Cognitive Midterm
Self awareness
-"knowledge of one's illness and deficits" -ability to recognize the problems caused by the brain impaired functioning -knowledge and regulation of a person's own cognitive processes and capacities -the accurate appraisal and understanding of your abilities and preferences and their implications for your behavior and their impact on others
Glasgow Coma Scale (GCS)
-15 point scale commonly used to measure levels of consciousness following TBI
Visual Processing
-an information processing continuum involving the reception, organization, and assimilation of visual information
What does the CAM consist of?
-17 subtests (with total of 29 items) range from simple to complex -covers attention, memory, visual neglect, math, ability to follow directions and judgement -grouped into 4 categories: fund of acquired info or store of knowledge, manipulation of old knowledge, calculation of problem solving, social awareness/judgement, and abstract thinking
Intermediate transfer
-3-6 task parameters are changed -the task shares some physical features with the original task but the similarities are less obvious -ex. Intermediate transfer for sorting a basket of laundry would be still laundry/clothes but instead of folding them in piles you are not sorting them onto a shelf
less awareness usually observed in...
-IADL (driving, managing finance) -abstract reasoning/problem solving -socio-emotional/behavioral changes
Metacognitive Strategy Intervention
-Joan Toglia noticed treatment in the clinic wasnt carrying over to home life so she created this approach -combines functional with remedial components -designed to help clients think about what strategy or methods they will be using to complete a designated task -includes self management and self instructional strategies
Examples of cognitive screening tools
-MoCA -MMSE -St. Louis University Mental Status Exam (SLUMS) -orientation log (O-Log) -Cog-Log -Medi-Cog -Cognistat
Example of progression through the transfers, starting with making instant coffee
-NEAR = making instant coffee with a different cup, different pot, or pre measured packet -making tea or hot chocolate, instant iced tea, lemonade, etc. -INTERMEDIATE = making instant soup, oatmeal jello -making toast with butter or jelly -FAR = leading and starting the dishwasher, setting the table for 2 -making a bed, doing a small load of laundry
Examples of Satisfaction and QoL Scales
-SF-36 -stroke impact scale -satisfaction with life scale -all are self reports that ask how much are you satisfied with your life
Apraxia
-a disorder of skilled movement that cannot be adequately explained by primary motor or sensory impairments, visual spatial problems, language comprehension difficulties or cognitive problems alone
Unilateral Neglect
-a failure to orient to, respond to, or report stimuli that are presented on the side contralateral to the cerebral lesion in clients without primary sensory or motor impairments
Functional cognition
-a global "top down" construct that combines the constructs of function and cognition -it is not task limited -use of cognitive processes in the context of performing everyday activities and occupations -ability to use and integrate thinking and performance skills to accomplish complex everday activities -incorporating performance skills (cognitive and motor skills) with performance patterns (habits and routines)
Assessment
-a tool to gain info for the evaluation -how you are going to get the info about the person -standardized and non standardized -distinct feature
Divided Attention
-ability to respond to two tasks simultaneously -how many pieces of information a person can attend to at once -immediate recall: telephone number, digit span, sentence, 1 step direction -listening to the radio while cooking a meal -keep track of 2 or more stimuli simultaneously: multiple cooking tasks, cooking while listening to the radio
Why must OT address cognition?
-according to AOTA, the assessment of cognition should be in the context and should examine the ability of an individual to function, not just recall or reform a single cognitive task -OTs should identify when functional cognition is impairing occupational performance -assessing functional cognition can identify the right people for OT intervention -especially true for those with mild but functionally significant cognitive impairment, who may not be identified by mechanism used by CMS
Examples of Surveys and Questionnaires on occupational participation
-activity card sort (ACS): figuring out what they used to do before the injury to help you develop goals -COPM -goal attainment scale (GAS) -all 3 of these give us info on if they are doing things that are meaningful for them, how they are participating and the level of involvement in occupations
Examples of Occupational Performance Assessments
-actual reality -assessment of motor and process skills (AMPS): grilled cheese making video -executive function performance test (EFPT) -multiple errands test (MET) -cognitive performance test (CPT) -the menu test
Delirium
-acute confusional states that often occur without any structural abnormality in the brain -most commonly observed in an ICU or acute care setting -develops within a short period of time following surgery, trauma, or critical illness -can be seen in children as well as older adults: may be misinterpreted as a behavioral problem in critically ill children -observed in medical conditions such as low blood sugar, severe infections, carbon monoxide poisoning or substance withdrawal
Self-efficacy
-affects choices and willingness to engage in an activity; take risks -amount of effort, level of persistence, motivation -we learn through doing -we must do to learn things -we also need to include such things as questions -we need to do self appraisal
Motor Planning
-aka praxis -the ability to execute learned and purposeful activities
Far transfer
-all task parameters are changed except 1-2 -the task is conceptually the same but physically different -ex. Far transfer for sorting a basket of laundry would be sorting food items instead now but the essence of sorting and putting things away stays the same
Near transfer
-alternate form of the same task while keeping the underlying conceptual characteristics consistent -near transfer for sorting a basket of laundry would be changing the basket or changing some baskets
