1 Cognitive Rehabilitation Evidence- Based Practices Cynthia Griggins, PhD Neuropsychologist, Neurological Institute UHCMC
2 What is Cognitive Rehab? Goal: ameliorate injury-related cognitive deficits (attention, memory, executive functioning, etc.) in order to maximize safety, daily functioning, independence, and quality of life. Retraining (attention) or using compensatory strategies (memory, executive fxs, etc.) Should be transdisciplinary (psych, OT, ST)
3 Patients Acquired injury Stroke TBI Post surgery (tumor, epilepsy, etc.) Progressive disorders Multiple sclerosis Other (compensatory, depends on available resources) Severity Severe: more behavioral training, specific skills Mild to moderate: teaching self-regulation
4 Training Strategies for Severity of Impairment Severe Task specific, teach by repeated practice Errorless learning ( my name is Cynthia. What is my name?) Spaced retrieval (immed, 15 sec, 30 sec, etc.) Chaining (can start with 1 st or last step) Mild to moderate Teach internal strategies, self-generated Expect generalization (can see similarities in situations, cause effect)
5 Stages of Treatment 1.Comprehensive assessment Neuropsych eval How are deficits interfering with daily life? Input from family, others Goal setting 2.Implementing treatment plan Clinic, office Structured environment Community
6 Stage 1: Comprehensive Assessment Must be detailed assessment of ALL cognitive functions Attention (sustained, divided, focused, etc.) Memory (verbal and nonverbal; encoding, storage, retrieval; retrograde, anterograde, prospective, etc.) Executive functions Emotional regulation Social, communication (listening, formulating thoughts, turn-taking, reading nonverbals, etc.)
7 Stage 1: Comprehensive Assessment Observation in community Questionnaires Family interview Integrate information to set goals Cognitive deficits Premorbid personality and abilities Living situation, family MOTIVATION
8 Setting Goals Patient-driven (work, live independently, drive ) Long Term Goals Short term goals Time lines Essential factors in goals: CLARITY Type of task (cognitive impairment or function) Complexity (simple, moderate, complex) Level of assistance Type of strategy to be employed Measurement of success (%, speed, level of cue)
9 Stage 2: Rehab Treatment 1. Acquisition Teach purpose and procedures of treatment Help pt. recognize and accept deficit and benefits of treatment (awareness) 2. Application Improve effectiveness and independence in compensating for deficits Promote internalization of strategies 3. Adaptation Promote transfer of training to tasks less structured, more novel, complex, distracting Generalization to home, community, work
10 Acquisition General education about brain injury Education re. patient s particular problems Increase awareness as necessary (behavioral experiments) Patient s prediction of performance Exercise (measurable, concrete, video) Review of results Acceptance of impairment
11 Application Therapist designs treatment plan, strategies to be learned based on patient goals Teaches, practices in sessions Increasing challenge (complexity, level of assistance, distractions, etc.) Careful monitoring of progress Predict-perform-evaluate
12 Adaptation Take strategy outside clinic Homework assignments Group work Home, community, work Increasing generalization, facility with strategy
Attention Training 13
14 Attentional Hierarchy (Sohlberg & Mateer) Focused attention: recognize and acknowledge specific sensory information Sustained attention: maintain attention over period of time during continuous, repetitive activity Selective attention: process target information and ignore nontargets Alternating attention: shift focus between different behaviors, tasks Divided attention: respond to 2 or more events at same time
Attention Spot light or light house Where the beam is directed: enhanced Other areas blocked out Beam can be narrow or broad, can be moved or locked, limited ability to divide it
Selective (Focused) Attention Description Shining bright, narrow beam Ignoring or filtering out extraneous stimuli Examples: Finding info on busy web page Blocking out other conversations to listen to one person Blocking out background noise while studying in coffee shop Finding your brand on supermarket shelf
Strategy for Selective Attention If you notice your attention has slipped Refocus STOP + THINK what were you supposed to be doing? May need to make cue card before you start task Get back on track THINK
Strategies Mental blackboard Writing on it Checking it
19 Attention training Practice standard in post-acute phase Recommend direct training + metacognitive strategy training Can use computer programs, but therapist guidance necessary
20 Attentional Training Attention Process Training (APT, Mateer & Sohlberg) see YouTube video Follows hierarchy Basic sustained attention Selective attention Alternating, divided attention Success in functional tasks, not scores!
