1. The invisible effects of stroke
Charlotte Riedel
Band 7 Stroke Occupational Therapist
September 2018

2. Aims of presentation:
Understand the invisible impairments caused by stroke
Gain an understanding of cognitive impairments
Gain an understanding of the cognitive hierarchy
Understand how OT’s assess cognitive impairments in an acute environment
Increase awareness of cognition and associated impairments within the wider MDT

3. Definition of stroke:
Stroke is the single, greatest cause of complex and severe adult disability in the UK (Wolfe, 2000; Adamson et al., 2004).
Common problems following stroke include aphasia, physical disability, loss of cognitive and communication skills, depression and other mental health problems.

4. Stroke guidelines:
National Clinical Guideline for Stroke: Occupational Therapy concise guide for stroke 2016.
4.3.1A
People with stroke should be considered to have at least some cognitive impairment in the early phase. Routine screening should be undertaken:
to identify the person’s level of functioning
using standardised measures.
4.3.1G
People with continuing cognitive difficulties after stroke should be considered for comprehensive interventions aimed at developing compensatory behaviours and learning adaptive skills.

5. Consider the patient:

6. Ward information regarding the patient
Medically stable
Medically fit for discharge
No on-going need for acute medical care
On the ward round the doctors have suggested patient can go home
BUT…

7. Are they fit for discharge?
Sitting out in the armchair
Mobilising independently on the ward
Dressed in own clothes
Able to walk to the hospital coffee shop
Using mobile phone independently
Talking to nurses without obvious difficulty
Independent with basic ADLs on the ward

8. Possible invisible effects of stroke:
Difficulty problem solving
Reduced insight into the situation
Difficulty organising and planning for self
Memory problems
Emotional challenges
Difficulty making decisions
Difficulty completing basic and complex tasks

9. Brain, lobes and function

10. Potential impact of impairments:
Assistance with ADLs
Not able to make decisions
Prompts with daily routine
Challenges organising self
Not able to engage in meaningful pre morbid occupations/leisure choices
Limited to an acute environment with 24 hour support which does not mimic the home/community environment
Difficulty returning to work
Burden on family/carers
Loss of identity

11. What is Cognition?

12. Cognition- a definition
Cognition refers to those mental functions which help us to acquire, organise, manipulate and use information and knowledge. It includes all of our ‘thinking’ processes.
The processes that allow us to
Recognise
Learn changing
Remember information in
Attend environment. to

13. For normal cognition we need to: Receive
information from senses
Integrate
information with memory and stored knowledge
Monitor and correct
action and behaviour in response to changes in environment

14. Cognitive Hierarchy Praxis Memory Object Recognition
Executive Function
Praxis
Memory
Object Recognition
Visual Spatial Perception
Attention
Sensory Registration

15. Sensory Registration Vision is preferred sense of humans.
Visual Acuity (accurate)
Visual Field (complete)
Also need information from:
Auditory - Gustatory
Tactile - Olfactory
Proprioception.

16. Attention We only process what we attend to.
Is selected to what is relevant at the time.
Affected by internal and external influences.
+Focused
+Sustained
+Selective
+Alternating /Switching
+Divided
What could be the internal and external influences?
Motivation, fatigue, temperature, depression, elation, itchy skin, noise control etc etc
Focused: fix on specific stimuli.
Sustained: maintain specific response during continuing or repetitive activity.
Alternating or switching: switch attention flexibly from one attention set to another with different requirements eg listening to radio, taking a phone call, then going back to radio.
Divided attention: one or more task carried out at same time, eg talking to passenger while driving.
Most difficult as use different modalities eg visual and auditory.

17. Visual and Spatial Perception
Perception is the interpretation of information.
Information is given reason through association with stored knowledge of world
Visuoperceptual- what an object is and it’s attributes
Visuospatial- where and object is in relation to use and other objects, or relative position of different parts of objects.
Visuoconstructive: links with motor function. Create and manipulate, putting tasks together.
Some people think that Visuocontstruction could be classified with either visuospatial or visuoperceptual.