Problem-Solving Approach to Goal Setting
-an individual who attaches low personal value (importance) to altering his or her behavior can be expected to make little effort in engaging with treatment or maintaining changes, whereas the opposite is true when the change is personally valuable -patient's perceived self efficacy (confidence) may also influence whether he or she attempts to alter aspects of his or her behavior
Limb Activation Training (LAT)
-an intervention designed to call attention to the affected limb and the neglected hemispace of an individual post right CVA -purpose = to address left unilateral neglect through the movement of the contralesional (left) limb within the neglected hemispace -LAT activate and re-organize the affected right hemisphere of the brain and result in the improvement of left neglect, whereas movement of the ipsilateral (right) limb would activate the left hemisphere and further inhibit the already damaged right hemisphere -performed through verbal cueing -a limb activation device (LAD) delivers sensory cues or passive motion
Cognitive Adaptation Training (CAT)
-an intervention that aims to help individuals learn how to use environmental supports and strategies to compensate for cognitive impairments -involves identifying the specific cognitive difficulties that an individual is experiencing and working collaboratively to develop strategies and environmental supports to address those difficulties -includes calendars, task lists, reminders, and other tools to help individuals stay organized and on task -OTs modify env to improve ability to perform tasks
Treatment Strategies for Attention/Awareness
-anticipation - prediction -self-questioning, error detection and other self-monitoring strategies -auditory cueing: place a buzzer or alarm on left -anchoring -paced speed of visual scanning -initiation of search on the left -actively place a cue on the left prior to beginning a task (Lt arm or object)
Treatment of Awareness Deficits via Compensation (Pyramid of Self Awareness)
-anticipatory compensation -recognition compensation -situational compensation -external compensation
Online Awareness
-anticipatory, emergent, error monitoring, task specific awareness -self-appraisal of task or situation —> task experience —> self monitoring (error recognition/correction, performance adjustments) —> self evaluation -varies across TASKS
Lack of self awareness
-appears to be rooted in neurologic dysfunction -clients lack info about themselves -are perplexed and surprised or confused when given feedback regarding limitations -can co-occur with denial
Intervention approaches for people with cognitive dysfunction vary in terms of...
-areas that are targeted for intervention -underlying assumptions about individuals' abilities to learn and generalize info
Assessment of Attention
-assessed as part of a larger cognitive assessment -standardized testing: assess theoretically grounded aspects of attention -rating scales/questionnaires -structured interviews/observations
Assessing and treating functional cognition
-assessing functional cognition can identify individuals who are having difficulty performing real-life tasks -as a result, the approach is generally applicable across patient populations (not to be limited to any 1 diagnostic group)
Assessments and treatments in the remedial approach
-assessments will identify specific cognitive deficits -treatment methods and materials are closely related to assessments -treat with repetitive practice of skills -generalization to other tasks which require the use of the skill is assumed to take place spontaneously
Treatment of Attention
-attention process training: involve the use of cognitive exercise that are designed to improve and remediate attentional systems -use of strategies and environmental support -use of external aids -psychosocial support: address the emotional and social factors that can result from an attentional deficits
What cognitive skills are linked to activity and participation?
-awareness -memory -attention -organization -rigidity
Task Predictors
-awareness questions prior to task performance -general: have you noticed any changes in your memory -specific: if you studied 20 objects for 90 seconds, how many objects do you think you would be able to remember
Cognitive Factors as an Evaluation Domain in the C-FE Framework
-baseline cognitive functioning includes both cognitive deficits and strengths -gathered via cognitive screens and comprehensive assessments which can be static or dynamic
Focused Attention
-basic responding to stimuli
Strategy Training and Levels in the Multi-Contextual Approach
-begin strategy training at the level of breakdown -treatment needs to include practice in recognition situations where the strategy would be useful and or predicting the need to use a strategy
Process of Cognitive Rehab: Evaluation
-begins with occupational profile that considers the client's typical routines and occupations -comprehensive cog eval needed for 2 reasons: to provide evidence and info about presence of impairments and competencies and to gather info for intervention planning
Executive functions
-broad range of performance skills that allow a person to engage in independent, purposeful and self directed behavior -fundamental components of EF include higher level cognitive skills such as planning, cognitive flexibility, organization, problem solving, and self regulation
Use of External Devices for Attention Issues
-can assist individuals in tracking info and initiating planned activities -written calendar system with day planners -written checklists -electronic organizers -voice activated message recorders
Far extra-personal neglect
-cannot navigate door way -cannot locate source of voice -difficulty watching TV -get lost easily during ambulation
Alternating/shifting attnetion
-capacity for mental flexibility -ability to alternate between a stimuli or task -task that involves increased effort or vigilance is harder to shift from -shift back and forth between two tasks/sequences: trail-making tests -answering the telephone and typing
Environmental Supports for Attention Issues
-careful assessment of the env should be part of any treatment plan -organize client's physical space -helping to reduce visual distractions -task-specific devices such as pill box reminders, key finders, and watch alarm
Metacognitive Strategy Intervention is directed at...
