Evaluation and Treatment of Limited Occupational Performance Secondary to Cognitive Dysfunction

• Evaluations/assessment should be focused on clients performing relevant occupations. Simultaneously (as will be described later), the OT documents what impairment or patterns of impairment in client factors and performance skills are interfering with performance and participation.¹⁰

• Goals should be related to improving performance in areas of occupation, as described by the second edition of the Occupational Therapy Practice Framework.³

• Interventions should consist of primarily graded relevant occupations being performed in natural contexts.

• Finally, the outcomes of occupational therapy intervention for this population should document improved performance in areas of occupation.

Dynamic Interactional Approach

The Dynamic Interactional Approach views cognition as a product of the interaction among the person, activity, and environment.¹⁰⁶ Therefore, performance of a skill can be promoted by changing either the demands of the activity, the environment in which the activity is carried out, or the person’s use of particular strategies to facilitate skill performance. Toglia describes several constructs associated with this model, including the following:

Toglia summarizes that “to understand cognitive function and occupational performance, one needs to analyze the interaction among person, activity, and environment. If the activity and environmental demands change, the type of cognitive strategies needed for efficient performance changes as well. Optimal performance is observed when there is a match between all three variables. Assessment and treatment reflect this dynamic view of cognition.” This approach may be used with adults, children, and adolescents.

Toglia used the Dynamic Interactional Model to develop the Multicontext Treatment Approach.^106,107 Combining both remedial and compensatory strategies, this approach focuses on teaching a particular strategy to perform a task and practicing this strategy across different activities, situations, and environments over time. Toglia summarizes the components of this approach to include the following:

Quadraphonic Approach

The Quadraphonic Approach was developed by Abreu and Peloquin for use with those who are cognitively impaired after brain injury.¹ This approach is described as including both a “micro” perspective (i.e., a focus on the remediation of subskills such as attention, memory, etc.) and a “macro” perspective (i.e., a focus on functional skills such as activities of daily living [ADLs], leisure, etc.). The approach supports the use of remediation, as well as compensatory strategies.

The micro perspective incorporates four theories:

The macro perspective involves the use of narrative and functional analysis to explain behavior based on the following four characteristics:

Cognitive-Retraining Model

The Cognitive-Retraining Model is used for adolescents and adults with neurologic and neuropsychologic dysfunction.¹¹ Based on neuropsychologic, cognitive, and neurobiologic rationales, this model focuses on cognitive training by enhancing clients’ remaining skills and teaching cognitive strategies, learning strategies, or procedural strategies.

Neurofunctional Approach

The neurofunctional approach is applied to those with severe cognitive impairments secondary to brain injuries.³⁷ The approach focuses on training clients in highly specific compensatory strategies (not expecting generalization) and specific task training. Contextual and metacognitive factors are specifically considered during intervention planning. The approach does not target the underlying cause of the functional limitation but focuses directly on retraining the skill itself.

Task-Oriented Approach

Though usually discussed in relation to motor control dysfunction, the Task-Oriented Approach has potential application to this population as well.⁷⁸ Mathiowetz has discussed this approach in detail.⁶⁴ Summary points related to the adoption of a framework for evaluation with this approach include evaluating the following areas in the described order^64,65:

In terms of intervention, Mathiowetz and Bass Haugen⁶⁵ and Mathiowetz⁶⁴ recommend the following:

• Outcome 1: Following occupational therapy, Jane has improved her scores on a standardized memory scale (decreased impairment in client factors), but the changes are not detected on measures of instrumental activities of daily living (IADLs) and quality of life (stable performance in areas of occupation).

• Outcome 2: Following occupational therapy, Jane has no detectable changes on the standardized memory scale (stable impairment in client factors), but changes are detected on measures of IADL and quality of life (improved performance in areas of occupation).

• Outcome 3: Following occupational therapy, Jane has detectable changes on the standardized memory scale (decreased impairment in client factors), as well as changes detected on measures of IADL and quality of life (improved performance in areas of occupation).

