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Tuesday, January 18, 2011

Top 10 Things You Should Know About Executive Function and My bvFTD

What are executive functions? This seems to confuse many people because there are so many different aspects involved with Frontotemporal Degeneration.

The term “Executive Functions” refers to the higher-level cognitive skills you use to control and coordinate your other cognitive abilities and behaviors. The term is a business metaphor, where the chief executive monitors all of the different departments so that the company can move forward as efficiently and effectively as possible. Who we are, how we organize our lives, how we plan and how we then execute those plans is largely guided by our executive system.

Executive functions can be divided into organizational and regulatory abilities. Organization includes gathering information and structuring it for evaluation. Regulation involves evaluating the available information and modulating your responses to the environment. Seeing a wonderful dessert in front of you may be tempting to devour, but your executive system might remind you that eating it would conflict with your inner goals, such as losing weight. That long range thinking and reasoning is typical of the executive system. One type of executive function is called prospective memory, the ability to project into the future and solve problems that are likely to arise.

    * Organization: attention, planning, sequencing, problem solving, working memory, cognitive flexibility, abstract thinking, rule acquisition, selecting relevant sensory information
    * Regulation: initiation of action, self-control, emotional regulation, monitoring internal and external stimuli, initiating and inhibiting context-specific behavior, moral reasoning, decision-making

Impaired executive functions - see my post on (Dysexecutive Syndrome)

Because these skills integrate information at higher level across cognitive domains, damage to the executive system typically involves a cluster of deficiencies, not just one ability. The loss of that "administrative" control affects the ability to organize and regulate multiple types of information and, therefore, behaviors.

Damage to the executive system, often leads to:
(I have bolded the items on the following list which seem to cause me the most difficulty.)

    * Socially inappropriate behavior
    * Inability to apply consequences from past actions
    * Difficulty with abstract concepts (the inability to make the leap from the symbolic to the real world)
    * Difficulty in planning and initiation (getting started)
    * Difficulty with verbal fluency
    * Inability to multitask
    * Difficulty processing, storing, and/or retrieving information
    * Frequent “policing” by others to monitor the appropriateness of their actions
    * Loss of fine motor skills like grabbing something with your thumb and forefinger more than gross motor skills like running and jumping
    * Moody or “roller coaster” emotions
    * Lack of concern toward people and animals
    * Loss of interest in activities
    * Unawareness or denial that their behavior is a problem (How can you self-asses this one?)
    * Antisocial behavior associated with disinhibition
    * Trouble planning for the future

In addition to frontotemporal dementia, executive function deficits are associated with a number of psychiatric and developmental disorders, including obsessive-compulsive disorder, Tourette's syndrome, depression, schizophrenia, attention-deficit/hyperactivity disorder, autism and addiction.

Executive functions are difficult to assess directly since they coordinate other cognitive skills. Damage to memory, language, visuospatial skills and other cognitive functions can impact how a person performs on tests of executive function. Executive skills are also grounded in real world experience, which makes laboratory tests more difficult to create. The instruments used to assess executive behavior require mental agility, foresight, planning and freedom from distraction. Widely used tests include the Word Fluency Task, Stroop Test, Wisconsin Card Sorting Test (I did poorly on this one, though I thought I was doing well), Trailmaking Test (Another one I had difficulty with on the second phase which is typical) and Porteus Mazes. These tests are typically administered as part of a Psychoneurological Exam.

Executive deficits have been associated with damage to the most forward areas of the frontal lobes (located just above your eyes), as well as the cortical and subcortical structures that connect to the frontal lobes. The executive system involves the prefrontal cortex, basal ganglia and thalamus.

The frontal lobes are the last areas of the brain to fully develop. This area of the brain was evolutionarily late to appear and is much larger in human beings than in our closest non-human primate relatives. The frontal lobes typically account for about 40% of the human brain.

Impact of FTD
Behavioral variant Frontotemporal Dementia (bvFTD)

Progressive shrinking of the tissue in the frontal and anterior temporal lobes of the brain defines bvFTD. The changes most commonly associated with bvFTD are a loss of social skills, loss of concern for the emotions of others, disinhibition and antisocial behaviors, poor moral reasoning, lack of initiation, inappropriate humor, trouble making plans and moderating food intake. Sometimes patients with bvFTD also develop addictive behaviors late in life or show diminished response to pain.

