Cognition - Instructed by Dr. Lamar Bolden. PDF

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Instructed by Dr. Lamar Bolden....

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Module 1: Severe Cognitive Impairment Monday, January 13, 2020

9:27 AM

Objectives: intro to cognition - Differences b/w cognitive screenings/assessments - Components of Cognitive Functional Evaluation - Various practice settings in which OT's provide cognitive services - Role of OT and OTA regarding providing cognitive services Objectives: severe cognitive impairment - FOR that describe severe cognitive impairment - Assessments for individuals with severe cognitive impairment - Interventions for individuals w/ severe cognitive impairments

Chapter 1: Understanding Functional Cognition - Advantages of functional cognition ○ Functional cognition: combines the constructs of function and cognition and refers to the use of cognitive processes in the widest sense (ex. in context of performing everyday activities/occupations) ▪ Person in the environmental context ▪ Top-down construct ▪ Metacognition, executive function, other cog domains, perf skills, perf patterns ▪ Ability of individuals to perform tasks in presence of cog impairment ○ OT view: cog functioning can only be understood/facilitated fully within context of occupational perf (allows therapist to estimate amount/type of support needed to manage activity demands) ▪ Occ. Perf. --> expands framework to include environment contexts and allows interventions broader than targeting individual alone ○ Advantages: ▪ Acceptability of the assessment ▪ Neutral word, avoids focus on impairment or deficits ▪ Allows for transition toward universal cognitive access (providing cog supports as a natural/intrinsic part of the lived environment) - Approaches to evaluating functional cog ○ Questionnaires: take less time, can cover many functional areas, less expensive, can be self-reported ○ Results of neuropsychological testing: help OT understand clients' capacities - Performance-based testing ○ Cognitive level screen (Allen): uses leather lacing activity ▪ Info interpreted with Allen's Cognitive Level Scale ○ Allen Diagnostic Module ○ Routine Task Inventory-Expanded ○ Multiple Errands Test (Shallice and Burgess): identify types of deficits clients were manifesting in their daily life ▪ Offered less clarity about environmental influences on test performance ○ Behavioral assessment of the dysexecutive syndrome ○ Shift away from neuropsychology --> performance skills ▪ Performance assessment of self-care skills ▪ ADL focused occupation-based neurobehavioral evaluation ▪ Kitchen task assessment ▪ Executive function performance test

Assignments: DUE @ 11:59pm on 1/31 BCA Quiz 1: Wolf et al. (chapter 1) BCA Quiz 2: Wolf et al. (chapter 6) BCA Quiz 3: Wolf et al. (chapter 18) ACA – Case Study 1

▪ The kettle test ▪ IADL profile - Characteristics of performance-based tests of functional cognition ○ Top-down measures: allow for direct observation on individual's ability to perform tasks and to infer performance abilities ○ Metacognition: awareness of self (intellectual self-awareness) ○ Complexity (7) ○ Quantifying ability: ▪ Categorical approach: straightforward count of number of correct responses ▪ Dimensional approach - Common observations of performance during functional-cog eval ○ Fail to comprehend goal ○ Fail to plan ○ Oversimplify task ○ Fail to recognize errors ○ Recognize errors, but not self-correct ○ Plan adequately but have poor execution and become derailed ○ Reject complexity of task

Chapter 6: Baseline Cognitive Screening Tools - 2 stages of assessment: screening test and comprehensive diagnostic assessment ○ Screening measures: used when presence of condition is unknown in order to assess likelihood the person has a particular problem or condition ▪ Not used for treatment planning; used to determine if further eval is needed ○ Diagnostic tests: used with people who have specific indications of a possible condition, problem or illness (to confirm presence/extent of a problem) ○ Table 6.1 (p.2) - 3 types of screening: ○ Selective: assessments used to evaluate individuals thought to be of high risk for underlying problem when compared with the population at large ○ Mass public health ○ Surveillance - 2 perspectives when evaluating screening tests: ○ Statistical examination of test; investigate validity and reliability ○ Clinical yield; ability of the test to quickly identify problems/risk of problems - Establishing validity of screening tests ○ Screenings are compared with the gold standard (well-validated diagnostic test seen as definitive) ○ Look at sensitivity and specificity compared with the GS ▪ Sensitivity: capacity of the test to correctly identify individuals with the condition; very few false negatives ▪ Specificity: capacity of the test to correctly identify individuals without the condition; very few false positives ▪ Both values range from 0-100% ○ Positive predictive value: percentage of individuals with a positive test who actually have the problem ○ Negative predictive value: percent of individuals with a negative test who do not have the problem - Cognitive screening measures (p. 5)

