Frontal Lobe Handout Package

Transcription

1 Frontal Lobe Handout Package

2 Frontal Lobe Function Learning Objectives 1. Explain the basic anatomy and functions of the frontal lobe. 2. Describe clinical signs of frontal lobe damage and areas of frontal lobe deficit. 3. Identify therapeutic interventions including compensatory and cognitive rehabilitation strategies. 4. Be aware of assessment tools to identify frontal lobe deficits. Lobes of the Cerebrum Limbic Lobe Frontal Lobe Parietal Lobe Temporal Lobe Occipital Lobe 1

3 H e L o HeLo HeLo Frontal Lobe Lies at the front of the cerebral cortex Contains the main areas of motor control Main Areas of Motor Control Hi He Lo He Lo He H Lo e L o He Lo He Lo H e Lo Primary motor Hello cortex Primary Motor Cortex hi There Premotor Cortex Hello there (Schwerin, 2006) Main Areas of Motor Control Broca s Area (Chudler, 2006) 2

4 Main Areas of Motor Control Prefrontal Cortex Frontal Lobe Functions of the Frontal Lobe Learning new tasks Abstract thinking Inhibition and impulse control Goal-directed behaviour Planning Personality Clinical Signs of Frontal Lobe Damage Disinhibition Apathetic Medial frontal syndrome Behavioural changes Memory impairment Attention deficit Concrete thinking Perseveration 3

5 Associated Diagnoses Stroke Tumor Epilepsy Schizophrenia Dementia Other Degenerative Diseases Associated Diagnoses Multiple Sclerosis Substance-Induced Hypoxia Toxic Substances Infection Traumatic Brain Injury Coup Contrecoup Primary Impact Secondary Impact 4

6 Frontal vs. Alzheimer Dementia FTD Reduced speech output Good comprehension Personality changes early Preserved spatial orientation Memory loss variable Apraxia uncommon Possible motor signs AD Fluent aphasia Reduced comprehension Personality changes late Impaired spatial orientation Memory loss early Apraxia common Motor signs uncommon early Frontal Lobe Assessment Standardized Assessment Tools Executive Interview (Exit) Frontal Assessment Battery (FAB) 5

7 Executive Interview (EXIT) 25-item screen to detect possible frontal lobe dysfunction Helps predict: Executive cognitive function Behaviour caused by executive impairment Care strategies to prevent problem behaviours Frontal Assessment Battery (FAB) A short bedside cognitive and behavioural battery to assess frontal lobe functions Comprised of 6 subtests: Conceptualization Mental flexibility Motor programming Sensitivity to interference Inhibitory control test Environmental autonomy Additional Cognitive Deficits Aphasia Praxis Neglect Anosognosia Judgment, insight, and social appropriateness 6

8 Additional Cognitive Deficits Memory deficits Lack of originality, inattentiveness, and inappropriate emotional reactions Frontal release responses Interventions 1. Activity-Based 2. Compensatory Strategies 3. Cognitive Rehabilitation 1. Activity-Based Interventions Leisure Activities Multi-Sensory Interventions Role Renewal Exercise Crafts 7

9 2. Compensatory Strategies Use concrete language Limit choice Structured environment Predictable routines Recognize antecedents Understand purpose of disruptive behaviour 3. Cognitive Rehabilitation Limits Plasticity What Can You Do To Prevent This? 8

10 Frontal Lobe Resource Package

11 Frontal vs. Alzheimer Dementia FTD Reduced speech output Good comprehension Personality changes early Preserved spatial orientation Memory loss variable Apraxia uncommon Possible motor signs AD Fluent aphasia Reduced comprehension Personality changes late Impaired spatial orientation Memory loss early Apraxia common Motor signs uncommon early

12 Seniors Mental Health Programs Standardized Assessment Scales ADMINISTRATION AND SCORING GUIDELINES Scale/Screen: Use(s): The Executive Interview (EXIT) 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: Rationale(s): Commentary: Approximately 15 minutes 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 in Alzheimer s Disease. The EXIT is a valid and reliable tool to identify 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 impairment than the SMMSE. 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 by interfering 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 of many 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)

