The odds are very likely that if your client has a neurological condition, they will have low level cognitive and executive function deficits. In OT school we are taught the over-arching principles of working with cognitive deficits, but that’s where it stops. If we are being pragmatic, unless you have worked in a practice setting where you have needed to refine your competence on the restorative potential of cognition and executive function, you probably won’t be teaching it in your classes. Remember that school teaches you the bare minimum and it’s your job to research and continue learning restorative. Rehabilitative, and habilitative principles of these diagnoses! I know I say this all the time, but we are restorative aides first.  That’s how we stay true to our history, but also it’s important to know where you fit as an OTP working in rehabilitative or habilitative principles.

In outpatient rehab, you will work with many adults with progressive disorders and it will be your job as an OT to understand cognitive mechanisms and how to restore and maintain executive functioning superimposed on occupational performance! This is EVERYTHING! The occupational therapy practitioner is often times the first health care professional to spot these concerns as they become apparent during task/activity analysis when we look at  attention, executive function, memory, and behavioral components of tasks.

Cognitive-based plans of care can take into consideration cognitive enhancement medications prescribed (if any),  cognitive stimulation activities (discussion-based activities to promote stimulating mental activity), compensatory and adaptive strategies (both internal and external) for the completion of tasks while living with altered brain function, and cognitive training which is designed specifically to the patient’s cognitive deficits and incorporates elements from the client’s personal factors, environmental factors, and occupational (Activity-based) analysis [1].

You want to teach your clients about these completely temporary changes! Nobody else is helping people understand that there are SO MANY reasons that they could be experiences memory and executive function-related concerns! That’s why they need to be followed by occupational therapy!

• Debility 
• UTI
• Anesthesia 
• Dehydration
• Medication Management 
• insomnia/sleep issues
• Cancer/chemotherapy
• NEW Environment [hospital delirium]

Habilitation

So let’s explain those two terms first. In every plan of care, an OTP must decide if they are using a rehabilitative or habilitative approach. Which box are you going to check?

AOTA has a ‘Uniform Explanation of Habilitation Services’ article where they define these two principles: “Habilitative is helping a person learn something for the first time including services and devices”  [2]. For example, working with early intervention or school-based clients progressing through human development and experiencing skill acquisition for the first time. Or, those with a neurodegenerative condition or post-traumatic incident where their foundational capabilities have been altered secondary to progressive or permanent function-related, structural-related, or performance skill-related changes of the body. If you still need a visual in your mind, here are some OT-specific scenarios:

• Training a client on using adaptive mobility and adaptive equipment after a posterior hip replacement to ensure independence without breaking precautions (as of 2021-2022), more and more surgeons are using an anterior approach).
• Training a client on internal and external strategies to use for loss of memory and executive function, health management, adaptive mobility strategies, durable medical equipment, orthoses, and adaptive equipment who has a progressive neurological condition. This will be true during every stage of their illness as you must teach your clients new skills to promote independence during a new season of life. This is no different than what we more commonly do in the pediatric age group!
• Training a client on health management strategies, joint protection strategies, modalities, adaptive mobility techniques (new motor patterns) who has arthritic-natured diagnosis.

Without getting too far from executive function, Habilitation is where we live and breathe in many settings when it comes to executive dysfunction.

Rehabilitation

Then, there is rehabilitative.  According to AOTA, “rehabilitative is helping a person relearn something after an injury, illness, or disabling condition” [2]. Rehabilitative is truly restorative, and we do both. Can an occupational therapy really restore executive function and low-level cognition? The short answer is – YES! It is important to note that most of the time, 100% evolution to prior level of function is not what the goal for our plan of care is. With that said, any ability to improve a remaining function using our client’s familiar ways of performing an activity is restorative. There is available research that supports restorative potential, albeit a limited capacity, into moderate stages of Alzheimer’s Disease. As occupational therapy practitioners who are charged with allowing our client a least-restrictive (adaptations, modifications, and compensations) lifestyle while living with any diagnosis, we must do our part to explore all avenues of this major body function!

I want to express the work AOTA did on a national level from 2010-2017 to ensure that every insurance plan offered throughout the United States provided comparable benefits for both habilitative and rehabilitative benefits to expand comprehensive accessibility for occupational therapy services. Could you imagine being unable to bill for habilitative services as an OT? This is a crucial part of our domain.

