Lecture 4: Neuropsychological interventions

Rehabilitation by medical specialist care is done for those who are limited by illness, accident or congenital diseases. The patient receives multidisciplinary care headed by a rehabilitation physician. The main goals of rehabilitation are for the patient to receive optimal recovery, independence and to be able to participate in the community again.

Brain injury can be divided in three main categories of causes. Those categories are acquired brain injury (trauma, tumor, infection/diseases, strokes), progressive disorders (Alzheimer’s, Parkinson, MS) and congenital disorders (from birth on) (Fetal Alcohol Syndrome, Down syndrome, ADHD).

Traumatic brain injury

About 1.6 million people with traumatic brain injury are admitted to hospital every year in Europe. Causes can be falling (mostly children), a traffic accident, violence or sport injuries. The vast majority of those admitted have closed brain injury. The highest incidence is for children younger than 4 years old and men between 18 and 24 years old. Due to the force of the head and different densities of the brain secondary lesions may occur when acquiring brain injury.

Disorders following acquired brain injury can be divided into three main categories. Cognitive disorders following acquired brain injury are deficits in attention and memory, neglect and visuo-spatial disorders. Emotional/psychosocial/behavioural consequences are personality changes, aggression, less impulse control and symptoms of depression or anxiety. Sensorimotor disorders are paralysis, loss of strength, central pain, spasticity, tinnitus and hemianopia.

Psychosocial effects of acquired brain injury are affected basic functions, changes in views of the world, change in roles and difficulty carrying on as the patient did before acquiring brain injury. The injury is often invisible to others.

Acquired brain injury doesn’t only affect the patient, but the family as well. Changes in roles may occur (someone else has to do the cooking) and about 50% of the marriages fall apart. Other consequences may be personality changes, impulsivity and lack of initiative.

The course of action following acquired brain injury is an acute phase: the patient will be taken to hospital after the accident. 20-30% of the patients will go into rehab, which is the subacute phase. In this phase the patient will learn how to walk and talk again and it takes up to 6 months. After this phase there may be a chronic phase. Many patients go home directly after submission to hospital.

Cerebrovascular Accident (CVA, stroke)

There are about 120.000 patients in the Netherlands at the moment and every year about 41.000 new people will experience a cerebrovascular accident, of which about a third dies. The main forms of a cerebrovascular accident are ischemic strokes, caused by a blocked artery, and intracerebral haemorrhage, caused by a spontaneous bleeding in the brain.

Hidden effects of strokes, which often go unnoticed by others, are not being able to speak, being confused, not being able to read a book, not feeling anything with their hand and having a hard time focussing.

International Classification of Functioning, disability and health

* check the slides for an overview of the model

The ICF model is used to make sense and order of not only the affliction and all the disorders a patient has, but to also include the person and the situation he/she is in. it is a model used worldwide in the rehabilitation and it is also part of the DSM-V. An ICF model provides a clear picture of a person in rehabilitation in a language that the entire team understands (physician, psychologist, psychotherapist, language therapist, occupational therapist, etc.). For every member on the team, an ICF model gives clues as to where to focus their treatment on.

Example Mrs. Brown

Health condition (disorders, diseases) (physician): mild stroke, one year ago

Body functions and structures (physical rehabilitation)

• Cognitive/somatic: memory, attention, language / pareses, reflexes
• Must be determined with neuropsychological investigation
• Structures: is there an impairment or change of the body’s structure? (E.g. loss of legs)
• Possible disorders/symptoms Mrs. Brown
  
  • Memory disorder
  • Mental slowness
  • Attentional deficits
  • Reduced executive control
  • Unable to cope with fatigability
  • Mood and anxiety problems

Activities/limitations (occupational therapist, psychologist)

• Activities: the actions performed by an individual
  • Taking a shower
  • Cooking
  • Walking
  • Following conversations
  • Reading
• Limitations: difficulties that an individual has in carrying out activities
• Possible problems Mrs. Brown
  
  • Difficulty remembering things → problems in grocery shopping
  • Difficulty keeping track of things → cannot keep track of children
  • Problems in doing daily chores (housework)
  • Limitations of activities because of fatigue → cannot do as much anymore

