frontal lobe resource coveronehealth.ca/r_alberta_nwt/video_conferences/e110302-hoa.pdf · frontal...

FFrroonnttaall LLoobbee Resource Package

Frontal vs. Alzheimer Dementia

Motor signs uncommon early

Possible motor signs

Apraxia commonApraxia uncommon

Memory loss earlyMemory loss variable

Impaired spatial orientation

Preserved spatial orientation

Personality changes latePersonality changes early

Reduced comprehensionGood comprehension

Fluent aphasiaReduced speech output

ADFTD

Seniors’ Mental Health Programs Standardized Assessment Scales

ADMINISTRATION AND SCORING GUIDELINES

Scale/Screen: The Executive Interview (EXIT)

Use(s): A short screen (25 items) to detect possible frontal lobe dysfunction.

To help predict executive cognitive function (ECF) related impairments in self care and functional status. To help predict behaviours caused by executive dyscontrol. To help determine appropriate care strategies to prevent or reduce problem behaviours.

Time Taken: Approximately 15 minutes

Rationale(s):The Folstein MMSE is relatively insensitive as a measure of frontal lobe dysfunction. Some dementias present initially with personality and behavioural changes related to frontal lobe dysfunction, rather than the more familiar orientation and memory problems seen inAlzheimer’s Disease. The EXIT is a valid and reliable tool toidentify and measure the severity of these problems. It correlates well with level of care and problem behaviour It discriminates people at earlier stages of cognitive impairmentthan the SMMSE.

Commentary:Executive dysfunction is common in dementia. The disturbed behaviour in demented elderly may be a consequence of impaired executive dysfunction. This influences a person’s independence byinterfering with directing, planning, execution, and self-regulation of behaviour. The EXIT defines the behavioural consequence of executive dysfunction and provides a standard clinical encounter in which they can be observed.

“Executive Cognitive Function (ECF) are those processes which orchestrate relatively simple ideas, movements, or actions into complex goal directed behaviour. Without them, behaviour important to independent living, such as cooking, dressing, or self care can be expected to break down into their component parts. We believe that executive deficits undermine the independence ofmany patients and lead directly to the expression of common behaviour problems in the nursing home.” (Donald R. Royall)

Enquiries: S.A.S. Committee Chair, c/o AHE Community Geriatric Psychiatry, (780) 424-4660


Administration:The rules and time limits are outlined for each item in the screen.Practise administering the screen if you haven’t done one in the past 2 weeks.Keep continuity between the sections (i.e. cue yourself between sections – use a red arrow to ensure you turn the page and continue the test without a break between tasks).Use a monotone, neutral voice. Practise the gestures beforehand and know the type/how manycues to give.Explain to the person being tested that, “the reason for the assessment is to help us better understand how you are able to organize your thoughts to cope with everyday problems and activities.” You can also say “parts of the assessment mayseem odd to you, but it all has a point, so do the best you can.” Make comments on the side rather than scoring during administration.Pay attention to the behaviours seen and be prepared for unusual responses (re: perseveration), so you can deal with them while minimizing effects on standardized administration.

Scoring: A scoring sheet is included in the screen format. Royall, Mahurin & Gray did the original research with a population randomly selected across 4 levels of care. EXIT scores greater than 15 were stronglycorrelated with a variety of common disruptive behaviours. Inter-rater reliability was high(r = .90). EXIT scores correlated well with other measures ofExecutive Cognitive Function (ECF).

Reference: Royall D.R., Mahurin R.K., Gray K.F., (1992) Bedside Assessment of Executive Cognitive Impairment. The EXIT Interview. JAGS (Journal of theAmerican Geriatrics Society)

40: 1221-1226.

Tips on How to Administer The EXIT

Royall D.R., Cabello M., Polk M.J., (1998). Executive Dyscontrol: AnImportant Factor Affecting The Level of are Received by Older Retirees.JAGS 46:1519 – 1524.

Updated: May 18, 2005WP/SMHPCC/Guidelines – EXIT Test


S e n iors ‘ M e n ta l H e alth P rog ra m s S ta n da rdiz e d A s s e s s m e n t S c a le s

R o y a ll, D .R ., M ah u rin , R .K ., a n d G ra y , K .F ., 1992 P a g e 1 R e v is e d: M a y 18, 2005

E n qu ire s : S A S C o m m itte e C h a ir/ A lbe rta H o s pita l E dm o n ton C o m m u n ity G e ria tric P s y c h iatry , (780) 424-4660.

