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Examining the role of

Executive Functions to predict

Functional Performance after

Acquired Brain Injury

Presented By : Malabika Ghosh

Clinical Lead Occupational Therapist- Lancashire Teaching Hospitals

PhD Student– Lancaster University E-Mail: malkaush99@yahoo.com

BACKGROUND

Acquired brain injury affects information processing capacities difficulties in volition, planning, purposive action, and action monitoring aspects of task performance (Yogev et al, 2008)

Routine cognitive testing in the acute hospital setting is not sensitive to subtle executive dysfunction, and its impact on functional performance (Wilby,2005)

Executive Functions-

What are they?

These are higher cognitive processes that

modify information from many cortical

systems to modulate and produce

behaviour (Fuster, 1999)

It has cognitive and behavioural

components ( Fuster, 1999)

Executive Functions

Goal directed

actions

Control of

attention

resources

Engaging in

day to day tasks

The Supervisory Role Of Executive Functions (Gazzaniga et al, 2002 & Fuster, 1999)

Planning Attention Error Correction Information

Inhibition Processing

of habitual

responses

Cognitive

Component

Behavioural

Component Executive Functions

RATIONALE

Occupational therapy assessment in the acute setting aims to establish functional baseline, and predict functional performance and needs to be responsive to pressures for discharge alongside ensuring risks are minimised.

Cognitive screening on admission is advised to help predict expected functional recovery (Sands et al, 2003)

Inspite of routine assessments and advice, families and carers find it really hard to deal with subtle aspects of behaviours and functioning.

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OBJECTIVES

To evaluate cognitive and executive dysfunction,

to predict functional performance, and need for

support services after acquired brain injury, in

the acute setting.

Use of behavioural observations during test

administration and functional assessments, to

augment assessment findings.

METHOD

A Practice Analysis

15 consecutive patients (11 males, 4 females) – diagnosed with acquired brain injury – admitted to the acute neurosurgical ward - referred to Occupational Therapy Services.

Neurosurgical intervention completed

METHOD contd.

The Addenbrooke’s Cognitive Assessment Battery used as the Standardised Test

for assessment of cognition and executive functions alongside behavioural observations (Wilby,2005)

This has test of cognition ( MMSE) incorporated in it (Mioshi et al, 2006).

RESULTS

Patients scored between 23 to 77 out of 100. Test norms indicate a score of 89 or above is required to reflect effective

participation in everyday tasks

6 patients unable to complete the test in one session, due to eg. fatigue, & inability to sustain engagement for the duration of the assessment

Main Problem Areas identified: Attention

Memory

Verbal fluency

RESULTS contd.

Fluency : most impaired component

13 out of 15 patients i.e 86% of patients demonstrated difficulties

Functional Implications : Patients become over-focussed on particular aspects

of a task

Cannot initiate engagement in activities in a timely and efficient manner

RESULTS contd.

Attention and Concentration: second most affected component.

12 out of 15 patients demonstrated difficulties i.e 80 %.

Functional Implications:

Inability to focus sufficiently to support new learning

Allocating priority to tasks leading to difficulties in making informed choices

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RESULTS contd.

MEMORY: next most affected component

11 out of 15 patients affected i.e 73 %

Functional Implications:

Ability to learn new skills

Recall of recent pertinent information severely compromised

Retrieval of long term memories was less affected

Patients were able to tap into automatic schemas for function

IMPLICATIONS ON PATIENT

MANAGEMENT

All patients needed support services for discharge

Patients discharged home with ongoing close monitoring by family/carer – 66%

Patients needing support services in the community ( eg. ABI Team) – 46%

Patients needing Residential care – 20%

Patients needing further inpatient rehabilitation before going home – 13%

CONCLUSION Occupational Therapy plays a unique role in assessing

functional performance

The acute setting requires quick, efficient and effective methods of data inquiry

Need for ongoing management of disability following acquired brain injury and this has a profound impact on the wider family and support networks

It was possible to make valuable suggestions about patient’s needs due to holistic assessment approach used.

Executive functions in addition to cognitive testing should be routinely considered for all patients, following acquired brain injury

SUMMARY

Efficient and effective methods of inquiry to extrapolate executive dysfunction helps to identify issues which have an impact on functional performance following acquired brain injury

Further research in this field on a larger patient group will help provide valuable insights which will improve quality of patient care.

REFERENCES

Fuster JM. 1999. ‘Synopsis of function and dysfunction of the frontal lobe’. Acta Psychhiatr Scand Suppl; 395:51-57.

Gazzaniga M.S. Ivry R. Mangun, G. (2002) ‘Cognitive Neuroscience- the Biology of the Mind’ 2nd Ed. Norton and Company Inc. London.

• Mioshi E, dawson K, Mitchell J et al ( 2006) ‘ The Addenbrooke’s Cognitive

Assessment Revised ( ACE-R): a brief cognitive test battery for dementia

screening’ International Journal Of Geriatric Psychiatry; 21:1078-1085.

Sands LP, Yaffe K, Covinsky K ( 2003) ‘ Cognitive Screening predicts magnitude of functional recovery from admission to 3 months after discharge in hospitalised elders’. Journal of Gerontol A Biol Sci Med Sci; 58(1):37-45.

Van Iersal MB, Verbeek AL, Bloem BR et al, (2006) ‘Frail elderly patients with dementia go too fast’ J Neurol Neurosurg Psychiatry; 77:874-876.

Wilby H.(2005) ‘A description of a Functional Screening Assessment for the Acute physical setting’ British Journal of Occupational Therapy. 68(1), 39-44.

Yogev G, Hausdorff JM, Nir Giladi MD, (2008) ‘ The Role Of Executive Function and Attention In Gait’ Movement Disorders; 15;23(3):329-472.