Cognition and Behaviour

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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

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Components of Cognition tested on MMSE or similar

• Orientation
• Registration
• Attention/Calculation
• Recall
• Language
• Design
• Construction

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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?

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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

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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

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Language

• Receptive difficulties
• Cant make sense of incoming language
• Unable to follow instructions, conversations
• Expressive difficulties
• Cant 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

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Design

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

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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)

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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)

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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)

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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)

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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

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ECF Impairment can lead to

• Impaired inhibition
• Aggression
• Sexual impulsiveness
• Social inappropriateness
• Reflexive responses
• Financial management problems
• Other signs of poor judgement

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ECF Impairment can lead to

• Impaired initiation
• Of activity
• Cant get started on things without aid
• Of ideas
• Cant think of things that need doing, generate
  options

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ECF Impairment can lead to

• Distractability
• Intrusions
• Cant keep focussed on task
• Perseveration
• Inability to stop a behaviour when it is no
  longer useful

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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

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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

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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

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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

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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

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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.

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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

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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.

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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!