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HOURS
Continuing Education
Screening
Older Adults for
Executive Dysfunction
Ed Eckstein
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http://www.nursingcenter.com
Web Video
Watch a video demonstrating best
practices for assessing executive function in older adults at http://links.lww.
com/A326.
Online Only
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How To
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Figure 1. Elements of Executive Function
Elements of Executive Function
Planning
Abstract
thinking
Initiating
Stopping
complex
behavior
Sequencing
Monitoring
Watch It!
o to http://links.lww.com/A326 to watch a
nurse assess executive function in a hospitalized patient. Then watch the health care team
plan interventions.
View this video in its entirety and then apply
for CE credit at www.nursingcenter.com/
AJNolderadults; click on the How to Try This
series link. All videos are free and in a downloadable format (not streaming video) that
requires Windows Media Player.
G
The test environment should be quiet and private.
The patients attention level, degree of literacy, and
ability to use the dominant hand should be assessed
first.5 If the patient has fluctuating awareness or
attention levels, assessment should take place during
a period of clarity. If the patient has paresis or arthritis of the hands, the nurse should choose a test that
doesnt require manual dexterity, such as the oral
version of the Trail Making Test or the Controlled
Oral Word Association Test (COWAT). If the person
doesnt read or write, or its not possible to administer oral tests in the patients primary language, a
clock drawing test such as the CLOX would be
preferable. Patients who normally use glasses or
hearing aids should have these available. To view the
portion of the online video demonstrating how to
use the screening tests for assessing and interpreting
executive dysfunction, go to http://links.lww.com/
A327.
The Trail Making Test, oral version. In part A the
patient is asked to count from 1 to 25; in part B
the patient is asked to pair numbers and letters in a
sequence: 1-A, 2-B, continuing up to 13-M.6, 7 (At
our facility, we also ask patients to recite the alphabet, to verify that they know it, before proceeding to
part B.) It may be helpful for the nurse to have a
written list of the correct number and letter pairs.
Incorrect responses shouldnt be cause for interruption but should be recorded discreetly. If the patient
has difficulty, the nurse might offer encouragement
by saying, Keep going; were almost done.
Ms. Dove says, This first test is like a connectthe-dots puzzle, except Ill ask you to connect letters
to numbers. First, please recite the alphabet. Mr.
Lee does this without hesitation. Ms. Dove: Now
please count from 1 to 25. Mr. Lee again does so,
confirming that he has no communication deficits
such as aphasia. Ms. Dove: OK. Now what letter
corresponds to the number one? Mr. Lee: A; its
1-A. Ms. Dove: Thats right; now keep going
until I say Stop. Mr. Lee: 2-B, 3-C, 4-D, 5-E
[he pauses]7-F, 8-H, 9-I, 11-J, 12-K, 13-L, 14-M.
Oh, I might have gotten mixed up there. Ms. Dove
replies, Good effort. Its hard to do this in your
head. Lets try one thats easier.
The COWAT. After hearing a given letter, the
patient is asked to name, for a period of one minute,
all the words beginning with that letter that come to
mind.8 (The test is sometimes called the F-A-S
test, after the letters used, which are common in
both English and Spanish. Other versions of the
COWAT use different letters.)
Both correct and incorrect responses should be
recorded. The nurse might introduce the test by sayajn@wolterskluwer.com
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Figure 2. The
Complete CLOX
Rating
Organizational Elements
Point Value
CLOX 1
CLOX 2
TOTAL
The complete CLOX. Copyright 1995 by Donald R. Royall. Adapted with permission.
CLOX test results as they might be produced by a patient with executive dysfunction. In CLOX 1, the patient
does a free-form drawing (left); in CLOX 2, the nurses example (middle) is copied by the patient (right).
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How To
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Online Resources
For more information on this and other geriatric assessment tools and best practices go to
www.ConsultGeriRN.orgthe clinical Web
site of the Hartford Institute for Geriatric
Nursing, New York University College of
Nursing, and the Nurses Improving Care for
Healthsystem Elders (NICHE) program. The
site presents authoritative clinical products,
resources, and continuing education opportunities that support individual nurses and practice settings.
For versions of the CLOX in other languages,
including a validated Spanish translation,
contact Dr. Donald R. Royall, Department of
Psychiatry, the University of Texas Health Science
Center at San Antonio: royall@uthscsa.edu.
Visit the Hartford Institute site, www.hartfordign.
org, and the NICHE site, www.nicheprogram.org,
for additional products and resources.
