Attention

Attention

1. Theories

   • Selective Attention debate
     • Broadbent's Filter model of selective attention
       • Filter comes before perceptual processing
         • What about the cocktail party effect?
     • Deutsch and Deutsch. Late Selection Theory
       • Filter comes after perceptual processing
         • Inefficient
     • Treisman's Attentuation Theory
       • Anne Treisman was Broadbent's Phd Student
       • Information is not completely filtered out but rather is attentuated
   • Clinical Model of Attenion
     • Identifies 5 types of attention
       • Focused Attention
         • The ability to focus on discrete sensory stimuli.
         • To select an object and attend to it
         • When disrupted a patient will not be able to attent to specfic stimuli, sometimes disrupted as a pt emerges from coma
       • Alternating attention
         • Switching between listening to a lecture and taking notes
         • Set shifting
         • Mental flexibility
         • The ability to switch between different activities
         • Problems are evident in patients who have difficulty changing tasks
       • Sustained Attention
         • Maintain attention over time
         • Vigilance
         • Concerntration
         • Continous
         • When disrupted, pt cannot focus for more than a brief period. May cause dramatic fluctuation in test results.
       • Selective Attention
         • Ability to maintain attention in the presence of distracting stimuli
         • Suppress distractions
         • LINK WITH SELECTIVE ATTENTION THEORIES
         • When disrupted individuals are easily drawn of tasks, especially in more stimulating environements
       • Divided Attention
         • Talking on the phone whilst cooking
         • The ability to pay attention to two tasks simultaneously
         • Deficit causes inability to multitask
     • Sohlberg & Mateer
     • Useful theory for organising assessment and treatment of attention in a clinical setting.
     • Functional Definitions
   • Baddeley's Working Memory Theory
     • Central Executive
       • Phonological Loop
         • Inner voice
       • Visuo-Spatial Sketchpad
         • Inner eye
       • Episodic Buffer
         • Binds information

2. Assesment

   • Interview
     • Patient AND Relative/Informant
     • General Complaints
     • Specific exmaples
     • Interview schedules
       • Tyerman and King, 2008
         • Adaption of several schedules from an article by Tyerman, 1987
           • Head Injury Background Interview Schedule
             • Social and Medical History
           • Head Injury Problem Schedule
             • Current Physical, Sensory, Cognitive, Emotional, Behavioural and Social Problems experienced.
               • According to patient and relative or informant
           • Head Injury Semantic Differential
             • Changes in self concept as reported by the patient
             • Changes in emotion and behaviour as reported by relative
           • HADS - Hospital Anxiety and Depression Scale
             • Zigmond and Snaith, 1983
             • Quick check
       • Rivermead Life Goals Questionaire
       • Rivermead Patient (and Relative) Expectation and Wishes Interview
       • Attention specific questionaires
         • Attentional Rating Scale
           • Ponsford and Kinsella, 1991
   • Observation of patient behaviour
     • Structured observations
   • If possible obtain relevent medical records and neuroimaging
     • Is the patient taking medication?
   • Neuropsychological Tests
     • Many generalised measures of cognition include measures of attention
       • CAMCOG - Cambridge Cognitive Examination
         • for elderly patients
         • Part of CAMDEX
         • Includes measures of attention
           • Also, Orientation, Language, Memory, Praxis Calcutlaion, Abstract thinking, Perception
         • Roth et al 1986, 1988
         • CAMCOG-R contains a new measures of executive function
       • MMSE - Mini Mental State Exam
         • Quick
         • Folstein 1988
       • Repeatable Battery for the Assessment of Neurological Status. (RBANS)
         • No measure of Executive Function
         • Measures Attention
         • Parrallel Tests
     • One positive result alone is not enough
       • Convergent Evidence
     • Specific tests of Attention
       • Working Memory Index of the WAIS-IV
       • TEA - Test of Everyday Attention
   • Attention is often assessed as part of a larger cognitive exam

