Transcript Neuropsychological Evaluation

Cognitive Rehabilitation
Mary Pepping, Ph.D., ABPP-CN
Professor
Director, Neuropsychology Service and
Outpatient Neuro-Rehabilitation Program
Department of Rehabilitation Medicine
University of Washington Medical Center
Seattle, WA
Cognitive Rehabilitation
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What is it?
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Evidence-based, systematic treatments
designed to improve thinking performance
One important component of effective
neuro-rehabilitation
Who provides it?
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Neuropsychologists, speech pathologists,
occupational therapists
Evidence for effectiveness of
Cognitive Rehabilitation
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There is a literature on this topic
(handout list available at front)
Can we teach people how to think more
effectively?
How do you train people to apply that
good thinking more effectively in life?
What are the barriers to effective
function?
Barriers to treatment benefit
for improved cognitive function
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Very severe cognitive or behavioral
impairments that prevent participation
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Inability to pay attention
No demonstrated evidence of ability to
learn new information or prodecures
Active drug or alcohol abuse
Aggressive behaviors
Suicidal behaviors
Psychotic hallucinations, delusions
Cognitive Rehabilitation:
How does it work?
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Determine “upstream” or underlying sources
of cognitive deficits
Teach the patient techniques to manage or
improve those deficits
Drill the techniques until they become overlearned, automatic procedures
Practice the techniques in a range of settings:
clinic, home, community, workplace, school
Role of Neuropsychological
Evaluation in Cog Rehab
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Comprehensive evaluation to identify
overall level of skills and deficits and
specific features of ability and difficulty
What are primary obstacles to improved
thinking and function?
How does the person learn best?
What kinds of techniques are they able
to manage and accept?
Common Neurocognitive
Problems in TBI/ABI
Complex Attention
Screening out distractions
Maintaining one’s focus
Multi-tasking
Complex Memory
Acquisition
Retrieval
Executive Functions
Main Idea Development, Inferences, Planning,
Organization, Higher level problem solving
Speed of information processing
Complex Attention –
Screening out Distractions
Basic techniques for work or home tasks:
Reduce environmental noise and clutter
TV, radio, iPod off
Phones and electronic devices muted
One project at a time on desk or desktop
Create blocks of “no interruptions” time
Use re-direction for inner distractions, e.g.
“I’m doing (THIS TASK ONLY) now”
Quickly jot down distracting ideas then ignore
Complex Attention:
Multi-Tasking at Work
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Reduce incoming information load
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Smaller group meetings
Focused agenda
Note-taking help
One person talks at a time
Send out summary for feedback
Use email when possible for incoming
and outgoing ideas and plans
Complex Attention:
Multi-tasking at home
Practice with two tasks:
Laundry and cooking
Bill paying and answering phone
 Use electronic supports to cue you
Set timers/alarms to check tasks
Remind self of two tasks – post notes
Note on door to garage to check tasks
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Memory Acquisition
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Divide and Conquer:
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Organize new information into fewer and
more meaningful sub-groups
Learn how to take good notes
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Main ideas and key details
Record and review soon after
Correct notes, write summary
Memorize the main ideas and key words
Memory Acquisition
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In conversation
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Ask speaker to talk more slowly if needed
Briefly summarize points of conversation
Clarify confusion by asking questions
Jot down notes as soon as possible
Call to double-check you have it right
Memory Retrieval
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Review your notes prior to your next
meeting or conversation and refer to
them as needed during meeting
Practice recalling main points of what
you hear or read before meeting
Use helpful mnemonic devices, e.g., link
name of new person to something that
will help cue you to their name
Electronic Devices
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Smart phones – iPhone, Droids,
Blackberrys, Palm
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Schedules of appointments
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Who, what, when, where, why
Names, addresses and phone numbers
To do lists, shopping lists
Special alarm tones linked to specific
tasks, appts, reminders, people, events
Electronic Devices continued
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Sync with your computer – Google
calendar, Palm calendar, contacts
Get your kids or grandkids to help you!
Arrange for computer support
Use dictation software
Get assistive technology consultation at
your medical center
Executive Function:
Main Idea Development
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Start with professional help: SP, NP, OT
How to determine main ideas
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“What is the article or program about?”
Summarize main points in 2-3 sentences
Using “telegram” technique to winnow
down to one or two essential ideas, e.g.,
can you create a 7-10 word telegram that
conveys basic topic?
Executive Function:
Main Idea Development con’t
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Reading comprehension
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Usually one main idea per paragraph
Use title, first and last sentence as cues
Look for people, events, actions, ideas
Jot down key ideas, characters as you read
Write a summary note
Explain what you have read to someone else
Ask yourself questions about the topic, look for
answers in the article
Start with something brief and manageable
Executive Function:
Organization, Problem-Solving
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Get professional help to set up
strategies and systems – SP, NP, OT
Practice systems on real projects
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ABODES systems
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Assess situation, Break into steps, Order the
steps chronologically, Determine what supplies
or personnel are needed, Estimate time to
complete each step, Survey work as it
proceeds to make needed corrections.
Executive Function:
Organization continued
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Consider hiring a home organizer
Divide and conquer – do not tackle all
your projects or problems at once
Schedule specific times to tackle the
task, pace yourself, reward yourself
Get a well-organized friend to help you
sort through papers or belongings, e.g.,
the “Yes, No, Maybe” system
Higher Level Problem Solving
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Use of a grid/table for figuring out best
options: e.g., travel plans
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What are all of the variables to consider?
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What are your preferences and limits:
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Where to go (family visit, foreign travel, U.S?), with
whom, budget, time for trip, airline miles, hotel
preferences/credits, preferred activities, travel ins.,
energy levels, medical needs, cancellation policies
Airlines/Airplanes, Hotel/Rental, Ground
transport, Meals, Entertainment, Clothing
Meta-Cognitive Skills
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“The Big Picture”
What is the best approach for a
particular kind of problem or task?
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Where do main points work best?
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Brief conversations
Email communication at work
Basic To-Do Lists
Meta-Cognitive Skills (con’t)
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Where do you need added details
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Complex projects and plans
Multi-step errand lists
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Priority items (Bank, Post office, Dry cleaners, Store)
Geographic layout of locations
What needs to be done at each place?
 Bank: Deposits, cash check
 Post office: Pick up package, buy postage
 Drop off three items, schedule P/U date in book!
 Buy groceries for party (bring list!)
Other general supports for
improved cognitive function
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Appropriate use of medications
Pacing of activities
Exercise
Fatigue Management
Treatment of depression, anxiety
Make sure vision and hearing are as
good as possible
Cognitive Rehabilitation:
General supports continued
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Create and maintain efficient weekly
schedules for routine tasks so they become
automatic habits
Develop and use only one memory system
for calendar, schedule, to do list
Pick one specific practical problem to change,
work on that, make it better, then tackle the
next one
Practice thought-stopping to redirect your
attention and stick with your task or plan
Cognitive Rehabilitation
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A critical component of neuro-rehabilitation
Targets each patient’s key cognitive hurdles
Develops hierarchical plan of intervention,
e.g., upstream or underlying issues first
Teaches patient awareness of + and Trains specific approaches to problems
Extends strategies to real life settings
Teaches metacognitive skills (how to
observe, understand and change thinking)