ADDRESSING META-COGNITION

AND EXECUTIVE FUNCTION IN

PATIENTS WITH TRAUMATIC
AND ACQUIRED BRAIN INJURY:
AN OVERVIEW OF ASSESSMENT
AND TREATMENT APPROACHES
Dani Goddard, OTS
Touro University Nevada

WHAT IS EXECUTIVE FUNCTION & WHY DOES

IT MATTER?

Executive cognitive function allows

for abstract and analytical thought,
the planning and taking of actions
toward a goal, and adaptation to the
unexpected (mental flexibility)

Planning, problem-solving, selfmonitoring, and self-awareness

Executive function depends on

working memory, which resides
mainly in the prefrontal cortex,
whereas other types of memory
reside in the temporal lobes
Whether or not memory is impaired,
executive dysfunction can degrade
ones ability to carry out ADLs and
IADLs and to direct ones caregivers
Neuropsychological studies of older
adults suggest that executive
dysfunction may more reliably
predict loss of autonomy than
memory impairment

Retrieved from
http://www.nursingcenter.com/pdf.asp?AI
D=828299

BENEFITS TO ADDRESSING COGNITION

THROUGH THE CONTINUUM OF CARE

Holistic treatment
approach

Overall, cognition affects

every aspect of the
persons life

More realistic discharge

planning and
recommendations
Patient safety
May increase patient
insight over time

Retrieved from
http://www.beechwoodneurorehab.org/_
1

BARRIERS TO ADDRESSING COGNITION IN

THE INPATIENT REHAB SETTING

Retrieved from
http://psychcentral.com/news/20
09/02/10/are-brain-exercisesmainly-hype/4009.html

Patient motivation
Memory problems and carryover
(often anterograde amnesia)
Patient insight regarding cognitive
and functional deficits (meta
functions controlled by frontal lobe)
Distraction
Pragmatic issues such as time &
money constraints for the therapist
Keeping up with recent EBP can be
challenging
Creating individualized, creative,
patient-centered interventions may
also be challenging

TREATMENT PROGRESSION BASED ON

COMPLEXITY

* Basic
Cognition
(orientation,
comprehension,
expression,
memory, basic
problemsolving)

* ADL
Processing

* IADL
Processing

* Community
Re-Entry

Work Re-Entry

As always, safety should be addressed and corrected

immediately during each stage
* = covered today

BASIC
COGNITION

SCREENING, ASSESSMENT, & RE-EVALUATION TOOLS:

BASIC COGNITION

Mini Mental State Examination (MMSE)

Basic info: screens patients orientation, registration, attention & calculation,
recall, and language using an 11-item, 30-point questionnaire
Pros: available for free online; widely utilized and recognized; quick to administer
Cons: the official version is now published and must be purchased; not
appropriate for detecting mild cognitive impairment (MCI) or mild dementia;
learning effects may alter scores if re-administered in close succession

Montreal Cognitive Assessment (MoCA)

Basic info: designed as a rapid screening tool for detecting MCI; assesses attention
and concentration, executive functions, memory, language, visuo-constructional
skills, conceptual thinking, calculations, and orientation
Pros: available for free online in 35 languages and in a version for patients who
are blind; quick to administer (~10 minutes); multiple versions to avoid test-retest
learning effects
Cons: requires additional assessment if scores indicate potential cognitive
impairment

Trail-Making Test (oral version), COWAT (letters F/A/S), & CLOX 1 & 2

FIM-Based Communication/Cognition Screening

Provides examples of questions the practitioner can use to assess comprehension,

expression, problem-solving, and memory

MMSE VS. MOCA: HOW DO THEY COMPARE?

Category

MMSE

MoCA

Primary use

Created to screen for

cognitive impairment and
measure change over time

Created to screen for MCI

& measure change over
time

How to acquire

Official version is now

copy-written and must be
purchased (however, many
free versions can be found
online); 2nd edition and 10
translations now available

Free online; has been

translated in 35 languages
(version also available for
the blind)

Abilities addressed

Orientation (time, place),

registration, attention,
calculation, memory/recall,
& language

Visuospatial/executive
skills, naming, memory,
attention, language,
abstraction, delayed recall,
and orientation

Total points

30 total points

30 total points

Time to administer

~10 minutes

~10 minutes

Learning effects

Easy for patients to learn

some items

Most translations also have

multiple versions

MMSE VS. MOCA: HOW DO THEY COMPARE?

