Executive Dysfunction in Patients with Cerebrovascular

Risk FactorsLaura Grande, Ph.D.

Geriatric Neuropsychology Laboratory,

New England GRECC

VA Boston Healthcare System

Harvard Medical School

August 23, 2006

Neuropsychology: What is it good for?

Neuropsychology

• Behavioral expression of brain dysfunction

• Neuropsych exam:– Assists in diagnosis– Pt care (management & planning)

• Provides insight into level of functioning

• Not only elderly and geriatric pt’s

Neuropsychology and Medicine

• Ability for self-care and independence

• Understanding and remembering instructions and recommendations

• Managing complex medical regimens

• Remembering and accurately verbalizing concerns to physician

• Pt safety (driving)

Cognitive Impairment

• Dementia - prototypical

• Two most common forms:– Vascular dementia (VaD)– Dementia of the Alzheimer’s type (AD)

• Differ in initial cognitive changes

Learning/Memory

AttentionExecutiveFunctions

LanguageVisuo-spatial

Domains of Cognition

Learning/Memory

Attention ExecutiveFunctions

LanguageVisuo-spatial

Domains of Cognition

Cortical DementiaAlzheimer’s Disease

• Affects every area of behavior• Learning and memory - problems with new

information, better recall for older memories • Visuoperceptual - poor copying & constructional

abilities• Language - speech, comprehension, semantic

problems, naming, empty speech• Executive functions• Personality - emotional changes, irritability, lack of

awareness• Insidious onset, steady decline

Alzheimer’s Disease

Vascular (Multi-Infarct) Dementia

• Learning and memory - problems learning and remembering new information, relatively better than AD pts.

• Other cognitive deficits may include– Language - aphasia– Motor - apraxia– Visuospatial - agnosia– Executive functions - inattention

• Personality - later in course of disease• Acute onset, step-wise decline• Similar to subcortical dementias (PD, HD)

Vascular Dementia (VaD)• VaD may not be a specific single disease.

• VaD associated with neuroanatomical changes resulting from vascular disease.

• DSM-IV criteria - mandatory memory impairment.

• Cognitive impairment observed in those at risk for VaD (Brady et al 1999; Pugh et al in prep).

Bowler, Steenhuis & Hachinski (1999); Schmidtke & Hill (2002)

Memory vs. Executive Function

• “Memory” problems - Elderly– Most commonly reported cognitive problem– Pts concerned about Alzheimer’s disease– Many problems labeled as memory

• Executive dysfunction in those at risk for VaD– Hypertension (Brady et al 2001), diabetes (Pugh et al 2004)

– Problems detected prior to pt/family report

• Associated with frontal lobe functions.

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Heart Dis & Stroke, 42%Suicides, homicies, 2%MVA 1%Accidents, 3%Kidney Disease, 3%Liver Disease, 1%Respiratory Disease, 6%Pneumonia & Influ., 4%AD, 3%Diabetes, 3%Cancer, 31%HIV, 1%

Major Causes of Death in MA - 2001

American Heart Association. Heart Disease and Stroke Statistics — 2005 Update. Dallas, Tex.: American Heart Association; 2004

Early identification and Screening• Evaluation occurs after problems are noticed.

• Cognitive testing for all patients?– Unnecessary, time consuming, expensive

• Screening in the primary care clinics?– Physicians reported need for screening (Hogervorst et al, 2001)

– Time is biggest obstacle– Test familiarity

• Could cognitive decline be minimized by early detection?

• Obtain useful information through observation and discussion– Pt’s use of language– Pt’s memory for own personal history, and new

learning– Pt’s ability to attend and stay on topic

• Naturalistic environment

Non-Formal Assessment

Clock Drawing Test as a Screener

• Considered measure of executive functioning.• Good psychometric properties across versions and

scoring procedures.• Highly correlated with other cognitive measures.• Quick administration (≈ 2 minutes).• Useful as a screening tool in the medical setting?

