Executive cognitive dysfunction is typically the first area of cognitive impairment and these problems can precede the memory disturbances of dementia. People with executive cognitive dysfunction can have a normal MMSE score but still have severe functional limitations.
How Executive Functioning Is Affected by Dementia
Executive functioning involves the ability to organize, plan and carry out a set of tasks in an efficient manner. It also includes the ability to self-monitor and control our behaviors and multiple other cognitive functions and to perform goal-directed behavior. It can be described as high level thinking skills that control and direct lower levels of cognitive functioning.
Interestingly, although memory impairment often goes along with executive impairment, a person can show no memory problems but still be impaired in decision-making and executive functioning.
On a practical level, impairments in executive functioning have been associated with impairments in activities of daily living which include getting dressed, the ability to feed oneself, bathe oneself and more.
Executive functioning ability has been strongly connected to working memory ability.
In people with Alzheimer's disease, executive functioning is significantly impacted, and more so as the disease progresses. Some of the challenging behaviors that often accompany Alzheimer's and other types of dementia may be related to problems in executive functioning.
Other Types of Dementia
One study involved 76 people with Alzheimer's disease and 46 people with vascular dementia and found similar levels of executive functioning impairments in both groups of people. However, another study found that memory is typically more impaired earlier in Alzheimer's disease while executive functioning is usually more impaired in vascular dementia.
When comparing the executive functioning in people with Alzheimer's disease to that of those with frontotemporal dementia, those with frontotemporal dementia will usually display a greater impairment in executive functioning, and will do so earlier in the disease process.
Another study compared the executive functioning in people with frontotemporal dementia and Lewy body dementia and found similar levels of executive dysfunction in both disorders.
How Executive Functioning Is Assessed
There are several tests that help assess executive functioning. They include the clock-drawing test, the Stroop test, the verbal fluency test, the Wisconsin card-sorting test, and the executive interview, among others.
Examples of Executive Dysfunction in Dementia
Be aware that multi-step processes such as cooking and driving carry the possibility of danger when executive functioning is impaired, so take precautions in those areas, whether that's disconnecting the stove or talking to your loved one about quitting driving.
Other examples of impaired executive functioning in dementia include poor judgment, disorganization, socially inappropriate behavior, difficulty making plans for an event later in the day, and an inability to understand how their behavior or choices affect those around them. Executive functioning impairments may make it seem like the person is behaving selfishly, especially if their memory is still quite intact.
Can You Improve Executive Functioning in Dementia?
Some studies suggest that physical exercise can help improve executive functioning in people with dementia. For example, one study found that people with Alzheimer's disease experienced less decline in their executive functioning when they had higher rates of physical activity.
Other studies have demonstrated that certain diets, such as the MIND diet or the Mediterranean diet, have the potential to slow cognitive decline in those who have dementia, and this benefit may extend to executive functioning, as well as memory.
A Word From Verywell
An impairment in executive functioning can be frustrating at times, both for the person experiencing it as well as for her loved ones, but if you're able to respond and interact positively, it will help both of you. Also, reminding yourself that this challenge is due to dementia and is not a deliberate choice can also help reduce your potential to respond emotionally instead of with a deep breath and patience.
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, suggesting that your executive functions are akin to the chief executive that monitors all of the different departments so that the company can move forward as efficiently and effectively as possible. 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.
- 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
Anatomy of Executive Functions
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 (i.e., parietal lobes) 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 nonhuman primate relatives. The frontal lobes typically account for about 40% of the human brain.
Disorders of Executive Functions
Because these skills integrate information at a 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 often cause behavioral change.
Damage to the executive system often leads to:
- Difficulty organizing
- Difficulty in planning and initiation (getting started)
- Inability to multitask
- Difficulty with verbal fluency
- Trouble planning for the future
- Difficulty processing, storing, and/or retrieving information
- Mood swings
- Lack of concern for people and animals
- Loss of interest in activities
- Socially inappropriate behavior
- Inability to learn from consequences from past actions
- Difficulty with abstract concepts (the inability to make the leap from the symbolic to the real world)
- Unawareness or denial that their behavior is a problem
The instruments used to assess executive behavior draw on the cognitive skills described above, such as mental agility, planning, organization, inhibition and freedom from distraction. Widely used tests include the Word Fluency Task, Stroop Test, Wisconsin Card Sorting Test and the Trail Making Test.
Executive function deficits can occur as the result of a variety of neurologic conditions including traumatic brain injury, neurodegenerative diseases including frontotemporal dementia, cerebrovascular disease, as well as a number of psychiatric and developmental disorders, including obsessive-compulsive disorder, Tourette’s syndrome, depression, schizophrenia, attention-deficit/hyperactivity disorder, autism and addiction.