EXECUTIVE FUNCTIONS

By Carla Cothran, RN, MSN, MAEd, Coordinator, APDA I&R Center, Birmingham, AL

Thinking is sometimes impaired in Parkinson’s disease (PD). The term “bradyphrenia” means slowed thinking, and this is a well-recognized phenomenon by patients, caregivers, and medical staff.

There is another thinking impairment in PD that is not so well known but is often the cause of much conflict between caregivers and patients.

Psychologists refer to this PD related thinking impairment as “loss of executive functions.” Neurologists often label this thinking impairment as the PD symptom apathy. Doctors and nurses may not even recognize “loss of executive functions” in their patients and become frustrated and puzzled by patients’ behaviors and the conflicts between patients and caregivers.

Defining executive functions is not easy. Executive function refers to a diverse range of abilities that share the common feature of exerting higher-level control over behavior and adjust behavior in response to changing task requirements. Words (or thinking skills) that may be used to describe executive functions are: creative and abstract thought, planning, multi-tasking, sequencing, problem-solving, attention, concentration, and controlling short-term behavior to achieve long-term goals. Executive functions may also play a role in complex social behaviors such as being tactful or deceitful or adapting old skills to new or unique situations.

The loss of executive functions in the PD patient is often very subtle and takes many months or years. Caregivers are usually the first to notice the changes in patient behavior that signal a loss of thinking ability. Social and community activities will be stopped or avoided. If the patient is still employed, co-workers may notice a change in behavior at work. An example would be a female patient who reported that she was no longer able to be the chairman of a committee at church. She was able to recognize in herself the inability to assess, evaluate, plan and implement. These are skills required to organize and motivate the committee to carry out its tasks. Another example is a male patient who reported he no longer was able to carry out tasks that took “more than an hour to complete.” He said that if he thought the task would take over an hour, he would just not do it. This gradual withdrawal from usual patterns of behavior and of day-to-day work in the world is very distressing to caregivers. In the past, doctors and nurses have told caregivers that the patient’s social withdrawal was caused by embarrassment at being seen in public with tremors or with a slowed gait or postural instability. It seems, though, that this gradual withdrawal from social interaction and into the home environment may also be due to the patient’s loss of ability to cope with the constant bombardment of external stimuli from the outside world.

Recognizing that PD patients may feel threatened or anxious by tasks that require executive functions, thinking skills may be the most effective way of lessening caregiver/patient conflicts and doctor/patient frustrations. Nurses and doctors often say that a patient “doesn’t hear anything that is said to him for the first 10 times in the clinic.” This may be true because the patient is unable to process and problem-solve his way through large amounts of information at once. A good recommendation could be to write a simple list of activities, changes in medication or steps to perform a task during the day.

Caregivers are required to take over many physical tasks for patients, e.g. cooking or driving. This is a gradual process, and the skills required to physically care for a patient are not difficult to learn. However, taking over the thinking skills for a patient is a much more puzzling and frustrating caregiver role. It seems to be unclear whether the current PD treatments are useful in preserving the executive functions in patients. Drug side effects such as hallucinations or obsessive/compulsive behaviors may compound the problem. Perhaps just naming the loss and recognizing the problem will be of some help.

Source: The American Parkinson Disease Association Winter 2005 Newsletter

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