Please read and do the following carefully:

In the blue box on the next page:

Draw a picture of a clock

Put in all the numbers

Set the time to ten after eleven.

Hand this sheet back and go to the next page

Clock Scoring

• Working Memory Subscale– Correct square

– Resembles clock

– Includes all numbers

– Correct time indicated (in any manner)

• Four WM points

• Planning & Organization Subscale– Appropriate size– Numbers in correct order– Numbers evenly spaced– Hands of different length

• Four PO points

Total Score = WM subscale + PO subscale

Clock-in-a-Box Score = 8

Clock-in-a-Box Score = 6

Clock-in-a-Box Score = 5

Clock-in-a-Box Score = 3

Clock-in-a-Box = 0

CIB Participants

• 191 participants– 56 Healthy controls (HC)– 135 Cardiovascular pts

• 31 Geriatric patients– Referred for evaluation at MGH

Demographic Information

HC CV Geri

Age, M(SD) 65 (8) 66 (9) 78 (9)

Education, M(SD)* 15 (3) 13 (2) 14(2)

Sex (n, % male) 26, 46% 97, 72% 17, 55%

Race (n, % Caucasian) 39, 70% 59, 66% 28, 90%

MMSE* 28.2 27.0 --

*

*

CIB - Total Score

0

2

4

6

8

CIB

HCCVGeri

*

* p<.01

*

CIB - Subscores

0

1

2

3

4

Working Memory Planning &Organization

HCCVGeri

*

* p<.01

**

CIB & EF Measures

Trail A Trail B Phonemic

Fluency

Semantic Fluency

CIB Total .074 -.257 * .192 * .010

Working Memory .097 -.166 * .065 .026

Planning/Organization .031 .255 * .240* .005

* p<.05

CIB & Memory Measures

Learning Recall Retention Recognition

CIB Total .330* .304 * .130 .160*

Working Memory .249* .249 * .111 .133

Planning/Organization .300* .263 * .107 .138*

* p<.05

Is the CIB a predictor?

• Does CIB predict performance on standardized cognitive measures?– Stepwise linear regression

• CIB total, age & education entered into model

Prediction of performance

• Executive Function Measures– Trail Making A

54.6 + CIB (-2.211) + Educ (-1.39) + Age (.345)

– Trail Making B199.98 + CIB (-14.75) + Educ (-7) + Age (.237)

– NOT a significant predictor of fluency

• Memory Measures– Learning

10.64 + Educ (.341) + CIB (.273) + Age (-.137)

– Recall3.09 + CIB (.279) + Educ (.256) + Age (-.175)

– Retention54.25 + CIB (.194)

– NOT a significant predictor of recognition

Cycle of ProblemsCardiac Illness

Diabetes

Missing medicationsNot following Dr.’s plan

Illnesses not well-controlled

White matter changesDisrupted frontal lobe messages

Problems with planning & problem

solving

Difficulty managing own medications

and problems following Dr.’s plan

Procedures for Registering and Getting CE credit

• VA people go to https://vaww.ees.aac.va.gov

• Non-VA go to https://www.ees-learning.net

• First-time users will need to “click for first time users”; others should enter username and password

• On “Librix homepage” click on “Available courses” and enter keyword “geriatric”

• Click on “Geriatric Audioconference Series: Executive Dysfunction…”

• Click on “Sign me in” and follow procedures

For Further Information:

• Vascular Dementia and CIB– Laura Grande, PhD– lgrande@heartbrain.com

• New England GRECC– Kathy Horvath, PhD RN– Kathy.Horvath@med.va.gov

• Geriatric Audioconference Series– Ken Shay, DDS, MS– Kenneth.Shay@va.gov

• Evaluation and CE Credit– http://vaww.sites.lrn.va.gov/vacatalog/cu_detail.asp?id=22502 – Instructions in “Brochure”

Upcoming Calls

• Thursday, September 28, 3 pm eastern: “Sleep disorders in older people” (Sepulveda and Madison GRECCs)