Understanding Executive Functioning in Dementia: Why Everyday Tasks Get Harder

Your loved one was always a great cook. People complimented their dinners for years. Now boiling the water while prepping the vegetables is suddenly too many things going on at once.

That’s often a problem with executive functioning in dementia. You may never have heard the term before, but I can almost guarantee you’ve seen it in your loved one. You may also see it called executive dysfunction, which simply means problems with executive functioning.

So let’s go through what it is, how it shows up, how it’s tested, and what you can do about it.

What Is Executive Functioning?

Executive functioning lives in the frontal lobes, the largest lobe of the brain.

You can think about it like the CEO. Executive functioning, chief executive officer. Think about a really great CEO and everything they’re able to manage, maintain and control. That’s what our executive functioning does for us.

It’s responsible for:

• managing tasks
• coordinating things
• juggling multiple people and pieces of information
• planning ahead
• focusing attention
• staying on task

All of those really high-level things we do as human beings. That’s our executive functioning at work.

So when someone starts to have problems with executive functioning, things that used to come second nature to them suddenly become more difficult.

How Executive Functioning Problems Show Up in Dementia

In the Kitchen

Back to the great cook. Sure, maybe they’re forgetting parts of the recipe. But more importantly with executive functioning, they can’t keep track of the order the recipe goes in. Or they can’t do multiple things at once: the water boiling over here while they prep the veggies over there. It’s just too many things going on at once.

Staying Organized

Or say your loved one has always been pretty organized. Executive functioning problems might show up as suddenly not being able to stay organized. They can’t plan their day. They forget tasks and details they would normally never forget. They have trouble arranging appointments, or they double-book themselves.

Social Behavior and Saying Things Out Loud

Another way executive functioning problems can show up in dementia is in social behavior.

There are things we do to be socially appropriate. If we’re in a quiet library, we know to lower our voice, because we understand that environment calls for it. If we started having problems with our frontal lobes and executive functioning, we might not recognize the environment. We might start speaking loudly, or even yelling.

Or we might say something out loud that we would normally only think.

You’ve probably noticed this with young kids. They’ll say things like “What’s that thing on your face?” or “Why do you look funny?” They don’t mean to be mean. They just don’t grasp what’s socially appropriate yet. It can be like that when someone has problems with executive functioning in dementia. They don’t recognize what’s socially appropriate anymore. (If you’d like to see where the frontal lobes sit and what the other three lobes do, I go through the lobes of the brain and how dementia affects each one.)

I remember one man from when I worked in home-based primary care, where we saw people with dementia in their homes. He had so much trouble with his executive functioning that he would blurt out all kinds of things. I remember feeling so nervous going to see him. What’s he going to say to me today?

He would comment on people’s appearance, and sometimes on their weight. His wife was always so embarrassed and appalled that he said these things to people.

So we worked with her on this: that part of his brain was really struggling, and here were some ways she could adapt. I’ll share those below.

Which Types of Dementia Affect Executive Functioning?

There are many different types of dementia: Alzheimer’s disease, frontotemporal dementia, vascular dementia. It’s possible for someone to have problems with executive functioning in all of them.

Someone with Alzheimer’s disease absolutely can start to show problems with executive functioning.

In frontotemporal dementia, we expect to see them. The frontal lobes and the temporal lobes are the parts of the brain primarily affected in frontotemporal dementia, and because the frontal lobes are so affected, we would certainly expect executive functioning problems there.

Everyday Signs of Executive Functioning Problems

It’s probably pretty easy for you to think through your loved one’s behaviors and figure out whether they have problems in this area. Maybe they’re:

• interrupting people all the time when they’re trying to talk
• mixing up their medications, or not able to plan them right
• mixing up the bills

All of these are executive functioning problems.

So is the more “magnetic” behavior, where someone with dementia sees something and grabs it, like somebody else’s fork or somebody else’s drink. I talk about that one in utilization behavior, when everyday objects become hazards.

