6 - Promoting a Sense of Control Over Memory Aging

Editors: Backman, Lars; Hill, Robert D.; Neely, Anna Stigsdotter

Title: Cognitive Rehabilitation in Old Age, 1st Edition

Copyright 2000 Oxford University Press

> Table of Contents > Part III - The Influence of Health and Health Behaviors on the Rehabilitation of Cognitive Processes in Late Life > 9 - Executive Function and Cognitive Rehabilitation

9

Executive Function and Cognitive Rehabilitation

Jeffrey W. Elias

Julia E. Treland

Researchers and practitioners have become increasingly aware that executive cognitive functions (ECFs) appear to choreograph abilities such as insight, planning, problem solving, and motivation into the goal-directed behavior required for daily living. Deficits in ECFs are common and result in specific behavioral and affective impairments that impact an individual's cognition and ability to participate in rehabilitation. Irritability, mood swings, disorganization, apathy, indifference, and inattention are some of the manifestations of ECF deficits. Impaired ECFs due to head injury, stroke, disease process, or normal aging challenges both physical and cognitive rehabilitation. For effective rehabilitation treatment and discharge planning, it is essential for the practitioner to anticipate and recognize impaired ECFs in the client. In this chapter, we will discuss definitions of ECF, its anatomical correlates, the assessment of ECF, behavior associated with ECF impairment, and issues related to cognitive rehabilitation.

Defining Executive Cognitive Function

Definitions of ECF are influenced by theory, clinical observation, and brain circuitry. As a consequence, the concept of ECF can be elusive and difficult to confine. Lezak (1995) described ECF as capacities that enable a person to engage successfully in independent, purposive, self-serving behaviors (p. 42). Royall (1994), citing Lezak (1983), Stuss and Benson (1986), and Shallice (1982) described ECF as cognitive processes that govern the orchestration of relatively simple ideas, movements, and actions into complex goal-directed behaviors; they help orchestrate and maintain

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goal-directed behavior in the face of both internal, and external distractions (p. 75). A succinct definition was offered by Denkla (1996), who suggested that ECF is the manipulation of representational systems and is what goes on during the delay between stimulus and response; for example, ECF is the working component of working memory.

To explain the ECF concept to others, we offer the acronym SOS-MOMMI, which stands for selection, organization, sequencing, motivation, monitoring, memory (working or event updating), and inhibition. As information-processing systems, individuals are constantly bombarded with stimuli and potential behavioral options. Once a behavioral option is chosen (selected), behavioral organization is an important element in the successful attainment of the final goal. Behavioral patterns must be initiated and maintained (motivation). An evaluative component (self-monitoring) is needed to judge the viability of the organization and behavioral sequence relative to the goal. This evaluative component is necessary for cognitive flexibility when an ineffective strategy needs to be altered. To effectively self-monitor, one must be able to keep track of what has been accomplished (memory), while updating and carrying out the next part of the sequence. This involves what has been called working memory, or holding information on-line while adding to it and updating or changing it (Baddeley, 1996). Once a task has been initiated, there are many stimuli competing for attention, including both external and internal distractions. Attention needs to be diverted from these competing distractions, and at times, the competing distractions may have to be actively inhibited from breaking into the primary behavior sequence.

The acronym SOS-MOMMI not only represents the elements involved in carrying out goal-directed behavior but is descriptive metaphorically: To be functionally independent, individuals must be able to direct themselves. From a developmental perspective, executive functions should be maturing about the time parental influence on planning and everyday functioning decreases. As ECF develops, the ability to efficiently execute on-line functions in the present also leads to the ability to integrate old and new information. With further cognitive development, this integration process can be used to plan for the future.

The ability to plan for the future is a major benefit of adult-level ECF. One should be cautious, however, in evaluating ECF based on the effectiveness of the plan. That is, with regard to planning, ECF should be defined as the process of planning, not the outcome. In lieu of the ability to develop a new plan, it is possible to achieve a successful outcome by executing a routine based on past knowledge. In measuring ECF, it can be difficult to tease apart planning ability from past knowledge because higher cognitive functioning and effective decisions are not simply the result of ECF; that is, the whole is greater than the sum of the parts.

The issue of definition is important when considering the assessment of ECF. As described above, ECF would seem necessary for performing well on IQ tests. The concept of ECF has been considered analogous to the concept of IQ. Attempts to discriminate between the concepts of IQ and ECF have associated ECF more closely with the doing or fluid aspects of IQ (Denkla, 1996; Pennington, 1997), and less closely with the knowing or crystallized aspects of IQ, such as those related to verbal IQ (Pennington, 1997). This does not mean that verbal IQ can be ignored when assessing ECF. Denkla (1996) pointed out that some tests of ECF may be less sensitive

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in individuals with a high IQ (much of it determined as verbal IQ). In many cases, therefore, changes in ECF need to be evaluated against some estimate of IQ.

