12: Cognitive Rehabilitation - Attention

Question 1

Why is attention a foundational skill?

Answer 1

it underlies/supports all other cognitive abilities

Question 2

What are 4 methods of attention rehab?

Answer 2

1) Behavioral Therapy (early TBI)
2) Direct attention training
3) strategy training (metacognitive)
4) environmental modification and external aids

Question 3

What is bheavioral therapy?

Answer 3

focus on direct modification of abnormal behaviors using stimulus control, reinforcement, and punishment

Question 4

What is direct attention training

Answer 4

A restorative component approach that trains sustained attention

Question 5

What is strategy (metacognitive) training?

Answer 5

a compensatory strategy

Question 6

What does research say about strategy training?

Answer 6

more benefit for complex tasks that require attention regulation, fewer for basic aspects of attention

Question 7

What does research say about acute stages of treatment?

Answer 7

inssufficient evidence to seperate effects of specfic training vs spontaneous recovery

Question 8

What does research say about computer attention training

Answer 8

Can be used as supplement, but not only treatment

Question 9

What are prinicples of attention rehab?

Answer 9

1) should work from a theoretical model/framework
2) tasks should be hierarchically organized
3) repetition is essential but supplement with strategy training
4) real world application is key
5) record performance with treatment decisions in mind (accuracy and speed)

Question 10

How is attention affected in TBI/Rt CVA? (4)

Answer 10

1) all aspects can be impaired
2) unable to complete formal diagnostics secondary to attentional impairments
3) may have intact attention during simple/daily routines
4) demonstrate deficits in demanding tasks or distracting environments

Question 11

Rancho Levels 2-3

• __________ __________
• _________ attention
• Sessions?
• GOAL = (3)

Answer 11

• sensory stimulation
• focused attention
• several short 10-15 min daily
• 1) increases alertness/response to environment, 2) increase consistency and specificity of response, 3) SLPs train others how to do this

Question 12

What is coma stimulation?

Answer 12

the application of enviornmental stimuli to attempts to heighten arousal and elicity meaningful beahvorial responses

Question 13

What is the theory behind coma stimulation?

Answer 13

environmental enrichment prevents sensory deprivation

Question 14

Who is coma stimulation done with?

Answer 14

Coma/severe TBI
GCS < 10
Rancho 2, 3

Question 15

What would be in a coma stimulation kit? (5)

Answer 15

1) visual (flashlight, favorite photos, familiar faces, mirror)
2) auditory (music, audiobooks, familiar voices)
3) olfactory (coffee, oranges, perfume)
4) tactile (stuff bristle brush, fur, hot/cold packs)
5) kinesthetic (passive ROM)

*use items of personal relevance when possible

Question 16

What are 5 strengths of coma stimulation?

Answer 16

1) low risk
2) low cost
3) stimulates all senses
4) family participation
5) can be meaninful

Question 17

What are 3 weaknesses of coma stimulation?

Answer 17

1) class III evidence (small studies, weak methods)
2) increased arousal doesn’t necessarily correlate with improved vigilance
3) questionable outcomes with individuals in persistent vegetative states

Question 18

Rancho Level 4:

• What is done to reduce confusion, disordiention, and control innapropriate bhevior?
• _____________ treatment
• _____________ management
• works best with what type of consequences?

Answer 18

• environmental control
• behavioral
• pharmacologic
• tangible, primary (food, music, massage) consistently following occurrence of targeted behavior

Question 19

What are environmental modifications that may occur for Rancho Level 4?
Acute?
Chronic?

Answer 19

Acute = caregiver directed
Chronic = goal is patient directed

Question 20

Enviornmental modifications are ____________ in nature. What are some examples?

Answer 20

compensatory

avoid crowds, silence phone, manage fatigue, use noise cancelling headphones, etc

Question 21

The use of enviornmental control does what?

Answer 21

creates maximally stable and predictable surroundings

ex: therapy, meals, and family visits scheduled at consistent times

Question 22

What are the 2 types of orientation training/drills?

Answer 22

1) passive

2) active

Question 23

Passive orientation drills are used for what patients?

Answer 23

immediate post coma phase

Ranchos 3, 4, and 5

Question 24

Passive orientation drills help orient the patient to what? (4)

Answer 24

1) who they are
2) where they are
3) why are they here
4) current hour, day, month, and year

Question 25

What is active orientation training?

