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Psychosomatics 44:290-297, August 2003
© 2003 The Academy of Psychosomatic Medicine

Prevalence of Executive Impairment in Patients Seen by a Psychiatry Consultation Service

Jason E. Schillerstrom, M.D., Melissa S. Deuter, M.D., Rob Wyatt, M.D., Stephen L. Stern, M.D., and Donald R. Royall, M.D.

Received April 10, 2002; revision received Sept. 24, 2002; accepted Oct. 18, 2002. From the University of Texas Health Science Center at San Antonio. Address reprint requests to Dr. Schillerstrom, Department of Psychiatry, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229; schillerstr{at}uthscsa.edu (e-mail).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
The prevalence of impairment of executive function among 50 medical inpatients referred for psychiatric consultation was assessed by using the Executive Interview (EXIT25) and an executive clock-drawing task (CLOX). The Mini-Mental Status Examination (MMSE) was also administered to assess general cognition. The percentage of patients who failed each test was calculated. Seventy-two percent failed at least one measure of executive function, whereas only 30% failed the MMSE. The results suggest that impairment of executive function is common among inpatients referred for psychiatric consultation. Because impairment of executive function has been specifically associated with behavioral and functional disability, routine assessment of executive function should be integrated into psychiatric case management.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Clinicians' interest in measuring executive function has been increasing because such measures may be used to predict the functional outcomes of patients with psychiatric and medical illness. Although DSM-IV1 recognizes impairment of executive function as a diagnostic criterion only for dementia, poor executive function is found in many other psychiatric disorders, including schizophrenia,2,3 substance use disorders,4 and depression.5,6 Furthermore, executive impairment is associated with many common medical disorders, including ischemic and hemorrhagic stroke,7,8 chronic obstructive pulmonary disease,9 hypertension,10 and diabetes.11,12

As defined by DSM-IV, "executive function" is one's ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior.1 It includes the orchestration of many simple tasks to carry out a preconceived plan while successfully adapting to changing environmental cues.

Executive dysfunction predicts poor everyday functioning and more specifically predicts the inability to attend to one's own health care needs. Measures of executive function correlate more strongly with measures of physical and instrumental function than with scores on the Cumulative Illness Rating Scale, a standard measure of somatic disease burden.13 Furthermore, executive impairment is associated with resistance to care in demented patients and with the need for a high level of care in elderly patients.14,15 Executively impaired patients may take their medications incorrectly, miss doctors' appointments, and not be able to attend to tasks such as wound care, blood sugar monitoring, and nonmedicinal therapies such as a diet and exercise regimen. Thus, these patients may appear noncompliant when in fact they lack the cognitive ability to attend to their health care needs.

Several neuropsychological tests have been used to evaluate executive function. They include the Wisconsin Card Sorting Test,16 Stroop Interference Task,17 Tower of London/Hanoi,18 and Tinker Toy Test.18 Unfortunately, none of these tests are practical at the bedside. The Halstead-Reitan Neuropsychological Battery,19 which includes Trail Making Tests A and B, and the Luria-Nebraska Neuropsychological Battery20 extensively evaluate executive function. However, they take 2–6 hours to complete and require the expertise of a well-trained neuropsychologist to administer.

The Executive Interview (EXIT25) and the executive clock-drawing task (CLOX) were developed to help clinicians overcome these obstacles. The EXIT25 is a 25-item, structured bedside clinical assessment that incorporates multiple executive tasks.21 Scores on the EXIT25 correlate well with those of other neuropsychological measures of executive function such as the Wisconsin Card Sorting Test (r=0.52), Trail Making Tests A and B (r=0.73 and r=0.64, respectively), and the Tinker Toy Test (r=0.57). The EXIT25 has high interrater reliability (Pearson's r=0.90) and can be administered and scored by any clinician.21 EXIT25 scores have been specifically associated with left frontal system structural lesions by magnetic resonance imaging and with left mesiofrontal cerebral blood flow by single photon emission computed tomography.22,23

