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Evaluation of Cognition after Neurological Injury in Adolescents and Adults Charity Shelton, MS, CCC-SLP, CBISTCommon 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.”Pre-EvaluationNever underestimate the power of a good history and chart reviewIf you can talk with a previous therapist, social worker, etc. familiar with the patient, do itBefore beginning eval, chat with the patient (and/or family if available)If possible, know discharge plan/related issuesTalk with other treatment team members for input about functional abilitiesNational Cognitive Function MeasuresRancho Levels of Cognitive FunctionFunctional Independence Measure (FIM)Functional Assessment Measure (FAM)ASHA National Outcome Measure System (NOMS); Functional Communication Measures (FCM)Cognitive Screening ToolsConsiderationsA screening is not intended to replace more comprehensive assessmentsThe 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.Cognitive Screening ToolsMini Mental Status Exam (MMSE)Saint Louis University Mental Status (SLUMS) ExamMontreal Cognitive Assessment (MOCA)Brief Cognitive Assessment Tool (T)Mini-CogAssessment of Low Functioning CognitionDisability Rating Scale (DRS)Rappaport Coma/Near Coma ScaleWestern Neuro Sensory Stimulation Profile (WNSSP)Ross Information Processing Assessment-Second Edition and Geriatric (RIPA-2 & RIPA-G)Assessment of Moderate Severity Cognitive ImpairmentScales of Cognitive Ability for Traumatic Brain Injury (SCATBI)Ross Information Processing Assessment-Second Edition and Geriatric (RIPA-2 & RIPA-G)Assessment of Language-Related Functional Activities (ALFA)Measure of Cognitive-Linguistic Abilities (MCLA)DynavisionCognitive-Linguistic Quick Test (CLQT)Rivermead Behavioural Memory Test-3rd Edition (RBMT-3)Mini Inventory of Right Brain Injury-2nd Edition (MIRBI-2)Test of Memory and Learning-2nd Edition (TOMAL-2)Arizona Battery for Communication Disorders of Dementia (ABCD)Assessment of High Functioning Mild Severity Cognitive ImpairmentTest of Everyday Attention (TEA)Randt Memory TestBehavioural Assessment of the Dysexecutive System (BADS)Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES)Delis Kaplan Executive Function System (DKEFS)Wisconsin Card Sorting Test (WCST)Executive Function Route Finding Test (EFRT)Other Considerations of Cognitive AssessmentUse non-standardized assessment tasks when appropriateFor patients who have poor awareness, it may be appropriate to ask patient to predict how they will doWhen evaluating patients who are anxious, consider the manner in which you record responses and/or give feedbackObservations of overall processing, behaviors, responses to stress, etc are important Unless you are conducting research, it will be beneficial for you and your patient to assess response to cueing (after recording initial responses with no cueing)Evaluation Report WritingLength? Too little versus too muchShould be a combination of standardized test results and observations/report of functional observationsClearly stated information In addition to evaluation results, long term goals, etc., include the following in the evaluation summary:-recs for frequency, length of treatment-patient’s awareness of deficits, motivated to improve or not-patient’s and/or family’s goals-prognosis for improvementWithin Treatment AssessmentOf course, you want to Continue mini-assessments throughout treatmentFor low-functioning patients, you may not be able to do standardized assessment at first, but conduct assessments at later pointAdjust short-term, long-term goals as neededReassessment during treatment may be needed to determine need to continue or discontinue treatmentEvaluation SummaryAlways Use feedback from other members of treatment team to supplement evaluationBe sure to pick diagnostic tools appropriate and sensitive for severity levelObservation and informal assessment is VERY important – check out functional daily activitiesInclude level of cueing – whether it was needed or not When appropriate, you should do therapeutic evaluationCase StudiesCase Study #144 year old male, TBI with skull fracture from fallCompletes all self-care skills independentlyHas good awareness of deficits; decreased memory most significantly affects daily livingWith use of planner, calendar can follow schedule independently and can do basic executive function taskshas difficulty handling busy, noisy situationsHe reports his overall thinking is “slow”Patient goals: to return to work, improve cognitionIt is likely that this patient is functioning at what level?What are his likely deficits?What are some standardized assessments you might use?Which functional activities would likely be affected by his deficits?Case Study #222 year old male, TBI from car accidentEmerged from coma 1 week prior to your assessmentUpon observation/chart review:-restless, poor attention to others & environment-inconsistent use of yes/no responses-has occasional verbal responses, not always appropriate to situationIt is likely that this patient is functioning at what level?What are his likely deficits?What are some standardized assessments you might use?What functional activities would you like to see him complete?Case Study #354 year old male; TBI from fallPrior to your evaluation, had receptive/ expressive aphasia, but has mostly resolvedCan Communicates basic wants and needs and solve simple daily problemsNeeds considerable assistance with executive function tasksParticipates in structured sessions, but has poor attentionPatient goal: return to work: aware of deficits, but not severity nor impact on daily living/independenceIt is likely that this patient is functioning at what level?What are his likely deficits?What are some standardized assessments you might use?What functional activities would you like to see him complete? ................
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