Cog & Percept Disorders (Final)

8/14/2019 Cog & Percept Disorders (Final)

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COGNITIVE&PERCEPTUAL DISORDERS


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L DISORDERS COGNITION

Cognition is a method used by CNS to processinformation.

It includes : Knowing Understanding

Awareness Judgement Decision making


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PERCEPTIONIntegration of sensory impressions into

information that is psychologically

meaningful.Thus perception is the ability to select those

stimuli which require attention & action,integrate them with each other & with prior

information and finally to interpret the results.


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Cognitive & perceptual capacities prerequisites for

learning and rehabilitation is largely a learning

process.

Thus, patients with cognitive and perceptual

disorders are limited in their abilities to learn self-care activities & ADL skills.

Therapists modification of assessment &intervention in light of these deficits will ensure that

patient receives the full benefits of these services.


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CLINICAL INDICATORSInability to do simple tasks independently or safely.

Difficulty in initiating or completing a task.

Difficulty in switching from 1 task to the next.Diminished capacity to locate visually or to identify objects

that seem obviously necessary for task completion.

Unable to follow simple one-stage instructions despiteapparently good comprehension.


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Make same mistakes over and over.

Activities may take an inordinately long time to

complete.

Activities may be done impulsively.

Appear distracted and frustrated and exhibit

poor planning.

May deny the presence or extent of disability.


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PERCEPTUAL DISORDERS1 . Body image/body scheme disorders

i. Somatognosia

ii. Unilateral neglect

iii. Right/left discrimination

iv. Finger agnosia

v. Anosognosia

2. Spatial relation syndromes

i. Figure ground discrimination

ii. Form constancy

iii. Position in space

iv. Topographic disorientation


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3 . Agnosias

i. Visual

ii. Auditory

iii.Tactile

4. Apraxias

i. Ideomotor

ii. Ideationaliii.Constructional


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Attention Memory Initiation

Judgment

Insight

Problem solving

Abstraction

Mental flexibility

Calculation

CATEGORIES OF COGNITIVEDEFICITS

SUNIL BHATT


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IMPAIRMENTS ASSESSMENT

AND

REHABILITATI

ON


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ATTENTIONAbility to select n attend to a specific stimulus while

simultaneously suppressing extraneous stimuli

Active process that helps to determine which

sensations n experiences are alerting n relevant to the

individual


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TYPES Sustained attention : capacity to attend to relevant information during

activity

Focused or selective attention : capacity to attend to a task despite

environmental visual or auditory stimuli

Alternating attention : capacity to move flexibly between task n

respond appropriately to the demands of each task

Divided attention : capacity to respond simultaneously to 2 or more

tasks or stimuli when all stimuli are relevant


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CLINICAL PRESENTATIONSustained attention: pt. just drifts off from an activity

Focused attention:

-stop dressing activity to talk

-easily disturbed by music or other noises

-distractibility

Divided attention: required when more than 1 response

is required or more than 1 stimuli need to be monitored

Alternating attention


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LESION SITE

Reticular activation system: arousal or

alertness

Frontal n temporal lobes: R>L

Sensory systems: bring n code relevantsensory information


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ASSESSMENTLoewenstein occupational therapy cognitive

assessment

Chessington occupational therapy neurological

assessment battery(COTNAB)

Stroop test

Paced auditory serial attention test(PASAT)

Trail making test


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STROOP TEST


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TESTSRandom letter test

Digit repetition test

Clinical observation n activity analysis


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BEDSIDE TESTING OF ATTENTION ANDCONCENTRATION

Digit span forwards and backwards*Recite months of the year, or days of the week, backwards

Serial subtraction of 7s (although note that calculation ability

needs to be intact)

*The normal range is forwards: 6 1; backwards: 5 1.


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REHABILITATIONPurpose:

To increase pt.s attention to appropriate stimuli and

disregard inappropriate stimuli.


