10 - The Influence of Depression on Cognitive Rehabilitation in Older Adults

Editors: Backman, Lars; Hill, Robert D.; Neely, Anna Stigsdotter

Title: Cognitive Rehabilitation in Old Age, 1st Edition

> Table of Contents > Part IV - Rehabilitation Strategies for Cognitive Loss in Age-Related Disease > 14 - Strategies for the Rehabilitation of Cognitive Loss in Late Life Due to Stroke

Strategies for the Rehabilitation of Cognitive Loss in Late Life Due to Stroke

Clive Skilbeck

The Importance of Cognitive Deficits Following Stroke

Increasingly, the importance of cognitive rehabilitation is being recognized as a key factor in the outcome of general rehabilitation following stroke. Most areas of rehabilitation rely upon the patient's learning, and if cognitive deficits are frustrating this learning process, then all aspects of the rehabilitation program will be frustrated to some degree. For example, Lincoln, Drummond, and Berman (1997), in a multiple regression study of 315 inpatients, found that a main predictor of activities-of-daily-living (ADL) outcome at 12 months poststroke was a measure of visual organization (Rey figure copy score; Lezak, 1995) on admission.

Calvanio, Levine, and Petrone (1993) also addressed this issue, pointing out that deficits in perception, memory, and executive functions are central to ADL failures. Similarly, Galski, Bruno, Zorowitz, and Walker (1993) found that cognitive deficits after stroke were associated with longer inpatient stays and higher rates of referral for outpatient therapy or domiciliary services. In a retrospective investigation, Carter, Oliveira, Duponte, and Lynch (1988) found significantly better ADL scores in stroke patients who had received cognitive remediation in addition to the routine rehabilitation programs from physiotherapists, speech therapists, and occupational therapists, than in those who received only the routine programs. The cognitive retraining included visual scanning, spatial perception, and time judgment exercises. These authors went on to carry out a prospective study of the relationships between cognitive remediation and ADL, which is discussed in the section titled Strategies for Other Areas of Attention/Spatial Deficit.

In a prospective study, Moroney and Desmond (1996) followed 242 older stroke

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patients to research the risk of stroke recurrence. They noted that cognitive status independently predicted a subsequent recurrence, a finding that underlines the importance of cognitive deficits after stroke.

General Strategies for Remediating Cognitive Deficits

Introduction

Wilson (1987) described four basic strategies used when attempting cognitive rehabilitation:

Those focusing on drills or exercises, the underlying assumption being that it is possible to remediate cognitive deficits by stimulation and practice (analogous to physical exercise to improve muscle tone). The work of Sohlberg and Mateer (1989) and of Diller and colleagues (e.g., Diller & Riley, 1993), reported later, would be classified under this strategy.
Those drawing upon models from cognitive neuropsychology. The cognitive model is used to identify and characterize the deficit so that the dysfunctional elements can be isolated and treated. Often, however, remediation employs the methods outlined above. This strategic approach is favored in reading, language, and visual attention. This strategy is reviewed in Riddoch and Humphreys (1994).
Those combining theory and practice elements from cognitive psychology, neuropsychology, and learning theory. This approach draws upon the behavioral and neuropsychological traditions, which are included in clinical psychology training, and combines these with cognitive psychology elements. The work of Robertson provides examples of this approach, as does the case study described by von Cramon and Matthes-von Cramon (1994); both are discussed later.
Those providing a holistic treatment strategy, which addresses noncognitive aspects, including emotional and motivational factors in thepatient. Important in this conceptualization is the patient's own experience of their illness (Prigatano, 1997).

The strengths and limitations of these strategies will be returned to in the discussion, following descriptions of a variety of applications. Sohlberg and Mateer (1989) provided a wealth of practical information on cognitive retraining using their process-specific approach. This approach aims to identify specific deficits and then provides targeted rehabilitation input. It utilizes theory and is similar to the cognitive neuropsychology approach, although the level of detail in the model is lower. Other aspects of the process-specific approach are the repetitive presentation of retraining tasks, the use of a hierarchy of therapy goals, and the use of generalization data as measures of outcome.

In general terms, approaches to the process of cognitive rehabilitation can be divided into:

Internal approaches, where the rehabilitative effort is focused upon improving patients' impaired cognitive behavior, or on developing alternative appropriate skills. Examples include training of visual scanning in remediation of neglect, and the use of mnemonics in memory impairment.
External approaches, in which appropriate aids are provided to reduce the effects of the cognitive deficit (e.g., prosthetic language device). These can include designing environments for patients on the basis of their cognitive deficits.

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Personal computers (PCs) have been used often in cognitive rehabilitation, in ways that may embody the principles of either of the above strategies. Two different approaches have been employed in using PCs to assist cognitive functioning in elderly people. The more popular is to use the PC as the vehicle for delivering cognitive retraining routines. This strategy has evolved since the late 1970s and has been applied to a wide range of cognitive deficits (see Skilbeck, 1991) with variable success, as indicated below. Sohlberg and Mateer (1989) viewed PC-based cognitive retraining as being highly consistent with their process-specific approach to rehabilitation. In their study, Finkel and Yesavage (1990) compared the learning by elderly people of a mnemonic device (method of loci) using either a traditional teaching or computer-aided instruction (CAI). The CAI approach proved as effective as the traditional training (14 hours of basic skills training and classroom teaching) on a word-learning task using the method of loci, even though CAI participants were significantly older and had lower initial pretraining scores on the task.