18. visual-perceptual skills
Colour perception.
Perceptual constancy:
size colour
Visual Discrimination:
recognition matching categorisation
Movement perception
Figure ground perception.
Depth/ Distance Perception-
shape
Colour perception- ability to recognise different colours and shades of colour.
Helps with depth perception and figure ground (eg camouflage)
Perceptual constancy:
Size- ability to perceieve real size of object (small and far away)
Colour- colour as same regardless of the lighting.
Shape- same regardless of perception (eg unusual view in the MEAMS assessment).
Visual closure:
Ability to identify objects or shapes from partial or incomplete presentation- eg the letters in the MEAMS and ACE-R assessment.
Visual discrimination: detect the features of s stimuli for recognition, matching and categorisation. (See future slide)
Allows us to notice the similaries and differences- related to short term memory.
Recognition- note key features and relate to memory.
Matching- note similarities
Categorisation- determine category by the similarities and differences.
Movement perception: ability to detect movement
Figure-ground perception: ability to identify one part of incoming information as figure/ foreground.
Use cues such as colour, depth, texture, movement and continuity.

19. Object Recognition
Integrates basic perception & stored knowledge of objects and their use.
2 stage process:
Perceptual analysis Matching
Of incoming information to a stored representation of object

20. Memory Fundamental to all aspects of cognition.
Three stages of memory:
Encoding
Storage
Retrieval
Can only make sense of perception by referring to store of previous experience.
ALL STAGES OF HIERARCHY ARE INTERDEPENDENT!
Encoding- transforms stimulus into a code that memory accepts.
Storage- retaining information.
Retrieval- process of accessing stored information.
Retrieved by recall or recognition.
Recall- retrieval without a cue
Recognition- identifying something as been previously experienced and retrieving information about it.

21. Short term memory
Recalls information immediately (keeps information for about 60 seconds)
Working memory includes the executive processes necessary to perform a task, routine or occupation.

22. Long Term Memory Declarative/ Explicit Memory.
retrieved by conscious access eg what you know.
*Semantic
*Episodic
*Prospective
-Habitual
-Event-based
-Time based
Semantic- what we know, facts about world, info essential for functioning.- encyclopaedia
Episodic- particular episode in time eg what did at weekend- autobiographical.
Prospective- store of plans and actions/ future events. Eg to post a birthday card or take meds…
If loose prospective memory have no internal timetable and need external prompts
Divided into:
Habitual- remember to carry out tasks that are performed repeatedly in the future eg taking meds
Event based- in response to a particular event- eg when alarm sounds turn off the rice.
Time based- in a particular time – eg when 7.40 need to leave for work.

23. Long term memory cont. Non-Declarative/ Implicit Memory
non-conscious memories.
- Procedural memory
Laying down of memories not a conscious process.
Procedural memory most common type of implicit memory.
Motor and mental processes such as walking, riding a bike, swimming.
Speaking a language.
Tends to be spared in memory loss.

24. Praxis How we carry out skilled/ previously learnt tasks.
Ideomotor apraxia
Ideational apraxia.
Many habitual tasks are performed v automatically in a familiar environment w familiar objects.
When situation is unfamiliar or when multiple objects required- tests our praxis skills.
EG- cooking in unfamiliar kitchen.
Washing in unfamiliar bathroom etc etc. washing hair in bath instead of shower etc.
Ideomotor dyspraxia
Disorder of the initiation and execution of planned sequences of movement.
Concept of the task is understood but movement lack correct force, direction and timing in order to achieve the motor goal.
Ideational dyspraxia.
Impairment of conceptual system.
Concept of the action related to the object is impaired.
Single actions may sometimes be performed automatically and appropriately especially in familiar environment.
Conceptual- forming concept of an action and knowing what to do.
= integrate the recognition of objects with knowledge of actions and action sequences related to use of those objects.
Production system
= motor planning
Organising sequence of movements involved in the task given the particular task demands.
= execuation
Carrying out the planned movements with correct force, direction, timing. (eg playing tennis- how hard to hit ball, when to hit it, direction etc)

25. Executive Function Components include: Realistic goal setting Planning
Organisation
Self-initiation
Self-directing
Self-inhibition
Self monitoring/ self correcting
Flexible problem solving.
Realistic goal setting
Awareness/insight into:
strengths and limitations
environmental constraints
social acceptability and consequences.
Planning
Set out steps in specific order to achieve task
Steps related and to be carried out in certain order
Organisation
Carry out plan appropriately
May involve delegation or resources
Self-initiation
Ability to start activity without command
Spontaneous action.
Self-directing
Carry out task without constant feedback
Self-inhibition
Inhibit inappropriate responses or behaviours
Move or switch attention
Maintain selective attention
Appropriate social skills.
Self monitoring/ self correcting
Monitor task, and if going wrong to change as going along.
Flexible problem solving.
Recognise more than one solution to a problem and to think more divergently.

