Category: Advancing Modules

Educate and explain- while concepts such as memory and attention mean something to most people ‘executive functioning’ is often an unfamiliar idea. This makes education for the individual and those around them particularly important:

• Minimise distractions
• Don’t rush. Encourage the individual to STOP and THINK about what they are doing
• Work on one task at a time and make sure the goal is clear
• Encourage the individual to check they are still ‘on task’ that is they are still working towards the goal they set and haven’t become side tracked
• On more complex tasks encourage a step by step approach, perhaps suggesting planning and writing out the steps in the advance
• Break larger tasks into smaller manageable chunks
• Support the individual to create a structure and routine in day to day life
• Smart devices (phones, watches etc) can be useful to help plan and organise but unless familiar the individual may need support to set up and use this technology. For some people wall planners and diaries may be just as effective

It is sometimes said ‘we learn from our mistakes’ this is often less true for people with executive difficulties. Rather than watching an individual fail at a task try to provide support to allow them to succeed but without taking over and doing it for them- yes, it can be difficult to get the balance right.

This scenario has explored executive functioning problems post stroke, the impact on daily life, how they might be assessed and some rehabilitation strategies.
You should now be able to:

• Give an explanation of executive functioning
• More readily identify executive difficulties in patients you come into contact with
• Describe the sorts of difficulties these problems create in day to day life
• Explain some useful rehabilitation strategies

Ray responded well to psychoeducation about how his thinking skills have been affected

He understood that reducing distractions helped him to focus – when making time to chat with his daughter, it was better to schedule a regular time and make sure the TV and radio are off to reduce distractions.

Although it felt uncomfortable, Ray was, in time, able acknowledge the observations his daughter shared about the pupils at school. This allowed him to be more accepting of his need to step out of class and to use his Teaching Assistant to prompt him to help him identify cues from pupils.

It was also helpful for Andrew and Olivia to have the opportunity to revisit the findings of the cognitive assessment and put these together with their experiences of living with Ray since his discharge from hospital. They both now have a better understanding of how to support Ray and have been able to reflect on what is important to them as a family.

Caring for a person with executive deficits can be a full-time job and living with personality and behaviour changes in a relative or friend can be very distressing.

Problems that carers may experience include:

• Stress, anxiety or depression
• Increased responsibility
• Strained relationships
• Reduced communication with partner
• Restricted leisure/social life
• Reduced sexual and emotional intimacy with a partner
• Feeling tired and frustrated

It is important for family members, carers and friends to access support for their practical and emotional needs. Input from a rehabilitation team can help, and some people find peer support groups for carers useful. Headway’s groups and branches offer valuable support for both survivors and family members. It is also important to see a GP, who will be able to refer to local counselling and therapy services where they are available.

For further information see the Headway booklet Caring for someone with a brain injury, which can be obtained free-of-charge from the Headway helpline, or visit the ‘Caring‘ section for more information. The helpline can also provide support and refer to local groups and branches.

One of the challenges of executive dysfunction is the impact on self-awareness. How can we encourage someone to use strategies when they are unaware that there is something they need to compensate for? This can be evident in people who have hemispatial neglect after right posterior parietal lobe damage, who are unaware that they are not paying attention to the left side.

• Insight and awareness can be conceptualised as three interdependent domains (Pyramid Model of Self-awareness, Crosson et al., 1989):
• Intellectual awareness:The person knows they have a problem and can describe their difficulties
• Emergent awareness:The person knows they have a problem and are able to recognise the problem when it is actually happening
• Anticipatory awareness:The person anticipates that a problem will occur in advance of action, and makes deliberate compensatory plans.

Helpful information about working with poor insight or self-awareness can be found on the Headway website: lack-of-insight-after-brain-injury-factsheet.pdf (headway.org.uk)

 

The area of the brain most closely associated with executive functions is the frontal lobes and particularly areas of the prefrontal cortex (PFC). However, it would be a mistake to think that an injury to the frontal lobes MUST result in executive problems or that an injury elsewhere in the brain CANNOT give rise to executive difficulties.

It is now well understood that the PFC is not the only brain area involved in executive functions. The frontal lobes are richly connected to a variety of other brain regions, such as the basal ganglia, the thalamus, and the cerebellum, as well as cortical areas outside of the frontal lobes, therefore most executive processes depend on the integrity of complex networks rather than a single frontal lobe region.

 

Sometimes an analogy can be a useful way of explaining executive functioning. A popular one is an orchestra analogy where the different sections of the orchestra represent cognitive functions such as memory, concentration, visuo-spatial skills, etc and the conductor and additional backstage staff represent executive functioning.

When the orchestra is playing a familiar piece the conductor may have little to do – analogous to us performing routine everyday tasks. When learning a new piece, however, the conductor becomes very important (analogous to performing novel, unfamiliar tasks). They must provide feedback inhibiting certain sections of the orchestra while encouraging others and at the same time keep in mind the bigger picture and not get too caught up in the details.

Secondly it is part of the conductors role to problem solve and improvise – if they go to do a concert in Vienna and some of their instruments end up in Venezuela what do they do? An important role for the conductor and executive functioning is problem solving (see When are Executive Functions Needed from Core Competencies 16).

Also the conductor is usually central to planning ahead- what sort of music are they going to play, where and to whom?

 

 

The weaknesses highlighted in Ray’s assessment suggest he has difficulty with executive functioning.

Executive functions are a group of higher-order skills that allow us to achieve our goals.

They include, but are not limited to:

• self-awareness
• abstract thinking
• planning and executing
• mental flexibility
• working memory and complex attention
• reasoning and problem-solving
• judgment
• behavioural control
• regulation of emotions

It is clear that impairments in executive functioning can negatively impact on relationships, ability to manage responsibilities at work and in family life, understanding social norms which negatively impact quality of life and wellbeing.

This page has been created thanks to the Headway website resources.

Outcome of meeting:

• As part of the meeting, Ray and the neuro-rehab team member revisit and redefine Ray’s goals. Ray identifies the things that feel most important to him are:
• Looking after his daughter, Olivia
• Managing his return to work
• Getting back to driving

Ray is encouraged to try and focus on one goal at a time, and whilst being on the waiting list for driving assessment, it was felt that this would provide an opportunity to concentrate on phased return to work.

One specific outcome from the meeting is for the neuropsychologist to revisit the feedback from the cognitive assessment with Ray, Andrew and Olivia. This information would have been provided after the assessment, but it is important to make this information available repeatedly if required, to help Ray and his family understand the reasons behind his difficulties, and to help promote Ray’s insight into why retuning to work has not gone as smoothly as he’d hoped.