Although the assumption may be made that older people will be more anxious and resistant to change where the use of PCs is concerned, there is evidence that their attitudes and responses to new technology are similar to those of younger age groups. For example, in their survey research, Ansley and Erber (1988) observed that older adults (aged 55 86) held attitudes toward computer applications that were not significantly different from those of undergraduates. These authors also noted no differences between these two participant groups on subsequent tasks involving PC interaction, in either time taken or number of errors made.

An approach using the PC as a prosthetic device (e.g., Chute & Bliss, 1994) has been introduced as an external approach to rehabilitation. It is not designed to remediate the cognitive deficits of stroke patients; rather, it seeks to augment their impaired functioning within their particular environment. The strengths and weaknesses of this prosthesis strategy are illustrated in the section on applications to language difficulties.

Whichever strategic approach is implemented, Kurlychek and Levin (1987) suggested a number of core elements that maximize cognitive gains in use of a PC in cognitive retraining:

Present tasks in sequence from simple to complex.
Select the initial task difficulty level to ensure a high success rate.
Move to more a difficult level only after high success at a current one.
Emphasize the rate/speed of the response, not just accuracy.
Provide frequent positive or corrective feedback.
Gradually reduce/fade the cues.
Gradually increase required initiative and endurance.

Evaluation of Outcome

Calvanio et al. (1993) considered three indices when judging the success of a cognitive intervention, namely, efficacy, generality, and utility. Efficacy refers to the amount of change produced by the intervention on the training tasks. Generality (or generalization) is the index reflecting the degree to which beneficial effects of the intervention can be demonstrated beyond the training tasks themselves (the transfer-of-training effect). The intervention's utility is its ability to produce clinically significant (not just statistically significant) improvement that is lasting. Utility is of particular

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importance to the patient who is seeking a meaningful change in his or her condition.

Many studies still do not address the issue of generalization from the cognitive retraining task to related objective neuropsychological assessment and real life, and those that do often fail to observe an appropriate generalization effect. For example, McClure (1997) carried out iconic memory training with 12 brain-injured patients, noting significant improvements in iconic memory skills, but no evidence of generalization to a parallel real-life task (reading speed). Bradley, Welch, and Skilbeck (1993) discussed the issue of generalization in some detail, stressing that the most desirable outcome of cognitive retraining is an improvement in functional status. Their research investigated the use of PCs in a number of neurological groups, including stroke patients. They concluded that gains obtained during retraining generalized to neuropsychological test scores, and self-report questionnaire measures suggested generalization to real-life contexts as well. The retraining software proved useful with stroke patients.

An important measure of utility is long-term outcome, which has received little attention in the cognitive retraining literature. One such investigation was carried out by Kelly, Skilbeck, Welch, Bradley, and Britton (1993), using PC-based retraining. These researchers followed up the patients studied by Bradley et al. (1993) more than 2 years after completion of the retraining. They noted that on most PC tasks, the gains made during training were maintained at the long-term follow-up.

Summary

Cognitive deficits following stroke are important because they can interfere with attempts at rehabilitation. General strategies to remediate such deficits include the use of practice and strategies based upon cognitive neuropsychology, cognitive psychology, and/or learning theory. The approach adopted may attempt to improve the patient's cognitive deficits or may employ external aids to help limit the effects of the deficits. PCs have been used to deliver the cognitive retraining, though their involvement as prosthetic devices is a recent development. In evaluating the success of an intervention to improve cognition, efficacy, generality, and utility are important in judging outcome.

Perceptual and Attentional Deficits

Strategies for Neglect

Remediation of perceptual impairment is the neuropsychological area with the longest history of rehabilitation research following stroke. Although much of the research undertaken in this domain has not had a strong basis in theory, most used the exercise approach outlined in the previous section. This literature began in the early 1970s and is characterized by the work of Diller and his colleagues, whose research focused on remediating perceptual disorders acquired in right-hemisphere stroke, particularly visual neglect (reviewed by Diller & Riley, 1993). The strategy behind this research was to directly address impaired visual scanning, viewed as a major factor in spatial

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dysfunction, and several techniques were described that attempted to remediate the dysfunction in scanning:

Anchoring use of strong cues to fix the initial point for scanning.
Pacing introducing a method to aid steady search.
Feedback confirmation of the accuracy of responses.
Density increasing distance between targets, and use of larger targets, to reduce errors.
Awareness encouraging engagement in the task.
Repetition practice to convert a new strategy into a habit.
Platforms combining acquired behaviors into new skills.

The results obtained from this research demonstrated significant gains on target and relevant nontarget tasks in the experimental group, but not in the control group. The findings showed both generality and utility and a severity effect (patients with the more severe deficits improved most). Details of these studies are available elsewhere (e.g., Gordon et al., 1985; Wienberg et al., 1977, 1979). Diller and Riley (1993) provided a historical review of the concept of visual neglect and its rehabilitation.