The Executive Interview (EXIT)

Global Testing Observations:

Check as many as observed during testing

P e rs e v e ration D ate

Im itation B e hav ior

Intrus ions D iag nos is

F ron tal R e le as e S ig ns

L ac k o f S pon tane ity /P rom pting N e e d e d

D is inh ibite d B e h av iors E du cation L e v e l

U tiliz ation B e hav ior

T O T A L S C O R E

1. Number-Letter Task

—I‘d like y ou to s ay s om e num be rs and le tte rs for m e like th is .“

—1-A , 2-B , 3-w ha t w ould c om e ne x t?“ —C “

—N ow y ou try it s tartin g w ith the num be r 1“. K e e p g oing until I s ay —s top“.

1 2 3 4 5 —S top“A B C D E

S C O R E 0 N o e rro rs1 C o m ple te tas k w ith pro m ptin g (o r re pe a t ins truc tio n )2 D o e s n ‘t c om ple te tas k

Patient/Client Label




2. Word Fluency

—I am g o ing to g iv e y ou a le tte r. Y ou w ill hav e on e m in ute to n am e as m any w ords as y ou c an h ink of w hic h be g in w ith tha t le tte r.“t

—F or e x am ple , w ith the le tte r ”P ‘ y ou co uld s ay ”P e te r, pot, p lant‘… and s o on. A re y ou re ady ?“ —D o y ou hav e any que s tions ?“

—T he le tte r is œ A . G o!“

S C O R E 0 10 or m o re w o rds1 5 to 9 w o rds2 L e s s th a n 5 w o rds

3. Design Fluency(Examiner draws while patient watches) —L ook at the s e pictu re s . E ach is m ad e w ith o nly four (4) line s . I am g oing to g iv e y ou o ne m inute to dra w as m any D IF F E R E N T de s ig ns as y o u ca n. T he only ru le s are that the y m us t e ac h be d iffe re nt an d be draw n w ith four line s . N ow g o !“ If patient cannot do due to poor vision, score 0

S C O R E 0 10 o r m ore u n ique dra w ing s (n o co pie s o f e x a m ple s ) 1 5 to 9 u n iqu e dra w in g s2 L e s s th an 5 un ique dra w in g s

4. Anomalous Sentence Repetition

—L is te n v e ry c are fu lly an d re pe at the s e s e nte n ce s e x a ctly … (Read the sentence in a neutral tone.) Can use any familiar, overlearned phrase that 1) has one word changed 2) is part of a

nger sequence, poem, prayer, etc.lo

a) —I ple dg e a lle g ianc e to tho s e flag s “ o r — O h C anad a, y o ur hom e a nd nativ e land.“ b) —M ary fe d a little lam b.“ c ) —A s titc h in tim e s av e s liv e s .“ d) —T inkle tinkle little s tar.“ e ) —A B C D U F G “

S C O R E 0 N o e rro rs1 F a ils to m a ke o n e o r m ore c ha n g e s2 C o n tinu e s w ith o n e o r m o re e x pre s s io ns ( e .g . —M a ry h a d a little la m b w h o s e fle e c e w a s w h ite

a s s n ow “)




5. Thematic Perception (see previous page)

(Patient shown picture by examiner) —T e ll m e w hat is h appe ning in th is pictu re .“ If patient cannot see picture due to poor vision, score 0

S C O R E 0 T e lls s po n tan e o us s to ry (s to ry = s e ttin g , 3 c h a ra cte rs , ac tion )1 T e lls s to ry w ith pro m pting x 1 (—a n y thin g e ls e “?)2 F a ils to te ll s to ry de s pite pro m pt ( pa tie n t m u s t n am e th e s e ttin g )

6. Memory/Distraction Task

—R e m e m be r the s e thre e w o rds .“ —B O O K , T R E E , H O U S E “

(Patient repeats words till all three are registered).

—R e m e m be r the m œ —I‘ll as k y ou to re pe at the m fo r m e la te r.“

N ow œ s pe ll C A T for m e … “

—G ood . N ow s pe ll it backw ard s … “

—O K . T e ll m e tho s e w ords w e le arne d.

S C O R E 0 P a tie n t n a m e s o ne or a ll o f th e thre e w o rds c o rre c tly w ith o ut n a m in g C a t (E x am in e r m ay pro m pt: —A n y th in g e ls e ?“)

1 O the r re s po ns e s ( de s c ribe :________________________________________)2 P a tie n t n a m e s C A T as o ne o f th e thre e w o rds (pe rs e v e ratio n)

7. Interference Task (s e e pre v ious pag e )

—W hat color are the s e le tte rs ?“ (E x am ine r s h ow s th e patie nt and s w e e ps han d bac k an d forth ov e r the le tte rs .)

