Hello and welcome. I'm Tristan Grindow, Deputy Medical Director and Director of Education for the American Psychiatric Association. I'm pleased that you're joining us for today's SMI Advisor webinar, Compensatory Cognitive Training for Neuropsychiatric Conditions. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now, I'd like to introduce you to the faculty for today's webinar, Elizabeth Twomley. Dr. Twomley is a Professor of Psychiatry at UC San Diego and the Director of the Clinical Research Unit of the Center of Excellence for Stress and Mental Health at the VA San Diego Healthcare System. She's the developer of Compensatory Cognitive Training and COGSMART interventions for multiple neuropsychiatric populations. Elizabeth, welcome to SMI Advisor and thank you so much for leading today's webinar. It's a pleasure. Thank you so much and I'm happy to get started right away. I have no disclosures and I'm assuming that people signed up for today's webinar because they're interested in cognitive health for people with serious mental illness and we will be talking a lot about that. I'm hoping to achieve some additional objectives. I hope that you all will be able to describe both compensatory and restorative approaches to improving cognition in people with psychiatric disorders. I hope that you'll be able to identify the domains of cognitive functioning that we focus on in Compensatory Cognitive Training. And I want you to be able to give examples of how to link some of the cognitive strategies that you might teach with individual rehabilitation goals. So with those objectives in mind, I will get started by showing you some examples of tools that can be used to promote good cognitive functioning and functional capacity in people with neuropsychiatric conditions. Many of these are organizational tools or reminder tools that you may even use yourself. So lots of different ways to organize our stuff, to remind ourselves, to take our important items with us when we leave for the day. Lots of ways to remember appointments and tasks. This is the old-fashioned way and here's the newfangled way. So hopefully everybody is using something like one of these to-do lists. They could be on paper, they could be post-it notes. I don't suggest this approach, generally not very effective. And of course some people use their smart devices for their to-do lists. Then finally, a really big concern with a lot of the folks that we work with is medication adherence. Here are some simple ways to remember to take medications and to organize them. There are more complicated ways for more complicated regimens and also apps that can remind folks to take medications. Now I'll take a little diversion here and tell you that I have a Cogsmart app, which is a compensatory cognitive training app, which is available on my website, which is www.cogsmart.com. This is a free web-based app that has 12 different modules that really mirror the intervention that I'm going to tell you about in today's webinar. And there are also some videos inserted into the app that you can also access separately on YouTube. So I'm telling you about this now because one of the interesting things that I get out of the back end of the app is information on what users of the app say they're willing to do. So after presenting each cognitive strategy, I ask them, are you willing to try this? And the answers are always yes, no, or I already do this. And so as an example, will you try using a calendar to keep track of your events and appointments? You can see that about half of the people using the app so far are indicating that they're already using a calendar, which is great. And then there's a very tiny sliver of folks that are saying, no, they're not willing to try it. And then there's that big blue area of the pie. Those are folks saying, yes, I'm willing to try this. But what that means to me is that almost half of the folks that we are targeting with this app are saying that they're not already using a calendar, which is really in some ways quite surprising. Here's another example. The question here was, will you try to write things down in order to remember them later? This is a cornerstone of remembering things that has been used for a long time. So writing things down to remember them later, a minority of users are saying they're already doing that. And most people are saying they're willing to try that. So again, these things are reminders to us that not everybody has the same skills that we do, that we rely on to be successful every single day. And very basic skills like writing things down to remember them later may not have been taught to them, or maybe they just haven't been mastered, or maybe they used to use them and they don't use them anymore. So I think it's really important to ask clients how they use these skills and maybe even have them demonstrate the skills to you. So I've had many clients, for example, tell me, oh, I use a calendar. And then when I see them pull it out and show me, it's clear that there's really a lot of room for improvement in how they're using the calendar. So that as a lead-in to the rest of my talk, I want to give you an outline of what I'll talk about. So first, I'm going to talk about the rationale for these interventions and how they were developed. I'll give you some evidence to support their use from previous studies. And then I'm going to dive a little bit deeper into the interventions themselves, show you how they work, and talk about some clinical applications. So we know, for example, in the case of psychosis, that cognitive impairment is the rule rather than the exception, tends to be present from an early age. And what you usually see is that people who are affected by psychosis