2. Introduction
Epidemiology of cognitive Impairments
Classification
Aims
Principle
Uses
Rehabilitation Strategies
Review of Literature
References
3. Cognition
The mental faculty of knowing, which includes
perceiving, recognizing, conceiving, judging,
reasoning, and imagining.
4. Cognitive impairment is an inclusive term to describe any
characteristic that acts as a barrier to the cognition process.
The term may describe
Deficits in overall intelligence
Specific and restricted deficits in cognitive abilities
Neuropsychological deficits
5. A cross-sectional study was carried out in 2010 found out
prevalence of cognitive impairment as 3.5%.
The prevalence of cognitive impairment in the study
population among elderly adults aged over 60 years, of both
sexes was 8.8% .
If one were able to successfully treat mild cognitive
impairment such that the progression of these individuals to
AD could be delayed by one year, there would be significant
savings.
6. The concept of cognitive disabilities is
Extremely broad
Not always well-defined.
Have greater difficulty with one or more types of mental
tasks.
7. Clinical disability
Functional disability.
Clinical diagnoses of cognitive disabilities include
Traumatic brain injury (TBI), and even dementia,
Autism, Down Syndrome.
Less severe cognitive conditions include attention
deficit disorder (ADD), dyslexia (difficulty reading),
dyscalculia (difficulty with math), and learning
disabilities in general.
8. Some of the main categories of functional cognitive
disabilities include deficits or difficulties with:
Executive Functions
Memory
Information processing
Visual Processing
Attention
10. Cognitive Rehabilitation is a complex collection of
techniques designed to enhance perception, attention,
comprehension, learning, remembering, problem solving,
reasoning, and so forth in individuals who have
impairments in these areas.
11. 1. Reinforce, strengthen or re-establish previously
learned patterns of behavior.
2. Establish new patterns of cognitive activity through
internal compensatory cognitive mechanisms for
impaired neurological systems.
3. Establish new patterns of activity through external
compensatory mechanism such as external aids, or
environmental structuring and support.
4. Enable persons to adapt to their cognitive disability.
12. Cognitive rehabilitation operates on the principle that
enriched and enhanced learning environments can promote
gains via neuronal plasticity
13. Neglect and apraxia
Rehabilitation after stroke
Attention training after TBI
Memory rehabilitation with compensatory training in
patients with mild amnesia
14.
15. A person may wish to address more general memory
problems or person may specify area of concern s/he
would like to work on.
Hence the rehabilitation should depend on the focus of
the individual.
The person can be assisted in eliciting goals either
informally through the discussion or by using
structured goal setting approaches like Bangor goal
setting Interview or Canadian Occupational
Performance Measure
16. Sessions can be conducted in the person’s home or in
a comfortable setting suited to practicing the identified
goals.
Family members should be debriefed on each sessions
and provided with explanations of strategies so that
they can be practiced outside of intervention sessions.
17. There are four approaches to successful cognitive
rehabilitation (Malia & Brannagan, 2000):
Education
Process Training
Strategy development and implementation
Functional Application
18. Education
• Individuals should receive education appropriate to their
abilities and needs.
• In an inpatient center, done through a formal education
group.
• At sufficient intensity and
with adequate repetition to
ensure learning.
19. • At least once, so long as their language skills, attention
skills and awareness levels permit.
• Understanding their own brain problems and what
rehabilitation is all about.
• Cognitive and Emotional problems associated.
• Coping strategies.
20. Process Training
To stimulate poorly functioning neurological pathways
in the brain in order to maximize their efficiency and
effectiveness.
This will sometimes mean using new undamaged
pathways (redundant representations) and, sometimes,
old partially damaged pathways.
Process training therefore aims to overcome the
damage.
21. Components:
- Good comprehensive assessment
- Analysis of the results according to a practical cognitive
model
The analysis should always ask, “Why is that problem
occurring?” until an impaired component skill or cluster of
skills is revealed.
To develop and improve the impaired skills.
Generation of a hypothesis, which is then tested with
appropriate training materials. Formal reassessment to
determine the accuracy of the hypothesis.
22. • The development of awareness through the exercises.
• The structured programmed approach to the materials.
• Daily concrete feedback and concrete goals.
• The relatively short time frames to complete blocks of work.
• The development of patient self-confidence.
• The development of patients’ feelings of being in control.
23. The massed practice available via homework exercises.
improves performance.
enables them to accept constructive feedback more
readily.
The activities are easily quantifiable and scoreable.
Results can be easily graphed to demonstrate
improvement and this, in turn, leads to improved
motivation and self-esteem.
24. Strategy deelopment and implementation
External strategies consist of those things that are
external to the person, such as alarms, notebooks, notes,
and calendars.
Internal strategies are those mnemonics that cannot be
observed by anyone else, such as visualizations and word
associations (Malia & Brannagan, 1997)
25. Functional Activities Training
Should focus on improving real life functioning.
