"Functional Cognition identifies predictable of motor and verbal skills, social behavior, self awareness and awareness of contexts (circumstances in which an event occurs). Within the model this model, all of these diverse elements are viewed as interrelated. They are bundled or associated together because they all arise from a unified set of underlying cognitive (mental) processes" - Earhart (2006). Therapists trained to use the model can identify, through standardized assessment, these underlying patterns of behavior. Therefore, therapists are aware that the person they have been asked to assess and assist are not always able to plan and organize their daily life activities.

Though this page speaks mainly about people who are elderly, a great deal of the information can apply to young people who have deficit in functional cognition.

Many people who are elderly develop physical limitations and disabilities due to a variety of medical reasons including heart conditions, diabetes, arthritis and osteoporosis. However, the real problems occur when a disease process adversely affects the functioning of the brain. Even before a mentally debilitating medical problem becomes apparent many people are already having the greatest difficulty dealing with new situations. Normally the carer notices these difficulties by the way in which their charge tries to work out a problem and/or shows signs of panic, which is often more than is warranted. At this stage the person’s ability to functionally process new information is generally at greater risk than either the doctor or the primary caregiver realise. 

Once an aged person has a moderate to severe cognitive disability, it is difficult if not impossible for them to learn new skills, such as how to correctly use a walking frame.

An ongoing myth in the healthcare community is that people who are ageing are actually capable of doing what they say they can do! Often they are assessed using all kinds of tests involving the use of pencil and paper, or they are asked questions about knowledge that is stored in their (long term) procedural memories. Unfortunately these types of assessments do not identify the real safety and emergency issues that confront them in their every-day living environment. The problem is that in many cases a person with deficits in functional cognition can present well using information pulled from procedural memory, but when an “at risk” situation arises they are neither able to functionally process information as to what to do nor can they act quickly. They use well-learnt skills and habits, laid down over a lifetime, which are stored in procedural memory of the brain. In other words, their reactions are based on habit, not logical thought. In these circumstances the deficits in functional cognition becomes most apparent, because a person can be suddenly at a complete loss to know what to do; they panic and call for assistance, normally they try and contact their primary caregiver and forget completely the drilling they had been given on ringing an emergency number. The reason being, of course, that procedural memory is stronger and less fragile than working memory, which is the memory that is able to hold and manipulate images and functionally processes new information. 

The following are case histories of two people living in an Australian care facility, who are typical examples of situations where concern was raised in providing the best care. In compiling information on each case, assessment was undertaken where observations were made on their ability to both pay attention to cues and the speed with which they completed a standardized assessment (ADM).

Case one was a female who walked independently, dressed well, read light novels, but was very dependent on staff. She focused only on her own needs and constantly made demands for immediate attention. When this was not forthcoming she became argumentative and aggressive. During assessment it was noted she attempted new tasks using trial and error, constantly trying to correct her mistakes by using another step or action. Eventually she became frustrated, stopped what she was trying to do, and said she couldn’t continue, as “her eyes felt sore”. In social situations she would start talking without due regard for the listener, or the work that needed to be done and would use every means to get what she wanted from the staff and her caring relative. She argued about her rights, blamed others for her misfortune and her inability to follow instructions, and she was incapable of showing any empathy for the needs of others. She considered herself superior to the other people living in rooms near hers, saying she was normal and they were not. Her self-awareness was limited and she was not aware of the marks, spots and wrinkles on her dress. She wore the same items of clothing over and over again, and was not able to visually scan and select a particular item of clothing from all the clothes hanging in her wardrobe. She needed to be cued when showering to attend to unseen surface areas and to be made aware of safety when she closed her eyes to wash her hair. When she went to the toilet she was not aware of urine spills or the need to check the condition in which she left the toilet. Her inability to satisfactorily process new functional  cognitive information, her reliance on tangible thought (long term memory) and the accompanying self-centered behavior made her behavior problematic for care assistances to handle.

Case two was a male who retained high verbal skills, insisted on handling his own affairs and had very definite ideas about how to do every-day life tasks. He had no concept of his physical and cognitive limitations and insisted he could do everything himself.  During assessment he was unable to perform a demonstrated action or task. Even after repeatedly asking for demonstrations he was still unable to comprehend the requirement for which he made excuses and said it was silly!  This man was assessed at requiring 42% cognitive assistance ( 6 to 7 hours per day), which included assisting him to do minimal problem solving, personal hygiene tasks, toileting, meals, drinks, transfers and mobility. Continuous assistance was necessary because he could not retain new information.  He insisted he should have his own bankbook and that a relative escorts him to the bank each fortnight. He distrusted and verbally abused caregivers (affectionately known as carers in Great Britain, Australia and New Zealand) because he saw them as constantly challenging his way of doing things.  Even though he was having great difficulty with day-to-day activities, and depended on caregiver help, he detested others telling him what to do!  He had no concept that his behavior upset others or that he required the amount of assistance he was receiving.

Behavioral problems such as these occur in response to deficiencies in the overall brain activity of the person. There is a relationship between a chronic disease process, functional cognitive impairment and the consequent severity of behavioral problems; these cases demonstrate that both people could no long consider the needs of others. Therefore, to suggest recommendations, that would change the anomalous behavior of the two cited cases would have been futile. It would be more appropriate to adapt the environment and advise caregivers on how to successfully approach, communicate with and handle each individual. The assistance given was developed as care plans in consultation with others and provided advice on the safety issues that may arise.

In both cases the assessments resulted in an upgrading, by two levels, on the Australian Residential Classification Scale (RCS), which proved to be of substantial financial and care benefit to the aged care providers, as well as providing more appropriate and hence better care for those people with deficits in functional cognition.