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Cognitive Functioning in Individuals with Spinal Cord Injury (SCI)
Nancy D. Chiaravalloti, Ph.D.
Director of Neuroscience and Neuropsychology and Traumatic Brain Injury Research
Kessler Foundation
Professor of Physical Medicine and Rehabilitation Rutgers-New Jersey Medical School
Disclosures
Dr. Chiaravalloti has no disclosures to report.
Outline • Defining Cognition
– Cognitive domains
• SCI and Cognitive Functioning
• Potential causes/ sources of Cognitive
Deficits in SCI
Outline • Defining Cognition
– Cognitive domains
• SCI and Cognitive Functioning
• Potential causes / sources of Cognitive
Deficits in SCI
Cognition
• "the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.”
– conscious and unconscious
– Concrete and abstract
– Intuitive and conceptual
Cognition • Includes the concepts of
– Knowledge
– Attention
– Memory
– Judgment and evaluation
– Reasoning and "computation”
– Problem solving and decision making
– Comprehension and language production
Cognition
• Cognitive processes use existing knowledge and generate new knowledge
• Ongoing changing process.
• We rely on cognition EVERY day.
• Central to who we are and what we do with our lives.
Impact of Cognition on Daily Life
• Cognitive deficits lead to: – Depression, anxiety – Decreased participation – Increased unemployment – Decreased quality of life
So What? • Age of onset and career productivity
– Career development may slow or stop
• Physical and cognitive impairments lead to early retirement
• Biggest Obstacles to maintaining employment – information processing deficits – memory deficits
What does this mean?
• MUST identify cognitive deficits when they present and treat them effectively
• First step: Reliably identify the deficits experienced
Cognitive Domains
• Attention • Working Memory • Processing Speed • Visuospatial processing • Long Term Memory • Executive Functioning
Intelligence - not a cognitive domain, culmination of cognitive abilities
Breaking Down the Domains
• Attention – Simple – Sustained – Divided
• Working Memory – Maintenance – Manipulation
• Long Term Memory – Verbal and Non-verbal – Episodic, procedural – Retrospective, Prospective – Encoding, Consolidation, Retrieval
• Executive Functioning – Fluency – Mental flexibility – Disinhibition – Problem Solving – Abstract Reasoning
Learning & Memory
Attention Working Memory
Visuospatial Processing
Executive Functions
Processing Speed
Outline • Defining Cognition
– Cognitive domains
• SCI and Cognitive Functioning
• Potential causes / sources of Cognitive
Deficits in SCI
Sample Characteristics Tetraplegia N=18 C3-C8
High Para N=5 T1-T5
Low Para N=14 T7-T12
Older Controls N=14
Age Matched Controls N=18
Age
38±8
39±6
34±6
60±3
36±8
Duration of Injury
14.2±8.9
13.6±5.1
8.4±4.5
n/a
n/a
Education
14.1±2.8
13.8±1.5
13.3±2.2
16.3±2.5
15.9±2.0
Our Data (unpublished)
Our Data (unpublished)
Our Data (unpublished)
Our Data (unpublished)
Thinking about treatment
• EXACTLY what is the deficit? – Off to a good start – Learning, immediate recall, long term recall – Processing speed
• Are there other deficits?
Learning & Memory
Attention Working Memory
Visuospatial Processing
Executive Functions
Processing Speed
How does Processing Speed affect memory?
• When information is coming in fast – Cannot process all of it – Certainly cannot process it correctly
• All working memory tasks requiring one to process information within a circumscribed period of time – Tasks may not be timed, but there is a decay of
information (decay occurs over time) • What does this mean?
