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Neuropsychological correlates of instrumental activities of daily living in neurocognitive disorders: a possible role for executive dysfunction and mood changes

  • Martina Amanzio (a1) (a2), Sara Palermo (a1), Milena Zucca (a3), Rosalba Rosato (a1) (a4), Elisa Rubino (a3), Daniela Leotta (a5), Massimo Bartoli (a1) and Innocenzo Rainero (a3)...


Since baseline executive dysfunction predicts worsening Instrumental Activities of Daily Living (i-ADL) over time and progression to Alzheimer's Disease (AD), we aimed to analyze the role of neuropsychological variables to outline which factors can contribute to functional impairment. Specific attention to executive functions (EFs) has been given.

A total of 144 subjects complaining of different cognitive deficits – ranging from “MCI likely due to AD” to “mild AD patients” – underwent an overall neuropsychological assessment. The Behavioral Assessment of the Dysexecutive Syndrome was used to analyze EFs. We conducted multiple linear regression analyses to study whether the level of independent living skills – assessed with the Lawton-scale – could be associated with cognitive and behavioral measurements.

We found a significant association between i-ADL and specific EFs measured by Rule Shift Cards (p = 0.04) and Modified Six Elements (p = 0.02). Moreover, considering i-ADL scores, we observed an involvement of mood changes and a reduced awareness of deficits in terms of Hamilton Depression Rating Scale (p = 0.02) and Awareness of Deficit Questionnaire – Dementia scale (p < 0.0001), respectively.

Our results suggest the importance of considering the association between a reduction in i-ADL and executive dysfunction in patients who have AD etiopathology, for which the ability to inhibit a response, self-monitoring, set-shifting and mood deflection play a key role. Besides, no straightforward associations between i-ADL scores and global cognition, memory, language comprehension, attention, and perspective taking abilities were found.


Corresponding author

Correspondence should be addressed to: Sara Palermo, Department of Psychology, University of Turin, Via Verdi 10, Turin 10124, Italy. E-mail:


