Zanetti N.1, Fait S.,2, Ubertoni A.,3, Dissegna G.,4, Ventagli M.,5, and Venzi S.,6
- Dr.Psychological Sciences e-mail: firstname.lastname@example.org
2 Doctor e-mail: email@example.com ?
3 Psychologist e-mail: firstname.lastname@example.org
4 Physiotherapist e-mail: email@example.com
5 Physiotherapist manager e-mail: firstname.lastname@example.org
6 Ward coordinator e-mail: email@example.com
In this article, the description of a clinical case with executive functions disorder is proposed. The description is made from the point of view of the various professional figures who act interventions towards patients. The treatment and rehabilitation process is in fact the result of an integrated work that acts from many sides. The most significant passages of the path of care and assistance and the objectives achieved by the interventions implemented are highlighted. A critical consideration of the case is also made in light of the concrete process of daily assistance within the care environment. Finally, a proposal for a rehabilitation program is presented.
Key words. Disexecutive syndrome, central executive, cognitive rehabilitation frontal lobe, temporal lobe.
1 – Introduction
Dysexecutive syndrome is a particularly complex disorder being studied. It is difficult to use the classic approach of neuropsychological sciences based solely on the “symptom” (Burgess, 1997). The executive functions in fact involve many other cognitive functions, such as memory, language, attention, abstract reasoning, planning, and it is difficult to attribute the specific deficit to this function by excluding a different origin.
This aspect that makes the study complex is called “task impurity”, referring to the fact that all the tasks investigating EF inevitably involve many other cognitive functions. For this reason, it is of fundamental importance that both the assessment of the deficit, the detection by diagnostic tools, and the setting of a rehabilitation project are as precise and specific as possible. EF patients also have a very wide and diverse variety of clinical pictures and dysfunctions.
Current studies on EF try to better understand this function starting from an anatomical-functional correlation. Historically, this path has already been undertaken by identifying in the frontal lobes the seat of the most complex and advanced functions of the human being (Lurija, 1966).
With the development of increasingly sophisticated instruments of the last century, two main cognitive models have emerged: Supervisory Attentional System (Norman and Shallice, 1986) and the Central Executive model (Baddeley, 1986). It is, in particular with the Central Executive model that the term “dysexecutive syndrome” is introduced precisely to differentiate the deficits presented due to the lack of this specific function. The dysexecutive syndromes correlate with the lateral prefrontal areas, for which behavioural rigidity and planning difficulties are highlighted, with the orbital-frontal cortex, with consequent difficulties in regulating social behaviour, and with the anterior cingulate cortex, which does emerge a clinical picture characterized above all by lack of initiative (Conson, Barbarulo, Trojano, 2005).
Research in the frontal and prefrontal cortex and the study of EF are still under development to try to answer the numerous unsolved questions and to better understand the functioning of these processes, so as, to be able to create increasingly effective interventions. However, it is clear that, holistic treatment programs for this type of patient is characterized by better results, than other therapies and that the study of single clinical cases can be an elective site for the study of this pathology.
The single case study presented concerns a 75-year-old woman, called AC, no longer able to walk independently, initially hospitalized for ulcers in the lower limbs and later transferred to an assisted healthcare residence where she is currently accepted. At the entrance, several diagnostic tests were arranged to clearly define the general clinical condition.
Six chapters are written below; the first fourth describe the most important points from the specific perspective of the profession that approaches the patient, the fifth chapter deals with some critical considerations on the distance between the academic and study
world and the concrete and daily reality of the places of treatment and tries to trace a historical path of assistance provided over 3 years by integrating the different professional points of view into a single vision and with a focus on the interventions that have brought improvements, finally proposed a treatment and rehabilitation program in light of the considerations made.
2 – Medical assessment
The case presented at the entrance to the residential care facility indicates pathologies of arterial hypertension with renal organ damage, hypertensive heart disease and type II diabetes mellitus without complications, arthrosis, venous insuffciency and cognitive impairment with mixed etiology. In the specific interest of this article, one of the first tests that were requested was that of a neurological examination for suspected memory disorders. The outcome of this visit indicated that there are no obvious sensory-motor signs and that neuropsychological assessment and cerebral nuclear magnetic resonance are recommended. The following brain MRI report reports: Ventricular complex in place, regular for morphology and volume. Cyst of the pellucid septum. Regular subarachnoid spaces. Multiple small areas of ischemic-type hyper-intense T2 signal in the bilateral frontal and parietal subcortical white matter. The visit with neuropsychological evaluation, on the other hand, showed a slight cognitive impairment with a predominantly non-educational nature with associated visual-constructive difficulties.
