Agenda W hy W orking Mem ory, attention and executive functioning ( - PowerPoint PPT Presentation

Why Cogmed Matters for Traumatic Brain I njury – TBI .

Contact I nformation: Presenter: Alison Winter alison.winter@pearson.com Tel: + 44 (0) 7734 744 771 Facebook : CogmedUK Twitter : CogmedUK Customer Services: 0845 630 88 88 info@pearsonclinical.co.uk

Credit for notes and slides to: Charles Shinaver, Ph.D Cognitive Consultant US charles.shinaver@pearson.com Peter Entwistle, Ph.D Cognitive Consultant US peter.entwistle@pearson.com

Agenda  W hy W orking Mem ory, attention and executive functioning ( EF) m atter for TBI .  WM & TBI: Survival, community integration, Quality of life, reduced depression  WM Correlates with EF  EF & TBI: O btaining competitive employment, occupational outcomes, and social integration .  Cogm ed Specific Studies & TBI  Going back to W ork : Adults with TBI and vocational outcomes.  Going back to School : Children with TBI and the effects upon learning.

1 . W hy does W orking Mem ory, attention and executive functioning ( EF) m atter for TBI .

W hat is Traum atic Brain I njury [ TBI ] ? Traum atic brain injury ( TBI ) , also known as intracranial injury, occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism (closed or penetrating head injury), or other features (e.g., occurring in a specific location or over a widespread area). Key feature: TBI can cause a host of physical, cognitive, social, emotional, and behavioral effects

W hat is W orking Mem ory [ W M] ? Working memory is the ability to keep inform ation in your mind for a short period of tim e (seconds) and be able to use this inform ation in your thinking Key feature: It has a limited capacity that varies greatly between individuals

W hat is Executive Functioning [ EF] ? Executive functions (also known as cognitive control and supervisory attentional system) is an umbrella term for the management (regulation, control) of cognitive processes, including: • Working memory • Reasoning • Task flexibility, • Problem solving • Planning and execution. Key feature: It is often affected by TBI even mild TBI can impair EF

TBI Long term effects & w orking m em ory ( W M) TBI can result in significant long-term negative effects on multiple aspects of life including employment. • Reduced w orking m em ory along with age, injury, and lifestyle factors was associated w ith reduced long-term survival (Himanen, et al., 2011). – Age at injury and vocational outcom e also correlated with reduced long-term survival (Himanen, et al., 2011). – Vocational outcome was associated with age, TBI severity, cognitive im pairm ent , later TBI’s, and alcohol abuse (Himanen, et al., 2011). • Better W orking Mem ory predicted “increased community integration, greater life satisfaction, and lower levels of depression. " – General self-efficacy m ediated the predictive value of working memory on life satisfaction and depression.” (Wood & Rutterford 2006). This was more than 10 years post TBI. In This study injury severity predicted only decreased life satisfaction. – Dem ographic and cognitive factors m ay be more predictive of long- term outcomes than injury severity. These authors em phasize the im portance of early social intervention post TBI . (Wood & Rutterford, 2006).

Adult TBI , W M and EF correlate w ith Quality of Life ( Dissertation, DaVanzo, 2 0 0 9 ) • 60 adult survivors of TBI. • Administered Quality of Life after Brain Injury scale. • “Results revealed moderate correlations between cognitive/ linguistic impairment functions of short- term memory and w orking m em ory/ executive function with QOL .” • A strong correlation between participation and QOL.

Focal lesions in adults w ith acute m ild TBI & neurocognitive outcom e ( Lee, et al., 2 0 0 8 ) • Mild adult TBI patients had significantly w orse perform ance on w orking m em ory tasks than m atched controls at acute ( < 2 w eeks) , at 1 m onth and 1 year post injury. • Also, CT and 3TMR imaging findings didn’t account for the cognitive impairment which may suggest that new techniques such as “diffusion tensor imaging” may be needed to provide biomarkers for Neurocognitive and functional outcome in mTBI.