Neuroplasticity [3] [4] 

• 1960’s : Dr. Bogan and Dr. Sperry did a procedure to reduce seizures by cutting into the corpus callosum. This began the work of the two hemispheres (right and left brain) [4]

• 1950’s : Donald Hebb explored the idea that “Nerves that first together, wire together” (i.e. Neuroplasticity). Look at the parts of the brain and design your treatments to fire activity in that area. OT treatments can actually change the morphology (structural elements) of the brain. [4]

• The ability of the nervous system to change on the cellular level

• Neurons or nerve cells can change their functions, the types of neurotransmitters they manufacture and transmit, and their genetic material. They can also develop more synapses, build more dendrites, and regrow after damage

• Neuroplasticity is a permanent change in the cellular structure and the way cells communicate

• Neuroplasticity exists from birth to death, age does not affect this ability – never give up on a  patient’s ability to recover

• Cognitive Reserve plays a part in the responsiveness of neuroplasticity

Cognitive Reserve (CR)

Memory is actually more complicated than you would think. There are several types of memory and each can be affected differently depending on many factors. Did you know that two people could have the exact same diagnosis, but their memory will be impacted differently and at different rates? This means that may have two patients admitted to the memory unit that require an evaluation. Both of these patients have the same diagnosis for the same number of years yet one of them will require min A x1 for all ADLs and the other will require stand by supervision.

 This all stems from what we call cognitive reserve.  Cognitive Reserve has been studied and proven benefit to many conditions aside from Alzheimer’s Disease, including vascular disease, Parkinson’s Disease, TBI, HIV, MS, and neuropsychiatric disorders [5]. Cognitive reserve suggests the brain has the ability to withstand a certain amount of injury (we are speaking about any kind of injury, even changes from disease/trauma) before symptoms of dementia become visible. In fact, based on someone’s level of education, occupational attainment, and the number of leisure activities in which they regularly engage, the brain builds a certain amount of protection against the amount of amyloid plaques in certain areas of the brain and builds greater resilience against functional performance implications. I will speak more about his in our CEU course for executive function but this idea of cognitive reserve explains the varying presentations of symptoms between those with the same diagnosis . 

Motor Components of Executive Function

Motor Elements:

Remember that the brain is all connected. If someone’s executive function is being impacted, their motor skills or various neuromuscular functions will also be implicated at some level! Especially during dual tasking (both motor-motor and cognitive-motor). Specifically, Alzheimer’s Disease and Lewy Body Dementia will impact mobility so it is important to look at the entire body during an Alzheimer’s and other related dementias or Mild Cognitive Impairment evaluations. This content is focused on executive function implications, but we can’t entirely take motor out of occupational therapy-based cognitive remedial therapy because we believe the entire body is connected and must be addressed and leveraged in the therapeutic process.

Environmental Components of Executive Function

Life Space:

Life-Space Mobility (LSM) – the spatial environment a person moves through within a specific time period. It captures social interactions, higher levels of community engagement, and real-world applications of functional skills. [6]

Mild Cognitive Impairment does not NEED to become dementia or progressive decline. Preventative actions CAN impede cognitive degeneration in memory changes due to age. [6]

Longitudinal analysis found that individuals who are restricted to home versus those who are not have a higher risk of developing mild cognitive impairment, Alzheimer’s Disease, and accelerated decline in global cognitive function. [6]

What is the difference between cognitive and executive function?

 That’s a loaded question. Technically, the two things are the same. If you want to be specific (I prefer specifics), cognition is divided into low level cognitive function and executive function. Executive function controls the low level cognitive tasks. If someone is experiencing deficits in low level cognitive tasks then you know beyond a shadow of any doubt that their executive functioning capabilities are also being impacted. Occupational therapy practitioners tend to live in the executive dysfunction space because we specialize in rehabilitation of dual tasking (motor-motor or motor-cognitive). All occupations require dual tasking.