Chapter 18: Neurofunctional Approach - Task/habit training approach ○ OT identifies area of dysfunction ○ Designs a procedure that allows client to accomplish needed ADL and simple IADL tasks ○ Facilitates client's practice of the procedure (i.e. repetition of behavior) until they can perform it automatically - Theoretical foundations of NFA ○ Learning theory ○ Motor learning theory ○ Social psychology ○ **given sufficient practice, individuals who had sustained TBI could reach skill levels that approximated those who were neurologically healthy** --> develop skill-training methods of NFS - Habits and routines ○ Central to NFA/main goal of therapy = structured retaining programs to develop habits and routines - Provides framework for assessment and intervention rather than collection of specific measures and interventions - Target population ○ Individuals during PTA acute rehab ○ Individuals with mod to severe attention impairment and episodic memory ○ Individuals with severe EF ○ Individuals with mild to mod attention, memory or EF impairment in combo with severely impaired self-awareness - Administration ○ Step 1: develop positive therapeutic alliance ▪ Focus on clients' perspectives, values, goals, what they want to do ▪ Develop trust to enhance therapeutic engagement ○ Step 2: gather and assimilate relevant info ▪ Understand clients' current functioning in their natural environment; identify likely responses to intervention ○ Step 3: determine client's goals and available resources ○ Step 4: set operational performance goals ▪ Determine area where assistance is required, document functional level and implement retaining program ○ Step 5: observe performance ▪ Refer to nature of task, client characteristics, environmental resources, constraints ▪ Task analysis - process of identifying essential behaviors required for completion of a task ○ Step 6: create skill-retaining programs ▪ Therapist focus on areas where client needs cueing and engages in cue experimentation (to ensure cue is adequate to achieve functionally equivalent performance of the activity step) ▪ Error-less learning - once error is established, it may be difficult for client to override it ▪ Whole-task method - client cued through entire activity ○ Step 7: develop automaticity, generalization, and skill maintenance ▪ Therapist records at each intervention client's need for cues to chart progression ○ Step 8: provide feedback

Case Study 1: Severe Cog Impairment Monday, February 3, 2020

11:47 AM

Standardized vs. Dynamic - Standardized = very strict, clear instructions - Dynamic = adding own thing to it Acute vs. inpatient - Typically go to Acute Care after ICU DRS - Addresses self-care performance Minimally conscious state: - Client can respond to stimuli

Module 2: Attention Impairments (in class notes) Monday, February 3, 2020

11:45 AM

February 3, 2020 Unilateral neglect: - Failure to orient to, respond to stimulus on contralateral side - Debilitating Using OT terminology to document client with unilateral neglect: - Clock drawing test: something used to screen for unilateral (personal space) neglect - Video Observations: ○ Drawing numbers on clock ○ Neglected most of left side of circle ○ Started on right side ○ Poor ability to detect errors and problem solve ○ Spatial relations: did not recognize entire circle so spacing was poor and did not detect the mistakes ○ Client did not plan properly to space numbers Environmental Strategies to reduce unilateral neglect - Ex. making a peanut butter and jelly sandwich with a glass of milk - How can client find the peanut butter and jelly; where is it located - Think about all components of making PB&J - 4 environmental strategies: ○ Encourage use of affected side ○ Anchoring ○ Color coding to increase saliency ○ Decrease amount of items (reducing the field) ○ Grouping (categorization)

Module 2: Attention Impairments (quizzes) Monday, February 3, 2020

1:34 PM

Assignments: DUE @ 11:59pm on 2/21 BCA Quiz 4: Wolf et al. (chapter 3) BCA Quiz 5: Wolf et al. (chapter 4) BCA Quiz 6: Wolf et al. (chapter 16) BCA Quiz 7: Wolf et al. (chapter 17) BCA Quiz 8: Wolf et al. (chapter 21)

