Nursing Management of Cognitive Dysfunction in Adults With Brain Injury: Summary of Best Evidence‐Practiced Strategies

Journal of Clinical Nursing

Gao, Y., Zhou, W., et al. (2024).

Journal of Clinical Nursing, 33(7), 2496-2508.

<div>This systematic review explores recommendations for nurses regarding the management of cognitive impairment in individuals with brain injury. Recommendations relevant to the scope of speech-language pathology are included within this article summary.&nbsp;</div>

Army Nursing Innovation and Cultivation Special Program Innovation Project (China); Yangpu District Science and Technology Committee Yangpu District Health Committee Scientific Research Topic Project (China)

From database inception to June 21, 2023

<div>Clinical decisions, guidelines, evidence summaries, best practices, recommended practices, expert consensus, systematic reviews, meta-analyses</div>

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<div>The following recommendations were reported regarding the screening/assessment of cognition in individuals with brain injury:</div> <div> <ul> <li>Cognitive screening/assessment should be performed within eight hours of hospital admission using the Mini-mental State Examination or the Montreal Cognitive Assessment (Level 5, Grade A Evidence).</li> <li>Within each unit, at least one nurse/physician/psychometrist should be trained to conduct an initial cognitive function assessment (Level 5, Grade B Evidence).&nbsp;</li> <li>Contributing factors and potential limitations should be considered during the assessment process, whenever possible (e.g., personal factors, preinjury medical conditions, injury-related factors, conditions; Level 5, Grade A Evidence).&nbsp;</li> </ul> </div>

<div>The following recommendations were reported regarding multidisciplinary care for individuals with cognitive impairment following brain injury:</div> <div> <ul> <li>Individuals with brain injury should receive care from a multidisciplinary rehabilitation team including neurosurgeons, internists, rehabilitation physicians, physical therapists, occupational therapists, speech therapists, nurses, etc. These teams should be formed with a neurologist or rehabilitation physician as the team leader. Physical therapists, occupational therapists, and nurses should act as the primary implementers of rehabilitation treatment (Level 5, Grade A Evidence).</li> <li>Each member should have a clearly defined role. Team members should communicate and collaborate with each other and hold regular team meetings to dynamically assess progress and set treatment goals (Level 5, Grade A Evidence).</li> <li>A case manager or clinical coordinator should be appointed at each phase of the continuum of care. They should serve as a primary point of contact for patients, families, team members, and any other relevant party (Level 5, Grade A Evidence).</li> </ul> </div>

<div>The following recommendations were reported for rehabilitation programs for individuals with cognitive impairment secondary to brain injury:</div> <div> <ul> <li>Rehabilitation programs should be goal-oriented. There should be high involvement of patients, families and rehabilitation team members in goal setting early in the rehabilitation process (Level 5, Grade A Evidence).&nbsp;</li> <li>Rehabilitation should focus on activities that are meaningful to the patient and their care partners. Rehabilitation should include personally meaningful everyday activities and life contexts (Level 5, Grade A Evidence).</li> <li>Clinicians should tailor interventions to individual needs while considering severity of cognitive deficits and the patient's stage of recovery (Level 5, Grade A Evidence).&nbsp;</li> </ul> </div>

<div>The following consensus-based recommendations were reported regarding cognitive and/or communication interventions for individuals with brain injury:</div> <div> <ul> <li>Cognitive rehabilitation interventions can be started as early as 24&thinsp;hour after neurological stabilization (Level 5, Grade A Evidence).</li> <li>Reorientation training, with the participation of the family, should be provided to orient patients to space, time, seasons, objects and the environment. Depending on injury, therapy may also target the patient's ability to perceive similarities and differences, to recognize their own limitations, to use appropriate interpersonal distancing, and to self-evaluate and improve their speech and behavior (Level 5, Grade A Evidence).&nbsp;</li> <li>Patients with communication difficulties should be receive speech and language therapy targeting simple pronunciation, conscious word recognition, verbal expression, and simple conversation training (Level 5, Grade A Evidence).</li> <li>Patients should be guided to recall past events. Recall should be gradually increased to include notable events, family, friends, colleagues, etc. Responses should be prompted, corrected, appreciated, and affirmed when appropriate (Level 5, Grade A Evidence).</li> </ul> </div>

<div>The following evidence-based recommendations were reported regarding cognitive interventions for individuals with brain injury:</div> <div> <ul> <li>Restorative approaches should be taken in order to reduce impairment and improve cognitive function (Level 2, Grade A Evidence).</li> <li>Metacognitive and/or instructional strategies (e.g. goal management training, plan-do-check-review, prediction performance) are recommended (Level 1, Grade A Evidence).</li> <li>When training for multistep procedures, clinicians should break tasks into smaller components and allow for sufficient time and opportunity to practice (Level 1, Grade A Evidence).</li> <li>Clinicians should use strategies that allow for more effortful processing of information/stimuli such as verbal elaboration and visual imagery (Level 1, Grade A Evidence).</li> <li>Dual task training should be used to improve divided attention (Level 1, Grade B Evidence).</li> <li>Compensatory techniques should be used to reduce impairment and improve function (Level 2, Grade A Evidence).&nbsp;&nbsp;</li> <li>The use of environmental supports and reminders is recommended. Individuals with TBI and their care partners must be trained in how to use these external supports (Level 2, Grade A Evidence)..</li> <li>Computer-based cognitive interventions such as virtual reality, virtual meetings, virtual games and virtual driving can be used to improve cognition (Level 1, Grade B Evidence).</li> <li>Group therapy should be used to provide opportunities for peer support and generalization (Level 1, Grade B Evidence).&nbsp;</li> </ul> </div>