The CLOX clock-drawing task is divided into two parts. In the first part, CLOX1, the patient draws a clock in response to the examiner's command; in the second part, CLOX2, the patient copies a clock drawn by the examiner.24 The CLOX is a valid and reliable measure of general cognitive impairment and executive function. It has high internal consistency (Cronbach's alpha=0.82) and high between-rater reliability (CLOX1: r=0.94, CLOX2: r=0.93; both p<0.001).24 EXIT25 scores account for 68% of the variance in CLOX1 scores (partial R2=0.68).24 Scores on the Mini-Mental Status Examination (MMSE)25 correlate well with CLOX2 scores (r=0.85) and account for 72% of the variance in CLOX2 scores (partial R2=0.72).24 CLOX1 is more sensitive to executive impairment, as measured by the EXIT25, than similar clock-drawing tasks.26

It is our impression that executive impairment is poorly detected by traditional cognitive assessments and therefore often undiagnosed or unaddressed by clinicians. Practical measures such as the EXIT25 and the CLOX may provide the means to make assessment of executive function a routine part of clinical practice. This study used the EXIT25 and the CLOX to determine the prevalence of executive impairment among patients seen by a psychiatry consultation-liaison service and examined the clinical characteristics of the patients with impaired executive function.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Subjects
During a 4-month period, patients seen by a psychiatry consultation-liaison service in a public teaching hospital were recruited. Although the patients were consecutively recruited during this period, we were unable to collect data during one continuous month. The protocol was approved by the Institutional Review Board of the University of Texas Health Science Center at San Antonio. Subjects included any general or specialty medicine /surgery service inpatient referred to the University of Texas Health Science Center at San Antonio psychiatry consultation service who was at least 16 years old (legal age to consent to psychiatric care in Texas). Twelve subjects were excluded for refusal or inability to provide informed consent, leaving a total of 50 study participants.

Each patient was evaluated by one of three psychiatry residents (J.E.S., M.S.D., R.W.), who collected demographic and clinical data and administered the cognitive tests. Subjects were recruited after completion of their routine history and mental status assessments. Clinical diagnoses were made according to DSM-IV and confirmed by one of three senior psychiatry professors. Table 1 summarizes the demographic and diagnostic characteristics of the patients.


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TABLE 1. Demographic and Clinical Characteristics of 50 Inpatients Referred to a Psychiatric Consultation Service Who Were Assessed for Impairment of Executive Functiona



Neuropsychological Tests
After written informed consent was obtained, each subject was administered the EXIT25, CLOX, and MMSE.

EXIT25
The EXIT25 is a compilation of 25 executive tasks that measure executive impairment, including the Luria motor tasks, verbal trails, and verbal fluency. It takes approximately 15 minutes to administer and score. Each of the 25 items is scored from 0 to 2, with 0 meaning intact performance, 1 meaning either specific partial error or equivocal response, and 2 meaning specific incorrect response or inability to complete the task. A score of 15 or higher indicates executive impairment. This cutoff point may underestimate the statistical prevalence of executive impairment in younger patients. Other authors have reported that a score of 10 of 50 best discriminates between young adult patients with and without HIV-associated cognitive impairment.27 However, the EXIT25's threshold has been set to define clinically significant executive impairment, not merely statistically defined impairment. A cutoff point of 15 of 50 best discriminates well elderly retirees from those in supervised care settings21 and best predicts capacity to give informed consent for health care.28 This cutoff point is equally valid for young adults with schizophrenia.29

The Executive Clock Drawing Task (CLOX)
The CLOX consists of two parts that each take approximately 2 minutes to administer. For CLOX1, the patient is asked to "draw a clock that says 1:45 and put the hands and numbers on the face so that a child can read it." The patient's clock is scored from 1 to 15 on the basis of fulfillment of 15 specific criteria, such as dimensions greater than 1 inch, arrows on the hands, hour hand shorter than minute hand, etc. Scores on CLOX1 correlate strongly with those on the EXIT25 (r=-0.83).24

During CLOX2, the patient is instructed to copy a clock drawn by the examiner. CLOX2 is a general cognitive measure that assesses for drawing ability, tremor, vision, and right parietal cortical function. Scores on the CLOX2 correlate well with MMSE scores (r=0.85), another general measure of cognition.24

The CLOX takes approximately 5–10 minutes to administer and score. Scores <=10 of 15 for CLOX1 or <=12 of 15 for CLOX2 represent the lowest fifth percentile for young adults.24

