Dr. Simone Carton
Clinical Neuropsychologist
National Rehabilitation Hospital
simone.carton@nrh.ie
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Neuropsychology
Know the person’s story
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Cognitive status
Emotional status
Behaviour & personality
Cognitive rehabilitation
Psychotherapy
Common Sense
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Does it make a difference? (Yes)
Where does it make a
difference? (Strategies that can
be practically applied to day to
day life).
Importance of adopting a
holistic approach with patient,
family, team etc. in any
intervention.
Clinical summersaults
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Family/social
support
Pre-morbid
factors
e.g coping style
Brain pathology
Cognitive
Impairment
Affect
Insight
Physical
Loss
Functional consequences
Adapted from Biopsychosocial Model (Evans 2006)
Dr. Simone Carton 15.7.2015
Family/social
support
Brain pathology
Stroke, head injury, etc
Cognitive
Impairment
e.g. Memory
Perception
Language
Attention
Executive
Pre-morbid
factors
e.g coping style
Affect
Insight
Physical
e.g. Depression
Anxiety
Anger
Confidence
Motivation
e.g. Hemiplegia
Sensory loss
Dysarthria
Pain
Loss
Functional consequences
Biopsychosocial
Model (Evans
2006)
e.g. Work
ADL
Leisure
Driving
Preliminary Goals
Work, adl, leisure, etc.
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Pre-injury Self
Discrepancy
– threat to self
Current Self
Engage in Tx
Goals; Plan
Develop safety
Make
Activity; Feedback
predictions – reduce threat
Reflection
Updated, adaptive, realistic Self-Presentation
Achieve safety
Identity & build on
Positives
Support generalisation and social participation.
Build confidence and identity
“Safe uncertainty”
Dr. Simone Carton 15.7.2015
Bronfenbrenner (1979)
Dr. Simone Carton 15.7.2015
The diagnosis
Acquired Brain Injury
Dementia
The symptoms: cognitive,
behavioural, emotional
Sense of self
Role in life/society
Supports & opportunities
Future planning
Dr. Simone Carton 15.7.2015
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Rehabilitation implies the restoration of patients to the highest level of
physical, psychological and social adaptation attainable. It includes all
measures aimed at reducing the impact of disabling and handicapping
conditions and at enabling disabled people to achieve optimum social
integration.
(WHO 1986)
A problem-solving process in which the person who experiences a
neurological impairment or loss of function acquires the knowledge, skills
and supports needed for their optimal physical, psychological, social and
economic function.
Dr. Simone Carton 15.7.2015
Cognitive rehabilitation is:
• the systematic use of instruction and structured experience
• to manipulate the functioning of cognitive systems
• such as to improve quality or quantity of cognitive processing
in a particular domain (Robertson, 1999)
Dr. Simone Carton 15.7.2015
Neuropsychological rehabilitation can be described
as any intervention, strategy or technique
which enables patients and their families or
carers to live with, manage, by-pass,
reduce or come to terms with
cognitive deficits.
(Wilson 1999)
Dr. Simone Carton 15.7.2015
Cognitive rehabilitation aims to enable people with cognitive impairments to achieve
their optimum level of well-being by helping to reduce the functional disability
resulting from damage to the brain. Central to this process is the collaborative
identification of personally-meaningful goals and development of interventions to
address these goals.
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Restoration of function
Compensatory strategies
Environmental modification
Emotional support
Psychosocial difficulties
Dr. Simone Carton 15.7.2015
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Restoration
Compensation
Neuroplasticity
Positive Psychology
Problem-solving processes
Educate
Skills training
Supports
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Does the intervention make a
difference?
Does the intervention allow the
person to live their life as fully
as possible?
Dr. Simone Carton 15.7.2015
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Cognitive
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Emotional
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Behaviour
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Personality
Dr. Simone Carton 15.7.2015
Neurorehabilitation in the midst of:
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Despair
Pessimism
Regret
Uncertainty
Absence of hope
Unresolved premorbid issues
Dr. Simone Carton 15.7.2015
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Anxiety
Low Mood,
depression
Apathy
Poor motivation
Anger
Frustration
Irritability
Low self-esteem
Grief
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Aggression
Disinhibition
Impulsive
Inflexible, Rigid
Self-centredness
Emotional ‘Lability’Mood swings
Emotional
flattening/ blunting
Poor insight
Dr. Simone Carton 15.7.2015
Depression
Stroke:
30%
TBI:
27%
Risk of suicide increases
3-4 times.
Anxiety
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Prevalence:
Stroke – 21%
PTSD- 3-27%
following TBI.
