Download Neuropsychology: What is it good for

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
Learning/
Memory
Attention
Visuo-spatial
Executive
Functions
Language
Domains of Cognition
Learning/
Memory
Attention
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.
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
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;
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
• Planning & Organization
Subscale
–
–
–
–
Appropriate size
Numbers in correct order
Numbers evenly spaced
Hands of different length
(in any manner)
• Four WM points
• 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%
28.2
27.0
--
MMSE*
CIB - Total Score
8
*
6
*
4
HC
CV
Geri
2
0
CIB
* p<.01
CIB - Subscores
4
3
*
*
*
2
HC
CV
Geri
1
0
Working Memory
Planning &
Organization
* p<.01
CIB & EF Measures
Trail A
Trail B
Phonemic
Fluency
Semantic
Fluency
.074
-.257 *
.192 *
.010
Working Memory
.097
-.166 *
.065
.026
Planning/Organization
.031
.255 *
.240*
.005
CIB Total
* p<.05
CIB & Memory Measures
Learning
Recall
Retention
Recognition
.330*
.304 *
.130
.160*
Working Memory
.249*
.249 *
.111
.133
Planning/Organization
.300*
.263 *
.107
.138*
CIB Total
* 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
Problems with
planning & problem
solving
Missing medications
Not following Dr.’s plan
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)