Functional activities should be used in two distinct ways:
-As a vehicle within which to treat the cognitive skill
deficits
-To train the person to complete the particular functional
task
Goals should be written for each of these approaches.
28. Role of healthcare professional
to help the individual understand how to use these strategies
individual is responsible for practice and implementation
between sessions.
The requirement of commitment and effort on the part of the
patient need to be explained.
Typically, therapist identifies target areas or goals to work
on, practise a number of different strategies, and then decide
which strategies the person prefers and can use most
efficiently.
37. A quasi-experimental study was done among of 40 patients
with mild cognitive impairment in 2012 to evaluate the
effectiveness of cognitive rehabilitation on improving
selective attention in patients with mild cognitive showed an
increase in selective attention scores in the experimental
group compared with the control group leading to the
conclusion that cognitive rehabilitation leads to improvement
in the performance of selective attention.
38. A literature review conducted in 2015 to identify and
summarize interdisciplinary evidence-based practice
targeting cognitive rehabilitation for civilian adults
with TBI highlighted that more empirical,
interdisciplinary research is needed in the field of
cognitive rehabilitation.
39. There are problems with studying efficacy that
include the following:
Partitioning out the effects of spontaneous recovery from the
treatment effect.
The effects of concurrent treatments, i.e., language therapy
and physiotherapy, which may assist with emotional
adjustment, which then can interact with the cognitive gains.
The standardized treatment usually required for
experimental research reduces the opportunity to tailor the
treatment to the needs of the individual.
40. CRT is rarely offered in isolation.
CRT cannot be easily studied in a ‘blind’ or ‘double blind’
experimental design.
It is difficult to maintain experimental control for the length of
time one would expect to be required for meaningful change
of brain function.
41. CRT is not just about restoration; rehabilitation includes
compensation and environmental re-design—which are
patently helpful, e.g., giving a patient a talking watch
(modified to prevent resetting), which keeps a cortically
blind stroke survivor from waking his wife all night to find
out if it is time to get up.
42. Kelly ME, Sullivan MO. Strategies and Techniques for
Cognitive Rehabilitation. TASI. 2012.
Sengupta P, Benjamin AI, Singh Y, Grover A. Prevalence
and correlates of cognitive impairment in a north Indian
elderly population.
Cognitive Rehabilitation : Information for Patients and
Families. Stroke Engine
Tomás P, Fuentes I, Roder V, Ruiz JC. Cognitive
rehabilitation programs in schizophrenia: current status
and perspectives. International Journal of Psychology
and Psychological Therapy. 2010;10(2).
Petersen RC, Stevens JC, Ganguli M, Tangalos EG.
Practice parameter: Early detection of dementia: Mild
cognitive impairment (an evidence-based review).
Aphasia and neglect
In clinical practice, two of the most prominent focal cognitive deficits after stroke are aphasia and hemispatial neglect. The relationship between type of aphasia or neglect and location of infarction is well described. The limitation to spoken output that is characteristic of Broca’s aphasia is associated with damage in the left posterior, inferior frontal gyrus, in addition to other regions supplied by the upper division of the left middle cerebral artery (30). Wernicke’s aphasia, on the other hand, is characterized by fluent but relatively meaningless speech alongside poor language comprehension and is linked to damage in the left posterior, superior temporal gyrus (30). In hemispatial neglect, the visuospatial component is linked to the right inferior parietal lobule, the visuomotor component to the right dorsolateral prefrontal cortex, and the object-centered component to the deep
temporal lobe regions (31)
MMSE: The maximum score on this examination is 30 and a score below 25 suggests the possible demolition of cognition and a score below 20 indicates a definite demolition.
Cognitive rehabilitation is seen as a combination of compensation skills, retraining of previously learned skills, and the teaching of new skills that patients can use to adapt to the effects of their injury.
Coren, Stanley; Lawrence M. Ward; James T. Enns (1999). Sensation and Perception. Harcourt Brace. p. 9.
overall intelligence (as with intellectual disabilities)
Specific and restricted deficits in cognitive abilities (such as in learning disorders like dyslexia)
Neuropsychological deficits (such as in attention, working memory or executive function)
Acutely, TBI severity is assessed using the Glasgow Coma Scale (GCS; Teasdale & Jennett, 1974). GCS scores can be grouped according to TBI severity: mild (13+), moderate (8-12), or severe (<8)
The prevalence of cognitive impairment in the study population was 8.8%.
As of 1990, there were 4 million individuals in the United States with AD. This number is expected to increase to 14 million by 2050.
In 1998, the annual cost for the care of patients with AD in the United States was approximately $40,000 per patient.
Reference: http://webaim.org/articles/cognitive/
-is most obvious in the case of traumatic brain injury and genetic disorders.
Functional disabilities ignore the medical or behavioral causes of the disability and instead focus on the resulting abilities and challenges.