The variable sensitivity of instruments designed to assess ECF raises a difficult measurement and definition issue. Correlations between measures of ECF often are lower than would be expected if ECF is to be considered a construct (cf. Baddeley, 1996). This lack of correlation between ECF measures is more likely to be observed in normal young adults. In an older or impaired population, however, the same set of ECF measures may correlate well, perhaps due to the interaction of ECF and various cognitive domains (e.g., memory and attention; cf. Royall, 1994). For example, greater attentional demands may require greater executive control, resulting in increased correlation between measurements of the domains of ECF and attention. Further, the impact of ECF on overall functioning frequently is modulated by interactions between the individual, the environment, and the familiarity or novelty of task requirements. For example, a highly structured setting can reduce the degree of ECF required for task performance, while the same task, carried out in an unstructured environment, places more importance on ECF.

Anatomy of Executive Function

ECF also has functional anatomy correlates. Executive function developmental processes and ECF deficits have been primarily associated with the functions of the frontal lobes or with lesions involving the frontal systems. As an anatomical area, the frontal lobes per se are confined by the central sulcus as the posterior boundary, the lateral fissure as the inferior boundary, and the cingulate sulcus as a medial boundary (Kolb & Whishaw, 1996). Within this anatomical area, the brain is composed of specialized subregions, each contributing to a specific set of behaviors. Five frontal circuits have been identified: a motor circuit originating in the supplementary motor area, an oculomotor circuit starting in the frontal eye fields, and three prefrontal cortex circuits originating in the dorsolateral prefrontal cortex, lateral orbital cortex, and anterior cingulate cortex (Cummings, 1993; Malloy & Richardson, 1994).

The three regions composing the prefrontal cortex are most often referred to with respect to the ECF concept and behavioral syndromes (Krasnegor, Lyon, & Goldman-Rakic (1997). The prefrontal-dorsolateral circuit is involved in the planning, organizational, monitoring, sensory integration, and cognitive flexibility components of ECF. The prefrontal-lateral orbital circuit is involved in inhibition and affective control, and the prefrontal-anterior cingulate circuit in initiation, motivation, and adherence to task (Cummings, 1993; Malloy & Richardson, 1994).1

It is important to note that these regions have numerous projections to and from other areas of the cortex, to include the posterior parietal and temporal sulcus areas (Kolb & Whishaw, 1996), as well as the subcortex (Cummings, 1993; Denkla & Reiss, 1997; Malloy & Richardson, 1994). Therefore, a lesion anywhere within a frontal circuit could result in an ECF failure.

All three prefrontal cortical circuits have common structures with the subcortex (striatum, globus pallidus, substantia nigra, and thalamus) (Cummings, 1993; Denkla & Reiss, 1997). The circuits are described as contiguous but are anatomically separated

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throughout the subcortical structures (Cummings, 1993). This emphasis on the involvement of the basal ganglia in frontal lobe circuitry is very important for understanding the behavioral changes associated with disorders of subcortical origin (e.g., Parkinson's disease, Huntington's disease, and attention deficit/hyperactivity disorders; Denkla & Reiss, 1997), as well as understanding the distinction between dementias that present with cortical features (memory, language, constructions) and dementias that present with prefrontal-subcortical ECF features (Elias, 1995; Lovell & Smith, 1997; Royall & Mahurin, 1996; Royall & Polk, 1998; Usman, 1997).

Cummings (1993) noted that as the projections pass from the cortical structures of the prefrontal cortex to the subcortical structures of the basal ganglia (putamen, globus pallidus, striatum), they are progressively focused into smaller bundles of neurons. Therefore, a focal lesion in the basal ganglion area could have more diffuse effects on frontal functions than a lesion in a frontal area.

While changes in behavior related to the prefrontal cortex area have received the most attention, Malloy and Richardson (1994) noted the importance of evaluating motor functioning due to the prefrontal cortex. They suggested assessing fine motor function and the volitional movements and praxis associated with the premotor and supplementary motor areas.

Assessment of Executive Function

Assessment is a vital part of any rehabilitation plan. The client's current cognitive and ECF abilities are the vehicle for reaching rehabilitation goals; neuropsychological assessment delineates the client's cognitive capacities. Considering the assessment results in terms of why particular errors occurred can result in a list of target impairments to be used in rehabilitation treatment planning (Goldstein, 1984). From this perspective, the assessment data are not only diagnostic (knowing), but also prescriptive (doing) (Golden, 1984).

A number of investigators have provided good summary tables of neuropsychological assessment batteries focused on ECF (cf. Chafetz, Friedman, Kevorkian, & Levy, 1996; Lezak, 1995; Lovell & Smith, 1997; Malloy & Richardson, 1994; Royall, 1994). These assessment batteries cover the general areas of planning, organization, set shifting, staying on task, overcoming distraction, visual construction and planning, inhibition, use of strategies, and working memory. There is no one test that assesses all of ECF; a group of tests is usually chosen that will fulfill the particular needs of the examiner.

A number of these measures may be quite arduous for clients and can drain their attentional and motivational reserves (e.g., Wisconsin Card Sort Heaton, 1981; California Verbal Learning Test Delis, Kramer, Kaplan, & Ober, 1987). Although it would be difficult to achieve a good score by chance on most tests of ECF, poor motivation or the presence of tiredness or depression can adversely affect test performance. This highlights a problem of most individual measures of ECF: They do not isolate specific aspects of ECF, and most require memory, attention, visual perception, and language, which are separate from, but are to some extent under the control of, ECF.

