The Polytrauma Experience: Clinical Practice Guidelines for CognitiveCommunication Rehabilitation

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The Polytrauma Experience Clinical Practice
Guidelines for Cognitive-Communication
Rehabilitation The Acute Care Setting
Heidi D. Bassani MEd, CCC-SLP Walter Reed Army
Medical Center
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Disclaimer

• The views expressed in this presentation are
  those of the author and do not reflect the
  official policy of the Department of Army,
  Department of Defense or U.S. Government

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Polytrauma Referred to Speech Pathology at Walter
Reed

Courtesy of Lisa A. Newman, ScD Walter Reed Army
Medical Center
From March 2003-March 2005
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Brain Injuries Referred to Speech Pathology at
WRAMC
Courtesy of Lisa A. Newman, ScD Walter Reed Army
Medical Center
From March 2003-March 2005
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Prevalence of Swallowing and Cognitive-Communicati
on Disorders (CCD)
71
54
37
n265
n262
n262
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Acute Care Assessment

• How is it different from assessment in rehab?
• Barriers
• Shorter time for completing procedures
• Less immediate access to information
• Follow up at discharge is crucial

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Barriers to Assessment of Cognitive-Communication
in the Acute Setting
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Co-morbidities

• Visual deficits
• Hearing Loss
• Multiple Fractures
• Tracheostomy
• Maxillo-mandibular fixation (MMF)
• Amputations

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Co-morbidities

• ICU dementia
• Stroke
• Metabolic changes
• Renal failure
• Infections

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Scheduling Conflicts

• Multiple surgeries
• PT/OT (less structured scheduling than in
  rehabilitation settings)
• PRN pain medications
• Multiple interruptions
• Unpredictable acute SLP schedules

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Pain and Pain Management
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Case Study

• 25 year old active duty male s/p IED blast
• Injuries include
• CT head showed left IPH with increasing temporal
  EDH, with shift and brainstem compression
• Left craniectomy
• Right ventriculostomy
• Numerous soft tissue injuries to LUE and b/l
  LE/buttocks

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• Pt is alert and oriented x3 with good daily
  recall
• Current meds include
• Hydromorphone (Dilaudid) by PCA pump
• Tylenol Q6hrs
• Fentanyl 25Mcg/hr (patch) Q72 hrs
• Can you adequately evaluate cognitive-communicatio
  n without false positive results?

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Case Study - Findings

• Patient passed initial screening (less writing
  due to injuries) without difficulty
• Later presented with whole word substitutions in
  narrative writing determined to be secondary to
  mild attention deficits
• After completing pain medications, substitutions
  no longer occurred

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Pain Literature

• Majority of pain management literature written on
  non-brain injured patients
• Majority written on chronic pain
• Steady doses of medications
• Testing involved simple neuropsychological tasks
• - Short Orientation Memory Test
• - Paced Auditory Serial Addition Test
• - Hasegawa Dementia Scale

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Pain and Cognitive-Communication Functioning

• No or few studies discussing cognitive-communicati
  on deficits in relation to pain/pain management
• Need for further research with brain injury
• High-level skills requiring optimal conditions
  for testing

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Clinical Observations

• Acute phase
• PCA pump with obvious somnolence
• Pt report of grogginess or slowness attributed
  to medication
• Sedation after surgeries
• Overt deficits in attention and concentration

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Pain Management

• Know the basics
• Speak to your pain management/anesthesia
  department
• Be familiar with the research
• Speak to nurse about patients med schedule
• Aim for optimal testing conditions
• Know names of medications used in your facility

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Assessment
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Preferred Practice Patterns

• Consistent with the World Health Organization
  (WHO) framework, assessment will
• Assess underlying strengths and weaknesses
• Identify effects of cognitive-communication
  impairments on the individuals activities and
  participation
• Identify contextual factors that serve as
  barriers to or facilitators of participation

ASHA (2004)
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Assessment

• Relevant case history
• Review of auditory, visual, motor, cognitive, and
  emotional status
• Pt reports of goals and preferences
• Standardized and/or non-standardized methods
  selected with consideration for ecological
  validity
• Follow-up services to monitor status and ensure
  appropriate intervention

ASHA (2004)
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Screening

• Screening needs to be
• Brief
• Cost-efficient
• Effective
• - Sensitivity ( ID of true deficits)
• - Specificity ( ID of true lack of deficits)

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Areas of Assessment

• Communication
• Attention
• Memory
• Executive Function
• Insight
• Self-regulation/self-correction
• Ability to adapt
• Planning

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Review of CCD Assessment Tools

• An ANCDS writing committee reviewed tests and
  measures of performance recommended by SLPs
  (n84) and by publishers/distributors (n40) for
  assessment of cognitive-communication deficits
• Turkstra, Coehlo Ylvisaker (2005)

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Choosing an Assessment Instrument

• Tests meeting the following criteria
• Standardized, norm-referenced for TBI (n31)
• Met most reliability and validity criteria (n7)

