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Table of Contents    
ORIGINAL ARTICLE
Year : 2019  |  Volume : 67  |  Issue : 2  |  Page : 433-438

Frontal assessment battery in Parkinson's disease: A study on 170 patients


1 Department of Neurology, RG Kar Medical College and Hospital, Kolkata, India
2 Department of Neurology, North Bengal Medical College, Siliguri, West Bengal, India
3 Department of Neurology, Bangur Institute of Neurosciences, Kolkata, India

Date of Web Publication13-May-2019

Correspondence Address:
Dr. Dhiman Das
2/1, Moore Avenue, Kolkata - 700 040, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.258052

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 » Abstract 


Background: Frontal assessment battery (FAB) was devised as a specific study design to assess frontal lobe dysfunction. Since Parkinson's disease (PD) is often associated with cognitive and other higher mental function complications, FAB test has been carried out by a number of workers to assess the integrity of the frontal lobe. On the other hand, the other frequently conducted test, performed in order to evaluate the mental status, is the Mini Mental State examination of Folstein (MMSE), but its reliability has been questioned in PD, since it does not assess the functions of the frontal lobe alone.
Material and Methods: The present study was undertaken in order to assess the suitability of application of the FAB test in Indian patients and to perform its comparative analysis with the MMSE scale.
Results and Conclusions: It was observed that the FAB test correlated with the age and the level of education of the patient. The results also correlated with that of the MMSE study, in spite of the fact that the latter is not considered to be a test which can assess exclusively the status of the frontal lobe. To the best of our knowledge, this is first study undertaken in India in this regard.


Keywords: Cognitive function, frontal assessment battery, frontal lobe, higher mental function, Mini Mental Scale examination of Folstein, Parkinson's disease
Key Message: Frontal assessment battery (FAB) was devised as a specific study design to assess frontal lobe dysfunction. Parkinson's disease (PD) is often associated with cognitive and other complications, and therefore, the FAB test has been carried out to assess the integrity of the frontal lobe in these patients.


How to cite this article:
Datta AK, Das D, Bhattacharyya KB, Bose P, Mishra AK, Das SK. Frontal assessment battery in Parkinson's disease: A study on 170 patients. Neurol India 2019;67:433-8

How to cite this URL:
Datta AK, Das D, Bhattacharyya KB, Bose P, Mishra AK, Das SK. Frontal assessment battery in Parkinson's disease: A study on 170 patients. Neurol India [serial online] 2019 [cited 2019 Jul 19];67:433-8. Available from: http://www.neurologyindia.com/text.asp?2019/67/2/433/258052




The frontal assessment battery (FAB) was devised by Alexander Luria, a Soviet neuropsychologist, in 1966. It is a screening test to assess the functional integrity of the frontal lobe in clinical practice.[1],[2],[3] It involves six items such as conceptualization, which utilizes abstract reasoning by testing interpretation of proverb or similarities between two objects; mental flexibility, tested by literal fluency; motor programming and executive control by utilizing Luria motor test or fist-palm-edge test; resistance to interference tested by Stroop test and the go-no-go paradigm test; inhibitory control, assessed by the go-no-go paradigm test; and environmental autonomy, assessed by the subject's naturally inherent inhibition to react to unwanted sensory stimuli, as tested by the prehension behavior and utilization behavior. The global performance on these six subtests gives a composite score summarizing the severity of the dysexecutive syndrome, whereas the individual subscores help in classifying the pattern of these problems in a given patient. A validation study performed on patients suffering from different degenerative disorders has shown that FAB is a sensitive tool for assessing frontal lobe pathology.[3]

Dubois et al., have shown that the FAB scores correlate well with other sensitive tests of executive dysfunctions like the Mattis dementia rating scale (MDRS) and perseverative errors in the Wisconsin card sorting test, etc., Tests like the mini-mental scale examination of Folstein (MMSE), Addenbrooke cognitive examination (ACE), Wisconsin card sorting test, and MDRS often fail to pick up subtle executive deficits; and ACE was designed to detect cognitive dysfunctions in Alzheimer's disease and, therefore, some domains specific for cognitive impairment in Parkinson' disease (PD) may remain unidentified by the sole use of this test.[3] It has been seen in a number of works that FAB is a useful bedside test to pick up even subtle dysexecutive problems in PD, the fundamental neuropsychological deficit in this disease.[4],[5],[6],[7],[8]