Only a few of the measures of ECF are easily administered at the bedside. A bedside measure that we highly recommend is the Executive Interview (EXIT) (or

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EXIT25), developed by Royall, Mahurin, and Gray (1992). The EXIT consists of 25 items (each scored 0, 1, or 2), administered in a structured interview format that can be completed in about 15 minutes. The interview follows a set format, but the items are not highly structured, so the client must organize and initiate a response. As shown in Table 9.1, the EXIT items cover several symptoms of ECF failure. As a consequence, this brief screening measure covers the general area of ECF about as well as any of the assessment batteries in current use. The EXIT can be given across the life span, beginning with age 6. The interview has demonstrated ECF impairment in several conditions, to include Alzheimer's disease, Pick's disease, subcortical vascular dementia, major depression, and schizophrenia (Royall & Mahurin, 1996).

Table 9.1 Symptoms of ECF Failure Elicited by the EXIT

  1. Perseveration
  2. Imitation behavior: echopraxia, echolalia
  3. Intrusions
  4. Frontal release signs
  5. Lack of spontaneity/prompting required
  6. Disinhibited behaviors
  7. Utilization behavior

We have used this assessment extensively in our own research with individuals diagnosed with Parkinson's disease (PD). The EXIT has detected cognitive impairment, while the most commonly used cognitive screen, the Mini-Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975), has indicated no impairment (Elias & Treland, 1999).

In one data set consisting of 46 PD patients, 21 patients were within normal limits on the MMSE (scores of 23 and above) but were in the impaired range on the EXIT (scores of 15 and above). Nineteen patients showed impairment on both the MMSE and the EXIT. Six patients showed no impairment on either test. If only MMSE scores had been used to screen these patients, we would have missed 21 cases of ECF impairment (Elias, 1995).

Parkinson's disease is a motor disorder that originates in the basal ganglia-nigrostriatal area. A second data set, shown in Table 9.2, is composed of PD patients who were staged according to the Hoehn and Yahr (1967) system (Elias et al., 1996). Parkinson's disease patients in Stage I have unilateral motor symptoms with little balance difficulty. Stage II represents the appearance of bilateral symptoms and some

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gait and balance difficulty. Stage III represents bilateral symptoms and increased gait and balance difficulty, including loss of the postural righting reflex (retropulsion on the pull test). Stage IV represents advanced motor, gait, and balance difficulties, plus inability to function independently. The progression of the disease is paralleled by declining ECF and increasing EXIT scores. As can be seen in Table 9.2, ECF impairment as measured by the EXIT (scores >15) begins to appear in Stage III PD. All but one individual in Stage IV PD showed ECF impairment. The loss of independent functioning observed in Stage IV PD is not simply due to impaired motor functioning; it also is strongly affected by a cognitive component. Only one of the 38 PD patients had an MMSE score below 24.

Table 9.2 Frequency of EXIT Scores Within Each Hoehn and Yahr Stage for 36 Patients With Parkinson's Disease

I 5, 6, 7, 9, 11, 12
II 7, 7, 9, 8, 1, 10, 12, 12, 13, 14, 14, 14, 14
III 9, 9, 11, 12, 14, 14, 18, 19, 19, 23
IV 14, 17, 19, 21, 21, 22, 22, 25
Note. Scores >15 indicate executive function impairment.

Royall (1994) estimated that screening with the MMSE alone misses 40% of serious noncortical dementias in the general population. This does not mean that the MMSE is not a good screening device for cognitive impairment, merely that it is insensitive to ECF impairment in the absence of postcortical dysfunction (Royall & Polk, 1998). The use of both instruments as screening measures is recommended.

As noted above, the issue of IQ assessment is always important with respect to ECF. In the case of rehabilitation, premorbid estimates of IQ often are not available and have to be obtained following a loss of functioning (e.g., stroke, head injury). To separate premorbid IQ from premorbid ECF, the premorbid estimate of IQ should reflect the crystallized (knowing) components of intelligence (i.e., verbal IQ estimates). Tests such as the National Adult Reading Test (NART; Nelson, 1982) estimate crystallized IQ by focusing on the correct pronunciation of words. The automatic, overlearned, and procedural aspect of the pronunciation of well-known words is expected to only minimally tap ECF. The number of words that are correctly pronounced (regional pronunciations considered) would indicate knowledge and/or use of those words and therefore reflect verbal IQ. Such tests generally correlate modestly to moderately with IQ (Lezak, 1995, pp. 102 106).2

We suggest the use of the Wide Range Achievement Test Revised (WRAT-R) for North American clients.3 If premorbid Verbal and Performance IQ scores are available, then some premorbid estimate of crystallized (knowing) and fluid (doing) intelligence could be provided by the Verbal IQ and Performance IQ, respectively.

The Behavioral Sequelae of Impaired ECF

When executive function is impaired, complex goal-directed behavior breaks down (Royall, 1994). Many behavioral routines are habitual, so this breakdown is particularly noticeable in situations that are relatively unstructured or novel (Gillis, 1996; Royall, 1994). Instrumental activities of daily living (e.g., cooking, cleaning, self-care) can become disrupted so that living independently is no longer prudent. The ability to interact socially (e.g., with family or friends) also may be diminished (Eslinger, Grattan, & Geder, 1996).