After one year, during the redefinition of the care pathway, there is evidence of platelet already known to the medical evaluation and with indicated possible aetiology from chronic myeloproliferative syndrome. After a further year, always during the redefinition of the treatment process, the medical condition is broadly unchanged.
3 – Physiotherapy assessment
From the first examination, from a physiotherapeutic point of view, the collaborating patient is defined, with a fairly preserved joint even if the right lower limb lacks full extension at the level of the knee. Patient able to make postural passages from bed to wheelchair with support and help from a person. Interventions in an equipped gym are described but with a significant difficulty due to non-continuity in the exercises and easy distraction.
The assessment after about a year refers to the discontinuity of the patient in rehabilitation and the activation, in collaboration with the psychologist and the assistance staff, of interventions to maintain attendance at the gym and the indicated exercises. There are no significant changes.
Still, after a further year, the third evaluation reports of transfers in autonomy with the presence of a person only for supervision. Resuming walking for medium-short sections. Knee extension improved thanks to passive treatments. However, the patient’s attitude is still fluctuating with respect to this type of intervention.
4 -Psychological and Neuropsychological assessment
With reference to the initial neuropsychological assessment re-quired for suspected memory disorders and cognitive impairment, it is partially confirmed with a conclusive outcome of mild cognitive impairment with a prevalently non-executive nature and associated visual-constructive difficulties. The mnestic tests record falls in tests that investigate frontal-executive skills, there-fore attentional monitoring, inhibitory control, programming but not in the specific memory function. To go into more detail on the analyzes carried out, a collaborative attitude is highlighted during the evaluation session but with a tendency to deny the relevant cognitive difficulties and fatuous attitude. Spontaneous speech is correct from a morpho-syntactic point of view, poor lexicon and circumstantial and redundant and sometimes childish content. Understanding is adequate even if it tends to be limited to concrete contents.
The level of sustained attention is discontinuous and early saturable, the visual-motor research test for complained ipo-visus is refused. Memory, as previously mentioned, is not compromised and sufficiently adequate both in the short and in the long-term recall tests of new material.
The frontal executive functions are particularly fragile and have an overall deficit score on the FAB (Frontal Assessment Battery). Compromised the abstract-conceptual reasoning is investigated with verbal material and when visual-spatial material is used. Difficulties also emerge in the executive processes of visual-spatial planning. Within the care structure, at the first assessment carried out, it obtains a score of 4 in the SPMSQ (Short portable mental status questionnaire) in a context of mild cognitive impairment and moderate level of visual-spatial disorganization. A year after the first evaluation, there was a slight improvement in functions with a score of 2 at the SPMSQ.
During the redefinition, the importance of some interventions carried out during the year for the recovery of motor autonomies that underwent a discontinuous and strenuous trend from a relational point of view, but to which presumably is attributed an effect in improving, is underlined.
Also, during the second evaluation, the interventions on the relational and social level that characterized the care path from a more purely psychological point of view are described. It was possible to accompany the person in establishing relationships within the care environment that can provide a rewarding return. Furthermore, interventions were carried out aimed at a more specific definition of the effective relationship modalities to be activated for the personnel who deal with assistance in such a way as to strengthen the concept of “therapeutic alliance”, fundamental for a successful outcome of any assistance or rehabilitation intervention.
5 – General framework considerations
In light of the professional evaluations of the various figures who rotate around the patient during the treatment and rehabilitation process, we wish to express some considerations regarding the distance between the academic world or professional evaluation and that of the concrete and daily reality of the wards and places of care. The purpose of these considerations is to be able to out-line interventions that can then find concrete application. In fact, it happens that the interventions required are often too expensive or expensive to implement. Healthcare facilities have to deal with final and forecast budgets and, unfortunately, it is not al-ways possible to apply everything that would ideally be the best answer. However, precisely for these reasons we believe it is important to highlight these aspects. This allows you to opt for a mediation solution between the ideal intervention and the applicable intervention, thus resulting as the best solution to the problem encountered.
In the specific case treated, the assistance path considered both over time and from multiple professional points of view has revealed two main strengths. The effects that appear to have improved the patient’s quality of life are physiotherapy and motor rehabilitation interventions and relational and social interventions with professionals and other patients within the ward. We believe that these two points can be the key from which to set up an integrated rehabilitation intervention program. By working more on relational aspects, it may also be possible to implement interventions to increase motivation for treatment and strengthen the therapeutic alliance.
The patient has a deficit of intentionality in rehabilitation, in fact, even though she proves to be collaborative in the verbal contracts that are sometimes established, when the concrete implementation occurs, she puts in place behaviours of resistance. Being able to find a more functional way of communication, especially in stimulating motivation, with the patient is therefore of fundamental importance also for the e effectiveness of other types of intervention.
