1. 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

2. Neuropsychology: What is it good for?

3. 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

4. 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)

5. Cognitive Impairment Dementia - prototypical Two most common forms: –Vascular dementia (VaD) –Dementia of the Alzheimer’s type (AD) Differ in initial cognitive changes

6. Learning/ Memory Attention Executive Functions LanguageVisuo-spatial Domains of Cognition

7. Learning/ Memory Attention Executive Functions LanguageVisuo-spatial Domains of Cognition

8. 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

9. Alzheimer’s Disease

10. 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)

11. 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)

12. 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.

14. Major Causes of Death in MA - 2001 American Heart Association. Heart Disease and Stroke Statistics — 2005 Update. Dallas, Tex.: American Heart Association; 2004

15. 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?

16. 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

17. 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?

18. 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

20. 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

21. Clock-in-a-Box Score = 8

22. Clock-in-a-Box Score = 6

23. Clock-in-a-Box Score = 5

24. Clock-in-a-Box Score = 3

25. Clock-in-a-Box = 0

26. CIB Participants 191 participants –56 Healthy controls (HC) –135 Cardiovascular pts 31 Geriatric patients –Referred for evaluation at MGH

27. Demographic Information HCCVGeri 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 * 28.227.0-- * *

28. CIB - Total Score * * p<.01 *

29. CIB - Subscores * * p<.01 * *

30. CIB & EF Measures Trail ATrail BPhonemic Fluency Semantic Fluency CIB Total.074-.257 *.192 *.010 Working Memory.097 -.166 *.065.026 Planning/Organization.031.255 *.240*.005 * p<.05

31. CIB & Memory Measures LearningRecallRetentionRecognition CIB Total.330 *.304 *.130.160 * Working Memory.249 *.111.133 Planning/Organization.300 *.263 *.107.138 * * p<.05

32. Is the CIB a predictor? Does CIB predict performance on standardized cognitive measures? –Stepwise linear regression CIB total, age & education entered into model

33. 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

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

35. Procedures for Registering and Getting CE credit VA people go to https://vaww.ees.aac.va.govhttps://vaww.ees.aac.va.gov Non-VA go to https://www.ees-learning.nethttps://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

36. 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”

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