COGNITIVE

&
PERCEPTUA
L DISORDERS
COGNITION
 Cognition is a method used by CNS to process
information.
 It includes :
• Knowing
• Understanding
• Awareness
• Judgement
• Decision making
PERCEPTION
 Integration of sensory impressions into
information that is psychologically
meaningful.
 Thus perception is the ability to select those
stimuli which require attention & action,
integrate them with each other & with prior
information and finally to interpret the results.
 COGNITION PERCEPTION
 Integration of sensory
 Acquisition, processing n
impressions into
application of information in
information that is
daily life
psychologically meaningful
 Ability to select those
stimuli that require
attention n action, to
integrate n finally to
interpret them

SUNIL BHATT
 Cognitive & perceptual capacities prerequisites for
learning and rehabilitation is largely a learning
process.
 Thus, patients with cognitive and perceptual
disorders are limited in their abilities to learn self-
care activities & ADL skills.
 Therapist’s modification of assessment &
intervention in light of these deficits will ensure that
patient receives the full benefits of these services.
CLINICAL INDICATORS
 Inability to do simple tasks independently or safely.
 Difficulty in initiating or completing a task.
 Difficulty in switching from 1 task to the next.
 Diminished capacity to locate visually or to identify objects
that seem obviously necessary for task completion.
 Unable to follow simple one-stage instructions despite
apparently good comprehension.
 Make same mistakes over and over.
 Activities may take an inordinately long time to
complete.
 Activities may be done impulsively.
 Appear distracted and frustrated and exhibit
poor planning.
 May deny the presence or extent of disability.
PERCEPTUAL DISORDERS
1. Body image/body scheme disorders
i. Somatognosia
ii. Unilateral neglect
iii. Right/left discrimination
iv. Finger agnosia
v. Anosognosia
2. Spatial relation syndromes
i. Figure ground discrimination
ii. Form constancy
iii. Position in space
iv. Topographic disorientation
3. Agnosias
i. Visual
ii. Auditory

iii.Tactile

4. Apraxias
i. Ideomotor
ii. Ideational

iii.Constructional
 Attention Memory Initiation

Abstraction Judgment

CATEGORIES OF COGNITIVE
DEFICITS

Insight
Calculation

Mental flexibility Problem solving

SUNIL BHATT 05/28/10 10

IMPAIRMENTS
– ASSESSMENT
AND
REHABILITATI
ON
ATTENTION
 Ability to select n attend to a specific stimulus while
simultaneously suppressing extraneous stimuli

 Active process that helps to determine which

sensations n experiences are alerting n relevant to the
individual
TYPES
 Sustained attention: capacity to attend to relevant information during

activity

 Focused or selective attention: capacity to attend to a task despite

environmental visual or auditory stimuli

 Alternating attention: capacity to move flexibly between task n

respond appropriately to the demands of each task

 Divided attention: capacity to respond simultaneously to 2 or more

tasks or stimuli when all stimuli are relevant

CLINICAL PRESENTATION
 Sustained attention: pt. just drifts off from an activity
 Focused attention:
-stop dressing activity to talk
-easily disturbed by music or other noises
-distractibility
 Divided attention: required when more than 1 response
is required or more than 1 stimuli need to be monitored
 Alternating attention
LESION SITE
Reticular activation system: arousal or
alertness
Frontal n temporal lobes: R>L
Sensory systems: bring n code relevant
sensory information
ASSESSMENT
 Loewenstein occupational therapy cognitive
assessment
 Chessington occupational therapy neurological
assessment battery(COTNAB)
 Stroop test
 Paced auditory serial attention test(PASAT)
 Trail making test
STROOP TEST
TESTS
 Random letter test

 Digit repetition test

 Clinical observation n activity analysis

 BEDSIDE TESTING OF ATTENTION AND
CONCENTRATION
 Digit span forwards and backwards*
 Recite months of the year, or days of the week, backwards
 Serial subtraction of 7s (although note that calculation ability
needs to be intact)

*The normal range is forwards: 6·± 1; backwards: 5 ± 1.