How Executive Functioning Is Tested

You probably didn’t need formal testing to know your loved one has trouble with this. But when someone is tested for dementia with formal neuropsychological testing, there are tests that look specifically at this ability. Here are a few examples of what they can look like.

Holding Back the First Answer

Imagine a list of words, each printed in a color. The word “cat” is written in blue, and the word “dog” is written in red. The task might say: tell me the color of each word, but don’t say the word.

So instead of saying “cat” or “dog,” the person has to say “blue” or “red.” It’s a higher-level task. You have to inhibit your first response and give the one you’re being asked for.

Switching Back and Forth

Another is cognitive flexibility, the ability to be flexible in your thinking. Someone might have to connect dots, but not just numbers or just letters. They have to go back and forth between them. They can’t just go 1, 2, 3, 4, 5. They have to go 1, A, 2, B, 3. That shows how well someone can keep multiple pieces of information in their mind at once.

Drawing a Clock

Many people are familiar with the clock drawing task. There are different instructions for it, but one way it measures executive functioning is by how the person approaches it.

Did they approach it in an organized, planned-out way that leaves enough space between all the numbers? Or did they just start numbering, so by the time they got to 12, nothing is evenly spaced? Someone with pretty good executive functioning knows to put the anchor numbers in first, the 12, the 6, the 3 and the 9, and then fill in the numbers between them.

Another way is the time. When I ask for a time like ten past three, there’s the right way to set the hands, and there’s a concrete way, where the person takes the instruction too literally. Technically it makes sense, and you can see how they came up with it. But that concrete thinking can suggest difficulty with executive functioning.

Please forgive me if I’m being a bit vague here. Professional ethical standards mean we have to keep these tests secure, because once people can look up the specifics and learn them, the tests are no longer secure.

Why the Tests Seem So Silly

A lot of people come out of testing thinking, “What does this have to do with how I function day to day?” Repeating a bunch of numbers, drawing a clock or putting blocks together can seem silly.

But we’re not only looking at whether the person gets the correct answer. We’re looking at how they approach the task and how they think it through. That lets us tap into all the different areas of the brain and what each one does. That’s what the person giving the test is looking for. I go into more of this in how doctors tell normal thinking from dementia with neuropsychological testing.

What Helps When Your Loved One Has Executive Functioning Problems

In a nutshell, executive functioning is the highest level of functioning our brain does. It’s what sets us apart as human beings: how we think, plan, coordinate and put all these pieces together.

Many, many people with dementia struggle with it. Here’s what can help.

Tell People Ahead of Time

If your loved one has more of the social difficulties, educating the people who come around a lot can help.

With the man I visited, one thing we suggested was alerting anyone coming into the home for the first time. Your loved one has this condition. They might say things that are unexpected, or things that would usually be rude or socially inappropriate, because that part of the brain just isn’t working anymore.

Carry a Small Card

Some caregivers carry little cards they can hand out in passing.

Say your loved one says something offensive at the checkout counter, and the clerk is left wondering what’s going on. Without causing a scene, you can walk away and hand them a card that says: “My loved one has a brain condition and sometimes says things that are unexpected. Thank you for understanding.”

Make Everyday Tasks Easier to Manage

• Keep things as much of a routine as possible.
• Break tasks down into as many small steps as you can.
• Give only one or two steps at a time, depending on what they’re able to do.
• Use visual clues.
• Cut down how much information, and how many things, they have in front of them.

Executive functioning problems can be incredibly hard for family members, and even professional caregivers, to witness, to be around, and to know what to do with.

If you’d like more than information, and want help working out what to do with your loved one’s specific symptoms, that’s what the Care Collective is for. We come together every week with Careblazers around the world to talk through the hardest moments of caregiving: how to support your loved one, how to make the best caregiving decisions you can, and how to take care of yourself along the way. You can learn more here.