PRetocole BREF DETAILCE CfooR S/*RPLROPRIER é Test) Batterie Rapide d’Evaluation Frontale (BREF) ou Frontal Assessment Battery (FAB) Historique et présentation Historique Cette échelle est destinge & permettre une évaluation rapide des fonctions exécutives au lit du pation Présentation Elie comprend les six items suivants: simitudes, évo- Cation lexicale, séquences motrices, consignes conflotuel- les, Go-No Go, recherche du comportement de préhension. Etudes de validation Le score global de échelle est sigifcativement conéis ‘au score giobel de échelle de Matis (tho = 0,82), le nombre de erttres (ho = 0,77) etl nombre c'erteurs persévratives \tho = 0,68) & la version Nelson du test de Wisconsin, La ‘alii inter juges (k= 0,87), la consistansintame (alpha = 2.78) et la valid discriminante (89,1) entre patients avec ‘endrome dysexécutt et contrbles sont bonnes (1). ‘ode de passation et cotation ie de passation 46 test complet est donné en fin de fiche, Il inclut les 'gnes de passation. in : ‘Sraque item est coté de 0 a 3, permettant un score 2.0 8 18, Pour des aujets ayant au moins le niveau ‘2 de Poitrenaud, un score < 16 peut étre considéré pathoogiqu ; le cut-off est < 18 pour des patients “seu culture! 1. Bruno Dubois Applications Intérét ‘est un test rapide et ‘spécifique du syndrome frontal, ten particulier de screening des démences fronto-tempo- rales (DFT). Limites En cas d'échec il faut faire passer une batterie neurop- ‘Sychologique plus complete pour explorer les fonctions exécutives, Référence, copyrights et langues existantes Référence 1, Dupois B, SuAcHEveKY A, LivaN |, PLLON B. (2000). The FAB: A Frontal Assessment Battery at bedside. ‘Neurology, 65: 1621-1626. Copyrights ‘Auoun, mais il faut demander V'autorisation des autours pour lee recherches cliniques. Pour une utilisation clinique, le test pout étre obtenu librement auprés de Bruno Dubois. Contact information : bruno.dubois@ pslaphp.tr Langues existantes Frangais, anglais, japonais, italien, Mots-clés Fonctions exécutives, syndrome dysexécuti, Mild Cognitive Impairment, démence & comps de’ Lewy, démence fronto-temporale, maladie <’Alzhelmer, démence, maladie de Parkinson,SOO TESTS EMRLES DE AMAL AER Tos SOREN PETES TEST : BREF (Battarie Rapide d’Evaluation Frontale) ou FAB (Frontal Assessment Battery) En quoi ee reesemblent ‘une orange et une banane ? ert en Ser a a Art 8») pa cua date ps or te ene csent: «Une orange et une banane eon outs door doesn ° Ne pas aider le patient pour ies deux tems suivants : une table et une chaiee 2 une tullpe, une rose et une marguerite 7 Cotation : Soules ls réponses catégorieis (rts, meubes, fours) ont considérées comme correctos, Aucune réponse corrects 0 = 1 réponse correcte 4 2 réponses comectes 2 ~Sréponses comectes 3 nl pono S28 ites, nome commana, pr xople et enn So pts, dex + objets, mals ni prénoms, ¥ 1 nome propres, commengant par la lettre &. ge Patient ne donne aucune réponse pendant les premres ‘Secondes, lui dire : « Par exemple, nt.» Sie patient fit des pauses de plus de 10 secondes, 8.» serpel te stmulr aps chaque pause en lui dsant: « Nmporte uel mot commengant par Ia lettre Cotation ; ~~ Moins de 8 mots, 0 ~De3.a5 mots 1 De 6210 mots 2 = Plus de 10 mots 3 {ols avec sa main gauche la séquence de Luria : « rane "ous alles exécuter avec votre main dro la méme séquance, chores ‘ese tle a séquere eee sa main gauche en mime tps quo open, pus dt: « Continuez, » “Le Ptr cet xtc 9 aéquenescorsécutves cores méme ave Fexainseur o ~ Le patient échoue sau, mais exéoute 3 séquences consseutios Correctes en méme temps que l'examinateur. Te baton exécute seul au moins 3 séquences conséoutves comectos, ~ Le pation exécute seul 6 séquences conséoutves conectes,Batterie Rapide e'Evaluatoin Frontal (BREF, Dire au patient: « Lorsque je tape une fois, vous devez taper deux fois. » Pour #'¢ssurer quo le patent ben compris laconsige examinateur li fat réalser une séquence dessal de trois coups: 1-1-1 Continuer en disant : « Mais Pour s'assurer que le pati ‘tois coups 2-2-2 1 rats: « Done, quan je tape une fois vous tapez deux fois et quand je tape deux fls vous taper une fois. Allons-y. » lorsque Je tape deux fois, vous devez taper une fois. » jent a bien compris la consigne, I'examinateur lui fait réaliser une séquence d'essai de a séquence proposée est la suivante: 1-2-2-1-2-2-2-4-4-2 Cotation : ~ Le patient tape fe méme nomiore —Plus de deux erreurs, =10u2 erreurs, Aucune erreur. ‘de coups que examinateur au moins 4 fois consécutives. enso i pies Maintenant, on change le rage Lorequo Je tape une fois, vous devez taper une fois. » Pour slassurer que le patient a bien compris la consign, Yexemingteur iu fat éaliser une ‘séquence dassal de trols coups : 1-1 —1, Continuer en disant: « Mais lorsque je tape deux foi Pour s'assurer que le patient a bien compris, exami 2-2-2 Dire: « Vous avez com, ‘tapez plus. Allons y. » ig, maintenant vous ne devez plus taper. » inateur ul felt éaliser une séquence d'essai de trols coupe : pris: quand Jo tape une fols vous tapez une fois ; quand je tape deux fols vous ne | La séquence proposée est la suivante: 1-2-2-1-2-2-2- Cotation : T Eg Batont tape le méme nombre de coups que Fexaminatour au moins 4 fie conséeutives o — Plus de deux erreurs, 1 ~1 ou 2 erreurs. 2 Aucune erreur. 