Executive function impairment (EFI) appears to be accompanied by active and passive patterns of behavior (Royall, 1994; see Table 9.3). The active pattern is distinguished by behavioral disinhibition, such as environmentally dependent (i.e., stimulus-bound) behavior. For example, an object can elicit spontaneous, yet purpose less,

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handling or use (utilization behavior). Active behavior can be seen in individuals diagnosed with Alzheimer's or Pick's disease.

Table 9.3 Active and Passive Behavior Patterns Seen With Executive Function Impairment

Active behaviors Passive behaviors
Environmental dependency
   Utilization behavior
Imitation behavior
   Echolalia, echopraxia
Disinhibition
   Occupational or other habits
   Impulsivity
   Social awkwardness
Vulnerability to intrusions
   Distractibility
   Tangentiality
    Childishness
Apathy
   Loss of initiative
   Loss of spontaneity
   Lack of persistence
   Need for prompting
Behavioral stereotypy
   Perseveration (motor and cognitive)
Note. From Precis of Executive Dyscontrol as a Cause of Problem Behavior in Dementia, by D. R. Royall, 1994, Experimental Aging Research, 20, p. 74. Copyright 1994 by Taylor and Francis. Adapted by permission.

The passive pattern of behavior is characterized by environmental indifference, or apathy (Royall, 1994). These clients can show cognitive and motor perseveration, as be linked with difficulty in shifiting attentional focus, so that a particular behavior continues despite a change in contextual cues (Malec, 1984). These clients may have deficient abstract thinking and so have difficulty generating alternatives (i.e., concrete thinking); the result is in perseverative behavior (Jones, Anderson, Cole, & Hathaway-Nepple, 1996). The passive pattern can be observed in people who have dementia associated with PD or the pseudodementia of depression.

The family or caregivers of clients with EFI often note personaligy changes in the client (Jones et al., 1996; Royall, 1994). Disinhibition, social awkwardness, childishness, impulsivity, and low frustration tolerance are some of the behavioral expressions of these personality changes. Disinhibited behaviors tend to be related to the client's life story, that is, her or his habits, occupation, hobbies, and premorbid personality characteristics (Jones et al., 1996; Royall, 1994).

Eslinger and colleagues (1996) emphasized the distinction between personality changes and social-emotional executive impairments. Clients can have difficulty in prioritizing, organizing, and managing social information as well as their own emotional reactions in novel and complex social settings (p. 427; see this reference for a more detailed description of this concept). The degree to which social functioning may have changed with EFI should not be underestimated. Individuals with EFI often describe themselves as being at a loss in social encounters, unable to read the subtileties in human interaction or to apply rules for social interaction (e.g., turn taking in conversation).

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Executive Function and Rehabilitation

Planning for the rehabilitation of ECF reveals a frustrating dilemma: The problem (the failure of ECF) interferes with traditional solutions to the problem (the application of ECF). A clear definition of ECF (as discussed above) and an awareness of the basis of rehabilitation are helpful in resolving the dilemma.

Ability, skill, process, and function are terms used in rehabilitation that need clarification relative to ECF. In ECF, ability refers to having sufficient resources for orchestrating and executing behaviors. A skill can be thought of as a well-learned habit. Well-learned habits appear to remain intact despite ECF impairment and can provide a foundation upon which to build new habits (Royall, 1994). A process is a series of operations executed to a specific end; this relates to the way ECF facilitates goal-directed behavior. Function refers generally to natural, required, or expected activity (Gillis, 1996, p. 142). In ECF, it is necessary to consider function in terms of the individual's context or environment.

The theoretical constructs that fit well with ECF address restorative and compensatory approaches to cognitive rehabilitation. The restorative approach, rooted in theories of neuronal plasticity and redundancy of functional neural systems (Anderson, 1996, p. 458), would employ cognitive retraining to facilitate recovery of functioning. From this perspective, the goal would be to improve ECF, rather than merely to compensate for the impairment. The compensatory approach accepts that cognitive ability may remain impaired, so the goal is to train the client to function by performing tasks using compensatory strategies.

In treatment planning, the distinction between the restorative and compensatory approaches highlights the need to consider the origins of the EFI. If the EFI is the result of a nonprogressive brain disorder (e.g., head injury), the client is stable relative to a client who develops EFI in the course of a progressive illness (e.g., Alzheimer's disease, late-stage PD). In the latter case, the expected course of the illness is an important consideration in developing the rehabilitation treatment plan (Goldstein, 1984). In some conditions, like PD, the rehabilitation goal may be restorative in the early stages and compensatory in the later stages.

When working with clients with EFI, augmenting the cognitive rehabilitation with psychosocial perspective is beneficial. Self-concept is likely to be affected by EFI, and depression, low frustration tolerance, and an inability to appropriately express emotions often accompany EFI (Gillis, 1996; Muir & Haffey, 1990). Interactions with the client may be facilitated by sensitivity to these issues.

