Introduction

An important aim of rehabilitation is to enable patients to contribute – wherever possible to the management of their condition. Eventually, most patients will need to be discharged from a health-care setting and, if left with a long-term condition such as multiple sclerosis (MS) or stroke, learn to live their lives as fully as possible. Self-management of one’s long-term condition requires patients to be motivated and able to articulate appropriate goals, follow a plan, adjust their behaviour where necessary, and reflect on progress. Patients with clear and realistic goals, who are keen and driven, are often ‘easy’ to work with. In contrast, those with difficulty formulating appropriate goals, sticking to a plan, apparently lacking in motivation or displaying disruptive behaviour are much more of a challenge.

Case study 12.1 describes a person with executive dysfunction and indicates the challenges this may pose for the person themselves, their family and health-care professionals involved in their rehabilitation.

Case study 12.1

Mr F., a 26-year-old self-employed painter and decorator, has recently been discharged from neurosurgery, where he was treated for a traumatic brain injury (TBI) affecting mainly both frontal lobes (left more than right). Mr F. is the victim of an assault; he was attacked in the street by strangers after leaving his church. He sustained multiple head injuries, including a basal skull fracture, due to blows to his head.

Mr F. has just been admitted to an in-patient unit for further rehabilitation.

Mr F. has been married for 2 years and his wife is expecting their first child in 3 months’ time. Before the accident, Mr F’s hobbies were playing the flute in a local orchestra and organising charity events in his church. Mr F. was known to be kind and considerate and was respected for his excellent organisational skills.

Initial assessment by the multidisciplinary team yields the following information. The main effects of the TBI are: right-sided weakness, reduced motor control of his right arm, including loss of fine dexterity, reduced weight bearing on the affected leg and poor balance. During transfers and more complex activities of daily living, Mr F. demonstrates disorganised behaviour, e.g. he often forgets that he has already placed in a teabag in a cup when making tea, repeats this action even when a therapist points out to him that he has already done so, and is easily distracted. Mr F.’s speech and swallowing have also been affected; Mr F. has difficulty expressing himself because of dysarthria and dysphasia. Marked changes have been observed in Mr F’s overall behaviour since the accident; he is irritable, makes inappropriate jokes and has emotional outbursts. He seems to be unaware of how this affects others and does not seem to care. He appears to be unconcerned about his wife who is pregnant, and who has reported that her husband has been verbally aggressive towards her – a behaviour that is ‘totally out of character’.

Mr F. is unable to undertake any activities of daily living independently, despite his physical recovery, and requires constant supervision from the occupational therapist to complete activities such as dressing and food preparation. Especially during his speech and language therapy sessions, Mr F. often gets frustrated and upset, and sometimes refuses to cooperate.

Mr F. has been referred for further in-patient specialist rehabilitation in order to reduce his impairments, improve his activities of daily living, address his communication needs and behavioural difficulties, and prepare him for discharge home in 3 months’ time. Mr F.’s own goal is to go home next month and resume his business.

It is clear from this case study why one of the most important goals of Mr F.’s treatment plan is to address his challenging behaviour, as this affects his relationship with his wife, and could affect his recovery as well as prospects of community re-integration and return to work.

The behaviour of patients with executive dysfunction like Mr F. is often misinterpreted as ‘unmotivated’, ‘un-cooperative’ or ‘disruptive’. This, in turn, may jeopardise their relationships with family, health-care professionals and colleagues.

Thus, executive dysfunction is one of the most persistent and disabling effects of brain injury (McDonald et al. 2002) and can be one of the most difficult problems to manage (Worthington 2003). It may present a real bottleneck for rehabilitation and participation in the wider community, as patients may have considerable and ongoing difficulties in forming and maintaining personal relationships and meeting job requirements (Burgess 2003).

This chapter on executive dysfunction aims to explain how a number of neurological conditions may affect a person’s ability to plan and govern their behaviour as well as their emotions, and deepen your understanding of these difficulties and the impact they may have. This chapter will introduce the concept of normal executive function, describe the signs and symptoms of executive dysfunction, outline the role of specific areas of the brain in executive function, and finally discuss the implications of executive dysfunction for rehabilitation.

Executive function

Daily life is governed by executive functioning. Consider the following scenario: you enter the hospital ward in the morning, where new patients have been admitted overnight – some of which require urgent care. One of your colleagues is off sick, hence you need to prioritise your workload, plan which patients you will see first, inform the consultant, keep track of time, consider how you could involve another colleague, talk to patients’ anxious relatives while trying not to be distracted by other conversations around you, and ensure that your notes are up to date for the next colleague. All the time, you are governing your behaviour, which involves a number of executive processes. There is debate on how many executive processes there are, with some models including just one and others including multiple. Smith and Kosslyn (2007) identify the following five executive processes:

• Selective attention focusing on achieving one’s goal (i.e. executive attention)

• Switching executive attention from one activity to another

• Inhibiting/ignoring information that has already been registered

• Planning a sequence of activities

• Monitoring behaviour.

The notion of a central executive was proposed by Baddeley (1986), although Stuss and Alexander (2000) emphasised that there is no unitary executive (i.e. a ‘homunculus’, or ‘ghost in the machine’) that is solely responsible for this function, nor is there a single anatomical site in the brain where executive function resides. Instead, executive function is understood to comprise a number of different yet interrelated processes that enable us to engage in metacognition; a supervisory function that governs underlying cognitive functions of attention, thinking, problem solving and memory, and which enables us to reflect on processes themselves. Which processes and brain regions are involved in executive functioning depends on the task and its complexity, the intention and context in which it takes place (Stuss and Alexander 2007).