3 Lexaminateurne dt rin. lest assis en face du patient dont las mains reposent eur les genoux, paumes ouvertes Mei att: Lexaminatour approche les maine et touche celles du paint, pour vor sive lee caine spontanément, Ne rien dire, méme si le patient demande ce quil dot faire, Se patent les prend, ui dre alors et alors seulement: « Malntenant, ne prenez plus mes mains. » Cotation : ~£p Batlont continue & prendre les mains de lexaminateur, méme apres que celui alt demande de ne plus les prendre, Le patient prend les mains sans hésitation. ~ Le patient hésite ou demande ce quill doit faire, ~ Le patient ne prend pas ies mains de lexeminateur, 161nb 20 apuewep ° ove ny saide mejeuero, ap suew so] puaid oqed 27 1 ‘oyeysey sues sew so, pus uoged 07 «sue $9] snd zoverd @u jueUa|UEW » z “ove yop Unb eo opuewep no ospuWOREE TT — aos wn ws yon od € “naRUMENA, Su3h Saylearo seuned eroveS sans juasode SUEW $9 1UopuaRed np 208) Ua Terewusuaucenn 0 sou f 9p SuOHy ‘ souseeea z sou gL 9.¢a e sou 9} 6p Snid eR AAT STIG WORST TS Soj2009 BuNUCa SeaiepSUOD U08 [Sine ‘SaxgnaW “sR sajeuRb qed sasuOds) 8 ° ‘0010 asvod aunone 4 ‘oeuo esuod | Hie came z ssjpanco sasuodaiz | 801 sano yuos aueueg oun yo eBues0 un » UES : fag (M0 € Sed WRRWODSEL a8 OU SANDY: OY BEYER SED VB UEHEd 3] (Jaa) « S[ejWOI] » UOHEN|eA p opldey sueyegay TWwioL 0 ‘saNgrogsuN0 Sip SuOW ne Ne}eUHEX® end Bb-b-2-2-Z-1b-Z- 1-4 equenms 2s a9sodaxd aouant: doco ep auquou eww oj adey waned 27 2-2-2: stinoo si op esso.p eouendgs aun Jesieas 1 Suna xn@p 8p Stig snejeuluexe, ‘sudwoo uelq @ juaged 2 enb seinsse.s nod « sede} sed ZaAep au Sn ‘soy xnep z sina Z 90 | ‘af anbsioy» “| - | — |: sdnoo siog ap ressap eouenbes oun sesyeeu ye) In sneyeuexa| ‘au su00 € sau auromy ; suduico ueige yuened a} anb Jeunsse.s smog, So} un sade) zanap snon 'sinj aun adey of anbsi07, TReFTATTUT SHTUGSY 6 - ON = OH"S ‘sannogsuoo si} SUL 0 | nesnajeumwexe, and dnco ap aiqwou owou oj ade quoned 27 paar ‘ sina xnep 6p sm neyeUlUeXe| ‘aubisuca i sicauat, 2 suduioo vag e Wat jamsse S dg ¢ S15 Bun ade; ZaAap snOh ‘so, xnap ade of onbsI07 » zn 4 mnajeyurexa oubssuc0 e ameueaunany |e suuco vag e seansse' nod «soy nap rode} zanep ‘un ade} af anbsio7 » (SSURTE ETAT e BH TATSUES] SHSM BHGUCS SSUBSTOS ST ‘neqeuNwexd,| 29M2 0 | swow sacar saninoasuca seouanbos ¢ seynogr9 ynad eu juoged © aaeiens) oad BAUR] up UD eaUOD «zane 1 waned 0 anb sue} augus ua eupnes uew es oane ' ssanynogsuco s2ouanbes ¢ aynogr se nope waned a1} couanbys e| sy six oryoay snaye 28 sind ‘ow anb sdway ew9w ue puogep 20 }0Np ew aon ane sea 2 |__‘salauco soxtnagsuno senuanbgs ¢ Suu ne Res e\RORKEHWEHETET| ay souantps e| ayone6 YEW eS JOKE SO} SON Ws a|NOeNe jaKEd Np 208) UB SESE MEIEUILEKD € ‘sajpauoo sanimnogsuoo seouenbes g nos ejno—x@ uated 7 «8 l anb 20 wawenquaye zapseBay > (op eTIETBSI GUT SESTORORS Fe]INSUB 4Ip Je JUaHed 9] Dene SIO} SiON uss e| a]nogXe sNe}eUIWEXE?] wIN@S @yNsUS Jo OW DaAE P1oge,p ‘esoYD eLUELL e] Sei!e} ‘sjOspUIEW e1jOA DAA "JUEUBTUIEY\,, (ulews e| ep yeid — ayoues| ~ Bulod) eun7 ep eugs e| ayone6 UIeW es dene S104 SioN} e}nogxe UEH|ed Np e0ej Us sisse ‘UNeTeUIWUEXa,"| 4'S1e} ef enb 20 juswennuene zepuebe; (uonewuesbosd) seopjow seouent ujod Q :suiow no sjow z lujod | ‘sow see 0d 2 'S]OW 6 BD ‘syujod ¢ :snjd y9 S}ow OL seiduioo sed yuos au seudosd swou s9| no swougud s9| enb |sule (jueAnow-siges 36 9|q28) sjuajeninbg no sejedeu SJoW $9} ;oIaLIOD ‘sepuoses 0g :eno|je sdwe | ,"""s sed juedueWUCo jou! 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Liépreuve des similitudes explore I'élaboration conceptuelle, L’épreuye d’évocation lexicale explore la flexibilité mentale, e*est-R-dite la capacité d’adapter ses choix aux contingences, La séquence gestuelle de Luria permet d’ explorer Ia programmation des actes moteurs. ‘épreuve des consignes conflictuelles explore la sensibilité aux interférences, Lreprenve Go-No Go explore le contrble inhibiteur. La recherche dun comportement de préhension explore l'autonomie environnementale, Cotation : Chaque item est noté de 0 a 3, permettant un score total de 0 a 18. Pour des sujets ayant été scolarisé au moins jusqu’au niveau du college, un score inférieur & 16 peut étre considéré comme pathologique. Le seuil pathologique est 4 15 pour des patients de niveau inférieur,Test Cotation 4. Similitudes (conceptualsaton) «En quoise essemblrt: | ue banane et une orange une able et une chaise | ne tulpe, une oso et une marquee» Nmbea do rgonses carats |_—_ Sie patent done ue reponse compiemertincoret lc par exe fon en commun ») ou en parte incoret (es deux at une done «vous Tad on isan: « La bonae et aus orange son un fu» Natuszoependan ucin pont po ‘ereponse Nae pas aecles toms suivant 2,Fluence verbale(fexiilté mentale) «Dest autant de mots que possible qui commencent parla lettre S, sauf das ‘rénoms ou des noms popes.» DDonnez ‘ minute de temps pour lépreuve, Se pte a pas répond au bout de 5 seconds des: «par exemple, semen.» Sle Penne repond pas pencant 10 socondes, fates una aure suggeston et ies «Mango que meu commence pal ete $» = moins do 3 mete 12885 ais ‘3, Séquence motrice de Luria (orogramretion) « Regardez exactoment 2 que fas.» Lexaminateur est asis devant le patent ot effectue seu tls fois la sequence « ing bord de main = paume » de a rain gauche «Foie la méme chose dela main dite cabo avec mol pus tout seu.» LLexaminateureflecue la sre avec le paint