4/12/2016. Cognitive rehabilitation is therapy to improve cognitive skills and has two main approaches, remediation and compensation:

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problem solving, decision making, and judgment Controlling impulses Cognitive rehabilitation is therapy to improve cognitive skills and has two main approaches, remediation and compensation:

1 Brain injury can affect how a person feels, thinks, acts, and relates to others. Sandi Mulliner, MS, CCC SLP St. Cloud Hospital Speech Therapy Department Cognition includes: Attention and concentration Processing and understanding information Memory Communication Planning, organizing, and sequencing Reasoning, problem solving, decision making, and judgment Controlling impulses Cognitive rehabilitation is therapy to improve cognitive skills and has two main approaches, remediation and compensation: Remediation focuses on improving skills that have been lost or impaired. Compensation helps you learn to use different ways to achieve a goal. A person with a brain injury may be unable to focus, pay attention, or attend to more than one thing at a time. This may result in: Restlessness and being easily distracted. Difficulty finishing a project or working on more than one task at a time. Problems carrying on long conversations or sitting still for long periods of time. What can be done to improve attention and concentration? Decrease distractions. Focus on one task at a time. Begin practicing attention skills on simple, yet practical activities (such as reading a paragraph or adding numbers) in a quiet room. Gradually make the tasks harder (read a short story or balance a checkbook) or work in a more noisy environment. Teach the person to recognize mental fatigue, and to take rest breaks as needed. After brain injury, a person s ability to process and understand information often slows down, resulting in the following problems: Taking longer to grasp what others are saying. Taking more time to understand and follow directions. Having trouble following television shows, movies, etc. Taking longer to read and understand written information including books, newspapers or magazines. Being slower to react. Being slower to carry out physical tasks, including routine activities like getting dressed or cooking. 1

2 What can be done to improve the ability to process and understand information? Being able to focus attention is important. Decrease distractions when able. Focus on attention training in therapy. Provide the person more time to think about the information before moving on. Teach the person to re read information as needed, make notes and summarize in their own words. Teach the person to ask people to repeat themselves, to say something in a different way, or to speak slower. Communication problems can cause persons with TBI to have difficulty understanding and expressing information in some of the following ways: Difficulty thinking of the right word Trouble starting or following conversations or understanding what others say Rambling or getting off topic easily Difficulty with more complex language skills, such as expressing thoughts in an organized manner Trouble communicating thoughts and feelings using facial expressions, tone of voice and body language (non verbal communication) Having problems reading others emotions and not responding appropriately to another person s feelings or to the social situation Misunderstanding jokes or sarcasm Try and use a gentle or non threatening tone of voice. Try not to talk down to the person. When talking to someone with a brain injury, ask every so often if he or she understands what you are saying, or ask the person a question to determine if he or she understood what you said. Do not speak too fast or say too much at once. Try to limit the number of people involved in conversations. Persons with TBI may have trouble learning and remembering new information and events. They may have difficulty remembering events that happened several weeks or months before the injury (although this often comes back over time). Persons with ihtbi are usually able to remember events that happened long ago. They may have problems remembering entire events or conversations. The mind tries to fill in the gaps of missing information and recalls things that did not actually happen. Sometimes bits and pieces from several situations are remembered as one event. If possible, put together a structured routine of daily tasks and activities. Teach the person of their caregivers the importance of organization and keeping things in set locations. Some people benefit from memory aids such as memory notebooks, calendars, daily schedules, daily task lists, cue cards, and computer or phone reminder programs/ apps. In therapy, time and attention is devoted to reviewing and practicing new information often. Persons with TBI may have difficulty planning their day and scheduling appointments. They may have trouble with tasks that require multiple steps done in a particular order, such as laundry or cooking. 2

3 In therapy, exercises are chosen to target planning and organization skills: Make a list of things that need to be done and when. List them in order of what should be done first. Break down activities into smaller steps. When figuring out what steps are needed to complete an activity, sometimes thinking of the end goal and working backwards Individuals with TBI may have difficulty recognizing when there is a problem, which is the first step in problem solving. They may have trouble analyzing information or changing the way they are thinking (being flexible). When solving problems, they may have difficulty deciding the best solution, or get stuck on one solution and not consider other, better options. They may make quick decisions without thinking about the consequences, or not use the best judgment. One goal of cognitive rehabilitation is to teach an organized approach for daily problem solving. Work through a step by step problem solving strategy in writing (e.g. define the problem, brain storm possible solutions, list the pros and cons of each solution, pick a solution to try, evaluate the success of the solution, and try another solution if the first one doesn t work). Individuals with brain injuries may lack self control and self awareness, and as a result they may behave inappropriately or impulsively (without thinking it through) in social situations. They may deny they have cognitive problems, even if these are obvious to others. They may say hurtful or insensitive things, act out of place, or behave in inconsiderate ways. They may lack awareness of social boundaries and others feelings, such as being too personal with people they don t know well or not realizing when they have made someone uncomfortable. Impulsive and socially inappropriate behavior results from decreased reasoning abilities and lack of control. Self awareness requires complex thinking skills that are often weakened after brain injury. Knowing what factors contribute to a behavior s occurrence is critical for understanding and treating behaviors. A (Antecedent) B (Behavior) C (Consequence) Behavior change can result from changing the antecedents or the consequences. Focusing on antecedents for persons with brain injury is critical. You might be able to prevent an unwanted behavior from happening in the 1 st place. Understanding what is rewarding to a person is an important step for effective rehabilitation. Can be used to support positive behaviors. 3