However, impressive as the early findings from visual scanning research were, it is clear that there are difficulties in the generalization of improvement beyond the training tasks themselves (Robertson, Halligan, & Marshall, 1993). For example, Wagenaar et al. (1992), using five single cases, observed significant improvement for four patients after scanning training, but these gains did not generalize beyond the task specifically trained.

Ladavas, Menghini, and Umilta (1994) adopted the cognitive neuropsychology strategy and reviewed the theoretical basis of visual neglect (arousal, representational, and orientating hypotheses), favoring the orientating explanation. They carried out a PC-based rehabilitation study that attempted to manipulate the orienting aspects of spatial attention and to address the question of whether spatial attention is controlled by one central mechanism, or by a number of modular processes. Although the left-sided visual neglect remained stable during baseline, the training intervention, based upon visual cuing of attention (both covert and directed), led to significant reductions in neglect. An untreated control group did not show improvement. The findings indicated that covert orienting was as effective as overt cuing, an outcome that argues against the position that neglect results principally from biased gaze direction. Ladavas et al.'s findings, too, provided support for the modular view of control of attention. This study is helpful in determining which strategies might be applied to the remediation of neglect, although evidence of generalization was not sought, as is frequently the case in the cognitive neuropsychology approach.

Another treatment strategy for neglect is limb activation. Joanette, Brouchon, Gauthier, and Samson (1986) noted that neglect was reduced when the limb contralateral to the lesion, compared with the ipsilateral limb, was used to indicate target stimuli. This finding accords with the theory of Rizzolatti and Camarda (1987) that spatial attention is associated with a range of motor planning circuits. In a number of studies (see Robertson et al., 1993), Robertson and his colleagues have investigated the use of contralateral limb activation to reduce neglect. These studies offer strong support for Rizzolatti and Camarda's position, demonstrating that it is the activation of the left limb itself (rather than the use of the arm as a visual anchor cue) that produces

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the therapeutic effect. Similarly, Robertson and North (1992) showed that producing motor activation in the left extrapersonal space by right arm movements yields no beneficial effect.

Robertson et al. (1993) reviewed a number of additional techniques for reducing neglect, each of which had an underlying rationale. However, as there is little evidence that they produced effects that generalized to the real world of ADL, some of them might better be regarded as minor environmental, or external, aids. For example, Butters and his coworkers proposed placing an eye patch over the right eye in left visual neglect (as retinal projection to the right and left superior colliculi is primarily from the contralateral eye). Reduction in neglect was noted, but only for the time that the eye patch was in place. The same technique was investigated by Walker, Young, and Lincoln (1996), who also concluded that eye patching was unlikely to be of general value when attempting to treat neglect. Similarly, attachment of Fresnel prisms, which displace a retinal image to the right or the left according to prism orientation, to the glasses of stroke patients yielded gains on perceptual tasks (compared with the outcome in a control group), but not on ADL tasks (Rossi, Kheyfets, & Reding, 1990).

However, Seron, Deloche, and Coyette (1989) employed an external aid (a buzzer) to assist in the reduction of neglect. The buzzer was placed in the patient's left shirt pocket and emitted its sound at random 5- to 20-second intervals. The task was to locate the buzzer and switch it off, and the result was significant gains in ADL functioning.

Strategies for Other Areas of Attention/Spatial Deficit

Beyond the area of neglect, there are a number of often ill-defined cognitive problems following stroke that appear to arise due to spatial/attentional deficits. Although this field is less popular than neglect, some literature exists on attempts at remediation for these problems, and Sohlberg and Mateer (1989) provided both a clinically relevant classification of attentional deficits and a range of tasks that might be employed in remediation. In their study of 58 patients in the first 12 months poststroke, Egelko et al. (1989) noted improvements in visual neglect and affect comprehension in the right-hemisphere group, but not in the left-hemisphere group. In addition, reaction time (RT) did not improve in the right-hemisphere group between initial assessment and the 10-month follow-up, an outcome leading the authors to advocate more intensive remediation in this cognitive area.

Following the recommendations of Egelko et al. (1989), Sturm and Willmes (1991) provided RT training for both right- and left-hemisphere stroke patients. These authors reviewed evidence that specific aspects of attention may be differentially affected, according to the hemisphere of damage (right-hemisphere lesions particularly disrupting sustained attention, or vigilance, and left-hemisphere damage being associated more with reduced speed and accuracy in choice RT). Sturm and Willmes employed a PC-based approach, along cognitive neuropsychology lines, utilizing training-program routines that included comparisons of stimulus configurations with a multiple-choice array to detect matches. Stimulus material was varied according to complexity, employing letters, digits, geometric figures, and nonsense patterns. Rate of presentation and spatial rotation of material were also used to manipulate complexity. The results demonstrated significant attention-training effects, except for vigilance, although there

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was no evidence of generalization to other cognitive tasks. Gains in attentional performance were maintained over a 6- to 9-week period of no training.