Visit www.nursingcenter.com/AJNolderadults
and click on the How to Try This link to access
all articles and videos in this series.
modest sensitivity (44%) and good specificity
(84%), so its more likely to miss finding executive
dysfunction in some people than to identify executive dysfunction in people who dont have it.
The COWAT is one example of a verbal fluency
test; in such tests, the respondent is asked to produce
items from a specific category, in this case words
starting with particular letters. Verbal fluency tests
generally have high sensitivity and specificity for executive dysfunction. Monsch and colleagues, using the
COWAT, found it had 89% sensitivity and 85%
specificity for Alzheimers disease, but it was less sensitive and specific when compared with verbal fluency
tests using animal, fruit, or vegetable categories.10
The CLOX has been shown to be a valid measure of executive dysfunction.9 Its developers found
that it had good reliability, with a Cronbach of
0.82. Interrater reliability was high for both CLOX
1 and CLOX 2 (0.94 and 0.93, respectively).
CLOX 1 and CLOX 2 have both construct validity
and discriminant validity. Both were able to correctly classify 92% of the Alzheimers disease subgroups.9 An unspecified clock drawing test was
found to have modest sensitivity (47%) and high
specificity (92%),7 indicating that this type of test is
more likely to identify those who dont have cognitive impairment than those who do.
Because of the varying psychometric properties
in these tests for executive dysfunction, its best to
use multiple tests.3
How valid are brief tests of executive function
among different cultural and ethnic groups? The
http://www.nursingcenter.com
Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that
The Hartford Institute for Geriatric Nursing, College of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic
format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: hartford.ign@nyu.edu.
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A SERIES PROVIDED BY
EMAIL : hartford.ign@nyu.edu
HARTFORD INSTITUTE WEBSITE : www.hartfordign.org
CONSULTGERIRN WEBSITE : www.ConsultGeriRN.org
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http://www.nursingcenter.com
Trail Making Test and the CLOX have been validated in ethnically diverse populations. For details,
see More on the Validity of Brief Tests of Executive
Function, http://links.lww.com/A589.
REFERENCES
1. Cooney LM, Jr., et al. Who can stay at home? Assessing the
capacity to choose to live in the community. Arch Intern
Med 2004;164(4):357-60.
2. Budson AE, Price BH. Memory dysfunction. N Engl J Med
2005;352(7):692-9.
3. Royall DR, et al. The cognitive correlates of functional status: a review from the Committee on Research of the
American Neuropsychiatric Association. J Neuropsychiatry
Clin Neurosci 2007;19(3):249-65.
4. Dyer CB, et al. Vulnerable elders: when it is no longer safe
to live alone. JAMA 2007;298(12):1448-50.
5. Smith AD, et al. Around the clock surveillance: simple
graphic disturbance in patients with hemispatial neglect carries implications for the clock drawing task. J Neurol
Neurosurg Psychiatry 2006;77(3):407-9.
6. Ricker JH, Axelrod BN. Analysis of an oral paradigm for
the Trail Making Test. Assessment 1994;1(1):47-52.
7. Grober E, et al. Neuropsychological strategies for detecting
early dementia. J Int Neuropsychol Soc 2008;14(1):130-42.
8. Benton AL, et al. Controlled Oral Word Association Test
(COWAT). In: Multilingual aphasia examination. 3rd ed.
Iowa City, IA: AJA Associates; 1994.
9. Royall DR, et al. CLOX: an executive clock drawing task.
J Neurol Neurosurg Psychiatry 1998;64(5):588-94.
10. Monsch AU, et al. Comparisons of verbal fluency tasks in
the detection of dementia of the Alzheimer type. Arch
Neurol 1992;49(12):1253-8.
HOURS
Continuing Education
GENERAL PURPOSE: To instruct registered professional nurses in the use of various tests that screen older adults for
executive cognitive dysfunction.
PROVIDER ACCREDITATION
LWW, publisher of AJN, will award 2 contact hours for
this continuing nursing education activity.
LWW is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Centers
Commission on Accreditation.
LWW is also an approved provider of continuing nursing education by the American Association of CriticalCare Nurses #00012278 (CERP category A), District of
Columbia, Florida #FBN2454, and Iowa #75. LWW
home study activities are classified for Texas nursing
continuing education requirements as Type 1. This activity
is also provider approved by the California Board of
Registered Nursing, provider number CEP 11749, for
2 contact hours.
Your certificate is valid in all states.
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