Executive Dysfunction in Patients with Cerebrovascular Risk Factors

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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

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Neuropsychology What is it good for?
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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 pts

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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)

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Cognitive Impairment

• Dementia - prototypical
• Two most common forms
• Vascular dementia (VaD)
• Dementia of the Alzheimers type (AD)
• Differ in initial cognitive changes

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Domains of Cognition
Learning/ Memory
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Domains of Cognition
Learning/ Memory
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Cortical DementiaAlzheimers 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

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Alzheimers Disease
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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)

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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)
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Memory vs. Executive Function

• Memory problems - Elderly
• Most commonly reported cognitive problem
• Pts concerned about Alzheimers 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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(No Transcript)
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Major Causes of Death in MA - 2001
American Heart Association. Heart Disease and
Stroke Statistics 2005 Update. Dallas, Tex.
American Heart Association 2004
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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?

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Non-Formal Assessment

• Obtain useful information through observation and
  discussion
• Pts use of language
• Pts memory for own personal history, and new
  learning
• Pts ability to attend and stay on topic
• Naturalistic environment

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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?

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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
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(No Transcript)
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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
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Clock-in-a-Box Score 8
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Clock-in-a-Box Score 6
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Clock-in-a-Box Score 5
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Clock-in-a-Box Score 3
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Clock-in-a-Box 0
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CIB Participants

• 191 participants
• 56 Healthy controls (HC)
• 135 Cardiovascular pts
• 31 Geriatric patients
• Referred for evaluation at MGH

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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 --


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CIB - Total Score


plt.01
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CIB - Subscores



plt.01
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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
plt.05
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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
plt.05
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Is the CIB a predictor?

• Does CIB predict performance on standardized
  cognitive measures?
• Stepwise linear regression
• CIB total, age education entered into model

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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

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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
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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

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For Further Information

• Vascular Dementia and CIB
• Laura Grande, PhD
• lgrande_at_heartbrain.com
• New England GRECC
• Kathy Horvath, PhD RN
• Kathy.Horvath_at_med.va.gov
• Geriatric Audioconference Series
• Ken Shay, DDS, MS
• Kenneth.Shay_at_va.gov
• Evaluation and CE Credit
• http//vaww.sites.lrn.va.gov/vacatalog/cu_detail.a
  sp?id22502
• Instructions in Brochure

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Upcoming Calls

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