26. Basic checklist of questions or tasks directed at cognitive skills
Level of alertness
Does the patient engage or participate in conversation or daily tasks?
Does the patient’s level of alertness fluctuate or change over time?
Orientation
Can the patient determine time, place and person?
Is the patient aware of their surroundings and what has happened?
Attention
Does the patient sustain their attention during conversation?
Is the patient easily distractible?
Communication
Does the patient follow 1, 2 or 3 step commands?
Is the patient able to respond appropriately to questions?

27. Cont.… Memory Can the patient recall information accurately?
Does the patient appear to recognise you and what has happened over the recent days?
Problem solving
Does the patient need prompts to carry out simple tasks?
Does the patient initiate tasks or engage actively in their environment?
Praxis
Can the patient copy movements?
Can the patient demonstrate movements to command?
Can the patient imitate how to use certain objects?

28. Why assess cognition?
In acute care cognitive assessment is commonly used for the following reasons:
(i) screening for cognitive impairment
(ii) differential diagnosis of cause
(iii) rating of severity of disorder, or monitoring disease progression.

29. Why OT’s assess cognition:
Cognition is a fundamental component of all purposeful activity.
Cognitive deficits impact upon every aspect of life & can result in the loss of abilities & skills therefore creating difficulties in all areas of occupation.
Potential cognitive deficits need to be identified to allow for effective treatment planning.
(COT, 2012)

30. Assessment continued Functional assessments/observations
Isolate relevant features of a task
Breakdown a task into steps
Perform actions & behave in such a way to compete a task in the correct sequence
Modify responses as appropriate

31. Assessment: Standardised assessments
Are user friendly – (sometimes quick to administer, easy to perform & score; results easy to interpret & explain to MDT)
Have clinical utility – allow for a functional capacity analysis that can be converted into a treatment plan/ goals & can identify the need for further ax in particular area
Can be repeated with good inter-rater reliability
Aim to assess all components of the cognitive hierarchy

32. Standardised cognitive assessments used in an acute setting:
AMTS (cognitive screen used within elderly settings, scored out of 10).
ACE-R (100 point assessment used to identify cognitive impairment).
MOCA (30 point screen for cognitive impairment)
MEAMS (assesses various components of cognition, scored out of 47).
CAM (developed for use with patients who have brain injury, length assessment with various sub sections).
COTNAB (assessment for those with neurological impairment, assesses 4 main components)
Rivermead (memory test, specific cognitive assessment).

33. Treatment approaches: to aid recovery
Assessment
Education
Process training
Strategy training
Functional activities training
Evaluation
(Malia and Brannagan, 2005; Halligan and Wade, 2007)
Assessment – to determine the specific impairments involved and their functional impact on occupational performance.
Education – to develop patients’ and others’ awareness of cognitive strengths and weaknesses and how they influence occupational performance. Without developing awareness and self-monitoring skills, the patient will not engage in therapy and will not be able to independently implement treatment strategies on their own – the ultimate aim of rehabilitation!
Process training – to restore the impaired cognitive skill through targeted practice and retraining of the skill itself. This is usually completed out of context in pen and paper tasks to enable patients to consciously focus on the targeted skill and may be given as homework activities.
Strategy training – to learn how to use external and internal adaptive strategies to overcome the impaired skill. This involves targeted rehearsal of the taught strategy in a variety of contexts.
Functional activities training – to consciously apply strategies learnt in process and strategy training in everyday life.
Evaluation – is required at impairment, activity and participation levels to determine the effectiveness of intervention.

34. As a wider team
Feedback to OT staff any concerns you have regarding cognition with your patients
Consider diagnosis/potential cognitive impairment
Joint sessions with OT if you feel necessary/helpful
Liaise with medical staff if you notice cognitive decline to aid identifying cause/deterioration

35. Thank you for listening…