Family involvement in the rehabilitation program benefits both the family members and the treatment staff in terms of information and support (Anderson, 1996; Gillis, 1996). The family or caregivers probably will wonder why previous means of interacting are no longer effective or why they may have to assume some of the client's ECF responsibilities. Educating the family about the client's EFI helps quell some of the uncertainty about the client's condition. Involving the family in the rehabilitation goal-setting and training techniques allows them to be active, rather than passive, in the treatment process.

The rehabilitation treatment plan for a client with EFI generally focuses on two areas: changes in the environment (contextual variables) and interventions with the client (intrinsic variables). The ideal rehabilitation setting would be highly structured

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and distraction-free and have ample rest breaks. Home or community settings are not ideal, however, so treatment planning should focus on the contextual and intrinsic variables that can be manipulated to elicit optimal performance and benefit under conditions that more closely mirror reality (Gillis, 1996; see Table 9.4). Interventions in these areas fit with the goals of the compensatory approach.

Table 9.4 Extrinsic and Intrinsic Variables That Affect Treatment Performance and Daily Functioning

Extrinsic variables Intrinsic variables
Speed/rate of presentation State of arousal
Order of presentation Mood state
Length of each stimulus item Hunger
Complexity of information Pain
Single or multiple choice Medications
Therapist attitude Alcohol/drugs
Note. From Traumatic Brain Injury Rehabilitation for Speech-Language Pathologists (p. 165), by R. J. Gillis, 1996, Boston: Butterworth Heinemann. Copyright 1996 by Butterworth Heinemann. Adapted by permission.

Environmental stimuli can serve as cues to overlearned subroutines and evoke either compensatory or problem behavior (Royall, 1994); altering contextual variables can have a significant impact on the disinhibited client's actions (Gillis, 1996; Royall, 1994). Royall (1994) used an example of a nursing-home resident who wandered outside when cued by the sight of the door. Placing a Stop sign at the door reduced the problem behavior by providing a cue for the desired behavior (staying indoors). The family or caregiver can work with the rehabilitation specialist to listen to what the environment is telling the client (Royall, 1994). Once the potential triggers are elucidated, then the stimuli may be changed or disguised. For example, a door knob could be concealed by a shoe box, or elevator buttons could be covered with a picture. Royall's (1994) recommendations for managing problem behavior are provided in Table 9.5.

When uncooperative behavior is the target of treatment, it is important to remember the link between environmental stimuli and behavioral responses. Resistance to care

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can be conceptualized as a conflict between the client's old habits and the demands of a new environment (Royall, 1994). A positive social cue (e.g., a handshake), rather than a stern tone of voice, might disarm the conflict and make it easier to redirect the client's behavior. Verbal or physical force should be avoided in favor of a supportive, clear, gentle, but firm approach.

Table 9.5 Recommendations for the Management of Problem Behavior in Dementia

  1. Establish a daily ritual.
  2. Use new routines to break old habits.
  3. Build good habits through repetition.
  4. Listen to what the environment is saying to the patient.
  5. Use social and environmental cues to your advantage.
  6. Remove or alter cues that seem to trigger problem behaviors.
Note. From Precis of Executive Dyscontrol as a Cause of Problem Behavior in Dementia, by D. R. Royall, 1994, Experimental Aging Research, 20, p. 86. Copyright 1994 by Taylor and Francis. Reprinted by permission.

Clients with EFI may not immediately comprehend or follow instructions. Rushing these clients elicits opposition and can provoke aggressive behavior. If aggressive behavior is present, the situation needs to be carefully evaluated for possible triggers of this behavior (Anderson, 1996). In a highly structured environment, it may help to reinforce prosocial behavior in situations likely to activate aggression. Extinction techniques also could be effective. In cases of persistent or serious disruptive behavior, a psychological consultation may assist in devising interventions (Sufrin, 1984).

Behavior modification techniques (e.g., a token economy) provide structure for clients with EFI and can be used to decrease inappropriate behavior and increase prosocial behavior. This type of intervention works best in a structured inpatient setting and is more difficult to manage on an outpatient basis (Anderson, 1996). Behavior modification procedures are enhanced by family or caregiver participation and exaggerated reinforcement schedules; delayed or variable reinforcement is less effective.

With clients who are able to be self-aware, short-term anger control may be accomplished by teaching the client self-instruction in anger management. This could be enhanced by training the family or caregiver in the use of time-out procedures (Anderson, 1996).

Group rehabilitation settings provide practice for prosocial behavior, as they resemble social situations and supply multiple distractions and increased unpredictability. While the group experience can foster social skills, group social skills training may be needed before other rehabilitation activities can proceed.

If the client has the capacity for recovery of function, interventions at the client level facilitate the restorative approach to rehabilitation. Intervention at this level can also help clients function within their environment, the aim of the compensatory approach. What follows is a brief summary of techniques that have been used with clients with EFI.

In order to adapt to the environment, the client requires executive strategy training. This includes training to recognize a problem (requires awareness), select a strategy (requires goal setting and planning), apply the strategy (requires initiation), and monitor the success of the strategy (requires self-monitoring and self-regulation) (Gillis, 1996). Training in metacognitive or verbal self-strategies, along with the use of checklists and schedules, has provided effective compensatory techniques for planning, self-monitoring, and problem-solving.