Executive function is particularly important in situations where one is learning a complex or new behaviour (Stuss 1992), as is often the case in adjusting to life after brain injury.

Taken together, executive function has been described as:

‘… the abilities that enable a person to establish new behaviour patterns and ways of thinking and to introspect upon them’

(Burgess 2003, p. 302.)

The ability to introspect, or self-reflect, is necessary for self-awareness, as well as for being aware of other people’s thoughts and emotions (Stuss and Levine 2002). Furthermore, self-awareness is necessary for self-regulation, which is the ability to orchestrate one’s behaviour in the direction of one’s goals, taking account of constraints (Stuss and Levine 2002). Stuss (1991, 1992) proposed a model that comprised executive function as part of the self: in his hierarchical model of interacting levels of information processing, the lowest level covers sensory and perceptual functions, the second level comprises executive functions, while the highest level represents self-reflection and meta-cognition.

Although executive function, self-awareness and self-regulation are different, all three are often found impaired in people with frontal lobe lesions (Stuss and Benson 1986), such as frontal lobe tumours, traumatic brain injury or the later stages of Alzheimer’s disease.

Executive dysfunction

Terminology used in the literature for impaired executive function include: dysexecutive function, dysexecutive syndrome, and frontal (lobe) syndrome. Although there is robust clinical evidence that executive dysfunction is often associated with frontal lobe lesions, the term ‘frontal (lobe) syndrome’ has been criticised, because executive functions are likely to extend beyond the frontal lobe (e.g. executive dysfunction has been observed in cerebellar patients, see Case Study 12.3). Additionally, it is probably more useful to focus on a patient’s behavioural problems, rather than a presumed anatomical lesion site (Baddeley 1996). Furthermore, given the complexity and diversity of executive function described above, it is only logical that there is no such thing as a unitary ‘executive dysfunction’ (Stuss and Alexander 2007).

Case study 12.3 Effects of goal management training on executive dysfunction

Schweizer et al. (2008) evaluated the effects of goal management training (GMT), devised by Robertson (1996), in a male person with executive dysfunction, initiated at approximately 4 months following a right-sided cerebellar stroke. This 41-year-old patient experienced a rupture of an arteriovenous malformation in the right cerebellar hemisphere, resulting in focal cerebellar damage. Before this event, he had been employed as a high-level bank executive. Following neurosurgery, the patient was referred for 5 weeks of inpatient rehabilitation, concentrating on gait and speech. The patient was also referred for a neurobehavioural assessment, where executive dysfunction was noted. At follow-up, some 8 weeks after the acute event, the patient complained about dizziness upon sudden movement, slurred speech, and an inability to get back to work because of slowed thinking and impaired organisational skills. A detailed neuropsychological assessment was undertaken, following which GMT was instituted. GMT uses task breakdown, self-prompting to halt automatic behaviours that impede progress, resuming control and monitoring progress with a task, to overcome disorganised behaviour. The intervention consisted of 2-hour sessions, once per week for 7 weeks. The effectiveness of GMT was assessed using a battery of standardised tests for attention and executive function, administered before, immediately after and 4 months after the completion of the GMT. Interestingly, before the treatment commenced, the patient’s wife reported a greater number of difficulties than did the patient – an indication of the patient’s lack of insight into his problems.

Following the intervention, improvements were noted in a number of outcomes, while there was an indication that the patient had become more aware of his difficulties. In functional terms, the patient was able to return to work, while his spouse noted that the symptoms of executive dysfunction had disappeared.

Many patients undergoing rehabilitation, especially those who have experienced a crisis in their life, or whose condition will make it unlikely that they will be able to return to their ‘old way of life’, are challenged to find new behaviours, solve new problems and reflect on these. In the case of Mr. F (case study 12.1) limited use of one side of his body means that transferring from bed to wheelchair presents an entirely new problem. This may be compounded if his problem-solving capacity has been reduced. Mr F. may ‘get stuck’ and become frustrated – especially if he is unable to communicate effectively. Unable to govern his behaviour and being unaware of what is appropriate in a certain situation, he may vocalise his frustration and cause disruption. To compound the situation even further, Mr F. may lack the ability to reflect on his behaviour, remaining unaware that he has caused upset to others. This apparent lack of sensitivity towards others may cause even more upset – particularly if family members are unaware of executive dysfunction. Education has, therefore, an important role to play in the rehabilitation of people with executive dysfunction.

Following discharge, new problems are likely to emerge: not only will Mr F. need to adapt to the new role of being a father (a challenge in itself!), but also he is likely to need a new job to match his changed abilities, and to adjust to living with these impairments, activity limitations and participation restrictions.

In some cases, where the person will not be able to go back to their former lifestyle, but needs to create a new identity with new roles and a new purpose in life, it might actually be more appropriate to use the term ‘habilitation’ (from the Latin habilitat, meaning ‘made able’, (Oxford English on-line Dictionary)) rather than ‘re-habilitation’. In these circumstances, executive behaviour is often challenged, and patients and their families need to be resourceful to be able to solve the many problems they are suddenly confronted with.