13 Seniors Mental Health Programs Standardized Assessment Scales Administration: Scoring: 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 many cues 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 may seem 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. 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 strongly correlated with a variety of common disruptive behaviours. Interrater reliability was high (r =.90). EXIT scores correlated well with other measures of Executive 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 the American Geriatrics Society) 40: Tips on How to Administer The EXIT Royall D.R., Cabello M., Polk M.J., (1998). Executive Dyscontrol: An Important Factor Affecting The Level of are Received by Older Retirees. JAGS 46: Updated: May 18, 2005 WP/SMHPCC/Guidelines EXIT Test Enquiries: S.A.S. Committee Chair, c/o AHE Community Geriatric Psychiatry, (780)

14 The Executive Interview (EXIT) Seniors Mental Health Programs Standardized Assessment Scales Global Testing Observations: Check as many as observed during testing Patient/Client Label Perseveration Date Imitation Behavior Intrusions Diagnosis Frontal Release Signs Lack of Spontaneity/Prompting Needed Disinhibited Behaviors Education Level Utilization Behavior TOTAL SCORE 1. Number-Letter Task I d like you to say some numbers and letters for me like this. 1-A, 2-B, 3-what would come next? C Now you try it starting with the number 1. Keep going until I say stop A B C D E Stop SCORE 0 No errors 1 Complete task with prompting (or repeat instruction) 2 Doesn t complete task Royall, D.R., Mahurin, R.K., and Gray, K.F., 1992 Page 1 Revised: May 18, 2005 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780)

15 Seniors Mental Health Programs Standardized Assessment Scales 2. Word Fluency I am going to give you a letter. You will have one minute to name as many words as you can thinkofwhichbegin with thatletter. For example, with the letter P you could say Peter, pot, plant and so on. Are you ready? Do you have any questions? The letter is œ A. Go! SCORE 0 10 or more words 1 5 to 9 words 2 Less than 5 words 3. Design Fluency (Examiner draws while patient watches) Look at these pictures. Each is made with only four (4) lines. I am going to give you one minute to draw as many DIFFERENT designs as you can. The only rules are that they must each be different and be drawn with four lines. Now go! If patient cannot do due to poor vision, score 0 SCORE 0 10 or more unique drawings (no copies of examples) 1 5 to 9 unique drawings 2 Less than 5 unique drawings 4. Anomalous Sentence Repetition Listen very carefully and repeat these sentences exactly (Read the sentence in a neutral tone.) Can use any familiar, overlearned phrase that 1) has one word changed 2) is part of a longer sequence, poem, prayer, etc. a) I pledge allegiance to those flags or Oh Canada, your home and native land. b) Mary fed a little lamb. c) A stitch in time saves lives. d) Tinkle tinkle little star. e) A B C D U F G SCORE 0 No errors 1 Fails to make one or more changes 2 Continues with one or more expressions (e.g. Mary had a little lamb whose fleece was white as snow ) Royall, D.R., Mahurin, R.K., and Gray, K.F., 1992 Page 2 Revised: May 18, 2005 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780)

16 Seniors Mental Health Programs Standardized Assessment Scales 5. Thematic Perception (see previous page) (Patient shown picture by examiner) Tell me what is happening in this picture. If patient cannot see picture due to poor vision, score 0 SCORE 0 Tells spontaneous story (story = setting,3 characters, action) 1 Tells story with prompting x 1 ( anything else?) 2 Fails to tell story despite prompt (patientmust name the setting) 6. Memory/Distraction Task Remember these three words. BOOK, TREE,HOUSE (Patient repeats words till all three are registered). Remember them œ I ll ask you to repeat them for me later. Now œ spell CAT for me Good. Now spell it backwards OK. Tell me those words we learned. SCORE 0 Patient names one or all of the three words correctly without naming Cat (Examiner may prompt: Anything else? ) 1 Other responses (describe: ) 2 Patient names CAT as one of the three words (perseveration) 7. Interference Task (see previous page) What color are these letters? (Examinershows the patient and sweeps hand back and forth over the letters.) SCORE 0 black 1 brown (repeat questions x1) black 2 brown (prompt) brown (intrusion) If patient names any other colour, score 0 but make a note of response. Royall, D.R., Mahurin, R.K., and Gray, K.F., 1992 Page 3 Revised: May 18, 2005 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780)