That was more than 10 things, but I never really counted them anyway - I just needed to come up with a title. There are probably a lot more important things to know about Executive Functions, and there is a lot of very specific information in the book, What If It's Not Alzheimer's?

From my personal perspective I tend to divide these Executive Functions more between those that are Cognitive, and those that are Emotional when I try to understand my symptoms. As I describe in several places my biggest Cognitive challenges are with planning and organization, initiation, working memory. My biggest Emotional challenge is my desire to isolate myself, so I guess this is a form of antisocial behavior. I also exhibit an overall damping of emotions which usually manifests itself as, "I just don't give a rat's-ass!".

The drugs, and supplements which I am currently taking seem to alleviate the Cognitive symptoms more than the Emotional ones. Generally speaking, since I started taking Aricept and Ginkgo Biloba I think better overall than I did a year ago. The flip-side is that Aricept may make my Emotional symptoms worse. This is why Aricept is not recommended for people with bvFTD. In my case I find it easier to ignore telephone calls, and not reply to emails. For me with my specific set of symptoms and personality I think this is an acceptable trade-off. I am very comfortable with my own company, and I have very understanding friends who do not allow me to isolate myself completely.


So, though I still have Dysexecutive Syndrome, it is my belief that the medications and supplements I am currently taking are having some beneficial effects, though the purpose in my taking them is to attempt to slow the disease progression rather than to treat any specific symptoms.

Please leave you comments or questions below.

6 comments:

  1. A question: have you or your doctor noticed the results of supplements + Aricept being greater than anticipated? So a combination might help increase your ability to multi-task more than what was expected?

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  2. Good Question, Eileen. Yes. Aricept is reported to show minor improvements in day-to-day activities, but those measures are taken from the standpoint of the caregiver. In my case all we are hoping for is to slow or halt the progression. It is a pure bonus that for me it is helping with my cognitive symptoms. Since I can now do mental arithmetic I know it is directly helping my Working Memory. Note that a caregiver would see no change, but to me the change is huge. The Ginkgo Biloba works as a a delivery system increasing circulation to the brain, and thereby delivering more medication, nutrients, and oxygen. I can sometimes feel the rush after taking it. My other supplements are all to protect cells so would be unlikely to show any outward signs of improvement. My Neurologist is very encouraged by the results so far, and will be adding Nemanda to the cocktail in a couple months.

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  3. Thank you for your wonderful blog. You have done such a great job. You have helped me find more compassion for my husband. He has dementia, dysexecutivesyndrome, and 9 large lesions on the brain. His damage is in the frontotemporal area of the brain as well.

    It was so frustrating thinking that he was in denial. You have cleared this matter up. He simply cannot process the information.

    Interesting to point out that, like you, my husband has three degrees in psychology up to the PhD level.

    You seem to have a superb understanding of what is happening with you. Good job. Thank you for your blog.

    I now found myself full of mostly compassion for him. He is sicker than you and I miss him so much. His deterioration, although it is obvious now that it had to be gradual, felt so sudden!

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  4. Thank you for your comment, Whitney.

    Some days it is very difficult for me to get motivated to keep writing, and comments like yours really help.

    I noted that you mentioned that your husband had lesions. My MRI showed that I did not have any abnormal lesions. I would guess that with lesions the onset might come in steps rather than a steady gradual decline. As each lesion caused additional damage a new decline and symptoms would become evident giving the outward appearance of a sudden onset or worsening. Just a guess.

    My own onset seemed sudden to me, but that is because "all of a sudden one day I noticed the symptoms". In fact they had been there gradually getting worse for quite some time.

    Some days are better than others.

    -Lee

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  5. My Dad has just been diagnosed.Thank you so much for your helpful blog. Like you he has multiple degrees, which I find interesting. In my research I have found some trials going on now at GAAD/in Canada on using Far infrared for Frontal Temporal dementia, also some using oxytocin to help with the social symptoms that you are experiencing. Oxytocin is known as the "tend/befriend" hormone if you are not familiar. I'm just trying to sort out what may help him and perhaps you'd like to check these out. Thanks for giving me inspiration & courage. (which I will share with my Dad)

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  6. Thanks for your comment.

    I had not heard of Oxytocin being used for FTD. I would be surprised if it is effective as from what I know it does not easily cross the blood-brain barrier, so most of its actions are systemic. I will look into it.

    Best wishes to you and your Dad. Some days are better than others.

    ~Lee

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