Computerized Cognitive Rehabilitation A Case Study Some sustained

Computerized Cognitive Rehabilitation: A Case Study Some sustained benefit of cognitive rehabilitation for a man with anoxic brain injury STUDY AIM Would regular student-assisted computerized cognitive rehabilitation improve cognitive function in this man with a severe anoxic brain injury more than two years post arrest? INTRODUCTION Cognitive rehabilitation follows a process of: Identifying areas of impairment Facilitating compensatory mechanisms to rapidly improve some function Challenging the brain to restore function Michael J Gilewski, Ph. D Base = raw of total or Z-score ++ Z-score improve of 1. 0+ + Improve Z of +0. 5 to +1. 0 – Decline Z of -0. 5 to -1. 0 -- Z-score of -1. 0 or worse Elizabeth M. Zelinski, Ph. D Physical Medicine & Rehabilitation Leonard Davis School of Gerontology Loma Linda Univ School of Medicine University of Southern California There is substantial evidence to show the benefit of cognitive rehabilitation in persons with acquired brain injury, specifically: • attention, • visual spatial function • executive functions • some aspects of language • some aspects of memory Because there is limited research on computerized training and even less research on training with persons with old brain injuries, the results of this study could be informative. • Most research is focused on where treatment is provided and reimbursed, that is, in acute inpatient rehabilitation post medical stability, in structured residential or day treatment programs, and in outpatient rehabilitation. • Recent research, e. g. , constraint-induced treatment in stroke, is demonstrating some potential long-term benefit of some treatment for persons outside formal treatment and long after a brain injury was acquired. Neuropsychologist screen with options to monitor and direct training 6 Cognitive domains x 12 graded tasks x 3 -4 difficulty levels/task CASE STUDY Consistency of sustained attention was very difficult – he never mastered the task Variable Level 1 Level 2 Level 3 Level 4 Start Date 2011 -01 -15 0000 -00 -00 14 0 0 Total Time on Task (minutes) 33 0 0 0 # Clicks (baseline) 39 0 0 0 Aver. RT (last 5 - baseline) 295 0 0 0 Aver. RT (overall - baseline) 421 0 0 0 Variance (last 5 - baseline) 8582. 00 0. 00 Variance (overall - baseline) 94201. 00 0. 00 Submissions Restarts 5 0 0 0 50 0 Aver. RT (last 5 - most current) 295 0 0 0 Aver. RT (overall - most current) 372 0 0 0 Variance (last 5 - most current) 6382. 00 0. 00 Variance (overall - most current) 31563. 00 0. 00 4 0 0 0 Date (most current) 2011 -07 -25 0000 -00 -00 Total Clicks (overall) 433 0 0 0 Consecutive Passes 0 0 1 0 0 0 13 0 0 0 # Clicks (most current) Background Age 60 at baseline assessment 14 years education, owned successful film production business Married to wife and their daughter in her 20 s at home # errors (most current) Total Passes Total Fails Grade - most current Demographic predicted ability = %ile, AM-NART estimated = %ile Blessed and Folstein mental status tests (some items analyzed separately) Attention – Digit span, trail making, letter-number sequencing, digit-symbol coding Learning-Memory – Logical Memory story, California Verbal Learning Test Language – Boston naming, Letter fluency (FAS), Category fluency (animals, vegetables), Token Test (substituted Rule Governed Drawing) Visual-spatial – Block design Geriatric Depression Scale Added physical – full-tandem standing time and 12 -foot walking speed Added behavior/QOL – Frontal Systems Behavior Scale and Mayo-Portland f Executive skills – he spent a long time on task but passed first difficulty level Neuropsychonline Cognitive Rehabilitation Therapy System Progress Report - Track 02 - Executive Skills - Organizing Information (Commonality) Variable Level 1 Level 2 Level 3 Level 4 Start Date 2011 -01 -15 0000 -00 -00 88 0 0 310 0 % Correct (baseline) 55 0 0 0 % Correct (current) 100 0 Date (most current) 2011 -08 -01 0000 -00 -00 Consecutive Passes 3 0 0 0 Total Passes 24 0 0 0 Total Fails 64 0 0 0 p n n n Submissions Restarts Total Time on Task (minutes) 93 rd Computerized cognitive rehabilitation program: www. neuropsychonline. com Browser-based program by subscription. Data stored in HIPAA-compliant database by Neuropsychology vendor. Mental Status Folstein 22 of 30 0 - - Attention Blessed ment. control 0 + + “ ” Serial 7 s - 3 of 5 + + 0 “ ” Digit span 8 F, 5 B ++ + + “ ” Trails A Z = -7. 