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Cognition and Perceptual Disorders

Original Editor - Nupur Smit Shah Top Contributors - Nupur Smit Shah, Romy Hageman, Kim Jackson, Mohamed A Hassanin, Rachael Lowe and Ewa Jaraczewska

Introduction

Cognition is the process of acquiring knowledge[1]. It includes reasoning, memory, awareness, judgment, and intuition. Some authors include executive function under cognition too, such as problem-solving, planning capacity, recognition of errors, and abstract thinking[2][3]. Executive functions are often classified as higher-level cognitive functions or metacognitive functions[4].

Perception is the integration of sensations into information that is meaningful in terms of psychology[5]. It is the ability to choose the stimuli that need attention and action, to integrate them, and to interpret them.

Perception and sensation are not the same and should not be confused with each other. The sensation is defined as the awareness of stimuli through eyes, ears, nose, etc., internal receptions, or the peripheral cutaneous system[6]. Perception, however, is a more complex process involving the interpretation of these sensations.[7]

Perception disorders

They are classified into body scheme/image disorders, visual discrimination skills disorders, agnosia and apraxia.

Subcategories of Perception Disorders
Body Scheme/Image disorders Visual discrimination skills Agnosia Apraxia
Unilateral Neglect Figure-ground discrimination Visual agnosia Ideomotor apraxia
Anosognosia Form discrimination   Visual Object agnosia Ideational apraxia
Asomatognosia Spatial relations Simultagnosia Constructional apraxia
Right - Left discrimination Position in space Prosopagnosia Oral apraxia
Finger agnosia Depth and distance perception Tactile agnosia Dressing apraxia
Topographical disorientation Auditory agnosia
Vertical disorientation Color agnosia

Body image impairments

Unilateral neglect is reported nearly in 30% of the stroke patients. It is commonly associated with right parietal lesions[8].

[9]A short video about hemineglect. Anosognosia is the denial of illness that may be seen in the patients of head injury[10]. The patients present either lack of concern about the deficit or verbal denial of their illness[11]. They don't realize the benefits of rehabilitation and are not willing to undergo any treatment. Visual field defect, apathy, and unable to identify pictures are common in anosognosia[12]. It is commonly seen in neurological conditions such as Hemiplegia and Alzheimer's disease and has a significant impact on patients, but also on their caregivers[13][14].The occurrence of anosognosia among individuals with Alzheimer's disease is estimated to range from 20% to 40%[15].

[16] An explanation of Anosognosia.

Asomatognosia is a lack of awareness of the body structure[17]. The patient even doesn't understand the relationship of body parts with oneself or to others. They may not be able to imitate the movements of the therapist.[18] They deny the existence of their body part and is also known as autotopagnosia.[19]

Right and left discrimination: The patient cannot discriminate between the commands of right and left-handed tasks. This can significantly impact daily activities, as they may have difficulty following instructions that involve directional commands.

Finger agnosia: In this condition the client doesn't indicate, name, select/ differentiate the fingers of their hand[20]. It happens in patients with cerebral lesions.[21]

[22]In this video you will learn how to screen for finger agnosia.

Spatial Relation impairments

Figure-Ground Discrimination

Figure-ground discrimination: Patients struggle to distinguish elements from the background visually[23]. This impairment can affect reading, writing, and other activities that require visual discrimination.[24]

Form discrimination: Inability to identify objects of similar shapes. For example, if you ask to identify two similar objects such as an orange and a ball the patient will not be able to identify/differentiate them.

Spatial Relations: The patient is not able to locate things properly and cannot understand their relationship with one another in space and with oneself. For example, he cannot set a dining table properly and doesn't place spoons, bowls, plates appropriately.

An example of a patient, who was asked to set the dining table. This was the result.

Position in space: The patient is unable to understand spatial concepts of up-down, front-back, out-in. If he is told to kick a ball kept in front of him via his right leg, he will not know what to do.

Depth and distance perception: The patient doesn't understand where to put the leg during stair climbing. He cannot judge how much water to pour into the glass and keeps pouring even after the glass gets filled.

Topographical disorientation: The patient has difficulty commuting from one location to the other and doesn't understand the relationship of one location to the other[25]. For example, the patient cannot find his bedroom in the house[26]. This condition is linked to lesions in the right retrosplenial cortex.

These are drawings of the same household drawn by a person with Topographical disorientation (A), their unaffected spouse (B), and their unaffected child (C). Note the absence of precise spatial details in the drawing (A), which only reflects the general order of the rooms. Individuals with topographical disorientation frequently rely on a verbal strategy when sketching maps, describing the sequence of landmarks encountered along a familiar route, and using that sequential information to create an approximate map.