tos fos ett ensuite « Meintenant fae tout seu. » Ne pou pas efocuer 3 siquonces conséuives corer, lve ave Tee de erarinataur féchous seul mals pout efecuer 3 squences comets fade fexaminaur 2 = ceut efector seul au moins 2 séqienoes ‘canséeuves coreciemen peut efecuer seul 6 sequences constouties erecmen 4. Consianes conflictual (sensibillé& 'nterférence) 1 Tapez deux ols quand tape une fis.» Pout re sor que le patent it comps Finstucton, files rs fis Fexecie: 1-1-1, «Taper une fois quand tape deur fois.» Pour est que le patient compris nstucton, tts trois fois Texercice: 2-2-2 Levaminaterefectue ensuite la sre suivante: 11-24-22-2 (0 tape au mcns qua fo cnséaitves comme Texsrinatou += puede 2orous 2= 1012 enous 3 aucune eeu 9 = rtueiaandomé $.Go/ no go (inhittion de comportement) « Tapez une fois quand je tape une fos » Pour te sir que le patient ait comors Finstucton, fates ris fois Vexercice: 1-1-1, «No taper pas quand je tape deur fos.» Pour @re sir que le patent at comps instruction, fies tris fis exercioe: 22-2 Levaminatev effect onsite la série suivante: 1-1.241.2.22-14-2 (tape a moins quar fois conseutves cone Fexaninatow | 1 =pusde2 eras 251002 reun 3 =eucune exe 6. Comportement d'utilisation autonomie environnementale) {Levaminateur est assis devant le patet, Le patient met ses mains sur ses genoux Diagant ses paumes on haut Sons vin dice et sans tegarder le patent, "examinatour place ses mains & la proximié de oeles du palent et touche les aumes des deux mains du patent pour voir il skit sa main ‘Sie patert pend sa ai, fexamateuressaye 6 noweau aps avi it « Ne me prenez ps mes mains cet isc» (= pred ia main Fexamiatut Hen qon batt dene pas prendre man 1 = prendia main de examinateur sens Néster 2 hse et denance ce ell dt ire ‘= neprendpasia main de examinaleur Nom: Date Prénom : Total de la BREF : | fAsf-neuro.org [Version imprimable] Page | sur 1 Laurent Lefebvre | jeudi 8 fevrier 2007 &) imprimer cette page Test bref de Dubois et Pillon (ou FAB en langue anglaise) Famille : Fonctions exécutives Mots clés : fonctions executives, syndrome dysexécutif, Mild Cognitive Impairment, Démence a corps de Lewy, Démence fronto-temporale, Maladie d Alzheimer, Démence-Maladie de Parkinson 41) Objectif de l'outil et description Cette échelle est destinée & permettre une évaluation rapide des fonctions exécutives au it du patient. Elle comprend les items suivants similtudes, évocation lexicale, sequences motrices, consignes conflctuelles, go-no go, recherche du comportement de préhension. 2) Travaux de validation Le score giobal de I'échelle est signficativement corrélé au score global de échelle de Matts (tho=0.82), le nombre de cries (rho=0.77) ete nombre d erreurs persévératives (rho=0.68) a la version Nelson du test de Wisconsin. La validité inter-juges (k-0.87), la consistence interne (alpha=0.78) et la validté disoriminantes (69.1) entre patients avec syndrome. dysexécutf et contrdles sont bonnes. 3) Principe et cotation Chaque item est coté de 0 3, permettant un score total de 04 18, Pour des sujets ayant au moins le niveau culturel 2 de Poitrenaud, un score <16 peut étre considéré comme pathologique ; le cut-off est <15 pour des patients de niveau culturel 1 4) Rétérences et copyrights B. Dubois, A. Siachevsty, | Litvan, B. Pllon. The FAB: A Frontal Assessment Battery at bedside. Neurology 2000; 55: 1621-1626, Pour une utilisation clinique, le test peut étre obtenu librement auprés de Brune Dubois A propos de la base de données des tests Pour tous renseignements sur ces tests, contacter : Dr Laurence Hugenot-Diener / coordination de la mise en ligne des tests du GRECO | e-mail: mecformagopda.fr Retour a la page de recherche © Santor 2002 - 2008 | tous droits réservés http://www.sf-neuro.org/index! php3?pageID=greco fiche&id=bref&affichage=print&.... 8/02/2007 Az.The FAB A frontal assessment battery at bedside B. Dubois, MD; A. Slachevsky, MD; J. Litvan, MD; and B. Pillon, PhD Article abstract—Objective: To devise a short bedside cognitive and behavioral battery to assess frontal lobe functions ‘Methods: The designed battery consists of six subtests exploring the following: eonceptualization, mental flexibility, motor programming, sensitivity to interference, inhibitory control, and environmontal autonomy. It takes approximately 10 minutes to administer, The authors studied 42 normal subjects and 121 patients with various degrees of frontal lobe dysfunction (PD, n = 24; multiple system atrophy, n = 6; corticobasal degeneration, n = 21; progressive supranuclear palsy, n = 47; frontotemporal dementia, n = 23). Results: The Frontal Assessment Battery scores correlated with the Matiis Dementia Rating Scale scores (rho = 0.82, p < 0.01) and with the number of oritoria (rho = 0.77, p < 0.01) and perseverative errors (cho = 0.68, p < 0.01) of the Wisconsin Card Sorting Test. These variables accounted for 79% of the variance in a stepwise multiple regression, whereas age or Mini-Mental State Exemination scores had no significant influence. There was good interrater reliability (« = 0.87, p < 0.001), internal consistency (Cronbach's coefficient alph: 0.78), and discriminant validity (89.1% of cases correctly identified in a discriminant: analysis of patients and controls). Conclusion: The Frontal Assessment, Battery is easy to administer at bedside and is sensitive to frontal lobe dysfunction, [NEUROLOGY 2000%65:1621-1628 Assessing frontal lobe function and thus being able to identify a dysexecutive syndrome are helpful for the diagnosis and prognosis of brain diseases such as frontotemporal dementias? and for evaluation of the severity of brain injuries. It can also help to identify vascular dementias’ and parkinsonian disorders, particularly progressive supranuclear paley (PSP), in which the presence of frontal lobe dysfunction sup- ports the diagnosis.