have pre-morbid cognitive impairments, and then they have a little bit more cognitive decline as they get older. And so we know that at the onset of their illness, and then it seems to be pretty stable from then out. It involves most cognitive domains, so things like attention, working memory, processing speed, learning, memory, executive functioning, and so on. And these cognitive impairments are highly correlated with functional impairment, and they don't tend to respond to any of our available antipsychotic treatments. This is another way of showing the same thing. These cognitive impairments are really the biggest contributors to social and work dysfunction in people with schizophrenia, much more so than negative symptoms and mood symptoms, and significantly more so than positive symptoms as well. But it's not just psychosis that is affected. Psychiatric disorders of all kinds are brain disorders. And so we know, for example, that people with bipolar disorder, major depression, PTSD, many of the most serious mental illnesses that we work with tend to be affected in terms of their cognition. And one of the things that I often say to patients is that, you know, any psychiatric illness or any distress that you have really is going to compete for your brain resources, and the brain is just not going to be able to work as effectively if it's trying to keep your symptoms under control at the same time. And so we see in a lot of different conditions these very common cognitive impairments that lead to poor role functioning, people having difficulties living by themselves independently, going to work, maintaining a job or a career, struggling with education, struggling to connect with other people, and form social relationships. And those difficulties really tend to lead to low quality of life. People report low satisfaction with their role functioning and really poor community integration. So let me give you the textbook definition of cognitive remediation now. This was from a very recent schizophrenia research white paper by Chris Bowie et al. And cognitive remediation is a behavioral training intervention targeting cognitive deficit, attention, memory, executive function, social cognition, metacognition, using scientific principles of learning with the ultimate goal of improving functional outcomes. Its effectiveness is enhanced when provided in a context, formal or informal, that provides support and opportunity for extending to everyday functioning. So you hear a lot of terms that refer to similar interventions. Cognitive remediation is one term. I tend to use the term cognitive training because I'm not always confident that remediation is really possible. But cognitive training is possible for everyone. And I work with a lot of folks with different types of cognitive disorders. And cognitive training tends to be a term that's applicable across those different disorders. So there are two basic theoretical approaches to cognitive training, the restorative approach and the compensatory approach. The restorative approach really relies on drill and practice. These are typically computerized interventions that focus initially on very basic cognitive functions like early auditory and visual processing. And so they're called bottom-up approaches. So they're focusing on really elemental cognitive abilities and then progressing upward to more higher cognitive functions. The goal here is really to restore functioning of the impaired neural circuitry. And again, these interventions are almost always computerized these days. In the early days, they used to be more paper and pencil. But these days, they're almost all computerized. And the real difficulty with some of these approaches has been showing that the cognitive gains made with these interventions actually transfer to improved community functioning. And so generalizability has been a bit of an issue with those interventions. And the generalizability is much enhanced when these interventions are delivered along with a psychiatric rehabilitation program. On the other hand, we have compensatory interventions, which is what I'm going to be talking about today. These really focus more on top-down processing, so higher order cognitive processing, not intended to restore impaired neural circuits, but rather to work around or compensate for a cognitive impairment. So the goal is really a bit different. Typically, these are done either individually or in groups, whereas restorative interventions tend to be done more in individual settings because of the nature of the computer intervention. With compensatory interventions, I feel like there is a shorter bridge to cross before you can get to real-world outcomes. And so if you're teaching someone how to compensate, you can teach them how to do that in a way that's very similar to the problem that they have in the real world. Cost is probably a little bit higher with these interventions because it's more provider-intensive. You can't get an RA to just lead someone through a computer program. You have to have a provider who really knows how to teach these strategies. So on the restorative side, you may be familiar with some of these brands. Some of them are very heavily marketed toward consumers. So Lumosity is the one that I hear about all the time on NPR, for example. Some of them are marketed more toward providers. Cogmed is a good example of that. Posit Science Brain HQ, I think, markets somewhat to providers as well. And then some are really being used more in the context of research these days. So Till Weick's intervention called CIRCUITS, I would put in that category. And there are just a bunch of different ones. These are just some examples. So again, what I'll be focusing on