REHABILITATION
 Purpose:

To increase pt.’s attention to appropriate stimuli and

disregard inappropriate stimuli.
REMEDIAL APPROACH

 Train to scan visual environment in slow n systematic manner

 Setting time n speed limit
 Amplification of critical stimuli
 Environmental gradation(non distractible)
 ADAPTIVE APPROACH
 Removing the distraction

 Interventions :

• Computerized training programmes using reaction times

• Pattern recognition (cognitrone)

• Paper n pencil tasks

ORIENTATION
time

place

person
 Characteristics common to orientation loss:
 Reflected verbally or behaviorally
 May be temporary or long lasting
 All or none phenomenon
 Dimension of time most vulnerable
 Most common sequence of recovery of orientation: person
place time
 Associated with memory impairment
EVALUATION OF
ORIENTATION
TEST OF ORIENATION FOR REHABILITATION
PATIENTS (TORP)

 Contains 46 items n measures orientation to person n

personal situation, place, time, schedule n temporal
continuity
LOWENSTEIN OCCUPATIONAL
THERAPY COGNITIVE ASSESSMANT
(LOTCA) ORIENTATION SUBTEST
REHABILITATION FOR ORIENTATION
 REMEDIAL APPROACH:
 Pt. participate in daily orientation gp.
 Provide daily individual reality orientation
 ADAPTIVE APPROACH
 Labeled pics of family members etc
 Personal items from home
 Organize daily routine
 INTERVENTIONS :
 Computerized training programmes using reaction times

 Pattern recognition (cognitrone)

 Paper n pencil tasks

MEMORY
 A mental process that allows the individual to
store experiences n perceptions for recall at a
later time
 Not localized in one particular place in nervous
system
 Important for rehab.
 Comprises:
 Acquisition or learning
 Storage or retention
 Retrieval or recall
 Levels of memory:
 Immediate recall: retention of information that has been stored for a
few seconds
 Short term memory: retention of events or learning that has taken
place within few min, hours or days
 Long term memory:
 Consists of early experiences n information acquired over a period of
years
 Not commonly seen foll. stroke
 Common foll. brain injury n in Alzheimer dis.
ASSESSMENT OF
MEMORY
Rivermed Behavioral Memory
Test (RBMT)
 Test of everyday memory functioning

Contextual memory test(CMT)

 BEDSIDE TESTING OF MEMORY.
 First check that patient is attentive and that language function is adequate

Anterograde verbal memory

 Ask the patient to name three distinct objects (e.g. ‘Ball,Flag, Tree’)
 Ensure that the patient has registered the information(repeat up to three times
if necessary)
 If the patient can immediately name the objects, ask the patient to repeat the
three objects three minutes later
Anterograde visual memory
 Show the patient faces in a magazine
 Ensure they have recognized them
 Retest after 5 min

Retrograde memory
 Ask the patient to describe recent events on the ward, or visits
from relatives
 Ask about important historical events and major events in the
patient’s life, e.g. date of marriage
MEMORY RETRAINING
 Purpose:

to enable the pt to effectively encode n recall information so that learning can occur.
 Remedial approach :
 Organizing material to be remembered
 Build strategies
 Computer games
 Memory tests
COMPENSATORY APPROACH

Use of diary or
notebook(memory
log)

Beeper or wall
calender
 Training:
 Date books, post-it notes, timers, calendars
 External self talk, routines n habits, organization n
planning in ways that will reduce number of memory
slips
HIGHER LEVEL THINKING
ABILITIES
 Result of complex n dynamic interactions between a no.
of brain structures united in functional systems
 Depend on intact primary cognitive capabilities
 Problem solving
 Reasoning

 Concept formation
EXECUTIVE FUNCTIONS
Consists of those capacities that enable a person
to engage successfully in independent, purposive,
self serving behavior
4 overlapping components
 Assessment:

Executive Functions Assessment

Good Samaritan Hospital For Cognitive
Rehabilitation’s Executive Functions
Behavioral Rating Scale
 REMEDIAL APPROACH
 Provide structure, feedback n routine
 PT initially acting as pt’s frontal lobe

COMPENSATORY APPROACH
 Assist pt for poor abilities by utilizing other intact cognitive
functions
 Environment modification
 SHORT ORIENTATION- Patient Name: ____________________________
MEMORY- Rater Name: ____________________________
CONCENTRATION TEST Date: ____________________________

