Cognitive Rehabilitation
Mary Pepping, Ph.D., ABPP-CN
Professor
Director, Neuropsychology Service and
Outpatient Neuro-Rehabilitation Program
Department of Rehabilitation Medicine
University of Washington Medical Center
Seattle, WA

Cognitive Rehabilitation
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What is it?

Evidence-based, systematic treatments designed to improve thinking performance
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One important component of effective neuro-rehabilitation
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Who provides it?
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Neuropsychologists, speech pathologists, occupational therapists

Evidence for effectiveness of
Cognitive Rehabilitation
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There is a literature on this topic
(handout list available at front)
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Can we teach people how to think more effectively?
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How do you train people to apply that good thinking more effectively in life?
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What are the barriers to effective function?

Barriers to treatment benefit for improved cognitive function
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Very severe cognitive or behavioral impairments that prevent participation
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Inability to pay attention
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No demonstrated evidence of ability to learn new information or prodecures
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Active drug or alcohol abuse
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Aggressive behaviors
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Suicidal behaviors
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Psychotic hallucinations, delusions

Cognitive Rehabilitation:
How does it work?
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Determine “upstream” or underlying sources of cognitive deficits
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Teach the patient techniques to manage or improve those deficits
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Drill the techniques until they become overlearned, automatic procedures
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Practice the techniques in a range of settings: clinic, home, community, workplace, school

Role of Neuropsychological
Evaluation in Cog Rehab
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Comprehensive evaluation to identify overall level of skills and deficits and specific features of ability and difficulty
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What are primary obstacles to improved thinking and function?
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How does the person learn best?
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What kinds of techniques are they able to manage and accept?

Common Neurocognitive
Problems in TBI/ABI
Complex Attention
Screening out distractions
Maintaining one’s focus
Multi-tasking
Complex Memory
Acquisition
Retrieval
Executive Functions
Main Idea Development, Inferences, Planning,
Organization, Higher level problem solving
Speed of information processing

Complex Attention –
Screening out Distractions
Basic techniques for work or home tasks:
Reduce environmental noise and clutter
TV, radio, iPod off
Phones and electronic devices muted
One project at a time on desk or desktop
Create blocks of “no interruptions” time
Use re-direction for inner distractions, e.g.
“I’m doing (THIS TASK ONLY) now”
Quickly jot down distracting ideas then ignore

Complex Attention:
Multi-Tasking at Work
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Reduce incoming information load
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Smaller group meetings
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Focused agenda
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Note-taking help
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One person talks at a time
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Send out summary for feedback
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Use email when possible for incoming and outgoing ideas and plans

Complex Attention:
Multi-tasking at home

Practice with two tasks:
Laundry and cooking
Bill paying and answering phone
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Use electronic supports to cue you
Set timers/alarms to check tasks
Remind self of two tasks – post notes
Note on door to garage to check tasks

Memory Acquisition
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Divide and Conquer:
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Organize new information into fewer and more meaningful sub-groups
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Learn how to take good notes
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Main ideas and key details
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Record and review soon after
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Correct notes, write summary
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Memorize the main ideas and key words

Memory Acquisition
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In conversation
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Ask speaker to talk more slowly if needed
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Briefly summarize points of conversation
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Clarify confusion by asking questions
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Jot down notes as soon as possible
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Call to double-check you have it right

Memory Retrieval
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Review your notes prior to your next meeting or conversation and refer to them as needed during meeting
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Practice recalling main points of what you hear or read before meeting
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Use helpful mnemonic devices, e.g., link name of new person to something that will help cue you to their name

Electronic Devices
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Smart phones – iPhone, Droids,
Blackberrys, Palm
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Schedules of appointments
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Who, what, when, where, why
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Names, addresses and phone numbers
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To do lists, shopping lists
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Special alarm tones linked to specific tasks, appts, reminders, people, events

Electronic Devices continued
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Sync with your computer – Google calendar, Palm calendar, contacts
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Get your kids or grandkids to help you!
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Arrange for computer support
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Use dictation software
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Get assistive technology consultation at your medical center

Executive Function:
Main Idea Development
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Start with professional help: SP, NP, OT
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How to determine main ideas
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“What is the article or program about?”


Summarize main points in 2-3 sentences
Using “telegram” technique to winnow down to one or two essential ideas, e.g., can you create a 7-10 word telegram that conveys basic topic?

Executive Function:
Main Idea Development con’t

Reading comprehension
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Usually one main idea per paragraph
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Use title, first and last sentence as cues
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Look for people, events, actions, ideas
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Jot down key ideas, characters as you read
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Write a summary note
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Explain what you have read to someone else
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Ask yourself questions about the topic, look for answers in the article
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Start with something brief and manageable

Executive Function:
Organization, Problem-Solving
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Get professional help to set up strategies and systems – SP, NP, OT
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Practice systems on real projects
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ABODES systems
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A ssess situation, B reak into steps, O rder the steps chronologically, D etermine what supplies or personnel are needed, E stimate time to complete each step, S urvey work as it proceeds to make needed corrections.

Executive Function:
Organization continued


Consider hiring a home organizer
Divide and conquer – do not tackle all your projects or problems at once
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Schedule specific times to tackle the task, pace yourself, reward yourself
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Get a well-organized friend to help you sort through papers or belongings, e.g., the “Yes, No, Maybe” system

Higher Level Problem Solving
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Use of a grid/table for figuring out best options: e.g., travel plans
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What are all of the variables to consider?
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What are your preferences and limits:
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Where to go (family visit, foreign travel, U.S?), with whom, budget, time for trip, airline miles, hotel preferences/credits, preferred activities, travel ins., energy levels, medical needs, cancellation policies
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Airlines/Airplanes, Hotel/Rental, Ground transport, Meals, Entertainment, Clothing

Meta-Cognitive Skills
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“The Big Picture”
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What is the best approach for a particular kind of problem or task?
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Where do main points work best?
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Brief conversations
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Email communication at work
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Basic To-Do Lists

MetaCognitive Skills (con’t)
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Where do you need added details
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Complex projects and plans
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Multi-step errand lists
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Priority items (Bank, Post office, Dry cleaners, Store)
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Geographic layout of locations
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What needs to be done at each place?
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Bank: Deposits, cash check

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Post office: Pick up package, buy postage
Drop off three items, schedule P/U date in book!
Buy groceries for party (bring list!)

Other general supports for improved cognitive function
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Appropriate use of medications
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Pacing of activities
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Exercise
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Fatigue Management
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Treatment of depression, anxiety
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Make sure vision and hearing are as good as possible

Cognitive Rehabilitation:
General supports continued
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Create and maintain efficient weekly schedules for routine tasks so they become automatic habits
Develop and use only one memory system for calendar, schedule, to do list
Pick one specific practical problem to change, work on that, make it better, then tackle the next one
Practice thought-stopping to redirect your attention and stick with your task or plan

Cognitive Rehabilitation


A critical component of neuro-rehabilitation
Targets each patient’s key cognitive hurdles

Develops hierarchical plan of intervention, e.g., upstream or underlying issues first

Teaches patient awareness of + and -
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Trains specific approaches to problems
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Extends strategies to real life settings
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Teaches metacognitive skills (how to observe, understand and change thinking)