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Cognitive rehabilitation
- 1. )Diker Dev Joshi MPT(Neuro) CIMT,MIAP, IASTM
- 2. Introduction Epidemiologyof cognitive Impairments Classification Aims Principle Uses Rehabilitation Strategies Review of Literature References
- 3. Cognition The mental facultyof knowing, which includes perceiving, recognizing, conceiving, judging, reasoning, and imagining.
- 4. Cognitive impairmentis 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-sectionalstudy 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 ofcognitive 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 ofthe main categories of functional cognitive disabilities include deficits or difficulties with: Executive Functions Memory Information processing Visual Processing Attention
- 9. Attention Memory Executive Function Selective attention,Sustained attention, Alternating attention, Divided attention Visual memory, Auditory memory, working memory, episodic memory, Semantic memory, Procedural memory Initiation, processing speed, problem solving, planning
- 10. Cognitive Rehabilitationis 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 rehabilitationoperates on the principle that enriched and enhanced learning environments can promote gains via neuronal plasticity
- 13. Neglect andapraxia Rehabilitation after stroke Attention training after TBI Memory rehabilitation with compensatory training in patients with mild amnesia
- 15. A personmay 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 canbe 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 arefour approaches to successful cognitive rehabilitation (Malia & Brannagan, 2000): Education Process Training Strategy development and implementation Functional Application
- 18. Education • Individualsshould 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 leastonce, 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: - Goodcomprehensive 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 developmentof 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 massedpractice 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 deelopmentand 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.
- 27. Awareness Awarenessshould be considered to be the key to successful rehabilitation.
- 28. Role ofhealthcare 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.
- 30. Effortful Processing Dual Cognitive Support Errorless Learning
- 31. Mnemonics Cueing Chunking Method of Loci Spaced Retrieval
- 33. Face-name Recall Number Recall
- 34. Story Recall List/Object Recall
- 35. Fluency Training Semantic Impairments
- 36.
- 37. A quasi-experimental studywas 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 literaturereview 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 problemswith 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 israrely 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 isnot 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).
- 43.
Editor's Notes
- #2 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)
- #3 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.
- #4 The American Heritage® Stedman's Medical Dictionary Copyright © 2002, 2001, 1995 by Houghton Mifflin Company. Published by Houghton Mifflin Company.
- #5 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)
- #6 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.
- #7 Reference: http://webaim.org/articles/cognitive/ -is most obvious in the case of traumatic brain injury and genetic disorders.
- #9 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
- #10 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
- #11 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
- #12 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
- #13 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.
- #16 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.
- #18 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.
- #19 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
- #20 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.
- #23 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:
- #24 8. Activation of neurological pathways through appropriately targeted repetitive cognitive exercises.
- #28 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.
- #29 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
- #30 Types Stimulation therapy Process Training Attention concentration training Strategy Training Nutrient and drug treatment Prosthetic orthotic devices Domain specific training Indirect training
- #38 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.
- #39 Cognitive Rehabilitation After Traumatic Brain Injury: A Reference for Occupational Therapists