Cognitive mediation and verbal self-regulation have been effective strategies for planning. These strategies appear to transfer to other circumstances (Eslinger et al., 1996). External aids (e.g., calendars, checklists, flowcharts, programmed strategies) also can facilitate planning (Chafetz et al., 1996). Verbal analysis of the components of a task can be used to encourage sequencing and self-instruction and to correct errors in problem solving (Malec, 1984).

Strategies used in a restorative approach target improving the underlying processing operations. Toward this goal, planning could be trained by beginning with simple

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sequencing and categorization tasks and gradually progressing to more complex tasks (Gillis, 1996). Another technique is to reduce the task into its component parts, then use time estimation tasks to address the time constraint aspects of completing the task. Additionally, asking clients to appraise their ability to perform the task encourages self-awareness.

Gillis (1996) suggested using self-appraisal (e.g., How well am I doing? ) to improve self-monitoring. Error detection and correction tasks (e.g., spelling, arithmetic problems) also are useful. To be effective, this training requires repetitive practice of self-check strategies together with external signals (e.g., sounds, commands). Improved self-regulation also has been seen with training in self-instruction, self-prediction, and error-monitoring techniques (e.g., notebooks; cf. Burke, Zencius, Wesolowski, & Doubleday, 1991; Cicerone & Giacino, 1992).

Problem-solving models have utility in helping clients systematically analyze a situation. The process of solving a problem is active and changing and may require several repetitions to achieve an effective solution. In some cases, cognitive functions utilized in problem solving (e.g., attention, memory) will need remediation before they can be used in the service of solving problems. The IDEAL problem-solving model, devised by Gillis (1996), is shown in Table 9.6. For additional examples of problem-solving models see Gillis (1996).

Impaired initiation (i.e., passive features of EFI) can be difficult to treat. Clients may have both the motivation and the capacity to perform but may lack the ability to initiate and sustain purposeful activity (Royall, 1994). These individuals should not be labeled unmotivated. The lack of initiation or apathy may stem from the EFI.

In the case of apathetic clients, modeling and prompting could be helpful in activating the desired behavior. In the absence of naturally occurring environmental cues, external cues can be employed (e.g., watch alarm, timer; Gillis, 1996). Imposing structure (e.g., checklists, schedules) and training in self-instruction provide support in behavior initiation and problem solving (Anderson, 1996; Chafetz et al., 1996) and have been shown to be quite effective (cf. Burke et al., 1991).

In terms of general principles of intervention, Anderson (1996) and Gillis (1996) agreed that the rehabilitation treatment plan should be based on neuropsychological evaluation, client goals, and practical issues. Planned short-term interventions should be directed at specific goals with real-world impact.

Generalizing skills learned in therapy to the client's everyday life can be challenging.

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For example, strategy-specific memory techniques have been found useful and appear to be maintained about 3 years, but they tend not to generalize to other tasks or to be used in daily life (Malec, 1996). Suggestions for facilitating the generalization process include (a) addressing real-world problems from the onset of treatment; (b) using homework assignments; (c) choosing activities to simulate work and social environments; and (d) using in vivo experiences (Anderson, 1996). Multimodal rehabilitation approaches (combining ECF strategies with training specific to other cognitive functions) have been effective with the elderly (Malec, 1996) and are recommended to improve skills generalization. Research is needed to establish how treatment gains can be generalized and maintained.

Table 9.6 Gillis IDEAL Problem-Solving Model

Identify the problem
Define the problem
Explore alternative approaches (options)
Act on the plan
Look at the results
Note. From Traumatic Brain Injury Rehabilitation for Speech-Language Pathologists (p. 202) by R. J. Gillis, 1996, Boston: Butterworth Heinemann. Copyright 1996 by Butterworth Heinemann. Adapted by permission.

With respect to rehabilitation planning, Sufrin (1984) pointed out that the elderly often do not receive adequate rehabilitation treatment because they are viewed as experiencing the normal consequences of aging. The negative bias toward older adults promotes the myth that the elderly are crotchety, stubborn, unmotivated, and unwilling to actively engage in a treatment program. In fact, these behaviors can be indicative of EFI. When these assumptions are operating, diagnosis, treatment, and rehabilitation tend to be nonaggressive. Consider the implications of this bias in the case of head injury. Studies show that initial recovery in uncomplicated cases appears similar for young and old patients (cf. Goldstein, 1984). Advanced age, however, is a risk factor for not returning to premorbid functioning (Fields, 1997). Less aggressive treatment practices with older patients could mediate this age-related risk factor.

Executive cognitive functions are specifically affected by normal aging (Malloy & Richardson, 1994). Raz (1996) reported MRI findings showing shrinkage of the prefrontal cortex as a function of age. Coffey and associates (1992) examined the MRI data of healthy elderly individuals (i.e., those with no vascular disease or hypertension) and found that cortical atrophy of the frontal regions was disproportionately greater than atrophy in temporal, parietal, and hippocampal regions. Likewise, disproportional frontal metabolic deficits have been observed in the healthy elderly (Kuhl, 1984). Royall and Polk (1998) suggested that normal aging can be associated with an ECF dementia syndrome in the absence of Alzheimer's disease or ischemic vascular disease.