In a subsequent PC-based study, Sturm, Willmes, Orgass, and Hartje (1997) used single-case methodology to separate out different components of attention and found specific training effects according to the targeted component of the intervention: In patients with localised vascular lesions, specific attention disorders need specific training (p. 97). Patients (27 with left-hemisphere damage, 8 with right-hemisphere lesions) completed 14 sessions of 30 minutes each, over 3 weeks, and training outcome was assessed on a battery of 10 psychometric tests. Evidence in support of the lateralization of different aspects of attention was obtained. Significant gains in performance over the training period were noted on tasks that closely resembled the training tasks, though the number of significant improvements fell as similarity to the training task decreased. Overall, training gains were lower in the right-hemisphere stroke patients, though a lack of improvement in vigilance was apparent in both groups.

Carter et al. (1988) carried out a prospective study of the relationships between cognitive functioning and ADL outcome in 21 stroke patients, 17 of whom had right-hemisphere damage. They noted a significant correlation (r = +0.59; p < .01) between pretraining cognitive skills and (posttraining) ADL outcome. The single best predictor of outcome ADL was an auditory vigilance attention task, which correlated significantly with five out of six ADL indices (correlation range: +0.49 to +0.71). Visuospatial ability was the next best predictor of posttraining ADLs, correlating significantly with three activities (including dressing and personal hygiene, which replicated earlier findings from these researchers). Carter and her colleagues advocated that auditory vigilance attention should receive further attention as a cognitive remediation task, given its importance in their studies. This study is important as it specifically bears upon the critical question of carryover, or generalization, of cognitive retraining gains into real life.

Another investigation focusing upon real-life application was that of Klavora et al. (1995). These authors employed a specific apparatus (Dynavision) to retrain a number of attentional/information-processing abilities considered important in driving ability (including reaction time, anticipation, movement time, scanning, and endurance). Their study involved 10 patients who were 6 18 months poststroke and who had demonstrable attentional deficits sufficient to render them unsafe to drive. The retraining program used three sessions per week, each of approximately 20 minutes, for 6 weeks. Subjects underwent pre- and posttraining assessment, including follow-up assessment at 3 months. Of nine cognitive variables examined, seven showed significant improvement, the exceptions being choice visual reaction time and anticipation time. The gains on these seven variables were maintained at follow-up. As a consequence of the cognitive remediation program, 6 of the 10 patients moved from unsafe to drive to safe to resume driving and/or to receive on-road driving lessons.

Hajek, Kates, Donnelly, and McGree (1993) adopted a PC-based retraining strategy for visuospatial impairment in an attempt to augment routine rehabilitation. They failed to observe generalization of PC training (using the seven visuospatial exercises of Bracy, 1982) to the Rey-Osterrieth Complex Figure test, Raven's Coloured PM test, and the Benton line orientation test, although significant improvement in (WAIS-R) Block Design (see Lezak, 1995) score was noted in male patients. The study involved 20 right-hemisphere patients, half of whom received the usual rehabilitation

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program from physiotherapists and occupational therapists (control group), and half of whom also received additional PC visuospatial exercises, delivered as three 30-minute sessions each week for 4 weeks. Most patients were less than 3 months post-stroke. Gains were noted in both groups.

In their PC-based study, Bradley et al. (1993) included five stroke patients who were 4 72 months poststroke. Improvements on retraining tasks involving visual attention, speed of information processing, and performance on the WAIS-R Digit Symbol task were noted over the 12-week (24-session) rehabilitation period. Follow-up more than 2 years after retraining indicated that task and WAIS-R Digit Symbol gains were still significant.

Summary

There is along history of attempts to remediate neglect in elderly patients following stroke. Diller and his colleagues have researched the rehabilitation of visual scanning with considerable success, although achieving generalization to real life has proved problematic. Theories of visual neglect have been based on arousal, representation, or orientation. Treatments employing cuing or limb activation have yielded promising results, though eye patching appears to be ineffective. Attempts to address other areas of attentional/spatial impairment following stroke have also been researched, the work often involving PCs in the retraining intervention.

Memory Impairment

Strategies

Harris (1992) offered a classification of strategies for improving memory deficits arising from acquired brain damage. He divided internal strategies, which have some basis in theory, into those naturally learned (e.g., primacy and recency) and those employing artificial mnemonics, and he divided external strategies into those based upon a storage of useful information and those offering cues. Harris also included repetitive practice (exercise) and drugs as being of potential benefit. The strategy adopted should also take into account a number of factors. For example, the tasks selected for remediation attempts should be have practical and personal importance to the patient, should include other cognitive skills that the patient does possess, and should be capable of being manipulated in terms of level of difficulty (Moffat, 1992). Feedback is also important as a way of demonstrating to the stroke patient that progress is being made. In this regard, the use of graphs may better illustrate improvement to patients.

When deciding on an appropriate level of task difficulty, an entry point in the retraining should be selected to minimize the patient's errors. This minimization can be manipulated via amount or complexity of material, by the learning strategies offered to the patient, by duration of the retention required, and by the retrieval cues provided (Moffat, 1992). Short, frequent training sessions are preferred, as these usually yield greater learning, and thought should be given to providing the patient with maintenance mechanisms to preserve the gains achieved.