Dysfunctions of global and specific mental functions with an effect on grooming and hygiene tasks include ideational apraxia, organization and sequencing problems related to activity steps, impaired judgment, decreased level of arousal, lack of attention, distraction, field dependency, impaired memory, and impaired intention. Ideational apraxia may appear during grooming and hygiene activities; an individual may not know what to do with the toothbrush, toothpaste, or shaving cream or may use these items inappropriately (e.g., smear toothpaste over the face or spray the shaving cream over the sink). An individual with organization and sequencing difficulties only may have the general idea of how to perform but may have problems timing and sequencing activity steps. Such a patient may not complete one activity step before starting another or may perform activities too quickly as a result of problems in timing activity steps, resulting in a poor performance.

Lack of judgment may appear as an inability to make realistic decisions based on environmental information, providing that perception of those impulses is adequate. An individual so affected may leave the sink area without turning off the water taps or may leave the wash cloth in the sink, not noticing that the water level is increasing and threatening to overflow.

Field dependency has an attention component and a perseveration component. Individuals with this dysfunction may be distracted from performing a particular task by specific stimuli that they are compelled to act on or incorporate into the previous activity. For example, if an individual with field dependency sees a denture brush while washing the hands, that person may incorporate the brush into the activity and scrub the hands with the denture brush.

An individual with short-term memory problems may not remember the sequence of activity steps or instructions throughout activity performance. The therapist may have to remind an individual several times to comb the hair, even though the individual does not have comprehension problems.

Lack of initiation may occur during performance of grooming and hygiene tasks; the individual may sit by the sink without performing, even after being asked to wash. With repeated instructions to begin, the individual may indicate that the activity is about to start, yet nothing happens. After several such incidents and if the therapist asks for a plan, the individual may state a detailed plan of action in which the water will be turned on, the washcloth will be picked up and put under the running water, soap will be put on the cloth, and washing will begin. The individual has a plan of action but cannot start the plan. This impairment may be associated with ideational problems as well.

1. Comparing self-reports with observed performance provides the OT with critical information on awareness of the severity of impairment and functional status.

2. Comparing self-reports and caregiver reports is helpful in getting a “snapshot” of how clients perform in their own environments, which may or may not be congruent with observed performance in an occupational therapy clinic.

3. It is important that clients and caregivers see benefit from the occupational therapy services provided. It is problematic if the OT is documenting improvements that cannot be detected by those to whom we provide services (Table 26-3).

Awareness Deficits Having an Impact on Daily Function

Management of deficits in awareness may be considered a foundational intervention for this population.⁴¹ Findings from standardized assessments of awareness may dictate the overall management of a client’s functional limitations, as discussed later. Different terminology and definitions related to limited self-awareness are used in the literature, including lack of insight, lack of/impaired self-awareness or unawareness, anosognosia, and denial. Nonimpaired self-awareness has been defined as “the capacity to perceive the self in relatively objective terms, while maintaining a sense of subjectivity.”^81–83 The terms impaired self-awareness and anosognosia are used interchangeably and are defined as follows: the clinical phenomenon in which a person “does not appear to be aware of impaired neurological or neuropsychological function, which is obvious to the clinician and other reasonably attentive individuals. The lack of awareness appears specific to individual deficits and cannot be accounted for by hyperarousal or widespread cognitive impairment.”⁸⁰

Other authors reserve the term anosognosia for describing unawareness of physical deficits only (i.e., not including cognitive impairments), such as “anosognosia for hemiplegia” or “anosognosia for hemianopia.”

Although impaired self-awareness and anosognosia have clearly been used as overlapping terms in the literature, the term denial must be considered separately. Psychologic denial has been defined as “a subconscious process that spares the patient the psychological pain of accepting the serious consequences of a brain injury and its unwanted effects on his or her life.”²⁵ Complicating the matter is that impaired self-awareness and denial may occur together. Differentiation between denial (a psychologic method of coping) and lack of awareness that is neurologically based is difficult because some individuals have both types of clinical manifestations.⁸²

The pyramid model of self-awareness was developed by Crosson and colleagues.²⁵ This model includes three interdependent types of awareness:

Those with brain injury or cognitive deterioration may be impaired across all three awareness domains⁷⁰ or may have better skills in one or more domains of awareness. Crosson and associates further applied this model to the selection of compensatory strategies and categorized compensations appropriate to each type of awareness.²⁵ They classified compensatory strategies according to the way that their implementation is triggered:

This pyramid model was constructively criticized and expanded on by Toglia and Kirk.¹⁰⁸ Their model, the Dynamic Comprehensive Model of Awareness, suggests a dynamic rather than a hierarchic relationship. The model proposes a dynamic relationship among knowledge, beliefs, task demands, and the context of a situation based on the concept of metacognition. This model differentiates between metacognitive knowledge or declarative knowledge and beliefs about your abilities before performing the task (incorporating aspects of intellectual awareness) and online monitoring and regulation of the performance of a task (i.e., during task performance), which integrates aspects of emergent and anticipatory awareness.

