Traditionally, executive functions have been ascribed to the frontal lobes. They involve the ability to assess ongoing stimuli for relevance to specific goals, the formation of goals, planning action to achieve goals, ability to evaluate
plans for efficacy, and executing plans. According to this description, executive functions involve many processes associated with reasoning and intellectual performance. Indeed, the Digit Symbol subtest of the WAIS-R (discussed in the section on Tests of Attention and Vigilance), Category Test, Wisconsin Card Sorting Test, Raven's Progressive Matrices (all discussed in the section on Tests of Reasoning and Problem Solving Through Concept Formation), Rey- Osterrieth Complex Figure (discussed in the section on Memory), and tests of visual scanning (discussed in the section on Perception and Construction Abilities) can all be used to assess executive function. A few additional tests are listed below.
Proteus Mazes.y This test of planning requires the patient to trace a path through progressive difficult mazes without entering any blind alleys. Scoring is based on number of errors (entering a blind alley) and on time to complete the mazes. Both of these measures have been found to be sensitive to patients with frontal-lobe damage.
Design Fluency.y This test of mental flexibility requires the patient to create as many designs as possible that are not objects or shapes in 5 minutes. Next, the patient is required to make as many designs as possible using only four lines (straight or curved) in 4 minutes. Adequate norms exist for this test.
Stroop Word-Color Interference Test. y This test of inhibition has three trials. The first trial requires the patient to read the color names printed in black ink as quickly as possible. On the second trial, the patient is required to name the color of colored dots as quickly as possible. The third trial requires the patient to name the color of ink of color name words. The color name does not match the color of the ink. Forty-five seconds are allowed for completion of each trial. Scores for each trial indicate the number of correct responses. An interference score can be generated, which quantifies the patient's ability to inhibit the inappropriate response of reading the color name as opposed to the color of ink used to print the name in the third trial.
Assessment of motor performance is particularly helpful in identifying integrity of each hemisphere and subtle motor performance. Tests of motor performance include simple motor speed, strength, and complex motor/dexterity abilities.
Finger Tapping Test. y This is a test of primary motor speed of the index finger of each hand. Patients tap a finger as quickly as possible for five consecutive 10-second trials. Because fatigue may affect performance, a rest period is given between each trial. Large differences between left and right finger speed may reflect lateralized hemispheric dysfunction. Adequate norms are available for this test.
Hand Dynamometer.^ This test measures grip strength in each hand. Patients are given three trials with each hand, the first considered practice. Large differences between left and right grip strength may reflect lateralized hemispheric dysfunction. Adequate norms are available for this test.
Purdue Pegboard Test. y This test of finger dexterity requires patients to place pegs in vertically arranged holes. They perform the task using each hand separately and then using both hands. Each trial last 30 seconds. Large differences between left and right performance in comparison to performance using both hands may reflect lateralized hemispheric dysfunction. Adequate norms are available for this test.
CLINICAL SITUATIONS FOR TESTS OF EXECUTIVE FUNCTION AND MOTOR PERFORMANCE
Assessment of executive function is very important for patients presenting with impairments of higher cognitive functioning such as memory, language, and reasoning. Because these higher-cognitive functions are highly correlated with planning, inhibition of inappropriate responses, and goal execution, executive function assessment also aids the examiner in interpretation of tests assessing memory, language, intelligence, and reasoning performance. Assessment of executive function is also helpful in patients with disturbances in level of consciousness (see Chaipter..1 ), disrupted sleep/wake cycles (see Chapter ^ ), and neglect and dyspraxia (see Chapter ...4 ).
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