* It may also be useful for differ- entiating between degenerative disorders involving subcortical structures and for evaluating the pro- gression of these disorders over time.* The functions of the frontal lobes are difficult to assess clinically. There is no test that reliably identi- fies a dysexecative syndrome.* In practice, extensive neuropsychological batteries are needed to assess the frontal lobe provesses.*? Given the modular func- tional organization of the frontal lobes,** searching for a possible dysexecutive syndrome requires time- consuming tests exploring functions associated with different frontal areas. Therefore, there is a need for a brief tool exploring different domains of executive fune- tion that are impaired in several neurologic diseases. We devised a bedside battery to assess the pres- ence and severity of a dysexecutive ayndrome aifect- ing both cognition and motor behavior, and to evaluate it for 1) content and concurrent validity, 2) discriminant validity, comparing normal controls and patients with various degrees of executive dys- function, and 3) interrater reliability. Methods. Description of the Frontal Assessment Battery (PAB). According to current theories, the frontal lobes control coneeptualization and abstract reasoning, mental flexibility, motor programming and executive control of ac- tion, resistance to interference, self-romulation, inhibitory control, and environmental autonomy.‘ Bach of these processes is needed for elaborating appropriate goal- directed behaviors and for adapting the subject's response to new or challenging situations—functions thet are medi- ated by the prefrontal cortex. For that reason, the designed battery consists of six subtests, each exploring one of the aforementioned functions related to the fronfal lobes. Moreover, thase subtests were chosen because the score of each cf them significantly correlated with frontal metabo- lism, as measured in terms of the regional distribution of 18-fluorodoorygiucose in a PET study of patients with frontal lobe damage of various eticlogies.® The processes « studied and the corresponding subtests of the FAB are Presented below. The content, instructions and scoring of ‘each subtest are provided in the Appendix. The total scores are calculated by adding the notes of the six subtests. The overall duration of the battery is approximately 10 minutes. 1. Conceptualization: Abstract ressoning is impaired in frontal lobe lesions." This function is currently investi- Bee also pages 1601, 1609, and 1618, rom INSERM EPI 007 and Pédérai ‘Neuropharmacology Unit (Dr. Litran), Supported hy INSERM. Funded by @ grant from Mideplan-Chile (4.8) ‘Reseived June 12, 2000. Accepted in final form Septembsr 18, 2000 de Newologle (Drs. Dubois, Slachevaky, and Pillon), Hapital de 1a Salptritre, Paris, France; and Cognitive ny M. Joekon Foundation, Bethesda, MD. ‘Adlrosecomaspordence and reprint reqocsta to Dr. Brane Dubois, Pédération de Neurclogie, Hopital dela Salptritxe, 47 Boulevard de PHOpital, 16861 Paria cedex 18, France; email hdbla@pal.ap-hop-pars Copyright © 2000 by AN Enterprsgs, Tne, 1621 ASTable Study group characteristics Population a Seo MMSE Mattie DRS FAB Controls 2 580 144" 289 = 08" wat £24" Waser Patienta st ota 9.9" 25.5 = 40" nao 191° 1034 PD * 594s 12.96 28.0 + 1.98 19402 15.28 16.9 + sgt MSA 6 65.0 * 105, 21 #89! 127.0 + 162° 185 +404 opp a 614 +81 264 2 0.8 128.7 + 150% 31.0 + gine PSP a 65.9 + 7.08 262 8.7" 17 4 152 85 234i PD 23 603 + 8.5% 20.7 + aah 101.5 + 20.0%" Te aes Values are presented as moan * SD. Significantly different at p < 0.06 for: “oonirols end patients; ftontotemporal dementia (PTD) end cortioobesal degeneration (CBD) patients; “PD and OBD patients; ‘uultiple ayatem atrophy (MSA) patients; ‘PSP and MSA patients; tlonts; /PD snd MSA patients, “progressive suprancclear palsy (PSP) and CBD patients; “PTD aa “PD and PSP patients; "TD and PSP patients; ‘PD and FTD. pa MMSE = Mini-Mental State Rxamination; DRS = Dementia Rating Soale; PAB = Frontal Assessment Battery gated by card-sorting tasks, proverb interpretation, or similarities. The last task is easier for bedside assess- mont and scoring. Subjects have to conceptualize the Links between two objects from the same category (o.g., an apple and a benana), Patients with frontal lobe dys- function nay be unable to establish an abstract lini between the items (ie. fruit), adhering to the concrete aspects of objects (i., both are yellow), or may be un- able to establish a link of similarity (.o,, one is round but the other is elongated), 2. Mental flexibility: Patients with frontal lobe lesions are specifically disturbed in nonroutine situations in which self-organized cognitive strategies have to be built up."