-changing the persons abilities while simultaneously adapting the task and env to be at the just right challenge level -addressing the person, task and env
External strategies in the Multi-Contextual Approach
-checklist or task guidance -anchor for scanning -highlighting most critical points
Posttraumatic confusional state
-children and adults who sustain moderate to severe TBI often experience this transitory state of impaired consciousness and confusion
Direct Intervention Approaches
-client focused training approaches -include both task/habit training and strategy training -can either train a specific task or habit or train a strategy to improve performance -changing the env
Examples of environmental adaptation in the functional approach
-clothes pre-chosen -items for lunch/dinner pre-organized -programmed alarm messages -introduce task or task step one at at time -work task directed by another person -adaptation of the house
Examples of Comprehensive Cognitive Assessments
-cognitive assessment of Minnesota (CAM) -Lowenstein Occupational Therapy Cognitive Assessment (LOTCA) and dynamic LOTCA-C (for children)
Multi-Contextual Treatment Approach
-cognitive dysfunction is conceptualized in terms of deficits in underlying strategies -strategies are small units of behaviors that contribute to the effectiveness and efficiency of occupational performance -specific task performance/ end results are not emphasized -process is emphasized -assessments focus on strategies and conditions -therapy is delivered in reactive mode
The Lighthouse Strategy (LHS)
-combines mental imagery and attention training -developed to address effect of neglect on long-term post-injury recovery and outcomes -pre-treatment assessment is completed using cancellation test -with demonstration of how to move head and eyes together, and the level of cueing needed, therapists ask patients to find first 3-dimensional objects and then flat pictures of objects placed in front of them
Assessing Self Awareness
-comparison between self rating with relative or clinician and actual performance -comparison among prediction, actual performance and estimation
Option Appraisal Stage of Problem-Solving Approach to Goal Setting
-considering the potential ways of addressing a problem -it is the patient who must decide which approach is best for him and the clinician should resist the temptation to provide a steer to the discussion
Denial
-coping strategy -psychological symptom/reaction to protect the individual -response to feedback = resistance, blame others, hostility
Orientation to Time
-current point in time -continuity and sequence of time -association of events with time
Remedial Approach
-deficit specific (bottom up approach) -emphasis on improving and restoring the underlying impairment -based on repetitive practice of impaired skill and graded activity -predetermined hierarchical treatment sequence -learning principles: practice, repetitions, verbal feedback
Specific Components to Intervention
-define goals in concrete and measurable way: engage client, measurable way motivates client, helpful to know errors -self-estimation -educational methods -anticipation and pre planning -journaling to keep summary of strengths and weaknesses -self questioning -focus on process rather then end product -role reversal and role playing
Attention Disorder
-described as a wide assortment of skills, processes and cognitive states (includes: decreased reaction time and speed of info processing) -attention disorder vary between task, contexts, etc.
Task Specific Training
-direct training of functional task -repetition with vanishing cues -combines with behavioral and errorless learning techniques -errorless = learn things in the correct manner so that your habits are appropriately learned -capitalizes on procedural learning -can use this approach with someone with severe cognitive impairment
Multi-contextual approach
-directed at changing the person's abilities while simultaneously adapting the task and env to be at the just right challenge level -addressing the person, task and env
Confusional States Involve...
-disturbances in orientation, fluctuating periods of consciousness, and reduced ability to focus or sustain attention, remember, or think
Task Specific Functional Training Methods
-divide tasks into sub-steps -count number of tactile, verbal and visual cues for each sub steps -gradually fade cues
Indirect Intervention Approaches
-do not directly involve the client -typically focused on environmental modifications, task adaptations, or caregiver training and education -ex. Setting out clothes for someone to get dressed in the morning
Personal or body neglect
-does not shave left side of body -does not comb left side of head -does not wash or dry left side of body -does not apply makeup to left side of face
Critiques of the Pyramid of Self Awareness Model
-does not tell you how a person moves from one level to another -very static model
The Functional Approach
-emphasis on changing task performance rather than underlying skills -minimizes or reduces use of impaired skills -based on pessimism regarding recovery of function -adaptation = modify or adapt the env -could refer to an indirect approach
Patient Competency Rating Scale (PCRS)
-evaluates self awareness following TBI -30 item self report instrument using a 5 point likert to rate the degree of difficulty in a variety of tasks and functions -not used in acute care
Cueing in the functional approach
-increase or decrease the salience of environmental stimuli or cues -create cues in the env to enhance function -re-organize or re-arrange the env -design or create new envs
Evaluation
-evaluation provides evidence and no about the presence of impairments and disability and competencies (baseline and treatment effectiveness) -needed to gather info to guide the treatment planning process -helps you decide if you need an assessment -the process where you gain info
Evolution in OT practice in cognitive rehabilitation
-first began during WWI to treat soldiers recovering from brain injuries -became area of OT practice in 1940 -70s and 80s: OTs focused on perceptual functioning and sensory integration using remediation approach -Neistadt (1987) was first to compare remedial and functional approaches -late 80s: more publications on cog rehab in AJOT -importance of functional cognition is now recognized across lifespan and in populations beyond acute neurological population -new CPT codes for cognitive function support work of OT in this area
Importance of Delirium Identification and Treatment
-for both children and adults who survive a critical illness, the presence and duration of delirium in the early stages of an illness is a strong predictor of long-term subtle cognitive deficits that can significantly impact participation and quality of life years after the illness -detection, prevention, and treatment of delirium has become a priority in healthcare
Selective Attention
-freedom from distractibility -e.g. selecting specific locations on a map -as the amount of irrelevant stimuli or interference increases, selection becomes ore difficult -attend to a target and inhibit competition, distraction: attending to a task and ignoring music or people talking
Two aspects of information processing include...