Instruction
Score 1 error for each incorrect response, to maximum for each item

No. Question Maximum Score x Weight

error
1. What year is it now? 1 _____ x 4 =______

2. What month is it now? 1 _____ x 3 =______

Repeat this phrase

John Brown,
42 Market Street,
Chicago
or (UK):
John Brown,
42 West Street,
Gateshead
3. About what time is it? 1 _____ x 3 =______

(within one hour)

4. Count backwards 20 to 1 2 _____ x 2 =______

5. Say the months in reverse order 2 _____ x 2 =______

6. Repeat the phrase just given 5 _____ x 5 =______

Total error score = _____/28

PERCEPTUAL
DISORDERS AND
REHABILITATION
UNILATERAL NEGLECT
 Inability to register and integrate stimuli and

perceptions from one side of the body, and the

environment which is not due to sensory loss.

 Clinically, pt. may ignore one half of the body while

performing ADLs.

 Lesions involving infero-posterior regions of right

parietal lobe are significant determinants of neglect.

ASSESSMENT

 Behavioural inattention test (BIT)

Which includes making simple drawings.

 Patient is asked to perform tasks such as baking

cookies & changes in pt’s performance in response to

cueing are observed.

INTERVENTION
1. Remedial approach
 Stimuli specialised for rt. And lt. side of the brain should be
used.
 Eg. Rt. Brain activation – shapes & blocks

Lt. brain activation – letters , numbers etc.

 Simple verbal instructions to encourage turning of head to
neglected side and anchor the attention towards the same.
2. Cognitive compensation
 Patient taught to be aware of the deficit through visual scanning
starting from the neglected side.
 Training for ADL & other required tasks by repeated practice.
3. Adapting the environment
 Patient should be addressed & demos should be given from the
unaffected side.
 Mirror placed in front of the patient when he is dressing to draw
attention towards the neglected side.
 In transfer of training, pt. participates in tasks which require him
to look from the affected side such as watching TV.
ANOSOGNOSIA
 Denial & lack of awareness of the presence of severity of

one’s paralysis.

 Pt. maintains there is nothing wrong & may disown the

paralysed limbs & refuse to accept the responsibility for

them.

 Pts. Have tendency to cover the paretic limb.

 Lesion usually in the non-dominant parietal lobe in the

region of supramarginal gyrus.

ASSESSMENT

 Assessed by talking to the pt. & asking him questions

like :

• What happened to the arm/leg

• Whether he/she is paralysed

• Why the limb cannot be moved

INTERVENTION

 Extremely difficult to compensate for this

deficit.

 Safety is of paramount importance as the

typically do not acknowledge that they have

a disability & will therefore refuse to be

careful.
SOMATOAGNOSIA

 Lack of awareness of the body structure & the relationship of

body parts to oneself or others.

 Lesion in dominant parietal or posterior temporal lobe , thus,

disorder is primarily seen with right hemiplegia.

• Clinically, pt. may have difficulty in performing transfer

activities.

• Difficulty in dressing.
ASSESSMENT

 Pt. is asked to point the body parts being

named by the therapist.

 Imitate movements of the therapist.

 Answer questions about relationship of body

parts.
INTERVENTION

 Sensorimotor approach- facilitation of body

awareness through sensory stimulation of the

affected body part.

 Transfer of training – pt. verbally identifies body

parts or points to pictures.

RIGHT LEFT DISCRIMINATION

 Inability to identify the right & left side of the body.

 Patients are often unable to imitate movements.

 Clinically, pt. is unable to follow instructions using the

concept of right & left.

 Lesion site parietal lobe of either hemisphere.

ASSESSMENT

 Patient is asked to point body parts on

command

Eg. Right ear, left arm, right leg so on & so

forth.

Six responses should be elicited.

INTERVENTION

 In giving instructions to the pt. avoid using

directional words such as “right” or “left”,

instead use “arm with the watch”.

 Adaptive environment

Right side of all common objects like wall,

shoes & clothing to be marked with red tape.