– Poor PS poor learning and memory
Impact of PS on treatment efficacy
CVLT Learning Trials
PS Intact PS Impaired
* No significant group difference pre-treatment
p=.006
Chart1
Trial 1Trial 1
Trial 2Trial 2
Trial 3Trial 3
Trial 4Trial 4
Trial 5Trial 5
Treatment
Control
6.41
5.84
10.14
8.68
11.72
10.03
12.79
10.52
12.93
10.94
Sheet1
TreatmentControl
Trial 16.415.84
Trial 210.148.68
Trial 311.7210.03
Trial 412.7910.52
Trial 512.9310.94
To resize chart data range, drag lower right corner of range.
Chart1
Trial 1Trial 1
Trial 2Trial 2
Trial 3Trial 3
Trial 4Trial 4
Trial 5Trial 5
Treatment
Control
5.64
5.8
7.36
8
8.86
8.6
9.93
9.3
9.64
9
Sheet1
TreatmentControl
Trial 15.645.8
Trial 27.368
Trial 38.868.6
Trial 49.939.3
Trial 59.649
To resize chart data range, drag lower right corner of range.
Memory Impairment
PS Impaired PS
Intact
If memory still impaired,
treat the memory deficit
Memory Treatment
Treat PS
Model Decision Tree
Memory Impairment
PS Impaired PS
Intact
If memory still impaired,
treat the memory deficit
Memory Treatment
Treat PS
Model Decision Tree
Need to know the source of the deficit
Outline • Defining Cognition
– Cognitive domains
• SCI and Cognitive Functioning
• Potential sources / causes of Cognitive
Deficits in SCI
Potential Causes of Cognitive Deficits in SCI Population
• Cerebrovascular Insufficiency • Concomitant TBI
– Dual Diagnosis – TBI may be mild
• Both
Methods for Determining Cause
• Cerebrovascular Testing during cognitive performance
• Imaging – Brain – DTI, fMRI
• Observing trajectory of change
MAP Data (unpublished)
MAP and Memory Data (unpublished)
MFV Data (unpublished)
MFV and Memory Data (unpublished)
fMRI Data (unpublished) subset (n=29)
Increased activation in frontal and parietal areas in LP compared to AM (red), Less activation (blue) in memory areas
More activation in frontal and motor regions than AM controls during PS task, performance required more cerebral resources in Tetra
** fMRI findings corroborate behavioral findings
What does this mean? Informing Treatment
• Data indicate a contribution of cerebrovascular insufficiency – Treat low BP and observe cognition
• Ongoing with Mitodrine • Observing immediate and long term effects
• Also observing fMRI abnormalities – Early CR
• Launching cognitive rehab trial in SCI – Treat for mild TBI early
Collaborators
Jill Wecht, PhD Glenn Wylie, D.Phil.
Trevor Dyson-Hudson, MD Steve Kirshblum, MD
William Baum, MD Kathy Chiou, PhD
Erica Weber, PhD Ekaterina Dobryakova, PhD
Nancy Moore, MA Caitlyn Katzelnick, M.A.
Christopher M. Cirnigliaro, M.S.
Funding Sources
NJ Commission on SCI Research
Craig Nielson Foundation
Kessler Foundation
Kessler Institute for Rehabilitation
Cognitive Functioning in Individuals �with Spinal Cord Injury (SCI)��Slide Number 2Slide Number 3Slide Number 4CognitionCognitionCognitionImpact of Cognition on Daily LifeSo What? What does this mean?Cognitive DomainsBreaking Down the DomainsSlide Number 13Slide Number 14Slide Number 15Sample CharacteristicsOur Data (unpublished)Our Data (unpublished)Slide Number 19Slide Number 20Thinking about treatmentSlide Number 22How does Processing Speed affect memory?Impact of PS on treatment efficacySlide Number 25Slide Number 26Slide Number 27Potential Causes of Cognitive Deficits in SCI PopulationMethods for Determining CauseSlide Number 30MAP and Memory Data (unpublished)MFV Data (unpublished)MFV and Memory Data (unpublished)fMRI Data (unpublished)�subset (n=29)What does this mean?�Informing TreatmentCollaboratorsFunding Sources