17 Seniors Mental Health Programs Standardized Assessment Scales 8. Automatic Behavior I (Patient holds hands forward palms down.) Relax while I check your reflexes (Rotate patient s arms one at a time at the elbow. Gauge patient s active participation/anticipation of the rotation.) SCORE 0 Patient remains passive 1 Equivocal 2 Patient actively copies the circular motion 9. Automatic Behavior II (Patient holds hands out palms up.) Just relax. (Examiner pushes down on patient s hands gently at first, becoming more forceful. Gauge patient s active participation in the responses.) SCORE 0 Patient offers no resistance (remains passive) 1 Equivocalresponse 2 Actively resists (or complies)with examiner 10. Grasp Reflex (Patient holds hand out with open palms down.) Just Relax. (Both palms are lightly stroked simultaneous by the examiner, who looks for grasping/gripping actions in the fingers.) SCORE 0 Absent 1 Equivocal 2 Present Patient grasps firmly enough to drawn up and out of chair by examiner. Royall, D.R., Mahurin, R.K., and Gray, K.F., 1992 Page 4 Revised: May 18, 2005 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780)

18 Seniors Mental Health Programs Standardized Assessment Scales 11. Social Habit I Fix subject s eyes. Silently count to three while maintaining subject s gaze, then say Thank you. SCORE 0 Replies with a question (e.g. Thank you for what? ) 1 Other responses œ describe: 2 You re welcome. 12. Motor Impersistence Stick out your tongue and say aah till I say stop Go! (count to three silently) (Subject must sustain a constant tone, not ah ah ah ) SCORE 0 Completes taskspontaneously 1 Completes taskwith examiner modeling task for patient 2 Fails task despite modeling by examiner 13. Snout Reflex Just Relax. (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.) SCORE 0 Notpresent 1 Equivocal 2 Present Suck reflex œ lips pucker while examiner is pausing 2 away 14. Finger-Nose-Finger Task (Examiner holds up index finger.) Touch my finger. (Leaving finger in place, examiner says ) Now touch your nose. SCORE 0 Patient complies, using same hand 1 Other response œ describe: 2 Patient complies, using other hand while continuing to touch examiner s finger Royall, D.R., Mahurin, R.K., and Gray, K.F., 1992 Page 5 Revised: May 18, 2005 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780)

19 15. Go/No-Go Task Seniors Mental Health Programs Standardized Assessment Scales Now when I touch my nose, you raise your finger like this. (Examiner raises index finger.) When I raise my finger, you touch your nose like this. (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.) Examiner Patient F N F N F N F N F F N F N F N SCORE 0 Performs sequence correctly 1 Correct, required prompting/repeat instructions 2 Fail sequence despite prompting/repeat instructions 16. Echopraxia Now listen carefully. I want you to do exactly what I say. Ready? Touch your ear. (Examiner touches his nose and keeps finger there.) SCORE 0 Patient touches his ear 1 Other response (look for mid-position stance) 2 Patient touches his nose 17. Luria Hand Sequence I Palm/Fist Can you do this? (Invite patient to watch while alternating palms/fist with either hand. Once patient begins, ask patient to Keep going while examiner stops. Count the number of successive palm/fist cycles.) SCORE 0 4 cycles without error after examiner stops 1 4 cycles with additional verbal prompt ( Keep going ) or modeling 2 Unsuccessful despite prompting/modeling (watch for mid position stances) Royall, D.R., Mahurin, R.K., and Gray, K.F., 1992 Page 6 Revised: May 18, 2005 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780)

