Cognition Assessment and Intervention Chapter 7 COGNITION ASSESSMENT AND INTERVENTION † MARY VINING RADOMSKI, PHD, OTR/L*; SHARI GOO-YOSHINO, MS ; CAROL SMITH HAMMOND, PHD, CCC/ ‡ § ¥ ¶ SLP ; EMI ISAKI, PHD ; DON MACLENNAN, MA ; R. KEVIN MANNING, PHD ; PAULINE MASHIMA, PHD, CCC/ ** †† ‡‡ §§ SLP ; LINDA M. PICON, MCD, CCC/SLP ; CAROLE R. ROTH, PHD, BC-ANCDS ; AND JOETTE ZOLA, BS, OT INTRODUCTION SECTION 1: ASSESSMENT Introduction Brief Cognitive Assessment Broad Assessment of Cognitive-Linguistic Abilities Domain-Specific Assessments Functional Performance Assessments SECTION 2: INTERVENTION Introduction Overview of Cognitive Rehabilitation Intervention Methods Clinician Tip Sheet: Principles of Cognitive Rehabilitation Cognitive Intervention Techniques to Promote Patient Engagement, Awareness, and Learning Clinician Tip Sheet: Motivational Interviewing Clinician Tip Sheet: AAA Self-Reflection Form Clinician Tip Sheet: Methods to Promote Compensatory Cognitive Strategy Learning Clinician Tip Sheet: Core Cognitive Strategy Recommendations Grid and Working Log Cognition Education Clinician Tip Sheet: How to Explain Human Information Processing Improving Attention and Speed of Processing Clinician Tip Sheet: Inventory of Attention/Speed-of-Processing Difficulties 175 Mild TBI Rehabilitation Toolkit Clinician Tip Sheet: Experiencing Attention Levels Clinician Tip Sheet: Overview of Strategies to Cope with Attention and Speed-of-Processing Difficulties Clinician Tip Sheet: Strategies to Improve Attention—Identifying High- and Low-Demand Tasks Clinician Tip Sheet: Menu of Strategies Based on Attention Hierarchy Clinician Tip Sheet: Practice Tasks for Attention Strategy Rehearsal and Transfer Compensating for Memory Inefficiencies Clinician Tip Sheet: Intervention for Memory Impairment Clinician Tip Sheet: Training Hierarchy for Memory Strategies Clinician Tip Sheet: Electronic Memory and Organization Aids Practice Tasks for Memory Strategy Rehearsal and Transfer Improving Executive Functions Clinician Tip Sheet: Treating Executive Dysfunction Clinician Tip Sheet: Improving Emotional Self-Management Clinician Tip Sheet: Understanding Executive Functions Clinician Tip Sheet: Strategies to Improve Self-Regulation—Pausing Clinician Tip Sheet: Strategies to Improve Initiation Clinician Tip Sheet: Building Habits and Routines Clinician Tip Sheet: Generative Thinking Strategies Clinician Tip Sheet: Project Planning Strategy—Divide and Conquer Clinician Tip Sheet: Problem-Solving Process Clinician Tip Sheet: Strategy—Prioritization Clinician Tip Sheet: Menu of Strategies to Manage Executive Function Inefficiencies Clinician Tip Sheet: Practice Tasks for Executive Functions Strategy Rehearsal and Transfer Social Communication Clinician Tip Sheet: Assessment and Treatment of Social Communication Problems Clinician Tip Sheet: Treatment Suggestions for Specific Problems in Social Communication Acquired Stuttering and Other Speech Dysfluencies Clinician Tip Sheet: Acquired Stuttering and Other Speech Dysfluencies Assessment Clinician Tip Sheet: Intervention for Acquired Stuttering and Other Speech Dysfluencies 176 Cognition Assessment and Intervention PATIENT HANDOUTS REFERENCES *Clinical Scientist, Courage Kenny Research Center, 800 East 28th Street, Mail Stop 12212, Minneapolis, Minnesota 55407-3799 †Staff, Speech-Language Pathologist, Otolaryngology Service, Department of Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Tripler Army Medical Center, Honolulu, Hawaii 96859-5000 ‡Research Speech Pathologist, Audiology/Speech Pathology, Durham VA Medical Center, #126, 508 Fulton Street, Durham, North Carolina 27705 §Assistant Professor, Communication Sciences & Disorders, Northern Arizona University, Department of Communication Sciences & Disorders, Building 66, PO Box 15045, Flagstaff, Arizona 86011-5045 ¥Chief, Speech Pathology Section, Minneapolis VA Health Care System, One Veterans’ Drive 127A, Minneapolis, Minnesota 55417 ¶Speech Pathologist, Traumatic Brain Injury Service, San Antonio Military Medical Center–North, 3551 Roger Brooke Drive, Joint-Base Fort Sam Houston, Texas 78234-6500 **Chief, Speech Pathology Section, Department of Surgery, Otolaryngology Service, Tripler Army Medical Center, 1 Jarrett White Road, Tripler Army Medical Center, Honolulu, Hawaii 96859-5000 ††Speech-Language Pathologist, Veterans’ Health Administration, James A. Haley Veterans’ Hospital, Audiology and Speech Pathology (ASP 126), 13000 Bruce B. Downs Boulevard, Tampa, FL 33612; and 4202 East Fowler Avenue, PCD1017, Tampa, Florida 33620-8200 ‡‡Division Head, Speech Pathology, Naval Medical Center San Diego, 34800 Bob Wilson Drive, Building 2/2, 2K-11R5, San Diego, California 92134-6200 §§Occupational Therapist, Brain Injury Clinic, Courage Kenny