21 Other approaches Time Pressure Management Working Memory Rehab (Cicerone) N-back procedure
Executive Functioning 22
Common Executive Impairments 23 Cognitive Awareness Anticipating problems Analyzing situations Planning solutions Executing plans Maintaining flexible approach Monitoring self Emotional Inability to regulate Lability Overwhelmed by feelings Behavioral Positive sxs Disinhibition Impulsivity Cognitive inflexibility Negative sxs Lack of initiative Lack of motivation Apathy impersistence
24 General Approach: Executive Functions Making what used to be automatic, now on manual Metacognitve, internal strategies, self-regulation Variations on basic steps: 1. Become aware of problem, identify task demands 2. Identify options, steps 3. Choose plan (predict performance) 4. Execute using strategies, monitoring self 5. Review, evaluate results, make necessary changes
25 Problem Solving Strategies STOP! WHAT is the problem? ALTERNATIVES PICK and PLAN SATISFIED? GOAL PLAN DO REVIEW
Memory 26
27 Memory-External Aids iphone, smart phone, memory books, calendars, post-its, alarms, etc. Need constant, easy access All staff and family trained in use Require multiple learning and generalization trials Fade out cues New technology: Memorycam; OZC paging system
28 Memory Book Monthly calendar, check for anything today and this week Go to daily page, transfer appts. Write notes connected to specific event Add things to do not connected with specific time; prioritize, estimate time, put in time slot Write notes during, immed. after appt. Write notes during, after conversations For severely impaired, section with key info Intensive training, practice, faded cues
External Strategies Diaries, notebooks Taking notes Making frequent (daily) entries REVIEW regularly Appointment calendar (smartphone, Filofax, etc.) Basic alarms (watches, phones, kitchen timers, etc.) Post it notes Pill boxes Dictaphone (smartphone) To do lists (must be organized and updated daily)
30 Memory-Internal Strategies Determine when these should be employed Association techniques Visual-verbal association Visual-verbal schematics Visual Peg Method Method of Loci deeper understanding Organizational 1 st letter mnemonics Semantic clustering PQRST Use of humor storytelling
Internal Strategies Mnemonics (e.g., spring forward, fall back; PQRST) Visual imagery Using familiar space, like your house Flow chart (my example of brain)
Neglect 32
33 Neglect Inferior right hemisphere lesions, right dorsolateral 50% right CVAs have neglect Close + distant + personal space Decreased awareness of visual, sounds, tactile, smells, movement on left Poor awareness of deficit
34 Neglect Training Cancellation tasks (symbols, letters, numbers, words) Anchoring (verbal + visual cues to begin on far left side) Pacing: slow down, recite targets out loud Density more errors Information load more errors Gradually fade cues Increase from letters words sentences, etc.
35 Limb Activation Patient is asked to move left hand during tasks (e.g., tap hand, open and close; lift left shldr) Put left hand in field, instruct to look at hand
Social Communication 36
37 Communication Problems Communicating thoughts, needs Listening and understanding others Nonverbal (giving and interpreting) Regulating emotions in social interactions Following social rules, respecting boundaries Working collaboratively assertiveness
38 Communication Skills Social aspects Reading faces (emotion cards) Interpreting social cues (silent movies, etc.) Verbal communication skills Listening, paraphrasing Turn-taking Disinhibition Excessive talking
Social Awareness Watching for verbal, nonverbal cues Facial expression Tone Eye contact
Becoming an Active Listener Manage attention Nonverbal Eye contact Occasional nodding Facial expression Posture Encourage speaker to continue with small uh-huh OK, etc.
Becoming an Active Listener Provide feedback Paraphrasing Clarifying Summarizing Defer judgment Respond appropriately
Conversational Control Verbal expression/organization Initiating/starting conversations Maintaining Ending conversations Social Awareness Turn-taking Repair
Social Awareness What can go wrong? Assuming the listener has more information than is accurate Giving the listener too much information Not being specific enough Responding, but not answering the question
44 Treatment Plan Identify problem (TMI, no eye contact, can t read nonverbals, etc.) Use pt s label Circumstances, triggers, what makes better/worse Data collection: baseline Monitoring may need to be done by others Gradual self awareness Behavioral program Feedback
45 Group Work Education (Understanding brain injury, attention, memory, executive fx, etc.) Presenting basic strategies Lab to practice behaviors Give and receive feedback Application, try out strategies
46 Topics Key social communication skills Setting goals Starting/maintaining conversations Dating Handling families Increasing self confidence, decreasing selfdestructive behavior Conflict resolution Giving feedback (direct, kind, honest, etc.)