-function capacity —> can be modified -structural capacity —> is fixed -treatment is directed to maximize functional capacity: zone of ordinal development (Vygotsky)
The relationship between general and online self awareness
-general/offline awareness is NOT activated during a task: self-knowledge and beliefs that exist outside the context of tasks -online/task-specific awareness: process of activating within a task, appraisal of task, task experience, self monitoring, self evaluation
Dynamic Assessments
-given with the use of cues or gestures or physical assist to see how the patient may best complete the tsk given the examiner info on what is required for optimal performance (such as the EFPT) -asked a question in class and no one answers so she asks it in another way and cues us and changes things as needed to get correct responses -actual reality would be dynamic because you can give them cues
Task analysis and establishment for criteria for transfer in the Multi-Contextual Approach
-gradually vary the surface features of the task while keeping the underlying conceptual characteristics consistent -near transfer, intermediate transfer, far transfer, very far transfer
Self-Regulation Skills Interview (SRSI)
-have 6 screening questions benefits of this interview: -inclusion strategies can help you understand -touches on the different types of awareness (intellectual, emergent, anticipatory) -motivation change -conducting this assessment allows us to know if they have self awareness so we know what intervention approach to use (bc some you need awareness for)
Orienting Procedure
-help clients monitor their activities and focus their attention -e.g. device beeps every hour and a client ask himself 1) what am i currently doing? 2) what was i doing before this? 3) what am i supposed to do next?
Pacing
-help clients who are tired with maintaining concentration over time -take a break every X period of time -self-monitor and take a break when needed
Cognitive Assessment of Minnesota (CAM)
-hierarchical approach to screening a range of cognitive skills to identify general areas of cognitive impairment and to guide treatment activities -can be used as a baseline, to measure change, and to indicate areas for in-depth investigation
In planning intervention and selecting an approach, the practitioner considers what questions?
-how much is change expected from the person? -how much learning and generalization are expected? -how much do the activity demands or context need to be changed or altered to meet the person's capabilities? -is the person responsive to cues? -is the person aware of his or her difficulties?
Types of Delirium
-hyperactive delirium: restless or agitated or aggressive -hypoactive delirium: lethargic and apathetic
Matching Task and Env Demands to the Person: Functional Approach
-identify task components within ability range (wipe table, fold napkins) -identify env factors which optimize function
Use of Strategies and Environmental Support when Treating Attention
-if decreased attention is problematic for particular tasks or settings, identity an appropriate strategy or form of environmental support may be the best method for mitigating problems -simplifying task instructions so that only one step is presented at a time -pre-selecting relevant objects needed for tasks -task segmentation
Anticipatory Compensation
-implementation of a compensatory technique by anticipating that a problem will occur -ex. Patient needs groceries for the week and is aware that because busy environments result in increased memory and attention deficits, decides to defer shopping until 7pm when the store is less busy
What are the 3 things involved in cognitive rehabilitation/treatment?
-improvement of cognitive and behavioral skills -compensating for cognitive and behavioral limitations -assisting the client to understand and manage reactions to change in functioning
Visual Motor Skills
-include drawing tasks (drawing a map, copying a design) or construction of 3 dimensional figures (assembling a coffee pot)
Overall Treatment Goals
-increase the variety and quality of processing strategies and behaviors -increase the ability to anticipate, monitor, and verify the accuracy of performance -increase the ability to flexibly apply strategies and metacognitive skills to a variety of situations -emphasis working on generalization
Self Management Strategies for Attention Issues
-individuals have difficulties concentrating and process info —> important to understand how, when and where the attention problem is troublesome -clients should be involved as much as possible in strategy selection -strategies: orienting procedure, pacing
Individual Characteristics to Increase Motivation and Active Participation
-info is better learned and retained when patient can relate it to previously learned material -choose treatment tasks with interest, experience, and personality in mind -task intro: define purpose, create and atmosphere of challenge -define goals -establish measurable goals, rating for each task -connect each new treatment task with previous experiences -help client gain sense of control
What are the components of functional cognition
-integrates underlying executive functioning and cognitive skills and everyday tasks within the context of the demands of the activity and the env -observable performance of everyday activities resulting from the dynamic interaction between motor abilities, activity demands, and the task env which is guided by cognitive abilities
Self-Awareness of Deficits Interview (SADI)
-interviewer rated structured interview used to obtain quantitative and qualitative data on the status of self awareness s/p brain injury -good to use in acute care -anticipatory awareness and intellectual -semi-structured questionnaire
Example of self awareness and beliefs in the dynamic assessment
-its important to understand the patient's awareness of their abilities, limitations and beliefs will impact the approach you use for treatment -someone who doesn't recognize any limitations is going to be difficult to treat compared to someone who is aware and open to new ways of engaging in tasks to continue performing their occupations
Awareness
-judgement and decision making in social situations -development of realistic goals -consequences of actions
impaired self awareness associated with neurological dysfunction includes...
