1. Cognitive Rehabilitation: A Neuropsychological Perspective October 27 th, 2016 Amy Pacos Martinez, Psy.D.

2. Lecture Objectives: Define Cognitive Rehabilitation (CR) Review the history and theory behind CR Discuss the goal(s) and components of CR Identify the role of neuropsychologists within CR Learn about common presentations and reported problems Briefly outline the University of Rochester Medical Center Integrated Cognitive Rehabilitation Program (ICRP) Review a case study

3. Class Poll What is Cognitive Rehabilitation? Does anyone want to take a guess? What is your experience with Cognitive Rehabilitation? Have you personally received Cognitive Rehabilitation treatment? Do you know anyone who has?

4. What is Cognitive Rehabilitation? The use of a set of interventions which aim to restore, or compensate for, cognitive deficits. Skills may be lost or altered due to brain damage resulting form disease or injury. A two-way interactive process whereby people with neurological impairments work with professional staff, families, and community members to alleviate the impact of cognitive deficits. Areas of cognitive deficits may include: Attention Memory Mental flexibility Learning Language Perception Sensory motor Other executive functions (e.g., planning, organization) *Cognitive deficits interfere with everyday activities*

5. Continuum of Cognitive Change Cognitive functioning difficulties which affect behaviour and ability to complete everyday tasks Effective cognitive functioning to enable us to complete everyday tasks

6. History of Cognitive Rehabilitation Post-World War I Introduction of functional skill building for injured veterans “Schools for soldiers” – German rehabilitation hospitals Involved psychological testing and measurement of concrete skills Did not emphasize attention, concentration, and memory training like we do today Post-World War II Continued use of rehabilitation strategies in multiple countries Treatment of soldiers with brain injuries

7. History of Cognitive Rehabilitation: Russia Alexander Luria: Rehabilitated soldiers on a neurosurgical unit in the Ural Mountains post-WWII Assessed neurocognitive functioning, the use of various adaptive mechanisms, and identified a patient’s spared skills that could be used to avert deficits Investigated drug treatments for improved memory Developed the two-pronged strategy of cognitive rehabilitation Goal: To strengthen spared skills and teach compensatory skills Still used today

8. Key Categories (Prongs) of Cognitive Rehabilitation Cognitive Rehabilitation interventions often fall into two categories:  Retraining cognitive processes that have been impaired by injury/illness Damaged circuits may be able to be retrained if they have been partially or substantially spared after injury (also called “process” training) Functional improvements are made over many months, or even years  Development of new compensatory skills to enhance daily performance Retained skills and functional reorganization are used to learn new strategies Also called “strategy” training, and may involve the use of external tools (e.g., diaries, electronics, adaptive equipment)

9. History of Cognitive Rehabilitation: Great Britain Brain injury centers in Oxford and Edinburgh (post WW II) Oliver Zangwill: (prominent British neuropsychologist) Substitution method – replacing damaged skills with new skills Like the compensatory method Direct retraining method – mental exercises to strengthen the mind Zangwill argued that this method had less real world applicability First systematic evaluations of aphasia treatment

10. History of Cognitive Rehabilitation: United States CR occurred under the name of “nervous and mental re-education” Developed from psychiatric influences that were growing at the time Post-WWII Brain injury centers Psychologists, and speech-language pathologists spearheaded treatment at this time Shepherd Franz: Notable neuropsychologist Wanted to open a research institute in the U.S. to study aphasia and neuroscience

11. The Influence of Cognitive Psychology During the 1970’s and 1980’s, advances in cognitive psychology was greatly impacted by the study of neurocognition and the treatment of cognitive impairments New rehabilitation techniques began to be studied to address cognitive impairment New publications (e.g., Journal of Head Trauma Rehabilitation and Neurorehabilitation) documented advances in the field and fueled continued research

12. Theory of Cognitive Rehabilitation CR treatment operates under the assumption that stimulation of the cognitive system will lead to an improvement in cognitive function Various mental and physical exercises, and computer training, aim to enhance an individual’s cognitive ability, which transfers into activities of daily living Specific stimulation training aims to focus on the processes in specific areas of cognition

13. Neuroplasticity Enables Recovery Changing of neurons, the organization of their networks and their function via new experience The brain's ability to reorganize itself by forming new neural connections throughout life. Neuroplasticity allows the neurons in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment. Functional rehabilitation programs support neuroplasticity with goal-directed experiential therapeutic programs in the context of rehabilitation approaches to the functional consequences of the injury. Dr. Simone Carton 15.7.2015

14. 1.Use it or lose it 2.Use it and improve it 3.Specificity 4.Repetition matters 5.Intensity matters 6.Time matters 7.Salience matters 8.Age matters 9.Transference 10. Interference Dr. Simone Carton 15.7.2015 Neural plasticity (Kleim & Jones, 2008)