S C O R E 0 —blac k“1 —bro w n “ (re pe a t que s tion s x 1) —bla ck“2 —bro w n “ (prom pt) —brow n“ ( in tru s io n )

If patient names any other colour, score 0 but make a note of response.




8. Automatic Behavior I

(Patient holds hands forward palms down.)

—R e lax w hile I che ck y our re fle x e s … “

(Rotate patient’s arms one at a time at the elbow. Gauge patient’s active participation/anticipation of the rotation.)

S C O R E 0 P a tie n t re m ain s pa s s iv e1 E qu iv o c al2 P a tie n t a ctiv e ly co pie s th e c ircu lar m otio n

9. Automatic Behavior II

(Patient holds hands out palms up.)

—J us t re lax .“

(Examiner pushes down on patient’s hands – gently at first, becoming more forceful. Gauge patient’s active participation in the responses.)

S C O R E 0 P a tie nt o ffe rs n o re s is tan c e (re m a in s pa s s iv e )1 E qu iv o c a l re s po n s e2 A c tiv e ly re s is ts (or c om plie s ) w ith e x a m in e r

10. Grasp Reflex

(Patient holds hand out with open palms down.)

—J us t R e lax .“

(Both palms are lightly stroked simultaneous by the examiner, who looks for grasping/grippingactions in the fingers.)

S C O R E 0 A bs e n t1 E qu iv o c al2 P re s e n t

P atie nt g ras ps firm ly e noug h to draw n up a nd out o f ch air by e x am ine r.




11. Social Habit I

Fix subject’s eyes. Silently count to three while maintaining subject’s gaze, then say “Thank you.”

S C O R E 0 R e plie s w ith a qu e s tio n (e .g . —T h a n k y o u fo r w h a t?“)1 O th e r re s pon s e s œ de s cribe : _______________________________________2 —Y o u ‘re w e lc om e .“

12. Motor Impersistence

—S tic k out y our tong ue an d s a y ”aah‘ till I s ay s top … G o!“ (co unt to thre e s ile ntly )

(Subject must sustain a constant tone, not “ah…ah…ah…”)

S C O R E 0 C o m ple te s ta s k s pon ta n e o u s ly1 C o m ple te s ta s k w ith e x a m in e r m o de lin g ta s k fo r pa tie n t2 F a ils tas k de s pite m o de lin g by e x am in e r

13. Snout Reflex

—J us t R e lax .“

(Examiner slowly brings index finger towards patient’s lips, pausing momentarily 2” away.Finger is then placed vertically across lips and then is lightly tapped with the other hand.Observe lips for puckering.)

S C O R E 0 N o t pre s e n t1 E qu iv o c al2 P re s e n t

S uc k re fle x œ lips pucke r w hile e x am ine r is paus ing 2“ aw ay

14. Finger-Nose-Finger Task

(Examiner holds up index finger.)

—T o uch m y fing e r.“

(Leaving finger in place, examiner says…)

—N ow touc h y o ur nos e .“

S C O R E 0 P a tie n t c om plie s , u s in g s a m e h a n d 1 O th e r re s pon s e œ de s cribe : _______________________________________2 P a tie nt c o m plie s , u s in g o th e r h a nd w h ile co n tin uin g to to uc h e x a m in e r‘s fin g e r




15. Go/No-Go Task

—N ow … w he n I to uch m y nos e , y ou ra is e y o ur fing e r like th is .“ (Examiner raises index finger.)

—W he n I ra is e m y fing e r, y ou touc h y o ur n os e like th is .“ (Examiner touches nose with index finger.)

(Have patient repeat instructions if possible.)

(Examiner begins task. Leave finger in place while awaiting patient’s response. After each presentation, examiner puts his/her hand down.)

E x am in e r P atie ntF N FN F NF N FF N FN F N

S C O R E 0 P e rfo rm s s e qu e nc e c o rre c tly1 C o rre c t, re qu ire d pro m pting /re pe a t in s tru ctio n s2 F a il s e qu e nc e de s pite pro m ptin g /re pe at ins tru c tio n s

16. Echopraxia

—N ow lis te n care fu lly . I w ant y ou to do e x ac tly w hat I s ay . R e a dy ?“

—T o uch y our e ar.“ (Examiner touches his nose and keeps finger there.)

