Cognitive Functioning

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Do you know why we are able to perform all daily living activities and work tasks with same procedure, minimum error and repeatedly everyday? And also how are we able to plan, experiment and implement new tasks?. The answer to this is your cognitive functioning. Making sense of the world around us are fundamental to carry out daily living activities. To be functionally independent various body factors (cognition, physical, mental factors) and environmental factors (social, physical occupational factors) should be coordinated properly.

Cognition consists of interrelated processes including the ability to perceive, organize, assimilate and manipulate information to enable the person to process information, learn and generalize. 

Fig : Cognitive functioning is necessary to plan and achieve your goal.

Cognitive impairment : 

Cognitive impairments results in significant activity limitations and participation restrictions in all aspects of client's life. Cognitive impairments hamper safety, health, and well-being of that person and it even affects the quality of life and concern of patient's relatives.

Cognitive impairments according to the DSM-5 (June 2013) are classified into minor and major neurocognitive impairments. The DSM-5 defined six key domains of cognitive function, and each of these has subdomains. Six domains are language, learing and memory, social cognition, complex attention, executive function and perceptual-motor function.

• Minor Neurocognitive Disorder (often called Mild Cognitive impairment or MCI), with the necessary neurocognitive impairment in one or more domain, and do not interfere with capacity for independence in everyday activities. Modest impairment in cognitive performance preferably documented by standardized testing or another clinical assessment.
• Major Neurocognitive Disorder or Dementia, which would typically involves two or more domains, and interferes with independence in everyday activities. Substantial impairment in cognitive performance preferably documented by standardized testing or another clinical assessment.

Fig : Six neurocognitive domains of Cognitive function in DSM-5.

Safety hazards of patients with cognitive impairments includes :

• Decreased abilities to recognize potential hazards.
• Decreased ability to anticipate consequences of actions and behaviors.
• Difficulty following safety precautions.
• Difficulty and slow in responding to emergency situations.

Cognitive dysfunction can diminish :

• one's sense of competence
• self-efficacy and self-esteem
• difficulty in facing and adapting to demands of everyday living activities.
• Loss of office job due to inability to fullfill job requirements. 

Cognitive impairments are caused due to : 

1) Chronic diseases of brain or body's organ : hypertension, stroke, peripheral vascular disease, diabetes, depression, multiple sclerosis, epilepsy, brain tumors, alcohol addiction, attention deficit disorder etc.

2) Neurodegenerative diseases such as Alzheimer disease (AD), frontotemporal dementia, Parkinson disease, and multiple sclerosis etc

3) Single or repeated head injury : open or closed head injury.

Cognitive functions : 

1. Orientation : the ability to understand the self and the relationship between the self and the past and present environment.

2. Attention : multidimensional capacity that involves several components namely alertness (detection and reaction), selective attention, sustained attention, shifting of attention,and mental tracking.

3. Neglect : failure to orient to, respond to, or report stimuli presented on the side contralateral to the cerebral lesion in clients who do not have primary sensory or motor impairments.

4. Memory : gives us the ability to draw upon past experiences and learn new informations.

5. Visual Processing : involves the reception, organization, and assimilation of visual information. Visual processing disorders includes difficulty in discriminating between objects, pictures of objects, and basic shapes (form constancy); difficulty in detecting gross differences in size, position, direction, angles, and rotations; decreased ability to visually locate single visual targets in space or judge gross distance between two objects; figure-ground perception and depth perception and decreased ability to detect simple part-whole relationships in objects or basic shapes (agnosia). 

6. Executive function : broad band of performance skills that allow a person to engage in independent, purposeful, self-directed behavior (i.e., volition, planning, purposeful action, and self-awareness and self-monitoring).

7. Motor Planning or Praxis : ability to figure out how to get one’s body to do what one wants it to do. Motor planning, or praxis, is the ability to execute learned and purposeful activities. Apraxia is defined as a disorder of skilled movement that cannot be adequately explained by primary motor or sensory impairments, visual spatial problems, language comprehension difficulties, or cognitive problems alone.

8. Awareness : the degree of understanding one has regarding one’s own physical or cognitive-perceptual impairments.

Cognitive Rehabilitation : 

Cognitive approaches : Which cognitive approach to be used depends of patient's learning capabilities, chronicity and severity of disorder. It includes : 

• Cognitive disability approach and Neurofunctional approach (develop splinter skills) for severe stroke patients.
• Cognitive retraining approach, Dynamic Interactional approach and Quadraphonic approach for mild to moderately affected stroke patients who has a scope for learning and retraining for lost function by developing new or alternate strategies.

