Using Assistive Technology to Aid with Cognitive Functioning

Regina Lesako, MAClinical Director

ReMed

Eduardo Jorge, BA, CBISClinical Specialist

ReMed

Presented By:

What is Assistive Technology?• “In general.--The term ‘assistive technology device' means any

item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of a [person] with a disability.” – U.S. Department of Education

• Examples of Assistive Technology•Wheel chair•Computer software/hardware•Equipment to allow for easier use of objects (leisure, cooking, dressing, etc.)•Bowling balls

•Walkers•Shower chairs•Medication dispensers•Alarms

(IDEA - Building The Legacy of IDEA, 2004)

(Assistive Technology for Individuals with Traumatic Brain Injury, 2014)

What is Cognition?

“The workings of the mind through which we are able to make sense of the world including speed of thought, memory, understanding, concentration, ability to solve problems, and the use of language.”

K. Malia & A Brannagan, Therapy.Neurological Training for Professionals: Distance Learning Cognitive

Rehabilitation Training Course

(Malia & Brannagan, 2007)

Areas of Cognition

Attention

Information Processing

Memory

Executive Function

(Malia & Brannagan, 2007)

Attention/Concentration

“The ability to focus on certain aspects of the environment that one considers important or interesting and the flexibly to manipulate this information.” – K. Malia & A Brannagan

Focused

Sustained

Selective

Alternating

Divided

(Malia & Brannagan, 2007)

Information Processing

• “The ability to make sense of our world by dealing effectively and efficiently with sensory and other information that constantly enters the system.”

–K. Malia & A Brannagan taking in information

creating meaning from that information

selection and activation of a response to that information

receptive and expressive communication

(Malia & Brannagan, 2007)

Memory

“The ability to keep things in the mind and to recall them at some point in the future”

– K. Malia & A Brannagan

Sensory memory

Short Term Memory

Long Term Memory

(Malia & Brannagan, 2007)

Executive Functions• Skills that enable us to develop and work towards

accomplishing goal directed behavior

• Executive functioning is commonly associated with, but not limited to:

Planning and organizationFlexible thinkingMonitoring performanceMulti-taskingSolving unusual problemsSelf-awarenessLearning rulesSocial behaviorMaking decisions

MotivationInitiating appropriate behaviorInhibiting inappropriate

behaviorControlling emotionsConcentrating and taking in information

(Malia & Brannagan, 2007) (Executive Dysfunction After Brain Injury,

2014)

Case Study• John is a 42 year old veteran that was exposed to

multiple IEDs during his combat assignment in Iraq.

• John had worked as an electrical engineer prior to enlisting in the Army.

• After being medically discharged from the Army, he looked to return to work, but was limited due to barriers related to his injury.

• He held a limited role within a family realty business.

Case Study

• Delayed thought processing

• Word finding ability

• Visual construction tasks

• Early onset of cognitive fatigue

• Increased anxiousness and irritability

• Short term memory

• Attention/concentration

• reduced math skills.

• John expressed a desire to progress his vocational aspirations either in his family’s business or through other options available to him to vocationally, including returning to school for additional training.

• At the beginning of his rehabilitation program and struggled with:

Attention

Attention

A person with Acquired Brain Injury may:•Become easily distracted

•Have difficulty multi-tasking

•Experience information overload

•Be slower at processing information

(Acquired brain injury: the facts : the practical guide to understanding and

responding to acquired brain injury., 2008)

Tools to Aid with Attention

White Noise

Stochastic Resonance– the process where by moderate noise aids to increase cognitive performance

Reduce Auditory Distractions

Increases in neural activity aid with cognitive performance.

(Söderlund, Sikström, & Smart, 2007)

Metronomes

(Hill, Dunn, Dunning, & Page, 2011)

Training with an Interactive Metronome

Tools to carry over training into the community

• Metronomes, Metronome Apps, and Tap metronome Apps.

Audio RecorderHelps to compensate for difficulties attending to details presented in a conversation and allows for information to be recorded for later review with the option for pausing, rewinding, and repeating.