Numerous interventions have been carried out with respect to physiotherapy, particularly in the last year important milestones have been achieved for the increase in motor autonomy, up to the recovery of an assisted gait, even if for short stretches. The effects on mood after the treatments and results are evident and manifested with satisfaction and sharing with the assistance staff.
The relational modality that occurs instead in situations of restriction, such as during the setting of a period of food diet, is very opposing also because of the deficit, at times aggressive and offensive towards the staff. This aspect is of considerable importance since it represents the relational counterpart, as well as manifesting itself as a symptom, which needs to find more suitable, so to speak “soft” ways of containment or resolution, also in order not to invalidate the work done positively.
Even at the beginning of the rehabilitation process, physiotherapy saw fluctuating actions due to rigid opposition from the patient. Subsequently, the patient-professional relationship was changed with 1:1, while previously it was followed in a group context, and perhaps the correct relationship was found to make it more available.
The last aspect of observation that we want to indicate is that planning behaviours, even if simple and concrete, have manifested themselves by the patient. At the time of food restriction introduced due to an increase in excessive weight that threatened to make people lose motor autonomies, the patient did not prove to be cooperative. In this period, however, it was noted that it was able to plan actions to escape the diet. We believe that this aspect may be relevant to be able to use this ability for purposes that provide for the good of the person and which she or she is, in charge of, or at least, to participate in.
This observation made it clear that the motivation factor is one of the key points on which to structure the interventions and necessary to achieve the objectives.
6 – Hypothesis for a rehabilitation intervention program
Research on EF rehabilitation is still in its infancy and few studies have been conducted so far. The fundamental approaches identified are 5 mainly: training based on external signals and environmental changes, teaching of meta-cognitive strategies, training of strategic thinking, rehabilitation of specific processes, and behavioural techniques. For the specific case we are dealing with, we can say that external signals and environmental changes have been made to improve the patient’s autonomy in her life context. Some examples are devices used to facilitate the motor autonomy of getting out of bed, or even, simply, the arrangement of the bathroom mirror at a height that allows it to be used also from the wheelchair seat for the personal toilet. Interventions were made on the spot at the table during meals, in order to identify a location as favorable as possible for the patient’s well-being and the absence of complications or distractions during this moment. However, these types of techniques are not properly rehabilitative because they do not rehabilitate
the function, in any case they aim to improve the quality of life and are an attempt to eliminate or at least reduce the deficit. As for behavioural approaches with reinforcement techniques, both positive and negative, they are considered, at first sight, not very efficient and unable to obtain the result, nevertheless there is the use, even daily, when the patient demonstrates particular collaboration.
The process-specific approach turns out to be a good intervention to be structured, with motor exercises performed simultaneously for an improvement of the motor and planning function. This type of intervention is supported in the literature by studies that identify a stronger therapeutic validity. Performing multiple tasks at the same time requires sustained attention over time and requires cognitive commitment of multiple functions.
Another election approach for EF deficits appears to be the meta-cognitive one, that is, the patient’s awareness of their deficit through self-monitoring and self-regulation strategies for solving problems.
Feasible within the rehabilitation process is therefore the proposal for self-monitoring on the physical skills and exercises of physiotherapy or, again, on the patient’s communication interactions, in order to increase his meta-cognitive abilities. The goal is to stimulate meta-cognition, increase the patient’s initiative through this tool of co-participation so that it does not continue to be a passive object of the treatment but can gradually begin to become an active part of it. Self-awareness of the deficit has a significant impact on rehabilitation outcome (Fleming, Ownsworth, 2006).
7 – Conclusions
Rehabilitation of EF is a very complex process. Certainly, further studies are needed for a better understanding of the functioning of this ability, and through these the possibility of identifying more precisely appropriate interventions. In this article we have tried to give a broad interpretation of the numerous obstacles encountered in the rehabilitation process, both given by the patient’s clinical complications, but also by difficulties that are part of the concrete reality of the places where the operations are per-formed. Considering this, an attempt was made to summarize the specific case by reporting the significant steps, and, in particular, those with a positive outcome identified in physiotherapy and actions aimed at improving the relational aspects.
Finally, two interventions have been proposed (monitoring for increased meta-cognition and motor rehabilitation interventions involving multiple contemporary tasks) not yet carried out and which are not particularly di cult for the assistance process and therefore achievable.
The hope is that this short work can make a small contribution in the patient’s care process and in the general care and rehabilitation process with the occurrence of close collaboration between the different professions in actions and interventions.
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