Teasdale and Engberg (2001)
Dr. Simone Carton 15.7.2015
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Depression
Generalised Anxiety Disorder
Panic attacks
Obsessive Compulsive Disorder
PTSD
Conversion Disorders
Delusions/
Misidentification (Depersonalisation/Derealisation)
Dr. Simone Carton 15.7.2015
Any behaviour or lack of behaviour of such intensity, frequency,
and/or duration that has the potential to
cause distress or harm to clients/carers/staff
create feelings of discomfort, powerlessness, frustration, fear,
anxiety
delays or limits access to ordinary services or facilities
or is outside socially acceptable norms.
Dr. Simone Carton 15.7.2015
 Challenging behaviour has significant impact on the lives of the
person exhibiting the behaviour, their family and friends, those
supporting them.
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Limit or prevent
participating in
therapies
Reduced quality of life
Family and relationship
strain
Physical Health
Mental Health
STRESS
Expense (e.g.
specialing)
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Isolation
Neglect
Social Isolation and
Exclusion for patient
and family
Discharged early
Not eligible for some
services
Unable to go home
Institutionalisation
Dr. Simone Carton 15.7.2015
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Prigatano (1999) suggests that rehabilitation is
likely to fail if we do not deal with emotional issues.
Feelings of threatened or altered identity are
common (Tyerman and Humphrey, 1984;
Nochi, 1997,1998)
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Being misunderstood or judged by others
(Nochi,1998)
Dr. Simone Carton 15.7.2015
Cognitive changes following ABI
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Intellectual functioning
Attention
Speed and capacity to process information
Learning ability
Memory - specify type e.g. verbal, non-verbal,
immediate, delayed, recognition, episodic,
autobiographical, semantic etc
Perception
Construction
Praxis – Able to plan & undertake basic tasks
Language
Executive (cognitive and behaviour)
Dr. Simone Carton 15.7.2015
The aim of treatment is to improve the
person’s ability to carry out everyday tasks.
The process includes
 Educating about the injury and how and why
it effects them in that way
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Re-establishment of direct skills through
direct retraining.
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Use of compensatory strategies and external
aids
Dr. Simone Carton 15.7.2015
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Changing of neurons, the organisation of
their networks and their function via new
experience
The brain's ability to reorganize itself by
forming new neural connections throughout
life.
Neuroplasticity allows the neurons in the
brain to compensate for injury and disease
and to adjust their activities in response to
new situations or to changes in their
environment.
Functional rehabilitation programmes
support neuroplasticity with goal-directed
experiential therapeutic programs in the
context of rehabilitation approaches to the
functional consequences of the injury.
Dr. Simone Carton 15.7.2015
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Use it or lose it
Use it and improve it
Specificity
Repetition matters
Intensity matters
Time matters
Salience matters
Age matters
Transference
Interference
Dr. Simone Carton 15.7.2015
Low Tech:
 Checklists
 Diaries
 Orientation boards
 Wall calendar/ planner
 Hot spot
High Tech:
 Computer software
 Alarms
 Phones
 SenseCam
 Switches
 Dictaphone
Dr. Simone Carton 15.7.2015
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Pay attention
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Minimise distraction
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Regular routine for
everyday activities
Provide a consistent and
well organised living
environment
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Break down tasks into
small, chunks
Encourage/Remind
family member to use
strategies
Give plenty of time and
practice to learn new
things
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
Low tech
High tech
Dr. Simone Carton 15.7.2015
Not a recipe or a ‘mental gym’
Pick and Mix
Dr. Simone Carton 15.7.2015
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Minimise distractions
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Talk yourself through the
task “What should I be
doing now?”
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Discover the best time of
day to work
Plan a schedule of
activities
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Set deadlines
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Do one thing at a time
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Structure the task within a
set time frame
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Take frequent breaks
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Use incentives
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Don't rush things
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Check work for errors
Dr. Simone Carton 15.7.2015
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Ensure you have attention before proceeding
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Cue that what you are saying is important and they need to
listen
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Keep instructions simple and direct
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Speak slowly
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Encourage retelling
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Cue to write information down
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Provide a quite area for work that is challenging
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Give advanced warning and preparation time prior to changing
activity
Dr. Simone Carton 15.7.2015
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Establish structure
Set goals
Use checklists
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Give direct feedback
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Use Self-questioning
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Problem solve step by step
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Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
In the majority of domains, current evidence indicates
that some form of strategy (compensation) based
intervention that is set in the context of (or clearly
transferable to) functional settings will be the most
effective approach.