is really the more compensatory approach. I'll be talking about two different interventions. One's called COGSMART, and that stands for Cognitive Symptom Management and Rehabilitation Therapy. And the other one is called Compensatory Cognitive Training, or CCT. These are very similar interventions, and I'm not going to get into the weeds too much about how they were developed separately. But I will say that they share in common a focus on the same cognitive domains. And they both really share this focus on cognitive compensation, which is just working around deficits by reducing the cognitive demands or handling those cognitive demands in a different way, and also really promoting habit learning. So we're trying to make these strategies into habits, because habits are really resistant to forgetting. Habit learning relies on neostriatal pathways instead of declarative memory systems, and those tend to be a little bit more robust in the kind of folks that we work with. Okay. So this is a quick tour through some of the development of these manuals. I'll say that the randomized controlled trials that I've done have shown positive effects of these interventions on cognitive performance, psychiatric, and in the case of brain injury, also post-concussive symptoms and quality of life. These are some of the trials that we've done in San Diego. So you can see there are lots of trials in psychosis, but also different disorders, young adults with autism, older people with hoarding disorder, lots of work in traumatic brain injury in veterans, homelessness, older veterans with mild cognitive impairment, and Parkinson's disease. So those are the trials that are going on or have been completed in San Diego. There have also been some international trials in different places. The manuals are available in a bunch of different languages, which has been really exciting to watch. The most recent one will be Ukrainian, and so I've got to add that to the slide. All of the manuals, well, the two main ones that I'm going to talk about today are available online for free. I'm hoping that you get all of the translations eventually added to the website as well. And I can update this little fact. So these manuals have been downloaded actually over 6,000 times from the website, and they're in use in many VA and Department of Defense facilities, lots of other community mental health facilities as well. The Cogsmart app that I mentioned in the beginning of the webinar went live in June of 2018. There were 800 downloads in the first three months, and now we have, I think, over 2,000 people registered for that. And there are a couple of interesting next steps. What I'd like to pursue is a better-looking cognitive training app, so I have plans with Philips Research in the Netherlands to do that, and also integrating some of the cognitive strategies with robotics to be delivered in the home. Okay, so why do I prefer the compensatory approach? There are a few reasons that I want to lay out. One is that the cause of the cognitive impairments isn't particularly important, doesn't really matter if the cognitive impairment is coming from the serious mental illness itself or 40 years of substance abuse or something else. It just really doesn't matter because we can provide some workarounds. These strategies help people work around their cognitive impairments and actually do have the potential to induce brain plasticity. So if you change your behavior, you can change your brain, and that's what we're going for here. This is very recovery-oriented. It focuses on linking the strategies to each person's real goals and roles in the community, and I think it's very de-stigmatizing because really everyone uses some kind of compensatory strategies, and so we can all talk as therapists about things that we do to be successful, and really none of these strategies can be stigmatized. It's not exactly therapy what we're doing. It's really training. It's more like taking a class, and we actually refer to, in group, when we do it in groups, we refer to it as a class, so that I think is de-stigmatizing as well. Habits and routines are extraordinarily powerful. I'm sure everyone on the webinar today has engaged in some habits and routines so far in their day, and finally, we have evidence to support the use of these approaches in terms of both cognition and generalization to functional outcomes. So these are the four domains that we focus on in CCT. The first one is prospective memory, which just means remembering to do things in the future, and we put that in the beginning of the intervention because we really want people to come back the next week, and so we want them to remember to be able to do that, and so that material is front-loaded in the beginning of the manual. Then, we move on to conversational and task attention as a building block of learning and memory. We then move on to learning and memory, and finally executive functioning and cognitive flexibility come last. So these four domains were chosen because at least when I started developing these manuals, these four were both considered important for everyday functioning and quality of life, and there was evidence at that time that these four were modifiable, so that was really important to me. I wanted to be able to actually move the dial on some of these functions. So the intervention for serious mental illness, CCT, is typically conducted once a week for 12 weeks. It can be done individually or in groups. There's a treatment manual that is very straightforward. This is a really low-tech intervention. It's very practical, pragmatic, portable. We've done this in coffee shops. We've done it in libraries. We could do it anywhere. We've done it in people's homes as