replaced by an identical-looking imposter
Issues in assessment
- Inconsistent referrals –> changes can be extremely subtle
- Measurement concerns –> extremely hard to measure some of these changes
Informal tests
- Orientation
- Conversation: looking & listening
- Picture description
- Line bisection
- Copying drawings
- Card sorting/attention tasks
- Visual organization tests
Objectives in assessment
- Establish a behavioral profile
- Provide dx (also severity)
- Determine candidacy for tx
- Determine level of handicap
- ID pt’s/family’s concerns & goals
- Formulate tx focus
Other assessment tools
- Neuropsychologically oriented assessments
- Behavioral assessments
- Task analysis & probe procedures
Treatment
- Caregiver counseling & support
- Pragmatics (“Theory of Mind”)
- Denial of impairment
- Prosody
- Discourse
Treatment (reading)
- Visual scanning therapy
- “Edgeness” for neglect
Treatment (pragmatics)
Teach overt rules of social interaction by watching others, then attempting to transfer
Treatment (sustained attention)
- Object sorting
- Trail-making (#s, word-finding)
- Listening for targets
- Simple games (checkers, tic-tac-toe, Go Fish, poker, solitaire)
Selective attention
Stroop task
- Say colors, ignore words
- Say words, ignore colors
Letter cancellation
Distractors (radio, tv)
Alternating attention
- Sorting
- 2 simultaneous games
Divided attention
Answering questions while completing a taks
Other treatment targets
- Impulsivity
- Memory (metamemory)
- Problem solving/reasoning
- RC
- Homonyms
- Inferencing
- Humor
- Error recognition
- Distractibility
- Slower rate of learning
- Motivation
- Judgement
General tx tips
- Performance prediction/appraisal
- Build/maintain rapport
- Counsel pt/family
- Practice patience
- Generalization is key
- Measure outcomes (functional, QOL, NOMS system)
- Consider degree of neglect
- “Sell” the rationale
- Utilize pt’s spontaneous productive strategies
- Practice for generalization
- Self reliance is the goal
Naturalistic tasks
Natural settings for tasks
-Barrier tasks (e.g., PACE)
Targets of opportunity
-Teachable moments
Incorporate self-monitoring/instruction
Prognostic indicators
- Medical issues
- Age
- Education
- Social involvement
Outcomes
FIMS
- Asks about pt’s competency
- Multidisciplinary
Termination criteria
- Maximum benefit
- Decision will often be mutual
- Special problem of college clinics
Data
- There’s nothing you can’t count
- Use probes for efficient documentation
- Don’t keep data in your head
- Document generalization
- Be creative
TBI
- Major cause of death in U.S.
- High risk groups: racial & ethnic minorities, service members/veterans, homeless, those in correctional & detention facilities, survivors of intimate partner violence, those in rural areas
Causes of TBI in U.S.
- Falls lead to nearly 1/2 of TBI related hospitalization
- Firearm related suicide is most common cause of TBI related deaths
- MVAs & assaults are also common
- TBI can be overlooked among older adults
- About 10% of TBIs are due to assaults
- Men were nearly 3x as likely to die as women
- Falls were leading cause among children ages 0-14 & adults 45 years +
- MVAs were leading cause of hospitalizations for adolescents & young adults ages 15-44 years
- 40-60% of pts are intoxicated when admitted
Other factors: causes of TBI
- School adjustment (poor academic performance)
- SES
- Divorce rates 4x likely
- Type A > Type B
- Homeless 3x greater than general public
- High risk sports
Demographics of TBI
- ~6 million survivors alive today
- As many as 1/2 admitted to hospital w/ TBI are intoxicated (male drivers 16-44 2x as likely to be intoxicated)
- 50% of young males have poor academic history; increased probability of 2nd TBI
TBI primary damage
Actual impact to brain
TBI secondary damage
- Infection
- Hypoxia
- Edema
- Increased intracranial pressure
- Infarction
- Hematoma
TBI physiological changes
- Fatigue
- Seizure activity
- Spasticity
- Changes in bowel/bladder
- Dysphagia
Open head injury
Penetrating head injury
Closed head injury
- Non-penetrating brain injury (no opening or breakage of skill)
- More common thna open head injuries
- Most often caused by MVAs
Contra-coup injury
1 side of head is hit but impact causes opposite side of brain to be injured (whiplash)
Diffuse axonal injury
When cell bodies on outside of brain are injured in 1 place but b/c brain is shaken around, fibers become twisted & ripped & can’t send messages to other areas –> creates a lot of problems
Blast injury
- Struck by particles impelled w/ violent force from an explosion
- Nothing hits head primarily
- Levels of damage: primary (explosion itself), secondary (energized fragment move around), tertiary (thrown from blast into object), fourth (blood loss, amputation, inhalation of toxic gas)