FINGER AGNOSIA
 Inability to identify the fingers of one’s own hand or
the hands of the examiner.
 Usually occurs bilaterally & most common in the
middle 3 fingers.
 Correlates with poor dexterity in tasks such as tying
shoe laces, typing, buttoning etc.
 Lesion in either parietal lobe in the region of angular
or supramarginal gyrus.
 Gerstmann’s syndrome- bilateral finger agnosia +

right-left discrimination + agraphia + acalculia

ASSESSMENT

 A portion of Sauguet’s test :

 Name the fingers touched by the therapist with eyes open (5

times) if successful, with eyes closed (5 times).

 Point to fingers named by the therapist on pt’s own hands (10

times), therapist’s hand (10times),

on a schematic model.

 Point to equivalent finger on a life-sized picture.

 Imitate finger movements.

INTERVENTIONS

 Pt’s discriminative tactile systems are

stimulated.

 Transfer of training – pt. quizzed on finger

identification.
FIGURE GROUND
DISCRIMINATION
 Inability to visually distinguish a figure from the
background in which it is embedded.
 Pt. has difficulty in ignoring irrelevant visual stimuli and
cannot select the appropriate stimuli to which to respond
to.
 Clinically, pt. is unable to locate objects in a pocketbook or
drawer, buttons on a shirt, may not be able to tell when
one step ends & another begins esply. While descending.
 Lesion mostly in the parieto-occipital region of right
hemisphere.
ASSESSMENT

 Ayres figure ground test.

 Functional tests :

 White towel on a white sheet

 Pick out a spoon from an unsorted array of utensils.

INTERVENTIONS

 Compensation through cognitive awareness:

Pt. is taught to examine group of objects slowly &

systematically & sort them carefully using other intact
senses like touch.
 Adaptation & simplification of the environment:

Brightly colored tapes to mark edges of stairs.

 Transfer of training:

Start with 3 totally dissimilar objects & progress to more

similar ones.
FORM DISCRIMINATION

 Inability to perceive or attend to subtle differences in

form & shape.

 Clinically, pt. may confuse a pen with a toothbrush or

a cane with a crutch.

 Lesion site is parieto-temporo-occipital region of the

non-dominant lobe.
ASSESSMENT

 Items similar in shape & different in size are

kept together , pt. is asked to identify each

one.

Eg. One set – pencil, straw, toothbrush etc.

second set – coin, ring, paper clip etc.

INTERVENTION

 Frequently used objects with similar shapes

can be labeled.

 Encourage the pt. to use other intact senses

to identify & distinguish objects from each

other.
SPATIAL RELATION DEFICITS
 Inability to perceive the relationship of one object in space
to another object or to oneself.
 Crossing the midline may be a problem for such patients.
 Clinically, pt. may find it difficult to place the cutlery,
spoon & plate in proper position when setting the table.
 Pt. may be unable to tell the time from a clock due to
difficulty in perceiving the relative position of hands.
 Lesion site is predominantly inferior parietal lobe or
parieto-occipital-temporal junction usually on the right
side.
ASSESSMENT

 Therapist draws picture of a clock , pt. is asked to fill

the numbers and draw the hands corresponding to a

particular time as instructed by the therapist.

 2-3 objects placed on a paper in a particular pattern ,

pt. is asked to duplicate the pattern.

INTERVENTION

 Patient can be given instructions on

positioning himself in relation to the therapist
or any other object :

Eg. “sit next to me”

“stand behind the table”

“step over the line”

POSITION IN SPACE
 Inability to perceive & interpret spatial concepts such

as ‘up’ ‘down’ , ‘above’ ‘under’.

 Clinically, if the patient is asked to raise the arm

above his head during ROM assessment pt. would not

know what to do.

 Lesion usually in the non dominant parietal lobe.

ASSESSMENT

 Place the objects , one on top of another or

one below the other.

INTERVENTION

 3-4 objects are placed in a specific

orientation an additional object is placed in

different orientation & pt. is asked to pick the

odd one & place it in similar way as the

others.
TOPOGRAPHIC DISORIENTATION
 Difficulty in understanding & remembering relationship of
one location to another.
 Pt. is unable to get from one place to another with or
without a map.
 Clinically, pt. is unable to find his room in a physiotherapy
clinic despite being shown repeatedly.
 Possible lesion sites :
 Inferior parietal lobe
 Occipital association cortex
 Occipitotemporal cortex
 Bilateral parietal lesions
ASSESSMENT

 Patients is asked to draw a familiar route

either to his house or the neighbourhood.