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Albert, M. S. et al. (2011). The diagnosis of mild cognitive impairment due to Alzheimers disease: recommendations from the national institute on aging-Alzheimers association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimer's & Dementia, 7, 270279. doi: 10.1016/j.jalz.2011.03.008.
Albert, S. M., Bear-Lehman, J. and Anderson, S. J. (2015). Declines in mobility and changes in performance in the instrumental activities of daily living among mildly disabled community-dwelling older adults. Journal of Gerontology, Series A, Biological Science and Medical Science, 70, 7177. doi: 10.1093/gerona/glu088.
Allain, P. et al. (2007). A study of action planning in patients with Alzheimer's disease using the zoo map test. Revue Neurologique, 163, 222230.
Amanzio, M. et al. (2011). Unawareness of deficits in Alzheimer's disease: role of the cingulate cortex. Brain, 134, 10611076. doi: 10.1093/brain/awr020.
Amanzio, M., Geminiani, G., Leotta, D. and Cappa, S. (2008). Metaphor comprehension in Alzheimer's disease: novelty matters. Brain and Language, 107, 110.
Amanzio, M., Vase, L., Leotta, D., Miceli, R., Palermo, S. and Geminiani, G. (2013). Impaired awareness of deficits in Alzheimer's disease: the role of everyday executive dysfunction. Journal of the International Neuropsychological Society, 19, 6372. doi: 10.1017/S1355617712000896.
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Washington, DC: American Psychiatric Association Publishing.
Artaud, F., Singh-Manoux, A., Dugravot, A., Tzourio, C. and Elbaz, A. (2015). Decline in fast gait speed as a predictor of disability in older adults. Journal of American Geriatric Society, 63, 1129–36. doi: 10.1111/jgs.13442.
Bangen, K. J. et al. (2010). Complex activities of daily living vary by mild cognitive impairment subtype. Journal of the International Neuropsychological Society, 16, 630639. doi: 10.1017/S1355617710000330.
Bateman, R. J. et al. (2012). Clinical and biomarker changes in dominantly inherited Alzheimer's disease. New England Journal of Medicine, 367, 795804. doi: 10.1056/NEJMoa1202753.
Bech, P., Rafaelsen, O. J., Kramp, P. and Bolwig, T. G. (1978). The mania rating scale: scale construction and inter-observer agreement. Neuropharmacology, 17, 430431.
Boyle, P. A., Malloy, P. F., Salloway, S., Cahn-Weiner, D. A., Cohen, R. and Cummings, J. L. (2003). Executive dysfunction and apathy predict functional impairment in Alzheimer disease. American Journal of Geriatric Psychiatry, 11, 214–21.
Burton, C. L., Strauss, E., Hultsch, D. F. and Hunter, M. A. (2006). Cognitive functioning and everyday problem solving in older adults. Clinical Neuropsychologist, 20, 432452. doi: 10.1080/13854040590967063.
Cahn-Weiner, D. A. et al. (2007). Cognitive and neuroimaging predictors of instrumental activities of daily living. Journal of the International Neuropsychological Society, 13, 747757. doi: 10.1017/S1355617707070853.
Capezuti, E. A., Malone, M. L., Khan, A. K. and Baumann, S. L. (2017). The Encyclopedia of Elder Care: The Comprehensive Resource on Geriatric Health and Social Care, 4th edn. New York, NY: Springer Publishing Company.
Cools, R., Brouwer, W. H., De Jong, R. and Slooff, C. (2000). Flexibility, inhibition, and planning: frontal dysfunctioning in schizophrenia. Brain and Cognition, 108112.
da Costa Armentano, C. G., Porto, C. S., Nitrini, R. and Dozzi Brucki, S. M. (2013). Ecological evaluation of executive functions in mild cognitive impairment and Alzheimer disease. Alzheimer Disease & Associated Disorders, 27, 95101. doi: 10.1097/WAD.0b013e31826540b4.
De Renzi, E. and Vignolo, L. A. (1962). The token test: a sensitive test to detect receptive disturbances in aphasics. Brain, 85, 665678.
De Vriendt, P., Gorus, E., Cornelis, E., Velghe, A., Petrovic, M. and Mets, T. (2012). The process of decline in advanced activities of daily living: a qualitative explorative study in mild cognitive impairment. International Psychogeriatrics, 24, 974986. Doi: 10.1017/S1041610211002766.
De Vriendt, P., Mets, T., Petrovic, M. and Gorus, E. (2015). Discriminative power of the advanced activities of daily living (a-ADL) tool in the diagnosis of mild cognitive impairment in an older population. International Psychogeriatrics, 27, 14191427. Doi: 10.1017/S1041610215000563.
Dubois, B. et al. (2014). Advancing research diagnostic criteria for Alzheimer's disease: the IWG-2 criteria. Lancet Neurology, 13, 614–29. doi: 10.1016/S1474-4422(14)70090-0.
Ellis, K. A. et al. (2013). Decline in cognitive function over 18 months in healthy older adults with high amyloid. Journal of Alzheimer's Disease, 34, 861871. doi: 10.3233/JAD-122170.