-lack of knowledge about one own physical or cognitive perceptual impairments and/or their functional implications -inability to anticipate difficulties, recognize errors, or monitor performance within the context of an activity
Association of self awareness and outcome
-lack of self awareness of cognitive, behavioral and emotional sequelae = reported to be one of the greatest obstacles in brain injury rehab -can impair the patients ability to comprehend the impact of their deficits on a ability to function in daily activities, to benefit from rehab and to make successful return to work
Example of Dynamic Model of Self Awareness
-list of words we had to memorize as a class -used pre-existing knowledge -asked "do you have any memory problems? Do you think you will have trouble with this task?" At the beginning and the end
Activities in Attention Process Training
-listening to target words or sequence on attention tapes and pressing the buzzer when the target is identified (sustained attention) -while reading you need to count the number of "and" (divided attention) -paper and pencil task that require alternating between generating numbers or letters (alternating attention)
Metacognitive Framework
-mediated learning methods: guided questions, reflection, reframing of statements -before task: connect, anticipation, self-generalization of strategies -during task: mediation (therapist can intervene), error detection/correction, strategy and adjustment -after task: self-evaluation, strategy reflection and awareness, connections to previous/future activities
General Awareness
-metacognitive knowledge, intellectual awareness, offline awareness, declarative knowledge -self knowledge and beliefs: strengths & weaknesses, ability to function and fulfill roles, self-efficacy, why one is having difficulty and implications -knowledge about task characteristics, strategies, domains, cognitive processes, and procedures -varies across DOMAINS
Unawareness
-more frequently observed with frontal lesions, right hemisphere lesions, and breakdown of functional interactions between nodes within the front-parietal control network (neuroimaging data)
Rehabilitation Readiness
-motivation and readiness is key -transtheoretical model from addiction: pre-contemplation, contemplation, determination, action, maintenance, relapse -rehab can have these stages too -before use of compensatory aids, OTs should work to raise patient's awareness to learn the purpose and functions of potential memory aid systems
Is assessing cognition specific to the OT profession?
-no, other professions do it as well such as SLPs, neuropsychologists, psychiatrists, neurologists, and other clinicians -OTs have the distinct ability to asses how cognitive skills impact an individual's performance of occupations and roles
Awareness
-not a unitary disorder -varies across and within specific domains: cognitive, physical, social-emotional-behavioral, functional
Attention Process Training
-not functional and resemble laboratory tasks -activity packages and computer programs
During a confusional state, a person may...
-not know where they are or what day it is -not be able to remember personal details about themselves such as their address or names of family members -call out or ramble on without making sense -be unable to focus on a conversation or a simple task such as combing one's hair or self-feeding -experience hallucinations
Assessing Error Monitoring During Task Performance
-number of errors corrected -number of errors I corrected but aware via verbal acknowledgement, audible exclamation, facial expressions, head shaking, manual gesture -number of errors I corrected and unaware
Multi-Contextual Approach: assessing the task
-number of items -complexity -familiarity -spatial organization -movement demands
Occupational Performance as an Evaluation Domain in the C-FE Framework
-observable behaviors related to cognitive function during tasks, activities and occupations -includes process skills, errors, response to errors and behaviors, level of assistance required for tasks activities and occupations
Assessment of awareness requires considerations of multiple methods such as...
-observations across tasks especially if you are doing task specific approach -different aspects (anticipation, error monitoring) -timing of questions: before and after, just before or just after -specificity of questions: general vs specific
Non-Standardized Assessments measuring attention and confusional state
-open ended interview -can ask them "what day is it today?" Or "do you know where you are" or "do you know what season it is" or "who am i in relation to you" -orientation to person time location etc.
Scanning Training
-organized scanning -visuospatial scanning (computer based) -reading and copying training (sentences and newspaper) -copying of line drawing on a dot matrix -figure description of simple and realistic scene
Orientation to Person
-orientation to self: involve the ability to report personal facts and events and describe previous lifestyle -orientation to others: recognize people, associate them with their role, associate them with their names
Goal Definition Stage of Problem-Solving Approach to Goal Setting
-patient to translate a problem into a potential goal -an important issue at this stage is identifying which problem, out of potentially many, to discuss and address
Conclusion of the article on a combined model of online interventions for adults with cancer related cognitive impairments
-potential effectiveness was found for occupational performance, UFOV and QoL -found that the use of bottom up treatment, combined with an occupation based approach might have worthy therapeutic benefits
Multi-Contextual Approach: assessing the individual
-processing strategies and behaviors -structural and functional capacity -metacognition -individual characteristics
Awareness Training: Treatment Principles
-promote insight -gradually increase processing requirements by changing movement demands, task difficulty, environmental demands -videotape feedback -emphasize the same treatment strategy in different activities
Static Assessments
-question asked and answer given -static assessments are given to capture a baseline -given an exam, she does not intervene during the exam, whatever you do is the grade you get -most of our testing is static
Sample questions and prompts of SADI
-question: does your head injury have any effect on your everyday life? In what way? -prompt: ability to live independently? Managing finance?
Memory
-recall previous interactions with others -keeping track on conversations -gives us the ability to draw on past experiences and learn new information
What is the underlying assumption of the remedial approach
-regular or routine practice may improve or at least maintain functioning in a given domain and that any effects of practice will generalize to other activities beyond the immediate training context -abstract tasks out of context (tetris is an abstract task, not an every day activity, but it works on cognitive skills)
Questionnaires about Environmental Factors
-safety assessment for function and the env -westmed home safety -work environment impact scale -work environment scale
Self Awareness and Beliefs (dynamic assessment) as an Evaluation Domain in the C-FE Framework
-self awareness and beliefs regarding cognitive deficits and functional cognition performance -2 types: metacognitive knowledge/intellectual awareness and online awareness/task specific self awareness -multi context or compensatory approach requires self awareness
Key Concepts of Dynamic Model of Self Awareness
-self awareness is a dynamic process -differentiates between metacognitive knowledge and beliefs about ability prior to task -incorporates aspects of intellectual awareness and online monitoring and regulation of performance of tasks -integrates emergent and anticipatory awareness
SADI measures...
