Transcript Cognition and Behaviour - New Zealand Aged Care Association

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
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?
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
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
Language
Receptive difficulties


Can’t make sense of incoming language
Unable to follow instructions, conversations
Expressive difficulties

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
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 components
 Their relationship to one another
 Spatial orientation
 Skills in replicating/drawing
 Ability 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 inhibition
Aggression
 Sexual impulsiveness
 Social inappropriateness
 Reflexive responses
 Financial management problems
 Other signs of poor judgement

ECF Impairment can lead to;
Impaired initiation

Of activity

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Can’t get started on things without aid
Of ideas

Can’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 ECF
Our ECF is affected by
Fatigue
 Intoxication
 Cognitive overload
 Lack of practice
 Engagement in the task/situation
 Anxiety

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 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
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 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”
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!