well. This is a very individualized approach, and so it, even though it is a manual, we elicit the real-world cognitive problems and real-world functional goals from each participant, and then our job as facilitators or therapists is really to link every strategy that we teach them to that person's individual rehabilitation goals. We do assigned homework every week, because that is the person's chance to practice these strategies in their real-world settings and figure out what they like, what they don't like, what works for them, what's not working, and then we can troubleshoot from there. Living, learning, working, and socializing are generally the four domains of rehabilitation goals that we focus on the most. Here's how it's laid out. The first three sessions cover an introduction to cognitive training and what it is, and then really delve into perspective memory. We focus a lot on using calendars and reminders in the environment, how to link tasks together to form new habits, and so on. Then, we move into how to pay attention better during conversations and during tasks. We cover a number of conversation skills, and then we cover self-talk as a way to stay focused during tasks. In the verbal learning and memory sessions, that's sessions six through eight, the strategies that we teach are really classifiable into two different categories. On one hand, we've got strategies to help reduce the amount of information that needs to be actually remembered. For example, writing things down externalizes that and makes it so that you don't need to actually store it. For information that does need to be stored internally, we focus on making the information more personally meaningful so it's more likely to get encoded in a stronger way. We also have a separate section on learning and remembering people's names because that was something that was really important to clients. They asked for it, and so we added that to the manual many years ago. Then, finally, we wrap up with sessions nine through eleven on executive functioning and cognitive flexibility. We teach brainstorming as part of a six-step problem-solving method. We also have some content on planning to meet goals and deadlines and then transferring those deadlines into the calendar. Then, session 12 is not shown on this slide, but it's just a wrap-up session where we talk about all the strategies. We review anything that's unclear, and we really focus on what strategies folks are using versus what do they want to start implementing in their daily life and how to do that. In terms of the previous results, one thing I want you to keep in mind is that we've had now three meta-analyses of randomized controlled trials of cognitive remediation or cognitive training for people with schizophrenia. The schizophrenia literature is really the furthest along, I believe, in terms of what we know about what works with cognitive training and cognitive remediation. And so if you look at the orange values, these are Cohen's d effect sizes for cognition. And so they've hovered in the 0.3, 0.4 range, and that's a small to medium effect size. And you can see that the effect sizes for symptoms are a bit lower in the 0.1 to 0.2 range. And then the effect sizes for functioning measures are 0.36 to 0.51. So we're getting into some medium effect sizes here, but nothing that's really large and hopefully as we're moving forward, the time is actually right for a new meta-analysis. The last one was done in 2011. And so hopefully in the last few years, we've improved those effect sizes. So I'll tell you a little bit about some randomized controlled trials that I've done. This first one was the first trial of compensatory cognitive training. It was compared to treatment as usual for outpatients with psychosis. And the sample size was small. It was only 51 who had both baseline and follow-up data. We found significant effects of CCT on attention, verbal memory, functional capacity, which was the UCSD performance-based skills assessment, negative symptoms, and self-reported quality of life. You can see that the negative symptom and quality of life findings are large effect sizes. Those are coincides of 0.8, 0.9, a little bit smaller, 0.72 for functional capacity, and a little bit smaller yet, 0.2 to 0.5 for the cognitive outcomes. We've also done some follow-up analyses of this negative symptom finding. I apologize for my dog, if you guys are hearing that on the line. In terms of the negative symptoms, we found improvements on both expressive deficits and social amotivation on the PANS, negative symptom subscale. We found that these improvements in negative symptoms were also associated with improvements in quality of life. And improvements in social amotivation were actually linked to increased social context. So people were feeling more motivated to interact socially, and they did, which was really exciting to see. This was a small trial, really a pilot trial of CCT versus treatment as usual in Canada. And this was with individuals with first episode schizophrenia, so a younger group. We found in this case, large effects of CCT on a neuropsychological composite score, the matrix consensus cognitive data, matrix consensus cognitive battery composite score, trail making part A, which is a test of processing speed, and also on a social cognition scale. And these were five to seven point T-score increases. And so for those of you who are used to T-scores, that really represents about half to a little over half of a standard deviation. And so this was really exciting to see these larger effect sizes in the CCT group. A more recent trial was of CCT included with supported employment for adults with serious mental illness who were in a supported employment