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External Aids

Although use of external aids to memory is natural, developing across the life span, these aids usually lack theoretical underpinning. Harris (1992) provided a brief review of two types of possible external aids for those with damaged memories. The first relates to the external storage of required information, for example, (a) use of a diary to remind the person of important dates, such as birthdays, and (b) use of a shopping list to assist recall at the supermarket. More sophisticated examples include the employment of a pocket dictaphone to assist future recall or a pocket computer upon which very large quantities of personal information can be stored (e.g., names and phone numbers). Unfortunately, operation of the latter is often beyond the competence of a stroke patient.

The second class of external memory aid provides a reminder, or cue, for the patient that she or he has to do something. This cue often takes the form of an auditory signal, such as a wristwatch alarm. The difficulty with this form of aid is that usually little information is provided by the cue that connects it with the to-be-remembered activity. For example, although the buzzer may remind the patient that he or she should do something, it may not be clear what the something is. The recent development (the Neuropager; Wilson, Evans, Emslie, & Malinek, 1997) of a more comprehensive reminder system may offer a solution to this problem; that is, not only is the patient cued that it is time to do something, but specific information is also provided with the cue that informs the patient what has to be done. This type of external aid is in the early stages of development for clinical use, but it appears to offer a good combination of cue and specific information for the patient. Existing alternative devices to both cue and offer some information include electronic diaries and display alarm watches (Harris, 1992; Kapur, 1995).

Exploiting external devices to their full extent may result in manipulating the environment to provide cues. For example, reality orientation (RO) therapy (Woods, 1996) aims to help the orientation of patients in terms of time, place, and person. This therapy includes the color coding of doors to overcome topographical difficulties (e.g., to allow independent use of bathroom and sitting room). RO is based upon a number of principles (Moffatt, 1992):

Provision of information in a range of formats
Correction of confused behavior
Reinforcement of appropriate cognitive behavior
Use of cues, prompts, and rehearsal
Use of memory aids as prostheses

Skilbeck and Robertson (1992) reported case study material that indicated improvement in patient orientation when RO was delivered by a PC that included graphics software to enhance the clarity and interest of the presented material. In this study, PC-based RO was as effective in promoting orientation as when the same treatment was provided by a therapist. This latter finding is important, given that the provision of RO therapy is very labor-intensive.

Glisky, Schacter, and Butters (1994) specifically considered the issue of transfer, or generalization, of learning, pointing out that too often the acquired learning is

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closely associated with the learning context and not responsive to different cues. These authors concluded that retraining routines should try to build upon the patient's prior preserved knowledge and should include considerable overlearning to facilitate generalization to other tasks and settings, coupled with elaborated task material designed to link with the patient's infrastructure of knowledge.

Internal Strategies

Moffatt (1992) listed a variety of internal approaches to remediating memory deficits, including the use of visual imagery, in which, for example, the patient is taught to link a specific feature of a person with a visual image in order to remember that person's name. Visual imagery's effectiveness has been demonstrated in clinical studies (e.g., Wilson, 1987). Peg mnemonics were also considered by Moffatt (1992), a strategy whereby a rhyming mnemonic is combined with a visual image to aid retrieval. The technique may be particularly helpful with lists of material, such as shopping lists. The rhyming component might be One-is-a-bun, two-is-a-shoe, three-is-a-tree, and so on, and a visual image can be provided to link an item of shopping with one of the pegs.

Glasgow, Zeiss, Barrera, and Lewinsohn (1977) addressed the issue of improving recall for written material by using a structured study method. They taught their patient the following (PQRST) structure:

Preview: Skim the text and establish its general order.
Question: Devise the main questions to ask of the text.
Read: Read the text slowly and carefully.
State: State aloud the material that has been read.
Test: Test whether the material has been understood and the questions posed have been answered.

Wilson (1987) carried out a number of studies using the PQRST strategy, reporting that it proved superior to rehearsal alone for both immediate recall and retrieval after a delay. In their research, Downes et al. (1997) employed the concept of preexposure, which may be regarded as a brief version of the P and Q elements in the strategy. These authors aimed to teach 25 memory-impaired patients 10 face-name associations, using imagery, preexposure, or a combination of both. In the preexposure condition, subjects were initially shown each face for 6 seconds, and 10 questions were prepared, of which 2 or 3 were presented for each of the faces to be learned (e.g., Does he/ she look friendly/intelligent/honest? ). The results were clear: Preexposure enhanced learning significantly by itself and also boosted the effects of imagery (which alone was also effective).

The vanishing cues strategy involves providing prompts for an area of memory failure and gradually increasing the number of cues until reliable recall is established. Over succeeding sessions, the number of cues required diminishes until cues vanish. The approach is ideal for PC administration. In acquiring recall for the name Chloe, during Session 1 the following sequence may occur:

Trial	Cues	No. of cues
1	_____	0
2	C_____	1
3	CH____	2
4	CHL___	3
5	CHLO__	4
6	CHLOE	5

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Session 2 might require only four cues (CHLO), and by Session 4, a single cue might suffice (C).