These findings with respect to normal aging suggest that assessment of ECF in elderly individuals is advisable even when rehabilitation is not specifically related to cognition. For example, individuals who have knee replacement surgery have to follow directions, motivate themselves for rehabilitation, reorganize their lives, distinguish expected from unexpected pain, and plan to avoid environments that they can no longer easily negotiate. The tiredness, pain, anxiety, and depression following anesthesia and surgery can disrupt ECF for several months. It should not be taken for granted that ECF is intact before initiating physical rehabilitation programs.

A fact often overlooked in the days of managed care is that age is important with respect to speed of rehabilitation, particularly cognitive rehabilitation. For example, studies of stroke patients by Falconer, Naughton, Strasser, and Sinacore (1994) indicate that discharge options for older stroke patients are likely to be limited not only by the frailty and functional status of the patient, but also by the available social support and resources. For the elderly, longer, less intensive rehabilitation programs in many cases promote and maintain optimal functional status and are more cost-effective.

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References

Anderson, S. W. (1996). Cognitive rehabilitation in closed head injury. In M. Rizzo & D. Tranel (Eds.), Head injury and post concussive syndrome (pp. 457 468). New York: Churchill-Livingstone.

Baddeley, A. D. (1996). Exploring the central executive. Quarterly Journal of Experimental Psychology, 49A, 5 28.

Burke, W. H., Zencius, A. H., Wesolowski, M. D., & Doubleday, F. (1991). Improving executive function disorders in brain-injured clients. Brain Injury, 5, 241 252.

Chafetz, M. D., Friedman, A. L., Kevorkian, G. K., & Levy, J. D. (1996). The cerebellum and cognitive function: Implications for rehabilitation. Archives of Physical Medicine and Rehabilitation, 77, 1303 1308.

Cicerone, K. D., & Giacino, J. T. (1992). Remediation of executive function deficits after traumatic brain injury. Journal of Neurologic Rehabilitation, 2, 12 22.

Coffey, C. E., Wilkinson, W. E., Parashoe, I. A., Soady, S. A. R., Sullivan, R. J., Patterson, L. J., Figel, G. S., Webb, M. C, Spritzer, C. E., & Djang, W. T. (1992). Quantitative cerebral anatomy of the aging human brain: A cross-sectional study using magnetic resonance imaging. Neurology, 42, 527 536.

Cummings, J. L. (1993). Frontal-subcortical circuits and human behavior. Archives of Neurology, 50, 873 880.

Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A. (1987). California Verbal Learning Test: Research edition. New York: Psychological Corporation.

Denkla, M. B. (1996). A theory and model of executive function. In G. R. Lyon & M. A. Krasnegor (Eds.), Attention, memory, and executive function (pp. 263 278). Baltimore: Paul Brookes.

Denkla, M. B., & Reiss, A. L. (1997). Prefrontal-subcortical circuits in developmental disorders. In N. Krasnegor, G. R. Lyon, & P. S. Goldman-Rakic (Eds.), Development of the prefrontal cortex (pp. 283 293). Baltimore: Paul Brookes.

Elias, J. W. (1995). Normal versus pathological aging: Are we screening adequately for dementia? Experimental Aging Research, 21, 97 100.

Elias, J. W., & Treland, J. (1999). Executive function in Parkinson's disease and subcortical disorders. Seminars in Clinical Neuropsychiatry, 4, 34 40.

P.172


Elias, J., Treland, J., Hutton, J., New, P., Royall, D., & Shroyer, J. (1996, April). The value of using brief assessment measures for executive function as well as Mini-Mental State type screening measures. Poster session presented at the Sixth Cognitive Aging Conference, Atlanta, GA.

Eslinger, P. J., Grattan, L. M., & Geder, L. (1996). Neurologic and neuropsychologic aspects of frontal lobe impairments in postconcussive syndrome. In M. Rizzo & D. Tranel (Eds.), Head injury and post concussive syndrome (pp. 414 440). New York: Churchill-Livingstone.

Falconer, J. A., Naughton, B. J., Strasser, D. C, & Sinacore, J. M. (1994). Stroke inpatient rehabilitation: A comparison across age groups. Journal of the American Geriatrics Society, 42, 39 44.

Fields, R. B. (1997). Geriatric head injury. In P. D. Nussbaum (Ed.), Handbook of neuropsychology and aging (pp. 280 297). New York: Plenum Press.

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state. Journal of Psychiatric Research, 12, 189 198.

Gillis, R. J. (1996). Traumatic brain injury rehabilitation for speech-language pathologists. Boston: Butterworth Heinemann.

Golden, C. (1984). Rehabilitation and the Luria-Nebraska neuropsychological battery: Introduction to theory and practice. In B. A. Edelstein & E. T. Couture (Eds.), Behavioral assessment and rehabilitation of the traumatically brain-damaged (pp. 83 120). New York: Plenum Press.

Goldstein, G. (1984). Methodological and theoretical issues in neuropsychological assessment. In B. A. Edelstein & R. T. Couture (Eds.), Behavioral assessment rehabilitation of the traumatically brain-damaged (pp. 1 21). New York: Plenum Press.

