TBI Notes for test II Athena Hagerty 3/25/2017 11:40 AM © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

FAVR- Functional Assessment of Verbal Reasoning FAVR- Functional Assessment of Verbal Reasoning. Read a newspaper and ask them questions about what they read. Scheduling section. Evaluate Environment- ask them what they like to do in their leisure time, ask them what they do for work. Activites that are related to their home environment. Organize and prioritize tasks to get done. Things we can do at Ranchos level 3&4- we can do the GOAT. And we can start looking at different processes informally. Ranchos 6&7- when we should do intense standardized assessment. Nueropsych will do their testing.

Stuss-Benson Self Awareness: (need this before you can do therapy neuro psych view) you really don’t need this to do therapy…. Anticipation, goal selection, pre-planning, self-monitoring Drive and sequencing Attn, memory, cognition, Language, Emotion, Somatosensory, Information, Alertness.

Beukelman& Yorkston (motor speech) Cognitive Impairments: Physical sequelae (residual symptoms) Behavioral sequelae Premorbid (before the injury) Interpersonal & Personality Style Family changes Vocational changes Sequelae- is a pathological condition resulting from a disease, injury, or other trauma.

Continuous circular relationship problems- if you have one problem you have another. Attention deficits Memory problems Decreased coping skills Inability to control emotional

Central Pool: all cognitive processes and language abilities Central Pool: all cognitive processes and language abilities. If given a task or activity that pulls too many resources from the central pool, you’re going to fail. Simplify them so we don’t overload processes. Task or Activity Cognitive or language requirements Overload of processes Simplify the task, environment or directions.

Adamovich Hierarchy of Cognition: Attention- (Lowest form of cognition) Arousal/Alertness- most basic form of attention. Arousing patient. Sustained Attention- being able to focus on one task. However not eye contact. Completing a task. Selective Attention- competing activities and determining what’s most important. Ex- having a meeting and hearing siren and their attention goes to siren.

Divided Attention-multitasking. Being able to complete multiple task Divided Attention-multitasking. Being able to complete multiple task. Ex- if you are listening to radio and writing something, talking on the phone and cooking. Speed of Processing- speed of processing slows down. Do you want them to speed up and be less accurate? Or do you want them to go slowly and accurate.

Memory and New Learning- next level Working memory- short term memory. Short store until you need to recall it. Procedural memory- motor function type of memory, riding a bike. Episodic Memory- Emotionally related memories. Semantic memory- knowledge based memory (world knowledge). Stuff we learn in school. It’s the first to go if you have neurological disfunction. LT semantic memory good, ST bad. 1+1=2

Prospective memory- Ability to tell what is going to happen in the future. Look at calendar, friend for lunch etc. this also goes easily. Long-term memory- all of these memories can get stored into LT memory. Sensory info, encoding, storage, retrieval and decoding. In TBI- breakdown can occur anywhere in the system.

Organization, Categorization, Sequencing Higher Level Processes Executive Function Metacognition- how you think about your thinking (cognition). Reasoning Judgement, Problem Solving (very high functioning) Convergent- when you have multiple ideas and you have to solve the problem. Divergent- coming up with multiple solutions. The police are at my house.. what can I do?

TREATMENT: Cicerone et al. Attention: Attention Processing training was a very good approach. A bunch of tapes, pay them and remember a target and use a clicker when they heard the target. Listen for the number four. Considers a hierarchy, look for one target two target. Has a problem with generalization. No very practical. Patient might be good at tapes inside, outside cant handle it. Don’t necessarily write goals for attention.

Attn continued… MEASURE COMPLETION OF TASKS. Complete task and make sure it’s accurate. Can manipulate environment for hierarchy. (not stated explicitly in goals, look at other cognitive areas- have to attend in order to complete the tasks.

Cognitive Communication- Found that group communication was important. Good for language and pragmatic skills. Aphasia can tx the communication. Don’t forget the cognition. Cog comm. therapy is affective.

Hartley text- talk with somebody with TBI, based on THEIR comm Hartley text- talk with somebody with TBI, based on THEIR comm., we can determine what kind of cognitive def are affected. Memory problems= Might have repetitions, topic maintence, paraphasias, turn-taking, use of vague terms, circumlocution. If we have problems with organization= confused, disjointed, no opening, no ending. LOOK AT HARTLEY BOOK. If we fix cognition, may help language. May have to work on language directly. Take notes, put hands on shoulder.