 » Materials and Methods Top


The FAB test was performed on 170 consecutive patients suffering from PD and in 80 control subjects. The patients were recruited from the outpatient department and investigated separately in the neurology department on a specified day. Some of these patients were also admitted in the wards. Written consent from the patients was taken and in case the patient was in an advanced stage, the caregiver's consent was accepted. Permission to carry out the work was granted from the Institutional Ethics Committee. The clinical assessment was carried out by one or more of the senior neurologists in the department and the tests were applied by one of them along with a professional psychologist and psychoanalyst. The inclusion and exclusion criteria were devised according to Hughes' UK PD Society Brain Bank Clinical Diagnostic Criteria. Features like bradykinesia, rigidity, tremor or postural instability, a unilateral onset and asymmetry at the beginning, and a good response to levodopa, were taken as the inclusion criteria. Bilateral features in the beginning, presence of other neurological features like eye signs, cerebellar features, extensor plantar response, an early fall, an early severe autonomic involvement, an early dementia, and a poor response to levodopa constituted the exclusion criteria.[9] The control and test population were distributed across various age groups, different levels of education, and gender category. Additionally, the baseline MMSE evaluation was performed on both the test and control population. The parameters like age, sex, frequency distribution, motor disability in terms of the Hoehn and Yahr staging, mean duration of illness, and level of education of the patients were taken into account and the results are shown below in a tabular manner.


 » Results and Analysis Top


There were 117 male and 53 female patients in the test group with their mean age being 58.26 years and 56.62 years for the male and female subjects, respectively. In the control group, there were 39 male and 41 female subjects with their mean age being 64.26 years and 65.88 years, respectively.

The patients were staged according to the Hoehn and Yahr scale, while being assessed with respect to their motor disability. 17.06% (n = 29) of patients were in stage 1, 18.24% (n = 31) were in stage 1.5, 20.59% (n = 35) were in stage 2, 11.76% (n = 20) were in stage 2.5, 22.94% (n = 39) were in stage 3, and 9.41% (n = 16) in stage 4. The mean duration of illness of patients during the study period was 5.56 years [Figure 1].
Figure 1: Distribution of patients according to stage of illness and disease duration

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In the present study, we had categorized patients according to their years of education into the following groups: low (0--3 years of education), middle (4--7 years of education), mid-high (8--11 years of education), and high (12 years or more) level of education. 15.29% of patients belong to low, 19.41% belong to middle, 27.06% belong to mid-high, and 30.24% belong to high education levels [Figure 2].
Figure 2: Bar diagram showing various levels of education in the patients

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All patients were subjected to assessment using the FAB scale and the scores obtained were recorded in each of the subdomains: prehension, go-no-go, conflicting, Luria motor, and lexical fluency, respectively, and a total score was generated for each of the patient. The patients were analyzed according to their educational category and the FAB score was compared between the groups. A comparison between the FAB scores as well as scores in each subdomain was made between the groups by the analysis of variance (ANOVA) test. In this study, the FAB scores in all the subdomains have varied significantly among patients with different education, with low scores being recorded in the lower education group. The P values were recorded at P = 0.038 for the prehension, P = 0.029 for the go-no- go, P = 0.00 for the conflicting, P = 0.001 for the Luria motor, P = 0.00 for the lexical fluency, and P = 0.00 for the similarity subdomains. The P value of 0.00 obtained for the total score was considered as significant [Figure 3].
Figure 3: Comparison of FAB scores in various levels of education (graphical representation)

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The subjects were also analyzed by the MMSE, and the results of the FAB total scores and the subdomain scores and MMSE scores were compared between the test and control population by utilizing t-test. Both the MMSE and the FAB scores were significantly different (P = 0.00) between the test and control population. The P values between the various FAB subgroups were recorded at P = 0.084 for the prehension, P = 0.00 for the go-no- go, P = 0.00 for the conflicting, P = 0.00 for the Luria motor, P = 0.00 for the lexical fluency, P = 0.00 for the similarity subdomains [Figure 4].
Figure 4: Comparison of FAB scores and MMSE scores between test and control population

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Both the FAB scores and MMSE were studied with respect to various parameters like age, duration, unified Parkinson's disease rating scale (UPDRS) cores, and activities of daily living (ADL) scores by correlation studies. Significant correlation was obtained between the FAB score, the age of the patient, and the MMSE score. With increasing age, the FAB scores declined significantly (P =0.005), whereas a positive correlation was obtained between the FAB and MMSE scores (P = 0.000), meaning thereby that patients with a low FAB score were also found to have a low MMSE score [Figure 5].
Figure 5: Scatter diagram for variation of FAB and MMSE scores on multiple parameters

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Logistic regression analysis was done to look for contribution of the above-mentioned multiple parameters for variation in the FAB score between subjects.

Logistic regression analysis of the dependence of the FAB score on various variables suggested age as the single most significant predictor of the FAB score among variables like age, duration of illness, as well as the activities of daily living (ADL) and the unified Parkinson's disease rating scale (UPDRS) scores.


