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

Components of Cognition tested on MMSE or similar

Orientation

Registration

Attention/Calculation

Recall

Language

Design

Construction

OrientationNeeds some memory (What did I do to get here? Who are these people? What is familiar about this situation?)

Needs ability to problem solveIs an active process (but usually occurs unconsciously)

Relates not only to time, place & person, but also to situation

How might disturbance affect behaviour?

Registration and Recall

Critical components of memoryGetting information inDredging it back out

You cannot teach without memory being present in some formBehaviour may be repetitive and ignore new informationYou may need alternative reinforcers of information

Attention and Calculation

Attention fundamental to many other cognitive functionsCalculation 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 activityIf concentration is poor the person may not be able to finish things off

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

Design

Complex task requiring identification of Key componentsTheir relationship to one anotherSpatial orientationSkills in replicating/drawingAbility to self correct

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)

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)

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)

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)

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

ECF Impairment can lead to;

Impaired inhibitionAggressionSexual impulsivenessSocial inappropriatenessReflexive responsesFinancial management problemsOther signs of poor judgement

ECF Impairment can lead to;

Impaired initiationOf activity

Can’t get started on things without aid

Of ideasCan’t think of things that need doing, generate

options

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

ECF in general

We all have varying degrees of ECFOur ECF is affected byFatigue IntoxicationCognitive overloadLack of practiceEngagement in the task/situationAnxiety

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

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

Hints to helpDifficulty planning – reduce the need for planning, routines that support the person such that automatic responses are appropriateDifficulty 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

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

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.

What about “personality?”

Personality is related to the habitual ways in which we behaveIn 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 generallyWhen ECF breaks down people may start to act “out of character”

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.

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!