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REMEDIAL APPROACH

Train to scan visual environment in slow n systematic manner

Setting time n speed limit

Amplification of critical stimuli

Environmental gradation(non distractible)


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ADAPTIVE APPROACH

Removing the distraction

Interventions :

Computerized training programmes using reaction times

Pattern recognition (cognitrone)

Paper n pencil tasks


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ORIENTATION

time

place

person


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Characteristics common to orientation loss:

Reflected verbally or behaviorally

May be temporary or long lasting

All or none phenomenon

Dimension of time most vulnerable

Most common sequence of recovery of orientation: person

place time

Associated with memory impairment


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EVALUATION OFORIENTATIONTEST OF ORIENATION FOR REHABILITATION

PATIENTS (TORP)

Contains 46 items n measures orientation to person n

personal situation, place, time, schedule n temporal

continuity


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LOWENSTEIN OCCUPATIONAL

THERAPY COGNITIVE ASSESSMANT

(LOTCA) ORIENTATION SUBTEST


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REHABILITATION FOR ORIENTATION

REMEDIAL APPROAC H:

Pt. participate in daily orientation gp.

Provide daily individual reality orientationADAPTIVE APPROACH

Labeled pics of family members etc

Personal items from homeOrganize daily routine


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MEMORYA mental process that allows the individual to

store experiences n perceptions for recall at a

later time

Not localized in one particular place in nervous

systemImportant for rehab.


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Comprises:

Acquisition or learning

Storage or retention

Retrieval or recall


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Levels of memory:

Immediate recall : retention of information that has been stored for a

few seconds

Short term memory : retention of events or learning that has taken

place within few min, hours or days

Long term memory:

Consists of early experiences n information acquired over a period of

years

Not commonly seen foll. stroke

Common foll. brain injury n in Alzheimer dis.


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MEMORY

Rivermed Behavioral MemoryTest (RBMT)

Test of everyday memory functioning

Contextual memory test(CMT)


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BEDSIDE TESTING OF MEMORY .

First check that patient is attentive and that language function is adequate

Anterograde verbal memory

Ask the patient to name three distinct objects (e.g. Ball,Flag, Tree)

Ensure that the patient has registered the information(repeat up to three times

if necessary)

If the patient can immediately name the objects, ask the patient to repeat the

three objects three minutes later


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Anterograde visual memory

Show the patient faces in a magazine

Ensure they have recognized them

Retest after 5 min

Retrograde memory

Ask the patient to describe recent events on the ward, or visits

from relatives

Ask about important historical events and major events in the

patients life, e.g. date of marriage


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MEMORY RETRAINING

Purpose:to enable the pt to effectively encode n recall information so that learning can occur.

Remedial approach :

Organizing material to be remembered

Build strategies

Computer games

Memory tests


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COMPENSATORY APPROACH

Use of diary or notebook(memorylog)

Beeper or wallcalender


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Training:

Date books, post-it notes, timers, calendars

External self talk, routines n habits, organization n planning in ways that will reduce number of memory

slips


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ABILITIES

Result of complex n dynamic interactions between a no.

of brain structures united in functional systems

Depend on intact primary cognitive capabilitiesProblem solving

Reasoning

Concept formation


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EXECUTIVE FUNCTIONS

Consists of those capacities that enable a person

to engage successfully in independent, purposive,

self serving behavior

4 overlapping components


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Assessment:

Executive Functions Assessment

Good Samaritan Hospital For Cognitive

Rehabilitations Executive Functions

Behavioral Rating Scale


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REMEDIAL APPROACH

Provide structure, feedback n routine

PT initially acting as pts frontal lo be

COMPENSATORY APPROACH

Assist pt for poor abilities by utilizing other intact cognitivefunctions

Environment modification


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3. About what time is it? 1 _____ x 3 =______

(within one hour)

4. Count backwards 20 to 1 2 _____ x 2 =______

5. Say the months in reverse order 2 _____ x 2 =______

6. Repeat the phrase just given 5 _____ x 5 =______

Total error score = _____/28


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PERCEPTUAL

DISORDERS AND

REHABILITATION


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UNILATERAL NEGLECT

Inability to register and integrate stimuli and

perceptions from one side of the body, and the

environment which is not due to sensory loss.

