When working with cognition in occupational therapy, we recognize a spectrum of cognitive processes, from low-level cognition—such as sensory processing and reaction time—to executive functions, the brain's command center. Executive functions represent the higher-order processes that govern decision-making, planning, working memory, and emotional regulation. These processes are crucial for managing complex daily tasks, and their dysfunction can have profound effects on independence and quality of life.

Elements of Executive Function:

• Working Memory: The ability to hold and manipulate information temporarily, vital for tasks like problem-solving or following multi-step instructions.
• Inhibition: The capacity to filter distractions and control impulses, essential for staying on task.
• Cognitive Flexibility: The ability to adapt to new rules, environments, or demands, critical for problem-solving and multi-tasking.

The functional connectome of the brain highlights the interconnected nature of these processes. Executive functions are not isolated to a single region but arise from the interaction of networks across the prefrontal cortex, parietal lobe, subcortical structures, and cerebellum. Understanding these networks is essential for occupational therapy practitioners working with adults (or any human being), as it informs how we address cognitive deficits and how we collaborate with interdisciplinary teams.

It is imperative that any occupational therapy practitioners interested in employing strategies that impact ‘functional cognition’ respects and utilizes the existing lexicon of cognitive neuroscience, ensuring that our practices are rooted in rigorous, evidence-based frameworks. This approach allows us to effectively support clients while fostering collaboration with other disciplines.

Executive Function Support Tasks: Compensations and Adaptations

Those with executive dysfunction may struggle with initiating, sequencing, or completing daily tasks. As occupational therapy practitioners, our role is to provide compensatory strategies and adaptations to ensure clients maintain autonomy and dignity, regardless of their cognitive status.

Key Examples of Supportive Strategies

• Technology-Based Solutions:
• Digital Calendars and Reminders: Help clients manage appointments and daily schedules.
• Voice-Activated Devices: Assist with tasks like creating to-do lists or setting reminders.
• Environmental Modifications:
• Visual Schedules: Step-by-step task instructions displayed in a prominent location.
• Labeled Storage Areas: Reduce cognitive load for item retrieval.
• Task Simplification:
• Break down complex activities into smaller, more manageable steps to reduce overwhelm.
• Compensation for Working Memory:
• Use memory aids like sticky notes or notebooks to track ongoing tasks.

These strategies empower clients to define and achieve their own version of independence, whether that means managing a household or simply remembering to take medications on time.

Executive Function Remediation

While compensations are critical for supporting immediate function, remediation aims to improve or restore executive function abilities over time. Various methods exist across the bench-to-bedside continuum of research, and while not all are universally accepted, many show promise.

Examples of Executive Function Remediation Strategies

• Cognitive Training Programs:
• Research supports the use of computerized cognitive training to improve working memory, attention, and problem-solving skills. Programs like Cogmed and BrainHQ are designed to target specific executive functions through repetitive tasks.
• Cognitive-Emotional Strategies:
• Cognitive-Emotional Strategies has been shown to improve emotional regulation and self-awareness, essential components of executive function. Techniques include reframing negative thoughts and building adaptive problem-solving skills (This may require additional training and mentorship to develop competencies when dealing with behaviors and thought frameworks).
• Task-Oriented Training:
• Engaging clients in meaningful, occupation-based tasks while embedding graded cognitive challenges. For example, practicing grocery shopping with a shopping list to enhance working memory and sequencing.
• Dual-Task Training:
• Combining motor and cognitive tasks (e.g., walking while recalling information) improves divided attention and cognitive flexibility.
• Neurostimulation Techniques:
• Emerging evidence supports the use of non-invasive brain stimulation (e.g., tDCS, rTMS) to enhance neural plasticity in brain regions associated with executive function.

Case Example: A Mother with Long COVID

Client Profile:
A 40-year-old mother of three children under 12 presents with long COVID symptoms, including fatigue, brain fog, word-finding difficulties, working memory challenges during conversations, and frequent forgetfulness.

Challenges:

• Difficulty managing household tasks, such as preparing meals while overseeing children.
• Forgetting appointments and struggling to follow through on commitments.
• Losing confidence in her ability to function as a caregiver and professional.

Intervention Plan:

• Compensation and Adaptation:
• Implement digital tools like a shared family calendar synced with reminder notifications.
• Use whiteboards in key locations for daily schedules and task priorities.
• Create structured routines with built-in rest periods to reduce cognitive load.
• Cognitive Training and Task-Oriented Practice:
• Introduce memory games or task-based exercises like meal planning with a focus on sequencing steps and recalling ingredients.
• Practice mental rehearsal by having her visualize completing a task before starting it.
• Emotional Regulation and Stress Management:
• Incorporate mindfulness-based stress reduction exercises into her daily routine to improve focus and emotional resilience.
• Dual-Task Training:
• Combine physical activity with cognitive challenges, such as naming animals alphabetically while walking