S C O R E 0 P a tie nt to u ch e s h is e a r 1 O th e r re s pon s e _______________________________________________

(lo ok fo r —m id-pos itio n “ s ta n c e )2 P a tie nt to u ch e s h is n o s e

17. Luria Hand Sequence I

P alm /F is t

—C an y o u do th is ?“

( Inv ite patie nt to w atch w hile a lte rn ating palm s /fis t w ith e ithe r han d. O nce patie nt be g ins , as k patie nt to —K e e p g o ing “ w hile e x am ine r s tops . C ount the num be r of s u cc e s s iv e palm /fis t c y c le s .)

S C O R E 0 4 cy c le s w itho u t e rro r a fte r e x a m in e r s tops1 4 cy c le s w ith a dditio na l v e rbal pro m pt (—K e e p g o in g “) o r m o de lin g2 U n s uc ce s s fu l de s pite pro m ptin g /m o de ling (w a tc h fo r —m id po s ition “ s tan c e s )




18. Luria Hand Sequence II

3 H ands

—C an y o u do th is ?“

(Examiner models: a) slap, b) fist, c) cut – while patient imitates each step)

—N ow fo llow m e .“ (Examiner begins to repeat sequence.)

—K e e p doin g th is till I s ay s top.“ (Examiner stops.)

S C O R E 0 3 cy c le s w itho u t e rro r a fte r e x a m in e r s tops1 3 cy c le s w ith a dditio na l v e rbal pro m pt (—K e e p g o in g “) o r m o de lin g2 U n s uc c e s s fu l

19. Grip Task

(Examiner presents hands to patient as shown below.)

—S que e z e m y fing e rs .“

S C O R E 0 P a tie n t g rips fin g e rs 1 O th e r re s pon s e s œ de s cribe : _______________________________________2 P a tie n t pu lls e x a m ine r ‘s ha n ds to g e th e r

20. Echopraxia II

(Suddenly and without warning, the examiner slaps his hands together.)

S C O R E 0 P a tie n t do e s n o t im ita te e x a m in e r1 P a tie n t h e s itate s , u n ce rta in2 P a tie n t im ita te s s la p




21. Complex Command Task

—P ut y our le ft hand on top of y our he ad and c los e y o ur e y e s . T hat w as g ood … “

(Examiner remains aloof, begins next task.)

S C O R E 0 P a tie n t s tops w h e n n e x t ta s k be g a n1 E qu iv o c a l œ ho lds po s ture du rin g pa rt o f n e x t ta s k 2 P a tie n t m a in ta ins po s ture thro ug h c o m ple tion o f ne x t tas k œ h a s to be to ld to c e as e

(Q uickly g o on to ne x t tas k)

22. Serial Order Reversal Task

(H av e patie n t re cite the m onths of the y e ar)

—… N ow s tart w ith J anuary a nd s a y the m onths of the y e ar backw ards … “

S C O R E 0 N o e rro rs , a t le a s t pas t S e pte m be r1 G e ts pas t S e pte m be r bu t re qu ire s re pe a t ins truc tio n s (—J us t s ta rt w ith J an u a ry a nd s a y th e n a ll

ba ckw a rds .“)2 C a n ‘t s u cc e e d de s pite pro m ptin g . (Patient must start with January)

23. Counting Task I

(Examiner taps each picture around the figure in a clockwise direction.)

—P le as e count the fis h in th is pic ture out loud.“

S C O R E 0 F o u r1 L e s s th an fo ur2 M o re th a n fo u r

24. Utilization Behavior

(Examiner holds pen near point and dramatically “presents” it to the patient asking:)

—W hat is th is ca lle d?“

S C O R E 0 —P e n “1 R e a c h e s , h e s itate s2 P a tie n t ta ke s pe n fro m e x a m in e r (u tiliz a tio n be ha v io r)

25. Imitation Behavior

(Examiner flexes wrist up and down and points to it asking:)

—W hat is th is ca lle d?“

S C O R E 0 —W ris t“1 O th e r re s pon s e œ de s cribe : _______________________________________2 P a tie n t fle x e s w ris t up a nd do w n (e c ho pra x ia )

S e n iors ‘ M e n ta l H e alth P ro g ra m s S ta n da rdiz e d A s s e s s m e n t S c a le s

L e a , C ., L o u ie , N ., Q ua c h , J ., & T an , M . (09-06-2000) P a g e 9 R e v is e d: M ay 18, 2005

E nqu ire s : S A S C om m itte e C h a ir/ A lbe rta H o s pita l E dm o n ton C o m m u n ity G e r ia tric P s y ch ia try , (780) 424-4660.


