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Occupation and Cognitive Rehabilitation

Stephanie Tempest and Linda Maskill

AIMS

1. To understand cognition and the role of cognitive skills in occupational performance.
2. To introduce and discuss the importance of using two specific frameworks - the International Classification of Functioning, Disability and Health (ICF) and the Occupational Therapy Practice Framework (OTPF).
3. To demonstrate the use of the ICF and the OTPF to guide our analysis of occupational performance in cognitive rehabilitation.

What is Cognition?

Cognition is 'the process of obtaining knowledge through thought, experience and the senses' (Oxford English Dictionary 2005). It derives from a Latin verb, the meanings of which include to get to learn, to recognise and to find out.

Cognition is studied in many different disciplines and the meaning varies when applied to psychology, philosophy, linguistics or computer science. For example, in computer science, cognition includes the development of artificial intelligence and robotics.

But our understanding of cognition draws upon health science, neuropsychology and the concept of occupational performance. As therapists, we need to understand how the brain functions and subsequently dysfunctions following neurological insult, in specific cognitive modalities such as attention, memory and purposeful movement. Then we need to apply this knowledge of cognitive body functions to understand how people use them to build skills and to perform activities within the context of their everyday life.

There are different ways to classify cognitive functions and some of these debates will be evident in Part 2 when we seek definitions of 'individual' impairments. For the purposes of this introduction, when answering the question 'What is cognition?', let us consider two main groups. First, there are the broad cognitive functions which, it could be argued, are the foundation stones for our function, comprising consciousness, orientation, intellect, psychosocial skills, temperament and personality, energy, drive and sleep (WHO 2001). Second, there are specific cognitive modalities, the building blocks for our function, comprising attention, memory, psychomotor functions, emotions, perceptual skills across all the senses, higher level skills (executive functioning), praxis and experience of self and time (WHO 2001). Our ability to interact in a meaningful way, within our environment, is dependent on a complex interplay of these skills.

The Functional and Social Impact of Cognitive Impairments

The impact of cognitive impairments on the individual, their partners, family and friends can be significant. The lived experience allows us some insight into the real story.

The lived experience of cognitive impairments (adapted from Erikson and Tham 2010; Gelech and Desjardins 2011; Lorenz 2010)

I can get tired, irritable and worried because basic activities need more energy, planning and attention. These difficulties have persisted and sometimes I feel out of control. I wonder about the sort of person I have become but I recognise my old self when I do my previous occupations: 'I am a customer; yes I can be that for a while'. I use tricks so I can remember to do things like setting the table; sometimes I need them but not always.

Living with the effects of brain injury is like living in a fog; sometimes my head is scrambled and the shell of my life is broken. I think about my lost dreams and feel the chaos of my daily life. But I compensate for this; I put labels on things, I use a timetable and all the time I'm developing a new identity.

I'm building a new self now, with elements of my old self and new bits, some are good and some are not so good. But I need to accept the death of my old self.

The need for cognitive rehabilitation may be self-evident. But there is debate about what it is and the contributions made by occupational therapy. Within all forms of rehabilitation, models and frameworks help us to conceptualise the processes involved (Wilson 2002) and to think about how and why we should assess, intervene and evaluate. Of great importance is that they help us, as therapists, to understand and articulate the impact of, for example, cognitive impairments on an individual and their family.

To this end, Chapter 1 will start with a brief debate on what comprises cognitive rehabilitation and the unique role for occupational therapy within the process. Specific theoretical frameworks and models will be described in terms of their usefulness to aid our clinical reasoning and then applied to the occupational therapy process, to demonstrate the need to embed our clinical practice within the theory base. Finally, this chapter will summarise why it is essential for occupational therapists to understand the nature of cognitive impairments.

The Scope of Cognitive Rehabilitation

Cognitive rehabilitation draws upon theories from a number of disciplines including neuropsychology, occupational therapy, speech and language therapy and special education; therefore it is not the exclusive domain of one profession. A single definition of cognitive rehabilitation remains elusive; indeed, it has been questioned whether the term itself should be replaced by 'rehabilitation of individuals with cognitive impairments' (Sohlberg and Mateer 2001). This is of particular relevance to occupational therapists where the focus of rehabilitation belongs with the individuals in their context, rather than 'treating' impairments per se.

But Wilson (2002) argues that, in its broadest sense, cognitive rehabilitation should be defined as a process which focuses on real-life, functional problems and is collaborative, involving the individual, their relatives, the multidisciplinary team and the wider community.

In his seminal paper, in 1947, Oliver Zangwill (an influential British neuropsychologist) also spoke about the need to 'join forces' for the rehabilitation of psychological aspects in cases of brain injury. He outlined three activities comprising the scope of psychological rehabilitation: compensation, substitution and direct training. They are worthy of a brief exploration here as the different levels of intervention proposed by Zangwill (1947) resonate with current clinical practice, as will be explored further in Chapter 3. Zangwill defines direct retraining as an attempt to re-educate and remediate the actual impairment, more successful, he noted, in physical aspects of therapy. Substitution seeks to offer an alternative solution to solve the problem but in practice is likely to be a refined version of the final activity. Compensation aims to introduce new internal or external approaches to solve problems, despite the persistence of the underlying impairment.

Current evidence-based guidelines support comprehensive holistic rehabilitation using compensatory strategies, including Zangwill's concept of substitution, to manage the risks associated with cognitive impairments in multiple sclerosis (NICE 2014); to help people with their occupational performance post stroke (Gillen et al. 2014); or to compensate for any impairment affecting activities or safety (Intercollegiate Stroke Working Party 2016).

Cognitive Rehabilitation and the Role of Occupational Therapy

Occupation is defined as a 'group of activities that has personal and sociocultural meaning, is named within a culture and supports participation in society. Occupations can be categorised as self-care, productivity and/or leisure' (Creek 2010). But there are a number of definitions to expand upon and challenge our understanding of occupation in the literature, a debate of which is beyond the scope of this text. However, at the heart of the concept is the understanding that occupations are everything people do to occupy themselves while contributing to the communities in which they live (Law et al. 1997, p. 32).

That any health problem can have implications for all aspects of life, and not just the physical and mental state of the individual, is now an accepted view. It is endorsed and embodied within the World Health Organisation's definition of health (1946) as: '. a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'.

By accepting the definitions of occupation and health given above, it can be appreciated that the occupational components of an individual's life become central to health and well-being.

For individuals with neurological damage, cognitive impairments are often the source of functional problems but they are unseen, difficult to manage or misunderstood. Poor task performance, in the absence of motor deficits, may originate in poor object recognition or an inability to sequence. The man who cannot recognise his partner's face may be mistakenly labelled with memory loss rather than prosopagnosia. The older woman who does not respond to questions may have an attention problem which is often confused with deafness. Also there are several possible reasons which may account for a previously independent widower, who lives alone, being unable to organise his daily routine.

Disorders of brain...