Clinically, pt. may ignore one half of the body while

performing ADLs.

Lesions involving infero-posterior regions of right

parietal lobe are significant determinants of neglect.


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ASSESSMENT

Behavioural inattention test (BIT)

Which includes making simple drawings.

Patient is asked to perform tasks such as baking

cookies & changes in pts performance in response to

cueing are observed.


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INTERVENTION

1. Remedial approachStimuli specialised for rt. And lt. side of the brain should be

used.

Eg. Rt. Brain activation shapes & blocks

Lt. brain activation letters , numbers etc.

Simple verbal instructions to encourage turning of head to

neglected side and anchor the attention towards the same.

2


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2. Cognitive compensation

Patient taught to be aware of the deficit through visual scanning

starting from the neglected side.

Training for ADL & other required tasks by repeated practice.3. Adapting the environment

Patient should be addressed & demos should be given from the

unaffected side.

Mirror placed in front of the patient when he is dressing to draw

attention towards the neglected side.

In transfer of training, pt. participates in tasks which require him

to look from the affected side such as watching TV.

ANOSOGNOSIA


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ANOSOGNOSIA

Denial & lack of awareness of the presence of severity of

ones paralysis.

Pt. maintains there is nothing wrong & may disown the

paralysed limbs & refuse to accept the responsibility for

them.

Pts. Have tendency to cover the paretic limb.

Lesion usually in the non-dominant parietal lobe in the

region of supramarginal gyrus.


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ASSESSMENT

Assessed by talking to the pt. & asking him questions

like :

What happened to the arm/leg

Whether he/she is paralysed

Why the limb cannot be moved


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INTERVENTION

Extremely difficult to compensate for this

deficit.

Safety is of paramount importance as the

typically do not acknowledge that they have

a disability & will therefore refuse to be

careful.


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SOMATOAGNOSIA

Lack of awareness of the body structure & the relationship of

body parts to oneself or others.

Lesion in dominant parietal or posterior temporal lobe , thus,

disorder is primarily seen with right hemiplegia.

Clinically, pt. may have difficulty in performing transfer

activities.

Difficulty in dressing.


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ASSESSMENT

Pt. is asked to point the body parts being

named by the therapist.

Imitate movements of the therapist.

Answer questions about relationship of body

parts.


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RIGHT LEFT DISCRIMINATION


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RIGHT LEFT DISCRIMINATION

Inability to identify the right & left side of the body.

Patients are often unable to imitate movements.

Clinically, pt. is unable to follow instructions using the

concept of right & left.

Lesion site parietal lobe of either hemisphere.


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ASSESSMENT

Patient is asked to point body parts on

command

Eg. Right ear, left arm, right leg so on & so

forth.

Six responses should be elicited.


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INTERVENTION

In giving instructions to the pt. avoid using

directional words such as right or left,

instead use arm with the watch.

Adaptive environment

Right side of all common objects like wall,

shoes & clothing to be marked with red tape.

FINGER AGNOSIA


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FINGER AGNOSIA

Inability to identify the fingers of ones own hand orthe hands of the examiner.

Usually occurs bilaterally & most common in the

middle 3 fingers.Correlates with poor dexterity in tasks such as tying

shoe laces, typing, buttoning etc.

Lesion in either parietal lobe in the region of angular

or supramarginal gyrus.


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Gerstmanns syndrome- bilateral finger agnosia +

right-left discrimination + agraphia + acalculia


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ASSESSMENT

A portion of Sauguets test :

Name the fingers touched by the therapist with eyes open (5

times) if successful, with eyes closed (5 times).Point to fingers named by the therapist on pts own hands (10

times), therapists hand (10times),

on a schematic model.

Point to equivalent finger on a life-sized picture.

Imitate finger movements.


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INTERVENTIONS

Pts discriminative tactile systems are

stimulated.

Transfer of training pt. quizzed on finger

identification.