*"" Literal fluency tasks are unucual, require self organized retrieval from semantic memory, and are easy to score, Frontal lesions, regardless of side, tend to decrease verbal fluency, with left frontal lesions result- ing in lower word production than right frontal le sions. In this task, subjects need to recall as many words az they ean beginning with a given letter in a Lminute trial, 8. Motor programming: Patients with frontal lobe lesions are also impaired in tasks requiring temporal organiza- tion, maintenance, and execution of successive ac- Yions.!43 Tn Luria’s motor series, such as “fist-palm~ edge,” less severely impaired patients are unable to execute the series in correct order, whereas the most severely affected aro unable to learn the series. Simpli- fication of the task (two gestures instead of three) and perseveration (inappropriate repetition of the same ges- ftares) may be observed. Sensitivity to interference: Deficita in behavioral self regulation may be observed in tasks in which verbal commands conflict with sensory information. This oc- curs in the Stroop test, in which the subject must name the colors of words while inhibiting the natural ton- deney to read the words, This also occurs in the ease of conflicting instructions, in which subjects must provide ‘an opposite response to the examiner's alternating sig- nal, e.g. tapping once when the examiner taps twice. ‘Thus, subjects should obey yerbel commands and re- frain following what they see. Patients with a frontal lobe lesion usually fail to obey the verbal command and 1622 NEUROLOGY 65 December (1 of 2) 2000 tend to execute echopractic movements, imitating the examiner.* Inhibitory control: Withholding a response may be difficult for patients with damage to the ventral part of the frontal lobes.* In tasks anticipated to elicit a felao- alarm motor response, these patients are often unable to inhibit inappropriate responses.” This difficulty in controlling impulsiveness can be assessed with the go-no go paradigm,” in which the subjects must inhibit a response that was previously given to the same stim- ulus, e4g., not tapping when the examiner taps twice, Environmental autonomy: Patients with frontal lobe lesions are excessively dependent on environmental cues. Sensory stimuli can activate patterns of re sponses that are normally inhibited in normal controls, For example, the patient conceives the sight of a move. ment as an order to imitate (imitation behavior); the sight of an object implies the order to use it (utilization behavior); and the sight or sensory perception of the examiner's hands compels the patient to teke them (prehension behavior). In some eases, the pationts ean elicit these behaviors even if they have been explicitly told not to do so, These abnormal behaviors (the sponta- neous tendeney to adhere to the environment) express the lack of inhibition normally exerted by the prefrontal cortex on the activation of patterns of behavior trig- gered by sensory stimulations, Subjects. Subjects gave informed written consent to participate. Forty-two normal control subjects (moan SD; age, 68 + 14,4 years), without any neurologic or psy- chiatric history, were included (table). All control subjects had a Mattis Dementia Rating Scale (DRS¥* score >136 or a Mini-Mental State Examination (MMSE)* score >27. To evaluate the discriminative power of the FAB, 121 patients with mild (PD, n = 24; multiple system atrophy [MSAI, n = 6), moderate (corticobasal degonaration {CBD], n= 21), or severe (frontotemporal dementia [FTD], n = 23; progressive supranuclear palay [PSPI, n = 47) frontal lobe dysfunction™™# were included (see table). All patients un- derwent an extensive clinical evaluation to confirm their iagnosis and all met currently accepted diagnostic erite- ia, The diagnostic criteria for PD were based on the pres- Aqence of a parkinsonian syndrome with unilateral onset characterized by a resting tremor or an akinetorigid syn- drome, a good response to levodopa that persisted at the time of evaluation, and the absence of exclusion criteria (eg, supranuclear gaze palsy). The diagnostic criteria for MSA included the presence of an extrapyramidal syn- drome poorly responsive to levodopa, associated with an autonomie or urinary dysfunction in the absence of excls- sion criteria.” The diagnostic criteria for CBD included a slowly progressive asymmetric nkinetorigid syndrome and one or more of the following signs of cortical involvement: ideomotor apraxia, myoclonus, cortical sensory deficit, or alien limb syndrome." The criteria for PSP included the presonce of a gradually progressive disorder with an age at onset of 40 years or later; a supranuclear limitation of vertical gaze; a prominent postural instability, with falls cccurring in the first year of eymptom onset; and no evi- dence of another disease that could explain the symptoms; in the absence of exclusion eriteria.® Tho diagnosis of FTD ‘was based on a progressive onset of behavioral changes fulfilling the Lund and Manchester eriteria,t a severe dys- exocutive syndrome on neuropsychological evaluation, and the absence of any other neurclogic disorder sufficient to explain the frontotemporal cortical defict.