Finally, Fleming and Strong discuss a three-level model of self-awareness³⁴:

Most authors recommend that self-awareness be evaluated before initiating an intervention program focused on retraining living skills. The findings from standardized evaluations of self-awareness will clearly guide choices of intervention. For example, a person who exhibits insight into an everyday memory deficit may be a candidate for teaching compensatory strategies such as using a diary or notebook (see later). However, a person who does not realize that he or she has severe unilateral neglect (a lateralized attention deficit) may not be able to learn compensatory strategies and thus may require environmental modifications (e.g., all clothing hung on the right side of the closet) to improve everyday function. In addition, ascertaining the level of insight into a disability is one factor that may determine how motivated one is to participate in the rehabilitation process. In the most simplistic interpretation, one must be aware and concerned about a deficit in everyday function to be motivated to participate in what may be a long and difficult rehabilitation process. Returning to the case study, Jane has goals of returning to school and engaging in complex ADLs on returning home. It is imperative that Jane continue to gain insight so that she can implement strategies to compensate for her persistent deficits. Examples of strategies to return to school may include tape-recording lectures, having a “note taker” assigned so that Jane can fully attend to the lecture, switching to a part-time school schedule, and using electronic aids to organize her day, assignments, etc.

A variety of assessment measures are typically recommended for ascertaining a person’s level of self-awareness, including questionnaires (self or clinician rated); interviews; rating scales; functional observations; comparisons of self-ratings and ratings made by others such as significant others, caretakers, or rehabilitation staff; and comparisons of self-ratings and ratings based on objective measures of function or cognitive constructs. No method is universally accepted for assessing the construct of awareness or lack thereof. In addition, naturalistic observations can provide further information related to how decreased awareness is interfering with the performance of everyday tasks. See Table 26-4 for examples of standardized assessments of awareness.

Although most researchers and scholars agree that interventions focused on improving awareness are critical for maximizing rehabilitation and that greater awareness of deficits is associated with better treatment outcomes,⁷¹ others have documented functional changes via task-specific treatment without concurrent improvement in awareness. Overall, there is a lack of empiric studies that have examined the effectiveness of various interventions aimed at improving awareness. In addition, many of the published studies have not included functional outcomes. As a starting point in managing awareness, the entire team should encourage clients to predict their level of performance before any observed performance in areas of occupation. Those with brain injury or cognitive deterioration most often underestimate their level of cognitive impairment and overestimate their level of function. Clinicians should leave time at the end of each session to compare actual performance with predicted performance. This comparison of predicted versus actual performance is critical and should be done with all functional tasks. Examples of predictions include questions such as “How long will the task take?”, “How many times will you need to ask for help?”, “How many times will the therapist need to physically help you?”, and “How many times will the therapist need to verbally help you?” The goal is to decrease the discrepancy between the two levels of performance.

In is important for the OT to remember that the verbal or physical cues used to support participation in meaningful occupations are not provided simply to support the completion of tasks. Cues are used to facilitate insight and to encourage the client to solve problems by developing new strategies to overcome deficit areas (Table 26-5).

Tham and colleagues developed an intervention to improve awareness related to the effect of neglect (a lateralized attention deficit) on functional performance.¹⁰⁴ Purposeful and meaningful (for the participant) daily occupations were used as therapeutic change agents to improve awareness of disabilities. Specific interventions included encouraging participants to choose motivating tasks as the modality of intervention and discussions about task performance. Examples include the following:

With this approach, awareness of disabilities and ADL ability improved in all four participants, unilateral neglect decreased in three participants, and sustained attention improved in two participants. The authors concluded that training to improve awareness of disabilities might improve the ability to learn the use of compensatory techniques for performing ADLs by clients with unilateral neglect.

