EVALUATION OF COGNITION AFTER NEUROLOGICAL INJURY IN ADOLESCENTS AND ADULTS CHARITY SHELTON, MS, CCC-SLP, CBIST MERCY NEURO OUTPATIENT THERAPY SERVICES – SPRINGFIELD, MO

1 ST HOUR PRE-EVALUATION PROCEDURES NATIONAL COGNITIVE FUNCTION MEASURES COGNITIVE SCREENING TOOLS ASSESSMENT OF SEVERELY/PROFOUNDLY IMPAIRED COGNITION 2ND HOUR ASSESSMENT OF MODERATELY IMPAIRED COGNITION 3 RD HOUR ASSESSMENT OF MILDLY IMPAIRED COGNITION 4 TH HOUR EVALUATION REPORT WRITING WITHIN-TREATMENT ASSESSMENT CASE STUDIES AND REVIEW

COMMON “ISSUES” “MY PATIENT’S FUNCTIONING IS TOO LOW TO CONDUCT ANY TYPE OF COGNITIVE TESTING” “I AM NOT ALLOWED ENOUGH TIME TO CONDUCT THE TYPE OF EVALUATION I WOULD LIKE TO COMPLETE” “I COMPLETED MY EVALUATION AND THOUGHT I HAD A GOOD IDEA OF HIS/HER COGNITIVE FUNCTION, BUT NOW THAT I’VE WORKED WITH HIM/HER, I’M NOTICING SO MUCH MORE.” “MY PATIENT AND/OR THEIR FAMILY COMPLAIN OF COGNITIVE DEFICITS, BUT MY TESTING DOESN’T SHOW ANYTHING THAT IS BELOW NORMAL LIMITS.”

PRE-EVALUATION

BEFORE EVALUATION NEVER UNDERESTIMATE THE POWER OF A GOOD HISTORY AND CHART REVIEW IF YOU CAN TALK WITH A PREVIOUS THERAPIST, SOCIAL WORKER, ETC. FAMILIAR WITH THE PATIENT, DO IT BEFORE BEGINNING EVAL, CHAT WITH THE PATIENT (AND/OR FAMILY IF AVAILABLE) IF POSSIBLE, KNOW DISCHARGE PLAN/RELATED ISSUES TALK WITH OTHER TREATMENT TEAM MEMBERS FOR INPUT ABOUT FUNCTIONAL ABILITIES

INTERDISCIPLINARY EVALUATION IS VERY IMPORTANT YOU ARE NOT AN ISLAND UNTO YOURSELF SLPNURSING OTPHARMACIST PTSOCIAL SERVICES PHYSICIANFAMILY NEUROPSYCHPATIENT

NATIONAL COGNITIVE FUNCTION MEASURES 2012 MSHA Conference

RANCHO LEVELS RANCHO LEVELS OF COGNITIVE FUNCTION (DEVELOPED FOR USE AFTER TRAUMATIC BRAIN INJURY) EACH LEVEL IS DESCRIPTIVE OF A PERSON’S COGNITIVE FUNCTIONING, INCLUDING RELATED BEHAVIORS 10 LEVELS: 1 TO 10; 1 = COMPLETELY DEPENDENT; 10 = COMPLETELY INDEPENDENT

FIM (FUNCTIONAL INDEPENDENCE MEASURE) UNIFORM DATA SET/MEDICAL REHABILITATION, 1999 – FUNCTIONAL AREAS INCLUDING MOTOR, PHYSICAL, SELF- CARE AND COGNITIVE-LINGUISTIC FUNCTION. SLPS COMPLETE FIM SCORES FOR AUDITORY/VISUAL COMPREHENSION, VERBAL/NONVERBAL EXPRESSION, PROBLEM SOLVING, (SOCIAL INTERACTION), MEMORY SCALE OF 1 TO 7; 1 = COMPLETELY DEPENDENT OR LACK OF FUNCTIONAL ABILITY ; 7 = COMPLETELY INDEPENDENT

