1. Exploring Executive Functioning in Patients with Frontal Lobe and Temporal Lobe Epilepsy Using a Novel Ecologically-Valid Virtual Reality Task: The Jansari assessment of Executive Functions (JEF©)
Nidhi Deva, Jwala Narayanana, Surekha Chukkalib, Raghavendra Seetharama and Ashok Jansaric
Department of Neurology, Vikram Hospital, Bangalore, Indiaa
Christ University, Bangalore, Indiab
University of East London, London, UKc
Introduction:
Epilepsy is a common condition affecting about 0.5% of the world's population. Frontal Lobe Epilepsy (FLE) accounts for approximately 20-30% while temporal lobe epilepsy (TLE) accounts for % of all focal epilepsies. Executive dysfunctions are seen to be associated with FLE. However, while studies show that TLE is associated with deficits in working memory [1], long term memory, autobiographical memory [2] and prospective memory, whether they have impairments in executive functions is still not clear [3,4,5].
Aim of study:
To study memory and executive functions in patients with FLE and TLE using standard neurocognitive assessments and to explore the latter using a new ecologically-valid non-immersive tool (see below).
Figure 2: Comparison of Executive Functions in FLE, TLE and healthy controls on the JEF©.
Figure 1: Comparison of Executive Functions in Epilepsy patients and healthy controls on the JEF©. * ** * * *
Method
Participants
FLE and TLE patients between the age-range from Vikram Hospital Bangalore, India.
HCs matched for age, education and gender.
Exclusion criteria:
Participants with a history of other neurological or psychiatric conditions.
Tests administered:
Standard neurocognitive assessment was conducted including: Auditory Verbal Learning Test (AVLT), Rey-Osterrith Complex Figure Test (RCFT) and Trail Making Test (TMT) A & B .
In addition, all participants were administered the Jansari assessment of Executive Functions (JEF©) [6]. JEF© is a novel ecologically-valid tool of executive functions that measures Planning, Prioritization, Selective-Thinking, Creative-Thinking, Adaptive-Thinking, Action Based Prospective Memory (PM), Event Based PM and Time Based PM simultaneously in a non-immersive virtual reality office setting that resembles a computer game.
*significant at 0.05 level
**significant at 0.01 level
*significant at 0.05 level
**significant at 0.01 level
Summary of Results
The epilepsy group had significantly lower scores than the controls on the JEF©, they also scored significantly lower on the subscale of selection, (See Figure 1).
The epilepsy group took a significantly longer time to complete the TMT-B, but not on the other standard tests of memory and attention, (See Table 1).
Subgroup Analyses
The FLE group scored significantly lower than the controls on the total JEF©, (See Figure 2 & Table 2 ). They also scored significantly lower on the subscales of selection.
FLE group did not significantly differ on the standard tests of memory, attention and working memory, (See Table 1).
The TLE group did better than the FLE group but scored lower than the controls on the total JEF©, however scores were not significant, (See Figure 2, Table 2)
The TLE group did not significantly differ on the standard tests of memory, attention and working memory, (See Table 1).
Table 1: Demographic details and neuropsychological test scores of TLE group, FLE group, Epilepsy group and Controls. *
Conclusions
Overall, the epilepsy group had higher executive function deficits compared to healthy controls on the JEF©. The epilepsy group differed on the TMT-B which measures working memory and attention shifting but they did not differ from the healthy controls on standard tests of memory and attention.
The FLE group seemed to have higher executive function deficits compared to healthy controls on the JEF©, however they did not differ on the standard tests of memory and attention.
The present study found the JEF©. to be sensitive to cognitive deficits in frontal lobe epilepsy.  
Additionally, as the performance of the TLE patients fell midway between that of FLE and HC groups on the JEF©., the results suggest that there is a spectrum of executive deficits across these conditions.
Implications
Identification of impairment holds significant clinical value, for diagnosis, treatment, surgery management and rehabilitation for patients with epilepsy.
Table 2: Total JEF© scores across epilepsy patients and controls
Group
Mean JEF % SD
p value
TLE (n = 10)
60.1
15.9
0.251+
FLE (n = 10)
51.9
21.4
0.012+*
Epilepsy (n = 20)
56.0
18.8
0.008+**
Controls (n = 20)
69.4
9.7
Limitations:
The epilepsy patients were heterogeneous, frequency of seizures, age of onset of seizures and medications were not controlled for.
The study did not have a standard test of executive functioning to compare with the JEF©.
The small sample size may played a role in not showing significant differences between the FLE and TLE groups.
+When compared to controls
++When compared to FLE
*Significant at 0.05 level
** Significant at 0.01 level
*Significant at 0.05 level
** Significant at 0.01 level
References
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Jansari, A., Agnew, R., Akesson, K., Murphy, L. & Leadbetter, A. (in press). Ecological assessment of executive functions: a new virtual reality paradigm. Brain Impairment.