Vertical disorientation: Anything vertical appears tilted to the patient. There is a lesion in the nondominant parietal lobe. If he is given the task of holding a cane, he will not hold it in a straight position, it will be tilted.[18]

Agnosia

In agnosia, there is the failure of recognition. Commonly seen in neurodegenerative diseases.[27]

Tactile agnosia: The tactile perceptions are intact but the patient cannot recognise the objects via palpation[28]. There is a parietal lobe lesion (unilateral/bilateral)[29]. The somatosensory functions, intellectual ability, linguistic capacity, and attention are appropriate.

The following video shows different methods to identify tactile agnosia.

[30]

Auditory agnosia: The term auditory agnosia refers to disorders in the processing of auditory input due to central nervous system damage, which are not attributable to peripheral hearing loss[31]. In severe cases, these disorders lead to cortical deafness, where the patient does not respond to auditory stimuli or does so inconsistently and often inappropriately[31]. Such patients have intact language and cognitive function.[32]

The following video shows a case of auditory agnosia:

[33]

Visual agnosia: Visual agnosia refers to an impairment in recognizing visually presented objects/ faces or words, despite otherwise normal visual field, acuity, color vision, brightness discrimination, language, and memory. Visual object agnosia is one of the common forms of visual agnosia in which the patient cannot name the objects presented in front of him despite the ability to see the object clearly. For example, the patient may call the bicycle , a pie. The condition may lead to -but not related to- misnaming, but it is related to no recognition objects accurately by vision. It can be assessed by copying /drawing of figures.[34]

Prosopagnosia: is the inability to recognise familiar faces. Patients can often identify other aspects like gender, hair, emotions. Prosopagnosia results from damage to fusiform face area (located in the inferior temporal cortex in fusiform gyrus).

Simultagnosia: is the inability to recognise and sort out objects when they appear together, but they can recognise them when they appear alone. Patients are unable to perceive the overall meaning of a picture or multiple things together, although they can describe isolated elements.

Color agnosia: is the inability to identify and distinguish colors, despite intact basic color vision and brightness discrimination mechanisms. Usually, it occurs following lesion in the left occipitotemporal region of the brain.

Apraxia

Apraxia is a disorder in which the patient cannot perform skilled actions.[27]It is most associated with left hemisphere strokes[35].

The client is unable to execute the action of combing the hair

Ideomotor apraxia: Loss of ability to imitate hand gestures[36]. The client understands the requirements but cannot execute appropriate movements. There occur errors in gesture production.

The following video shows an example of ideomotor apraxia:

[37]

Ideational apraxia: Patients have difficulty understanding the concept of a task, leading to problems with sequencing and using objects correctly[38].

Cognitive deficits

Attention Deficit Disorders

Attention Deficit Disorders are commonly seen after stroke.[39] They are common among the ones who have right brain damage. [40]The attention system has a connection with various cognitive functions like cognition, activity performance, language, memory, and spatial organization. Hence, attention deficits can highly affect the functional abilities of the person at home or work.[39]. After the cerebrovascular accident, focused attention(selective) deficit gets cured in the majority of the patients but higher-order attentional problems may persist later. This includes speed of processing, divided attention, working memory, and vigilance.[41]. Neuropsychological assessment is used to classify patients with cognitive issues like language, attention, and memory.[42]

Selective attention (focused attention): The capacity to do the task in presence of visual, auditory, or environmental stimuli.[18]It is needed when the patient has to ignore certain stimuli. For example, The patient stops the activity of dressing while talking to the therapist/bystander. Here, the focused attention is affected.

Sustained attention: The capacity to address relevant information during the activity. The patient can respond effectively during the task.[18]

Divided attention: The patient can respond to two or more tasks at a time.

Alternating attention: The capacity to do multiple tasks appropriately.[18]

Memory

Memory decline is common after stroke and affects the functional ability of the person[43]. It occurs in approximately half the patients[44]. There are various memory deficits like long-term memory loss, short-term memory loss, and immediate recall. The overall deterioration of memory is referred to as dementia.

General PT rehabilitation of perceptual disorders

patients with perceptual disorders are usually treated by occupational therapists.

Mainly there are two approaches used - The remedial approach and the Compensatory approach.

Remedial approach

As per this approach, the adult brain can repair itself after the brain injury using sensorimotor, cognitive, and perceptual exercises. During rehabilitation, the focus of the therapist is on the client's deficits. The functional abilities of the patient are improved by retraining particular perceptual components. Environmental stimuli are used during the rehabilitation.

