Integrated Neuropsychological Assessment

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1 Integrated Neuropsychological Assessment Dr. Diana Velikonja C.Psych Neuropsychology, Hamilton Health Sciences, ABI Program Assistant Professor, Psychiatry and Behavioural Neurosciences Faculty of Health Sciences, McMaster University Storrie, Velikonja and Associates Neuropsychological and Psychological Services Concussion Clinic

2 What is an Acquired Brain Injury Damage to the brain occurring after birth. Unrelated to degenerative diseases.

3 Types of Acquired Brain Injury Traumatic Penetrating Injuries Closed Head Injuries and Concussion Non Traumatic Aneurysm Swelling Disease Processes Anoxia Stroke A complex pathophysiological process affecting the brain, induced by traumatic biomechanic or other forces/changes resulting in the rapid onset of impairment of neurological function.

4 Predictive Indicators of Injury Severity MILD/ MODERATE/ SEVERE Duration of Coma/Loss of Consciousness Post-Traumatic Amnesia long term cognitive outcome Glasgow Coma Scale Initial level of function

5 Additional Mediating Variables Demographic variable age education and abilities (buffering) gender (male) pre-existing conditions

6 Model of Assessment Cognitive Processes

7 Acquired Skills and Knowledge Inherent verbally and visually mediated problem solving and reasoning skills; augmented by information we pick up through education, experience, interactions over the course of our lives. Formal and informal. The resources you have and acquire. Occupation, hobbies, leisure, interests Provides measure of extent of injury. Anchor for other cognitive skills. Role in recovery and long term outcomes.

8 Senses and Manual Abilities Sensory perception and manual motor skills

9 Attention and Information Processing Attention Verbal and Visual: focus divide/select sustain suppress distractions Processing Efficiency: how quickly and accurately can information be processed Working Memory mental manipulation of information

10 Memory Memory: Verbal and Visual: process and lateralization Acquired skills tell us how good should have been premorbidly Requires intact senses Dependent on attentional and processing integrity

11 Divergent thinking more than one answer to a question Creativity and Cognitive Flexibility generating ideas, thoughts; alternative ideas Strategy formation novel cognitive plans Metacognition Multi-tasking managing multiple tasks Behavioural Control: Executive Cognitive and Behavioural/Social Skills response inhibition risk taking and rule breaking perseverative thinking Temporal memory recency memory, frequency estimates, delayed response Impaired Social Behaviour

12 NEUROBEHAVIORAL SYNDROMES Disorders of Awareness: Anosognosia and anosodiaphoria. Frontal Syndromes: pseudo-depression, indifference, slowness, inertia, euphoria, disinhibition, hyperkinesia, lack of empathy and concern, poor insight. Temporolimbic: intense affect/, spontaneous rage, hyper- and hypo- sexuality Reactive Psychological Conditions: adjustment, PTSD, car phobia/anxiety, etc.

13 Effort and Consistency Ability to apply cognitive abilities Multiple factors emotional issues motivation sleep, medication, diet, etc. pain Understanding cognitive performance

14 Mechanisms of Recovery Acute Recovery Phase versus Chronic Recovery Phase neuroregeneration small scale addition of cells recovery compensation reorganization and stimulating plasticity key in rehabilitation lost functions not restored

15 Rehabilitation What Does the Evidence Tell Us

16 Rehabilitation What Does the Evidence Tell Us Herbs, vitamins and supplements Brain training and fitness cognitive reserve

17 Cognitive Reserve Aging and Demential Literature Brain reserve: number and density of neurons, structure; more pathology present before deficits become apparent. Cognitive reserve: pre-existing cognitive processes to employ in compensation (i.e., education, occupation, IQ, etc.). Richness and variety of experiences and activities. What improves reserve: aerobic exercise Shows promise: focused computerised training emphasis-change training extension of training to other tasks. Attention allocation. No clear evidence: cognitive training exercises.

18 Brain Training Limitations: Benefits short-lived once training discontinued. With longer periods of reported benefit there was questionable significance of training effects. Results open to many interpretations. Some limited cognitive benefits but can be task specific and not extend into practical tasks. Very limited evidence for generalized benefits.