MMSE
The MMSE is commonly used to assess general cognition.25 It is most often used to diagnose and monitor the progression of delirium and dementia. The MMSE is heavily weighted with verbal memory assessments; 16 of the 30 MMSE items assess orientation and short-term recall. Although cutoff scores for this instrument are controversial, we used a conventional cutoff score of <=24 to indicate general cognitive impairment.30

Data Analysis
Data on each patient's age, gender, education, ethnicity, DSM-IV axis I–III diagnoses, medications, and test scores were documented. A database of demographic information, diagnoses, medications, and neuropsychological test results was then generated. The published threshold for each measure was used to generate pass/fail ratings for MMSE, CLOX1, CLOX2, and EXIT25. The thresholds were 24 of 30, 10 of 15, 12 of 15, and 15 of 50, respectively.

The prevalence of executive function impairment was then calculated from failure rates for the EXIT25 and CLOX1, and the prevalence of general cognitive impairment was calculated from failure rates for the MMSE and CLOX2. The authors recognized that some information would be lost because the continuous measures were used as dichotomous variables. However, the pass/fail approach was used because it was felt to be more ecologically valid, given that most clinicians want to know whether the patient has passed or failed an assessment test and then use this information in conjunction with other continuous demographic variables such as age and education to complete the clinical picture. There were no significant zero-order correlations between the EXIT25, CLOX, or MMSE scores and either age or education in this group of subjects.

Chi-square analysis was used to determine if patients with certain psychiatric diagnoses or ethnicities were more likely to be executively impaired. By generating two-by-two grids of diagnosis versus EXIT25 pass/fail threshold, chi-square values were calculated and compared to critical values for alpha=0.05 with 1 degree of freedom.

To determine the effects of age and education on EXIT25 scores, the mean and standard deviation for age and years of education of patients who passed and failed the EXIT25 were calculated and compared using t tests.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Characteristics of Subjects
Table 1 shows the demographic and diagnostic composition of the study group. There were approximately equal numbers of men and women; the average educational level was just below 12 years. More than half of the subjects were Hispanic. Although both the EXIT25 and CLOX are available in Spanish translations, none of the subjects preferred to undergo their interviews in Spanish. The average age was 44.9 years (SD=16.7, range=16–83). The majority of patients had more than one axis I diagnosis. Depression was the most common diagnosis, accounting for half of the study group. It is interesting to note than only 22% of the subjects had a diagnosis of a cognitive disorder. This low proportion may be related to the fact that patients with severe dementia or delirium were excluded from the study because they were unable to make an informed decision with regard to consent. The EXIT25 is a significant independent correlate of the capacity to give informed consent for health care,31 and it was the strongest measure of decisional capacity in two other studies.28,32

Neuropsychological Tests
The study group's mean scores on the neuropsychological tests were 17.7 (SD=8.1) for the EXIT25, 10.1 (SD=3.2) for the CLOX1, 12.6 (SD=2.4) for the CLOX2, and 26.0 (SD=3.5) for the MMSE. Thirty-six patients (72%) failed at least one of the two executive measures. Thirty-one patients (62%) failed the EXIT25, and 24 (48%) failed the CLOX1. In contrast, smaller proportions of patients failed the CLOX2 (N=16, 32%) and the MMSE (N=15, 30%). Fourteen patients (28%) passed every cognitive measure. Of the 36 patients who failed at least one of the tests, the EXIT25 detected 86%, the CLOX1 detected 67%, the CLOX2 detected 44%, and the MMSE detected 42%. The instruments measuring executive function, the EXIT25 and CLOX1, respectively detected 44% and 28% more cases of cognitive impairment than the MMSE.

Chi-square analysis of the relationship between each of the cognitive measures showed dependent relationships between the EXIT25 and the CLOX1 ({chi}2=5.77, df=1, p<0.05) and between the CLOX2 and the MMSE ({chi}2=9.75, df=1, p<0.01). No significant relationship was detected between the EXIT25 and the MMSE ({chi}2=2.95, df=1, n.s.). It is interesting to note that five patients who failed the CLOX1 and two patients who failed the CLOX2 passed the EXIT25. Three patients who failed the MMSE passed the EXIT25, but each of these patients failed the CLOX1.