Psychometrics

MMSE

MoCA

Sensitivity for
identifying MCI,
dementia, or AD

MCI: 17%
Mild dementia: 25%
Alzheimers: 78%

MCI: 83%
Mild dementia: 94%
Alzheimers: 100%

Internal consistency

Poor-to-adequate

Excellent

Test-retest reliability

Excellent if reExcellent
administered within 2
months (*however, this is
not suggested due to
significant learning effects)

Inter-rater reliability

Adequate

Excellent

Criterion validity
(predictive,
concurrent)

Poor

Excellent

BOTTOM LINE:

Inferior to MoCA

Superior to MMSE

SAMPLE:
MINIMENTAL
STATE
EXAMINATION
(MMSE)

SAMPLE:
MONTREAL
COGNITIVE
ASSESSMENT
(MOCA)

SAMPLE: TRAIL-MAKING TEST (ORAL VERSION),

COWAT, & CLOX 1 & 2

Trail-Making Test, oral version: Ask the patient to recite the alphabet
and count 1-25 before beginning to check for automatic sequencing
and/or aphasia; then ask the patient to associate letters with
numbers in the form of 1-A, 2-B, 3-C etc. (all the way through 13M). More than 2 errors indicates possible impairment.
Controlled Oral Word Association Test (COWAT): Ask the patient to
come up with as many words (with 3+ letters) as he/she can that start
with each of the following letters: F, A, and S. Give the patient 1
minute to come up with as many words as possible for each letter. Do
not score repeats, mistakes, or versions of the same word (i.e. plurals).
Correct words receive 1 point each. Individuals with a high school
education should score at least 30 points.
CLOX*:

CLOX 1: Have the patient draw a simple clock set to 1:45 (allow 1 minute)
CLOX 2: Have the patient copy a correctly-drawn clock (allow 1 minute)
*Please see article at http://www.nursingcenter.com/pdf.asp?AID=828299
for full scoring protocol

SAMPLE: FIMBASED
COMMUNICATION
& COGNITION
SCREENING

INSIGHT & SELFAWARENESS

SCREENING, ASSESSMENT, & RE-EVALUATION

TOOLS: INSIGHT AND SELF-AWARENESS

Anosognosia: deficit of self-awareness

Insight & Self-Awareness

Self-Awareness of Deficits Interview (SADI)

Patient verbally answers 3 questions regarding deficits, functional

impact, and goal-setting (prompts provided for clarification if needed)
Scored by therapist on a 4-point scale based on patient insight (0-3)
0 = patient is aware of deficits and is realistic about goals
3 = patient fails to acknowledge deficits or only references an external
locus of control
Can easily be reviewed by therapist, 0-9 total score (9 indicating lower
insight regarding deficits)

Mayo-Portland Adaptability Inventory-4 (MPAI-4)

Created for patients with TBI; may also be appropriate for clients with
CVA
Assesses abilities, adjustment (including family/significant
relationships), participation, and pre-existing and associated conditions
(premorbid drug or alcohol abuse, psych conditions, or physical
conditions/disabilities)
Can be completed by patient, family member, or therapist
Should be scored using manual
Can be re-administered over time to show progress or improvements in
self-awareness

SAMPLE:
SELFAWARENESS
OF DEFICITS
INTERVIEW
(SADI)

SAMPLE:
MAYOPORTLAND
ADAPTABILITY
INVENTORY
(MPAI-4)

COGNITION IN
TERMS OF
ADL AND IADL
FUNCTIONALITY

SCREENING, ASSESSMENT, & RE-EVALUATION

TOOLS: ADL & IADL FUNCTIONALITY

Cognition in terms of ADL safety/independence:

Cognitive Screen for Grooming (CSG)

Assesses cognition in terms of initiation, sequencing, processing, and

completion of brushing teeth and/or caring for dentures
Scored on a 3-point scale: 0 indicates no problem, 2 indicates patient needs
3+ cues
Required cues are categorized as visual, verbal, or tactile

Cognition in terms of IADL safety/independence:

Executive Function Performance Test (EFPT)

