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