Fleming and coworkers completed a pilot study examining the effect of an occupation-based intervention program on the self-awareness and emotional status of four men after acquired brain injury.³³ Each participant received an individualized program that focused on the performance of three client-chosen occupations (e.g., writing a job application, budgeting, meal preparation, playing lawn bowling, cooking with one hand) for which they had decreased awareness according to significant others. The intervention was based on Toglia’s multicontextual approach described earlier.¹⁰⁵ Techniques included providing a nonthreatening environment to build positive therapeutic alliances; having the participants analyze their underlying skills, self-predict, and self-evaluate before and after the occupation; setting “just the right challenge”; supported and structured occupational performance; education on brain injury; timely and nonconfrontive verbal feedback in a sandwich format (negative comments are preceded and followed by positive feedback); and video feedback.

Repeated measures of participants’ self-awareness and emotional status were performed before and after intervention and analyzed descriptively. The authors found that their results indicated preliminary support for the effectiveness of the program in facilitating participants’ self-awareness, although baseline and follow-up data indicated a complex and inconsistent picture. Of note is that slightly increased anxiety was found to accompany improvements in participants’ self-awareness in all four cases and slight increases in depressive symptoms were noted in three participants. These findings are consistent with the literature discussed earlier focused on the relationships between emotional status and awareness, as well as the interconnections between denial and self-awareness (Box 26-1).

Jane’s OT administered the Self Awareness of Deficits Interview. Gary was present for this session. Jane reported that she was not any different now from what she was like before her hospitalization, her brain injury has not had any effect on everyday life, and she hopes to be ready to graduate and look for her first job as a social worker in the next 6 months. The findings and ratings were indicative of severely limited self-awareness. The OT consistently used the time needed to complete a task as the prediction that Jane would make before each task. The OT chose time as the predictor because Jane had poor initiation, was disorganized, and repeated steps of the tasks. Such behavior increased the amount of time needed to complete tasks. Jane consistently predicted length of time based on her preinjury status. When the OT compared the predicted time with the actual time, Jane reacted with disbelief. As sessions progressed, Jane began to increase her accuracy in reporting the time needed for each task (increased awareness). As her awareness increased, the OT noted that Jane was frequently teary. The OT notified the team that although Jane was developing a better understanding of her current functional status, she required increased emotional support from the team, as well as monitoring for increased levels of depression and anxiety.

Attention Deficits Having an Impact on Daily Function

Attention in its various forms is one of the most important and basic functions of the human brain, and it constitutes the basis for other cognitive processes. Integrity of the attention system is considered a prerequisite for all other higher cognitive systems such as memory, executive functions, and so on.⁷⁵ In particular, basic memory functions such as working memory are dependent on intact attention processes.²² If one does not attend to incoming information and cannot hold information in mind, information will not be remembered and cannot be used to guide appropriate behavior or successfully complete daily activities.⁶⁷ It comes to follow that attention skills serve as a cognitive foundation and are a prerequisite to engage in most if not all meaningful activities and that any impairment in attention processes will result in observable difficulties in everyday life, which may in fact decrease quality of life. Termino-logy related to attention impairments is summarized in Table 26-6.

During performance of a task, impaired attention results in increased rates of off-task behavior (e.g., looking up and away from the task at hand, engaging in unsolicited conversations) in comparison to controls. Those with impairments in attention are markedly less attentive than controls both in the presence of distractions (noise, movements) and in their absence.¹¹⁴ Further compounding this problem is a relationship between attention impairment and awareness of errors. McAvinue and colleagues investigated the processes of error awareness and sustained attention in those with TBI.⁶⁶ They found the following:

The finding of a significant relationship between these two deficits in clients with TBI suggests that there may be a link between these two processes.

Posner and Peterson proposed the existence of three main functionally and anatomically distinct attentional control subsystems⁷⁷:

Dockree and colleagues summarize the following²⁷:

The usual and customary tests of attention include pen-and-paper measures or laboratory-type tasks, such as the Paced Auditory Serial Addition Test, Trail Making Test Part A, and Wisconsin Card Sorting Task. As discussed earlier, when using these measures the question of ecologic validity arises as regards difficulty generalizing the results to everyday living tasks. Suggested assessments are described in Tables 26-2 and 26-3. Impairments in attention are manifested as observables errors during performance of tasks and should be documented as such (see Table 26-4).