3 + 0 0 “ ” L-N Seq Z = -2. 3 0 + + “ ” Digit sym Z = -2. 7 0 0 0 A Jan 2011 assess B Sep 2011 assess A Jan 2012 assess Ability June 2010 test baseline Learn/mem. All delayed recall=0 0 “ ” Story immediate Z = -2. 7 0 0 0 “ ” Word list total Z = -1. 7 0 0 - “ ” Recognition corr. NA Z = -5. 0 ++ ++ “ ” Recog. d’ Z = -3. 0 - + + “ ” Forced choice recog 81% - - A Jan 2011 assess B Sep 2011 assess A Jan 2012 assess B Grade - most current Visuospatial skills were a strength Track 04 - Visuospatial Skills Progress Report - Task Status Task Date Started Levels Passed Date Completed Luminosity Discrimination 2011 -01 -15 passed all 2011 -06 -20 Line Discrimination 2011 -03 -05 1 of 4 na Angle Discrimination 2011 -07 -05 1 of 4 na Design Completion na Shape and Pattern Discrimination na Complex Animated Pattern Discrimination na Ball In A Box : right na Ball In A Box : left na How Many Blocks? na Paddle Ball : right na Paddle Ball : left na Designer Patterns na Visual Analysis and Synthesis I na Visualization From Blueprints I na B Memory was the worst cognitive function. Some improvement in recognition. Ability June 2010 test baseline Language Naming Z = -2. 4 0 + ++ “ ” Letter Fluency Z=-1. 2 + + -- “ ” Cat. Fluency Z = -3. 0 ++ ++ + “ ” Token Test Z = 0. 9 “ ” Rule Gov Drawing (time) Z = -2. 1 + -- “ ” RGD Exec (corr) Z = -3. 2 ++ ++ “ ” RGD Exec (time) Z = -1. 5 ++ -- A Jan 2011 assess B Sep 2011 assess A Jan 2012 assess B Language – Improved naming, generally sustained fluency, some improved language comprehension. Last assessment performance was very slow. Ability June 2010 test baseline Visuospatial Block Design Z= -0. 7 0 - Depression GDS = WNL 0 0 0 A Jan 2011 assess B Sep 2011 assess A Jan 2012 assess Wife rated Assessment 86 th June 2010 test baseline Task 01 - Simple Visual Reaction - Fixed Point - Right Hand # errors (baseline) A-B-A-B Single Case Study Design June 2010 – Alzheimer’s Coordinating Center neuropsychological test battery at USC Jun–Dec 2010 - Initial control phase A: OT nonspecific cognitive enhancement with computer 2 -3 x/wk January 2011 – Readminister tests Feb–Aug 2011 Initial training phase B: Student-assisted computerized cognitive rehabilitation 2 -3 x/wk September 2011 – Readminister tests Sep–Dec 2011 – 2 nd control phase A: Group games and nonspecific cognitive enhancement or computer use 3+ x/wk at residential setting January 2012 – Readminister tests February 2012 – started 2 nd training phase B Ability Mental status – worse but orientation not trained Attention – some sustained improvement in attn capacity and working memory When computerized programs for cognitive rehabilitation are used, recommendations are to also have active involvement of a therapist and not just solely rely on the impaired person to self-train. DN is a man, who suffered a severe anoxic brain injury following several episodes of ventricular cardiac arrest in June 2008 • After internal defibrillator and medical stability, went through a course of acute inpatient rehabilitation, intensive outpatient and residential treatment through March 2009. • Discharge to home with full-time caregivers for supervision • May 2010 – his wife consulted USC Neurology for other treatment or research options Results Apathy Fr. SBe Z = -5. 8 + + Disinhib. Fr. SBe Z = -3. 4 0 + Exec Dys. Fr. SBe Z = -5. 8 + + Ability Mayo-Portland Z = -0. 8 + Adjustment Mayo-Portland Z = -1. 3 + Not depressed. Some sustained improvement in brain-related behavior as rated by wife. The second training episode has begun with an aim to sustain or improve cognitive functions and behavior. The study was given a human subjects exemption by USC IRB. There would be no case study with the support and assistance of Teresa Diaz (USC staff) and student assistants to facilitate the computer cognitive rehabilitation: Natalie Abrahamian Rachel Anderson Robert Grijalba Erin Lee Joanna Marantidis Josh Van Zak This work was partially funded by NIA P 50 AG 005142, Project 1, E. M. Zelinski, Project Director B