Wilson (1992) suggested a number of general principles to follow when attempting to remediate memory impairments:

Simplify the information you wish the patient to remember.
Reduce the amount to be remembered.
Ensure that the material has been understood.
Link the material to information already available to the patient.
Schedule frequent, short sessions, which produce better learning.
Categorize the material, or ask the patient to structure it.
Refresh the learning to aid long-term retention.
Use cues to prompt recall.
Improve learning and recall by teaching in a range of settings.

The material taught should be meaningful and relevant to the patient, who may have preferences with regard to learning style.

A neglected technique in the clinical literature is expanded retrieval practice (see Moffatt, 1992), which is based upon the finding that the longer the interval between first and second successful recall of a piece of information, the higher the probability of subsequent successful recall (Bjork, 1988). Moffatt (1989) employed this strategy in rehabilitating problems of memory, dysgraphia, and naming, using a gradual expansion of the interval between first and second recall. This concept is very similar to that of spaced retrieval (Camp & Schaller, 1989), a method in which associations are recalled repeatedly with an increasing retention interval. The technique has been used successfully to improve naming in degenerative dementia (Abrahams & Camp, 1993; McKitrick & Camp, 1993). Evidence of generalization beyond the training task was observed, and this approach appears particularly relevant to memory deficits in older stroke patients.

There has been relatively little research on patients' own compensatory mechanisms for their memory impairment. Backman and Dixon (1992) addressed this issue, providing a theoretical framework for its consideration. Following from this paper, Wilson and Watson (1996) offered a practical approach to understanding patients' compensatory behavior. Both papers are essential reading. Wilson and Hughes (1997) provided a detailed description of a patient's compensatory processes for dealing with memory deficits after an aneurysm hemorrhage.

An area of the literature that is not fully exploited by clinicians is research on normal aging. In a review of nonpharmacological treatments for memory loss in old age, Yesavage (1985) discussed a number of strategies that have been utilized, including group mnemonic training, categorization, visual mediators, spatial loci, and visual imagery. The studies he reviewed suggested that the method of spatial loci, in which

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persons name a number of locations within a familiar setting (e.g., their home) and then associate a visual image of the thing to be remembered with each of these loci, is very effective in improving recall. Verbal elaboration, too, appears to be a successful strategy when, for example, older people are attempting to remember faces. Yesavage indicated that anxiety often adversely affects the attentional capacity of older adults, and a number of studies have shown the recall benefits of training elderly subjects in relaxation techniques.

In a subsequent study involving 40 elderly people, Yesavage, Sheikh, Tanke, and Hill (1988) investigated variability in individual response to memory retraining. These authors found that higher WAIS Vocabulary scale scores correlated with better use of a combined mnemonics and verbal elaboration retraining strategy, and that higher state anxiety scores were associated with better recall performance after relaxation training (see also Hayslip, 1989).

A key issue is generalization to objective neuropsychological tests and to real life. Panza et al. (1997) dealt with it by offering most of their rehabilitation program for memory deficits in patients' own homes, with a minority of the retraining procedures employing a PC in the rehabilitation center. Their results showed significant improvements in memory on objective tests.

When reviewing the use of PCs in memory remediation, Glisky (1995) cautioned against the assumption that a retraining procedure is helpful merely because it is delivered via a PC. She predicted PCs will make a larger contribution to rehabilitation in the future, so it is important that we fully test and critically evaluate their programs in terms of their basis in psychological models and their relevance to treatment goals. As indicated in the next section, home use of PCs should offer greater independence to patients.

Language Dysfunction

Detailed consideration of language dysfunction rehabilitation in older stroke patients is beyond the scope of this chapter, although a few illustrations of the research findings will be offered. The cognitive neuropsychology strategic approach is most popular in this field.

Excellent reviews of language remediation are available (e.g., Holland, Fromm, DeRuyter, & Stein, 1996). The general field of speech therapy for aphasia following stroke has received a mixed press, some studies providing little support for its use. For example, Lincoln et al. (1984) randomly allocated 191 stroke patients to either speech therapy (two sessions per week for 24 weeks) or a no-treatment control group. No significant differences were observed between the two groups at the start of therapy, at 12 weeks into therapy, and at end of therapy. Similarly, Hartman and Landau (1987) failed to observe significant effects in their study of 60 stroke patients randomly assigned to 6 months of speech therapy or of emotionally supportive counseling.

Studies focusing upon specific aspects of language disorder have sometimes produced significant results. For example, Helm-Estabrooks, Emery, and Albert (1987) successfully remediated perseverative speech errors in three case studies of stroke. In a large study of 281 aphasic patients, 85% of whom had suffered a stroke; Basso, Capitani, and Vignolo (1979) noted significant gains in their treatment group, though

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a number of difficulties exist in this study: Over 200 patients were excluded, as they dropped out before completing treatment, and the control group comprised 119 patients unable to attend for rehabilitation. In their review of the literature on rehabilitation of naming disorders, Nickels and Best (1996) concluded that therapeutic gains can be expected. Davis and Pring (1991) obtained significant improvement in their study of seven patients with word-finding deficits, though they also observed generalization to unrelated, nontarget items in the therapy material.