* The neuropay- chological evaluation of patients consisted of the MMSE* and Maitis DRS for all patients, and the Wisconsin Card Sorting Test (CST) for 86 patients. The MMSE ranges were 30 to 24 for patients with PD, 90 to 21 for patients with MSA, 80 to 13 for patients with CBD, 30 to 17 for patients with PSP, and 80 to 6 for patients with FLD. Technical properties of the battery. Validation. Con- current validity. ‘The velidity of the FAB, Lo. how well fhe battery evaluates the existence of «frontal lobe ayn- drome," was analyzed by correlating the FAB total score with the pationt's performance on 1) the Wisconsin CST, a ‘est considered to be sensitive to executive dysfunetion™; and 2) the Mattis DRS, 2 global scale reported to be correlated ‘with the degree of executive dysfunction in neurodegenera- tive diseases.“ For the Wisconsin OST, the number of crte- achioved and the number of perseverative errors were considered because both have been shown to be sensitive to frontal lobe dysfunction.** We performed a correlational va- lidity study because there is no “gold standard” that deter- mines the existence and severity of a frontal lobe syndrome Discriminant validity. We determined the ability of the FAB to discriminate between normal control subjects and patients with cognitive impairment according to the Mattis DRS scale, Patients without cognitive impairment were excluded for this analysis. Only 95 patients with a Mattis DRS score below 136 were included. ‘The ability of the FAB to differentiate the frontal dys- funetion of patients with cortical and subcortical lesions ‘was studied by using a stepwise discriminant analysis in ‘two groups of patients with frontal lobe dysfunction of different origins—subeortical (47 patients with PSP) and cortical (23 patients with FTD). Reliability, Interrater reliability was determined by comparing the scores of two independent raters who were prosent during the administration of the FAB by one of them, Each rater was blind to the ratings made by the other. Interrater reliability was conducted in 17 patients and determined by calculating the kappa value. We studied the internal consistency of the battery, Le., the extent to which the six items of the FAB reflect the same underlying construct, by ealeulating the Cronbach's coefficient of alphas” Results. Technical properties of the battery. Validation. Concurrent validity. A correlation was found between the FAB scores and the Mattie DRS performance in 121 pa- tients (+ = 0.82, p < 0.001) Similarly, the FAB scores correlated with the number of eriteria (r = 0.77, p < 0.001) and perseverative errors (rho = 0.68, p < 0.001) achieved in the Wisconsin CST. A stepwise multiple regression was, ‘used to evaluate the influence on the FAB performance of the following independent variables: age of patient, MMSE and Mattis DRS scores, and the number of eriteria and persevarative errors in the Wisconsin CST. The Mattis DRS score and number of oriteria achieved in the Wiscon- sin CST accounted for 79% of variance in the FAB (F [2,82] = 152.9; p < 0,001; r? = 0.79), Interestingly, age and MMSE scores had no significant influence, Discriminant validity. The FAB discriminated be- twaon contra and paonts after adjuatng for ago a0 covariate (analysis of covariance: F{1,131) = 17. 24; p < 0.001), The performance on the FAB correctly identified 89.1% of the cases (Wilke's lambda = 0.48, F[1,185) = 176.2; p < 0.001). A stepwise discriminant analysis in pa- tients with FTD and PSP using the six FAB subscores as independent variables showed that similarities and pre- hhension behavior correctly classified 69.7% of the patients (Wilke’s lambda. = 0.8865, x° [dal = 2] = 10.6; p = 0.006). Reliability. Two raters independently evaluating a subset of 17 patients with the FAB achieved an optimal interrater reliability (x = 0.87, p < 0.001). The Cronbach's coefficient alpha between the items of the FAB of 121 pationts was 0.78, suggesting good internal consistency. Discussion. In order to provide a simple tool for assessing frontal lobe function that could be applied by any practitioner, we designed a short assessment battery, the FAB, based on our experionce with focal frontal lobe lesions™ and movement: disorders associ- ated with striatofrontal dysfunction* Other tools have already been designed to evaluate frontal lobe function at the bedside.“ A brief assessment of frontal and subcortical functions was proposed for patients with suspected subcortical pathology, but patients with AD scored significantly lower on this scale than those with Huntington's disease or PD.** ‘The EXIT 25, an executive interview, correlates not only with tests sensitive to frontal lobe dysfunction but also with the MMSE (r = -0.85). This suggests that the EXIT 26 is also sensitive to functions that are not executive.” Another brief tool sensitive to executive control, the CLOX (a clock drawing test), has been proposed, but only investigates one domain of cognitive function: drawing. Lastly, Etilin and Kischka* proposed the “frontal lobe score,” which is, however, not convenient for bedside assessment be- cause it includes tasks such as the Trail-Making Test and takes up to 40 minutes to complete. The FAB is an easy test to administer, requires less than 10 minutes to complete, and is well accepted by pe- tients, The six FAB subtests explore both cognitive December (1 of 2) 2000 NEUROLOGY 66 1623, ASand behavioral domains under the control of the frontal lobes, each of them having been shown to be significantly correlated with frontal lobe metabolic activity measured by 18-fluorodeoxygiucose using PET scan,” Moreover, each subtest is associated with specific areas of the frontal lobes on the basis of neuropsychological, electrophysiologic, and func- tional arguments: conceptualization with dorsolat- eral areas,** word generation with medial areas,“ and inhibitory control with orbital or medial frontal areas.