Executive Functions

Executive functions are self-direction activities include goal setting, planning, organizing, initiating actions,sequencing steps in a procedure, self-monitoring and evaluation. A person who has challenges in this area may seem to lack motivation, be disorganized or lack good judgement. In addition to brain dysfunction,fatigue can play a role in disrupting executive functions.

Lack of good judgement may lead the individual to act before thinking, putting the loved one at risk of injury from a fall or fire. The person may be disinhibited and act inappropriately in public or in social situations.Problem solving is impaired and the individual may fail to correct errors that have been made.

You may notice that your loved one procrastinates when an activity requires organization or a multi-step sequence of actions. The individual may be confused and lack the ability to conceptualize or plan activities. No matter how small the task, the person may find it overwhelming - so it is less threateningand anxiety-provoking to simply to procrastinate and not start the activity. This can be extremely frustrating for caregivers and others, and may be interpreted as laziness.

Sequencing is an executive function issue. Individuals may recollect thoughts or ideas, but they may not be recalled in the right order. Phone numbers may become confused. At the task level, the individual may not be able to remember the right order of doing things. For example, the loved one may not be able to navigate through the sequence of steps needed to access computer files or to make a pot of coffee.

One of the most common signs of disorganization is failing to complete day-to-day tasks; a once tidy home becomes a proverbial “bomb site.” The person’s home office becomes a mess and month-to-month business records become a thing of the past, replaced by envelopes and boxes of unsorted records.Getting organized in the morning and getting ready for the day may become stress-filled and/or an insurmountable task. You may observe significant frustration as the individual struggles to get organized on a daily basis.

• Work on personal organization matters during times of low fatigue and high energy combined with a positive mood - feeling disorganized can be an embarrassment, and attempts to help may be seen as threatening or at best, condescending.
• Find an acceptable form of personal organizer (e.g., a day timer,paper or electronic calendar). Help the individual set up a daily schedule and write the list in a notebook that fits in the person’s pocket or handbag. (Or place copies of the schedule in multiple locations.)
• Encourage routine in organizing personal items.
• Help the individual re-establish a routine for personal organization.
• Set up a to-do list and check off activities as they are completed.
• Set appropriate time frames for getting tasks done.
• Set up cues (e.g., alarm watch, calendar reminder function on a smart phone or iPad, or phone calls from family) to remind the individual to start a task. (Note: Get the individual’s agreement first as frequent telephone calls may be viewed as harassment.)
• Encourage the individual to get involved in activities previously enjoyed (e.g., physical activity and exercise, hobbies) that the person can still do.
• Help the individual recognize and follow through with the classic problem solving steps, i.e.,
  • What is the real issue?
  • What are the facts?
  • What do you want to have happen (goal)?
  • What are the alternatives and the pros and cons to these alternatives?
  • What is the best alternative?
  • Make a game out of thinking through problems and developing alternative solutions.
  • Play games requiring strategy (e.g., card or board games) to rebuild executive function skills.
  • Encourage repetition in writing down phone numbers.
  • Break down day-to-day tasks into consistent steps and write them down. For example, post a list of the steps to do laundry (with photos if helpful) by the washer and dryer.
  • List the steps required to use the computer on a sticky note affixed to the computer (e.g.,how to turn it on; access the correct program; access saved files; save a file etc.).