Attention and ConcentrationCognitive Impairment After Stroke

What is Attention?• Attention is something which we often take for granted. It is our ability to concentrate or focus

on a chosen stimulus and ignore all of the other options in our environment. Attention can be split up into four distinct aspects:

How to Spot Attention Difficulties

•It can be quite difficult to spot problems with attention and concentration, as initially after a stroke many patients experience extreme tiredness and fatigue which in itself will have an effect on attention.•The first thing to do is to talk to your patient. A lot of the time, they will have noticed that something is not right and they may mention it in conversation (either with yourself or with friends/relatives). •Keep an ear out for the complaints listed on the following slide.

How to Spot Attention Difficulties

Activity – Case Study

• Mrs T is an 84 year old lady who is in hospital following a stroke. She has been left with severe impairment to her memory and reduced attention/concentration. When working with Mrs T, what kind of problems/challenges might you come up against in your role?

Activity – Reflection

• Mrs T is an 84 year old lady who is in hospital following a stroke. She has been left with severe impairment to her memory and reduced attention/concentration. When working with Mrs T, what kind of problems/challenges might you come up against in your role?

How Can You Help?• You

• You will often have to adapt the way that you work to the individual.

• For example, if someone is having trouble with their divided attention, talking them through an activity while they do it may be very distracting indeed. In this situation, it can help to explain to the individual exactly what you want them to do BEFORE they start doing it so that their sole focus is the activity (without competition from your voice).

• Also make sure there is adequate time to complete an activity with a patient.

How Can You Help• Warm Up and Shelve Distractions

• Before you start with the proper activity/exercise you wish to do with a patient, warm up the part of the body/mind that they will be using first.

• For example, if they will be using their hands, rub some cream into their hands for a few minutes to ensure that focus is on that part of the body.

• When a patient becomes distracted during therapy, ignoring them can make things worse. Instead, try writing down whatever it is that is distracting them and tell them that you will come back to it later.

How Can You Help?• Meaningful Stimulation

• How meaningful something is to a patient significantly affects their attention and concentration.

• Many activities or exercises that we carry out with patients are quite abstract and do not obviously relate to real life situations.

• Try to explain why you are doing an exercise with a patient in a way that means something to them. For example, if you are working with a patient who is a keen DIYer, explain how a physiotherapy exercise will help them to get back to their hobby.

How Can You Help?• Conversation and language

• Use concrete, easy to follow language and remember that patients with limited attention will most likely struggle to keep track of long conversations or explanations.

• Use ‘chunking’ to help patients keep track in conversation and to aid understanding.

• Don’t be afraid to allow silences within conversations as they can be very helpful for your patient. It can allow some time to process or think about what has been said. A small silence can also give them the chance to ask questions.

How Can You Help?• The Environment

• Have you ever been in a crowded, noisy pub and found it almost impossible to listen to what your friend is saying to you? It can be particularly tricky if there is an interesting conversation taking part on the next table!

• If you are working with someone that has difficulties with attention then always try to take them to a quiet environment where you can work with them alone.

• This also applies for home visits, a television in the background or noise coming from an open window can make the environment just as distracting as a ward.

How Can You Help?• Timetables and Checklists• Timetables or calendars can help to stop

patients getting distracted about impending activities/visits.

• Calendars and timetables should be placed in an area your patient has full access to and should always be very visible.

• Written checklists should be short, succinct, concrete and clear, ensuring that an individual does not need to attend to them for a long period of time.

• There are examples of written checklists in the toolkit, but always make sure that checklists are tailored to the individual.

How Can You Help?• Voice message recorders and Electronic Organisers

• Using an electronic device to leave recorded voice messages for patients can help them to pay full attention to tasks and avoid losing concentration in the middle of a routine .

• The message could be a set of instructions, going through each task within a routine one at a time. For example, it could go through the process of cooking a certain meal.

• Many people have smart phones and tablets which can easily be used as electronic organisers.

• Many of these gadgets have calendars, notes, checklists and even voice recorders built within them, providing people with lots of options.

How Can You Help?• Internal Management

• You can also help patients to develop a ‘mantra’ to help them take the steps needed to carry out a task.

• For example, they could create a short song with the steps for making a cup of tea.

• Another example could include a patient walking with a frame and repeating to themselves (either out loud or in their head), “left foot, right foot, frame”.

• Mantras can help people to stay on task and prevent them from becoming distracted by their environment.

Summary• When someone has difficulties with

attention and concentration, it is vital that these are looked at and that strategies are put in place to help.

• Attention and concentration is really at the centre of most things we can do with patients in rehab. If an individual is unable to concentrate on a task, their rehabilitation in all areas is likely to be affected.

• For many patients, attention and concentration will improve with time after a stroke (even without using any intervention). However, the strategies mentioned in this presentation can help to speed up recovery in all areas.