Chapter 3: Principles of Functional - Cognitive Assessment - Performance-based tests: ○ Examine hoe of performance ACA – Case Study 2 ○ Not intended to identify brain dysfunction ○ Examine behavior produced ○ Goal: assessment and characterization of functional cognition and occupational performance, not identification of disease - OT's focus on individual's ability to apply client's metacognitive, cognitive and performance-based capacities/skills to achieve occupational performance goals - Performance-based testing of functional cognition = need a sample of performance of a novel task - Framework: the cognitive-functional evaluation (C-FE) - Importance of performance-based testing ○ Observation may not always be possible (ex. due to time constraints and environment constraints) ○ Cannot always assume you now the cog deficit when you see them - Assessment Considerations ○ Specific goals of testing ○ OT profile ○ Client factors - Common uses of performance-based tests of functional cog: ○ Identification of presence of impaired func cog ○ Questions about placement regarding safety and degree of support needed ○ Legal/compensation claims ○ Assessment of self-awareness during task performance ○ How test taker attempts to address task demands ○ Eval of response to intervention ○ Eval of use of strategies - Intrarater reliability vs. interrater reliability ○ Intrarater: observed agreement between the ratings of the same rater using the same measure with the same group of test takers ○ Interrater: observed agreement between different raters using the same measure with the same group of test takers Chapter 4: The Cognitive-Functional Evaluation Framework - Role of OT: understand clients' cognitive profile in relation to occupation - Functional cognition: how an individual uses and integrates their thinking/processing skills to accomplish everyday activities in clinica land community living settings ○ "cognition in everyday life" - Cognitive-functional evaluation framework ○ Eval domains: ("what" of eval) ▪ Cognitive occupational narrative □ Represents the way clients understand their cognitive profile and the way they interpret its impact on their occupational experiences □ Methods:  Semi-structured interviews  Standardized questionnaires targeting the implications of cognition on everyday life  Non standardized interviews  Generic occupational performance measures ▪ Cognitive factors □ To screen for cognitive deficits

□ Methods:  Short pen and paper tests  Mini-mental state exam  MOCA  Cambridge Neuropsychological Test Automated Battery □ May lack ecological validity ▪ Occupational performance □ Eval of functional cognition during performance of a task, activity, or occupation to understand how interactions of cog factors with occupational and contextual factors affect performance □ Methods:  Observation of strategies used, frequency of strategies used, flexibility of use, effectiveness of strategies chosen ◊ Naturalistic and standardized settings  Model of human occupation screening tool  Routine task inventory  Standardized, simulated real-life tasks ◊ Multiple errands test ◊ Kettle test ◊ Executive function performance test ▪ Self-awareness and beliefs (metacognitive and online awareness) □ Client's awareness of their cognitive profile and its impact on occupational performance □ Methods:  Semi structure interview  Comparison of self-reports with reports by an informant  Self-awareness of deficits interview  Awareness questionnaire ▪ Environmental factors □ Physical, social, cultural context □ Methods:  In home occupational performance evaluation (standardized)  Clinical judgement  Open-ended questions and standardized questionnaires ◊ Medical outcomes study social support survey ○ Eval methods: ("how" of eval) ▪ Interviews ▪ Self-reports and informant reports ▪ Performance-based assessments ○ Integrative approach - Clinical implications for intervention ○ Product = cognitive-functional profile Chapter 16: Cognitive Domain-Specific Testing to Support Interpretation of Performance Assessment - Cognitive domains ○ Attention ○ Memory ○ Executive functions ○ Language/comprehension ○ Visual-perceptual skills - Psychometric tests: ○ Used to assess specific cog domains ○ Tasks designed to evaluate specific cog functions ○ Administered and scored standardized way - Characteristics of Standardized Neuropsych Tests ○ Low levels of ecological validity (degree to which assessment results relate to, predict,

resemble everyday life behavior/context ○ Other factors should be considered when assessing occupational performance (environment, task demands) - Estimation of premorbid cog capacity and current intellectual functioning ○ Use measures that assess vocab and word pronunciation ○ General intelligence measured by WAIS - Neuropsych assessment of attention ○ Attention: behavioral and cognitive process of selectively concentrating on a discrete aspect of info while ignoring other perceivable info ○ Chapter addresses sustained, selective, divided ▪ Sustained: ex. preparing a meal with several dishes while maintaining focus on the duration of the task ▪ Selective: ability to attend to relevant info while ignoring irrelevant info/distractions ▪ Divided: 2 or more things at once (ex. walking while talking on phone) ▪ Alternating: shift among diff tasks ○ Assessing attention ▪ Commonly paper and pencil tests and computerized batteries ▪ Trail making test: info about attention, visual scanning, eye-hand coordination □ Assess selective and divided attention ▪ Continuous performance test: computerized □ Selective and sustained ▪ Test of everyday attention □ Attentional skills □ Assess selective, sustained, divided □ Good ecological validity ○ Assessment of memory and learning ▪ Memory: capacity to encode, store and retrieve info □ Short term and long term memory skills □ Short term: ability to hold but not manipulate small amount of info in an active, readily available state for a short period of time □ Working memory: manipulation of stored info □ Long term: hold info in storage indefinitely  Declarative (explicit) ◊ Episodic and semantic  Episodic: involve recall of temporal and spatial info  Semantic: knowledge of facts about world and of language – Temporal gradient loss to injury ◊ Conscious learning ◊ More susceptible to brain injury and disease  Procedural (implicit) ◊ Unconscious learning ◊ Remembering how to do tasks that are automatic and initiated without conscious awareness ◊ Habit rather than deliberate recall □ Tests of declarative memory  Word-list learning; Story recall used for episodic memory □ Standardized tests for verbal memory  Presentation of lists and asking test-taker to repeat □ Verbal learning and memory:  Hopkins verbal learning test  California verbal learning test  Both have: ◊ Good validity/reliability □ Test of verbal and nonverbal memory functions:  Wechsler Memory Scale □ Rivermead Behavioral Memory Test  Designed to predict everyday memory problems