FAM (FUNCTIONAL ASSESSMENT MEASURE) WRIGHT, J ( ) ADJUNCT TO FIM TO ADDRESS AREAS LESS EMPHASIZED IN FIM, INCLUDING COGNITIVE, BEHAVIORAL, COMMUNICATION AND COMMUNITY FUNCTIONING MEASURES. 12 ITEMS INTENDED TO BE ADDED TO FIM SCALE OF 1 TO 7; 1 = COMPLETELY DEPENDENT OR LACK OF FUNCTIONAL ABILITY; 7 = COMPLETELY INDEPENDENT FIM + FAM

FAM: AREAS PERTINENT TO COGNITION COMMUNITY ACCESS READING WRITING EMOTIONAL STATUS ADJUSTMENT TO LIMITATIONS EMPLOYABILITY ATTENTION ORIENTATION SAFETY JUDGMENT

ASHA NOMS/FCM ASHA, 2003 ASHA NATIONAL OUTCOME MEASURE SYSTEM; FUNCTIONAL COMMUNICATION MEASURES 15 AREAS COGNITIVE AREAS INCLUDE: ATTENTION, MEMORY, PRAGMATICS, PROBLEM SOLVING SCALE OF 1 TO 7; 1 = COMPLETELY DEPENDENT OR LACK OF FUNCTIONAL ABILITY; 7 = COMPLETELY INDEPENDENT

NATIONAL COGNITIVE FUNCTION MEASURES ALL THESE CAN BE USED AS ADDITIONAL INFORMATION TO BE ADDED TO YOUR MORE SPECIFIC, STANDARDIZED MEASURES OF COGNITIVE FUNCTION

COGNITIVE SCREENING TOOLS

CONSIDERATIONS CULLIN, O’NEILL, ET AL, 2007 A SCREENING IS NOT INTENDED TO REPLACE A MORE COMPREHENSIVE ASSESSMENTS THE BEST SCREENING TOOLS WILL COVER THE FOLLOWING 6 AREAS, BASED ON ESTABLISHED COGNITIVE AND NEUROPSYCHOLOGICAL CHARACTERISTICS IN VARIOUS DEMENTIAS (AND COGNITIVE DYSFUNCTION IN GENERAL) ATTENTION/WORKING MEMORY, NEW VERBAL LEARNING AND RECALL, EXPRESSIVE LANGUAGE, VISUAL CONSTRUCTION, EXECUTIVE FUNCTION AND ABSTRACT REASONING.

MINI MENTAL STATUS EXAM (MMSE) FOLSTEIN, M., FOLSTEIN, S.E., MCHUGH, P.R., 1975

MINI MENTAL STATUS EXAM (MMSE) DEVELOPED TO SCREEN FOR COGNITIVE FUNCTION IN OLDER ADULTS BUT MAY BE USED WITH OTHER ADOLESCENTS/ADULTS WITH COGNITIVE IMPAIRMENT 5 AREAS OF SCREENING: ORIENTATION, REGISTRATION, ATTENTION AND CALCULATION, RECALL, AND LANGUAGE MAXIMUM SCORE OF 30; 23 OR LOWER INDICATES COGNITIVE IMPAIRMENT TAKES 5 TO 10 MINUTES TO ADMINISTER

ST LOUIS UNIVERSITY MENTAL STATUS (SLUMS) EXAM TARIQ, TUMOSA, CHIBNALL, PERRY & MORLEY, 2006

DESIGNED TO DETECT EARLY NEUROCOGNITIVE DECLINE OR MILD DEFICITS AS A RESULT OF EARLY DEMENTIA 11 ITEMS: ORIENTATION, SHORT-TERM MEMORY, CALCULATIONS, NAMING, CLOCK DRAWING, AND RECOGNITION OF GEOMETRIC FIGURES.