Communication difficulty reflects a range of potential cognitive changes, such as:
Attention and concentration difficulties
Memory problems
Literal interpretation
Reduced reasoning and problem-solving skills
Cognitive fatigue
Slowed speed of information processing
Impaired social communication skills
Reduced insight
Some of the main categories of functional cognitive disabilities include deficits or difficulties with:
Memory
Problem-solving
Attention
Reading,linguistic, and verbal comprehension
Math comprehension
Visual comprehension
Mild cognitive impairment criteria
Memory complaint, preferably corroborated by an informant
Objective memory impairment
Normal general cognitive function
Intact activities of daily living
Not demented
cognitive functions (memory, attention, and concentration)
daily living skills (i.e. using the telephone, managing medication, and handling money)
Cognitive rehabilitation is a goal-oriented program that aims to improve cognitive functions and daily living skills that is affected by any neural pathology.
Cognitive rehabilitation is a complex collection of techniques designed to enhance perception, attention, comprehension, learning, remembering, problem solving, reasoning, and so forth (Callahan, 2001; Cavanaugh, Kramer, Sinnott, Camp, & Markley, 1985; Evans & Over, 1996; Patten, 1990) in individuals who have impairments in these area
Cognitive rehabilitation, by nature, results in gains, losses, and plateaus. It is estimated that at least 300 hr of appropriate therapy are needed to promote optimal outcomes
In general, greater cognitive improvement occurs within the first 5 months of recovery when compared with the subsequent 7 months (Christensen et al., 2008)
This recommendation modifies current practice, where therapists use remediation approaches in the acute stages (<5 months) of rehabilitation and shift to compensatory strategies in the later stages. It is clear that extending the use of remediation strategies may be advantageous in some recovery domains. The following sections describe existing and emerging interventions to improve cognitive outcomes.
When setting goals, it is helpful to ensure that those selected for intervention are Specific, Measurable, Achievable, Realistic, and Time-limited.
Examples of goals might include: remembering the names of familiar individuals, remembering important numbers (PIN codes, phone numbers), developing and using a strategy to help remember important events or keep track of important personal effects, remembering how to carry out multicomponent
daily tasks, learning to use a memory aid such as a calendar or memory board, or learning and retaining personally relevant information.
The four approaches to CRT should be used concurrently with all patients but the relative balance between them will alter according to the presenting neurological condition (e.g., tumors may not benefit from process training), stage post-injury, awareness level of the patient, and time constraints of the staff.
The education group should take place regularly. In institutions it is often helpful to run this for one hour each day until the content has been covered
This aspect of education is considered to be an ongoing process which aims to help the patient to develop appropriate self-awareness, heighten self-esteem, develop confidence, develop feelings of personal control, and develop a trusting, working relationship with the therapist.
A range of appropriate materials should be available for the person, including books, CD-ROMs, Internet access, and relevant articles, along with the education group notes.
The reasons for progress on these process-training exercises are complex, but the relationship between the following factors is thought to play a major role in the success:
8. Activation of neurological pathways through appropriately targeted repetitive cognitive exercises.
A great deal of the rehabilitation work should aim at developing appropriate awareness of cognitive skills and how these are important in the direction the person with cognitive impairment will take in the future.
Intellectual awareness has been achieved when the person is able to demonstrate that he or she knows what his or her problems are and what they have in common
Emergent awareness has been achieved when the person is able to demonstrate that he or she knows a problem is happening as it is occurring without prompting, i.e., on line awareness of a problem.
Anticipatory awareness has been achieved when the person is able to predict or anticipate the situations in which his or her problems are likely to occur.
There are a number of different rehabilitative strategies for assisting with difficulties in memory and everyday functioning.
There is a lot of individual variability in how people respond to different strategies.
Thus, it is preferable to try several strategies in an attempt to determine what works best for each individual.
Cognitive rehabilitation manual.pdf
Types
Stimulation therapy
Process Training
Attention concentration training
Strategy Training
Nutrient and drug treatment
Prosthetic orthotic devices
Domain specific training
Indirect training
Effectiveness of Cognitive Rehabilitation on Improving the Selective Attention in Patients with Mild Cognitive Impairment
The group was comprised of 40 patients with mild cognitive impairment who were evaluated with early detection and assessment by a medical psychologist (MMSE score lower than 25 and Wechsler memory test) and were selected by available sampling. The experi-mental group was given 12 sessions (two hours each section) of cognitive rehabilitation with Neurocognitive Joyful Attentive Training Intervention (NEJATI). The control group, as expected with this group, did not receive any trial pe riod. The selective attention of both groups was evaluated, before and after receiving intervention, by a Strop computer programme. Data were analysed using the covariance statistical test, MANCOVA. : The results showed an increase in selective attention scores in the experimental group compared with the control group. Therefore, we can con- clude that cognitive rehabilitation leads to improvement in the performance of selective attention (F = 4/97; sig < 0/05). Conclusion: Cognitive rehabilitation can impact on improving selective focus in people with mild cognitive impairment.
Cognitive Rehabilitation After
Traumatic Brain Injury: A Reference for
Occupational Therapists