Participation (occupational therapist)

• An individual’s participation in society
  • Working part-time in an office
  • Being a member of a bridge club
  • Being active on Facebook
• Possible problems Mrs. Brown
  
  • Role of friend has diminished → less friends, because she doesn’t do fun things anymore because she is too tired
  • Role of mother has diminished → children get out of her way because she is so irritable

Environmental factors (psycho-education

• An individual’s psychical and social environment (social, organisations, laws, regulations, attitudes)
• Possible problems Mrs. Brown
  
  • Not given any information about the stroke
  • Family expects a lot
  • Got sent to mental health care instead of rehab

Personal factors (Cognitive Behavioural Therapy, counselling, support group, psychotherapy)

• An individual’s personal background that characterises the individual and is independent of the individual’s functional health condition
• Possible problems Mrs. Brown
  
  • Already great need for control before stroke
  • Susceptible to anxiety and mood problems → tension in relationship

Neuropsychological treatment

Neuropsychological treatment focuses on cognitive, emotional, social and/or behavioural problems resulting from brain injury. The aims of neuropsychological treatment is to learn the patient to how to deal with their problems and to improve their skills and knowledge and broaden/improve their behaviour repertoire. General principles of treatments are that once the period of spontaneous recovery has passed, injury/disorder is largely chronic. Before this time it is important to train in language and walking. According to the handicap model it is important to deal with psychoeducation first. With strategy training a person can cope very well with the ‘disorder’, as long as they are sufficiently aware of their disorder. Another principle is that everything takes longer or is slower.

Cognitive training

Cognitive training focuses on teaching the patient skills that can reduce cognitive disorders and/or their effects. Main techniques used are modelling (the therapist shows the appropriate behaviour), shaping (rewarding steps towards the intended behaviour), reinforcement (working with own concrete goals and rewards) (I want to learn how to cook again, start with a one pan meal, eventually cook a four pan meal).

All cognitive functions are related to eachother and you can look at them either top down or bottom up, when looking at the cognitive pyramid. From bottom-up: arousal – sensory stimulus processing – speed of information processing – attention – memory, language, perception – executive functioning.

If you have trouble with the speed of information processing, you have more trouble paying attention. If you don’t pay any attention to X, you won’t be able to memorize it, and so on.

Top down, executive functioning will help you storage your memory and organize your language.

Memory storage

Memory is first to storage in the short term memory, which consists of the working memory, visual and auditory sketchpad and an episodic buffer. Storage and consolidation is done by the hippocampus and will send the memory to the long term memory. Long term memory consists of explicit and implicit memory. Explicit memory consists of episodic memory (memories of one’s life) and semantic memory (facts, words). Implicit memory consists of skills, habits, priming and conditioning.

Therapeutic strategies used in memory training are using attention and executive functioning to compensate, using external aids and computerized training.

Theoretically based, measurable treatment

Psychoeducation helps the patient to understand what is wrong. It greatly increases the patient’s participation in the treatment.

External strategies used for compensation are used to externalize working memory and giving the patient the ability to use other senses/modalities. Examples of external strategies are using a calendar, a whiteboard, a phone, an alarm, notes or someone else’s memory. Pitfalls of this technique are not doing it consistently, not using a fixed time or place, another person not knowing and embarrassment.

Internal strategies can be remembered by using the mnemonic A True Right Knight Orders Light, which stands for Attention, Time, Repetition, Knots, to Look ahead/back.

Attention increases and strengthens consolidation, lessens forgetting, decreases distractors and increases interest. Time promotes and strengthens consolidation and decreases rate of forgetting. Repetition lessens the rate of forgetting and strengthens consolidation. Knots increase and strengthen consolidation and makes retrieval easier by using mnemonics. Order eases retrieval and asks for less demand on working memory. If someone’s remembers to post a letter tomorrow morning, they already think about how they are going to do it by making an imagination (take the letter, put it in front of the door, have breakfast, get ready, then before you leave you take the letter).