What does neglect look like?

1. What does neglect look like? Allan Funk Occupational Therapist Foothills Medical Centre

2. glect look like? Funk al Therapist dical Centre

3. What does neglect look like? Allan Funk Occupational Therapist Foothills Medical Centre

4. at es lect ok ke? an nk tional apist hills ical tre

5. Not so neglected • Hot topic • Implications for safety, independence are varied and serious • Many subtypes • Limited understanding – many limitations in assessment and treatment

6. Impact • Mobility • Driving • ADL • IADL

7. Neglect • How does it work? • How does it break down?

8. What process or mechanism is breaking down? • Registration, integration, selection, action • Sensation, perception, cognition, praxis

9. Sensation • Peripheral or central • Attention

10. Integration • Coordinate systems – eye-centered, head-centered, body-centered, gravitational • Perceptual fields – relative leftness, environment vs. object • Peri-personal vs. extra-personal • Construction

11. Selection • Attention • Stimuli – number, structure, contrast, salience, novelty, speed • Recognition • Vigilance – Useful field of view • Central executive

12. Action • Visual or manual search • Mobility • Writing

13. Subtypes • Right vs. left • Incidence

14. Subtypes • Sensory- perceptual mode • Kinaesthetic • Auditory • Visual – spatial • Reading

15. Subtypes • Useful field of view

16. Subtypes • Extinction

17. Fellow travellers • Awareness - anosognosia • Indifference - anosodiaphoria • Sensory loss • Attention • Memory • Motor impairment

18. Anatomy • inferior parietal, frontal lobe, cingulate cortex, superior colliculus, lateral hypothalamus • anterior (lesion limited to the prefrontal cortex and adjacent white matter); posterior (lesion limited to the retrorolandic cortex, including parietal, but also temporal and/or occipital regions); anteroposterior (lesion involving both prefrontal, rolandic, and posterior regions,); subcortical (lesion limited to subcortical areas, such as internal capsule, centrum semiovale, striatum, or thalamus) • Occipital lobe, anterior limb of the internal capsule, posterior limb of the internal capsule, anterior portion of paraventricular white matter, posterior portion of paraventricular white matter, thalamus

19. Anatomy II • Top-down • Bottom-up • Posterior parietal cortex, frontal eye fields, cingulate gyrus • Thalamus, striatum, superior colliculus, ascending reticular activating system

20. Assessment • Pencil and paper or computer-based tasks • Scoring • Sensitivity

21. Assessment • Cancellation • Bisection • Visual scanning • Construction • Reading

22. Assessment • Cancellation – visual search pattern is most predictive • Right start >distribution of errors>number of errors • Bisection – placement and length

23. Assessment • Preponderance of pencil & paper • There is not yet a reliable, sensitive formal test of extra-personal neglect.

24. Function • Much better sensitivity than pencil and paper • Complexity of enivronment is key • interpretation requires knowledge of subtypes

25. Treatment • Focus on where the process is breaking down

26. Treatment • Sensation – use attention to compensate • Use soundbites or acronyms to facilitate acquisition of compensatory strategy • Minimum cueing & fading – ensure the patient is as active as possible in generating the desired behaviour • Target key functional tasks where safety is a particular concern – here you may need to cue more heavily

27. Treatment • Integration – poorly understood. • Eliminate distractions, try to use the simplest successful tasks/materials/environments.

28. Treatment • Selection/Attention – treatment may not generalise from one sensory-perceptual mode to another • Amenable to remediation • Delineate relevant subtypes • Manipulate key stimulus variables to grade and progress tasks – number, novelty, structure, salience, speed, contrast

29. Treatment • Action