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Results

• ASHA-FACS
• BRIEF
• CADL-2
• FIM
• RBANS
• TLC-Extended
• WAB

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Problems

• Only 4 (including FIM) evaluated predictive
  validity
• Only 2 formally evaluated performance outside
  clinical settings
• None formally measured ecological validity
• Did not measure what the manual claimed
  (construct validity)
• Few evaluated communication in context of
  cognitive deficits

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Other Tests

• Functional Assessment of Verbal Reasoning and
  Executive Strategies (FAVRES)
• Purpose a standardized test of subtle
  cognitive-communication difficulties designed
  specifically for those with acquired brain
  injuries (ABI)
• MacDonald (2005)

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Reliability of FAVRES

• The FAVRES scores of 52 adults with ABI were
  compared to those of 101 adults without ABI.
• OUTCOMES FAVRES scores clearly differentiated
  the performances of individuals with and without
  ABI. Individuals with ABI were slower and less
  accurate in reasoning and presented fewer
  adequate rationales for their decisions.
  Inter-rater reliability for scoring was
  acceptable.
• MacDonald Johnson (2005)

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Solution?

• Create a combination of
• -Standardized and non-standardized
• -Static and dynamic
• Use clinical experience
• Use patient and family input
• Constantly update protocol

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WRAMC Polytrauma/TBI Protocol

• Full case history and review of previous therapy
  notes
• Interview with patient and family
• Dysphagia, speech/language screening (especially
  reading/writing and naming)
• Cognitive-communication screening
• Therapy as needed

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Time to Administer

• WRAMC screening 20-30 min
• (not including administration of FAVRES)
• Time of completion is patient-dependent
• Is longer administration time predictive of
  deficits?
• Tolerance
• Verbosity
• Tangentiality
• Excuses

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Acknowledgements

• Thanks to the following people for their personal
  assistance in providing feedback in helping to
  create a cognitive-communication screening
  assessment
• Mary R. T. Kennedy, Ph.D.
• Therese ONeil-Pirozzi, Sc.D.
• Lyn Turkstra, Ph.D,

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WRAMC Polytrauma Protocol

• LOCF II-IV
• Western Neurosensory Battery
• Rappaport Coma/Near Coma Scale
• Disorders of Consciousness Scale

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WRAMC Polytrauma Protocol

• LOCF V
• Baseline Observation
• Personal interview (insight)
• Motor speech
• Voice

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WRAMC Polytrauma Protocol

• Auditory Comprehension
• Yes/No (WAB)
• Commands (BDAE)
• Complex Ideational Material (BDAE)

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WRAMC Polytrauma Protocol

• Verbal Expression
• Picture Description (Cookie Theft- BDAE)
• Naming (BNT)
• Generative naming (FAS)
• Reading Comprehension
• Sentences and paragraphs (BDAE)

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WRAMC Polytrauma Protocol

• Writing
• Narrative writing (BDAE and FAVRES)
• Word writing (BDAE)
• Visual Attention
• Clock drawing (CLQT)
• Symbol Cancellation (CLQT)

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WRAMC Polytrauma Protocol

• Memory
• GOAT
• Delayed recall 3 words (i.e. RIPA)
• Story recall (CLQT)
• Immediate recall
• To 7-digits
• Words/phrases

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WRAMC Polytrauma Protocol

• Executive Function
• Convergent and divergent naming
• Concrete
• Abstract
• Multiple definitions
• Verbal problem solving (RIPA)
• FAVRES (2 and/or 4)

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What next?

• When is full or further assessment warranted?
• Results of screening demonstrate deficits
• Pt and/or family attest to functional
  difficulties or changes as compared to baseline
• Reports from interdisciplinary team point to
  specific problems
• Difficulties on neuropsychological screening
• Often not predictive of mild
  cognitive-communication deficits

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Cognitive-Communication Interventions Acute vs.
Rehab

• Barriers
• Higher caseload
• Less time per patient
• Shorter length of stay
• Goals of cognitive-communication interventions in
  acute setting

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Goals of Cognitive-Communication Interventions in
Acute Medical Setting

• Identify deficits
• Remediate deficits
• Train compensatory strategies
• Facilitate carryover in functional activities
• Ensure appropriate intervention after d/c

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Priority Goals

• Length of stay may limit intervention in acute
  care
• Identify deficits
• Ensure appropriate intervention at d/c
• If length of stay is sufficient, ALL goals should
  be addressed in acute as well as in rehab settings

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Thank you!

• American Speech-Language-Hearing Association.
  (2004) Preferred Practice Patterns for the
  Profession of Speech-Language Pathology.
  Available at hhtp//www.asha.org
• MacDonald, S. (2005). The Functional Assessment
  of Verbal Reasoning and Executive Strategies.
  Adult Version. ON, Canada CCD Publishing.
• MacDonald, S. Johnson, C.J. (2005). Assessment
  of subtle cognitive-communication deficits
  following acquired brain injury A normative
  study of the Functional Assessment of Verbal
  Reasoning and Executive Strategies (FAVRES).
  Brain Injury 19(11)895-902.
• Turkstra, L.S., Coehlo, C. Ylvisaker, M.
  (2005). The use of standardized tests for
  individuals with cognitive-communication
  disorders. Seminars in Speech and Language
  26(4)215-22. Review.