Heaton, R. K. (1981). Wisconsin Card Sorting Test. Odess, FL: Psychological Assessment Resources.

Hoehn, M. M., & Yahr, M. D. (1967). Parkinson onset, progression and mortality. Neurology, 17, 427 442.

Johnstone, B., Callahan, C., Kapila, & Bowman, D. E. (1996). The comparability of the WRAT-R reading test and NAART as estimates of premorbid intelligence in neurologically impaired patients. Archives of Clinical Neuropsychology, 11, 513 519.

Jones, R. D., Anderson, S. W., Cole, T., & Hathaway-Nepple, J. (1996). In M. Rizzo & D. Tranel (Eds.), Head injury and post concussive syndrome (pp. 395 14). New York: Churchill-Livingstone.

Kolb, B., & Whishaw, I. Q. (1996). Fundamentals of human neuropsychology (4th ed.). New York: Freeman.

Krasnegor, N. A., Lyon, G. R., & Goldman-Rakic, S. (1997). Development of the prefrontal cortex. Baltimore: Paul Brookes.

Krull, K. R., Scott, J. G., & Sherer, M. (1995). Estimation of premorbid intelligence from combined performance and demographic variables. The Clinical Neuropsychologist, 9, 83 88.

Kuhl, D. E. (1984). The effects of normal aging on patterns of local cerebral glucose utilization. Annals of Neurology, 15, S133-137.

Lezak, M. D. (1983). Neuropsychological assessment (2nd ed.). New York: Oxford University Press.

Lezak, M. D. (1995). Neuropsychological assessment (3rd ed.). New York: Oxford University Press.

Lovell, M. R., & Smith, S. S. (1997). Neuropsychological evaluation of subcortical dementia. In P. D. Nussbaum (Ed.), Handbook of neuropsychology and aging (pp. 189 200). New York: Plenum Press.

P.173


Malec, J. (1984). Training the brain-injured client in behavioral self-management skills. In B. A. Edelstein & E. T. Couture (Eds.), Behavioral assessment and rehabilitation of the traumatically brain-damaged (pp. 121 150). New York: Plenum Press.

Malec, J. F. (1996). Cognitive rehabilitation. In R. W. Evans (Ed.), Neurology and trauma (pp. 231 248). Philadelphia: W. B Saunders.

Malloy, P. F., & Richardson, E. D. (1994). Assessment of frontal lobe functions. Journal of Neuropsychiatry, 6, 399 410.

Muir, C. A., & Haffey, W. J. (1990). Psychological and neuropsychological interventions in the mobile mourning process. In B. A. Edelstein & E. T. Couture (Eds.), Behavioral assessment and rehabilitation of the traumatically brain-damaged (pp. 247 271). New York: Plenum Press.

Nelson, H. E. (1982). The National Adult Reading Test (NART): Test manual. Windsor, UK: NFER-Nelson.

Pennington, B. F. (1997). Dimensions of executive functions in normal and abnormal development. In N. A. Krasnegor, G. R. Lyon, & P. S. Goldman-Rakic (Eds.), Development of the prefrontal cortex (pp. 265 281). Baltimore: Paul Brooks.

Raz, N. (1996). Neuroanatomy of the aging brain observed in vivo: a review of structural MRI findings. In E. D. Bigler (Ed.), Neuroimaging: Vol 2. Clinical applications (pp. 153 182). New York: Plenum Press.

Royall, D. R (1994). Precis of executive dyscontrol as a cause of problem behavior in dementia. Experimental Aging Research, 20, 73 94.

Royall, D. R., & Mahurin, R. K. (1996). Neuroanatomy, measurement, and clinical significance of the executive cognitive functions. In L. J. Dickstein, J. M. Oldham, & M. B. Riba (Eds.), Annual review of psychiatry (Vol. 15, pp. 175 204). Washington, DC: American Psychiatric Press.

Royall, D. R., Mahurin, R. K., & Cornell, J. (1994). Bedside assessment of frontal degeneration: Distinguishing Alzheimer's disease from non-Alzheimer's cortical dementia. Experimental Aging Research, 20, 95 103.

Royall, D. R., & Polk, M. P. (1998). Dementias that present with and without posterior cortical features: An important clinical distinction. Journal of the American Geriatrics Society, 46, 98 105.

Shallice, T. (1982). Specific impairments of planning. Philosophical Transactions of the Royal Society of London, 298, 199 209.

Stuss, D. T., & Benson, D. F. (1986). The frontal lobes. New York: Raven Press.

Sufrin, E. M. (1984). The physical rehabilitation of the brain-damaged elderly. In B. A. Edelstein & E. T. Couture (Eds.), Behavioral assessment and rehabilitation of the traumatically brain-damaged (pp. 191 226). New York: Plenum Press.

Usman, M. A. (1997). Frontotemporal dementias. In P. D. Nussbaum (Eds.), Handbook of neuropsychology and aging, (pp. 159 176). New York: Plenum Press.



Cognitive Rehabilitation in Old Age
Cognitive Rehabilitation in Old Age
ISBN: 0195119851
EAN: 2147483647
Year: 2000
Pages: 18

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