Trouble Planning and Organizing? Blame Your Frontal Lobes

In Why Self-Control Fails in Dementia, I explained how part of frontal lobe function is to regulate behavior. Another part of frontal lobe function is to help us plan and organize actions and activities for both short- and long-term goals.

Think about planning to do something in the future, such as hosting a special dinner with friends and family, remodeling the bathroom, planting a vegetable garden, or starting a company. In order to accomplish any of these activities, you need to begin with the end in mind. In other words, you need to actually start with your vision of what your end product will be, such as a delicious yet healthy dinner, a modern and functional bathroom, a colorful garden with vegetables in straight rows, or a profitable and environmentally conscious company. (Note that creating a detailed vision involves using the memory system in a flexible and creative way; I’ll talk more about that in future weeks.)

Once the vision is created, then the planning starts and the frontal lobes begin working. How do you create a delicious yet healthy dinner for friends and family? Well, you might begin by noting any allergies and food preferences of your guests. You’ll next need to combine that knowledge with that of what foods are healthy. Then you can begin to search for recipes, choosing ones that fit these criteria and your abilities as a cook. Next comes creating a grocery list and doing the shopping. The final step is the actual food preparation and cooking, which all needs to be sequenced and timed so that the food is prepared correctly and is ready to be served in the correct order.

It is the anterior (front) and dorsolateral (top and sides) parts of our frontal lobes (just behind our forehead), that help us to perform this strategic and coordinated planning. Verbal activities (such as planning a lecture) involve more left hemisphere regions, whereas spatial activities (such as planning a garden) involve more right hemisphere regions. Studies also show that the more challenging the planning of the activity, the greater the number of frontal lobe regions that become active and participate in the planning process, with complicated activities almost always recruiting both left and right hemispheres to help, regardless of the type of activity.

Many causes of dementia result in dysfunction of these parts of the frontal lobes. Frontotemporal dementia, dementia with Lewy bodies, Parkinson’s disease dementia, multiple sclerosis, traumatic brain injury, and vascular (stroke) dementia affect the frontal lobes or their white-matter connections in the early part of the disease. In Alzheimer’s disease, chronic traumatic encephalopathy (CTE), HIV associated dementia, and several other disorders, different parts of the brain may be involved first, but the disease eventually spreads to the frontal lobes. Individuals with other types of brain disorders can also show these problems, such as ADHD and cerebral palsy.

It is often possible to help individuals with these types of difficulties. Think about a young child who has learned to ski but does not have the planning and organizational skills to bring the correct clothes and equipment to the mountain, or even to dress herself in the proper sequence (snow pants first, then ski boots). We can help this child by bringing the equipment ourselves and getting her dressed and ready or, depending upon her age, perhaps simply by helping her make a checklist of what to bring and wear. The actual skiing activity she can do and enjoy all by herself.

We can help our gardener with dementia in the same way. Because he has worked gardening all his life, his hands know how to till the soil, plant the seeds, and remove the weeds. He has difficulty, however, knowing in what order to perform these activities and how to get the seeds, fertilizer, tools, and other materials. When his dementia is quite mild, an ordered checklist is all he needs. Later on, he will need the appropriate gardening tools and materials for the season laid out for him so he knows whether he should be tilling, planting, weeding, or raking. Similarly, the individual who can no longer cook a complicated meal can learn to follow simple directions to use a microwave, make a sandwich, or brew coffee. When reading becomes impaired, she can follow picture directions taken with a smart phone.

Trouble planning and organizing due to frontal lobe dysfunction are common in Alzheimer’s disease and other dementias. The good news is that we can often provide some help for those with this difficulty.

^{© Andrew E. Budson, MD, 2018, all rights reserved.}