T he E x e c utiv e In te rv ie w (E X IT )R oy all e t al. (1992) S um m a ry S he e t

Score Sheet

1. N u m be r-L e tte r T a s k 0 1 2

2. W ord F lu e n c y 0 1 2

3. D e s ig n F lue nc y 0 1 2

4. A n o m alou s S e n te n c e R e pe titio n 0 1 2

5. T h e m a tic P e rc e ption 0 1 2

6. M e m o ry /D is tra ctio n T a s k 0 1 2

7. In te rfe re n c e T a s k 0 1 2

8. A u to m a tic B e h a v io r I 0 1 2

9. A u to m a tic B e h a v io r II 0 1 2

10. G ras p R e fle x 0 1 2

11. S o c ia l H abit 0 1 2

12. M o to r Im pe rs is te nc e 0 1 2

13. S n o u t R e fle x 0 1 2

14. F in g e r-N os e -F in g e r T a s k 0 1 2

15. G o/N o-G o T a s k 0 1 2

16. E c h o pra x ia 0 1 2

17. L u ria H a nd S e qu e n ce I 0 1 2

18. L u ria H a nd S e que n ce II 0 1 2

19. G rip T as k 0 1 2

20. E c h opra x ia II 0 1 2

21. C o m ple x C om m a n d T as k 0 1 2

22. S e ria l O rde r R e v e rs a l T a s k 0 1 2

23. C o un ting T a s k I 0 1 2

24. U tiliz a tion B e ha v ior 0 1 2

25. Im ita tio n B e h av io r 0 1 2

S C O R E

T o tal

Global Test ObservationsE x e cu tiv e C o g n itiv e F u n ctio n s (E C F s ) o fte n be co m e im pa ire d in fro n ta l lo be da m a g e a nd de m e n tia . E C F s a reth e c o g n itiv e pro c e s s e s th a t o rc he s tra re la tiv e ly s im ple ide a s , m o v e m e n t, an d a c tion s into c o m ple x g o a l-dire c te d be h a v io rs durin g in te rn a l a n d e x te rna l dis trac tio n s . E x e cu tiv e c on tro l in c lude s g oa l s e le c tio n /fo rm a tio n, s e qu e nc in g , s e lf-m o nito rin g , a n d in h ibitio n o f irre le v an t o r in a ppro pria te be h a v io rs .

S e n iors ‘ M e n ta l H e a lth P ro g ra m s S ta nda rdiz e d A s s e s s m e n t S ca le s

L e a , C ., L o u ie , N ., Q u ac h , J ., & T an , M . (09-06-2000) P a g e 10 R e v is e d: M ay 18, 2005 E nqu ire s : S A S C om m itte e C h air/ A lbe rta H o s pita l E dm o n ton C o m m u n ity G e r ia tric P s y c hia try , (780) 424-4660.

C o m ple x be h a v io rs ( i.e ., m e a l pre para tio n, fin a n cia l a nd m e dic a tio n m a na g e m e n t) bre a k dow n in to th e ir c om po n e n t pa rts a nd pa tie n ts be co m e e ith e r o v e rde pe nde n t o n e nv iro n m e n ta l c u e s , e a s ily dis tra cte d a n d pe rs e v e ra tiv e , o r a pa th e tic a n d e n v iron m e nta lly in diffe re n t. T h is le ads to fun c tio n a l dis a bility by u n de rm in in g g o al-dire cte d a c tio n s (o rg a n iz a tion , pla n nin g , in s ig ht, ju dg m e n t, pe rs is te n c e , an d s e lf-co n trol) . E v ide n c e o f E C F im pa irm e n t c an be obs e rv e d in diffic ultie s w ith A D L , IA D L or im pa ire d be h a v io ra l fun c tio n s as de s cribe d in th e follow in g :