Answer 25

Pt given responsibility for carrying out daily life activities that involve orientation (e.g., know therapy schedule, know when to go to lunch, know when their fav tv show is on)

Question 26

Rancho Levels 5 and 6

• focus on increasing patients what?
• simulating basic what? (3)
• goals (3)

Answer 26

• control over immediate environment
• cog skills, motor func, sensory func
• 1) reestablish basic selfcare skills, 2) improve orientation, 3) reestablish functional communication

Question 27

What is component/direct training?

1) when to start it?
2) goal
3) start focusing on what?

Answer 27

1) when less agitation and disorientation, ranch 6 and 7 (some 5)
2) facilitate cog processes by drill
3) cog processes (att, mem, lang, comm)

Question 28

What is attention process training (APT) (sohlberg and mateer)

Answer 28

treatment program developed tasks in heirarchy for each component of attention

Question 29

What are tasks in APT?

Answer 29

shape/number cancellation
addition/subtraction flexibility
listening for specific number/letter orders

Question 30

What pt population would APT be used with?

Answer 30

mild to severe TBI and stroke

Question 31

What are strengths of attention process training? (4)

Answer 31

1) ease of admin
2) clear and concise
3) easy to monitor progress
4) different levels of difficulty

Question 32

What are weaknesses of attention process training? (4)

Answer 32

1) limited generalization
2) not functional
3) supplementation with other methods warranted
4) predictable and can improve with practice vs. attentional improvements

Question 33

What are areas of APT generalization activities?

Answer 33

1) sustained attention
2) alternating attention
3) selective attention
4) divided attention

Question 34

What are higher and lower level APT generalization activities for sustained attention?

Answer 34

lower: listen for target words or sequences
higher: cooking, child care, cleaning, typing, stocking shelves, paperwork, data entry, driving, completing a list of errrands

Question 35

What are higher and lower level APT generalization activities for alternating attention?

Answer 35

lower: listening for one word then switch to listening for another word, paper/pencil task requiring alternating addition and subtraction
higher: bookwork with phone interruptions, housecleaning with child care responsibilities, stocking shelves with interruptions from customers

Question 36

What are higher and lower level APT generalization activities for selective attention?

Answer 36

lower: any of above tasks while introducing distractions
higher: household chores with tv on, doing puzzles with background conversations, eating at a busy/loud cafe

Question 37

What are higher and lower level APT generalization activities for divided attention?

Answer 37

lower: reading paragraph for comprehension and simultaneously scanning for a target word
higher: getting your toddler dressed while talking on the phone, getting directions from maps while driving

Question 38

Rancho Level 7

• treatment of cognitive skills including what?
• what might become apparent at this level
• start teaching what?

Answer 38

• att, memory, planning, organization
• cog impairments may not improve with direct treatment
• teaching compensatory strategies

Question 39

Rancho Level 8+

• _______________ strategies
• facilitating what for the patient?

Answer 39

• compensatory

- reentry to family/community/school/work environments

Question 40

What are the findings about training specific skills (e.g., making a cup of coffee)

Answer 40

may be more effective treatment forms

Question 41

How should self-management strategies be used?

Answer 41

in combo with other approaches

Question 42

What are some types of self-management strategies? (2)

Answer 42

1) self-pacing to limit fatigue

2) orientation strategy to reduce lapses in attention

Question 43

What is neglect and what does it require?

Answer 43

unawareness often exhibited in the acute state, requires team approach

Question 44

What are treatments for neglect (3)

Answer 44

1) visual scanning strategies
2) “anchoring” training pt to look to the left
3) “lighthouse strategy”

Question 45

What are principles of visual scanning training?

Answer 45

1) locus of the stimulus
2) anchoring
3) pacing
4) density
5) information load
6) performance prediction and feedback

Question 46

What is required for systematic and orderly scanning training?

Answer 46

1) establish pt understanding of the problem
2) gather and prepare materials
3) training in single stimulus visual cancellation

Question 47

What is the next step of systematic and orderly scanning training once drill has been mastered?

Answer 47

can move to more functional tasks, reading, writing, describing pictures

Question 48

What are examples or functional applications of systematic and orderly scanning training

Answer 48

puzzles, simple board games, describing a scene/room