20 18. Luria Hand Sequence II 3Hands Can you do this? Seniors Mental Health Programs Standardized Assessment Scales (Examiner models: a) slap, b) fist, c) cut while patient imitates each step) Now follow me. (Examiner begins to repeat sequence.) Keep doing this till I say stop. (Examiner stops.) SCORE 0 3 cycles without error after examiner stops 1 3 cycles with additional verbal prompt ( Keep going ) or modeling 2 Unsuccessful 19. Grip Task (Examiner presents hands to patient as shown below.) Squeeze my fingers. SCORE 0 Patient grips fingers 1 Other responses œ describe: 2 Patient pulls examiner s hands together 20. Echopraxia II (Suddenly and without warning, the examiner slaps his hands together.) SCORE 0 Patient does not imitate examiner 1 Patient hesitates, uncertain 2 Patient imitates slap Royall, D.R., Mahurin, R.K., and Gray, K.F., 1992 Page 7 Revised: May 18, 2005 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780)

21 21. Complex Command Task Seniors Mental Health Programs Standardized Assessment Scales Put your left hand on top of your head and close your eyes. That was good (Examiner remains aloof, begins next task.) SCORE 0 Patient stops when next task began 1 Equivocal œ holds posture during part of next task 2 Patient maintains posture through completion of next task œ has to be told to cease (Quickly go on to next task) 22. Serial Order Reversal Task (Have patient recite the months of the year) Now start with January and say the months of the year backwards SCORE 0 No errors, at least past September 1 Gets past September but requires repeat instructions ( Just start with January and say then all backwards. ) 2 Can t succeed despite prompting. (Patient must start with January) 23. Counting Task I (Examiner taps each picture around the figure in a clockwise direction.) Please count the fish in this picture out loud. SCORE 0 Four 1 Less than four 2 More than four 24. Utilization Behavior (Examiner holds pen near point and dramatically presents it to the patient asking:) What is this called? SCORE 0 Pen 1 Reaches,hesitates 2 Patient takes pen from examiner (utilization behavior) 25. Imitation Behavior (Examiner flexes wrist up and down and points to it asking:) What is this called? SCORE 0 Wrist 1 Other response œ describe: 2 Patient flexes wrist up and down (echopraxia) Royall, D.R., Mahurin, R.K., and Gray, K.F., 1992 Page 8 Revised: May 18, 2005 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780)

22 Seniors Mental Health Programs Standardized Assessment Scales The Executive Interview (EXIT ) Royall et al. (1992) Summary Sheet Patient/Client Label Score Sheet 1. Number-LetterTask Word Fluency Design Fluency Anomalous Sentence Repetition Thematic Perception Memory/DistractionTask Interference Task Automatic Behavior I Automatic Behavior II GraspReflex SocialHabit MotorImpersistence SnoutReflex Finger-Nose-FingerTask Go/No-G otask Echopraxia Luria Hand Sequence I Luria Hand Sequence II Grip Task Echopraxia II Complex Command Task Serial Order Reversal Task Counting Task I UtilizationBehavior ImitationBehavior SCORE Total Global Test Observations Executive Cognitive Functions (ECFs) often become impaired in frontal lobe damage and dementia. ECFs are the cognitive processes that orchestra relatively simple ideas, movement, and actions into complex goaldirected behaviors during internal and external distractions. Executive control includes goal selection/formation, sequencing, self-monitoring, and inhibition of irrelevant or inappropriate behaviors. Lea, C., Louie, N., Quach, J., & Tan, M. ( ) Page 9 Revised: May 18, 2005 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry,(780)