Following the cognitive neuropsychology strategy, Ellis, Franklin, and Crerar (1994), recommended the use of a large number of case studies, covering a range of language disorders, each of which would have detailed profiling prior to receiving replicable treatment interventions. In this way, therapeutic outcome can be related to pretreatment characterization of patients. Patterson (1994) provided an excellent review of the cognitive neuropsychology approach applied to disorders of reading and writing. She concluded that this approach is proving helpful, although the field is still young, while noting the mixed evidence on the generalization of gains beyond the training task.

Chute and Bliss (1994) advocated the use of PCs as prostheses in cognitive rehabilitation following stroke, presenting SpeechWare, a prosthesis developed for people with expressive language impairment and physical disability; the program seeks to compensate for the deficit by offering augmented assistance in the person's particular environment. In order to be effective, it needs to be ecologically valid for that individual. SpeechWare provides both digitized and synthesized speech and can handle programmable events and word processing. In addition, video clips or photographs of the user offer the most realistic reminders to ensure that ADLs are carried out. Thus, customization and empowerment of the user are maximized; interfacing with telephones, faxes, and so on is facilitated. Weaknesses of the approach include the necessity for expensive hardware to gain good environmental control (the SpeechWare software itself costs only $50), the sophisticated programming skills required for customization, and the potential additional medicolegal risks associated with its inappropriate use.

Other Cognitive Functions

The most difficult cognitive impairment to rehabilitate is dysexecutive syndrome, involving poor planning, inappropriate social behavior, and so on. Von Cramon and Matthes-von Cramon (1994) used the cognitive neuropsychology model of Norman and Shallice (1986), centered on the concept of a supervisory attentional system (SAS) to reduce the dysexecutive difficulties of a medical practitioner. The patient (GL) had sustained a closed head injury, rather than vascular damage, but is presented here because of the scarcity of relevant studies. An MRI of GL approximately 9 years after the head injury, indicated bilateral frontal lobe damage. The authors found most cognitive abilities to be intact (GL had managed to complete his medical degree 6 months after the injury), including an IQ of 130+, though GL was relatively poor on tests sensitive to frontal lobe dysfunction. Complaints relating to his behavior included making sexual jokes in front of his boss at a social function, interrupting work colleagues in their rooms without warning, and being unable to organize coherent autopsy/biopsy

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reports in the lab where he worked. Von Cramon and Matthes-von Cramon (1994) concentrated upon improving GL's monitoring of his own behavior in the work environment; this case provided an excellent opportunity to assess generalization of cognitive retraining directly, although evaluation of outcome in such a subtle behavioral area was difficult. Using goal attainment scaling, the authors used observable work performance, such as accuracy, structure, and relevance of pathology reports. Feedback, offered via graphs, proved useful in increasing GL's motivation. Von Cramon and Matthes-von Cramon reported significant gains in work performance within a few weeks of retraining commencing. Therapy consisted of 2 3 hours per week over 12 months, and the authors found Norman and Shallice's model (SAS) helpful in both formulating the intervention and in discussing their treatment findings.

Crepeau, Scherzer, Belleville, and Desmarais (1997) provided a useful analysis of central executive (CE) deficits in a number of workplace tasks, correlating these with cognitive test scores, which should assist therapists plan rehabilitation routines to meet occupational requirements. Alderman (1996) advanced the hypothesis that SAS or CE deficits are associated with a poorer response to retraining procedures that are based on behavioral methods.

Practical assistance for those attempting to treat executive disorders has also been provided by Sohlberg and Mateer (1989), who discussed a clinical model for assessment and intervention comprising the selection and execution of cognitive plans, time management, and self-regulation. They gave a range of activities to help with this difficult area of retraining.

Other Aspects of Strategy

Depression

The adverse effects of coexisting depression upon cognitive functioning has often been suggested by significant correlations between mood state and neuropsychological test scores (e.g., Morris, Raphael, & Robinson, 1992; Downhill & Robinson, 1994). However, few studies have attempted to assess the benefits for cognitive recovery of treating depression following stroke. An exception is the research of Gonzalez-Torrecillas, Mendlewicz, and Lobo (1995). These authors compared the Mini-Mental State Examination (MMSE) scores, over a 6-week treatment period (starting 3 4 weeks poststroke), of 37 patients receiving antidepressant medication, 11 depressed patients who were not treated, and 82 patients who were not depressed. Initially, the non-depressed group had a higher MMSE score than the depressed groups, though differences between that group and the treated depression group, disappeared over the course of treatment. However, the untreated group showed little improvement in MMSE score, and by Week 5, significant differences were noted from the treated depression group. These findings are potentially very important in determining stroke rehabilitation strategies, and a replication study is needed. The Gonzalez-Torrecillas et al. (1995) investigation does not seem to have included active cognitive rehabilitation ( just natural cognitive recovery), and it would be even more interesting to examine the effects of antidepressant medication on patients undergoing cognitive retraining.