 Good ecological validity - Assessment of Language Skills ○ Aphasia: ▪ Fluent: produce speech spontaneously, but limitations in auditory comprehension and understanding of language □ Wernicke's aphasia: fluent speech articulation, difficulty conveying meaning/understanding spoken or written language ▪ Nonfluent: relatively spared comprehension of spoken/written language but difficulty producing syntactically corrrect speech output □ Broca's aphasia: slow/awkward speech production, can follow commands but difficulties naming objects ▪ Frenchay aphasia Screening Test: for clients with both types of aphasia ○ Anomia: can't express words they want to say ▪ Indicates temporal lobe damage ▪ Boston Naming Test - Assessment of Visual-Processing Skills ○ Visual-processing: processing info associated with reception, organization and assimilation of vis info ○ Hemispatial or visuospatial neglect: condition that can occur after damage to either hemisphere of the brain ▪ Deficit of attention to and awareness of one side of field of vision ▪ Assessed with: line-bisection, letter/symbol cancellation, figure-clock drawings □ Behavioral Inattention Test Chapter 17: Intervention Selection: Learning and Concepts of Transfer - Vital to choose appropriate intervention approach for success in helping clients achieve functional goals - Learning Theory ○ Foundation for functional-cognitive intervention aprroaches ○ Functional-cognitive intervention approaches ▪ Direct intervention □ Client-focused training □ Task/habit training  Therapists typically work with same task using same techniques until client demonstrates consistent task mastery  Client not expected to transfer learning of task to different tasks/situations  Ex. teaching TBI survivor self-care routine  Foundation = behaviorism (stimuli and responses)  Used for clients with more profound cognitive loss ◊ Clients unable to rely on high level cog processes to develop goals and modify behavior ◊ Client unable to develop cog skills necessary to transfer learned behavior to other activities/environments □ Strategy training  OT assists client in learning strategies to overcome existing cog challenges  Important goal: client being able to transfer strategy to a new activity/situation  Strateyg = too/method used to help facilitate toward a goal  2 primary strategies: ◊ Metacognitive  Teaching global strategy that client can use in any context to overcome cog limitations ◊ Domain specific  Compensate for specific cog limitations that affect occupational performance  Foundation = cognitivism (division of learning theory) ◊ Focuses on client as an active learner who learns by recognizing how

new info may compare with previously learned info ◊ Insight theory ◊ Transfer of learning: ability to reproduce learned behavior in another context  6 criteria (p.3) ▪ Indirect intervention □ Environmental mods □ Task adaptaions □ Caregiver training/education □ Do not focus on direct client training  Not focused on helping client learn a task or strategy □ Commonly used for persons with dementia or profound cog loss □ Foundation = learning theory ▪ BOTH focused on performance level □ Has goal to improve client participation and quality of life - PEO considerations in intervention selection ○ Person factors: ▪ Narrative ▪ Level of awareness □ No awareness □ Partial awareness □ Full awareness □ 3 major types of awareness deficits  Intellectual ◊ Client able to verbally state that a cognitive deficit exists but does not realize how the cog deficit actally affects daily functoining ◊ Base of awareness pyramid ◊ Common with severe memory and learning impairment or severe receptive aphasia ◊ Client may not be able to retain info long enough for intellectual awareness to be established  Emergent ◊ Next level on pyramid ◊ Client able to recognize cog difficulty while it is actually hindering performance in functional activity  Anticipatory ◊ Most advanced level of awareness ◊ Client able to ...