3. Management and Treatment of Attention

   • Cicerone et al 2011
     • Rehabilitation of attention should include direct training of attention as well as meta cognitive training to promote compensatory skills and facilitate generalisation to real world functional activities
       • Computer based attention training is suggested as a PRACTICE OPTION alongside clinician guided treatment
         • However, sole reliance, or repeated practice without clinician involvement is not recomended
       • Practice Standard
       • Training is recomended in the posta-acute phase
         • Currently insufficient evidence exists either way as to the efficacy of direct attentional training in the acute phase.
   • Sohlberg et al
     • Management of Attention can be broken down into 5 key sub catergories
       • Psychosocial Support
         • Psychoemotional factors can have a profound impact of cognitive functioning
         • Psychotherapy should be conducted alongside, particularly when deficit is the result of unexpected injury or illness
         • A therapy model where patient and clinician partner up has been demonstrated to improve a patients sense of sell-empowerment, self-confidence, and sense of indepenedence
           • This has positive treatment consequences
             • Reduces patients feelings of victimhood
             • Engagement in therapy
       • Direct Attention Training (Restorative)
         • Typically involves a training process of repetitive practice on a task that engages attention. Difficulty is matched to individual functioning and as they improve increasing demands are placed attentional abilities .
         • Unlike training programs for memory or ef, training programs for attention have been demonstrated to be effective. Cicerone et al 2011
           • Sohlberg et al 2001, mention a number of studies in children and brain injured persons demonstrating the effectiveness of these programs
         • Attention Process Training program (APT)
           • Commercially available example
           • Consists of hierarchically organised tasks designed to train sustained, selective, alternating and divided attention
             • Increasing demand on attentional system as tasks progress (with partcipant improvement)
           • Sohlberg et al. 2001 recommend 5 principles to ensure effective use of the APT program
             • THRPG
             • Theory Based
               • Treatment model should be grounded in attention theory
             • Hierarchically organised tasks
               • Attention should be trained in a step by step fashion from basic underlying processes up to more challenging tasks
                 • Some evidence to suggest that using tasks that are excessively difficult has no or even negative treatment outcomes.
             • Sufficient repetitive intensity
               • Allow enough time to practice each task before moving on
                 • May be necessary to enlist caregivers in homework
             • Progress based application of tasks
               • Treatment should be administered according to performance data
                 • Is patient struggling at the beginning of task and then improves?
                   • Initiation/ task switching, Alternating attention,
                 • Does performance drop off over time?
                   • Consider sustained attention.
                 • Consistent poor performance?
                   • Is the task too hard?
             • Generalisation
               • Begin fostering generalisation from the initial stages of therapy
                 • Include real world applications
                   • Sustained attention: Train patient in time spent reading the paper without loosing focus
                 • Include real world goals
       • External Aids
         • Any external tool that helps manage attention
         • Electronic Organisers
         • Pagers
         • Alarms
         • Day planners
       • Environmental Modification
         • Lists of appropriate environments
           • Busy/Quite times
           • Smaller shops vs Malls
           • Quieter restaurants
           • Patient can refer to the list when planning activities
         • Organising working and living environments to facilitate concerntration
           • Removing overstimulating aspects to reduce cognitive load
           • Do Not Disturb Signs
             • And pre arranged times with family and colleuges
           • Liase with Workplace, Educators and Living companions to adjust social environments
       • Self-Regulatory Strategies
         • Metacognitive strategies that encourage a individual to maintain focus
         • Orientating Proceedures
           • Simply mental strategies that aim to keep an individual on task
             • E.g Car Notepad w/ destination, direction, expected duration, and exit strategy
             • Hourly alarm to prompt an individual to stop and questions what they are supposed to be doing and what they have been doing
             • Selective and Sustained Attention
         • Key ideas log
           • An Individual notes down all questions and tasks to avoid changing activities
           • Alternating and Sustained attention
         • Pacing
           • Effective use of time so as to not fatigue concerntration
           • Taking breaks
           • Planning more demanding activites for the mornings
           • Sustained attention
   • Ongoing monitoring of patient's progress and recovery, effecicacy of treatment

4. Neuroanatomy and Function

   • Thalamus
     • Regulation of arousal
   • Cortex
     • Frontal
       • Sustained attention
       • Selecting and organising attention
     • Parietal
       • Spatial attention
         • damage can result in neglect