(Evans, 2012)
Dr. Simone Carton 15.7.2015
Sufficient information to support evidence-based
clinical protocols and to design and implement a
comprehensive program of empirically-supported
treatments for cognitive disability after TBI and stroke
(Cicerone et. al, 2011)
Cicerone et al and Tiersky et al (2005) evidence
that holistic approaches and those integrating both
emotional adjustment and cognitive strategies and
skills have more positive effects on outcome.
Dr. Simone Carton 15.7.2015
Effect
size
Large
Memory
Attention
(auditory)
Attention
(spatial)
“Training specific
functional skills that
make demands on
attention through
repetitive practice.”
Visual scanning training
(Cicerone et al 2011)
Electronic memory devices
Specific learning strategies e.g.
errorless learning
(Cappa et al 2005)
Teaching strategies
that compensate for
attention impairments
in every day tasks.
Visual scanning training
Mental imagery
Feedback training
Prism adaptation
(Luauté et al 2006)
“Memory groups” poor efficacy for
improving memory function
(Rees et al 2007)
Repetitive practice
drills (e.g.
computerized
exercises).
Inconclusive evidence for
Limb Activation (Luauté et
al 2006)
Mild BI:
Strategy training
Moderate /Severe BI:
External compensations
Assistive technology
Direct application to functional
activities
(Cicerone et al 2011)
Moderat
e
Small
Visual scanning and
visuomotor cuing (limb
activation)
(Cappa et al 2005)
Lack of evidence in
relation to other forms of
(Park & Ingles, 2001)
visual or spatial
Dr. Simone Carton 15.7.2015
perception disorders
Executive
Functioning
Communication
Behaviour
Emotion &
Psychosocial
Training of formal
problem solving
strategies and their
application to
everyday situations
and functional
activities
recommended as
practice guideline.
Cicerone et al (2011)
“The evidence is
strongly in favour of
efficacy of aphasia
therapy, provided…. is
sufficiently prolonged”
Basso (2005).
Multicomponent
behavioural
interventions,
incorporating
individually tailored
contingency
management
techniques and
positive behaviour
approaches (SIGN,
2011)
“CBT should be
considered for
treatment of anxiety
symptoms following
mild to moderate TBI
as part of a broader
neurorehabilitation
programme.”
(SIGN 2011)
Metacognitive
strategy training (e.g.
problem-solving, goal
management training)
Cognitive-linguistic
therapies recommended
as practice standard.
Cicerone et al. (2005)
“Serious
methodological
concerns weaken this
body of evidence”
(Ylvisaker et al, 2007)
Some evidence for
efficacy of CBT for
treating anxiety
symptomatology after
TBI (Soo and Tate,
2007).
Self-monitoring and
self-regulation
(Cicerone et al 2011)
CBT for depression
following ABI
‘inconclusive’.
Dr. Simone Carton 15.7.2015
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Development of ‘holistic’
rehabilitation programmes (e.g.
Ben Yishay, Prigatano, Wilson,
Evans, Klonoff, Christensen…)
Emphasis on integrated treatment
of cognitive and emotional
problems, with focus on return to
productive/personally meaningful
activity.
Dr. Simone Carton 15.7.2015
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Assessment
Premorbid history
Formal assessment of central
concerns
Real world/practical assessment
Insight
Motivation
Personality
Support network
Common sense
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Plan of action that is meaningful
for the person
Educate
Eg Kapur and Clare & Wilson ‘How
to cope with memory problems’.
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Support the inter-relationship
of all the relevant domains
Clinical summersaults
Dr. Simone Carton 15.7.2015
Dr. Simone Carton 15.7.2015
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Evans, J.J. (2010) Basic concepts and principles of neuropsychological
assessment. In Gurd, J.M., Kischka, U. and Marshall, J.C. (2010) Handbook of
Clinical Neuropsychology: Second Edition. Oxford University Press, Oxford.
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Goldstein, L.H. and McNeil, J.E. (2013) Clinical Neuropsychology: A Practical
Guide to Assessment and Management for Clinicians. Wiley, Chichester
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Lezak, M.D. (2012) Neuropsychological Assessment: Fifth edition. Oxford: OUP.
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Wilson, B.A., Gracey, F., Evans, J.J., Bateman, A. (2009). Neuropsychological
Rehabilitation: Theory, Models, Therapy and Outcome. Cambridge University
Press.
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Clare, L & Woods R. (2001) A role for cognitive rehabilitation in dementia care.
Neuropsychological rehabilitation: An International Journal, 11:3-4, 193-196.
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www.psychbite.com
Dr. Simone Carton 15.7.2015