ST LOUIS UNIVERSITY MENTAL STATUS (SLUMS) EXAM TARIQ, TUMOSA, CHIBNALL, PERRY & MORLEY, 2006 SCORES UP TO 30: = NORMAL IN A PERSON WITH A HIGH SCHOOL EDUCATION SUGGEST MILD COGNITIVE DEFICITS, INDICATE DEMENTIA OR MODERATE TO SEVERE COGNITIVE DEFICITS 7-10 MINUTES TO ADMINISTER

MONTREAL COGNITIVE ASSESSMENT (MOCA) NASREDDINE ZS, PHILLIPS NA, ET AL. 2005

MONTREAL COGNITIVE ASSESSMENT (MOCA) DESIGNED TO QUICKLY ASSESS COGNITION IN VARIOUS NEUROLOGICAL DISORDERS, INCLUDING DEMENTIA 7 AREAS INCLUDING: VISUOSPATIAL/EXECUTIVE, NAMING, MEMORY, ATTENTION, LANGUAGE, ABSTRACTION DELAYED RECALL, AND ORIENTATION SCORES UP TO 30: ***

MONTREAL COGNITIVE ASSESSMENT (MOCA) 10 MINUTES TO ADMINISTER HAS 3 DIFFERENT VERSIONS FOR PRE AND POST TREATMENT ASSESSMENT TEST IS AVAILABLE IN MULTIPLE LANGUAGES HAS AN ELECTRONIC VERSION FOR I-PAD

BRIEF COGNITIVE ASSESSMENT TOOL (BCAT) MANSBACH, W. E.; MACDOUGALL, E.E.; ROSENZWEIG, A.S. (2012)

BRIEF COGNITIVE ASSESSMENT TOOL (BCAT) DESIGNED TO QUICKLY ASSESS COGNITION TO DETERMINE NORMAL VERSUS MILD COGNITIVE IMPAIRMENT AND DEMENTIA 13 AREAS TO ASSESS: ORIENTATION, VERBAL RECALL, VISUAL RECOGNITION, VISUAL RECALL, ATTENTION, ABSTRACTION, LANGUAGE, EXECUTIVE FUNCTIONS, AND VISUO-SPATIAL PROCESSING

BRIEF COGNITIVE ASSESSMENT TOOL (BCAT) SCORES UP TO 50: SCORE RELATIVE TO NORMAL, MILD COGNITIVE IMPAIRMENT, MILD DEMENTIA, MILD TO SEVERE DEMENTIA MINUTES TO ADMINISTER THERE IS A 5 MINUTE VERSION AVAILABLE THERE IS ONLINE SCORING AND INTERPRETATION AVAILABLE IT HAS A “TEST SYSTEM” WITH VARIOUS ASSESSMENT TOOLS THAT CAN BE USED IN CONJUNCTION WITH THE BCAT

MINI-COG BORSON S, SCANLAN J, BRUSH M, VITALIANO P, DOKMAK A. (2000)

MINI-COG TESTS ONLY 2 AREAS: SHORT TERM RECALL AND CLOCK DRAWING TAKES ONLY 3 TO 5 MINUTES TO ADMINISTER EXAMINEES ARE ASKED TO IMMEDIATELY REPEAT 3 WORDS, DRAW A CLOCK, AND THEN RECALL THE 3 WORDS RECALLING ONLY 1 OR 2 WORDS OR ABNORMAL CLOCK INDICATES POSSIBLE DEMENTIA AND/OR COGNITIVE IMPAIRMENT

OTHER SCREENING TOOLS THE GENERAL PRACTITIONER ASSESSMENT OF COGNITION (GPCOG) BRODATY, H., ET AL., SOME LENGTHIER ASSESSMENTS HAVE A SCREENING-LENGTH VERSION – CHECK THEM OUT! NONSTANDARDIZED SCREENINGS

LOW FUNCTIONING COGNITION

SHORT CLIP OF COLBY

LOW FUNCTIONING COGNITION RANCHO LEVELS 3 TO 4 COGNITIVE FIM/FAM SCORES OF 1 AND 2 ASHA COGNITIVE NOMS OF 1 AND 2

LOW FUNCTIONING COGNITION PROFOUND IMPAIRMENT ALERT, BUT PROFOUND DEFICITS IN ATTENTION AND AWARENESS OF ENVIRONMENT AND OTHERS NO TO ONLY MINIMAL INITIATION OF COMMUNICATION IMPULSIVE/UNSAFE