Compensatory approach

Intact skills are utilized and compensated for the skills which are impaired. Specific training of Activities Of Daily Living is provided as it is difficult for the injured brain to learn generalized tasks.[7]

Rehabilitation Strategies for some perceptual, cognitive and memory disorders

Unilateral Neglect: The major goal here is to improve the attention of the neglected side along with proprioception and kinesthesia. The recent techniques of rehabilitation are neck muscle vibration, virtual reality, limb activation training, mental imagery training, Transcutaneous Electrical Stimulation (TENS), Eye patching, prism adaptation, vestibular rehabilitation, and mirror therapy [45][46][47][48][49][50][51][52].Neck Muscle vibration: Somatosensory stimulation in the form of neck muscle vibration can be applied on the neck of the patient with unilateral neglect for improved detection of stimuli in the same side (affected side) visual field [53].

Anosognosia Rehabilitation: Vestibular stimulation has proven effective in anosognosia by enhancing spatial orientation and self-awareness. This involves using vestibular inputs to stimulate the balance organs, helping patients develop a better understanding of their deficits[46].

Right and left discrimination: Therapists use activities that involve repetitive practice of right-left discrimination, such as identifying objects placed on the right or left side and performing tasks with specific hands.

Finger agnosia: Therapists use tactile and visual feedback exercises, where patients engage in activities that require them to touch and identify their fingers, such as finger counting games and matching tasks.

Figure-Ground discrimination: Therapists use activities that involve distinguishing objects from complex backgrounds, such as finding specific items in a cluttered room or sorting objects based on visual characteristics.

Form Discrimination: Activities include matching and sorting objects of different shapes, using tactile exploration to enhance recognition, and practicing with real-life objects to improve functional skills.

Spatial Relations: Rehabilitation focuses on spatial orientation exercises, such as arranging objects in specific patterns, navigating through obstacle courses, and using spatial language during activities.

Position in Space: Therapists use directional training exercises, such as obstacle courses that require following directional commands, and interactive games that involve placing objects in specific positions.

Depth and distance perception: Exercises include practicing depth perception tasks, such as reaching for objects at different distances, using tools to measure depth, and visual feedback activities to enhance spatial judgment.

Topographical disorientation: Therapists use wayfinding exercises, such as guided tours through familiar environments, map-reading tasks, and practicing navigation in controlled settings to improve spatial orientation.

Vertical disorientation: Therapists use alignment tasks, where patients practice aligning objects vertically, and visual feedback techniques to correct perceptions of tilt. Virtual reality training programs are applied on the patients with spatial relation impairments and studies have shown that it enhances the spatial cognition and it is as effective as real world training.[54]

Tactile agnosia: Faber's approach of manipulation is used in tactile agnosia[55]. This involves systematic handling of objects to enhance recognition through touch, combined with visual feedback to reinforce learning.

Auditory Agnosia Rehabilitation: Lip reading and communication technique is applied in patients with auditory agnosia[56].

Visual object agnosia: Compensatory strategies and restorative training is applied in visual object agnosia[57]. Compensatory strategies include teaching patients to use context clues and descriptive language to identify objects. Restorative training involves repetitive practice with object naming and recognition tasks.

Ideomotor apraxia: Therapists use imitation exercises, where patients replicate hand gestures and movements, combined with motor imagery techniques to improve execution of gestures. Virtual reality therapy can also be used[58].

Ideational apraxia: Rehabilitation involves breaking tasks into components and using visual and auditory feedback. The tasks are broken down into various components. Each component is taught at once and practiced. Visual and auditory feedback is proved to be effective. Once the individual tests are learned properly, the physiotherapist adds the complex movement pattern steadily.[46]

Selective attention deficits: Therapists use distraction-free environments for initial practice, gradually introducing distractions to improve focused attention. Techniques include attention control exercises and mindfulness training[59].

Divided attention deficits: Patients practice dual-task exercises, such as walking while counting, to improve divided attention. Gradual increases in task complexity help enhance multitasking abilities.

Alternating attention Rehabilitation: simple tasks are started initially and practiced several times. Slowly the complexity is added by the therapist.

Memory rehabilitation by the use of internal and external aids can be done. Internal aids consist of mental imagery, pneumonic, and rehearsal. External aids consist of notice boards, diaries, lists to help them recall and restore the memory.[60]Vestibular stimulation is proved to be effective to improve visual memory recall. Galvanic vestibular stimulation is a form of vestibular stimulation of low level delivers the current transcutaneously to the vestibular nerves. Here the electrodes are placed over the mastoid bones. The current is bipolar (opposite current applied over each electrode). Galvanic vestibular stimulation (GVS) is of low cost, easy to apply and the patient need not get involved actively.[61]

References

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