Danielle H. E. Boelen

Executive dysfunction in chronic brain-injured patients: Assessment in outpatient rehabilitation

In this study 81 chronic brain-injured patients referred for outpatient rehabilitation, who complained of executive impairments in daily life situations and were observed by proxies and therapists to have such problems, were assessed using various tests and questionnaires of executive functioning, such as the BADS and the DEX Questionnaire. The main purpose was to examine the sensitivity of these instruments in this particular group of patients. The tests and the DEX were also administered to healthy controls to investigate which of the instruments discriminate optimally between patients and controls. The results indicate that the tests as well as the questionnaires were sensitive to the executive problems of the patients. There were no significant differences between DEX ratings of patients, proxies and therapists. This suggests that patients who were eligible for outpatient rehabilitation showed relatively intact awareness into their executive problems. A specific combination of three “open-ended” tests and the DEX contributed significantly to the prediction of group membership.

Rehabilitation of executive disorders after brain injury: Are interventions effective?

In this paper, the effectiveness of interventions for executive disorders was reviewed. The objective was to evaluate the internal and external validity of intervention studies. A total of 46 papers, describing 54 studies, conducted in the last two decades meeting several preset inclusion criteria, was included in this review. The studies were categorized into three treatment approaches in order to enhance comparability. The overall results show that many interventions yield positive outcomes and seem to be effective in reducing executive problems in brain-injured subjects. However, several studies have only an explorative intent and are based on less sophisticated experimental designs. The verification of their results is generally more tenuous. The internal validity, or the set-up of experimental conditions necessary to draw valid conclusions about treatment effectiveness, including the choice of well-matched control groups, or the randomization of patients over treatment and control conditions, is not always strong. The same conclusion can be drawn for the external validity of a number of the intervention studies; often evidence of generalization to real-life situations, long-term follow-up, and transfer to non-trained situations, were (partially) lacking in the studies under review. The authors are aware that the design of proper randomized controlled trials for the investigation of the treatment effectiveness of executive disorders is cumbersome and time consuming. Nonetheless, the provisional results of several well-designed studies described in this review make the effort worthwhile.

A randomized controlled trial on errorless learning in goal management training: study rationale and protocol.

BackgroundMany brain-injured patients referred for outpatient rehabilitation have executive deficits, notably difficulties with planning, problem-solving and goal directed behaviour. Goal Management Training (GMT) has proven to be an efficacious cognitive treatment for these problems. GMT entails learning and applying an algorithm, in which daily tasks are subdivided into multiple steps. Main aim of the present study is to examine whether using an errorless learning approach (preventing the occurrence of errors during the acquisition phase of learning) contributes to the efficacy of Goal Management Training in the performance of complex daily tasks.Methods/DesignThe study is a double blind randomized controlled trial, in which the efficacy of Goal Management Training with an errorless learning approach will be compared with conventional Goal Management Training, based on trial and error learning. In both conditions 32 patients with acquired brain injury of mixed etiology will be examined. Main outcome measure will be the performance on two individually chosen everyday-tasks before and after treatment, using a standardized observation scale and goal attainment scaling.DiscussionThis is the first study that introduces errorless learning in Goal Management Training. It is expected that the GMT-errorless learning approach will improve the execution of complex daily tasks in brain-injured patients with executive deficits. The study can contribute to a better treatment of executive deficits in cognitive rehabilitation.Trial registration(Dutch Trial Register): http://NTR3567

Who benefits from treatment for executive dysfunction after brain injury? Negative effects of emotion recognition deficits

Deficits in emotion recognition, a crucial aspect of social cognition, are common after serious brain injury, as are executive deficits. Since social cognition and executive function are considered to be separate constructs, our first aim was to examine the presence of emotion recognition problems in brain injury patients with dysexecutive problems. We studied 65 brain injury patients of mixed aetiology participating in a randomised controlled trial evaluating the effects of a multifaceted treatment for executive dysfunction (Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2010) and 84 matched controls with a test for emotion recognition. Results showed that, in patients with acquired brain injury exhibiting executive deficits, emotion recognition deficits are also present. Male patients are more impaired than female patients, irrespective of aetiology. Our second aim was to investigate whether emotion recognition problems negatively predict the results of the treatment programme. Pre-treatment emotion recognition performance significantly predicted resumption of roles in daily life (Role Resumption List; RRL) and performance on an ecologically valid test for everyday executive functioning (Executive Secretarial Task; EST) post-treatment and, in addition, interfered negatively with treatment condition. Moreover, worse pre-treatment emotion recognition skills affect the learning of compensatory strategies for executive dysfunction negatively, whereas pre-treatment dysexecutive deficits do not.

Moderators, Mediators, and Nonspecific Predictors of Treatment Outcome in an Intervention for Everyday Task Improvement in Persons With Executive Deficits After Brain Injury

OBJECTIVE To identify moderators, mediators, and predictors of everyday task performance after an experimental combination of errorless learning and goal management training. DESIGN Predictor analysis of a randomized controlled intervention trial. SETTING Outpatient rehabilitation centers. PARTICIPANTS Patients (N=60) with acquired brain injury of nonprogressive nature with a minimal postonset time of 3 months. INTERVENTIONS Participants were randomly allocated to 8 sessions of errorless or conventional goal management training. MAIN OUTCOME MEASURE Everyday task performance, assessed at baseline and after treatment by evaluating correct, ineffective, and missing task steps. RESULTS Demographic variables, neuropsychological test performance, subjective cognitive function, and quality of life were selected as candidate predictors. The results showed that age (P=.03) and estimated intelligence quotient (IQ) (P=.02) emerged as moderators. Higher age was associated with better everyday task performance after conventional goal management training, whereas higher IQ was associated with better performance after errorless goal management training. Higher executive function scores after training predicted improved everyday task performance across the 2 treatment conditions (P=.04). CONCLUSIONS The identified predictors may contribute to a more tailored cognitive rehabilitation approach in which treatments and patients are better matched when clinicians decide to train everyday tasks.