23 Seniors Mental Health Programs Standardized Assessment Scales Complex behaviors (i.e., meal preparation, financial and medication management) break down into their component parts and patients become either overdependent on environmental cues, easily distracted and perseverative, or apathetic and environmentally indifferent. This leads to functional disability by undermining goal-directed actions (organization, planning, insight, judgment, persistence, and self-control). Evidence of ECF impairment can be observed in difficulties with ADL, IADL or impaired behavioral functions as described in the following: Global Observations of Executive Dyscontrol Behaviors Perseveration: The tendency to continue doing something in a previously established pattern beyond a desired degree of appropriateness (i.e., repeating the same word), even after a new stimulus is presented or difficulty shifting from one response pattern to another. This can be seen in tasks 1, 3, 6, 14, 15, 22. Imitation: Copying another s movements (or actions) without voluntary control, often in a pathological manner (echolalia, echpraxia). This can be seen in tasks 8, 15, 16, 20, 25. Intrusions: Inappropriate response influenced by lack of selective attention. This response often has something that corresponds to a super-imposed or preceding task or test procedure (i.e., interference of part of task into subsequent tasks). This can be seen in tasks 4, 6, 7, 15, 16, 22, 23. Frontal Release Signs: Primitive reflexes that indicate a lack of frontal lobe inhibition or decorticalization (i.e., grasping reflexes and sucking responses). This can be seen in tasks 8, 9, 10, 13, 19. Lack of Spontaneity/Prompting Needed: Evidence of decreased drive, inability to initiate tasks or plan ahead, apathetic behaviors for the opinions of others, and shallowness of affect. The apparent apathy improves with prompting. This can be seen in tasks 1, 2, 3, 5, 12, 14, 15, 17, 18, 21, 22. Disinhibited Behaviors: Involuntary behaviors that could be subtle but socially inappropriate. A person with disinhibited behaviors may have difficulty suppressing one idea while selecting another due to a lack of divided attention. This can be seen in tasks 3, 4, 11, 20. Utilization Behaviors: The tendency to grasp manually and use objects presented within reach of the hands of an individual. These behaviors often indicate a decrease ability to conceptualize. This behavior is triggered by familiar objects. This can be seen in tasks 19, 24, 25. Summary: Examiner: Date: References Becker, E.L., & Laudau, S.I. (Eds.) (1986). International Dictionary of Medicine and Biology. New York: Wiley. Mills, B., Royall, D., Mahurin, R., et al. (In press). Effects of executive cognitive deficits on decisional competency: Bedside assessment with Executive Interview (EXIT). Paulsen, J.S., Stout, J.C., DeLaPena, J. Romero, R. et al. (1996). Frontal behavioral syndromes in cortical and subcortical dementia. Assessment,3(3), Royall, D. (1994) Precis of executive dyscontrol as a cause of problem behavior in Dementia. Experimental Aging Research, 20, Royall, D., Mahurin, R., & Gray, K. (1992). Bedside assessment of executive cognitive impairment: The Executive Interview. Journal of American Geriatrics Society,40, Swash, M., Oxbury, J. (Eds). (1991). Clinical Neurology. New York: Churchill Livingstone. Walsh, K. (1991). Understanding brain damage: A primer of neuropsychological evaluation. (2 nd ed.). New York: Churchill Livingstone. Lea, C., Louie, N., Quach, J., & Tan, M. ( ) Page 10 Revised: May 18, 2005 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780)

24 Print, cut, laminate œ if you choose.

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26 Seniors Mental Health Programs Standardized Assessment Scales ADMINISTRATION AND SCORING GUIDELINES Scale/Screen: Use(s): Frontal Assessment Battery (FAB) A short bedside cognitive and behavioral battery to assess frontal lobe functions. Time Taken: Approximately ten minutes. Rationale(s): Commentary: The FAB is a more concise scale than the other commonly used bedside frontal lobe scale, the EXIT, which has 25 items. This may make it more acceptable to patients and clinicians alike. Whether it will be of equal clinical value is yet to be discerned. The FAB is comprised of six subtests which were selected by the 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 difficulty formulating 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 any similarity between the items. Mental Flexibility: Test item - Verbal Fluency Subjects with frontal lobe dysfunction experience problems in adapting 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. Enquiries: S.A.S. Committee Chair, c/o AHE Community Geriatric Psychiatry, (780)

