Evaluation of Cognition after Neurological Injury in Adolescents and Adults

1. Evaluation of Cognition after Neurological Injury in Adolescents and Adults Charity Shelton, MS, CCC-SLP, CBIST Mercy neuro outpatient therapy services – springfield, mo

2. 1st Hour • Pre-evaluation procedures • National cognitive function measures • Cognitive screening tools • Assessment of severely/profoundly impaired cognition 2nd Hour • Assessment of moderately impaired cognition 3rd Hour • Assessment of mildly impaired cognition 4th Hour • Evaluation report writing • Within-treatment assessment • Case studies and review

3. Common “issues” • “my patient’s functioning is too low to conduct any type of cognitive testing” • “I am not allowed enough time to conduct the type of evaluation I would like to complete” • “I completed my evaluation and thought I had a good idea of his/her cognitive function, but now that I’ve worked with him/her, I’m noticing so much more.” • “My patient and/or their family complain of cognitive deficits, but my testing doesn’t show anything that is below normal limits.”

4. Pre-Evaluation

5. Before Evaluation • Never underestimate the power of a good history and chart review • If you can talk with a previous therapist, social worker, etc. familiar with the patient, do it • Before beginning eval, chat with the patient (and/or family if available) • If possible, know discharge plan/related issues • Talk with other treatment team members for input about functional abilities

6. Interdisciplinary Evaluation • Is VERY important • You are NOT an island unto yourself SLP Nursing OT Pharmacist PT Social Services Physician Family Neuropsych Patient

7. National Cognitive Function Measures 2012 MSHA Conference

8. Rancho Levels Rancho Levels of Cognitive Function (Developed for use after traumatic brain injury) http://rancho.org • Each level is descriptive of a person’s cognitive functioning, including related behaviors • 10 levels: 1 to 10; 1 = completely dependent; 10 = completely independent

9. FIM (functional independence measure) Uniform Data Set/Medical Rehabilitation, 1999 –2011 • 18 functional areas including motor, physical, self-care and cognitive-linguistic function. • SLPs complete FIM scores for Auditory/Visual Comprehension, Verbal/Nonverbal Expression, Problem Solving, (Social Interaction), Memory • Scale of 1 to 7; 1 = completely dependent or lack of functional ability ; 7 = completely independent

11. FAM (Functional assessment measure) Wright, J. 2000 (www.tbims.org/combi/FAM ) • Adjunct to FIM to address areas less emphasized in FIM, including cognitive, behavioral, communication and community functioning measures. • 12 items intended to be added to FIM • Scale of 1 to 7; 1 = completely dependent or lack of functional ability; 7 = completely independent • FIM + FAM

12. Fam: areas pertinent to cognition • Community access • reading • writing • emotional status • adjustment to limitations • employability • attention • orientation • safety judgment

13. ASHA NOMS/FCMASHA, 2003 • ASHA National Outcome Measure System; Functional Communication Measures • 15 areas • Cognitive areas include: Attention, Memory, Pragmatics, Problem Solving • Scale of 1 to 7; 1 = completely dependent or lack of functional ability; 7 = completely independent

14. National cognitive function measures • All these can be used as additional information to be added to your more specific, standardized measures of cognitive function

15. Cognitive Screening Tools

16. Considerations Cullin, o’neill, et al, 2007 • A screening is not intended to replace a more comprehensive assessments • The best screening tools will cover the following 6 areas, based on established cognitive and neuropsychological characteristics in various dementias (and cognitive dysfunction in general) • attention/working memory, new verbal learning and recall, expressive language, visual construction, executive function and abstract reasoning.

17. Mini Mental Status Exam (MMSE)Folstein, M., Folstein, S.E., McHugh, P.R. , 1975

18. Mini Mental Status Exam (MMSE) • Developed to screen for cognitive function in older adults but may be used with other adolescents/adults with cognitive impairment • 5 areas of screening: orientation, registration, attention and calculation, recall, and language • Maximum score of 30; 23 or lower indicates cognitive impairment • Takes 5 to 10 minutes to administer

19. St Louis University Mental Status (SLUMS) ExamTariq, Tumosa, Chibnall, Perry & Morley, 2006

20. St Louis University Mental Status (SLUMS) ExamTariq, Tumosa, Chibnall, Perry & Morley, 2006 • Designed to detect early neurocognitive decline or mild deficits as a result of early dementia • 11 items: orientation, short-term memory, calculations, naming, clock drawing, and recognition of geometric figures.