*6*' Therefore, performance on the six subtests of the FAB can give a composite global score, which evaluates the severity of the dysexecutive syndrome and may suggest a descriptive pattern of executive dysfunction in a given patient. ‘The FAB presents good metric properties. The study demonstrated good internal consistency (Cron. bach’s alpha was 0.78),*" optimal interrater reliabi ity (k = 0.87), and concurrent validity. Indeed, the FAB score was strongly associated with the perfor- mance of patients on the Mattis DRS (rho = 0.82) and Wisconsin CST (rho = 0.77 for the number of criteria), both of which evaluate different cognitive functions under frontal lobe control. These functions include initiation, conceptualization, and attention for the Mattis DRS scale* and conceptualization and cognitive flexibility for the Wisconsin CST. Several recent studies have demonstrated that performance in the Wisconsin CST is related to functional activity in the prefrontal cortex.*4** In contrast, the FAB score is correlated neither with the MMSE score, a measure of more general cognitive function, nor with age (see the results of the stepwise multiple regres- sion). The battery also presents good diseriminant validity, allowing differentiation to be made between control subjects and patients with frontal or subcor- ticofrontel cognitive impairment. However, the FAB global score does not allow discrimination between patients with predominantly subcortical (PSP) or cortical (FTD) dysfunction. Only two subtests dis- criminated between these patients to some extent— prehension hehavior (more severely impaired in patients with PSP) and similarities (more severcly impaired in patients with FT'D). ‘This result is not unexpected because patients with frontal and sub- corticofrontal lesions usually present similar cogni- tive deficits and share only subtle neuropsychological differences.“ Some points should be stressed, however. Test— retest reliability was not assessed. The anatomic cor- relation of the different subtests of the battery was derived from data obtained with similar tests, but not from the subtests themselves. Finally, although highly significant correlations were shown between the FAB and tests sensitive to frontal lobe functions, but not between the FAB and MMSE, it would be necessary to demonstrate that patients with non— frontal lobe injuries perform at a higher level than that observed for patients with frontal lobe injuries, to definitively consider tho FAB as a measure of frontal lobe dysfunction. 1024 NEUROLOGY 85 December (1 of 2) 2000 Appendix Content, instructions, and scoring of the FAB 1, Similaritios (conceptualization) “in what way are they alike?” banana and an orange (inthe event of total failure: “they are not alike" ar partial failure: "both have peel?” help the pation fy saying: “both a banana and on orange are.,*; but credit O forthe item; do not help the patient for the two lowing items). ‘A table and a chair ‘A tolip, a rose and a daisy Score (only eatenory responsea lfruts, furniture, flowers) are coeidered corect) ‘Three correct: 3 2. Lexical fluency (mental flexibility) “Say as many words as you oan beginning with the letter ‘§ any words except sumamos or proper nouns.” Ifthe patient gives no response during the first 5 eeconda, say; “for instance, snake.” If tho pationt pauses 10 seconds, atimolate hhim by saying: “any word beginning with the lettar ‘S The {ime allowed is 60 seconde, ‘Score (word repetitions or variations (shoe, shoemaker), sur. ‘names, or proper nouns are not counted ee oaereet responses) ‘Maro than nine words: 8 Less than three words: 0 98. Motor series (programming) “Look earafully at what Pm doing." ‘The examiner, seated in front of the patient, performs alone threo times with his loft hand the series of Luria "fist-cdge~ palm.” "Now, with your right hand do the same series, firs with ‘mo, then alone.” The examiner performs the series threo times ‘with the pationt, then says to him/her: "Now, doit on your ows.” Score Patient performs six correct consecutive series alone: 8 Patient performs at least three correst eanaecutive series alone: 2 Patient fuils alone, but performs three covreet consecutive se- ries with the examiner: 1 Patient cannot perform three correct consecutive with the examiner: 0 4. Conflicting instructions (sonsitivity to interference) “Tap twice whon I tap once.” ‘To bo sure that the patient has understood the inatruetion, series of three trials is run: 1-1-4. “Tap onee when I tap twice: be sure that the patient ls understood the insiruetion, a series of tree trials is ran: 2-2-2. The examinor parforms the following serios: L1-21-2-2-2-1-1-2. Score No error: 8 One o two errora: 2 ‘More than two arraxe: 1 Patient taps like the examiner at least four eousocutive times 0 Go-No Go (inhibitory control) “Tap once when T tap once." ‘To be sure that the patient has undorstood the instruction, a sorlos of three triala is run: 1-1-1. "Do not tap when 1 tap bwice." To be sure that the pationt has understood the instruction, a series of three trials is run: 2-2-2. The examiner performs the following series: 1-1-21-2-2-2-1.1.2, Seore No error: 3 One or two errors: 2 ‘More than two errors: 1 Patient taps like the examiner at least four consecutive times: 0 6, Prehension behavior (environmental autonomy) “Do nol take my hands.” ‘The examiner is seated in front of tho patient, Place the pa- ‘fent’s hands palm up on hisvher knees. 