Rehabilitation Institute, Allina Health, 800 East 28th Street, Mail Stop 12210, Minneapolis, Minnesota 55407-3799 177 Mild TBI Rehabilitation Toolkit INTRODUCTION Cognitive complaints that follow concussion/ performance measures, self-report measures, and mild traumatic brain injury (c/mTBI), especially measures of effort.4 OTs and SLPs often contribute those resulting from blasts or other injuries sus- to this process with the use of multiple assessment tained in a combat zone, are multifactorial and not tools to fully characterize the extent of cognitive well understood. Clinicians serving service mem- and communication concerns. While it is a practice bers (SMs) with persistent cognitive complaints that standard to assess cognition and cognitive-commu- impact daily functions, including communication, nication complaints following c/mTBI, the choice must recognize potential contributing factors, such of which assessment tools to use is determined by as comorbid pain, fatigue, stress, sleep depriva- the individual clinician (practice option) based on tion, drug effects, and psychological concerns (eg, the needs of the SM and the specifics of the envi- posttraumatic stress disorder [PTSD], depression, ronment of care. Although the Toolkit includes the anxiety).1 For a more extensive discussion of these best available options, clinicians are advised that comorbid factors, as well as for literature reviews many of the assessments have not been validated of the evidence for the recommended assessments on adults with c/mTBI. and interventions, clinicians are referred to Occu- Similarly, most cognitive rehabilitation interven- pational and Physical Therapy Mild Traumatic Brain tions were developed for civilians with moderate Injury Clinical Management Guidance2 and the Speech- to severe traumatic brain injury. The efficacy and Language Pathology Clinical Management Guidance: effectiveness of these interventions have largely Cognitive-Communication Rehabilitation for Concus- been evaluated on more severely injured popula- sion/Mild Traumatic Brain Injury.3 tions or subject groups consisting of a range of This section of the Toolkit was developed by an injury severity levels. Despite this ambiguity of interdisciplinary group of clinicians, including oc- evidence, an expert panel convened by the Defense cupational therapists (OTs) and speech-language Centers of Excellence (DCoE) for Psychological pathologists (SLPs). The Toolkit and guidance docu- Health and Traumatic Brain Injury recommended ments were written to provide practical assistance cognitive rehabilitation for SMs with c/mTBI who for generalist clinicians working with SMs with c/ describe persistent cognitive symptoms at 3 months mTBI, including those clinicians with limited expe- or more after concussion.4 Therefore, those inter- rience in cognitive rehabilitation. SMs and veterans ventions that are either supported by empirical presenting with c/mTBI and persistent cognitive evidence involving studies of adults with c/mTBI symptoms often have complex comorbid conditions or endorsed by the DCoE expert panel are character- that may also undermine cognitive abilities and ized as practice standards in the Toolkit. Findings complicate the treatment process. Therefore, it is from future studies that are specific to SMs with imperative that clinicians recognize when to refer c/mTBI may lead to further modifications of these SMs with complex issues to specialists. Addition- recommendations. ally, clinicians are encouraged to move beyond the The approach and focus of cognitive and cogni- basics provided in this Toolkit to acquire knowledge tive-communication assessment and intervention and develop skills necessary to manage the chal- will vary by discipline and potentially by site. lenges and complexities of assessing and providing Clinicians are referred to the Toolkit introductions cognitive rehabilitation for this patient population. and to the companion guidance documents for a Experts recommend that cognitive assessment more in-depth discussion of the discipline-specific after c/mTBI consist of a thorough neurobehav- rationales for recommended rehabilitation practices ioral and cognitive evaluation using standardized for c/mTBI. SECTION 1: ASSESSMENT INTRODUCTION Cognitive assessment in acute c/mTBI focuses absence of cognitive changes as perceived by the pa- on tracking the resolution of symptoms to make tient, family members, or members of the patient’s return-to-activity decisions.5 OTs and SLPs may command. Interaction with the injured individual screen patients with c/mTBI within the first 90 days allows an opportunity to provide education about following concussion to determine the presence or the relationship between his or her symptoms 178 Cognition