Global Observations of Executive Dyscontrol BehaviorsPerseveration: T h e te nde nc y to c on tinu e doin g s om e th in g in a pre v io u s ly e s ta blis h e d pa tte rn be y o n d a de s ire d de g re e o f appro pria te n e s s ( i.e ., re pe a tin g th e s a m e w o rd), e v e n a fte r a ne w s tim u lu s is pre s e n te d o r difficu lty s h iftin g fro m on e re s po ns e pa tte rn to a n o th e r. T his c a n be s e e n in tas ks 1, 3, 6, 14, 15, 22. Imitation: C opy in g a n oth e r‘s m o v e m e n ts (o r a ctio ns ) w ith o ut v o lu n tary co n tro l, o fte n in a pa th o lo g ica l m a nn e r (e c h o la lia, e c hpra x ia ). T h is ca n be s e e n in ta s ks 8, 15, 16, 20, 25. Intrusions: In appro pria te re s po ns e in flu e nc e d by la ck o f s e le c tiv e a tte n tio n . T his re s po n s e o fte n ha s s om e th in g th a t c o rre s po n ds to a s u pe r-im po s e d or pre ce din g tas k o r te s t pro ce du re ( i.e ., in te rfe re n c e o f pa rt o f tas k in to s u bs e qu e nt ta s ks ). T h is c an be s e e n in ta s ks 4, 6, 7, 15, 16, 22, 23. Frontal Release Signs: P rim itiv e re fle x e s th a t in dica te a lac k o f fro n tal lo be in h ibition o r de c ortic aliz a tio n ( i.e ., g ra s pin g re fle x e s a nd s uc kin g re s po n s e s ). T h is ca n be s e e n in ta s ks 8, 9, 10, 13, 19. Lack of Spontaneity/Prompting Needed: E v ide nc e o f de cre a s e d driv e , in a bility to initia te tas ks or pla n a h e a d, a path e tic be h av iors fo r th e o pin ion s o f o th e rs , a nd s h a llo w n e s s o f a ffe c t. T he a ppa re n t a path y im pro v e s w ith pro m ptin g . T h is ca n be s e e n in ta s ks 1, 2, 3, 5, 12, 14, 15, 17, 18, 21, 22. Disinhibited Behaviors: Inv o lun ta ry be h a v io rs th at c o u ld be s u btle bu t s o cia lly in appro pria te . A pe rs o n w ith dis in h ibite d be h a v io rs m a y ha v e diffic ulty s u ppre s s in g o ne ide a w h ile s e le c tin g an o th e r du e to a la c k o f div ide d atte n tion . T h is c a n be s e e n in ta s ks 3, 4, 11, 20. Utilization Behaviors: T h e te n de n cy to g ras p m a n ua lly a nd u s e obje cts pre s e n te d w ith in re a c h o f th e h a nds o f an in div idu al. T h e s e be h a v io rs o fte n indica te a de c re a s e a bility to c o n ce ptua liz e . T h is be h a v io r is trig g e re d by fa m ilia r o bje c ts . T his c an be s e e n in tas ks 19, 24, 25.

Summary: ______________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________

Examiner: _____________________________________________ Date:__________________________

ReferencesB e c ke r, E .L ., & L au dau , S .I. (E ds .) ( 1986) . Inte rna tio na l D ic tiona ry of M e dic ine and B iolo g y . N e w Y ork: W ile y .

M ills , B ., R oy a ll, D ., M ah urin, R ., e t a l. ( In pre s s) . E ffe cts o f e x e cu tiv e c og nitiv e de fic its o n de cis io nal c om pe te nc y : B e ds ideas s e s sm e nt w ith E x e c utiv e Inte rv ie w (E X IT ). P au lse n, J .S ., S tout, J .C ., D e L aP e na , J . R om e ro , R . e t a l. (1996). F ro ntal be h a v io ral s y nd ro m e s in c ortic a l a nd s ub co rtic al de m e n tia . A s se ss m e nt, 3(3), 327-337. R oy all, D . ( 1994) P re c is of e x e c u tiv e d y sc o ntro l as a c au s e of p ro ble m b e h av ior in D e m e ntia. E x pe rim e ntal A g in g R e s e arc h,20, 73-94.

R oy all, D ., M ah u rin, R ., & G ra y , K . (1992) . B e ds id e as se ss m e nt of e x e c utiv e c og n itiv e im p airm e nt: T he E x e c u tiv e Inte rv ie w . J ourna l o f A m e ric a n G e riatric s S o c ie ty , 40, 1221-1226.

S w a sh , M ., O x bu ry , J . (E ds ). (1991). C lin ic al N e urolog y . N e w Y ork: C h urch ill L iv ing s tone . W als h, K . ( 1991). U nde rs tan ding brain da m ag e : A p rim e r of ne urop s y c ho lo g ic al e v a lu ation . (2nd e d .). N e w Y o rk: C hu rc hill L iv in g s to ne .

P rint, cut, lam inate œ if y ou c hoos e .