Closed head injury: acceleration injuries
Sudden acceleration or deceleration of the head, causing brain & brainstem to suffer diffuse damage caused by their movement inside skull
Closed head injury: linear acceleration injuries
Caused by sudden acceleration of head by a force that moves through midline
Closed head injury: angular acceleration injuries
Sudden deflection & rotation of head by a force that strikes head at an angle
Closed head injury: nonacceleration injury
Causes less severe brain damage than acceleration injuries. Deformation of skull by impact of object striking skull
Swallowing impairments (dysphagia)
Evident in ~25% of all TBI clients
Most common problems:
- Delayed triggering of swallow responses
- Reduced tongue control
- Reduced pharyngeal transit
- Sensory problems
Worsened by:
- Cognitive impairments
- Respiratory impairment
- Inability to cough
- Medications
Cognitive deficits: attention
- Focused attention
- Sustained attention (vigilance)
- Selective attention
- Alternating attention
- Divided attention
Cognitive deficits: amnesia
Pre-traumatic amnesia (retrograde)
-Doesn’t remember anything before incident
Post-traumatic amnesia (anterograde)
-Remember everything up to incidents, but difficulty forming new memories
Linguistic functioning
“Cognitive-Communication Disorder”
All of the above deficits impact language & communication
- Bilateral & diffuse damage compound communication problems
- Attention deficits interfere w/ comprehension
- Aphasia may or may not be clearly present (usually fluent or anomic & deficits in all 4 modalities)
Behavioral functioning
People with TBI generally experience:
- Irritability
- Aggression
- Anxiety
- Depression
- Dis-inhibition (impulsiveness)
- Social inappropriateness
- Rage reaction
- Pseudo-bulbar affect
Other common characteristics of TBI
- Slowed processing
- Excessive cautiousness
- Perseveration
- Concreteness
- Catastrophic reactions
- Sexual frustation
Prognostic indicators in TBI
Duration of coma (generally longer in coma, poorer prognosis)
Duration of posttraumatic amnesia (longer is lasts, poorer prognosis)
Patient related variables
- Age
- Substance abuse
- Education
- Intelligence
- SES
- Personality
Evaluating cognitive communication disorders
Warnings:
- Use caution when using existing standardized tests
- Evaluate individual’s pre-injury characteristics
- Collaborate w/ other professionals in interpreting level of impairment
Levels of consciousness & response to stimulation
Coma (typically come out 3-4 wks after injury, but not always)
Vegetative state
-Persistent vegetative state lasts no longer than 1 month
Minimally conscious state –> have to exhibit 1 or more of the following:
- Follow simple commands
- Intelligible verbalizations
- Movements/emotional responses to environmental stimuli (purposeful reaching, frowning, crying, visual tracking)
Treatment: goals of therapy
- Inform patient & caretaker(s) about nature & consequences of disorder
- Provide appropriate treatment approaches & techniques
4 major themes of treatment
- Management of health & disability
- Management of grief & coping
- Acceptance of injury & redefinition of self
- Development of social support networks
- Empowerment
Cognitive rehab: restorative
Neuronal growth through repetitive exercises & drills
Cognitive rehab: compensatory
Circumventing the impaired functions (component training)
External compensations
Anything you do to environment to make person more aware of impairments
Situational compensations
Train person to use compensatory strategies in certain situations
Recognition compensations
Training person to evoke strategy when they perceive that a problem is occurring
Anticipatory compensations
Teach person to use strategy at 1st sign of impending problem or maybe even before problem happens
Interventions: TBI
- Sensory stimulation
- Orientation
- Behavior management
- Pharmacologic intervention
- “Component training” e.g., memory, attention, awareness, reasoning, problem solving, visual processing
Crosson’s method
Poor awareness:
- Intellectual awareness: basic understanding that there’s an impairment
- Emergent awareness: how they are conducting themselves when engaged in task
- Anticipatory awareness: reflective on future & consequences of their actions
Visuospatial intervention
- Scanning drills
- Figure-ground discrimination
- Mental manipulation of visual stimuli
Interventions: TBI
Language & communication
Time pressure management
Compensatory memory strategies
- Internal strategies: mnemonic devices, imagery, self-talk
- External aids: checklists, calendars, phones
- Environmental compensation
- Setting these everyday routines
- Group treatment