-self awareness of deficits -functional implications -ability to set realistic goals
Awareness Quesionnaire (AQ)
-self report instrument used to measure impaired self awareness after TBI -forms filled out by client, significant other and clinician -not used in acute care
greater awareness usually observed in...
-self-care activities -motor and sensory impairments -memory
Assessment of Awareness of Disability (AAD)
-semi structured interview in conjunction with the APMS used to identify areas in occupational performance of which the client is more/less aware
Problem Identification Stage of Problem-Solving Approach to Goal Setting
-shared understanding of what problems are present -facilitate the patient's discovery of problems that represent the most salient obstacles to community reintegration and independent living -strategies: strengths/weaknesses method, structured info gathering, the question and answer method, role play, video feedback, roel reversal strategies
Internal strategies in the Multi-Contextual Approach
-situational strategies: effective in selected tasks and envs (grouping, rehearsal, visual imagery, scanning left-right) -non situational situations: effective in wide variety of tasks "context free" (planning a head, self monitoring, pacing speed)
Multi-Contextual Approach: assessing the env
-social, physical and cultural
Recognition Compensation
-strategies that are triggered and implemented because a person recognizes that a problem is occurring -ex. Asking a person to speak slower because you realize you are not processing info quickly enough and are having difficulty following the conversation
Situational Compensation
-strategies that can be triggered by a specific circumstance in which an impairment may affect function -ex. Student who, secondary to memory impairments s/p TBI, tape records all lectures in class, not always necessary but always used
Types of Feedback
-supportive but direct feedback -sandwich method -emphasize why the errors occurred rather than the errors themselves -video tape feedback -experimental feedback (getting feedback from the experience of performing the task)
Dynamic Model of Self Awareness (Toglia & Kirk's Model 2000)
-supports the idea of self-awareness as a dynamic ability that can be changed through experience with a task, and interactions between pre-existing knowledge of a certain task and any new knowledge that may emerge while performing a certain task -dynamic relationship between the beliefs, task demands and context of a situation based on concept of metacognition
Cognitive Functioning Evaluation (C-FE) Framework
-systematic method of evaluating the impact of cognitive deficits on daily living developed by OT -reflects understanding of factors involved in the interaction between cognition and everyday functioning and provides a comprehensive account of cognition in context
Complete Understanding of Unilateral Neglect Requires a Neglect Battery Which:
-taps wide range of skills -identify conditions which increase or decrease neglect -identify awareness prior to and immediately following a task -differentiates symptoms of neglect
Metacognitive Training in the Multi-Contextual Approach: Metacognitive skills include
-task evaluation -predicting consequences -goal formulation -self monitoring -self initiation -self control (inhibit impulsive responses)
Compensation
-task methods are changed -may include use of external aids -awareness and acceptance are prerequisites -learning and generalization are required -need to have awareness - if no awareness, use adaptation
Care of Older Persons in their Environment (COPE)
-team-based approach with healthcare providers working collaboratively with older adults and their caregivers to identify individualized goals and develop care plans tailored to their needs
Anticipatory Awareness
-the ability to anticipate that a problem will occur as the result of a particular impairment in advance of actions -realize that something like this can happen again and what do you need to do so it won't happen again -prerequisites = intellectual awareness & emergent awareness
Emergent Awareness
-the ability to recognize a problem when it is actually happening -if you a re aware that you made a mistake and you are able to correct it at that time -happens during the performance of the task and you are able to correct yourself -prerequisites = intellectual awareness
Intellectual Awareness
-the ability to understand at some level that a function is impaired -acknowledgement that you have or do not have impairments
Orientation
-the ability to understand the self and the relationship of the self to the past and present env -requires consistent, reliable, and ongoing integration of attention, memory and perception -disorientation is indicative of significant impairments in attention and memory
Sustained Attention
-the longer the task, the more persistence required -repetitive activity over time -vigilance: maintenance of attention over time during continuous activity
Cognition
-the mental processes involved in gaining knowledge and comprehension -includes perception, memory, awareness, reasoning, judgement, intellect, imagination and making sense of the world around us -an ongoing product of the dynamic interaction between the individual, the task and the env
Environmental Factors as an Evaluation Domain in the C-FE Framework
-the physical setting, social network, cultural context -can impact positively or negatively on overall performance -env factors are necessary to understand what the patient is already using -how can you add to these factors or utilize what is in place to improve participation
The neuropsychologist reports the client performed within normal ranges on a standardized test of EF however in your OT evaluation, the client showed difficulties initiating, planning and organizing during real life activities. How can you explain the discrepancy?
-the standardized test is so controlled and the conditions are minimized -in real life, there are environmental factors that include more unpredictable noises, conditions, people, distractions, etc. that affect the task performance
What do the surveys, questionnaires, and scales allow the patient to do?