15. Systems of Cognitive Rehab Stimulation Therapy Process Training Attention-Concentration Training Strategy Training Prosthetic-Orthotic Devices Domain-Specific Training Indirect Training

16. Common Presenting Medical Conditions Head injury Traumatic Brain Injury Anoxic brain injury Absence of oxygen = cell death Stroke Epilepsy Paralysis, or other sensory loss Spinal cord injury Other bodily injury E.g., falls, motor vehicle accident

17. Key Brain Sites and Implications for Injury

18. Neuropsychological difficulties occur within a context Bronfenbrenner (1979)

19. Commonly Reported Problems Decrease in intellectual functioning Slowed processing speed Memory loss/Forgetfulness Difficulty with language (e.g., word retrieval, comprehension) Speech Emotional changes (e.g., frustration, depression, impulsivity) Changes in insight Attention and Concentration changes (e.g., Easily distracted) Difficulty with planning and/or multitasking

20. Key Components of Cognitive Rehabilitation Thorough assessment Patient education about cognitive strengths and weaknesses Individual and group settings Clear goal setting and treatment planning Person-centered approach Intervention involving the practice of functional tasks, and the use of internal and external compensatory strategies Continued evaluation of mental health As cognition improves, some patients will become more aware of their deficits, and the major changes in their lives Increased anxiety and depression may follow

21. A Holistic Approach to Rehabilitation Involved Disciplines:What is the patient’s story? PsychologyWho was the patient prior to their Neuropsychology injury/illness? PsychiatryWhat was their personality like? Medical StaffWhat were their life roles? NeurologyWhat were their hobbies? Occupational therapyAre they spiritual? Speech therapyWhat was their social life like? Physical therapy **It is important to know and treat the whole person**

22. Collaborative Care Collaboration between disciplines is essential, in order to: Meet the needs of an aging population who have more complex needs Meet the complexity of any patient’s needs in a comprehensive way Promote continuity of care Match a diverse set of interventions to functional needs Communicate about goals and treatment planning Reduce costs Improve patient outcomes

23. The Role of a Neuropsychologist Assessment of Impairments via: Record review Clinical Interview Self-report Collateral information Standardized measures Education Inform the patient about their cognitive weaknesses As well as their strengths Educate family members

24. The Role of Neuropsychologists Cont. Treatment Psychoeducation Skills training Psychotherapy and other counseling (e.g., emotional regulation, Cognitive- Behavioral Therapy (CBT), communication strategies, solution-focused problem solving, relaxation training, career counseling) Liason Families Employers Other medical providers

25. Assessment Questionnaire Examples How much of a problem do I have in preparing my own meals? How much of a problem do I have in washing dishes? How much of a problem do I have in controlling crying? How much of a problem do I have in starting a conversation in a group? How much of a problem do I have in scheduling daily activities? How much of a problem do I have in remembering names of people I see often? How much of a problem do I have in staying involved in activities even when bored or tired? How much of a problem do I have in showing affection to people? How much of a problem do I have in recognizing when something I say or do has upset someone else? Scale 1Can’t do 2Very difficult to do 3Can do with some difficulty 4Fairly easy to do 5Can do with ease

26. In the majority of domains, current research indicates that some form of strategy (compensation) based intervention that is set in the context of (or clearly transferable to) functional settings will be the most effective approach. (Evans, 2012) Sufficient information to support evidence-based clinical protocols and to design and implement a comprehensive program of empirically-supported treatments for cognitive disability after TBI and stroke (Cicerone et. al, 2011) Cicerone et al and Tiersky et al (2005) evidence that holistic approaches and those integrating both emotional adjustment and cognitive strategies and skills have more positive effects on outcome. So……what is the evidence for neuropsychological rehabilitation?

27. URMC Integrated Cognitive Rehabilitation Program (ICRP) Patient/family-centered rehabilitation program focusing on strategies for minimally impaired, relatively high functioning individuals Collaborative, clinical approach with varying expertise of multiple disciplines Neuropsychology, Occupational Therapy, Speech Pathology Sharing of leadership role, with strong and open communication Weekly team rounds Co-located assessment and evidence-based treatment Focus on both impairments and strengths Individualized treatment planning

28. ICRP Continued Global Interventions: Begin with rapport building/empathy Team provides education & helps develop awareness (patient and caregiver training) Treatment is a goal oriented process, with an “underwhelming” approach Homework is utilized Introduction of cognitive prosthetics to support compensatory techniques Technology versus traditional “paper and pencil” (based on the patient’s strengths / preferences) Integration of compensatory techniques and cognitive prosthetics to maximize level of independence for daily activities and life roles