Types of  executive functioning impairments

Poor abstract thinking ability, impulsivity, confabulation, planning deficits, poor temporal sequencing, lack of insight, disinhibition, perseveration, and distractibility,

For a larger list, check out the Executive Function OT Profile

Types of attention and concentration being impacted

Remember, when writing your OT goals for Executive Function, mainly attention deficits, you need to first consider where they are in the attention continuum!

Consider the building blocks phasic Alertness and response inhibition and then where they fall in focused, sustained, selective, alternating, and divided attention. You can only maximize restorative potential prior to a habilitative approach if you know where you are starting! This will also help you design your intervention activities.

For a video and more detailed explanation of the attention continuum, check out the Executive Function OT Profile

Types of memory processes being impacted

In order to ensure your multi-modal and purpose-driven treatments are addressing the RIGHT memory concern, the OTP needs to be aware of the various types of memory. I will briefly list some here, but for more elaborate information, you will want to head into the BOT Portal for training and printable treatment resources.

Sensory memory , Working memory, Short-term memory, Long-term memory which is split between explicit and implicit memory

Remember that there are way more resources, videos, and explanations on interventions for occupational therapy regarding executive function on the BOT Portal. I am talking about ways to address attention impairments, visual memory, using the environment as a modality for intervention, ways to incorporate caregiving, and of course medication management, spaced retrieval therapy, and face recognition training,  but these things are only a small part of the potential occupational therapy has to work with executive functioning. For that reason, I want to highly two main intervention approaches an occupational therapy practitioner can incorporate when working with executive dysfunction and deficits in low level cognition.

Cognitive Remedial Therapy and Dual Tasking

Dual Tasking (DT) is an advanced function used in almost every activity within the 9 domains of occupation. It combines two high level functions like walking and talking when you are with friends or listening and writing while actively making connections to learn new information. Have you ever listened to your teacher while taking amazing notes but still fail to recall a single thing you discussed at the end of the day? This is decreased DT performance!

I wish I could discuss all of the research I have done in dual tasking, but that will need to wait for the executive function continuing education course I will build, instead I will focus on a systematic review of 14 total studies comprised of randomized controlled studies and repeated measure designs.

Fritz et al. (2015) helps us understand that the ability to multitask stems from an individual’s ability to have divided attention and their ability to perform the desired motor component(s). In fact, divided attention impairments and dual tasking deficits are seen in most neurological conditions [7]. How would you see these impairments? If your client is nervous, has symptoms of anxiety, or is having a social conversation during treatment while you have asked them to engage in an unsupported static sitting or standing activity, you may see them “wobble”, “become shaky”, or begin to “slump”. Balance, posture, pace and pattern of gait, and stability are all correlated to an individual’s ability to dual task. Thankfully, available studies show that in mild to severe brain injury deficits, dual tasking training has been shown to improve balance, gait speed, tolerance for complex activity, and the cognitive function itself [7]. How do we know this relates to occupational therapy? They use assessments we use in everyday practice like trail making test, STROOP, and MoCa on individual’s diagnosed with moderate Alzheimer’s disease, Parkinson’s disease, and other acquired brain injuries. This information tells us that your patients with advanced years have hope and potential for restorative treatment! Not just compensations and caregiving training!

So, let’s bring the early part of the conversation back into the mix and talk about cognitive reserve.  Stern states that by combining a cognitive intervention with an aerobic or mobility-based exercise we hope to invoke a synergistic effect. The active exercise may in boost brain reserve to improve plasticity and upregulation of BDNF and the cognitive intervention may increase cognitive reserve by staying the efficiency of the cognitive networks underlying executive control [5]. By doing this, the occupational therapy practitioner leverages the body functions, structures, AND performance-based aspects of activity performance (which is the very nature of the occupational therapy process!).

What are some of the outcomes and possible interventions?

 Serial Subtractions while ambulating using a tandem gait pattern.  Just a note on this example, you can also phrase it : “Walking heel to toe while counting backwards”. One is the skilled language of an activity analyst and one is something an unskilled person can lead in gym class. Elevate your practice by elevating the language you choose to use.

