Assessment and Treatment of Cognitive Impairment after Acquired Brain Injury

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1 Assessment and Treatment of Cognitive Impairment after Acquired Brain Injury Dr Brian O Neill, D.Clin.Psy. Brain Injury Rehabilitation Trust, Glasgow Honorary Research Fellow, University of Stirling

2 Brain Injury Rehabilitation Trust, Glasgow Graham Anderson House is a 25 bed specialist neuro-behavioural rehabilitation service in Glasgow, UK

3 Ethos Rehabilitation enables participation in meaningful social lives Society of Research in Rehabiliation, 2012 Understand how cognitive impairments (including emotional dysregulation) lead to behaviours that risk self and others Interdisciplinary team work with service users and their families to achieve personal goals

4 Team (Posts) Clinical Psychology (2); General Practice (0.1); Occupational Therapists (3) ; 2 Physiotherapy (2); Psychiatry (0.2); Neuropsychology (1); Nurses (6); Rehabilitation Support Workers (20); Speech and Language Therapists (2); Vocational Advice (1) Administration (4); Chefs (2); Domestic (4); Management (2);

5 Case of JM 62 year retired electrician, with history of hypertension, found unconscious Admission GCS was 3 (severe brain injury) Computerized tomography: Right intracerebral haemorrhage in the caudate nucleus; evidence of blood in the 3 rd and 4 th ventricles; hydrocephalus and midline shift Day two: extra ventricular drain

6 What deficits might we expect from the scan results?

7 Physical Full active and passive range of motion in his upper and lower limbs; normal muscle strength; normal core stability; kyphotic posture; normal co-ordination and tone Eye movements normal. Normal audition. No dysnosmia or taste changes Normal sensation

8 Neuropsychological Assessment How would you assess these problems? There are different approaches: 1. Interview, problem list, hypothesis testing Efficient Highly skilled 2. Battery assessment by domain Thorough Costly

9 Assessment by Domain International Classification of Function: 11 Specific Mental Functions (WHO 01) Memory Perception Psychomotor Movement Sequencing Higher-level cognition Calculation Attention Emotion Aberdeen Language Thought Experience of self and time

10 Attention Adequate for conversation and assessment In free behaviour, poor sustained attention to task - verbal self instructions are lost Confabulated plans in response to stimuli Visuospatial attention normal (Map Test) Sustained attention normal (Tone Counting)

11 Visual-Perceptual Abilities Visual Object and Space Perception Battery Spatial awareness intact Unable to identify degraded letters or objects from their silhouettes If the object was shown as one of four, he was quick to identify it Visual agnosia rather than anomia

12 Memory / learning Rivermead Behavioural Memory Test General memory index: 53 (<0.1%) Visual and spatial memory at floor Recalled gist of a story immediately but lost after a delay Severely memory impaired

13 Intellectual function WAIS-IV Verbal Comprehension Tests over Perceptual Reasoning tests Working memory was normal Digit span Forward: 8; Backward: 3 [Using rehearsal required to maintain contents] Difficulty recalling answers on Information Visual reasoning tests in impaired range Difficulty taking meaning from visual stimuli

14 Executive function Behavioural Assessment of the Dysexecutive Syndrome: impaired range He had a disorganised approach to novel problems Difficulty maintaining problem set Bizarre cognitive estimates Incapable Insightful to his difficulties when confronted but no recall later and stated he was fully recovered

15 Presenting Problems Irritability Memory difficulties - Episodic Disorientation Executive function - Sequencing

16 Treatment How would you begin to rehabilitate the multiple problem areas identified?

17 Irritability Not irritable all the time More when disoriented Careplan on Interpersonal Interactions Praise, reward, thanks when calm and polite Gently sharing with him when behaviour difficult to be around

18 Irritability

19 Episodic Memory Tended to confabulate Careplan so that all the team named this when it happened Grew to self question Sensecam Wore and enjoyed reviewing the automatically taken images improved ability to tell the story of his day Graduated onto using mobile phone camera to take pictures of to-be-remembered events

20 Disorientation WanderReminder Passive infrared sensor linked to time linked auditory prompts 12 Investigating the use of automated voice prompts to reduce nocturnal activity Movements- No. of times leaving bedroom Baseline Intervention Days

21 Executive Function - Sequencing Occupational Therapy supported practice for everyday activities: Road crossing; Kitchen safety; Laundry Morning routine prompts by support workers Noxious to him Bachelor But no change in ability over time Installed Guide in his room Interactive prompting which stores branching tree protocol to prompt users through the problem space (www.guide-research.com)

22 Executive Function - Sequencing Interactive verbal prompting errors made in morning routine to near zero Slight increase again after return home

23 Outcome On first assessment prognosis was very poor Memory problems, disorientation and wandering, indicated discharge to care home Family accepted risk of trial procedures JM demanded them! At 1 returned to his home (two visits/day) Changes to activity level and mood issue At 3 years he is happy with what he achieved

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