In their meta-analysis of attention rehabilitation after an acquired brain injury, Park and Ingles examined two approaches to treating attention deficits⁷⁴:

Park and Ingles concluded that specific skills training significantly improved the performance of tasks requiring attention.⁷⁴ In comparison, the cognitive-retraining methods (i.e., those focused on improving impairments in attention out of context) included in the meta-analysis did not significantly affect outcomes. Further analysis revealed that overall performance improved in 69% of the participants who received specific skills training (e.g., driving, ADLs) whereas performance improved in only 31% of those not so trained. In terms of effect size, the improvements in cognitive functions after direct retraining were small, whereas the improvements in performance after specific skills training were medium or large. Their findings demonstrate that acquired deficits in attention are treatable by specific skills training. The authors also proposed clinical implications of their study, including the following:

Strategies aimed at modification of task and environments have proved to be beneficial for this population (Box 26-2). Specific strategies include the following:

A case study by Webster and Scott demonstrated positive effects of this approach both immediately after treatment and at 18 months’ follow-up as the client demonstrated improved attention, which resulted in increased recall, increased sexual function, and improved job performance.¹¹³

Strategy training is considered a practice standard for the postacute period of rehabilitation by the American Congress of Rehabilitation Medicine.²³ Intervention should focus on strategy training to compensate for attention deficits in functional situations.

Memory Deficits Having an Impacting on Daily Function

Memory impairment is one of the most common consequences of brain injury and degenerative cognitive disorders. The severity and type of memory loss vary according to the structures affected. Human memory is composed of multiple and distinct systems that are required to support daily activities and participate in the community (Table 26-7).¹⁰¹ Examples include remembering your significant other’s birthday, remembering to take your medications, remembering to feed the dog, remembering how to type, remembering events that occurred during a vacation, and so on. Even this “simple” list of memory tasks requires intact functioning of multiple memory systems and includes knowledge of facts and events, procedures, and future intentions. Clearly, memory serves as a key cognitive support to facilitate independent living.

The steps or stages of memory have been well documented.^12,99 The flow of these stages follows (Table 26-8):

Traditional measures of memory have tended to tabletop laboratory-style tools. Contrived tasks commonly used are remembering a string of numbers, a list of words, or the details of a drawn figure and/or paired associate learning (i.e., requiring a person to recognize or recall recently presented material). How the results of these tests relate to everyday memory function is not clear, and associations between scores on this type of test and reports of everyday memory failure are not strong.¹⁰² Similarly, functional gains do not always correlate with improvement in memory processes based on objective testing.⁸⁵

A comprehensive evaluation of how impairments in memory affect everyday function includes the use of standardized assessments, nonstandardized observations, standardized self-reports, and standardized reports of caregivers and significant others. Tables 26-2 and 26-3 include descriptions of recommended assessments. The Contextual Memory Test is a useful screening tool.¹⁰⁵ It allows clinicians to objectify three aspects of memory and screen for possible further evaluation:

Interventions focused on those with memory deficits can be categorized as restorative approaches to improve underlying memory deficits, strategy training, use of nonelectronic memory aids, and use of electronic memory aids or assistive technology. Techniques aimed at improving the underlying memory impairment such as memory drills have been unsuccessful in terms of generalization to meaningful activities. In other words, an improvement may be detected on a laboratory-based measure of memory without a corresponding change in daily function or subjective memory reports.

The most promising interventions to improve function in those with memory deficits rely at least partially on compensatory techniques (Box 26-3). When using a compensatory approach, choosing the correct system of compensation is critical. Kime suggests a comprehensive evaluation that includes the following⁵³:

Specific evidenced-based interventions include the following:

The authors found that during the treatment phase, those who were in the diary and self-instruction training group consistently made more diary entries, reported fewer memory problems, compensated better via use of strategies, and made more positive ratings associated with the efficacy of treatment. Potential sections of a memory notebook are included in Table 26-9.