Available as:•An Independent Device (Audio Recorder)

•Full Size Device•Key Chain Size Device

•An app (Smart Phone/Tablet)•A Computer Program

Case Study• Attention:

Managing internal and external distractions

Early onset of Cognitive Fatigue

Increased pace and error rate with fatigue

• Tools and Strategies Used: Exposure to environmental stimuli with White Noise faded

over time

Interactive Metronome• Trained to allow for functional use of a metronome with activities

• Decreased internal distractions allowing for improved Focused attention.

Information Processing

Information Processing

(Killington, 2013) (Impact of Acquired Brain Injury on the Individual,

2014)

Changes in information processing often present as decreased speed of response to stimuli. This change in speed can be due to:

•Misinterpretations of communicated information•Interfering internal and external distractions•Receptive or Expressive Aphasias•Difficulties transitioning between topics

Tools to Aid With Information Processing

Changing Modalities

• Individualize the way information is presented Identification of the best modality

Visual – videos, demonstration

Tactile – hands on

Auditory – explanation and

communication

Verbal – paraphrasing and

learn and teach techniques

Text to Speech

•Technologies read text out loud

•Changing modalities•Aid with reading difficulties due to aphasia or vision problems

•Increasing both work and leisure capabilities.

AAC ToolsDynavox and Aphasia Apps

•Communicate via picture icons that can be used to form phrases or sentences

•Have the option to be digitally read aloud

•Custom phrases can be pre-programmed for commonly used expressions

•Layouts can be arranged to increase ease of use.

(Alternative & Augmentative Communication)

Case Study

• Information processing Difficulties understanding information presented in

large quantities or in complex formats.

• Tools and strategies used Identifying and using ideal modalities for

information processing

Incorporating tools for attention

Electronic text books with text-to-speech

capabilities

Memory

Memory

(Acquired brain injury: the facts : the practical guide to understanding and responding to acquired

brain injury., 2008) (Coping with Memory Problems: Practical Strategies, 2013)

The most commonly reported cognitive deficit after a brain injury.

Deficits in memory can impair a person’s ability to participate in

vocational, leisure, and social tasks as well as learning new information

related to these areas.

Establishing compensatory strategies is vital to lessen the impact of

memory problems for day-to-day functioning.

Five Common Approaches are:

1. Adapting the Environment

2. Using External Memory Aids

3. Following Set Routines

4. Combining Several Strategies to make an artificial memory system

5. Improving general physical, emotional, and mental well-being

Tools to Aid With Memory

Audio RecorderRecord now and recall later

•Save and organize recorded messages• Digital recordings can be stored in a number of formats- Smartphone, computer, CD’s, or other electronic storage devices.

Medication TechnologyComputerized Medication Boxes

•Meds can be pre-loaded for varying periods of time (4 days – 4 weeks)

•Set alarms for meds

•Pill boxes can be locked to prevent tampering

•Some offer text messaging support to verify if a medication has been taken out or not

Medication TechnologyMedication Apps

•Large number of apps that provide a variety of features to compensate for memory issues•Can be set up to:

• Store pictures, names, dosages, dosage times.•Detailed instructions•Set reminders and follow up reminders to check for changes in status•Allow for family members to get messages for missed and/or taken meds

Calendars• Stock computer, smart-phone, and tablet

calendars Customize colors of specific events

Set reminders•Text (for traditional phones as well)

•Email

•Pop-up

Easy customization

Note Taking/List Apps•Write down important information•Speech to text options•Audio recordings•Include pictures in notes (items, documents, people, etc.•Various ways to organize notes•Set reminders (time and location)

Note Taking/List Apps

•3rd party apps that allow for information to be synced across all devices. •Access information on Android, Apple, or Windows phones, tablets, or computers.•Multiple ways to input and store information

•Photos•Audio recordings•Videos•Text

Smart Pens

• School and Vocational Tool Digitally records written notes

Audio recording of lecture/conversations

Bookmark parts of audio recording

Email notes

Connect to note apps

Additional Memory Tools

• GPS and Bluetooth Trackers

Locate objects that have a GPS/bluetooth tag on them using your phone (keys, cars, wallet, pill box, etc.)

• Emergency Information

Apps that store all vital information that may be needed in-case of an emergency (medications, diagnoses, allergies, contact information, etc.)

