1. Cognition and Behaviour Cognition is the way we obtain, process and use information from the world around us It helps us make sense of things and allows us to take action as required

2. Components of Cognition tested on MMSE or similar Orientation Registration Attention/Calculation Recall Language Design Construction

3. Orientation Needs some memory (What did I do to get here? Who are these people? What is familiar about this situation?) Needs ability to problem solve Is an active process (but usually occurs unconsciously) Relates not only to time, place & person, but also to situation How might disturbance affect behaviour?

4. Registration and Recall Critical components of memory Getting information in Dredging it back out You cannot teach without memory being present in some form Behaviour may be repetitive and ignore new information You may need alternative reinforcers of information

5. Attention and Calculation Attention fundamental to many other cognitive functions Calculation indicative of learned skills at manipulating information for a purpose and the ability to maintain attention(concentrate) If attention is not gained there will be little ability to undertake purposeful activity If concentration is poor the person may not be able to finish things off

6. Language Receptive difficulties Can’t make sense of incoming language Unable to follow instructions, conversations Expressive difficulties Can’t express what they need to or name things May be regarded as more impaired than they really are May be fluent when they are emotionally aroused

7. Design Complex task requiring identification of Key components Their relationship to one another Spatial orientation Skills in replicating/drawing Ability to self correct

8. BUT……. Sometimes we find people with good scores on MMSE who are clearly having difficulty; what is the story?? Often these people will have impaired Executive Cognitive Function (ECF)

9. Executive Cognitive Functions The “High Priestess” of the Cognitive System A simple definition; “it is the ability to do all that it takes to keep your mind on what you are doing in order to accomplish a given task” (Twatchtwman-Cullen &DeLorenzo, 2000)

10. Executive Cognitive Function “those processes which orchestrate relatively simple ideas, movements or actions into complex goal directed behaviour. Without them, behaviours important to independent living,…., can be expected to break down into their component parts.” (Royall, Mahurin Gray, 1992)

11. ECF Studies First studies with people with long standing schizophrenia (1980s) Interest in dementia – why poor judgement, inability to cope when usual testing was OK Now being investigated in autism studies, developmental delay, and other mental health conditions and treatments. Appears to be a frontal lobe brain function (mostly)

12. Components of ECF Planning Initiating activity Carrying out the plan Modifying activity Selecting responses Suppressing inappropriate responses Not responding to distraction Finishing when the goal is achieved

13. ECF Impairment can lead to; Impaired inhibition Aggression Sexual impulsiveness Social inappropriateness Reflexive responses Financial management problems Other signs of poor judgement

14. ECF Impairment can lead to; Impaired initiation Of activity Can’t get started on things without aid Of ideas Can’t think of things that need doing, generate options

15. ECF Impairment can lead to; Distractability Intrusions Can’t keep focussed on task Perseveration Inability to stop a behaviour when it is no longer useful

16. ECF in general We all have varying degrees of ECF Our ECF is affected by Fatigue Intoxication Cognitive overload Lack of practice Engagement in the task/situation Anxiety

17. Important messages Impaired cognition will affect learning Impaired ECF will; reduce ability to generalise reduce ability to modify behaviour reduce performance in less than ideal situations require management of the environment and modification of approach

18. Hints for caring for someone with impaired ECF Impairment of ECF is a disability Understand the difficulties – observe carefully, try different things Difficulty initiating – provide cues, labels on rooms, put meals out with implements easy to reach, prepare clothes in the right order to put on

19. Hints to help Difficulty planning – reduce the need for planning, routines that support the person such that automatic responses are appropriate Difficulty choosing responses – present one stimulus, one instruction at a time. Practice and exercise improve ECF – keep the person involved as much as possible (e.g. walking and talking at the same time can be a challenging activity) Aim to maximise success

20. Hints to help Monitor responses to stimulation – too much can cause irritability, too little can cause apathy Try not to stimulate disinhibited responses – watch what you wear, avoid confrontating approaches, give clear messages about expected behaviour

21. Hints to help These people are often distractible – this can be used to change an activity that is inappropriate Automatic responses can be used – social responses such as shaking hands remain powerful after other responses have been lost.

22. What about “personality?” Personality is related to the habitual ways in which we behave In fully functional adults, much of our personality is controlled by our executive function (and also our emotional state and experiences) We make choices about how we behave generally When ECF breaks down people may start to act “out of character”

23. THE KEY MESSAGE People with dementia lose the ability to adapt their responses to situations and people The key role of caregivers of people who display challenging behaviour is to find ways to change the environment and situation such that distress for all is reduced Anything which makes a person feel competent for any period of time is worthwhile.

24. Last words….. Because people with impaired ECF can sometimes achieve tasks or appear capable in some areas, there can be a tendency to assume the person “knows what they are doing.” Watch out for times when people are frustrating you and investigate further!