Determines which executive functions are impaired, how independent and

safe the patient is during these tasks, and how much help he or she needs
for task initiation, execution, and termination
Tasks include: simple meal prep, using the telephone, medication
management, and bill pay (very functional!)
Cue sequence: indirect verbal guidance, gestural guidance, direct verbal
assistance, physical assistance, total assistance
Pros: free and easy to access; well-standardized; provides treatment
interventions; strong psychometric properties

SAMPLE:
COGNITIVE
SCREEN FOR
GROOMING
(CSG)

SAMPLE: EXECUTIVE FUNCTION

PERFORMANCE TEST (EFPT)

COMMUNITY
RE-ENTRY

COMMUNITY RE-ENTRY: ACTIVITIES &

EVALUATIONS (SIMPLE TO COMPLEX)

Path-finding, divided attention, following directions, &

navigating familiar environments:

Rehab floor scavenger hunt

Path-finding, divided attention, following directions, budgeting,

and navigating unfamiliar environments:

Multiple Errands Test (MET)

Can be created for each unit/hospital setting (Jen has created a Sunrise
version)
Comprised of 6 specific errands, 4 facts to be written down, a time-sensitive
task, and a requirement to verbalize termination of the activity
Record errors as follows:
Inefficiencies: where a more effective strategy could have been applied
Rule breaks: where a specific rule (either social or explicitly mentioned
in the task) is broken
Interpretation failure: where requirements of a particular task are
misunderstood
Task failure: where a task is either not carried out or not completed
satisfactorily

Walgreens TACO Scavenger Hunt

Allows patient to practice skills in a potentially recognizable environment

and may increase insight regarding deficits

SAMPLE:
REHAB
SCAVENGER
HUNT

SAMPLE:
MULTIPLE
ERRANDS
TEST (MET)

SAMPLE:
WALGREENS
TACO
SCAVENGER
HUNT

APPROACHES &
INTERVENTIONS

APPROACHES

Task-Specific Training: occupationally/functionally based and

meaningful, repetitive practice, spaced retrieval of
information (graded as memory improves), dual task training
as appropriate (completing two tasks simultaneously to
increase divided attention and working memory)
Metacognitive Strategies:

Cognitive Orientation to Daily Occupational Performance (CO-OP

Approach)

Predict and evaluate

Have patient predict how well they will do before completing a task; then
after completion, have them self-evaluate their performance

Error-free Learning

Goal, plan, do, check: patients are encouraged to create their own goals
for the session, create a plan for achievement, complete the activity, and
evaluate their performance (planning should be facilitated by therapist;
can use COPM-based format to set goals)

Break down the targeted task into small, discreet steps

Provide demonstration until patient is able to return demo properly
Encourage client to avoid guessing and ask for assistance if needed
Correct errors immediately
Carefully fade prompts (verbal, tactile, and physical)

Chaining (forward, backward)

INTERVENTION IDEAS

Create a memory book or daily log to help patients keep up with therapy (schedule, goals,
interventions, and plans), visits from loved ones, or other specific events
Practice shopping online, paying bills; provide budgets and needed tools like balance
register or calculator (or encourage patient to use tools on his/her phone)
Acquire a bus schedule/route map and have the patient plan a trip using public transit
Help the patient use social media, email, or text messages appropriately to communicate
with family and friends (or find online peer support groups)
Write a note or post card, address, and send it in the mail (downstairs, outside)
Print out a menu online, give the patient a budget, and have the patient choose a meal
(including beverage, appetizer, and dessert); have patient total amount and calculate tip
(even better, take them on a TACO to Dennys and complete these steps)
Plan a meal, use the internet to search for a recipe, create a shopping list, then cook the
meal (have the patient do all steps except grocery shop)
Review home safety/emergency protocols (see following page)
Play memory or categorization games such as Simon, Scattergories, or The Game of Things

Use a map to plan a day trip or sequence outings (i.e. post office, grocery store, mall)

Online word categories game for 1 or 2 players: http://www.quia.com/cb/6309.html

Learn how to use a navigation app on the phone or online for printed directions

Teach a novel sequence of exercises/steps to a task and have the person return demonstrate
Use newspaper or online resources to check weather, sports, or current events
Complete small fix-it tasks (install batteries and set a portable alarm clock for patients
room)
Unload dishwasher and sort utensils/put away dishes in the proper place
Help patient set up medication sorter before discharge
Walk to gift shop and purchase a small gift (book, magazine, snack, gift for a loved one); set
a budget beforehand and see if the patient can remember/follow limit

HOME SAFETY

DIGITAL APPS

DIGITAL APPS

Digital apps such as those created for smart phones

and tablets can target a wide range of needs, abilities,
and higher cognitive skills
They can be used by therapists in treatment sessions
or suggested for patients to utilize outside of
treatment
AOTA has created several lists of apps to use with
various populations (children & youth, mental health,
productive aging, rehab & disabilities, etc.)

