Page 47 - Handbook of Electronic Assistive Technology

34 HANDBOOK OF ELECTRONIC ASSISTIVE TECHNOLOGY

tests, those with executive impairment made significantly more task errors, task omissions
and errors of judgement compared to people with no neurological impairment.
Executive impairment can impede the uptake of EAT when it is available, but issues
with use may be particular to the presentation of the patient with executive impairment.
Alderman et al. (2003) described two different patterns of responding when people with
executive dysfunction were performing a shopping task in real life. Some patients made
many task omissions and failed to achieve the goals set for them (i.e., to buy several items).
These ‘task failers’ did not initiate behaviours in line with the goals they were given, but
followed the complex rules of the task closely. Other patients displayed contrasting behav-
iour; disinhibited responding. They performed the tasks but also broke the rules set by the
experimenters. These ‘rule-breaking’ patients were highly driven by their environment.
Studies of people with brain lesions and frontotemporal dementia have also highlighted
an anatomical distinction between apathetic presentations, when damage is located in
the dorsolateral prefrontal cortex and anterior cingulate, inferior, middle and superior
frontal regions; and disinhibited presentations, where damage or degeneration is present
in the posterior cingulate, left medial frontal regions and lateral temporal lobe (Zamboni
et al., 2008; Knutson et al., 2014; Burgess et al., 2000). There is therefore neuroanatomic
evidence of different processes that can lead to distinct responding, apathetic or disinhib-
ited, after frontal damage.
It is an oversimplification to categorise patients with executive impairment into ‘task
failers’ and ‘rule breakers’ and in reality there is considerable overlap between these pre-
sentations. However, this categorisation offers broad guidance when thinking about the
issues that could prevent someone from getting the best use out of EAT. For example, peo-
ple with an apathetic presentation may fail to initiate the use of technology even when it
is available; they might not set an alarm to help them remember an appointment, or fail to
call for help when it is needed. If somebody is disinhibited, then they may use EAT inap-
propriately or too often. For example, continually pressing a call button for support when
they do not need assistance.
Ownsworth et al. (2015) highlight the processes that support performance monitoring
and regulative control components of error self-regulation, which are often impaired by
neurological damage. Having difficulty keeping track of what one is doing, and regulating
behaviour accordingly, may make it difficult to perform a task with several substeps, such
as cooking a meal or carrying out the morning routine. As a consequence, there have been
a number of neuropsychological interventions to support people with executive function
to perform these types of tasks (e.g., food preparation – Chang et al., 2011; hand washing –
Mihailidis et al., 2004; morning routine – O’Neill et al., 2013).
There is growing evidence that microprompting assistive technologies are effective for
helping people to compensate for executive impairment. Microprompting technologies
aim to guide people through a task with several substeps. An example of these technolo-
gies is the General User Interface for Disorders of Execution (GUIDE) voice-based prompt-
ing system that has been used to support people with executive impairment after vascular
dementia to don prosthetic limbs, or to guide people with acquired brain injury (ABI)