-the surveys and questionnaires allow the patient to elaborate and provide info on activities and goals they have and want to perform -the QoL scales allow you to understand the patient's awareness, understanding of and impact of their current abilities on daily life -top down dynamic approach identifying what the patient does, what is important to them, what they need and want to do rather than focusing on what they can't do and focusing on deficits
Cognitive Occupational Narrative as an Evaluation Domain in the C-FE Framework
-the way clients understand their cognitive profile and the way they interpret its impact on their occupational experience -the narrative captures the individual's experience as it is shaped by subjective personal factors, values, priorities and choices
Cognitive Function Intervention: CPT Code 97127/HCPCS Code G0515
-therapeutic interventions that focus on cognitive function and compensatory strategies to manage the performance of an activity (managing time or schedules, initiating, organizing, sequencing tasks) -direct (one-on-one) patient contact -medicare will not pay for this code but has created a "G-code" for cognitive interventions that may be paid under Medicare
Evidence for the Metacognitive Strategy Intervention
-there is already evidence to support this approach -there is variability across treatment related to this approach
Use of Strategies in the Multi-Contextual Approach
-there is an important distinction between training that emphasize specific skills and training that emphasizes self regulation and strategy use -the patient needs to be able tot monitor his level of performance to promote learning from context dependent state to a context independent state -involves knowing when and how particular strategy should be used
What are the main purposes of cognitive rehabilitation?
-to enable people with disabilities to achieve their optimum level of well being -to reduce the impact of their problems on everyday life -help individuals return to their own most appropriate env -not to teach them to score better on tests but to improve their cognition TO ENABLE PATIENTS TO ACHIEVE THEIR PERSONAL GOALS
Awareness Interview
-tool to evaluate awareness of cognitive and motor deficits after cerebral infarction, dementia, or head trauma
Task Specific Functional Training
-training is specific -insight and generalization are not required -supported by several studies -used to improve severe cognitive impairment
Practice application of the strategy in multiple envs and tasks in the Multi-Contextual Approach
-transfer increases with the number of examples and situations provided -difficulty is not increased until evidence of far transfer is observed
Very far transfer
-transfer of what being learned in treatment to everyday functioning -another task that is similar in difficulty level but a whole different task
Training Techniques: General Principles
-trust relationship -discuss cognitive symptoms in direct but supportive manner -create balance: deficits and control for success (don't just focus on what is wrong, focus on what is good) -awareness: most likely to emerge when activities are in the just right challenge level
External Compensation
-type of compensation triggered via external agent, or involves an environmental modification -ex. Alarm watch, posted lists of steps related to meal prep, etc.
Orientation to Place
-understand the type of place you are in -ability to report the name and location of hte place -appreciation of distance and direction -topographical orientation: ability to follow a familiar route, ability to describe the relationship between one place to another, involves memory
Functional Approach: when to use adaptation, task specific training, or compensation?
-use adaptation when there is no change expected to happen in the person -use compensation when change in the person is expected -task specific training is used for severe cognitive impairment but still possible to see improvement in the person (somewhere in between adaptation and compensation)
Rancho Levels: What is it used for
-useful scale for describing a patients general cognitive and behavioral status after a head injury -NBCOT tool
Virtual Reality
-video game tech used in stroke therapy (render scenes and objects in 3-D) -stroke patients often have difficulty/feel overwhelmed with basic tasks such as shopping and everyday envs like malls -VMall can help reintroduce patients to these envs in a low-stakes way by capturing the patient's image and movements and placing them in an on-screen virtual mall where they can look for items on a shopping list
Near extra-personal neglect
-within arm's reach -cannot find objects on the left side of the sink -inability to read -inability to find numbers on the left side of the phone -does not eat food on left side of plate
Scoring of SADI
0 = accurately described 1 = some acknowledgement 2 = some acknowledgement but minimizes importance 3 = no acknowledgement
Pyramid of Self-Awareness (Crossan 1989)
1. Anticipatory awareness (top of the pyramid) 2. Emergent awareness 3. Intellectual awareness (bottom of the pyramid)
Components of the COPE
1. Assessment: comprehensive assessment, identify older adult's needs, functional abilities, living env 2. Care planning (based on assessment) 3. Care coordination: ensure needs are being met 4. Education and support: to help manage their health 5. Monitoring and follow-up: adjust care plan as needed
Evaluation Domains in the C-FE Framework
1. Cognitive occupational narrative 2. Cognitive factors 3. Occupational performance 4. Self awareness and beliefs 5. Environmental factors
Key Concepts of Functioning and Disability
1. Impairment: body, function/structure, severity, localization, duration 2. Activity limitation: person, activities, difficulty, duration, assistance needed 3. Participation restriction: society, participation, extent, facilitators and barriers in env **all affect functional performance and gives info about how the impairments manifest in everyday life functioning
2 Frameworks for Assessing Cognition
1. International Classification of Functioning, Disability and Health (ICF) 2. Cognitive Functioning Evaluation (C-FE) Framework
3 Methods of Assessment in the C-FE Framework
1. Interviews 2. Self reports and informant reports regarding everyday functioning 3. Performance-based assessments (actual reality)
Problem-Solving Approach to Goal Setting: Stages
1. Problem identification 2. Goal definition 3. Option appraisal 4. Solution selection
3 Main Cognitive Treatment Approaches
1. Remedial: deficit specific approach, if you have an impairment, let's fix it (direct) 2. Functional approaches: adaptation (indirect), compensation (direct), task specific training (direct) 3. Combined approach: multi contextual approach, co-op (combining indirect and direct, remediation and compensation)
Components of the Multi-Contextual Approach
1. Specify a processing strategy: internal and external strategies 2. Task analysis and establishment for criteria for transfer 3. Practice application of the strategy in multiple envs and tasks
Sessions within The Lighthouse Strategy
1. Training Session 1: a simple line-drawing of a lighthouse is used to make an analogy between consequences for ships and persons who are not able to see where they are going - this intro paves the way for demonstration of how patients can become like lighthouses to improve their own safety *all therapists are informed patient has begun LHS training and level of cueing they need 2. Training Session 2: therapists review the LHS and go back over the picture again at the beginning of the session, patients are then taken around the env and are asked to point out objects on the left or right side, cues to use LHS are given when needed
What are the 2 Approaches to Cognitive Rehabilitation/Treatment
1. treatment of cognitive deficits associated with neurological disease or injury: bottom up/restoration and remediation 2. An effort to promote maximal adaptive cognitive functioning in patients with neurologically induced cognitive deficits: partially top down, adaptive element of compensation
What does client centered mean? A. A match between clients goals and treatment B. Use only functional everyday activities C. Ask the family member to identify their goals D. Use real life env in rehab (for ex. Perform a shopping activity)
A. A match between clients goals and treatment
What could cause cognitive impairments?