Clinical Characteristics of Executively Impaired Subjects
Table 2 shows the clinical characteristics of the patients who failed the EXIT25. Those who failed the EXIT25 were significantly older than those who passed (mean=51.5 years, SD=16.2, versus 34.1 years, SD=11.6; t=-4.09, df=48, p<0.001) and significantly more likely to have a diagnosis of a cognitive disorder than those who passed ({chi}2=8.64, df=1, p<0.01). Chi-square analysis showed no significant group effects on executive function, except for the group effect of cognitive disorder. The presence of any cognitive disorder had a significant effect on EXIT25 scores, even after the effects of gender, education, and MMSE score were adjusted (analysis of covariance: F=6.29, df=1, 44, p<0.02). Executive impairment had no significant effects on either education or ethnicity.


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TABLE 2. Demographic and Clinical Characteristics of 50 Inpatients Referred to a Psychiatric Consultation Service Who Passed or Failed the Executive Interview (EXIT25)




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
This pilot study is potentially limited by several issues. First, it is a descriptive study of a relatively small number of patients. However, although data collection did not proceed continuously, a very high proportion of subjects who were available (50 of 62, 80.6%) were successfully recruited during this period of observation. Second, the diagnostic ascertainment method was based on clinical findings from the patient interviews. We did not use a standardized structured clinical interview, and the lack of standardized assessment may have obscured associations between other diagnoses and executive impairment. However, the subjects were probably comparable to patients seen in most psychiatry consultation-liaison services in large community hospitals.

Third, the reported prevalence of executive impairment in this study was based on measurements made with the EXIT25 and the CLOX. As executive function has multiple dimensions,33 these assessments may not represent a comprehensive evaluation of all "executive" cognitive functions. Since the EXIT25 and the CLOX1 were highly intercorrelated25 and since there was a high degree of overlap in the patients identified as executively impaired by these measures, addition of other putative executive measures might have increased the prevalence of executive impairment. However, an increased prevalence would only strengthen our conclusion that executive impairment is underrecognized by clinicians.

Another notable limitation of this study was the absence of a comparison group, which affects the interpretation of the chi-square statistics we report. For example, the failure to find a significant difference in the prevalence of executive impairment among subjects with axis II DSM diagnoses relative to the study group as a whole did not contribute evidence for the absence of executive impairment. On the contrary, patients with axis II diagnoses may have been no less likely to have executive impairment than other patients referred for psychiatric consultation. In fact, four (80%) of five patients with an axis II diagnosis failed the EXIT25.

Unfortunately, the study group was too small to allow testing of the independent association between clinical diagnosis and executive impairment, after the effects of age and comorbid conditions were adjusted. The number of patients in some diagnostic categories, especially in the thought disorder, mania, and personality disorder categories, may have been too small to draw valid conclusions, as the analysis may have lacked the power to detect a significant difference. The results should be considered provisional until they can be replicated in larger groups of subjects.

Despite these limitations, we observed a high prevalence of executive impairment among consecutive referrals for psychiatric consultation. Seventy-two percent of the subjects failed at least one test of executive function. In contrast, only 30% failed the MMSE, suggesting that this measure is insensitive to executive impairment and cannot be used as the sole basis on which to judge the presence or absence of cognitive impairment. Moreover, the EXIT25 has been found to be a significant predictor of functional status and level of care, independent of MMSE scores, in both the elderly,15,34 and young adults with schizophrenia.29 Thus, we conclude that executive function should be tested in all patients, regardless of diagnosis.

