Executive Function

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Executive Function

• Cognitive Impairment After Stroke

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What is Executive Function?

• Executive functions are located primarily in the
  pre-frontal regions of the frontal lobe. It is a
  collective term often referred to as higher level
  cognitive process those that allow us to manage
  our day to day lives whether that be paid work,
  household tasks or study.

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Imagine if you will!

• What steps would you need to go through to do the
  following tasks, in other words how does your
  brain compute the following

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What do executive function difficulties look
like?

• There can be some difficulty identifying what is
  executive function as they mirror or mask other
  problems such as depression, anxiety, confidence
  etc.
• The anterior cingulate cortex (ACC) is involved
  in emotional drives and damage to that region of
  the pre-frontal lobe can result in patients being
  demotivated, apathetic and resistant to basic
  drives such as food and drink.
• The orbitofrontal cortex (OFC) is involved in
  regulating behaviour and damage to that region
  can cause difficulty with anger, aggression,
  inappropriate and antisocial behaviour.

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Handling of novel situations (Norman and Shallice)

• Damage to the executive system or pre-frontal
  cortex could result in inefficient functions in
  the following functions
• Those that involve planning or decision making
• Those that involve error correction or
  troubleshooting
• Situations where responses are not well-rehearsed
  or contain novel sequences of actions
• Dangerous or technically difficult situations
• Situations that require the overcoming of a
  strong habitual response or resisting temptation.
  

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Presenting difficulties

• Lack of awareness and/or insight
• Lack of understanding of risks
• Unable to learn new information
• Unable to transfer newly learned skills
• Unable to adapt and regulate behaviour according
  to feedback from others
• Can appear self-centred and rude
• Likely to be isolated from others as a result of
  poor social communication skills
• Likely to self-neglect due to motivation,
  initiation, goal directed behaviour difficulties

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Activity Case Study

• Mr M is a 68 year old lady recently discharged
  from hospital. She has made a good physical
  recovery but just not progressing as well as
  expected. She appears uninterested in any social
  activity and watches TV for hours at a time. Her
  husband is having to do all housework despite her
  ability to do some of these tasks.
• How should you assess and understand her
  difficulties?

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How can I assess?

• Understand the following and whether this could
  impact on your client
• Fatigue cognitive and physical fatigue (Is
  medication impacting on fatigue)
• Depression very common after stroke and effects
  ones ability to engage in goal directed behaviour
• Anxiety some of what we ask our clients to do
  after stroke is new, e.g. they are doing them
  with a disability whether this be physical,
  sensory or cognitive

• Assess the following
• Your clients ability to set goals in very small
  steps
• Your clients ability to engage in activity with
  support e.g. do they need hand over hand or can
  they take some responsibility for task completion
  
• Formal neuropsychological testing might help
  this will allow the clinician to report on formal
  skills in problem solving, reasoning, inhibition,
  working memory etc.

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How can I assist?

• REMEMBER
• Know your client and their needs
• Remember their strengths as well as weaknesses

• The environment
• Consistency and routine work well for those that
  struggle with unpredictability and novel
  situations
• Prepare your client for what is coming next
• Support your client to reason by breaking down
  problems in very small steps
• Provide tools that might help such as reminders,
  auditory sequences for stepped approach
• Developing a consistent approach to help your
  client in day to day tasks with give them
  familiarity and is less likely to induce anxiety

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How Can You Help?

• You
• Discuss the difficulties you are finding with
  colleagues so that all are aware of the issues
• Ensure you rule out other difficulties such as
  mood and fatigue
• Understand your clients strengths and relative
  difficulties and how they impact on their
  independence a formulation
• Help your client and their relatives to
  understand the issues and why for instance,
  this isnt laziness or anger/irritation but a
  change in the way the brain allows one to behave
• Ensure the treatment approach is understood and
  followed by all
• Ensure the programme of intervention is reviewed
  and changed in accordance with feedback

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Summary

• Executive function difficulties contain a whole
  array of functions that allow us to manage our
  lives independently
• One can have a high level of intellect with
  impaired executive function that will prevent
  appropriate use of that intellect
• Management of challenging behaviour as a result
  of executive function difficulties are essential
  to allow integration into the community
• Assess for any other underlying difficulty and
  treat as this could exacerbate general decline in
  skill
• Help to improve skills such as problem solving by
  training