program. And so we had 153 outpatients divided between schizophrenia, schizoaffective disorder, bipolar disorder, and major depression. And the CCT intervention was actually delivered by the employment specialists during the first 12 weeks of supported employment. And so it was concurrent with supported employment activities. And then in the control condition, participants received enhanced supported employment, which was more sessions that compensated for the additional therapist's time in the experimental group. And this was the first randomized control trial of CCT that included a robust control condition. The previous ones were treatment as usual. It was the first with a serious mental illness sample that included people other than folks with psychotic disorders. And it was the first trial of CCT in the context of supported employment. And what we found was that there were CCT-associated improvements in working memory. This was a medium effect size in the severity of depressive symptoms, again, a medium effect size, and a medium to large effect size on quality of life. We didn't find any differences in the effects of diagnosis. So regardless of the initial diagnosis, it didn't really seem to matter what the final effects were. This is a newer study, just came out last year. And this is a population that you may or may not have much experience with, but hoarding disorder is incredibly common. A lot of us never ask about it, so we don't know. And since we don't see clients' homes typically, we don't see how they live. But it's a very common disorder, particularly among older people. And this was a study where we paired some cognitive training strategies with an exposure therapy intervention for older adults with hoarding disorder. And so there were six sessions of CCT content in the very beginning, focusing on organization, planning, cognitive flexibility, and problem solving, followed by 20 sessions of exposure therapy. And this was a six-month randomized controlled trial of this, what we call CREST versus case management. And we found very significant effects on inhibition and switching. So two aspects of executive functioning that tend to be impaired in this population. We already knew from previous work that CREST works really well for hoarding symptom reductions. It actually is the most effective treatment for hoarding that's been published so far. But we didn't know about these cognitive outcomes until relatively recently, and so that was very exciting to see. I just have these pictures because I think, you know, a picture is really worth a thousand words in this case. And this picture on the left is a participant's bedroom at the initial home visit. The bed is under there, but the person is unable to sleep in their own bed because of all the clutter. And I should point out, too, that this is a relatively low clutter volume. We see cases that are double this very routinely. But you can see after 18 sessions, there's quite a bit of improvement. There's still a lot of clutter in the room, but the bed is cleared, and the space is much more functional. Okay, now I'm going to switch to talk about some of the traumatic brain injury randomized control trials that we've done. There have been three publications so far on these interventions, and I know this is a little bit less germane to the webinar audience today, but just want to point out we found significant, pretty large effects on post-concussive symptoms, significant effects on prospective memory functioning, quality of life, and some smaller to medium effects on attention, learning, and executive functioning. But once again, the pattern here is that we're seeing both effects on cognition and more distal functional outcomes. We've also done some very preliminary neuroimaging work, looking at participants who've received CCT. This was in a TBI sample. And what we found was some data to suggest that CCT may improve some neural efficiency for processing event-based prospective memory information. This was presented a few years ago at Society for Neuroscience. So very preliminary, but encouraging findings that we may actually be doing something good for functioning in the brain. Okay, so with all that as background, I'll move quickly into to some of the treatment considerations. Every session of CCT is set up similarly. So we start with a review of homework, talk about generalization of the strategies to everyday life. We have participants take a really active role in going through the manual with us. I should say that the manuals are intended to be given to participants and the participant manual looks exactly the same to the participant as the facilitator manual. So everybody is literally on the same page at the same time. We introduce whatever the new skills are for that day. We talk about why we're learning these new skills, what it's gonna help with. And then we practice the skill. We really wanna provide a lot of feedback about how people are doing. We wanna make it challenging, but feasible for them to complete it. And we do provide any breaks that are necessary, but often there's so much shifting of topics within a session that it's not typically very hard for folks to sustain effort and attention during these sessions. And then we end by assigning homework. I told you earlier that the goals are really important and we elicit those goals in the first session. And then we come back to them frequently. So if you look at number three here, identify one or two important life goals that you wanna work toward during the course. And so that could be anything, but we really wanna respect people's individual goals and then link the content to those goals. So again, goals are number one. We have to get to know the