29. Case Review – Mr. X 61 year old Caucasian male Admitted to the hospital with hematemesis and hypovolemic/hemorhhagic shock associated with variceal bleed in gastric fundus Required intubation Cognitive impairment likely from hypovolemic shock, classified as anoxic brain injury History: Completed Bachelor’s degree and the equivalent of an MBA Worked as a manager in finance Married and living with wife pre-hospitalization Has two adult children, and grandchildren

30. Case Review – Mr. X Continued Seen in acute hospital by OT, PT, and SLP and recommended for acute rehabilitation Upon admission to acute rehabilitation, Mr. X was noted to be: Min A for mobility and transfers Min A LE dressing, Mod A bathing, Min A toileting On acute rehab unit he demonstrated poor judgment and problem-solving, as well as issues with impulsivity He demonstrated decreased insight into his cognitive deficits, although his awareness was thought to be increasing

31. Case Review – Mr. X Continued Inpatient Assessment Findings: Inpatient neuropsychology testing revealed global cognitive deficits (with performance in the extremely low/ impaired range), including domains of attention, processing speed, verbal fluency, visuospatial processing/ construction, and executive functions Confrontation naming was a relative strength (low average range) Upon discharge 24 hour supervision was recommended, along with supervision for IADLs (specifically money management, medication management, cooking) Referred for Outpatient Neuropsychological Testing and ICRP participation upon discharge

32. Case Review – Mr. X Continued Outpatient Clinical Interview: Improvement noted from inpatient stay Continued concerns with short term memory, judgment, and impulsivity Changes in mood (withdrawn, less social, some avoidance) Functional Concerns of Patient: Not driving Unable to return to work Fatigue Getting lost in familiar places (e.g., taking a walk) Requiring wife’s assistance with reminders and prompts for daily activities

33. Case Review – Mr. X Continued Outpatient Neuropsychological Testing results: Overall improvement from inpatient assessment Strengths: Confrontation naming Simple attention Abstract verbal reasoning skills Deficits in performance: Memory encoding, recall, and retrieval Aspects of executive functioning (working memory, task initiation, cognitive flexibility, task completion) Evidence of mild depression

34. Case Review – Mr. X Continued Occupational Therapy Evaluation: Impaired awareness and metacognition Awareness of memory difficulties appeared present, but the awareness of functional implications of memory deficits was lacking Self-reported difficulties with: Recalling information for self-care, IADL’s Social participation (mostly memory issues) Meeting his daily responsibilities Emotional regulation (depression, anxiety) Emotional issues affecting his ability to complete daily activities

35. Case Review – Mr. X Continued Speech-Language Testing Results: Patient was defensive re: cognitive evaluation, therefore only informal testing was completed Patient required education on anoxic brain injuries and the purpose of rehabilitation Patient demonstrated reduced insight into his deficits Difficulty with regulations of emotions, reduced tolerance for frustration, propensity to become easily irritated and cognitively overloaded with visual and auditory inputs Excessive and tangential verbal output (causing self-overload) and inability to monitor topic Difficulty understanding questions due to missing semantic information in questions Inattention / distraction from tasks due to verbal perseveration

36. Case Study - Mr. X – Goals/Interventions OT Interventions Structured daily routine check lists Routine training Introduction to technology for safety purposes E.g., having the routine to call for help if needed SLP Interventions Daily log – to “dump” information Reduce cognitive overload and reduce excessive verbal output and perseveration NP Interventions Individual psychotherapy Family Support

37. Additional Resources: Principles of cognitive rehabilitation - Nicole D. Anderson, Gordon Winocur, and Heather Palmer in The Handbook of Clinical Neuropsychology, Published in print: 2010 Neuropsychological presentation and treatment of traumatic brain injury - Nigel S. King and Andy Tyerman in The Handbook of Clinical Neuropsychology, Published in print: 2010 Methodological issues in evaluating the effectiveness of cognitive rehabilitation - Keith D. Cicerone in The Effectiveness of Rehabilitation for Cognitive Deficits, Published in print: 2005

38. Questions/Comments

39. References Carson, S., Dukelow, N., Maier, S., Martinez, A.P., Campeau, J.R., Stavisky, C. (2016). The amazing cognitive race: The integrative cognitive rehabilitation program [PowerPoint slides]. Parente, R. & Herrmann, D. (1996). Retraining cognition. Gaithersburg, Md.: Aspen Publishers. Prigatano, G. P et al. (1986). Neuropsychological Rehabilitation After Brain Injury. Baltimore: Johns Hopkins University Press. Shears, S. (2016). Cognitive Rehabilitation in Practice [PowerPoint slides]. Retrieved from http://slideplayer.com/slide/10399820/