OT role in Cog Assessment
Occupational therapists focus on functional cognition, or cognition that is necessary within the scope of performing his/her roles, daily occupations within the contexts performed. |
OTs may then only need to focus on assessing metacognition and strategy use in occupational performance. |
You may not need to assess cognitive skills unless you need to differentiate an underlying skill (e.g., sustained vs. divided attention) |
Different cognitive rehab intervention methods…
Adaptations/Modification of tasks and environment |
Technology to support cognitive performance |
Task-Specific Training (vanishing cues, errorless learning, spaced retrieval) |
Compensation |
Retraining/Remediati-on of Impairments |
Cognitive Strategy Training & Training in Self-awareness (metacognitive training) |
The Functional Approach
ADAPTATION by others |
TASK-SPECIFIC TRAINING |
METACOGNITIVE (person led compensation) |
No awareness |
No awareness |
Awareness required |
No learning |
Low-level task-specific learning |
Learning and generalization |
| |
No generalization |
Emphasis on changing task performance or environment rather than underlying skill
Task specific Training
| |
Metacognition |
Strategy Use |
Population |
Task Specific Training (e.g STOMP) |
Mild-Max Cues |
Minimal |
Mild-Mod dementia, Mod-Severe CVA, Mod-Severe TBI, Parkinson's w/cog imp, Cancer |
Environmental Modification
Alter properties of the environment |
Rice cooker stays plugged in-- |
Remove distracters (TV, clutter, people, use IPOD with headphones) |
Grab bars, ramps |
Re-arrange work areas (pots lower) |
Add light for improved vision |
Pictures to locate rooms (toilet) |
**Imbed all of the environmental mods into sequencing for task-oriented training.
Planning the Intervention: Supportive strategies
Based on the performance we see and individual consideration of HOW they wanted to do tasks, we determine if they needed any of the following ECT strategies to support task-oriented training: |
1. Environmental modifications |
2. Cognitive strategies |
3. Task modification |
Planning the Intervention: Natural tools
Rice cooker |
Rice, butter and salt |
Wooden spoon |
Kitchen |
Planning the Intervention: Task Steps
Where do people get dressed? |
Who is in the room when they do? |
What time of day? |
Is the TV or radio on? |
What goes on first? |
*Develop a list of steps for doing the task in a way that supports the habits and routines of the occupation as well as the social, temporal and physical context in which the occupation is performed.
EVALUATION: Caregiver-Rated Performance
| |
Performance Score |
Satisfaction with Performance |
1. Operate Rice cooker |
1 |
1 |
2. Put of shirt |
5 |
5 |
3. Take bus to and from market |
5 |
1 |
**Canadian Occupational Performance Measure (COPM): semi-structured interview tool for prioritizing goal areas of functional performance; caregiver reports performance on each task on a scale of 1-10 (1=worst, 10=best). (Law et al, 1990)
Evaluation: Choosing Fam & Client-centered Goals
Choose goals that matter the most and potentially change the quality of someone’s life if better at this skill. |
Make-up vs. cooking? |
If client unable to identify goals, caregivers assisted. |
Goals must be tasks that they did previously (procedural memory) and must have an obvious start and end point. |
Maintenance of therapeutic relationship
Evaluation |
Planning |
Implementation |
Individualized goal planning: |
Real-life tasks broke down into practice-able steps. |
Training is structured through motor learning principles: repetitive, blocked practice frequent verbal praise errorless learning contextually-appropriate environment with real life tools. |
Examiner and caregiver rating of performance |
Compensatory modifications built into practice sequences: environmental modification, cognitive strategies, task modification |
. |
Spaced Retrieval
Recalling info repetitively over gradually longer time intervals (30 sec, 1 min, 2 min, 4, min, 8 min, etc.) |
Often used for recall of specific facts, small chunks of info |
If retrieval is successful, length is increased |
Can be used to learn small amounts of information, facts, used external aids or recall information |
Can be combined with errorless learning |
Implementation of Training
Training is structured through motor learning principles: |
Repetitive, blocked practice |
High dose |
Errorless learning |
Frequent verbal praise |
Within a contextually-appropriate environment with real-life tools |
Revise the Sequencing List with ECT Built-In
Deficits in remembering steps of task |
Plug in rice cooker (or it stays plugged in) |
Measure and fill with rice, water, ingredients (if measuring is an issue, you can have pre-poured amounts of rice and ingredients in a baggy in refrigerator) |
Push “on” button. |
Alarms sounds when ready to eat. (If not alarm, set kitchen timer as one of the steps). |
Revise the Sequencing List with ECT Built-In
Deficits in remembering steps of task |
Plug in rice cooker (or it stays plugged in) |
Measure and fill with rice, water, ingredients (if measuring is an issue, you can have pre-poured amounts of rice and ingredients in a baggy in refrigerator) |
Push “on” button. |
Alarms sounds when ready to eat. (If not alarm, set kitchen timer as one of the steps). |
Revise the Sequencing List with ECT Built-In
Deficits in remembering steps of task |
Plug in rice cooker (or it stays plugged in) |
Measure and fill with rice, water, ingredients (if measuring is an issue, you can have pre-poured amounts of rice and ingredients in a baggy in refrigerator) |
Push “on” button. |
Alarms sounds when ready to eat. (If not alarm, set kitchen timer as one of the steps). |
Task Modification
Alter properties of the task |
1. Sit down to take a bath |
4. Simplify activity (rice, water in the pot—she turns on) |
3. Use assistive technology for a task (pill reminder system) |
5. Use pre-set microwave settings |
3. Shower in the morning vs. evening |
. |
Cognitive Strategies
External: external aids to cue to task |
Internal: conscious mental strategies to improve performance |
Sequencing lists (how to cook rice |
Search for information from left to right. |