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Cereb Cortex 1999;0745-768, 51, Rogers RD, Sahakian BJ, Hodges JR, Polkey CE, Kennard Rebun TW, Diswctating exeeeive meahinioos wees aera Renal neces mums of a ‘Brain 1998;121:815-842. * oa re soe in mane nerpercg Sr A ope eg ore meni, ‘Prog Neurobiol el a ec 58. Dimitrov M, Grafman J, AH, Clark K. it for: Cee nan eet Cnet fees isease patients assessed with the Califomia Card Sorting oy zane eo Hippocampal and cortical atrophy predict dementia in subcortical ischemic vascular disease . Fein, PhD; V. Di Sclafani, MPH; J. Tanabe, MD; V. Cardenas, PhD; M.W. Weiner, MD; WJ. Jagust, MD; B.R. Reed, PhD; D. Norman, MD; N. Sehuff, PhD; L, Kusdra; T. Greenfield; and H. Chui, MD Article abstract—Background: The cause of dementia in subcortical ischemic vascular disease (SIVD) is controversial. Objectives: To determine whether cognitive impairment in SIVD 1) correlates with measures of ischemic brain injury or brain atrophy, and/or 2) is due to concomitant AD. Methods: Volumetric MRI of the brain was performed in 1) elderly subjecte with lacunes (L) and a spectrum of cognitive impairment—normal cognition (NC+L, n = 32), mild cognitive impairment (CI+L, n = 26), and dementia (D+L, n = 29); 2) a comparison group with probable AD (n = 28); and 3) a control group with normal cognition and no lacunes (NC). The authors examined the relationship between the severity of cognitive impairment and 1) volume, number, and location of lacunes; 2) volume of white matter signal hyperintensities (WMSH); and 8) measures of brain atrophy (ie. hippocampal, cortical gray matter, and CSF volumes). Results: Among the three lacune groups, sevority of cognitive impairment correlated with atrophy of the hippocampus and cortical gray matter, but not with any lecune measure. Although hippocampal atrophy was the best predictor of severity of cognitive impairment, there was evidence for a second, partially independent, atrophic process associated with ventricular dilation, cortical gray matter atrophy, and increase in WMSH. Bight autopsied SIVD cases showed variable severity of ischemic and neurofibrillary degeneration in the hippocainpus, but no significant AD pathology in neocortex. The probable AD group gave evidence of only one atrophic process, reflected in the severity of hippocampal atrophy. Comparison of regional neocortical gray matier volumes showed sparing of the primary motor and visual cortiees in the probable AD group, but relatively uniform atrophy in the D+L group. Conclusions: Dementia in SIVD, as in AD, correlates best with hippocampal and cortical atrophy, rather than any measure of lacunes. In SIVD, unlike AD, there is evidence for partial independeneo dotween these two atrophic processes, Hippocampal atrophy may result from a mixture of ischemic and degenerative pathologies. The cause of diffuse cortical atrophy is not known, but may be partially indexed by the severity of WMSH. NEUROLOGY 2000;85:1626~1695 Subortical ischemic vascular disease (SIVD) is char- port risk of dementia to be higher among subjects acterized by lacunar infarcts and deep white matter changes. The proportion of vascular dementia (VaD) attributed to SIVD ranges from 86 to 50%, with with lacunar infarcts versus other subtypes of stroke,‘ and among patients with AD with concomi- tant lacunar versus large-artery infarcts.* Thus, higher rates noted among African Americans! and SIVD is an important subtype of VaD either alone or Asian Americans* than whites.“ A few studies re- in combination with AD. From Neurobehavoral Researeh, Ine. Ds. Fein and V, Di Selafani); Peyshialry Research (Dr. Cardenas) and Meynatie Resonance Unit (Drs, Tanabe, Wein, and Schull, and L, Kosdra and’. Groonfcld), Dopertment of Vetorens Affaire Medical Cuntor, the Departmenia of Radiology (Dre. Tanabe, Cardenss, ‘Weiner, Norman, and Shut) and Payehiatry (De, Weine:), University of California, San Pranelaee the Centey fr Functional Imaging (Dr. Jagat), Lawrence Bortoley Laboratory, the Department of Neurelogy (Drs, Jagust and Reed), University of California, Davia; and tho Departinent of Nowrelogy (Dr. Che, ‘University of Southarn California, Loe Angelos Suoported by Use National lastitete of Health (PO:-AG12435, P560-AG10129, ROL-AGI0G9T), the State of California Department of Hoslth Services ‘Alahelmer Program, a National Research Servis Award (DA-05680-02), and a Carour Seiatit Award (G..) from the Departinent of Votocans Alles, [Reeuived Angus 6, 1998, Azcapted in final form Oetaber 2, 2000. ‘Adlss sorrospondones and reprint requests to Dr, Helena Chi, Guriatele Nevrobohavior and Alshalmer Centar, 800 Annex Wost, 7601 Bast Imperial Highway, Downey, CA 80242; email: chul@heeuesedu 1626 Copyright © 2000 by AAN aterprises, Tne 16