 Catch/Release gross motor coordination activity while ambulating while categorizing (Bouncing a ball and forth while listing words in a single category)

 Ambulating with good obstacle clearance while using working memory to retrieve answers for questions based on a previously spoken/read narrative (walk around and over obstacles while answer questions about a story)

 Dynamic stepping outside base of support in multiple planes of movement while repeating digit spans or digit span reversals (stepping out to the sides, forward, and backward while repeating the numbers the therapist reads)

Finally, in an article by Lemke et. Al. (2019) entitled, “Transferability and Sustainability of Motor Cognitive Dual-Task Training in Patients with Dementia: A Randomized Controlled Trial” it is suggested that designing a dual tasking plan of care in a continuum from basic, trained, multi-component dual tasking activities to use dual tasking activities very similar to the demands of the activity being challenged in everyday life are proven to demonstrate good transfer and generalizable into the skills required for dual tasking events when not in therapy [8].  .

Additional Resources :

Cognitive rehabiliation in Alzheimer’s Disease [1]

Targeting Functional Decline in Alzheimer Disease: A Randomized Trial [9]

Transferability and Sustainability of Motor Cognitive Dual-Task Training in Patients with Dementia: A Randomized Controlled Trial [8]

Metacognition

What is metacognition? You probably don’t use the word that often, but I am 100% certain that you are addressing metacognition in every occupational therapy treatment. Why? Because it is an integral aspect of the following actions: global occupational performance, your client’s willingness and desire to participate in therapy, and a crucial component of therapeutic potential (whether you client will have good, long-lasting results from therapy or be discharged with limited observed functional gains).

More specifically, metacognition is the ability to think about thinking and occurs when self regulation is applied to cognition. It is the ability to set goals, decide how to alter one’s behavior to better meet these goals, and implement new behavior to act upon that desire [10]. When working in the biopsychosocial framework, it is often necessary to provide formal opportunity and training to maximize residual cognitive abilities, using Metacognitive Strategy Instruction (MSI) allows for the remediation of executive function disorders following acquired brain injuries [10].

If you have ever learned Bloom’s Taxonomy, which is a metacognitive perspective on categories of learning, you will have a better understanding of the conversation you need to facilitate in the treatment based on individual needs. After initial evaluation, you will understand where to start in the process from asking your patient to “remember and describe” daily events and through the continuum. The continuum is as follows: Remember, Understand, Apply, analyze, Evaluate, and Create. If you have never looked into Bloom’s Taxonomy, I would encourage you to do so!

So, how can you apply this to your treatments? The largest and most obvious way is leave time for the modality itself! Remember that modalities used within a treatment differ between professions based on their practice guidelines and scope of practice. For the occupational therapy practitioner, metacognitive instruction IS a modality to produce physical outcomes because of the frameworks by which we abide. What should you guided conversation look like?

1. Identify an appropriate goal based on current deficits/impairments
2. Have the patient anticipate what they need to do in order to reach that goal
3. Have the patient identify possible solutions to challenges and barriers they may face to reach the goal
4. Have the patient self-monitor and evaluate progress throughout the occupational therapy process
5. Have the patient modify the behavior or strategy in use if they are not making adequate progress.

By employing MSI into ever treatment and intervention when working with executive dysfunction, you call upon types of brain function that can only be improved and activated during the practice of metacognitive skills. This will also help you remain client centered and empower your patient to be in control of their care.

Some other helpful references:

Resilience of Metacognition in a dual-task paradigm [11]

Metacognition of Multitasking: How Well Do We Predict the Costs of Divided Attention? [12]

Information–integration category learning and the human uncertainty response[13]

Does metacognitive strategy instruction improve impaired receptive cognitive-communication skills following acquired brain injury?[10]

Clinical Applications of Problem-Solving Research in Neuropsychological Rehabilitation: Addressing the Subjective Experience of Cognitive Deficits in Outpatients With Acquired Brain Injury[14]

Cognitive rehabilitation after severe acquired brain injury: current evidence and future directions

[15]

In conclusion, Occupational Therapy has a crucial role in the treatment of cognitive and executive dysfunction. OT has a role that is exclusive to the occupational therapy knowledge base and must be utilized in order to help a patient arrive to their full functional capacity. Dual tasking and metacognitive strategy instruction are two approaches to execute in your OT treatments. Please look for the executive function resources on the BOT Portal to help you better execute these thoughts in every day practice! Thank you for listening and we will talk soon!