executivedysfunction.pdbYsS' H@kϾHF7RCH1DTGP @JR@Z!@#`@$$ %0 %< %^ & ))))-/x/z0executivedysfunctionpdbH@HAUnfiledexecutivedysfunctionTT< <     @TRY THIS DEMENTIA SERIES Volume 1, Number 3, Fall 2003 Series Editor: Marie Boltz, APRN, MSN, GNP Brief Evaluation of Executive Dysfunction: An Essential Refinement in the Assessment of Cognitive Impairment By: Gary J. Kennedy MD WHY: A hospital admission may surface a previously undetected dementia in some older adults. While at home in a familiar environment, patients and family may fail to recognize subtle, slowly progressive cognitive changes. Such changes however, often become apparent when the patient is moved to the unfamiliar setting of the hospital. These are the patients whose family report my mother was never like this at home. This Try This recommends assessing executive function for older patients not thought to have dementia prior to hospitalization but where the patient, family or staff feel the patient has not returned to baseline cognitive status at the time of discharge. Particularly when the older patient is alert and verbal and memory is not obviously impaired, screening for executive dysfunction can be critical to a safe, realistic treatment and discharge plan. Patients who exhibit executive dysfunction should be referred to their primary care provider or to an Aging and Dementia Center. EXECUTIVE DYSFUNCTION defined: Executive function is an interrelated set of abilities that includes: cognitive flexibility concept formation, and self-monitoring. Assessing executive function can help determine a patients capacity to execute health care decisions and with discharge planning decisions. With impaired executive function, instrumental activities of daily living (accounting, shopping, medication management, driving) may be beyond the persons capacity even though memory impairment is mild. The persons capacity to exercise command and self-control, and to direct others to provide care, becomes diminished. Executive dysfunction is one element in the DSM-IV criteria for the diagnosis of dementia and occurs in all dementing diseases. NOTE: Patients with impaired executive function need not have impaired memory. TARGET POPULATION: OLDER PATIENTS: Not thought to have dementia prior to hospitalization but where the patient, family or staff feel the patient has not returned to baseline cognitive status at the time of discharge. For whom other screening (e.g., MMSE, CAM: see Try This at www.hartfordign.org ) reveals no discernable cause for a cognitive impairment. For whom cognitive impairment, observed as alterations in memory, use of language and abstract thinking, and spatial sense, persists even when delirium has been identified and treated or ruled out. BEST PRACTICES: Few practitioners are familiar with testing for executive function, yet there are valid and reliable instruments. The instruments listed below have good internal consistency, inter-rater reliability and are strongly correlated with the MMSE and with lengthier neuropsychological assessments of executive function: Royalls CLOX (clock drawing), Controlled Oral Word Association Test, and Trailmaking Test, oral version. SCREENING TESTS OF EXECUTIVE FUNCTION The following brief screening tests of executive function can be administered in hospital and in the ambulatory setting: Royalls CLOX Clock drawing: First ask the patient to Draw me a clock that says 1:45. Set the hands and numbers on the face so that a child could read them. Once the task is complete, draw a clock with a 2 inch diameter, with all the numbers in place, and the hands set at 1:45. Then ask the patient to copy it. An unimpaired person will draw a round figure with the following elements: recognizable circle at least one inch in circumference with all the numbers present and in correct, symmetrical sequence. There will be two hands anchored in the center pointing to the correct time. If any of the above elements are missing the person is possibly impaired. If more than one element is missing the person is probably impaired. Intruded elements such as words or letters indicate impairment. Persons with only executive dysfunction will exhibit errors on the first clock but not the second. Those with both executive function and construction apraxia usually as a result of moderate Alzheimers disease or stroke will fail both. The Controlled Oral Word Association Test: With categories beginning with the letter F, then A, then S, the Controlled Oral Word Association Test by Spreen and Benton (1977) requires respondents to fill the category by providing words of 3 or more letters. For example, correct responses to the category cue F would include fish, foul, fact etc. This test reflects abstract mental operation related to problem solving, sequencing, resisting distractions, intrusions and perseverations. It is considered a frontal task as the organization of words by first letter is unfamiliar, and requires conscious, effortful, systematic organization and the filtering of irrelevant information such as natural taxonomic categories. Persons free of executive dysfunction will produce 10 words in each category within one minute. The Trailmaking Test, Oral Version: (Ricker & Axelrod, 1994) requires the subject to count from 1 to 25 and then recite the 26 letters of the alphabet. For testing the subject is asked to pair numbers and letters e.g. 1-A, 2-B, 3-C, etc. until the digit 13 is reached. This version does not make visual scanning or visually guided motor demands. However, the individual is required to keep the number and letter sequences in working memory so as not to lose place. More than 2 errors in 13 pairings are considered impairment. Try This Dementia Series is developed by the John A. Hartford Foundation Institute for Geriatric Nursing and the Alzheimer's Association. PERMISSION is hereby granted to reproduce, post, download, and/or distribute this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org. E-mail notification of usage to: hartford.ign@nyu.edu. Further reading: Cooney LM, Kennedy GJ, Hawkins KA, Hurme SB. Who can stay at home: Assessing the capacity to choose to live in the community (in press) Archives of Internal Medicine Daly S, Sawchuk PJ, Wertenberger DH. Sending the elderly home. Assessing the risk. The Canadian Nurse. 2000; Mar: 27-30. Kennedy GJ, Scalmati A: The importance of executive deficits; Assessing the older persons capacity to remain at home: Geriatrics 57:40-41, 2002 McCullough LB, Molinari V, Workman RH. Implications of impaired executive control functions for patient autonomy and surrogate decision making. J Clinical Ethics. 2001; 12(4):397-405. Ricker JH, Axelrod BN. Analysis of an oral paradigm for the trail making test. Assessment 1994;1:47-52 Royall DR, Cordes JA, Polk M. CLOX: an executive clock drawing task. J Neurol Neurosurg Psychiatry 1998; 64:588-594. Royall DR, Cabello M, Polk MJ. Executive dyscontrol: An important factor affecting the level of care received by elderly retirees. J Am Geriatrics Soc 1998;46:1519-1524. Spreen FO, Benton AL. Manual of instructions for the Neurosensory Center Comprehensive Examination for Aphasia. Victoria, British Columbia, Canada: University of Victoria. 1977 For complete versions of the CLOX, including a validated Spanish Translation, write to Donald R. Royall MD, Department of Psychiatry, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, TX 78284-7792. A series provided by The Hartford Institute for Geriatric Nursing and the Alzheimers Association www.hartfordign.org +mfCO#:+ &y<K= " M ME@ c !e"  ` #7{iw5Im   :   J   / R  :k% Q     LM"# ) _  " =  q  W 5   c  H-@U -  `  x  Z f x x @ Z @x " Z @Z  `῿ ῿ a a$$$$$$$$$$ $ $$$$$$$$$ $ $$$$$$$$$ $ $WHYDEFINITIONTARGETPOPULATIONBESTPRACTICESSCREENINGTESTSCLOXWORDASSOCIATIONTRAILMAKINGPERMISSIONREADINGArialCourieraRomanCourier NewmanHelveticaRomanSimSunSymbolTimesTimes New RomanWingdings