21. St Louis University Mental Status (SLUMS) ExamTariq, Tumosa, Chibnall, Perry & Morley, 2006 • Scores up to 30: 27-30 = normal in a person with a high school education. 21-26 suggest mild cognitive deficits, 0 -20 indicate dementia or moderate to severe cognitive deficits • 7-10 minutes to administer

22. Montreal Cognitive Assessment (MoCA) NasreddineZS, Phillips NA, et al. 2005

23. Montreal Cognitive Assessment (MoCA) • Designed to quickly assess cognition in various neurological disorders, including dementia • 7 areas including: VISUOSPATIAL/EXECUTIVE, NAMING, MEMORY, ATTENTION, LANGUAGE, ABSTRACTION DELAYED RECALL, AND ORIENTATION • Scores up to 30: ***

24. Montreal Cognitive Assessment (MoCA) • 10 minutes to administer • Has 3 different versions for pre and post treatment assessment • Test is available in multiple languages • Has an electronic version for i-pad

25. Brief cognitive assessment tool (BCAT)Mansbach, W. E.; MacDougall, E.E.; Rosenzweig, A.S. (2012)

26. Brief Cognitive Assessment tool (BCAT) • Designed to quickly assess cognition to determine normal versus mild cognitive impairment and dementia • 13 areas to assess: orientation, verbal recall, visual recognition, visual recall, attention, abstraction, language, executive functions, and visuo-spatial processing

27. Brief Cognitive Assessment tool (BCAT) • Scores up to 50: score relative to Normal, mild cognitive impairment, Mild dementia, mild to severe dementia • 10-15 minutes to administer • There is a 5 minute version available • There is online scoring and interpretation available • It has a “test system” with various assessment tools that can be used in conjunction with the bcat

28. Mini-cogBorson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. (2000)

29. Mini-cog • Tests only 2 areas: short term recall and clock drawing • Takes only 3 to 5 minutes to administer • Examinees are asked to immediately repeat 3 words, draw a clock, and then recall the 3 words • Recalling only 1 or 2 words or abnormal clock indicates possible dementia and/or cognitive impairment

30. Other Screening Tools • The General Practitioner assessment of COGnition (GPCOG) Brodaty, H., et al., 2002 http://gpcog.com.au/index.php • Some lengthier assessments have a screening-length version – check them out! • Nonstandardized screenings

31. Low Functioning Cognition

32. Low Functioning Cognition • Short clip of Colby

33. Low Functioning Cognition • Rancho Levels 3 to 4 • Cognitive FIM/FAM scores of 1 and 2 • ASHA Cognitive NOMS of 1 and 2

34. Low Functioning Cognition Profound Impairment • Alert, but profound deficits in attention and awareness of environment and others • No to only minimal initiation of communication • Impulsive/unsafe

35. Low Functioning Cognition • May exhibit perseverative behaviors • General processing deficits • Unable to participate in “back & forth” of structured evaluation/therapy session

36. Severe Impairment • Increased communication (compared to profound) • May state simple thoughts/ideas but not direct own care • Impulsive in physical and mental tasks • More aware of environment and others but very easily distracted • Better able to participate in structured therapy but with lots of cues

37. Low Functioning Cognition Severe Impairment continued • Not oriented • May be able to recognize, occasionally recall familiar information/routines • Dependent for problem solving At severe/profound cognitive impairment level, may also have cognitive-based voice and swallowing issues

38. Evaluation of Low Level Cognition • Disability Rating Scale • Rappaport Coma/Near Coma Scale • Western Neuro Sensory Stimulation Profile • Portions of RIPA-2/RIPA-G ? • Non-standardized Assessment/Observation

39. Disability Rating ScaleRappaport et. al, 1987

40. Disability Rating Scale • arousability awareness and responsivity • cognitive ability for self-care activities in: feeding toileting grooming • dependence on others and level of functioning • psychosocial adaptability and employability 2012 MSHA Conference

41. Disability Rating Scale • Eye Opening (score 0 to 3) • Communication Ability (score 0 to 4) • Motor Response (score 0 to 5) • Feeding (score 0 to 3) • Toileting (score 0 to 3) • Grooming (score 0 to 3) • Level of Functioning (score 0 to 5) • Employability (score 0 to 3) 2012 MSHA Conference

42. Disability Rating Scale • Can be used to track someone from coma to high functioning • Maximum score = 29 (extreme vegetative state) • Lowest score = 0 (a person without disability)

43. Rappaport Coma/Near Coma Scale Rappaport et. al, 1982 (revised form in 1987)

45. Rappaport Coma/Near Coma Scale Assessment of Response to Sensory Modalities: • Auditory: generalized/differentiated response to sound; following verbal commands • Visual: response to light flashes, visually locating therapist; visual threat • Olfactory: response to noxious stimuli • Tactile: response to touch, pain • Vocalization: observation of voicing

46. Rappaport Coma/Near Coma Scale For each task, responsiveness is rated as follows: • 0 = quick, consistent response 2 to 3x • 2 = delayed or partial response • 4 = no response

47. Rappaport Coma/Near Coma Scale

48. Western Neuro Sensory Stimulation Profile (WNSSP)Ansell, B, Keenan, J., & Rocha, O. 1989

49. WNSSP

50. WNSSP Recommended for patients who are slow to recover. Measures responsiveness as follows: • Arousal/Attention • Auditory Response: localization and comprehension • Expressive Communication: vocalization, facial expression/gestural communication, yes/no response • Visual Response: localization and comprehension