DISCRIMINATION


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DISCRIMINATION

Inability to visually distinguish a figure from thebackground in which it is embedded.

Pt. has difficulty in ignoring irrelevant visual stimuli and

cannot select the appropriate stimuli to which to respondto.

Clinically, pt. is unable to locate objects in a pocketbook or

drawer, buttons on a shirt, may not be able to tell when

one step ends & another begins esply. While descending.

Lesion mostly in the parieto-occipital region of right

hemisphere.


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ASSESSMENT

Ayres figure ground test.

Functional tests :

White towel on a white sheet

Pick out a spoon from an unsorted array of utensils.

INTERVENTIONS


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INTERVENTIONS

Compensation through cognitive awareness:

Pt. is taught to examine group of objects slowly &

systematically & sort them carefully using other intact

senses like touch.

Adaptation & simplification of the environment:

Brightly colored tapes to mark edges of stairs.

Transfer of training:Start with 3 totally dissimilar objects & progress to more

similar ones.

FORM DISCRIMINATION


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FORM DISCRIMINATION

Inability to perceive or attend to subtle differences inform & shape.

Clinically, pt. may confuse a pen with a toothbrush or

a cane with a crutch.

Lesion site is parieto-temporo-occipital region of the

non-dominant lobe.


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ASSESSMENT

Items similar in shape & different in size are

kept together , pt. is asked to identify each

one.

Eg. One set pencil, straw, toothbrush etc.

second set coin, ring, paper clip etc.


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INTERVENTION

Frequently used objects with similar shapes

can be labeled.

Encourage the pt. to use other intact senses

to identify & distinguish objects from each

other.

SPATIAL RELATION DEFICITS


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SPATIAL RELATION DEFICITS

Inability to perceive the relationship of one object in spaceto another object or to oneself.

Crossing the midline may be a problem for such patients.

Clinically, pt. may find it difficult to place the cutlery,spoon & plate in proper position when setting the table.

Pt. may be unable to tell the time from a clock due to

difficulty in perceiving the relative position of hands.Lesion site is predominantly inferior parietal lobe or

parieto-occipital-temporal junction usually on the right

side.


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ASSESSMENT

Therapist draws picture of a clock , pt. is asked to fill

the numbers and draw the hands corresponding to a

particular time as instructed by the therapist.

2-3 objects placed on a paper in a particular pattern ,

pt. is asked to duplicate the pattern.


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INTERVENTION

Patient can be given instructions on

positioning himself in relation to the therapist

or any other object :

Eg. sit next to me

stand behind the table

step over the line

POSITION IN SPACE


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POSITION IN SPACE

Inability to perceive & interpret spatial concepts such

as up down , above under.

Clinically, if the patient is asked to raise the arm

above his head during ROM assessment pt. would not

know what to do.

Lesion usually in the non dominant parietal lobe.


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ASSESSMENT

Place the objects , one on top of another or

one below the other.


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INTERVENTION

3-4 objects are placed in a specific

orientation an additional object is placed in

different orientation & pt. is asked to pick the

odd one & place it in similar way as the

others.

TOPOGRAPHIC DISORIENTATION


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TOPOGRAPHIC DISORIENTATIONDifficulty in understanding & remembering relationship of one location to another.

Pt. is unable to get from one place to another with orwithout a map.

Clinically, pt. is unable to find his room in a physiotherapyclinic despite being shown repeatedly.

Possible lesion sites :

Inferior parietal lobeOccipital association cortex

Occipitotemporal cortexBilateral parietal lesions


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ASSESSMENT

Patients is asked to draw a familiar route

either to his house or the neighbourhood.


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INTERVENTION

Frequently travelled routes to be marked with

dotted lines , gradually space between the dots is

reduced & eventually the line are removed.

Practice going from one place to another with the

help of verbal instructions.

Simple routes should be used.

DEPTH & DISTANCE PERCEPTION


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DEPTH & DISTANCE PERCEPTION

Inaccurate judgement of direction, distance & depth.

