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Assessment of attentional impairments Ed van
Zomeren and Joke Spikman Dept. of Neurology,
State University Groningen, the Netherlands
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Outline of presentation 1. relevant
impairments 2. theoretical background 3.
assessment 4. cognitive rehab, general remarks
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Why assessment ? - attentional impairments can
hinder the process of rehabilitation. -
attentional impairments can be rehab targets
themselves, as they will hinder the patient in
all domains of life.
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1. Which impairments are relevant ? -
hemi-neglect - mental slowness - impaired
attentional control - impaired sustained attention
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2. Theoretical background of attentional
impairments
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Robertson and Heutink (2002) Neglect consists of
a range of phenomena related to the high level
representation of, and attention to, space.
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Heilman (1985) Neglect is an attentional-arousal
disorder, caused by dysfunction of a
cortico-limbic-reticular loop.
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Mental slowness diffuse loss of neurons and/or
connections in CHI, resulting in - decreased
S/N ratio - detour effect - desynchronization
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Impaired divided attention - slowness of info
processing - impaired Supervisory Attentional
Control (SAC)
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Ponsford and Kinsella (1991), Attentional Rating
Scale 0 - 4 mental slowness
2.78 inability 2 things 2.44 easily
distracted 2.14
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Haggard et al. (2000),Cognitive-motor
interference when patients have to perform
cognitive tasks (category fluency, mental
arithmetic) while walking - gait cycle is
slowed - cognitive performance decreases
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Haggard et al. (2000) Increased dual-task
interference may arise because motor control
ceases to be automatic after brain injury.
Previously automatic actions may revert to the
status of controlled processes.
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Haggard et al. (2000) Dual task performance
exceeds available information processing capacity
in patients, but not in healthy controls. We
suggest that measures of dual task interference
should be included in standard clinical
assessment and used to inform content of therapy
programmes.
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Impaired divided attention - slowness of info
processing - impaired SAC - decreased
flexibility - deficient strategy - deficient
priority setting
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Flexibility, with increasing role of control -
stimulus-driven - memory-driven -
strategy-driven
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Impaired sustained attention - sustained
attention is sustained control - pathological
TOT effects
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3. Assessment of attentional impairments
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Along with assessment of impairments, awareness
of these impairments in the patient should be
checked.
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Methods of assessment - interview patient
(awareness!) - interview relative - observation
by staff - rating scales / questionnaires - tests
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Rating scales / questionnaires - Neurobehavioral
Rating Scale, Levin et al. (1987)- Cognitive
Failures Questionnaire, Broadbent et al.
(1982)- Rating Scale of Attentional Behaviour,
Ponsford and Kinsella (1991)- DEX
questionnaire (Wilson, 1996)
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Assessment of hemi-neglect
- drawing - line bisecting - visual search tasks
such as Bells - indented paragraph reading -
Neglect subtest in TAP - Behavioural Inattention
Test
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Assessment of mental slowness and impaired control
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Two empirical factors in attention (Spikman,
2001) - speed, or processing capacity - control,
or working memory
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Task characteristics - time pressure - structure
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Task characteristics - time pressure requires
speed - structure determines control
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Control is maximal in unstructured tasks that
cannot be tackled with routine responses. Control
always implies activity of working memory, in
which intentions and rules for the performance of
the task have to be kept activated.
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Three levels of task performance - operational
- tactical - strategic
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Operational level - time pressure is high, speed
is the main factor - task highly structured,
control is minimal (stimulus driven)
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Tactical level - timepressure intermediate -
structure intermediate, some control required
(memory- driven) Being fast is no longer
sufficient for satisfactory performance.
Findingpersonal speed/accuracy trade-off
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Strategic level - timepressure minimal - task
unstructured (strategy- driven) Instructions do
not dictate completely what should be done
-subject has to apply own strategy
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LEVEL TIMEPR. STRUCTURE OPE
high highly
structured TAC
interm. partially
structured STR low
unstructured
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Assessment at operational level,speed of IP -
RT measures - Stroop reading and colour naming -
Digit Symbols - in fact, any speed test with
finely graded and age-adjusted norms
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Assessment at the tactical level, focused and
divided attention - focused attention weak or
strong distractors - divided attention
subtasks, dual tasks
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Tactical level, focused attention - letter
cancellation tasks - visual search tasks (TEA) -
Continuous Performance Test - Stroop interference
subtest
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Tactical level, divided attention - dual tasks
such as Telephone Search while Counting, TEA
(Robertson et al., 1994) - Paced Auditory
Serial Addition Task (Gronwall and Sampson,
1974) - Test for Attentional Performance
(Zimmerman and Fimm, 1993)
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Assessment of executive aspects of attention
faces a psychometric dilemma initiative versus
structure
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Strategic level - flexibility in dual
tasks Bohnen-Stroop
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Strategic level - flexibility in dual
tasks Bohnen-Stroop - executive aspects
of attention WCST, Tower of London, Six
Elements Test, Zoo Test
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Strategic level - flexibility in dual
tasks Bohnen-Stroop - executive aspects
of attention WCST, Tower of London, Six
Elements Test, Zoo Test - Executive
Routefinding Task, (Spikman et al. 2000)
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Assessment of sustained attention - any test
with timeblocks - Vigilance subtest of TAP
(Zimmerman and Fimm, 2002)
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Vigilance subtest of TAP,patient Z.S. block
omis RT msec 1 - 5
0 358 6 - 10
1 500 11 - 15 3
563 16 - 20 4
457
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4. Cognitive rehabilitation of attention
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The Practical Approach - 1 Task adaptation -
reduce timepressure - improve structure
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The Practical Approach - 2 Give task-specific
training, i.e. relevant attention cues embedded
in routine by learning.
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The Practical Approach - 2 Give task-specific
training, i.e. relevant attention cues embedded
in routine by learning. No generalization - but
who cares ?
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. and the more Theoretical Approach
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Spikman (2002) There are two targets for
cognitive rehabilitation - learning patients to
deal with time pressure- learning patients to
deal with unstructured situations
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- Time Pressure Management, Fasotti et al.
(2000) - Multi-faceted program for the
Dysexecutive Syndrome, Spikman et al. (2002),
partly based on Goal Management Training
(Levine, et al., 2000) Problem Solving
Training (von Cramon et al., 1994)
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Summary of approaches P - task adaptation P -
task-specific training T - time-pressure
management T - executive training
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assessment
therapy hemineglect
? mental slowness
- impaired control -
impaired sustained
attention -
-
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And finally . What about social attention? Can
patients with frontal inadequate social
behavior be trained to attend to social cues?