REHABILITATION OF EXECUTIVE DISORDERS

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1 REHABILITATION OF EXECUTIVE DISORDERS Deirdre Dawson, PhD, OT Reg (ON) Senior Scientist, Baycrest Associate Professor, University of Toronto 2nd Central East Stroke Network Symposium April 14 th, 2010 Outline Where & What is Executive Function? Stroke & Executive Dysfunction Theories of Executive Function Assessment of Executive Function Rehabilitation Approaches By the end of this session You will have basic knowledge of: What executive function is Major theories of executive function and how they relate to assessment and intervention Broad approaches to assessment with 2 specific examples Rehabilitation principles Broad approaches to rehabilitation with several specific examples 1

2 Middle Cerebral Artery Anterior Communicating Artery What What are the skills of a Chief Executive Officer (CEO)? Executive Skills Planning Judgment Time sense Goal setting Monitoring Working memory Initiation Response inhibition Task persistence Generative thinking High level attention Awareness 2

3 Executive Function Integrative cognitive functions that determine goal-directed and purposeful behaviour and are superordinate in the orderly executive of daily life functions Cicerone et al., 2000 Sustained Attention to Response Test Robertson, Manly et al., 1997 A vigilance task predictive of everyday attentional failures and action slips in people with brain injuries and normal control participants Respond to all targets, withhold to rare targets (e.g., respond to every digit except 3 ) Task goal must be endogenously activated Arousal (cingulate/noradrenergic system) Goal representation (right prefrontal) Theories of Executive Dysfunction What is going on? Why are people making these errors? 3

4 The default mode * Actions are driven by immediate gratification and environmental triggers Behaviour is poorly modulated by context / experience There is a need for a buffer between stimulus and action * Mesulam, 2002 The default mode * To overcome this, executive control needs to be re-established Use of top-down approaches (internally driven,metacognitive strategies) Use of bottom-up strategies (externallybased cueing systems) * Mesulam, 2002 Assessment Standardized cognitive assessments Important, but often neglected outcomes of stroke are neuropsychological sequels, which occur in nearly half of stroke survivors (Dennis, O Rourke, Lewis, Sharpe, & Warlow,2000). Everyday life assessments 4

5 Sachdev et al., 2004, Neurology, 62, Value of Standardized Tests Strong psychometric properties Aid in diagnosis Provide a detailed profile of cognitive impairments Are modestly predictive of function Using New (to you) Standardized Tests Read & digest test manual Has the test been normed for your population? How good is the normative data? Is the test valid? Reliable? Familiarize self with test materials Pilot on several healthy controls Pilot on several patients /clients ideally be observed by experienced test giver and get feedback Interpret according to the manual. 5

6 Assessment of Executive Dysfunction Conundrum Executive dysfunction manifests itself in the unstructured, novel circumstances experienced in day-to-day life. Assessment & rehabilitation for executive dysfunction takes place almost exclusively in controlled, structured environments. International Classification of Functioning (WHO, 2000) cognitive, affective impairments Daily Life Performance Multiple Errands Test Original version by Shallice & Burgess (1991) 2 versions: Shopping Mall & Hospital Version Performance: correlates well with performance on executive function tests in samples of people with ABI; correlates well with other measures of daily life allows clinicians to make inferences about strategies and errors made in real-life and use these data to inform treatment Most recent version: Dawson et al., Arch Phys Med & Rehab,

7 Multiple Errands Test Multiple Errands Test in ABI 10 Stroke 8 Control Tasks complete Errors Time? for Help 7

8 Considerations for rehabilitation Compensation vs remediation Outcomes are congruent with the intervention if intervening at the impairment level, changes cannot and should not be expected at the participation level (Wilson, 2002) Generalization does not just happen Client s goals are central Self-efficacy, coping, locus of control, optimism impact cognition and real-world performance Categories of Interventions Environmental Modifications Task-specific training Meta-cognitive training Process specific training Reduce distractions check lists Cueing devices Random alerting tones e.g., verbal self-instruction e.g., CO-OP limited evidence for generalization to daily life Training for Energization Timer/alarm watch Task-planner with built-in rest periods, reinforcement Symbol or cue card in work area 8

9 Random Alerting Tones Manly et al. (2002) Deviation from optimal time Tasks attempted / 5 9

10 Self-instructional Techniques self-talk Development of scripts to guide behaviour Overt rehearsal and training on steps Fading out of vocalization (if possible) Inner speech serves as action regulator Assists with self-regulation Problem-solving / Meta-cognitive Training Goal management Training (Levine 2002) Stop Define List Learn Do Check CO-OP (Dawson 2009) Goal Plan Do Check WSTC (Lawson & Rice, 1989) What should I be doing? Select a strategy. Try the strategy. Check the strategy. Problem-Solving (von Cramon, 1990) Orient to problem Define problem Generate alternatives Make a decision Do it. Verify the solution 10

11 CO-OP Used to overcome performance break-down participant is guided to use a meta-cognitive problem solving strategy* across self-identified functional goals * GOAL -PLAN -DO -CHECK Originally designed for use with children with DCD Currently showing promise in older adults with traumatic brain injury and stroke (Dawson et al., 2009; McEwen et al., 2009) Key elements of CO-OP participant active in identifying treatment goals task is observed to identify performance problems within the context of the global strategy therapists guide participants to discover domain specific strategies that will solve their performance problems, to make a plan significant others (SO) are involved to reinforce use of global and domain-specific strategies CO-OP Session Details Each session: review how participant has or could have used global strategy (goal-plan-do-check) in daily activities follow-up on homework train 2 goals / session review the goal develop and/or do plan collaborate with participant to identify specific strategies at places where performance breaks down assign homework and talk about use in other places 11

12 Evidence for efficacy of intervention Evidence for task-specific effects: Performance improvement met criterion in self-report and significant other report on trained goals (COPM); Evidence of generalization: Performance improvement met criterion in self-report and significant other report on untrained goals (COPM). Results: Performance Criterion Met Trained Goals Untrained Goals Self So Self So Sam 2 / 3 3 / 3 1 / 3 2 / 3 Jane 3 / 3 3 / 3 2 / 3 1 / 3 Gray 2 / 3 3 / 3 1 / 1 0 / 1 TOTAL 7 / 9 9 / 9 4 / 7 3 / 7 Goal Examples Jane: to schedule activities so they are balanced across the week Domain-specific strategies: purchase and make routine, use of purse-size daytimer Sam: make a menu, shop, cook the meal Domain-specific strategies: use of check-lists SOs to refer Sam to strategies rather than doing 12

13 Goal Setting: COPM Canadian Occupational Performance Measure: Problem Definition a. Do you need to? If yes to either a,b, or c b. Do you want to? c. Are you expected to? d. Can you? And no to either d,e, or f e. Do you? f. Are you satisfied with the way you? COPM: Scoring How important is it to you to be able to do this activity? not able able to do it to do at all extremely well How would you rate the way you do this activity now? not able able to do it to do at all extremely well How satisfied are you with the way you do this activity now? not able able to do it to do at all extremely well A Helpful Resource 13

14 Summary Executive dysfunction occurs following stroke and is related to worse functional outcomes; Assessments of cognitive processes and the impact of executive function on real life are helpful; Research supports several types of intervention as having real-world impact. 14

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