ADMINISTRATION AND SCORING GUIDELINES

Scale/Screen: Frontal Assessment Battery (FAB)

Use(s):A short bedside cognitive and behavioral battery to assessfrontal lobe functions.

Time Taken: Approximately ten minutes.

Rationale(s):The FAB is a more concise scale than the other commonly used bedside frontal lobe scale, the EXIT, which has 25 items. This maymake it more acceptable to patients and clinicians alike. Whether it will be of equal clinical value is yet to be discerned.

Commentary:The FAB is comprised of six subtests which were selected bythe research team, “because the score of each of them significantly correlated with frontal metabolism, as measured in terms of the regional distribution of 18-fluorodeoxyglucose in a Positron Emission Tomography (PET) study of patients with frontal lobe damage of various etiologies.”

Summary of the six subtests:

Conceptualization: Test Item - “Similarities”

Patients with frontal lobe dysfunction may experience difficultyformulating abstract connections between the test items, eg.,banana and orange. They may, instead, show a tendency to offer more concrete links or they may be unable to establish anysimilarity between the items.

Mental Flexibility: Test item - “Verbal Fluency”

Subjects with frontal lobe dysfunction experience problems inadapting promptly and acting appropriately in novel or changing situations. Tests of verbal fluency have been shown to be an accurate reflection of mental flexibility. Frontal lobe lesions decrease lexical fluency with left frontal lesions causing lower word production than right.



Motor Programming: Test item - “Luria fist-palm-edge series.

Instrumental and basic activities of daily living are affected by frontal lobe lesions interfering in the subject’s ability to operationalize actions in an organized sequence to achieve desired goals. Luria’s fist-palm-edge test may uncover deficits in this area. Subjects with frontal lobe deficits may be unable to learn the demonstrated sequence or they may mimic two of the three actions or they may even perseverate with one gesture.

Sensitivity to Interference:Test item - “Conflicting Instructions”

Actions may speak louder than words for individuals with frontal lobe impairment. In the “conflicting instructions” subtest, i.e, “tap twice when I tap once” then “tap once when I tap twice”, subjects with frontal lobe dysfunction may be misdirected by the more powerful and obvious physical stimulus of tapping than with the examiner’s oral instruction.

Inhibitory Control Test: Test Item - “GO-NO-GO”

Impulsivity is characteristic of some forms of frontal lobe dysfunction. The “Go-No-Go” test is a measure of impulsivity. It examines the subject’s ability to inhibit the response previouslycalled for by the examiner, i.e., tap once when I tap once”, but then, “do not tap when I tap twice”. Subjects with frontal lobe lesionsmay have difficulty inhibiting their previously learned response.

Environmental Autonomy :Test item - “Environmental Control”

Patients with frontal lobe impairment may have a decreased abilityto inhibit inappropriate or automatic responses to sensory stimuli occurring in their immediate environment. For example, the sight ofan object may provoke the subject to reach out and use it (utilization behavior), or they may imitate actions witnessed inothers (imitation behavior). They are also more dependent on environmental cues to manage their daily activities becauseexecutive dyscontrol disrupts their self-directed planning abilities.



ADMINISTRATION AND SCORING INSTRUCTIONS

(The following instructions are taken from the Appendix of the referenced article by Dubois et al 2000)

1. Similarities (conceptualization)

“In what way are they alike?” A banana and an orange (in the event of total failure: “they are not alike” orpartial failure: “both have peel,” help the patient by saying: “both a banana and an orange are…”; but credit 0 for the item, do not help the patient for the two following items)

A table and a chair A tulip, a rose, and a daisy

Score: only category responses (fruits, furniture, flowers) are considered correct

2. Lexical fluency (mental flexibility)

“Say as many words as you can beginning with the letter ‘S’, any words exceptsurnames or proper nouns.”

If the patient gives no response during the first 5 seconds, say: “for instance, snake.” If the patient pauses 10 seconds, stimulate him by saying “any word beginning with the letter ‘S’. The time allowed is 60 seconds.

Score: word repetitions or variations (shoe, shoemaker), surnames, or proper nouns are not counted as correct responses.

3. Motor series (programming)

“Look carefully at what I’m doing.” The examiner, seated in front of the patient, performs alone three times with hisleft hand the series of Luria “fist-edge-palm”. “Now, with your right hand do the same series, first with me, then alone.” The examiner performs the series three times with the patient, then says to him/her: “Now, do it on your own.”

