I. Basic concepts
Executive function is a complex, higher-level cognitive function that refers to a set of skills necessary for a person to independently perform purposeful, self-controlled behavior, including mental operations such as planning, judgment, decision making, inhibition of inappropriate responses (behavior), initiation and control of purposeful behavior, response transfer, sequence analysis of action behavior, and problem solving. Executive function is an important function of the prefrontal cortex, and damage to the prefrontal lobe will produce long-term, destructive functional deficits. It is seen in frontal lobe dementia (Pjck’s disease) caused by frontal lobe atrophy, bilateral large and anterior hallux artery infarction, subarachnoid hemorrhage (anterior communicating artery aneurysm), severe closed traumatic brain injury, and tumor.
II. Clinical manifestations
(A) Start-up disorder
Inability to start movement when needed, manifested by passive behavior, loss of initiative or subjective effort, indifferent expression indifferent to and uninterested in surrounding things, slow response, “lazy feelings”.
(II) Inappropriate response disinhibition
Patients cannot spend a certain amount of time using the available information to make an appropriate response, often manifesting as overreaction and impulsivity. The failure to inhibit inappropriate responses is clinically evident in stroke patients who do not brake the handbrake before getting up from a wheelchair in the presence of a perceptual impairment that affects their ability to manipulate the handbrake, or who are eager to walk independently when assistance is clearly needed.
(iii) Difficulty in thought or behavior shifting
Patients are unable to change their response according to the change of stimulus due to response inhibition and response transfer or change disorder, and show a persistent state, i.e., they keep repeating the same movement or action when performing functional activities. For example, washing one part of the face repeatedly.
(iv) Specific thinking
The patient’s observation of things only stays on the surface and lacks deep insight. This is manifested by lack of planning ability, lack of vision, and inability to align behavior with goals. The ability to use and form abstract concepts is impaired. Patients who are not able to solve problems based on abstract thinking can only move around in familiar surroundings.
III. Assessment
(i) Wisconsin Card Sorting Test (wcsT)
The wcsT is the most commonly used test to evaluate executive dysfunction. It consists of four templates (1 red triangle, 2 green pentagons, 3 yellow crosses and 4 blue circles, respectively) and 128 cards of different colors (red, yellow, green, blue) and different numbers (1.23.4) according to different shapes (triangles, pentagons, crosses, circles). Subjects were asked to classify a total of 128 cards according to four templates. The tester did not tell the subject the principle of classification, but only whether each test was correct or incorrect. The test is completed when the participant completes 6 classifications or finishes classifying 128 pictures. wcsT provides 13 indicators, but the applied ratings are: number of persistent errors, number of completed classifications, number of incomplete classifications, number of non-persistent errors, number of responses required to complete the first classification, level of conceptualization, and number of persistent responses.
(ii) Verbal fluency check
It is used to check the activation function of prefrontal cortex. For example, in the Montreal Cognitive Assessment Inventory (ThecognltIveMonmalAssesslllent, M0cA), patients are asked to list as many words starting with the same phonetic prefix “F” as possible in one minute, but names, places and derivatives (e.g. happy The patient was asked to list as many words as possible starting with the same pinyin prefix “F” in one minute. A normal person with a high school diploma or above can say at least u words in one minute.
(C) Response inhibition and transformation ability check
1.To do or not to do the test
When the examiner holds up two fingers, ask the patient to hold up one finger; when the examiner holds up one finger, ask the patient to hold up two fingers. Do it 10 times in total. Make sure that the patient understands the examination requirements when examining. Complete imitation of the examiner’s action or repeated continuation of an action suggest that the patient lacks appropriate response inhibition and is unable to change the response according to different stimuli, which is a characteristic expression of frontal lobe damage.
2.Trallmaking test (TMT)
The test is divided into two parts, A and B. In part B, the paper contains the numbers 1-13 and the letters A-L, and the subject is asked to connect the numbers 1-13 and the letters A-L in alternating text. The subjects were asked to complete the task as quickly as possible, and the analysis index was the time to complete the task and the number of errors.
(D) Behavioral evaluation of executive deficit syndrome
The Behavioral Assessment of Executive Deficit Syndrome (BADs) is a neuropsychological examination method developed by wllson et al. in 1996, which combines a variety of executive function tests to measure different aspects of executive function, including six subtests and an executive deficit questionnaire. The six subtests were: Rule Switching Card Test, Action Planning Test, Key Finding Test, Spatial Judgment Test, Zoo Distribution Chart Test, and Revised Six Element Test. This test differs from the traditional laboratory method of checking executive functions in that it is ecologically validated and can measure and predict deficits related to executive functions in daily life. Therefore, it is more closely related to people’s daily life activities.