1. Interventions for Cognitive Dysfunction OT 460A
11/16/09
Interventions for Cognitive Dysfunction of Persons with Traumatic Brain Injuries
OT 460A
OT 460A

2. Interventions for Cognitive Dysfunction
11/16/09
Remedial Approach
Also called Cognitive Retraining
Focuses on cognitive domains, e.g., attention, that are identified through assessments
Belief is that cognitive skills can be dealt with in isolation
Interventions consist of cognitive exercises, e.g., computer programs, are used to work on deficits
Progress is measured through measuring percentage correct and speed of performance
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OT 460A
OT 460A

3. Graded Cognitive Exercises
Interventions for Cognitive Dysfunction
11/16/09
Graded Cognitive Exercises
Abreu and Toglia’s (1987) recommendation to gradually increase demands on the information processing system
Interventions consist of pencil and paper tasks such as mazes and work sheets
Computer-based activities and board games are also used.
11/16/09
OT 460A
OT 460A

4. Cognitive Remediation Strategies
Interventions for Cognitive Dysfunction
11/16/09
Cognitive Remediation Strategies
Pencil and Paper and Tabletop Activities
“Drill and practice” tasks, mazes, work sheets
Computer-based exercises
Offers repetition and consistency
There is specialized cognitive remediation software that offer assessment and intervention
Effectiveness hasn’t been well supported empirically
Some studies demonstrating correlation between drill and practice strategies and improvement in attention and memory
May be secondary gain of facilitating initial acceptance of disability (See Practice 29-1 on p. 756 for examples of interventions to improve self-awareness
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OT 460A
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5. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Change the context so as to lower the cognitive demands
Physical context: Examples: Use labels on drawers; decrease visual stimulation
Social context: Example: Teaching loved ones dignified methods for prompting and cueing
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OT 460A
OT 460A

6. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Establish Behavioral Routines and Habits
Loss of effortless predictability has profound impact on energy level and sense of continuity, competence, and self
Habit learning: Form of implicit learning
Includes “automaticity”: the ability to perform a skilled task with minimal or no processing resources
Context and encoding are associated; so, if you change the context, the person may not be able to retrieve the task-relevant information
11/16/09
OT 460A
OT 460A

7. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Guidelines for establishing behavioral routines and habits
Select target of intervention
Analyze physical and social contexts in which the routine is expected to occur
Complete a task analysis
Collaborate with client and significant others to decide optimal sequence of steps and the use of chaining, prompting, and reinforcement
Facilitate consistent repetition of routine beyond mastery to promote overlearning
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OT 460A
OT 460A

8. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Learn compensatory strategies
Includes the use of aids, devices, and thinking techniques in multiple contexts
Use of Toglia’s Dynamic Interactional Model of Cognition: cognition is a product of the dynamic interactions between the person, the activity, and the environment
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OT 460A
OT 460A

9. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
The General Model for Learning Compensatory Strategies
Organized around 4 training phases:
Anticipation: experience consequences of cognitive deficits
Acquisition: use of drill and practice exercises to learn compensatory tool or strategy
Application: use of compensatory strategies during clinic-based simulated work tasks
Adaptation: strategy is adapted to personal preferences and multiple applications in real life
11/16/09
OT 460A
OT 460A

10. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Internal Information-Processing Strategies:
Teach client to use mental strategies that facilitate encoding and storage of information
Techniques are similar to remedial approach and include strategies like rehearsal, visual imagery, semantic elaboration (see Table 29-4– it may help you with your study habits!)
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OT 460A
OT 460A

11. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Memory Prostheses
Include day planners, diaries, memory notebooks (some studies demonstrate effectiveness of use of memory notebooks)
Did you know that you were using a prosthesis everyday?
In order for the use of this to be successful, the client must carry it with her, religiously record information in appropriate sections, and look at it regularly during the day
11/16/09
OT 460A
OT 460A

12. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Other Memory Prostheses
Alarm watches, pagers, phones
Can be used for occupations like medication management
Client factors and not clinician preferences should be the most important determinants of selection of devices
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OT 460A
OT 460A

13. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Problem-Solving & Decision-making skills are comprised of:
A Situation (task, environment, and person)
A Process:
Problem definition
Evaluation of alternative solutions
Determining and implementing a plan
Evaluating the results of a implementation
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OT 460A
OT 460A

14. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Strategies for minimizing the demands on problem solving:
Change the environment
Establish consistent routines
Employ problem solving schemas
Means-end analysis
IDEAL Problem Solver
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OT 460A
OT 460A

15. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Strategies for minimizing the demands on problem solving
Means-Ends Analysis (Divide and Conquer)
Used to organize multi-step, unstructured projects
Involves a 4 step process:
List the major task components
Write down sub-steps under each component
Number the sub-steps
Determine deadlines
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OT 460A
OT 460A

16. Interventions for Cognitive Dysfunction
11/16/09
Adaptive Strategies
Strategies for minimizing the demands on problem solving:
IDEAL Problem Solver involves 5 steps:
Identify the problem
Define the problem
Evaluate all possible solutions
Act
Look back
11/16/09
OT 460A
OT 460A

17. What Does the Evidence Tell Us?
Interventions for Cognitive Dysfunction
11/16/09
What Does the Evidence Tell Us?
Strategy training can be successful for some clients in the post-acute phase of TBI, but there is insufficient evidence to support use of it in acute or inpatient phases
Compensatory training using notebooks, electronic devices, and internal strategies are most successful when applied to functional situations
11/16/09
OT 460A
OT 460A

18. What Does the Evidence Tell Us?
Interventions for Cognitive Dysfunction
11/16/09
What Does the Evidence Tell Us?
Training where problem-solving strategies are applied to functional situations is recommended in the post-acute phase
There is no evidence for effectiveness of interventions to restore memory function in clients with severe impairments
Therapists need to be involved where there is sole reliance on repeated exposure and practice on computer-based and workbook tasks
11/16/09
OT 460A
OT 460A