Espinosa, A. et al. (2009). Ecological assessment of executive functions in mild cognitive impairment and mild Alzheimer's disease. Journal of the International Neuropsychological Society, 15, 751757. doi: 10.1017/S135561770999035X.
Farias, S. T., Mungas, D. and Jagust, W. (2005). Degree of discrepancy between self and other‐reported everyday functioning by cognitive status: dementia, mild cognitive impairment, and healthy elders. International Journal of Geriatric Psychiatry, 20, 827834.
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189198.
Freund, R. J., Littell, R. C. and Spector, P. C. (1986). SAS System for Linear Models. Cary, NC: SAS Institute Inc.
Gobbens, R. J. and van Assen, M. A. (2014). The prediction of ADL and IADL disability using six physical indicators of frailty: a longitudinal study in the Netherlands. Current Gerontology and Geriatric Research, 2014, 358137. doi: 10.1155/2014/358137.
Graf, C. (2008). The Lawton instrumental activities of daily living scale. American Journal of Nursing, 108, 5262. doi: 10.1097/01.NAJ.0000314810.46029.74.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 5662.
Harrell, F. E., Lee, K. L., Califf, R. M., Pryor, D. B. and Rosati, R. A. (1984). Regression modelling strategies for improved prognostic prediction. Statistics in Medicine, 3, 143152.
Harrell, F. E., Lee, K. L. and Mark, D. B. (1996). Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Statistics in Medicine, 15, 361387.
Hughes, C. P., Berg, L., Danziger, W. L., Coben, L. A. and Martin, R. L. (1982). A new clinical scale for the staging of dementia. British Journal of Psychiatry, 140, 566572.
Hybels, C. F., Pieper, C. F. and Blazer, D. G. (2009). The complex relationship between depressive symptoms and functional limitations in community-dwelling older adults: the impact of subthreshold depression. Psychological Medicine, 39, 16771688. doi: 10.1017/S0033291709005650.
Jack, C. R. Jr. et al. (2010). Hypothetical model of dynamic biomarkers of the Alzheimer's pathological cascade. Lancet Neurology, 9, 119128. doi: 10.1016/S1474-4422(09)70299-6.
Jekel, K. et al. (2015). Mild cognitive impairment and deficits in instrumental activities of daily living: a sistematic review. Alzheimer's Research & Therapy, 7, 17. doi: 10.1186/s13195-015-0099-0.
Jungwirth, S., Zehetmayer, S., Hinterberger, M., Tragl, K. H. and Fischer, P. (2012). The validity of amnestic MCI and non-amnestic MCI at age 75 in the prediction of Alzheimer's dementia and vascular dementia. International Psychogeriatrics, 24, 959966. doi: 10.1017/S1041610211002870.
Kamiya, M., Sakurai, T., Ogama, N., Maki, Y. and Toba, K. (2014). Factors associated with increased caregivers’ burden in several cognitive stages of Alzheimer's disease. Geriatric & Gerontology International, 14 (Suppl. 2), 4555. doi: 10.1111/ggi.12260.
Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A. and Jaffe, M. W. (1963). Studies of illness in the aged. The index of Adl: a standardized measure of biological and psychosocial function. JAMA, 185, 914916.
Knopman, D. S. et al. (2012). Short-term clinical outcomes for stages of NIA-AA preclinical Alzheimer disease. Neurology, 78, 15761582. doi: 10.1212/WNL.0b013e3182563bbe.
Kondo, N., Kazama, M., Suzuki, K. and Yamagata, Z. (2008). Impact of mental health on daily living activities of Japanese elderly. Preventive Medicine, 46, 457462. doi: 10.1016/j.ypmed.2007.12.007.
Lawton, M. P. and Brody, E. M. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist, 9, 179186.
Lezak, M. D., Howieson, D. B. and Loring, D. W. (2004). Neuropsychological Assessment, 4th edn. New York: Oxford University Press.
Luck, T., Luppa, M., Angermeyer, M. C., Villringer, A., Konig, H. H. and Riedel-Heller, S. G. (2011). Impact of impairment in instrumental activities of daily living and mild cognitive impairment on time to incident dementia: results of the Leipzig longitudinal study of the aged. Psychological Medicine, 41, 10871097. doi: 10.1017/S003329171000142X.
Marshall, G. A. et al. (2011a). Instrumental activities of daily living impairment is associated with increased amyloid burden. Dementia and Geriatric Cognitive Disorders, 31, 443450. doi: 10.1159/000329543.
Marshall, G. A. et al. (2011b). Executive function and instrumental activities of daily living in mild cognitive impairment and Alzheimer's disease. Alzheimer's & Dementia, 7, 300308. doi: 10.1016/j.jalz.2010.04.005.
Marshall, G. A. et al. (2014). Regional cortical thinning and cerebrospinal biomarkers predict worsening daily functioning across the Alzheimer disease spectrum. Journal of Alzheimer's Disease, 41, 719728. doi: 10.3233/JAD-132768.
McKhann, G. M. et al. (2011). The diagnosis of dementia due to Alzheimer's disease: recommendations from the national institute on aging-Alzheimer's association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimer's & Dementia, 7, 263269. doi: 10.1016/j.jalz.2011.03.005.