For treating Cognitive areas work on patients :

• By improving their self awareness about cognitive or visual perceptual problems. It can be done by teaching and practising various techniques like mental imagery, verbalization, self-cueing, situational strategies, self-monitoring strategies. Feedback about his/ her performance should also be provided intermittently. 

• For visual-perceptual disorder : 

1. Teaching self monitoring strategies :  which includes anticipation of error causing situations, checking or double checking activity, pacing response in familiar and unfamiliar environment, stimulus reduction i.e avoiding clutters and organizing daily used objects in specific patterns. 
2. Teaching situational strategies : which includes scanning of things or environment in an organized manner (taking your own time), visually imagining the object patient is searching for, verbalizing the shape or colour or size or thickness of object patient is searching for. All these strategies will reduce confusion, decrease time for searching things, improve self esteem of patient, reduce chances of mistakes and dependency on others. 

• Making use of remedial or compensatory approaches for training cognitive areas like attention, memory, executive functions, neglect, apraxia, concentration.

• For unilateral neglect : support use of visuospatial interventions that include practice of visual scanning technique because it improves compensation for unilateral neglect and generalizes to everyday activities. Gross motor activities involving and activating vestibular input and whole-body movement in space increases general arousal and alertness and have been used in combination with visual scanning activities to increase gaze and attention to the affected side. Strategies specifically aimed at facilitating attention to the left side (contralateral side of affected brain lesion), strategies that focus on the general ability to sustain attention have also been found to reduce unilateral neglect. Intervention should be teaching the client to find the edges of a page or a table or the periphery of stimuli before beginning a task and to mark it with spatial point of reference, such as colored tape, a colored highlighter, a bright object, or placement of his or her arm on the left border. Auditory cueing, utilizing a beeper or alarm device, can be combined with strategy training to remind the person to use a strategy or visual cue. The alarm device can require the client to scan space and attend to the left to turn off the sound. Midline orientation and midline crossing activities should be given like passing a ball from left to right hand and again in opposite directions, touching the left shoulder with right hand and vice versa.

• Motor Planning impairment or Apraxia : practitioner might provide physical contact (i.e., hand-over-hand assistance or light touch) to limit inappropriate or extraneous movements while simultaneously using guiding methods to facilitate a smooth motor pattern or to guide the manipulation of objects. Through repeated practice in different tasks, the client begins to learn the movement patterns that feel “right,” and the practitioner gradually withdraws assistance. Before performing an activity, the client might mentally practice or imagine the task performance; or the client might imagine how an object should look in his or her hand before picking it up. Simple adaptations to objects that draw attention to the critical features of the object or activity can facilitate action and motor planning (e.g., colored tape on the knife handle or toothbrush handle). Patterns and designs on utensils or clothing might draw attention to the wrong detail and result in an inappropriate motor response.

• Home activities for patients and relatives : Simple activities to improve cognitive function should be done like : 

1. Asking the patient to recall all the activities, which were performed throughout the day from morning to evening or night. 
2. Tell the patient to recall and explain the steps used to perform a specific activities like making a tea, making any specific dish, steps in bathing, patient's role in his job, etc (Note : activities which patient has knowledge about and is familiar with should be asked).
3. Ask patients to think and name any 5 to 7 words starting with any specific alphabet. Patient can tell names of any person, animal, colour, fruit, daily use object, brand name starting from any specific alphabet as commanded. For example : Ask patients to name 5 or more words starting from 'B'. Then patient should tell names like blue, balloon, big, buffalo, British etc. If starting from 'R' then patient can answer red, rose, river, Rohan, rain etc.
4. Tell patient to write numbers in ascending or descending order with or without skipping one or two numbers. For example : (1,3,5,7...) or (22, 24, 26, 28...) or (100, 98, 96, 94...). Similarly, write alphabets from 'A' to 'Z' with skipping one or two alphabets. 
5. Activities should be given to patient by considering their areas of interest, severity of disease, educational level, familiarity with given activities/tasks. Activities should not be too easy or too difficult to perform. Patient should have scope to learn and actively involve in problem solving while performing given task.
6. Patient should be asked different questions regarding past memories of his school or college days, questions related to daily living activities, today's date or current time, what patient had for breakfast or lunch (recent past) etc. Make this an habit or frequently ask these kind of questions because this will keep the patient oriented and attentive. This will trigger and improve the thinking process and working memory of the patient.
7. Pictures of few activities are shown below.  These activities includes playing card, 2D puzzles, 3D block construction etc. All these activities will be helpful in improving cognitive functions namely attention, visual processing, concentration, neglect etc.

Thankyou for reading !!!!!!

Dr.Ashwini Sangar, Dr.Sheetal Tatar-Dhande, Dr.Pallavi Khadse-Kolhe.