[The cognitive rehabilitation process in a case of bithalamic infarction]

INTRODUCTION

One of the fundamental lines followed by Neuropsychology today focuses on rehabilitation processes and their effectiveness. Cognitive rehabilitation is an eclectic process that is dependent on a number of variables. This variability makes it necessary to establish a work plan that guides the intervention carried out by professionals and also makes it clear what objectives are to be achieved, as well as the strategies and tools that must be used to reach them. The purpose of this study is to offer a practical examination of the different points that must be developed in a cognitive rehabilitation process--exemplified here in a case of bithalamic infarction.

CASE REPORT

From a single case and from the specific needs of the individual, a thorough work plan is drawn up. This plan includes a description of everything from the choice of a practical framework for intervention and its underlying principles up to the different training processes, learning techniques and tools that were used and finally proved to be effective. The efficacy and safety of the different strategies and tools used are demonstrated by the short and long term results of the different neuropsychological examinations carried out, which at the same time proved the effectiveness of the work plan that was selected for application.

CONCLUSIONS

A clear understanding of the value of the cognitive rehabilitation processes chosen for use helps to improve the way clinical work is carried out, with the common purpose of restoring neuropsychological deficits and increasing the individual's independence and quality of life.

[Cognitive prerequisites of geriatric rehabilitation]

Rehabilitation aims at the restoration of maximal independence and autonomy after functional loss due to illness or accident. In old age losses of independence in daily life and autonomy are accounted for up to 60% by personal deficits in cognitive abilities. Functional losses in cognitive abilities represent a higher risk of having an accident or becoming ill. Cognitive performance proves to be predictive for success of rehabilitation, independent of functional state. Using the example of a fracture of the femur it can be shown that sensory and cognitive deficits increase the risk of accidents and that executive abilities co-influence long-term results. Strokes are more frequent if cognitive deficits have existed before and the resulting damages are stronger. Long-term results generally depend on complex abilities like everyday competence, reasoning and memory. Experiences with patients with dementia undergoing a memory training show that learning strategies are rarely generalized. Therefore in rehabilitation specific disorders, as for example cortical or subcortical patterns, have to be treated by different rehabilitation methods in the sense of differential rehabilitation. For this an early neuro-psychological assessment of the geriatric rehabilitation patient is needed. The cognitive-psychological findings only scarcely and insufficiently enter diagnostics and therapy. The diverse cognitive disorders have to be taken in account more frequently in education and differential rehabilitation methods have to be developed for geriatric patients with cognitive deficits.

Progressive motor deficits in lacunar infarction

OBJECTIVE

To study the clinical characteristics of the progression of motor deficits in lacunar stroke patients.

BACKGROUND

Some patients with lacunar infarction have progression of their neurologic deficits, but it is not known which patients will progress or why they progress.

METHODS

The authors evaluated 92 consecutive patients (47 men, 45 women; age, 69.4 +/- 10.9 years [mean +/- SD]) with first-ever stroke due to supratentorial lacunes in the internal capsule or the corona radiata. By defining lacunar infarction in which motor deficits progressed between admission and the day after admission as progressive lacunar infarction, the authors compared progressive lacunar infarction with stable lacunar infarction.

RESULTS

Of 92 patients, 25 (27%) had progression of deficits. Diabetes mellitus (p = 0.02) and severity of motor deficit on admission (p = 0.006) were related independently to progression in a logistic multiple regression analysis. Size of the infarct was slightly larger (1.2 +/- 0.4 cm2 versus 0.9 +/- 0.5 cm2; p = 0.01) and functional status at discharge was worse (median Barthel index, 45 versus 100; p < 0.001) in patients with progressive infarction than in those without progression. There were no significant differences between the two groups regarding the site of the infarct or blood pressure or hematocrit levels on or after admission.

CONCLUSIONS

The progression of motor deficits is associated with a relatively poor functional outcome. Diabetes mellitus and the severity of motor deficit on admission may predict progression of motor deficits.

The effect of prompting and reinforcement of activity in elderly demented inpatients

On a ward for 24 psychogeriatric patients, 18 were randomly assigned to three groups with different experimental conditions. The first group was prompted and reinforced for different activities; the second was only prompted; and the third served as a control group. Activities, both the trained ones and others, were continuously monitored throughout the five week study. The results showed a clear increase in the trained activities after training. The prompting condition was effective, and the addition of reinforcement did not add any to the effects. There was no generalization to untrained activities, and the effects did not last at the 1 hr or 21 hr assessments, but was clearly visible at 5 min after training. Time seemed to be more important than place, i.e. the effect ceased with elapsed time, not because of changes in the situation.