Memory- Use of strategies was effective, can be external and internal strategies. For severe and moderate external devices are best. Internal for mildly impaired TBI- External strategies and devices: Drawing a picture (birthday cake on calendar) Lists/daily planners/post-it notes-if it works for individual (groceries) Calendars

External Strategies Continued.. Watches- with alarms for medication. Make medication procedural memory. Cell phones- they can do everything Memory books- can be very low functioning. Notebook that has everything about you in it. Address, my Dr’s name is. Short to do list. Shrine- basket or box in the house that has keys or wallet in it. Another person- spouse or family member. If person’s gone it doesn’t work.

Internal Strategies: Association- specific in area of kitchen of canned goods, can associate with words, green beans are vegetable Chunking- digit span, phone numbers. Can do with words. Repetition- if you’re good at it. Mnemonics- have to be high functioning. First letter of every word. Cranial nerves. Visualization- I can see the green beans in the store. Rhyming /melody. “green beans” singing green beans”. 

Executive process/problem solving/awareness: Formal Problem Solving strategies are effective. ID the problems- what are the problems? Prioritze- order of importance Re-evaluate the problems Formulate solutions Analyze solutions Re-assess solutions

What are some problems you might face getting dressed in the morning?   Executive Function Discussing the problem Self regulation= self instruction & self monitoring (internalize) – would be tough with severe

Caregiver training/expectations. Self Awareness- all on handout Educational Experiential Procedural Training Caregiver training/expectations.

Cognitive Rehab is better than: Pseudo tx (leisure/social stimulation games etc) Psychosocial tx (psychotherapy/emotional support) we can counsel treatment  Use of computer programs and workbooks Computer based programs May be considered (clinician guided tx) NOT recommended (sole reliance on program) Workbooks are good for HW not for you to do photocopies.

STM- retention of info for a brief time. Giovanello Article:  STM- retention of info for a brief time. LTM- something that is stored in our brain. Declarative- acquisition and retention of knowledge Semantic/episodic Nondeclarative-experienced induced changes in performance. Performance/implicit. WM- Baddeley: holding things for a few seconds and giving info back Central executive: central pool… ? Selection and execution of strategies for attention Coordinating and manipulating info from sources

Visuospatial sketchpad-nonverbal spatial representation Visual object code=object wm Phonological loop=verbal; acoustic store. Episodic- emotional component Semantic- general factual, world knowledge. Implicit-Does not require awareness of learning episode Procedural patient thinks they can drive, but can figure out where to go, what to do if there is an accident.

Cues: (extra help) assist if client cant get target Stimulus- what you are using to get a response. Cues: (extra help) assist if client cant get target Verbal Tactile Visual: 3 types Written Gestures Pointing Maximum, moderate and minimal cues.- hard to measure.

Pragmatic Aspects of Language Prutting & Kirchner: Pragmatic Aspects of Language 1. verbal aspects 2. paralinguistic aspects 3. Nonverbal aspects

1)have a sense of being normal 2)inconsistent patterns of performance CHILDREN WITH TBI: 1)have a sense of being normal 2)inconsistent patterns of performance 3) vocabulary- have trouble learning new vocab. Multiple choice will be easier for them. Give the word and talk about it. 4) problems generalizing informating and integrating concepts. Just because they learn something in one class, doesn’t mean they get it in another class

CHILDREN WITH TBI: 5) inappropriate behaviors- mainstream them with normal kids otherwise they will mimmick the bad kids. 6) teach compensatory and adaptive strategies. Think cognitive verses developmental. Don’t just focus on colors. Focus on organization. 7) Severe TBI kids can be mainstreamed. Get them normed with kids their own age. 8) spelling- regurgitation of knowledge. Tough for kids with TBI. Norm for TBI. Multiple choice

PRAGMATICS- Cognitive communications- In Hartley book- checkoff list for pragmatics. Do they have the skill or not.

Pragmatic Skills- Cicerone: et al 2005 Pragmatic conversational interventions Recommended for persons with TBI Goals- increase or decrease a behavior =increase good, decrease bad (must show example for good behavior) Not enough to know appropriate/inappropriate (we can videotape them if they are laughing inappropriately) Can substitute it with smiling. If person has good problem solving abilities

Pragmatics continued… Patient will have no more than 5 times of inappropriate laughter.. (use with patient who has higher functioning abilities…)

PTSD- post traumatic stress disorder DSM, 4th edition. 4R Characteristics: Exposure/witnessing intense events- so intense they can’t sleep. Symptoms of re-experiencing the trauma- driving down road and reliving experience. Backfire from car, thinking it’s a gun. Avoidance/inability to recall the trauma.- whole unit passes away

PTSD CONTINUED…. Arousal responses: Hypervigilance Startled response High forms of anxiety

SLP- things we need to think about. PTSD CONTINUED…. SLP- things we need to think about. Determine if service member is mild TBI and PTSD, or PTSD only which could appear like cognitive deficits, or mild TBI only, or neither. Determine if they are malingering through testing and observation