AOTA members can find apps for rehab/working with

people with disabilities here:
http://www.aota.org/Practice/RehabilitationDisability/RDP-apps.aspx

BrainLine has also created a list of Life-Changing

Mobile Apps for People with Brain Injury:

http://www.brainline.org/content/2013/12/life-changingiphone-and-ipad-apps-for-people-with-brain.html

TOP 3 FAVORITE APPS FOR COGNITION

1.

2.
3.

Lumosity (Apple, Android, & PC)

Flow Free (Apple & Android)
Word Brew (Android) or Brew the
Word (Apple)

*There are plenty of other great apps

which can be used to target
communication, daily planning/memory,
medication management, navigation,
home management, and other
important client needs. However, these
three apps specifically use a game-based
format to target aspects of higher
cognition and executive functioning.

LUMOSITY

Cost: free basic program; free full program for clinicians who apply
through the CARE program and agree to share efficacy data;
otherwise, $11.95/month or $47.96/year for an individual (or $79.96
for up to 5 family members)
Available for Apple, Android, & PC
Pros: can individualize programs to target processing speed,
memory, problem-solving, divided attention, and cognitive
flexibility
Cons: most appropriate for high-level patients
Similar apps: NeuroNation (free), Elevate-Brain (free), Rosetta
Stone Fit Brains Trainer (free)

FLOW FREE

Cost: free
Available for Apple & Android
Pros: easy to learn, provides a colorful
and simple platform for visual learners;
can help patients strengthen problemsolving, visual-perceptual, and pathfinding abilities; provides levels from
easy (5x5 grids) all the way to hard (9x9
grids); grids can be refreshed or moves
can be undone if errors are made
Cons: frequent ads may confuse players;
there are no provided instructions, so
players may require orientation to the
app
Similar apps: Bubble Poke, Bejeweled,
Candy Crush

WORD BREW/BREW THE WORD

Cost: free
Available for Apple (Brew the Word) & Android (Word
Brew)
Pros: does not require additional players; free; can be
set to easy, normal, or hard levels
Cons: frequent ads may prove distracting for players
Similar apps: Words with Friends, Word Mix Lite
(Android) or Word Warp (Apple)

RESOURCES

RESOURCE LINKS

MMSE (free version, not official):

MoCA:

https://academiccommons.columbia.edu/download/fedora_content/
download/ac:157860/CONTENT/COG_SCREEN_GROOM_TEST_
MANUAL_OBSERVATION_SCHED_MORTERA_2011.pdf

EFPT:

http://tbims.org/combi/mpai/

CSG:

https://view.officeapps.live.com/op/view.aspx?src=http%3A%2F%
2Fwww.me.umn.edu%2F~wkdurfee%2Fprojects%2Fdriving%2Fs
elf-aware%2FFINAL%2520SADI%2520form.doc

MPAI-4:

http://www.mocatest.org/

SADI:

http://www.heartinstitutehd.com/Misc/Forms/MMSE.1276128605
.pdf

http://www.ot.wustl.edu/about/resources/executive-functionperformance-test-efpt-308

MET (basic info & how to create a site-specific version):

http://strokengine.ca/assess/module_met_indepth-en.html

UTILIZING THESE RESOURCES

I have created a resource binder for use by
therapists here on the rehab unit. Please make
copies as needed and return the master
versions to the binder.
I have also created a test kit for the EFPT. If you
are interested in using it, please read the manual
(included in the kit) and individualize the items
as needed for your patient (i.e. put the patients
name on the bills or medication bottles).
Enjoy!

THANK YOU
FOR YOUR
TIME AND
SUPPORT!!
Please email me at
ot15.danielle.goddard@nv.touro.edu for a
digital copy of this presentation.