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The Contribution of Normal Aging

Reviewing the field of cognitive retraining with elderly people, Hay slip (1989) considered the factors important to efficacy and utility and pointed up the deleterious effects of anxiety about performance on performance. Hayslip was concerned about the durability and generalizability of any gains achieved, advocating that these aspects receive more attention in future research. When discussing individual differences, Hayslip suggested that low self-esteem, lower intellectual competence, and an external locus of control can mediate for a better training outcome, and that individuals showing these features are more likely to find the training procedures credible and effective. Amount of practice with the training material also seems important for training efficacy.

Psychosocial Aspects

The research literature on cognitive remediation after acquired brain damage is mainly concerned with formal, targeted attempts by therapists to improve functioning (usually in the rehabilitation ward or unit). The literature fails to recognize the informal potential contribution of family and friends of the patient to the remediation process. In addition, the stress of the cognitive deficits exhibited by the stroke patient falls heavily upon family and friends. One way of addressing the needs of both patient and family is via self-help groups. Wearing (1992) outlined the case for such groups and their additional possible purpose as a vehicle for training family and friends to act as informal cognitive rehabilitation assistants.

Discussion

Basic cognitive rehabilitation strategies exist, the most popular to date being based upon drills and exercises. Wilson and Hughes (1997) criticized this approach, as evidence for its effectiveness is mixed. Choice of area of cognitive impairment for retraining and method of implementation (PC or otherwise) are important factors when weighing the available support for the approach. There is sufficient evidence for the use of PC-based exercise rehabilitation for visuospatial and attention/information-processing deficits. Results are very variable in relation to retraining in the face of memory deficits by means of PCs (e.g., Bradley et al., 1993). The exercise approach can also be criticized, as it lacks theoretical infrastructure, and it does not address the psychosocial aspects of stroke.

A refinement of cognitive rehabilitation strategies is the cognitive neuropsychological strategy. This is grounded in theory, and it is argued that identification of the underlying deficit by means of an appropriate cognitive model allows greater specificity of retraining elements: The treatment is tailored to fit the model's view of the functional impairment. Wilson and Hughes (1997) argued that description of the impairment does not necessarily lead to treatment of the disability (World Health Organization, 1980). The cognitive neuropsychology approach is best suited to patients with pure deficits, who can be characterized by means of their models. Like exercise retraining, this strategy does not incorporate psychosocial elements, and usually its studies are not concerned with generalization to ADLs.

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The combined strategy (cognitive psychology, neuropsychology, and learning theory) is popular with researchers and practitioners who are trained as clinical psychologists. Its strengths include careful monitoring and the evaluation of outcome. It might be argued that while it is wide-ranging, this approach still fails to encompass the emotional sequelae of stroke, although this lack is debatable. From an ethical viewpoint, it is very difficult to argue against the holistic approach (Prigatano, 1995, 1997), because it takes the widest possible psychological view of patients' problems post-stroke. There is a resource issue here, and in many countries, there would not be enough adequately trained psychotherapists to meet the needs of the number of people suffering stroke. Psychological therapies that are relatively brief may be preferred, and the continued success and development of cognitive therapy offer a proven, cost-effective method of intervention for a range of problems and settings (Padesky & Greenberger, 1995). The routine extension of cognitive therapy to the psychological sequelae of acquired brain damage seems only a matter of time.

Most reviewers and researchers remain optimistic about cognitive retraining following acquired brain damage. This is a young field, and there is need for well-controlled studies to test the validity of the various proposed approaches to cognitive rehabilitation. These studies should prioritize the evaluation of generalization from training-task gains to ADLs and other real-life activities. Careful and detailed pretraining assessment data should also be gathered to allow adequate investigation of the matching of retraining strategy to specific patient characteristics.

Summary

Cognitive deficits following stroke are not important only because they are an essential part of a person's identity and his or her ability to function satisfactorily in the world. These deficits are also significant predictors of a person's ability to benefit from the general rehabilitation process. This chapter outlined the available strategies for cognitive retraining and provided some example applications across a range of cognitive areas. The evidence remains mixed with regard to efficacy, although many studies are able to demonstrate robust improvements in the retraining tasks themselves. The critical test is generalization of retraining effects from the training tasks to objective neuropsychological tests and to the patient's real-world environment.

The use of PCs in the retraining process has sometimes been criticized, but as long as their employment is not regarded de facto as a guarantee of good-quality cognitive retraining, they appear to have a part to play (particularly when the rehabilitation process becomes sophisticated enough to routinely utilize the patient's own environment).

Even the most complex cognitive areas, including executive functioning, are now being researched, and we are increasingly aware of confounding factors in the retraining program, such as mood state. Until recently, the available literature from research on normal cognitive aging and compensatory strategies was largely ignored, but we are now beginning to use this source.

The recommendation of Ellis, Franklin, and Crerar (1994) is a good one to adopt: Future research needs to include a large number of case studies in each of the cognitive areas we wish to rehabilitate. Each case will require extensive and detailed pretraining

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assessment to yield a profile to act as the basis for undertaking replication studies on treatment efficacy. In this way, specific patient characteristics may be investigated.

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