Validity of an Adapted Scoring Method for a Modified Six Elements Test in Individuals with Brain Injury

The Modified Six Elements Test (MSET) assesses several executive functions. We examined whether an adapted scoring method is appropriate for discriminating between brain-injured persons with and without executive deficits. A MSET was administered to 70 participants with acquired brain injury in the chronic phase. The group was divided into individuals with and without executive impairments based on several other executive tests. The discriminative value for both the conventional raw score and the adapted scoring method was evaluated using receiver operating characteristic analyses. Both scoring methods discriminated significantly between persons with impaired and unimpaired executive functions (raw score: area under the curve, AUC = 0.703, p = .004; adapted score: AUC = 0.780, p = .000). Only the adapted scoring method proved sensitive (81%) and specific (67%) within a clinically useful range. Within this range, an acceptable cut-off score could be determined. Altogether, the proposed MSET scoring index is a potentially clinically useful contribution to the measurement of executive functions.

Interrater Reliability and Concurrent Validity of a New Rating Scale to Assess the Performance of Everyday Life Tasks in Dementia The Core Elements Method

Errorless learning (EL) is an instructional procedure involving error reduction during learning. Errorless learning is mostly examined by counting correctly executed task steps or by rating them using a Task Performance Scale (TPS). Here, we explore the validity and reliability of a new assessment procedure, the core elements method (CEM), which rates essential building blocks of activities rather than individual steps. Task performance was assessed in 35 patients with Alzheimer’s dementia recruited from the Relearning methods on Daily Living task performance of persons with Dementia (REDALI-DEM) study using TPS and CEM independently. Results showed excellent interrater reliabilities for both measure methods (CEM: intraclass coefficient [ICC] = .85; TPS: ICC = .97). Also, both methods showed a high agreement (CEM: mean of measurement difference [MD] = −3.44, standard deviation [SD] = 14.72; TPS: MD = −0.41, SD = 7.89) and correlated highly (>.75). Based on these results, TPS and CEM are both valid for assessing task performance. However, since TPS is more complicated and time consuming, CEM may be the preferred method for future research projects.

Transfer effects of errorless Goal Management Training on cognitive function and quality of life in brain-injured persons

BACKGROUND Previous findings had shown that the addition of errorless learning to traditional Goal Management Training (GMT) resulted in superior results when training everyday tasks in persons with executive deficits after brain injury. OBJECTIVE To investigate the additional effects of an errorless GMT on cognitive function and quality of life after acquired brain injury. METHODS This is a supplementary analysis of findings from an RCT in which 67 patients with executive impairments after acquired brain injury were randomly allocated to an experimental errorless GMT (n = 33) or conventional GMT (n = 34) to train two individually chosen everyday tasks. Objective cognitive function using neuropsychological tests, subjective cognitive complaints and quality of life using questionnaires were assessed before and after training. RESULTS No significant interaction effects between these three types of outcome measures and the two forms of GMT were found. Irrespective of treatment, performance on two executive tests (Modified Six Elements Test; p = 0.006, Zoo Map test; p = 0.001) improved and daily executive function problems as reported by the participants (EFI; p = 0.001) and proxies (DEX; p = 0.01) diminished. CONCLUSIONS Besides the previously found superiority of errorless GMT when training everyday tasks, additional improvements in cognition and quality of life did not differ between the two treatments.

Script generation and the dysexecutive syndrome in patients with brain injury

Objective: The authors investigated whether patients with brain injury suffering from dysexecutive symptoms had difficulties with script generation. Method: Forty-eight patients with brain injury of various etiology with complaints of executive dysfunctioning and deficient scores on executive tests were included in this study. They were compared with 99 healthy control subjects in a script-generation task. Participants were asked to describe how they would perform eight everyday activities. The script items were manipulated so that they varied in structure (open-ended vs. closed) and in frequency of performing (high vs. low). Results: Patients and control subjects evoked an equal number of actions, but patientsproduced significantly more irrelevant actions and made significantly more perseverative errors. Their most pronounced problems were found in open-ended and low-frequency scripts. Conclusion: This investigation shows that not only patients with prefrontal damage are impaired in script generation. The consequences for treatment are discussed.

Reliability of an Adapted Version of the Modified Six Elements Test as a Measure of Executive Function

The Modified Six Elements Test (MSET) is used to examine executive deficits—more specifically, planning deficits. This study investigates the reliability of an adapted version of the MSET and proposes a novel scoring method. Two parallel versions of the adapted MSET were administered in 60 healthy participants in a counterbalanced order. Test–retest and parallel-form reliability were examined using intraclass correlation coefficients, Bland-Altman analyses, standard errors of measurement, and smallest real differences, representing clinically relevant changes over time. Moreover, the ecological validity of the adapted MSET was evaluated using the Executive Function Index, a self-rating questionnaire measuring everyday executive performance. No systematic differences between the test occasions were present, and the adapted MSET including the proposed scoring method was capable of detecting real clinical changes. Intraclass correlations for the test–retest and parallel-form reliability were modest, and the variability between the test scores was high. The nonsignificant correlations with the Executive Function Index did not confirm the previously established ecological validity of the MSET. We show that both parallel versions of the test are clinically equivalent and can be used to measure executive function over the course of time without task-specific learning effects.