Alarms |
Check work against a list. |
Timers |
Day planner (mild) |
**Imbed all of these strategies into sequencing for task-oriented training
Vanishing Cues
The goal is to reduce cues over time as the person learns the task-specific methods unique to them |
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Adaptions
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Metacognition |
Strategy Use |
Population |
Adaptions: Environmental Modification to Support OP |
Total Cues |
None |
Severe dementia, chronic severe stroke, TBI not responsive to training; late stages of Parkinson's |
By the time we are done with this section, you will be able to choose an occupation-based Intervention based on Metacognition and Strategy use
Types of Adaptations
Change how the task is performed |
Change task goals or expectations |
Modify task demands |
Modify physical environment |
Modify social environment or the cues/interactions with others |
Adaptation Considerations
Who is doing the adapting? |
Are the adaptations fixed or do they require ongoing implementation? |
Are they confined to a particular environment (people)? |
How does it minimize demand on the impairment? |
Are they generic or specific to deficits or symptoms?- Task or task-specific problems |
Not specifically on test
Adaptation requires care partner collaboration…
Produces quick results |
Simplifies task |
May be compensatory if the client (not care partner) implements the adaptations once it is presented to them |
Determine who is doing the adaptation |
Does not require awareness (of the client), requires consistency |
Coaching Care Partners to Support FC
RECAPS Memory Strategies in Dementia |
Tailored Activity Program (TAPs) |
Care of Older Persons in their Environment (COPE) |
*FC= functional cognition
Metacognitive
| |
Metacognition |
Strategy Use |
Population |
Metacognition (e.g. MultiContext Approach) |
None-Maximal |
Good- Minimal (goal is good strategy use) |
Any Diagnosis |
Metacognitive (e.g. CO-OP) |
None- Mild Cues |
Good |
MCI, MS, Mild-mod CVA, mild TBI/concussion, CancerMild-Mod dementia Mod-Severe CVA |
Metacognitive Strategy Training: Key Elements
1. Focus on structured methods and/or strategies for managing multiple steps activities |
2. Self-monitoring, self regulation, awareness or self-management, and problem solving |
Variation in Strategies
Task-specific vs. General strategies |
Goal management vs. Self-awareness |
Guidance and prompts vs. Explicit strategy instruction |
CO-OP
Relationship between ability and performance can be modified by strategies. |
Two types of strategies: Global & Domain Specific |
CO-OP
Client-centered, performance-based, problem-solving approach that enables skill acquisition through a process of strategy use and guided discovery. |
1. Client-chosen goals |
2. Dynamic Performance Analysis |
(Observe motivation, task knowledge, and capability) |
3. Cognitive Strategy Use |
4. Guided Discovery |
5. Intervention |
Phase 1: Prep; Phase 2: Acquisition; Phase 3: Verify |
Strategies that improve performance
Global Strategy (Metacognitive) |
Domain Specific Strategy |
1. Goal |
Look to the left |
2. Plan |
Large handled spoon |
3. Do |
Use a calendar or alarm |
4. Check |
Task sequence list |
Intervention Process
Phase 1: Prep (Goal) |
Phase 2: Acquisition (Plan/Do) |
Plan 3: Verification |
Orient client/family to CO-OP process |
- Start practice or teach performance; Patient problem solves strategies or is coached to strategy; Ask person to consider strategy effectiveness |
Verify that the goal has been met |
Identify Goals-COPM Observe baseline performance |
Review Goal-Plan-Do-Check |
Re-administer COPM |
| |
Encourage others to help with transfer/generalization of strategies to other activities |
Probe for generalization |
Focus is NOT on the task itself but on...
1. Recognizing cognitive errors across functional tasks |
2. Enhancing self-awareness of task methods and self-monitoring skills |
3. Increasing strategy generation and effectiveness to manage cognitive error across functional activities |
MC Approach Helps Clients Learn...
The same error patterns are interfering with success across different activities and situations |
How similar methods can controls errors across situations |
MC Approach: Key Elements
1. Focus on cognitive strategies |
2. Activities structured to promote transfer and generalization |
3. Metacognitive Framework |
4. Functional Treatment Activities |
5. Therapeutic support focused on building self-efficacy |
6. Goal setting and revision |
What if we change to a similar activity?
Some error pattern likely to emerge |
Same strategy would likely be effective |
Must be an activity with similar characteristic (grocery list, following recipe) (all require working memory) |
Strategy Use Across Situation
Requires Variability |
Consistent practice |
Metacognitive skills (e.g. executive function) |
Cognitive Performance Error Patterns
Must be observed across activities of situation... |
- Misses important details |
- Loses track within an activity |
- Performs task steps in wrong order |
- Omits steps, information, or items |
- Gets side-tracked |
- Repeat actions, steps, or thoughts |
- Incomplete steps or information |
- Jumps into an activity without pre-planning |
Strategy Types:
External Strategies |
Internal Strategies |
Structured Activity Framework or Goal Management Strategies |
Emotional Self regulation strategies |
- Use a list to simplify directions or to ensure all items for a task have been gathered |
- Verbal or visual rehearsal |
- Stop, Plan, Review |
-Use of cue signs/labels |
- verbal self talk- talking through each step |
- Keep it simple, split, and remove (KISSR) |
- Talking aloud during task performance |
- Mental practice |
- Goal, plan, predict, do and review |
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- Implementation intentions (if-then) |
- Goal, plan, do, check (CO-OP) |
Mental/Verbal Rehearsal is Most Useful for..
- small bits of info |
- facts |
- temporary storage |
- focusing and concentrating |
Interprofessional Strategy
Find a common goal |
Major limiting component is working memory |
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