Aging, brain injury, medications, neurodegenerative disease/illness (e.g. Parkinson's), stroke, mental health illnesses, congenital complications or diseases, diabetes, malnutrition/dehydration
Rancho Question: a cognitive screening for a client with low-level cognitive skills should NOT focus on which one below? A. Arousal B. Multiple step command following C. Initiation activity D. Memory
B. Multiple step command following
Why is awareness important to improve cognitive rehab gains? A. to know what they are doing B. to report correct and accurate feeling C. increase motivation to participate D. Reduce frustration and depression
C. Increase motivation to participate
How is failure in neuro-rehabilitation defined? A. inability to learn B. improvements are observed in tools that are not validated C. no transfer and generalization of treatment gains D. lack of rapport between patient and therapist E. use of non client centered approach
C. No transfer and generalization of treatment gains -mis match between that is being done in the clinic and what the patient does at home -failure is the treatment not carrying over from the hospital/clinic to home
COAST Goals
Client (client will demonstrate ability) Occupation (to write a check and balance his checkbook) Assist level (with 2 verbal cues for sequencing and initiation) Specific conditions (during life skills management group) Timeline (by 4/4/23)
Why is goal setting important? A. Understand what problem should be addressed B. Understand how it would be measured, what to expect C. Connect the problem and its improvement with everyday life D. All of the above
D. All of the above
Rancho Question: Mark is detached from the present and responds primarily to his own internal confusion, he has shown aggressive behavior recently removing restraints and attempting to hit staff. The OTR is going to start with feeding/grooming interventions. Which Rancho level would BEST classify Marks's current state of cognition? A. Level 3: localized response, total assistant B. Level 5: confused-inappropriate nonagitated, max assistance C. Level 6: confused, moderate assistance D. Level 4: confused-agitated, maximal assistance
D. Level 4: confused-agitated, maximal assistance
Self Estimation
Estimate one or more of the following parameters: before after or during performance -less emphasis on performance -ask patients to evaluate and describe their performance -ask patients to think about if they could improve performance by doing task differently
What is the loop of Toglia & Kirk's Model
Experience with a task —> emerged new knowledge (self-estimation) —> pre-existing knowledge (self-prediction) —> experience with a task —> etc.
Mental Imagery
Experiencing a sensory impression in the absence of sensory input
Standardized Assessments measuring attention and confusional state
Galveston Orientation Amnesia Test (GOAT) Benton Temporal Orientation Test
In the remedial approach, cognition is divided into...
Hierarchical sub-skills -training is hierarchical, with increasing difficulty and targets specific impaired domains -attention is the basis and then you build up from there
What are the Rancho Levels
I. No response II. Generalized response III. Localized response IV. Confused-agitated V. Confused- inappropriate VI. Confused- appropriate VII. Automatic-inappropriate VIII. Purposeful and appropriate
Why would someone with self-awareness have better rehab outcomes
Motivation —> they understand why they are working on it
SMART Goals
S = specific, significant M = measurable, meaningful, motivational A = agreed upon, attainable, achievable, acceptable, action-oriented R = realistic, relevant, reasonable, rewarding, results oriented T = time-based, time-bound, timely, tangible, trackable
Types of Mental Imagery
Visual = imagining the movement of a visual form Motor = imagining your own hand moving Kinesthetic = imagining the feeling of your hand moving
Activity Grading Principles
• Meaningful → meaningless stimuli configuration • Linear structures array → scattered • Spread apart→ close or overlapping • Tell number of targets → number of targets is unknown ' • Pop out' → serial search
Assessments for Attention
• Questions to patient/caregiver regarding behavior • Patient's awareness of problem • Observe Behavior • Drawing tests: Clock, Flowers, etc. • Scanning Tests • Line Bisection Cross Out Task (Suter analysis) • Two Penlights-Extinction • Read Hart Chart → Auditory/tactile stimuli • Letter cancellation • Line bisection • Drew a person, clock, house
Semi Functional Assessments for Attention
• Rivermead behavioral Inattention Test (RBIT): eating meal, dialing telephone, reading menu, telling and setting time, sorting coins, copying address, following map • Arranging cookies in a tray
