Executive Dysfunction in Patients with Cerebrovascular Risk Factors

Laura 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

Domains of Cognition

Attention Learning/ Memory Executive Functions Visuo-spatial Language

Domains of Cognition

Attention Learning/ Memory Executive Functions Visuo-spatial Language

Cortical Dementia

Alzheimer’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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Major Causes of Death in MA - 2001 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% 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?

Non-Formal Assessment

• 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

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

Age, M(SD) Education, M(SD) * Sex (n, % male) Race (n, % Caucasian) MMSE * HC 65 (8) 15 (3) 26, 46% 39, 70% 28.2

CV 66 (9) 13 (2) * 97, 72% 59, 66% 27.0

Geri 78 (9) * 14(2) 17, 55% 28, 90% --

8 2 0 6 4

CIB - Total Score

* *

HC CV Geri CIB

* p<.01

CIB - Subscores

4 3

*

2 1 0 Working Memory

*

* Planning & Organization HC CV Geri

* p<.01

CIB & EF Measures

CIB Total Working Memory Planning/Organization Trail A Trail B .074

.097

.031

-.257 * -.166 * .255 * Phonemic Fluency .192 * .065

.240* Semantic Fluency .010

.026

.005

* p<.05

CIB & Memory Measures

CIB Total Working Memory Planning/Organization Learning .330

* .249

* .300

* Recall .304 * .249 * .263 * Retention .130

.111

.107

Recognition .160

* .133

.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 B 199.98 + CIB (-14.75) + Educ (-7) + Age (.237) – NOT a significant predictor of fluency • Memory Measures – Learning 10.64 + Educ (.341) + CIB (.273) + Age (-.137) – Recall 3.09 + CIB (.279) + Educ (.256) + Age (-.175) – Retention 54.25 + CIB (.194) – NOT a significant predictor of recognition

Cycle of Problems

Cardiac Illness Diabetes Difficulty managing own medications and problems following Dr.’s plan Missing medications Not following Dr.’s plan Problems with planning & problem solving Illnesses not well-controlled White matter changes Disrupted frontal lobe messages

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 – [email protected]

• New England GRECC – Kathy Horvath, PhD RN – [email protected]

• Geriatric Audioconference Series – Ken Shay, DDS, MS – [email protected]

• 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)