Meta-Analytic Review of Neurocognitive Effects of Pediatric TBI ( Babikian and Asarnow , 2 0 0 9 ) 28 publications reviewed from 1988-2007. 3 distinct injury severity levels, 3 time intervals for 14 key neurocognitive domains. Tim e intervals: Time 1: 0-5 months, Time 2: 6-23 months, Time 3: 24+ months. Severity was based upon the Glasgow Coma Scale (GCS) score and often confirmed by clinical findings (such as loss of consciousness, posttraumatic amnesia, and/ or positive neuroimaging findings). Mild (GCS 13-15) Moderate (GCS 9-12) Severe (GCS 3-8) W e w ill only look at few item s here. Highlights : Intellectual deficits Pediatric TBI (Time 3= long-term > 24 + months) • W orking Mem ory deficits Pediatric TBI – ES (Effect size) Mild (.092), Moderate (.194), Severe ( .453 ) • Attention deficits Pediatric TBI (long-term 24 + months) – ES Mild ( < .347) , Moderate ( .316 ) , Severe ( .710 ) • Processing speed deficits Pediatric TBI – ES Mild ( .336) , Moderate ( .731) , Severe ( .925)

Long term effects of Pediatric TBI w ith I ntra Cranial Pressure ( I CP) related to w orking m em ory, attention & executive functioning ( Slaw ik, et al., 2 0 0 9 ) • Study of Severe pediatric TBI patients: – One group had I CP - intracranial pressure – The other group did not. – Both groups had normal IQ’s. – I CP group only show ed long-term deficits on “various m easures of attention and executive function such as w orking m em ory, decision-m aking, and im pulsivity.” – This suggested I CP lead to “ diffuse brain injury ” – Also, m easures of attention and EF are sensitive to raised I CP.

TBI Severity & I m pact on W orking Mem ory ( W M) The m ore severe the injury the m ore severe the im pact on W M. (Levin, et al., 2002; Roncadin, et al., 2004; Ewing-Cobbs et al., 2004; Conklin, et al., 2008). TBI results in significantly low er VSW M & VW M (Gorman et al., 2012). Severity of TBI predicts difficulty in producing speech sounds w hich is predicted by W M and pragmatic inference. (Dennis, et al., 2000)

Other factors affecting TBI long term outcom e • General I ntellectual functioning/ Global Cognitive functioning : Post-injury relates to ability to return to work with less services – yet not receiving enough services might interfere with a successful transition for those that are more cognitively intact. (Ownsworth & McKenna, 2004; Perna, et al., 2012) • I njury Severity Of TBI has been found to be a strong predictor of early TBI recovery (Wood & Rutherford, 2006). • Prem orbid functioning .

Fam ily factors affecting Pediatric outcom es of TBI • Parent psychological distress, perceived family burden, and coping skills affect outcomes (Yeates et al, 2002: J Ped Psych). • Injury has long-term effects on academic and behavior outcomes but is m oderated by fam ily environm ent (Taylor et al, 2002: Neuropsychology). • Parent acceptance of injury report low er stress than denial group, active coping increases w hen stressing the use of hum or to decrease stress (Wade et la, 2001: J Clin Cons Psych).

Factors post TBI im pacting return to w ork. • Social perception abilities relate to interpersonal aspects of job functioning and social integration more generally. – May need to train on reading social cues and situations. – Social outcomes associated with executive functioning , pragmatic language skills and social problem-solving (Yeates et al, 2004: JINS). – Some authors suggest an early focus upon social intervention post TBI (Wood & Rutherford, 2006). Addressing attention, m em ory, w orking m em ory and executive deficits can im prove w orkplace outcom es . • A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested (Shames,Treger, Ring,& Giaquinto, 2007). • W eb-based fam ily interventions after pediatric TBI have been found effective in helping fam ilies and im proving outcom es (Wade et al, 2008: J head Trauma Rehab).

Cognitive Effects of Concussions – Mild TBI: Memory Problems • Mem ory problem s : This area has the most research supporting it. Many of these effects would be short-term. • W orking Mem ory (T erry, et al, 2012; Levin et al., 2002; Roncadin, et al., 2004; Levin et al., 2004) • Episodic Mem ory (T remblay, et al, 2013; DeBeaumont, et al, 2009) • Delayed m em ory (Killam, et al., 2005) • Visual/ verbal m em ory (Matser , et al, 2001; Covassin, et al., 2010) • I m m ediate m em ory perform ance (Chapman, et al., 2006) • Mem ory (Clark, 2010; Iverson, et al., 2004; Covassin et al, 2008)

One w ould expect that “returning to learn” m ight be a challenge after a concussion. Distractible, forgetful Students students will find may struggle school difficult. with response Struggles getting speed and started or need more completing tasks. time to complete Easily fatigued. work/tests.

2 . Cogm ed Specific Studies & TBI