Clinically, pt. may have difficulty in navigating stairs,

may miss the chair when attempting to sit, continuepouring juice when glass is filled.

Lesion in posterior right hemisphere in the superior

visual association cortices, bilateral or right sided

lesions.


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ASSESSMENT

Grasp an object that has been placed on the

table. Impaired pt. will undershoot or

overshoot the target. (distance perception)

Fill water in a glass (depth perception)


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INTERVENTION

Cognitive awareness (walking carefully on

uneven surfaces particularly stairs).

Place feet on designated spots during gait

training.

Blocks arranged in piles 2-8 inches high, pt.

is asked to touch the feet on top of each pile.

VERTICAL DISORIENTATION


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VERTICAL DISORIENTATION

Distorted perception of what is vertical.

Causes disturbances in motor performance, posture

& gait.

Lesion site non dominant parietal lobe.


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ASSESSMENT

Therapist holds a cane vertically, then

displaces it to horizontal position. Pt. is asked

to take the cane & return it to original

position.


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INTERVENTION

Patient is asked to use the sense of touch for

proper self orientation esply. When going

through doorways, in & out of elevators or on

the stairs.

VISUAL OBJECT AGNOSIA


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VISUAL OBJECT AGNOSIA

Inability to recognise familiar objects despite normal function of eyes &

optic tracts.

Simultanagnosia (Balints syndrome)- inability to perceive a visual

stimulus as a whole . Lesion is dominant parietal lobe.

Prosopagnosia related to any visually ambiguous stimuli, the

recognition of which depends on evoking memory context such as

different species of birds or different makes of cars. Bilaterally

symmetrical occipital lesions.


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Color agnosia inability to identify colors , ability

to name the objects is retained. Classic occipital

syndrome.

AUDITORY AGNOSIA


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AUDITORY AGNOSIA

Inability to recognise nonspeech sounds or to

discriminate between them.

Pt. is unable to tell the difference between sound of

a doorbell & that of a telephone or between dog

barking & thunder.

Lesion in dominant temporal lobe.

ASTEREOGNOSIS


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ASTEREOGNOSIS

Inability to recognize forms by handling them

although, tactile, proprioceptive & thermal

sensations may be intact.

Difficulty in ADLs.

Lesion in parieto-temporo-occipital lobe of either

hemisphere.

IDEOMOTOR APRAXIA


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IDEOMOTOR APRAXIA

Pt. is able to carry out habitual tasks automatically &

describe how they are done but is unable to imitate

gestures or perform on command.

Lesion in the left, dominant hemisphere.


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ASSESSMENT

Goodglass & Kaplan test for apraxia

Consists of universally known movements like

brushing teeth, blowing, hammering etc.

based on hierarchy of difficulty for pts. With

apraxia.


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INTERVENTION

Simplified commands

Short & precise set of instructions

Sensorimotor approach

IDEATIONAL APRAXIA


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IDEATIONAL APRAXIA

Inability to perform a purposeful motor act eitherautomatically or on command because the pt. no

longer understands the overall concept of the act,

cannot retain the idea of the task or cannot

formulate the motor patterns required.

Lesion in dominant parietal lobe.

CONSTRUCTIONAL APRAXIA


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CONSTRUCTIONAL APRAXIA

Faulty spatial analysis & conceptualisation of the task.

Pt. for eg. Understands everything about a sandwhich & what it is

for but, is unable to assemble one.

Lesion in the posterior parietal lobe of either hemisphere.

REFERENCES


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REFERENCES Textbook of medical physiology Guyton &Hall (9 th edition)Physical rehabilitation OSullivan (4 th edition)Impact of Motor, Cognitive, and PerceptualDisorders on Ability to Perform Activities of Daily Living After Stroke Louisette Mercier,

Thrse Audet, Rjean Hbert, AnnieRochette and Marie-France Dubois Stroke

2001;32;2602-2608www.acnr.co.uk/pdfs/volume4issue5/v4i5cognitive.pdf


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Cog & Percept Disorders (Final)