27 Seniors Mental Health Programs Standardized Assessment Scales 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 previously called 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 lesions may have difficulty inhibiting their previously learned response. Environmental Autonomy :Test item - Environmental Control Patients with frontal lobe impairment may have a decreased ability to inhibit inappropriate or automatic responses to sensory stimuli occurring in their immediate environment. For example, the sight of an object may provoke the subject to reach out and use it (utilization behavior), or they may imitate actions witnessed in others (imitation behavior). They are also more dependent on environmental cues to manage their daily activities because executive dyscontrol disrupts their self-directed planning abilities. Enquiries: S.A.S. Committee Chair, c/o AHE Community Geriatric Psychiatry, (780)

28 Seniors Mental Health Programs Standardized Assessment Scales 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 or partial 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 except surnames 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 his left 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 3 Patient performs at least three correct consecutive series alone 2 Patient fails alone, but performs three correct consecutive series with the examiner 1 Patient cannot perform three correct consecutive series even with the examiner 0 Enquiries: S.A.S. Committee Chair, c/o AHE Community Geriatric Psychiatry, (780)

29 Seniors Mental Health Programs Standardized Assessment Scales 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 trials is run: Tap once when I tap twice. To be sure that the patient has understood the instruction, a series of three trials is run: The examiner performs the following series: 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 trials is run: Do not tap when I tap twice. To be sure that the patient has understood the instruction, a series of three trials is run: The examiner performs the following series: Score: see test sheet 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. Score: see test sheet Reference: B. Dubois, A. Slachevsky, I. Litvan and B. Pillon. The FAB: A frontal assessment battery at bedside. Neurology 55, December 2000, Updated: June 8, 2005 WP/SMHPCC/Guidelines-FAB Enquiries: S.A.S. Committee Chair, c/o AHE Community Geriatric Psychiatry, (780)

30 Seniors Mental Health Programs Standardized Assessment Scales FAB: AFrontal Assessment Battery at the Bedside Age: Date: Patient/Client Label Assessed By: Test & Scoring Instructions: Score SIMILARITIES In what way are they alike? 3 correct correct correct correct LEXICAL FLUENCY > 9 words words words < 3 words (don t score repetitions or word variations) MOTOR SERIES PROGRAMMING 6 series alone series alone fails alone, but 3 with can t do CONFLICTING INSTRUCTIONS No error or 2 errors > 2 errors taps like examiner 4 consecutive times - 0 GO-NO-GO (INHIBITORY CONTROL) No error or 2 errors > 2 errors taps like examiner 4 consecutive times - 0 ENVIRONMENTAL CONTROL Patient doesn t take hands Hesitates and asks what to do Takes hands without hesitation Takes hands even after told not to (can prompt for #1 only) but score 0 for that item Say as many words as you can beginning with the letter S, except surnames or proper names. Look carefully at what I m doing: Luria: fistpalm-edge (3 times) Tap twice when I tap once: series Tap once when I tap twice: series Tap once when I tap once Do not tap when I tap twice Place the patient s hands palm up on his/her knees 1. A banana and orange? 2. A table and a chair? 3. A tulip, a rose and a daisy? Time 60 seconds. Can give example if no response in 5 seconds or prompt if quiet for 10 seconds. Now with your right hand, do the same series with me, then alone. (with X3, alone X6) Series: Series: Move your hands close to patient s hands and touch the palms of both hands with your fingers. If patient takes hands, say Now, do not take my hands and try again. Scoring: = normal or non significant = mild impairment significant 7-12 = moderate impairment 0-6 = severe impairment Score: /18 Comments: Dubois, B., Slachevsky, A., Litvan, I., & Pillon, B. (2000). The FAB: A frontal assessment battery at bedside. Neurology, 55, B. Dubois (personal communication, July 5, 2005) Revised: July 18/05 Enquires: SAS Committee Chair/ Alberta Hospital Edmonton Community Geriatric Psychiatry, (780)