goals really well. It's okay if they change, but every therapist really has to memorize each person's individual goals. Living, learning, working, socializing goals tend to be the best to work toward. Goals like I wanna be happy or I wanna quit smoking. We don't prefer goals like that because they're either too amorphous or they're not really rehabilitation goals. I want a job is a great rehabilitation goal. Sometimes we also work on financial and health-related goals. And I'm sure many of you have heard about SMART goals, goals that are specific, measurable. So you know when you've achieved it, they're actually achievable. They're relevant to the person's situation and there's a time limit on the goal attainment. So we use that format quite a bit. This is just a graphic of that. Sometimes the individual words are a little bit different like realistic or timely instead of relevant and time-bound, but you get the idea. Okay, and then we link each strategy that we teach to the goals that we're trying to focus on. And we have the person do a little bit of writing about that occasionally in the manual and we talk about it every single session. So here are some examples about how the cognitive strategies can be linked to goals. So for example, using the calendar efficiently is going to help you plan your job search activities or your work assignments or your school assignments. It's going to help you get to work or class on time. It'll remind you to call your best friend on his birthday, pay the rent on time and so on. The conversational attention skills are so important for any kind of social relationship that's important to the person. It's important for friendships, romantic relationships, really important at work. So colleagues and bosses need to know that they're being heard and understood. And it also is a building block for memory. Learning and memory strategies, almost everybody wants to improve in this domain. Learning and remembering new information at home, work, school is typically very important to people. And then the executive functioning strategies are going to help you with planning, prioritizing, solving problems as they come up, thinking flexibly and so on. And this is just going to be helpful with managing life and whatever is going on in life. So people often ask me, well, who benefits from this intervention? Are there moderators of treatment outcome? And in general, we find that there are very few predictors of response to CCT. And certainly demographic variables like race or ethnicity, gender, years of formal education, age, don't tend to predict response to these interventions at all. We have found that improvements tend to be correlated with worse baseline scores on measures of cognitive performance, symptom severity, functional capacity, and so on. So people who have worse functioning in the beginning of treatment may have more room to improve. That's sort of how I read this. And what it tells me is that we shouldn't assume that people are too ill to benefit, that even someone who's really struggling with cognitive functioning and everyday functioning may really be able to improve with something like this. So in terms of identifying people who might want to participate, I would say anybody with functional goals who has some cognitive impairments or declines and is interested in improving in some of these areas would be a good candidate. I really would consider all comers regardless of intellectual functioning or perceived cognitive impairment. I always assume that people with psychiatric illness have either some cognitive weaknesses or some decline. So even if they started out functioning really, really well at a superior level even, there has been probably some decline and now they're not functioning quite up to their potential or they're not using all the strategies that are available to them. And so our goal is really to build insight in the populations that we work with about cognitive health and why it's important and the links between cognitive functioning and being able to attain your goals. I always tell clinicians a few things before they get started. One is to be flexible and use the manual as a guide and not a script, right? So just going in and reading a manual is not cognitive training. And you can feel free to devote more time to areas of greater concern or relevance and gloss over areas that are, for example, about strategies that the person already uses well. Feel free to add your own examples of cognitive difficulties that you've had and how you overcame them or strategies that you use that might not be in the manual. I think it's great to do that. We often use some motivational interviewing techniques to elicit buy-in for using these strategies and having people show you what they can do is really helpful too. Since most people are using manuals, since most people are using smartphones these days, I think it's really great to be ready to teach how to use voice commands and the reminder apps and calendar apps on both iPhone and Android platforms. Really be willing to brainstorm with folks about implementing strategies and creating new ones. Feel free to refer people to the Cogsmart website if they'd like to use the app. It's not different, but it would be a nice backup or a way to reinforce some of the strategies, or you can just show them some of the videos from the Cogsmart channel on YouTube. I always do tell service users that, these are strategies that successful people use all the time. You may already use some of them or even a lot of them, and we're gonna work toward honing some of the strategies to just make it work better in the service of the person's goals and making some of the strategies more habitual. Sometimes I