Score:Patient performs six correct consecutive series alone 3Patient performs at least three correct consecutive series alone 2Patient fails alone, but performs three correct consecutive

series with the examiner 1 Patient cannot perform three correct consecutive series even with the examiner 0



4. Conflicting instructions (sensitivity to interference)

“Tap twice when I tap once”. To be sure that the patient has understood the instruction, a series of three trialsis run: 1-1-1. “Tap once when I tap twice.” To be sure that the patient hasunderstood the instruction, a series of three trials is run: 2-2-2. The examiner performs the following series: 1-1-2-1-2-2-2-1-1-2.

Score: see test sheet

5. Go-No Go (inhibitory control)

“Tap once when I tap once.” To be sure that the patient has understood the instruction, a series of three trialsis run: 1-1-1. “Do not tap when I tap twice.” To be sure that the patient hasunderstood the instruction, a series of three trials is run: 2-2-2. The examinerperforms the following series: 1-1-2-1-2-2-2-1-1-2.


6. Prehension behavior (environmental autonomy/control)

The examiner is seated in front of the patient. Place the patient’s hands palm up on his/her knees. Without saying anything, or looking at the patient, the examiner brings his/her hands close to the patient’s hands and touches the palms of both the patient’s hands to see if he/she will spontaneously take them. If the patient takes the hands, the examiner will try again after asking him/her: “Now, do not take my hands.”


Reference: B. Dubois, A. Slachevsky, I. Litvan and B. Pillon. The FAB: A frontal assessment battery at bedside. Neurology 55, December 2000, 1621-1626.

Updated: June 8, 2005 WP/SMHPCC/Guidelines-FAB



Dubois, B., Slachevsky, A., Litvan, I., & Pillon, B. (2000) . The FAB: A frontal assessment battery at bedside. Neurology,55, 1621-1626.B. Dubois (personal communication, July 5, 2005) Revised: July 18/05Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780) 424-4660.


FAB:A Frontal Assessment Battery at the BedsideAge: _____________

Date: _____________________________________

Assessed By: _______________________________

Test & Scoring Instructions: ScoreSIMILARITIES

3 correct ---------------------------------- 3 2 correct ---------------------------------- 2 1 correct ---------------------------------- 1 0 correct ---------------------------------- 0

In what way are theylike?a

(can prompt for #1 only) – but score 0 for that item

1. A banana and orange? 2. A table and a chair? 3. A tulip, a rose and a daisy?

LEXICAL FLUENCY> 9 words --------------------------------- 3 6 - 9 words ------------------------------- 2 3 - 5 words ------------------------------- 1 < 3 words --------------------------------- 0

(don’t score repetitions or word variations)

Say as many words as you can beginning withthe letter “S”, except surnames or proper names.

Time 60 seconds.

Can give example if no response in 5 seconds or prompt if quiet for 10 seconds.

MOTOR SERIESPROGRAMMING

6 series alone --------------------------- 3 3 series alone --------------------------- 2 fails alone, but 3 with ------------------ 1 can’t do ----------------------------------- 0

Look carefully at whatI’m doing: Luria: fist-palm-edge (3 times)

Now with your right hand, do the same series with me, then

lone.a(with X3, alone X6)

CONFLICTINGINSTRUCTIONS

No error ----------------------------------- 3 1 or 2 errors ------------------------------ 2 > 2 errors --------------------------------- 1 taps like examiner 4 consecutive times - 0

Tap twice when I tap once: series 1-1-1 Tap once when I tap twice: series 2-2-2

Series: 1-1-2-1-2-2-2-1-1-2

GO-NO-GO (INHIBITORY CONTROL)No error ---------------------------------- 3 1 or 2 errors ----------------------------- 2 > 2 errors -------------------------------- 1 taps like examiner 4 consecutive times - 0

Tap once when I tap once 1-1-1 Do not tap when I tap twice 2-2-2

Series: 1-1-2-1-2-2-2-1-1-2

ENVIRONMENTAL CONTROL Patient doesn’t take hands -------------- 3 Hesitates and asks what to do --------- 2 Takes hands without hesitation -------- 1 Takes hands even after told not to ---- 0

Place the patient’s handspalm up on his/her knees

Move your hands close topatient’s hands and touch the palms of both hands with your fingers. If patient takes hands,say “Now, do not take myhands” and try again.

Scoring: 16-18 = normal or non significant 13-15 = mild impairment significant 7-12 = moderate impairment 0-6 = severe impairment Score: /18

Comments:_______________________________________________________________________________________________________________________________________________________________________

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