Executive Dysfunction Having an Impact on Daily Function

Executive functions is an umbrella term that refers to complex cognitive processing requiring the coordination of several subprocesses to achieve a particular goal.²⁹ This term has been defined as “a product of the coordinated operation of various processes to accomplish a particular goal in a flexible manner”³⁶ or “those functions that enable a person to engage successfully in independent, purposive, self-serving behavior.”⁶¹ These higher-order mental capacities allow one to adapt to new situations and achieve goals. They include multiple specific functions such as decision making, problem solving, planning, task switching, modifying behavior in light of new information, self-correction, generating strategies, formulating goals, and sequencing complex actions. Unfortunately, there is a lack of consistency in the published literature related to whether a particular function is executive. Table 26-10 gives an in-depth list of the 20 most commonly reported dysexecutive symptoms, as well as the reported frequencies of these symptoms. Clearly, these executive functions support engagement in daily life activities and participation in the community, most important during new, nonroutine, complex, and unstructured situations (Table 26-11).

Indeed, recent studies examining meal preparation abilities in those with frontal lobe involvement support this hypothesis. Godbout and associates examined executive functions and ADLs in 10 clients with excised frontal lobe tumors and 10 normal controls by means of a neuropsychologic test battery, a script generation task, and a complex multitask ADL (planning and preparing a meal).⁴² The clients manifested numerous basic executive deficits on the pen-and-paper tests, were unimpaired on the script generation task (despite an aberrant semantic structure), and demonstrated marked difficulties in the meal preparation task. They concluded that the difficulties observed related to performing a lengthy complex multitask ADL can be explained by impairment of several executive functions, generalized slowness in performance, and paucity of behavior. Similarly, Fortin and colleagues investigated executive functions in performing ADLs in 10 clients with frontal lobe lesions after a mild to severe closed head injury (CHI) versus 12 normal controls by means of a neuropsychologic test battery, a script recitation task, and simulation of a complex multitask ADL.³⁵ The authors found that the groups did not differ on any neuropsychologic test by nonparametric testing. However, the clients with CHI manifested marked anomalies in the meal preparation task. Although small sequences of actions were easily produced, large action sets could not be executed correctly. They concluded that an outstanding deficit in strategic planning and prospective memory appears to be an important underpinning of the impairment in ADLs observed in CHI clients with frontal lobe lesions. Similarly, it has been found that components of executive functioning such as categorization and deductive reasoning ability in persons with brain injury are good predictors of IADL functional performance.⁴³

Lezak classified the various forms of executive disorders listed previously in a four-part schema^60,61:

Cicerone and associates also presented a schema based on executive functions. It includes four domains based on anatomy and evolutionary development²³:

People with impairments in executive functions, or dysexecutive syndrome, have impaired judgment, impulsiveness, apathy, poor insight, and lack of organization, planning, and decision making, as well as behavioral disinhibition and impaired intellectual abilities. Specific behavioral characteristics include impulsivity, poor attention, erratic response, lack of flexibility, and poor self-control.^84,100 Of note is that people with impaired executive function may perform normally on pen-and-paper tests of cognition but unfortunately are found to have catastrophic everyday problems that are particularly evident in situations requiring multitasking and planning.⁹⁴

The usual and customary tests of executive dysfunction include pen-and-paper measures or laboratory-type tasks, such as the Wisconsin Card Sorting Task, Trail Making Test, and Stroop Test, among others. As discussed earlier, the question of ecologic validity arises when using these measures, in addition to difficulty generalizing the results to everyday living tasks. These measures have only a low to moderate relationship to everyday skills.

Additionally, the standard clinical tests used to assess executive impairments are considered too structured and rater led; therefore, they fail to capture the common problems of initiation, planning, and self-monitoring. Recommended instruments are summarized in Tables 26-2 and 26-3.

Interventions for dysexecutive syndrome (Box 26-6) continue to be tested empirically.

Because executive functions act as a manager of other cognitive processes such as attention, memory, and language,⁶² some of the interventions previously described in this chapter are appropriate for those with dysexecutive symptoms, including TPM,³¹ self-instruction training,²⁴ WSTC strategy,⁵⁸ external cueing devices (paging system, recorded instructions, checklists, etc.),^20,30,93 and manipulation of environmental variables with a focus on level of distraction.⁴⁸ Other examples of specific interventions that have been tested and shown to be effective are described in the following sections.

Week 1:

Week 3:

Review Questions

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