Cognitive Communication Disorders

As I mentioned in a previous post, I was looking forward to attending a course on cognitive communication disorders. It was very informative and helpful. however, the instructor had to accommodate for therapists working in different settings, so there were instances when the application of material wasn't very pertinent to my setting, but useful and interesting nonetheless. I presented the information to my co-workers (see below for the power point). I went into the course with a particular patient on my mind.

Here is some background info on Mrs. R: She is in her mid 70's and has had a bilateral infarct stroke. She has severe right side neglect, anosognosia, and right visual field cut. She has delayed/slow processing speed. When we ask her where her right hand is she holds up her left hand.

Some areas of difficulty with Mrs. R:

1) SAFETY/impulsivity:
When we are practicing proper body mechanics and safety with transferring from chair to chair with the walker, she can go forward and turn (with assist) but cannot manage the walking backwards until she feels the chair behind her. In fact, when I asked her once which way was backward, she pointed forward. As she is unable to manage the backing up into the chair to sit safely, she will often attempt to sit too soon when there is no chair behind her because she is SO unaware of her spatial surroundings. Thus, she requires mod-max verbal cues so as to avoid sitting on the floor. we have tried several strategies- one being strapping her into the light gait and practicing the transfers in which we have allowed her to sit (securely) mid transfer with the hope that she will realize there is no chair and self-correct this error. However, this is still an issue for her and I am not quite sure how to solve this problem.

2) Memory Deficiencies:
I have noticed with her she still has her Implicit/Non-declarative memory when it comes to getting dressed. For example, when I ask her to put her right arm in, she puts her left arm in and is unable to without mod-max verbal/visual/tactile cues. Yet, if I hold out her tshirt or pants, she will put her arms and feet in, but wouldn't be able to describe 'how' to do it (Explicit/declarative memory).

3) Motivation:
When we approach her for therapy she is often still in bed and not dressed. It takes almost half the treatments session to convince her to get up, and often seems forced. "I don't want to get up", "I am sick", "They told me not to get up." Due to her decreased memory, she often forgets what she can do and will reply "I can't!" to almost any task, even if she just did it 2 minutes ago.

Any advice or input would be greatly appreciated on this complicated patient.