4 1. ASK! Ask the person what is motivating or reinforcing. 2. Ask family members for suggestions. 3. Watch how a person spends their free time or what makes them calm or happy. Person Centered Include the person, as much as possible, in the development of the treatment plan. Supportive Design a plan that makes it very likely the person will succeed, especially in the early stages. Consistency Be consistent when interacting with the person. Abrupt changes in the plan sends mixed messages, and reinforces inappropriate behavior. Positive Only discuss the person s successes when the person is nearby, no matter how minor. (Overhearing people discuss something negative, or behavioral outburst, can have very negative effects.) Treat People with Dignity and Respect The most effective staff those who treat people as unique persons with dignity and respect. Stay Calm When a patient is confused, frustrated, depressed, or actively agitated, the last thing needed is a staff member who exacerbates the situation by failing to stay calm. Don t Take Things Personally Unwanted behavior occurs for very specific reasons. The person may not have control over them so there is not reason to take things personally. Avoid Arguments Even if you are right, it is often impossible to win an argument in light of the person s cognitive deficits in reasoning, judgment, or impulsive decision making. It is better to avoid the arguments completely by declining to discuss the issue, or better yet, by redirecting the person to another topic. CHANGES IN THINKING Distractibility Difficulty with changes in routine Impaired safety awareness Poor insight Relating information or events believed to be true, that have not happened Difficulty understanding cause and effect BEHAVIORS/ EMOTIONS Aggression or property destruction Yelling and angry outbursts Decreased frustration tolerance Paranoia Mood swings (lability) Decreased sensitivity to others Impulsivity and hyperactivity Pt attempts to get out of bed, kicking, ripped through soft wrist restraint, attempts to strike and bite staff; poor safety awareness, risk for self injury. Staff assist called, able to get legs back into bed. Precedex gtt increased, 2 of Versed given, PRN Seroquel given. Resting with eyes closed. Pt displaying aggression, yelling out, and attempt to attack staff, also verbally threatening stating: You're dead, get me out and you are dead." Have attempted several approaches without success to deescalate behavior. Soft bilateral wrist and ankle restraints on, posey belt blin place. Pt able to manipulate soft restraints and continuously requiring restraint adjustments which escalates behavior. Pt not taking PO medications, refusing to open mouth or take any other PO. Per psych, IM zyprexa has not helped and only escalates behavior and IM Geodon not available until tomorrow per pharmacy. Due to behaviors, MD up to see and order for behavioral restraints obtained. Security and charge nurse present. 4

5 When I ask her if she remembers falling off the horse, she says she did not fall off a horse and says I need to get the story straight. What she says happened is that she injured her head while swimming. She says that she apparently ran into a muskrat den. I asked her when she was admitted to the hospital and she says two days ago when in reality she has been here since May 3. Posey restraint remained off during the night. Rested quietly with eyes closed for most of the night, then was awake at Pleasant and cooperative. Continues to be disoriented to situation. "I'm here because they are trying to figure out what is going on with my baby." Does not believe she has had a head injury and says that is a made up story. Reciting recipes and talking about craving home made food. Pt continues to believe she is going to Australia in July with family and friends and Channing Tatum in her husband ss plane. Patient believes she is at the St. Cloud Hospital for low heart rate and to see if she is pregnant. She believes she got the head wound from when she helped someone move. Patient cooperative this overnight shift; taking medications; allowing vitals and assessment; and resting between cares. Patient had popcorn and soup before bed, watched a movie. No restraints needed, 1:1 present both in and out of the room. Patient able to identify medications in med cup and stated she would refuse depakote if given for seizure, but she will take it if given as a mood stabilizer so she can get out of this hospital. Patient also spoke about having a slow heart rate, being pregnant, and her husband will pick her up tomorrow with his airplane. She has experienced significant behavioral problems and has been in and out of restraints. The head injury appears to have exacerbated her already strong, angry and unpredictable personality. Prior to this hospitalization she did not have any formal mental health diagnosis but, from the description of her behaviors from family members, it appears that there has been some type of undiagnosed personality disorder. VOA Positive reinforcers A B C Winning the argument Clear communication Routine Manage the environment Don t assume 5

6 Each person in rehabilitation must be approached as an individual with unique backgrounds and current abilities and disabilities. The most effective treatment planning is tailored to the specific needs of the individual. REMEMBER: A person with a brain injury is a person first. with braininjury.htm The Essential Brain Injury Guide: Edition 4.0. Brain Injury Association of America. (2009). No two brain injuries are exactly the same. 6

Functional Approaches to Managing Memory and Cognitive Deficits in Individuals with Traumatic Brain Injury. Janice Osborne Dowdy, MS, CCC-SLP, CBIS

Functional Approaches to Managing Memory and Cognitive Deficits in Individuals with Traumatic Brain Injury Janice Osborne Dowdy, MS, CCC-SLP, CBIS Objectives In this course, participants will 1. Understand