Tags or bracelets that emergency personnel can plug into a computer or scan to obtain vital information

Additional Memory Tools

• Timers provide a sometimes necessary cue to remember important information related to a task. Boil alert, Temperature alert, cell phones, kitchen

timers

Case Study

• Memory Incomplete retention of information

Degradation of memories over time

• Tools and strategies used Use of apps for notes and reminders

Smart Pen used during return to school.

Timers and limits used for breaks

Calendar app for scheduling

Executive Functions

Executive Functions

(Executive Dysfunction After Brain Injury, 2014)

Covers a broad category of complex and interconnected abilities and behaviors that are vital for:

•Planning and organization

•Flexible thinking

•Monitoring performance

•Multi-tasking

•Solving unusual problems

•Self-awareness

•Learning rules

•Social behavior

•Making decisions

•Motivation

•Initiating appropriate behavior

•Inhibiting inappropriate behavior

•Controlling emotions

•Concentrating and taking in

information

Behavior and Mood Trackers

• Executive functions are multifaceted complex behaviors that are best addressed with therapeutic intervention.

• Tools can be used to: Build awareness related to behaviors

Track frequency, intensity, and patterns of behavior

Provide resources for trained strategies to aid with desired behaviors

Case Study

• Executive Function

• Tools and strategies used Trackers for awareness

•Symptoms, Triggers, and Behaviors

Planning and problem solving

•Clear definition of goals and steps towards achieving them

•Vague goals•Feelings of overwhelm•Disorganization

•Unmanaged symptoms

Case Study

• John started his rehabilitation program in late 2012.

• Throughout his program there were a few medical setback and some changes to goals.

• He returned to school at one point to work towards advancing within his family’s real estate business

• Later opted to pursue schooling for

computer networking.

Case Study

• John completed his training with high marks and obtained his CCNA and CCNP certifications

• He is currently completing a work trial through the VA to work towards paid employment in the field of Networking and Switching for commercial businesses.

References• Acquired brain injury: the facts : the practical guide to understanding and responding to acquired brain injury. (2nd ed.). (2008).

Milton, Qld.: Brain Injury Association of Queensland.

• Assistive Technology for Individuals with Traumatic Brain Injury. (2014, January 1).Assistive Technology for Individuals with Traumatic Brain Injury. Retrieved May 10, 2014, from http://www.brainline.org/content/2011/04/assistive-technology-for-individuals-with-traumatic-brain-injury-tbi.html

• Coping with Memory Problems: Practical Strategies. (2013, January 1). . Retrieved May 10, 2014, from https://www.headway.org.uk/Core/DownloadDoc.aspx?documentID=570

• Executive dysfunction after brain injury. (2014, January 1). Headway -. Retrieved May 16, 2014, from https://www.headway.org.uk/executive-dysfunction-after-brain-injury.aspx

• Hill V, Dunn L, Dunning K, Page SJ. A pilot study of rhythm and timing training as a supplement to occupational therapy in stroke rehabilitation. Top Stroke Rehabilitation. 2011 Nov-Dec;18(6):728-37. doi: 10.1310/tsr1806-728.

• IDEA - Building The Legacy of IDEA 2004. (n.d.). IDEA - Building The Legacy of IDEA 2004. Retrieved May 16, 2014, from http://idea.ed.gov/explore/view/p/,root,statute,I,A,602,1,

• IMPACT OF ACQUIRED BRAIN INJURY ON THE INDIVIDUAL. (2014, January 1). . Retrieved May 16, 2014, from http://synapse.org.au/get-the-facts/impact-of-acquired-brain-injury-on-the-individual-fact-sheet.aspx

• Killington, M. (2013, July 3). Cognitive Impairments following Acquired Brain Injury. . Retrieved May 10, 2014, from http://www.rah.sa.gov.au/birs/bi_cognitive_impairment.php

• Malia, K., & Brannagan, A. (2007). Principles of Cognitive Rehabilitation Therapy.Neurological Training for Professionals: Distance Learning Cognitive Rehabilitation Training Course (). Leatherhead: Brain Tree Training.

• Söderlund G1, Sikström S, Smart A. Listen to the noise: noise is beneficial for cognitive performance in ADHD. J Child Psychol Psychiatry. 2007 Aug;48(8):840-7.