Although the CLOX1 was not as sensitive to executive impairment as the EXIT25, it was easier to administer and still detected 28% more cases of cognitive impairment than the MMSE. It is interesting to note that the CLOX1 detected executive impairment in five patients who passed the EXIT25. Together, the CLOX1 and the MMSE detected 87% of the cognitive impairment that the EXIT25 detected. The addition of clock-drawing has already been suggested as a convenient way to improve the sensitivity of the MMSE.35 However, we note that not all clock-drawing tasks are equivalent in their sensitivity to executive function.26

The MMSE, although a valid and practical general screen for certain dementias, has several deficiencies that can be misleading, especially when it is used on a psychiatry consultation service. The rate of false negative results of the MMSE has been shown to be particularly high for patients with primary psychiatric illness, mild cognitive impairment, and right hemisphere lesions.36,37 One study showed that the MMSE failed to detect impairment in 80% of patients with clear cognitive deficits as determined by the Luria-Nebraska Neuropsychologic Battery.38 Another study showed that 43% of patients with documented brain lesions test normal on the MMSE.37 Finally, the MMSE has been shown to be a poor predictor of capacity to consent to treatment, a domain that psychiatry consultants are often asked to evaluate.39 In contrast, the EXIT25 has been strongly associated with forensic capacities, including the capacity to make an advance directive and the capacity to give informed consent for inpatient psychiatric care.28,32 In one study, the EXIT25 was strongly and significantly associated with the capacity to give informed consent for medical care in patients with Parkinson's disease, and the results for the EXIT25 were independent of those obtained by using a full psychometric battery that included formal measures of memory, language, attention, and other domains of executive function.31 The EXIT25 was the only measure to significantly contribute to a multivariate model of a "rational reasons" legal standard for this capacity, accounting for 45% of the variance in this outcome.

One potential benefit of testing executive function in every patient is the insight provided with regard to a diverse spectrum of patient needs and abilities. In addition to being specifically associated with functional impairment, EXIT25 scores are also significantly associated with medication nonadherence in HIV-positive patients40 and increased risk of involuntary movements in schizophrenic patients.41 Furthermore, level of executive function has been shown to differentiate schizophrenic patients who work full time from those who work part time or are unemployed, as well as differentiating those who participate independently in activities of daily living.42–44 Depressed patients with poor executive function have been found to perform worse on activities of daily living and therefore presumably to require more care.45

However, in the study reported here, 65% of the patients who failed the EXIT25 and 63% of the patients who failed the CLOX1 were not given a diagnosis of a cognitive disorder by the consulting psychiatrist. Patients with unrecognized executive impairments may be held responsible for understanding information told to them by their care providers, for giving informed consent for medical treatment, and for contributing to the development of and cooperating with discharge plans that address their medical and social needs. By specifically measuring executive function, we were able to identify cognitively impaired patients who might otherwise have been overlooked.

In summary, the prevalence of executive impairment in patients seen by a psychiatry consultation-liaison service is likely to be high. Patients with recognized cognitive disorders are more likely to exhibit executive impairment than those with most other diagnoses. Nonetheless, in this study, the prevalence of executive impairment was high even among patients without a recognized cognitive disorder, and executive impairment was found in at least some patients in every diagnostic category. While further study is needed, we suggest that the prevalence of unrecognized executive impairment among hospitalized patients referred for psychiatric consultation is high. Since executive impairment is a significant independent correlate of patients' treatment plan adherence, the level of care needed by patients, and patients' decision-making capacity, the assessment of executive function should become a routine part of consultation practice. The EXIT25 and the CLOX are practical bedside measures of executive function and general cognition. In contrast, the MMSE is relatively insensitive to executive function and cannot be considered a comprehensive measure of cognitive function.


  ACKNOWLEDGMENTS

 
No sources of funding were solicited or used for this research project.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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J. B. Samton, S. J. Ferrando, P. Sanelli, S. Karimi, V. Raiteri, and J. W. Barnhill
The Clock Drawing Test: Diagnostic, Functional, and Neuroimaging Correlates in Older Medically Ill Adults
J Neuropsychiatry Clin Neurosci, November 1, 2005; 17(4): 533 - 540.
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 PsychosomaticsHome page
J. E. Schillerstrom, M. S. Horton, T. L. Schillerstrom, K. G. Joshi, B. S. Earthman, A. M. Velez, and D. R. Royall
Prevalence, Course, and Risk Factors for Executive Impairment in Patients Hospitalized on a General Medicine Service
Psychosomatics, October 1, 2005; 46(5): 411 - 417.
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M. S. Horton and J. E. Schillerstrom
Diagnostic Evaluation of Elderly Patients with Mild Memory Problems
Ann Intern Med, January 6, 2004; 140(1): 71 - 72.
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