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The Basics of Cognitive Intervention
How SLPs can incorporate language into overall cognitive rehabilitation.
Posted on:
December 13, 2010
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Traumatic brain injury (TBI), right-hemisphere stroke and Alzheimer's disease are the main diagnoses that can result in cognitive decline. Cognition can be subdivided into various cognitive abilities, including attention, memory, visual-spatial perception and language. Speech-language pathologists sometimes view the last component as a separate ability.
"We focus on language and look at cognitive disorders often as separate from language issues," said Jean Neils-Strunjas, PhD, CCC-SLP, professor in the Department of Communication Sciences and Disorders, College of Allied Health, at the University of Cincinnati in Ohio. "However, neuropsychologists, psychologists and neurologists would look at language as a type of cognition because it's a higher cortical function."
The subtypes are not the only aspects of cognition, Dr. Neils-Strunjas told ADVANCE. For example, she defined executive functioning as the "functions of an executive." Within each person's brain is a "businessman" acting as the executive of a company, which is the mind itself. This entity plans, organizes, sets goals, and determines time frames for completing tasks and self-monitoring, or determining whether the pursuit of a goal has been successful.
Orientation-or the awareness of time, place, people and circumstances-is yet another aspect of cognition. Specifically, temporal orientation includes things like time of day, date, season, and proximity to holidays, for example.
Memory was once believed to be a singular entity. That all changed in the 1950s with the case of a patient referred to in the literature as "H.M." Following a surgical procedure for epilepsy, H.M. had difficulty learning new information and creating new memories, although his past memory remained intact. After studying H.M. extensively, Canadian psychologist Brenda Milner, PhD, discovered that there are different types of memory.
"This case clearly illustrated how one aspect of memory may be preserved and other aspects may be severely impaired," said Dr. Neils-Strunjas.
While classifications vary, two subtypes of memory are explicit and implicit. Explicit, or declarative, memory allows people to talk about, or declare, memories, while implicit memory is automatic.
"We may not have conscious awareness that we are learning something, and we may not be able to talk about it, but we do learn it," she explained. "For example, we might learn to shift the gears on a car through repetition, but we may have a hard time describing it to someone. Once we are in a car with a gearshift, we know what to do."
Cognitive goals for behavioral treatment depend on a patient's severity of impairment. If a patient is severely impaired, clinicians should look to stimulating any remaining abilities.
"If the person has a very severe impairment of learning new information, the speech-language pathologist might try to elicit past memories or work on language skills or some aspect of the person's functioning that has been preserved," Dr. Neils-Strunjas said.
For patients with mild to moderate deficit, clinicians should focus on improving their existing abilities and giving them a chance to practice their skills.
"This is often termed a restorative approach because you are trying to improve a particular cognitive function," she said. "If improvement is limited, you might focus on compensatory strategies." For example, patients who have difficulty remembering appointments may benefit from using an iPhone, a watch alarm or a daily planner.
Cognitive therapy, and cognition in general, is relatively new to speech-language pathology, but it is deeply embedded in neuropsychology, a field that clinicians can mine for information regarding potential interventions.
Cognitive impairment is also a focus of behavioral neurologists, Dr. Neils-Strunjas said. "They look at the behaviors that result from neurologic impairment."
It is important to look into rehabilitation theories when developing a treatment plan, she noted. "Increasing the person's independence is a major theme across all rehabilitation approaches. Occupational and physical therapists are all striving to help the person become more independent."
Speech-language pathologists also can look to the field of cognitive psychology to gain a theoretical basis for developing interventions.
Clinicians need to know how a person functioned prior to a neurological episode and work with the family to develop goals. Patients should participate in this process, if possible, so their personal goals can be considered.
"If a person is severely impaired, the goals should be modest," she said, such as being able to take a phone message.
Resources for obtaining more information on cognition include mining university library systems, browsing scholarly journals approved by the American Psychological Association, searching the Internet, and attending the annual conference of the International Neuropsychological Society.
For More Information
Jason Mosheim is a Senior Associate Editor at ADVANCE. He can be contacted at jmosheim@advanceweb.com.
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