LOW FUNCTIONING COGNITION MAY EXHIBIT PERSEVERATIVE BEHAVIORS GENERAL PROCESSING DEFICITS UNABLE TO PARTICIPATE IN “BACK & FORTH” OF STRUCTURED EVALUATION/THERAPY SESSION

SEVERE IMPAIRMENT INCREASED COMMUNICATION (COMPARED TO PROFOUND) MAY STATE SIMPLE THOUGHTS/IDEAS BUT NOT DIRECT OWN CARE IMPULSIVE IN PHYSICAL AND MENTAL TASKS MORE AWARE OF ENVIRONMENT AND OTHERS BUT VERY EASILY DISTRACTED BETTER ABLE TO PARTICIPATE IN STRUCTURED THERAPY BUT WITH LOTS OF CUES

LOW FUNCTIONING COGNITION SEVERE IMPAIRMENT CONTINUED NOT ORIENTED MAY BE ABLE TO RECOGNIZE, OCCASIONALLY RECALL FAMILIAR INFORMATION/ROUTINES DEPENDENT FOR PROBLEM SOLVING AT SEVERE/PROFOUND COGNITIVE IMPAIRMENT LEVEL, MAY ALSO HAVE COGNITIVE-BASED VOICE AND SWALLOWING ISSUES

EVALUATION OF LOW LEVEL COGNITION DISABILITY RATING SCALE RAPPAPORT COMA/NEAR COMA SCALE WESTERN NEURO SENSORY STIMULATION PROFILE PORTIONS OF RIPA-2/RIPA-G ? NON-STANDARDIZED ASSESSMENT/OBSERVATION

DISABILITY RATING SCALE RAPPAPORT ET. AL, 1987

DISABILITY RATING SCALE AROUSABILITY AWARENESS AND RESPONSIVITY COGNITIVE ABILITY FOR SELF-CARE ACTIVITIES IN: FEEDING TOILETING GROOMING DEPENDENCE ON OTHERS AND LEVEL OF FUNCTIONING PSYCHOSOCIAL ADAPTABILITY AND EMPLOYABILITY 2012 MSHA Conference

DISABILITY RATING SCALE EYE OPENING (SCORE 0 TO 3) COMMUNICATION ABILITY (SCORE 0 TO 4) MOTOR RESPONSE (SCORE 0 TO 5) FEEDING (SCORE 0 TO 3) TOILETING (SCORE 0 TO 3) GROOMING (SCORE 0 TO 3) LEVEL OF FUNCTIONING (SCORE 0 TO 5) EMPLOYABILITY (SCORE 0 TO 3) 2012 MSHA Conference

DISABILITY RATING SCALE CAN BE USED TO TRACK SOMEONE FROM COMA TO HIGH FUNCTIONING MAXIMUM SCORE = 29 (EXTREME VEGETATIVE STATE) LOWEST SCORE = 0 (A PERSON WITHOUT DISABILITY)

Rappaport Coma/Near Coma Scale Rappaport et. al, 1982 (revised form in 1987)

RAPPAPORT COMA/NEAR COMA SCALE ASSESSMENT OF RESPONSE TO SENSORY MODALITIES: AUDITORY: GENERALIZED/DIFFERENTIATED RESPONSE TO SOUND; FOLLOWING VERBAL COMMANDS VISUAL: RESPONSE TO LIGHT FLASHES, VISUALLY LOCATING THERAPIST; VISUAL THREAT OLFACTORY: RESPONSE TO NOXIOUS STIMULI TACTILE: RESPONSE TO TOUCH, PAIN VOCALIZATION: OBSERVATION OF VOICING

RAPPAPORT COMA/NEAR COMA SCALE FOR EACH TASK, RESPONSIVENESS IS RATED AS FOLLOWS: 0 = QUICK, CONSISTENT RESPONSE 2 TO 3X 2 = DELAYED OR PARTIAL RESPONSE 4 = NO RESPONSE

