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Chapter 12

Chapter 12.docx

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University of Toronto Scarborough
Zachariah Campbell

Chapter 12: Cognitive and Memory Rehabilitation History Cognitive and memory rehabilitation have a pretty short history, with most agreeing that it only really got started in the 70s. Lashley  stated that he felt that there were multiple structures and functions related to recovery Goldstein  Established first rehabilitation program for brain-injured soldiers Luria  Developed an approach to the study of higher cerebral functions, their recovery, and rehabilitation Managed care and insurance have good and bad influences on health care • Managed care was originally so that everyone got the same level of care • Now means that there is a lack of choice for patients regarding treatment options and providers Is now a push for service to be delivered in a more ecological contextual framework  family, friends, and caregivers are included in rehab process Developments in computer technology and neuroscience have made for continual advances in treatment programs. 1980s  era for proliferation for brain injury rehabilitation • Major government funds for research were available for the first time 1990s  Decade of the brain • Human Genome Project gave a lot of info for the functioning and non-functioning of the human brain 2000s +  Era of consolidation • Health care reform is constant topic but reality is downsizing of programs, shorter hospital stays, less outpatient care, and more severely impaired children being put in mainstream classrooms • Patients and others need to advocate more Theories for Working With Cognitive Impairment Basic Assumptions 1. Cognition cannot be isolated. Brain injury/illness affects cognition, social, behavioural, and emotional functioning. They all interact. 2. Working with individuals in a rehabilitation capacity requires a multitude of specialties and skills. 3. Clear conceptualization of the difficulties being experienced by the individual is necessary before any form of rehabilitation is initiated a. No diagnosis means treatment isn’t possible 4. Fields of cognitive psychology and the neurosciences are growing rapidly 5. In the process of rehabilitation, the clinical neuropsychologist needs to work as a partner with the patient and his or her family. Models of Cognitive Processing Sohlberg and Mateer (2001) discuss 5 models for conceptualizing various cognitive processes. 1. Cognitive processing model: look at the cognitive task under consideration based on the normally functioning population. Then apply the knowledge to the disabled individual. 2. Factor-analytic models: psychometric approaches. Performance on tests that are designed to measure attention, concentration, and various other components of cognition are factor analyzed to determine constructs 3. Neuroanatomical models: identify parts of brain regions that are thought to be related to each of the components of cognition 4. Clinical models: observe the functioning of the disabled population to understand the functioning of components of cognition 5. Functional descriptions: include describing how cognitive processes might be used for completing day-to-day tasks Measuring Efficacy and Outcome We need more research on efficacy of treatment programs. However, is still held back by: • Heterogeneity of clients • Heterogeneity of treatment approaches and settings • Fact that rehabilitation is predominantly accomplished within clinical setting that lack research as a focus. Efficacy research and results are needed to act as justification for all the treatments and research that we currently have. Outcome research is necessary for: • Determine whether and which interventions result in functional gains, reduction of handicap, and achievement of goals • Determine whether gains are maintained over time and, if so, to what degree • Ascertain whether the intervention results in better outcomes than would be expected without provision of rehabilitation and if so, how • Obtain the information needed to modify programs to be more effective Measurement of treatment effectiveness should be specific to the intervention or treatment modality. Cognitive Rehabilitation Techniques Attention Attention is one of oldest parts of research on concentration. Those that sustain injury or illness consistently report difficulties associated with decreased reaction time and reduced speed of information. Sohlberg and Maheer’s research on attention suggest five components of attention, all of which can be affected by CNS difficulty 1. Focussed attention 2. Sustained attention 3. Selective attention a. Vigilance b. Working memory 4. Alternating attention 5. Divided attention Assessment must come first • Most neuropsychological evaluations, attention abilities are evaluated as part of a larger cognitive assessment • Test of Everyday Assessment has good ecological validity but is suggested to be combined with observation and interview to have a clearer view of individual outside of clinical setting. Has eight tasks meant to measure abilities with 4 different attention functions o Sustained attention, selective attention, attentional switching, and auditory-verbal working memory There are basically four methods to help with attentional problems: Attention Process Training (APT) Uses cognitive exercises to improve attentional systems. Primarily from neuropsychological theory Most APT programs are based on assumption that attentional difficulty may be improved by stimulating a particular aspect of attention Usually a series of repetitive drills or exercises designed to practice tasks with increasing attentional demands. This is thought to facilitate changes in cognitive capacity. Use of categories and environmental supports Self-managed strategies  self-instructional routines that help a person focus on their task • Goal is to encourage client to monitor their activities consciously, avoiding attentional lapses o Example: pacing for overcoming fatigue or maintaining attention for a long period of time Modification to environment. • Need to be tailored for client • Can be determining what areas cause greater distress due to divided attention. Also, what environmental noises may be distracting May sometimes be used with APT. May be used later in treatment when the patient is adapting to living at home. Based on behavioural and neuropsychological theories Use of external aids Help patients track and organize information • Calendars, day planners, pillboxes… Based on behavioural and neuropsychological principles Psychosocial support Address emotional or social factors that are caused by or exacerbate attentional difficulties. Considerable research has shown connection between emotional state and cognitive functioning. May include: listening, brain injury education, relaxation training, psychotherapy, and grief therapy. Based on sociological and psychological theories Memory Two main principles 1. Assessment must be completed first a. Needs assessment: assessment of the types of rehabilitation necessary based on the strengths and weaknesses of the client 2. Rehabilitation must be unique to client Most researchers state that there are three strengths exhibited by those with severe memory impairments, most of the time • Preservation of immediate memory or attentional abilities, procedural memory, and old learning Literature on memory rehabilitation has divided memory aids into three different types of programs: • Those which restore or improve memory ability across a variety of tasks and contexts o Practice drills, mnemonic strategy training, prospective memory training, and meta-memory training • Domain-specific memory intervention approaches o Mnemonic strategy training for specific situations, expanded rehearsal time, use of preserved priming, creating a personal history • External aids For all of these, one of the main treatment t
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