INTERVENTION

 Frequently travelled routes to be marked with

dotted lines , gradually space between the dots is

reduced & eventually the line are removed.

 Practice going from one place to another with the

help of verbal instructions.

 Simple routes should be used.

DEPTH & DISTANCE PERCEPTION

 Inaccurate judgement of direction, distance & depth.

 Clinically, pt. may have difficulty in navigating stairs,

may miss the chair when attempting to sit, continue

pouring juice when glass is filled.

 Lesion in posterior right hemisphere in the superior

visual association cortices, bilateral or right sided

lesions.
ASSESSMENT

 Grasp an object that has been placed on the

table. Impaired pt. will undershoot or

overshoot the target. (distance perception)

 Fill water in a glass (depth perception)

INTERVENTION

 Cognitive awareness (walking carefully on

uneven surfaces particularly stairs).

 Place feet on designated spots during gait

training.

 Blocks arranged in piles 2-8 inches high, pt.

is asked to touch the feet on top of each pile.

VERTICAL DISORIENTATION

 Distorted perception of what is vertical.

 Causes disturbances in motor performance, posture

& gait.

 Lesion site – non dominant parietal lobe.

ASSESSMENT

 Therapist holds a cane vertically, then

displaces it to horizontal position. Pt. is asked

to take the cane & return it to original

position.
INTERVENTION

 Patient is asked to use the sense of touch for

proper self orientation esply. When going

through doorways, in & out of elevators or on

the stairs.
VISUAL OBJECT AGNOSIA
 Inability to recognise familiar objects despite normal function of eyes &

optic tracts.

 Simultanagnosia (Balint’s syndrome)- inability to perceive a visual

stimulus as a whole . Lesion is dominant parietal lobe.

 Prosopagnosia – related to any visually ambiguous stimuli, the

recognition of which depends on evoking memory context such as

different species of birds or different makes of cars. Bilaterally

symmetrical occipital lesions.

 Color agnosia – inability to identify colors , ability

to name the objects is retained. Classic occipital

syndrome.
AUDITORY AGNOSIA
 Inability to recognise nonspeech sounds or to

discriminate between them.

 Pt. is unable to tell the difference between sound of

a doorbell & that of a telephone or between dog

barking & thunder.

 Lesion in dominant temporal lobe.

 TACTILE AGNOSIA /
ASTEREOGNOSIS
 Inability to recognize forms by handling them

although, tactile, proprioceptive & thermal

sensations may be intact.

 Difficulty in ADLs.

 Lesion in parieto-temporo-occipital lobe of either

hemisphere.
 IDEOMOTOR APRAXIA

 Pt. is able to carry out habitual tasks automatically &

describe how they are done but is unable to imitate

gestures or perform on command.

 Lesion in the left, dominant hemisphere.

ASSESSMENT

 Goodglass & Kaplan test for apraxia

Consists of universally known movements like

brushing teeth, blowing, hammering etc.

based on hierarchy of difficulty for pts. With

apraxia.
INTERVENTION

 Simplified commands

 Short & precise set of instructions

 Sensorimotor approach
IDEATIONAL APRAXIA
 Inability to perform a purposeful motor act either

automatically or on command because the pt. no

longer understands the overall concept of the act,

cannot retain the idea of the task or cannot

formulate the motor patterns required.

 Lesion in dominant parietal lobe.

 CONSTRUCTIONAL APRAXIA

 Faulty spatial analysis & conceptualisation of the task.

 Pt. for eg. Understands everything about a sandwhich & what it is

for but, is unable to assemble one.

 Lesion in the posterior parietal lobe of either hemisphere.

REFERENCES
 Textbook of medical physiology – Guyton &
Hall (9th edition)
 Physical rehabilitation O’Sullivan (4th edition)

 Impact of Motor, Cognitive, and Perceptual

Disorders on Ability to Perform Activities of
Daily Living After Stroke Louisette Mercier,
Thérèse Audet, Réjean Hébert, Annie
Rochette and Marie-France Dubois Stroke
2001;32;2602-2608
 www.acnr.co.uk/pdfs/volume4issue5/v4i5cog
nitive.pdf 
THANK
YOU !!!!!