19 Brain Injury and Cognitive Reserve Level of education, interest in occupation, IQ increased synaptic density, neurogenesis and synaptic plasticity slows ageing, and delays clinical manifestation of neurodegenerative diseases. Brain injury is associated not with the development of neurodegenerative diseases but with accelerated ageing. Even mild injuries and good recovery under conditions of stress show reduced cognitive abilities. Brain injury changes neural networks re-routing through plasticity and compensation. More of the brain in active during routine tasks. Not the same as degenerative diseases. Hypothesis is that brain injury lowers cognitive reserve resulting in different outcomes and prognoses.

20 Rehabilitation Managing Reserve Goal: To increase meaningful function based on reasonable and realistic expectations. Acute rehabilitation: Restoration or improvement of lost functions. Maximizing neurological recovery. Post-acute rehabilitation: Continuing to work with neuronal plasticity but changes may be slower and targeted. Integrate standardized test results, pre-injury characteristics, stage of development, contextual variables (i.e., meaning, goals, etc.)

21 Rehabilitation What Does the Evidence Tell Us Education as a Process: early education is associated with a significant reduction in symptom exacerbation and functional declines mechanisms of injury, how the injury caused certain deficits, retained strengths, realistic expectations rehabilitation process stages, developing meaningful and functional goals every session should involve review/education

22 Rehabilitation What Does the Evidence Tell Us Restorative Techniques: Attention/Processing, Memory and Executive Skills Neuro- / Bio- Feeback Computerized strategies Integrated into specific therapy sessions Identify the skills being taught Develop a strategy to transfer the skill to a real life task There must be practice of that skill in the context of a functional task

23 Rehabilitation What Does the Compensatory Strategies Evidence Tell Us Learning New Skills Developing strategies to manage disorganized behaviour

24 Scenarios Mona needed to clean up her apartment before some people were to arrive. On her dresser, she noticed a letter she had not opened. One hour later she was still re-reading the letter and trying to figure out how to deal with it and her visitors were about to arrive, but she had not done any cleaning. John was preparing to go to his medical appointment and placed his medications and a list of questions on the table. He got ready and then left to his appointment. When the got into the appointment room he realized he did not have his medications or list of questions.

25 Goals and Strategies Behavioural Goal client goal Goal attainment scaling framework to identify and quantify Current functioning and target functioning Strategies break down the function and identify how to fix it Metacognitive strategies Compensatory strategies

26 What Strategies Would You Suggest Compensatory Strategies White board Phone reminder Learning New Skills Review and checking strategy Developing strategies to manage disorganized behaviour Alerting, monitoring, reminding strategies Others???

27 Why is it not working?

28 Rehabilitation What Does the Evidence Tell Us Implementation and Teaching we do the metacognitive work passive approaches and strategies why we do not learn Individualized learning strategies

29 Rehabilitation What Does the Evidence Tell Us Metacognitive strategies: Precision teaching: acquisition, application and adaptation. Operant self-instruction: PQRST (preview, question, read, state, test). Goal management training Instruction: Task Analysis breaking down tasks and strategies and teaching individual steps Procedural learning: repetition of a procedure Error-free learning: especially important for severe memory impairments.

30 Task Analysis weighting scores using specific cueing breaking the task into component steps Incorporates the use of a composite functional score Has additional score system that uniquely accounts for cognitive as well as physical impairments unlike any of the other functional scales.

31 Task Analysis Composite Scores Composite Scores: 1 Total Physical Assistance (24 hour supervision): FIM (1) Total Assistance 2 Specific Verbal Cueing and Minimal Physical Assistance (75% assistance): FIM (2) Maximal Assistance 3 Specific Verbal Cueing and Gesture Modeling (assistance up to 50%): FIM (3) Moderate Assistance 4 Specific Verbal Cueing (monitoring for task up to 25%): FIM (4) Minimal Assistance 5 General Verbal Cue (monitoring for specific task under 25% of the time: FIM (5) Supervision 6 Independent (no supervision) : FIM (6-7) Independent, Complete and Modified

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