 » Discussion Top


The influential work of Brown and Marsden in 1984 suggested that dementia was a feature in about 20% of patients of PD, whereas Melo et al., and Bosboom et al., in their later works have shown that progressive cognitive decline can be a feature in almost 30% of cases.[10],[11],[12] The deficits mainly involve executive and visuospatial functions with secondary impairment in memory. Executive functions are skills that require planning and performance of activities and include task initiation, attention, selectivity of stimuli, abstraction ability, planning, flexibility, working memory, and impulse inhibition.[3],[13] The underlying pathology of cognitive deficits and dementia associated with PD has for quite some time been a matter of controversy, both in terms of the site and the type of lesion. Nigral pathology alone fails to explain it and there is some cogent argument regarding the nature of the changes in the brain. Various dopaminergic pathways in the brain like the mesocorticolimbic system are now known to be concerned with cognition.[14],[15],[16],[17] Other subcortical nuclei, the limbic system, and the cortex are all implicated in the pathogenesis, and Lewy body type degeneration with associated cellular and synaptic loss in these structures are also seen.[18],[19]

MMSE is one of the most commonly used tool for assessing cognitive deficits in clinical practice and it evaluates orientation, memory, visual abilities, attention and calculation, language, writing, reading, and constructional abilities. However, it is not sensitive enough for precisely identifying the frontal executive deficits and visuospatial dysfunctions. Moreover, it has poor sensitivity for detecting dementia in the early stages. The Stroop test relies on a single executive dysfunction resulting from frontal lobe damage, which may not necessarily be affected in a given patient with PD.[11],[12] On the other hand, Kaszás et al., have shown that the sensitivity and specificity of scores obtained using the FAB test was not comparable to that of the MMSE scores, and therefore, FAB when utilized as the sole screening tool for Parkinson's disease dementia (PDD) might be an insufficient test.[20] Although the FAB global score does not discriminate between the cortical and subcortical frontal involvement, the six subtests explored several cognitive and behavioral domains related to the frontal lobe, as has been correlated with sophisticated imaging studies and metabolic activities in various parts of the brain.[21] Our study, however, showed that although the FAB and MMSE scores were significantly reduced in PD patients, compared with age, sex, and education matched controls, no correlation could be established regarding whether or not the FAB scale was a superior tool compared with the MMSE scale in the assessment of cognitive dysfunction in PD.[3],[12] Neurophysiological and neuropsychological assessments as well as functional imaging suggest that the cognitive and behavioral domains might involve distinct and disparate neural networks. Conceptualization appears to be associated with dorsolateral frontal areas,[22],[23] word generation with medial frontal areas,[24],[25] and inhibitory control with orbital or medial frontal areas.[26],[27] One study from China has documented the association between florid neuropsychiatric symptoms and frontal behavioral changes in PD patients, and a low FAB score has also been the experience in a study among the Turkish population.[28],[29] Kataoka et al., have shown that a low FAB score is associated with a higher incidence of fall in patients in Hoehn and Yahr stage III, and the works of Lees and Smith have indicated that patients with PD have significantly greater difficulty in set shifting and have more perseverative errors.[30],[31] Furthermore, subtle cognitive deficits might underlie mental inflexibility in PD, which could be attributed to destruction of the ascending dopaminergic mesocorticolimbic pathways.[16] Finally, Paviour et al., reported a low FAB score in 82% cases of progressive supranuclear palsy (PSP), in 36% cases of multiple system atrophy (MSA), and in only 8% of cases of PD after a study on 17 patients with progressive PSP, 11 with MSA and 12 with PD and, therefore, the authors concluded that this test can differentiate between the various akinetic-rigid syndromes.[32]

A number of workers from other countries observed a low FAB score in patients of PD and it correlated with the age of the patients and their level of education.[4],[7],[28] The nature of executive dysfunctions most commonly encountered were in phonemic and semantic verbal fluency tests.[4] Some studies again found a correlation between the FAB and MMSE score, but not with age, education, or the UPDRS.[7] A Turkish and a Brazilian work, published independently of each other, reported that FAB was related to the level of education alone and did not correlate with age or gender.[29],[33] A Chinese article observed a weak correlation between the FAB scores and male patients, as well with the early onset and late onset disease groups.[28] In a 2-year longitudinal study, Bugalho et al., observed that cognitive function scores did not decrease significantly in the FAB test, except in the domain of lexical fluency score.[34],[35]


 » Concluding Remarks Top


In conclusion, our study on the role of FAB in detecting executive dysfunctions in PD showed reduction in scores in all domains in PD patients compared with controls, and the FAB and MMSE scores differed significantly between the test and control groups. Although the FAB score inversely correlated with the age of the patient, it was found to correlate directly with the MMSE score. Since the population studied consisted of subjects having various levels of education, a comparative analysis showed that the FAB scores declined significantly with lower levels of education. Although MMSE frequently underestimates pure frontal lobe functions and FAB is postulated to be a better tool in general, it was not found to be a superior tool compared with MMSE in this study. Further work is necessary to find out whether or not applying the FAB test in patients with good level of literacy can prove its superiority over the MMSE study.

Disclosure

A part of this work was sponsored by Department of Science and Technology, Government of West Bengal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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