get people who are a little resistant to being taught something new. And what I point out is that, even elite athletes get coaching to help improve their performance. And even if you know how to do something already, chances are good that you can still improve your performance even as an elite athlete might think that they could. You also don't have to use all the strategies. I would like people to learn them all and have them all in their toolbox so that they have them available when they need them. But certainly, give things a try, see which ones work best for you. These are a few examples of how people have used strategies in their lives. And I won't read all of them, but I will say that people come up with ways to use these that I never anticipated. I don't know if you can see my mouse, but this one in the middle of the bottom row, this was a person with diabetes who did not have very good glucose control and said that they didn't check their glucose very often either. And he developed a system to check his glucose twice a day and write down his levels in his calendar. And then he would take his calendar into his physician and have a month's worth of glucose data to talk about with the doctor. And so that was, you know, we never told him to do that, but he did it on his own and it was a really great health outcome. So generally people like this intervention. They would recommend it to other people in similar situations. They say it makes daily life less stressful, has tools for managing daily routines, helping them get organized and so on. Okay, I have some content here on working with people with cognitive impairments in general. I'm just gonna go through it very, very quickly so that we have some time for questions and answers later on. So these are some suggestions for adapting treatments for anybody with a cognitive difficulty. Have them figure out what time of day is their best time and then try to schedule the sessions for when they're feeling most alert. You can always have someone stand up or walk around if they're fatigued, it'll get blood flowing to the brain and help them pay attention better. Using a lot of breaks whenever they need it, using repetitions, written materials, encouraging them to take notes, have people paraphrase back to you and check on their understanding. It'll help them learn and remember as well. And try to figure out what their cognitive strengths are so that you can use those to work around some of the impairments. Anything that's structured and uses written work, as long as it's simple written work, I think can be very helpful. And with any treatment, you really wanna refer to the person's rehabilitation goals overtly and very often. Also involve the family as much as you can because the cognitive impairment definitely affects them too. And they can really be great reinforcers of cognitive strategies in everyday settings. I did say that we do some motivational interviewing approaches to help encourage people to want to learn new strategies. So these are some of the questions that we might ask them to help them really own their goals and their plan. We are always asking about homework. If people don't do homework, they're not gonna improve. And so they really have to implement these strategies in their daily life to see any effects. So we ask about homework a lot. We encourage them to do it and reward it when it happens, give a lot of positive feedback. And every time they do homework, we're linking that to the person's goal. And finally, providing cues. Changing behavior is difficult for everybody. Even if people wanna make a change, it's hard to do it. And a lot of what we think of as treatment non-adherence may just in fact be forgetting. And so really helping people figure out how they're gonna remember to do things, to practice their skills, to take their medications and so on can be very helpful. And any kind of cues that people have and any kind of backup reminders for the first few weeks can very much help establish a new habit. So I'll conclude here and just say that these interventions that I've talked about today can be useful to people with many different causes of cognitive impairments. You heard about some of them today. We found improvements in cognitive performance, functional skills, post-concussive symptoms, psychiatric symptoms and quality of life. It's really important to tell you that the strategies that we teach don't train to the test. So we don't teach people how to do better on memory tests, for example, by giving them a bunch of memory tests and telling them how to do them. It's very much not what we do. So these neuropsychological improvements that we're seeing really do suggest that the strategies are generalizing to actual cognitive performance and hopefully functioning as well. And then finally, I think these brain-based problems and cognitive health problems may have some simpler solutions than what we think. Again, remember that as successful people, you use these strategies every day. And some skills we assume that everyone has, but they really don't. And so we really have to assess their skill use and then give them the skills that they need to be successful. So I will stop there and show you this picture of some of my lab. They are the best trainees and staff and collaborators on the planet. I've gotten lots of great funding from NARSAD, NIMH, DOD, VA that I'm very grateful for. And I'll also leave this website up for a second. So it's cogsmart.com. So thank you again so much for your attention.

Compensatory Cognitive Training

COGSMART

cognitive impairments

individualized rehabilitation goals

prospective memory

learning and memory

executive functioning

motivational interviewing techniques