RAPPAPORT COMA/NEAR COMA SCALE LevelRangeLevel of Awareness/Responsitivity NO COMA: consistently responds to 3 sensory stimulation tests plus consistent response to commands NEAR COMA: consistently responds to 2 sensory modalities and/or inconsistently responds to commands MODERATE COMA: inconsistently responds to 2 or 3 modalities, not responsive to simple commands. May have spontaneous vocalizations MARKED COMA: inconsistent response to 1 sensory modality; not responsive to commands; no voicing EXTREME COMA: no response to any sensory modality; no response to comamnds, no voicing

WESTERN NEURO SENSORY STIMULATION PROFILE (WNSSP) ANSELL, B, KEENAN, J., & ROCHA, O. 1989

WNSSP

RECOMMENDED FOR PATIENTS WHO ARE SLOW TO RECOVER. MEASURES RESPONSIVENESS AS FOLLOWS: AROUSAL/ATTENTION AUDITORY RESPONSE: LOCALIZATION AND COMPREHENSION EXPRESSIVE COMMUNICATION: VOCALIZATION, FACIAL EXPRESSION/GESTURAL COMMUNICATION, YES/NO RESPONSE VISUAL RESPONSE: LOCALIZATION AND COMPREHENSION

WNSSP TACTILE RESPONSE: LOCALIZATION AND COMPREHENSION OLFACTORY RESPONSE: TO SMELL VARIOUS SCORING GUIDELINES BASED ON DIFFERENTIATED/ GENERALIZED RESPONSES, PROMPT OR DELAYED, CUED OR NOT CUED, ETC. CONTAINS 33 ITEMS IN 6 AREAS, FOR A TOTAL SCORE OF 1-113

ROSS INFORMATION PROCESSING ASSESSMENT-2(AGES 15-90) DEBORAH ROSS-SWAIN, 1996 ROSS-INFORMATION PROCESSING ASSESSMENT-G (GERIATRIC – 55+) DEBORAH ROSS-SWAIN, MA & PAUL FOGLE, 1996

RIPA-2 & RIPA-G SEVERE TO PROFOUND COGNITIVE IMPAIRMENT – WILL NOT USE ALL SUBTESTS FOR PROFOUND/SEVERE IMPAIRMENT, USE YES/NO SUBTEST, NAMING OBJECTS AND FUNCTIONAL ORAL READING (RIPA-G) SUBTESTS, PROBE WITH ORIENTATION SUBTESTS…

NON-STANDARDIZED ASSESSMENT/OBSERVATION DIFFERENTIATED VERSUS GENERALIZED RESPONSES AMOUNT OF CUEING NEEDED TO ATTEND FREQUENCY OF COMMUNICATION INITIATION FREQUENCY OF APPROPRIATE/RELEVANT VS INAPPROPRIATE/IRRELEVANT RESPONSES RESPONSE TO FAMILIAR/UNFAMILIAR PERSONS/ SITUATIONS

MODERATE SEVERITY COGNITIVE IMPAIRMENT

RANCHO LEVELS 5, 6, 7 COGNITIVE FIM/FAM SCORES OF 3, 4, EMERGING 5 ASHA COGNITIVE NOMS OF 4, 5

MODERATE IMPAIRMENT CAN PARTICIPATE IN STRUCTURED SESSIONS AWARENESS OF DEFICITS IS POOR – MAY ARGUMENTATIVE OR CONFRONTATIONAL AS A RESULT IMPULSIVE – MAY BE ELOPEMENT RISK CAN DIRECT CARE, BUT MAY NOT BE APPROPRIATE CAN INITIATE ATTEMPTS TO SOLVE PROBLEMS, BUT ONLY APPROPRIATE APPROX. 50% OF TIME

MODERATE IMPAIRMENT CONCRETE IN THINKING – DIFFICULTY OR UNABLE TO DO ABSTRACT REASONING “HIT AND MISS” RECALL OF INFORMATION PARTIALLY ORIENTED DISORGANIZED IN THOUGHT EXPRESSION, TANGENTIAL MAY BE INAPPROPRIATE IN SOCIAL SITUATIONS (DEC. INHIBITION) DECREASED EXECUTIVE FUNCTION ABILITIES

EVALUATION OF MODERATELY IMPAIRED COGNITION SCATBI RIPA-2/RIPA-G ALFA MCLA CLQT RBMT-3 MIRBI TOMAL-2