Migliorelli, R. et al. (1995). Anosognosia in Alzheimer's disease: a study of associated factors. Journal of Neuropsychiatry and Clinical Neurosciences, 7, 338344.
Millar, D., Griffiths, P., Zermansky, A. J. and Burn, D. J. (2006). Characterizing behavioral and cognitive dysexecutive changes in progressive supranuclear palsy. Movement Disorders, 21, 199207.
Milnac, M. E. and Feng, M. C. (2016). Assessment of activities of daily living, self-care, and independence. Archives of Clinical Neuropsychology, 31, 506516. doi: 10.1093/arclin/acw049.
Miyake, A., Friedman, N. P., Emerson, M. J., Witzki, A. H., Howerter, A. and Wagner, T. D. (2000). The unity and diversity of executive functions and their contributions to complex “frontal lobe” tasks: a latent variable analysis. Cognitive Psychology, 41, 49100. doi: 10.1006/cogp.1999.0734.
Morris, J. C. et al. (2009). Pittsburgh compound B imaging and prediction of progression from cognitive normality to symptomatic Alzheimer disease. Archives Neurology, 66, 14691475. doi: 10.1001/archneurol.2009.269.
Murakami, et al. (2015). Modified six elements test: earlier diagnosis of the correlation between motor and executive dysfunction in Parkinson's disease without dementia. Neurology and Clinical Neuroscience, 3, 209214.
Nyunt, M. S., Lim, M. L., Yap, K. B. and Ng, T. P. (2012). Changes in depressive symptoms and functional disability among community-dwelling depressive older adults. International Psychogeriatrics, 24, 16331641. doi: 10.1017/S1041610212000890.
Ogama, N., Sakurai, T., Shimizu, A. and Toba, K. (2014). Regional white matter lesions predict falls in patients with amnestic mild cognitive impairment and Alzheimer's disease. Journal of the American Medical Directors Association, 15, 3641. doi: 10.1016/j.jamda.2013.11.004.
Ogama, N., Yoshida, M., Nakai, T., Niida, S, Toba, K. and Sakurai, T. (2016). Frontal white matter hyperintensity predicts lower urinary tract dysfunction in older adults with amnestic mild cognitive impairment and Alzheimer's disease. Geriatric & Gerontology International, 16, 167174. doi: 10.1111/ggi.12447.
Pereira, F. S., Yassuda, M. S., Oliveira, A. M. and Forlenza, O. V. (2008). Executive dysfunction correlates with impaired functional status in older adults with varying degrees of cognitive impairment. International Psychogeriatrics, 20, 11041115. doi: 10.1017/S1041610208007631.
Pérès, K. et al. (2008). Natural history of decline in instrumental activities of daily living performance over the 10 years preceding the clinical diagnosis of dementia: a prospective population-based study. Journal of the American Geriatrics Society, 56, 3744.
Petersen, R. C., Caracciolo, B., Brayne, C., Gauthier, S., Vesna Jelic, V. and Fratiglioni, L. (2014). Mild cognitive impairment: a concept in evolution. Journal of Internal Medicine, 2014 Mar, 275, 214228.
Petersen, R. C. and Negash, S. (2008). Mild cognitive impairment: an overview. CNS spectrums, 13, 4553.
Petersen, R. C., Smith, G. E., Waring, S. C., Ivnik, R. J., Tangalos, E. G. and Kokmen, E. (1999). Mild cognitive impairment: clinical characterization and outcome. Archives of Neurology, 56, 303308.
Piquard, A., Derouesné, C., Lacomblez, L. and Siéroff, E. (2004). Planning and activities of daily living in Alzheimer's disease and frontotemporal dementia. Psychologie Neuropsychiatrie du Vieillissement, 2, 147156.
Premack, D. and Woodruff, G. (1978). Does the chimpanzee have a theory of mind?. Behavioral and Brain Sciences, 1, 515526.
Rentz, D. M. et al. (2010). Cognition, reserve, and amyloid deposition in normal aging. Annals of Neurology, 67, 5364. doi: 10.1002/ana.21904.
Reuben, D. B., Laliberte, L., Hiris, J. and Mor, V. (1990). A hierarchical exercise scale to measure function at the advanced activities of daily living (AADL) level. Journal of the American Geriatrics Society, 38, 855861.
Rodrigues Gouveia, P. A., Dozzi Brucki, S. M., Fleury Malheiros, S. M. and Bueno, O. F. A. (2007). Disorders in planning and strategy application in frontal lobe lesion patients. Brain and Cognition, 63, 240246.
Rosen, W. G., Mohs, R. C. and Davis, K. L. (1984). A new rating scale for Alzheimer's disease. American Journal of Psychiatry, 141, 13561364.
Royall, D. R. et al. (2007). The cognitive correlates of functional status: a review from the committee on research of the american neuropsychiatric association. Journal of Neuropsychiatry and Clinical Neurosciences, 19, 249265. doi: 10.1176/jnp.2007.19.3.249.
Sahin, A. et al. (2015). Factors affecting daily instrumental activities of the elderly. Turkish Journal of Medical Sciences, 45, 13531359.
Schlotzhauer, S. D. and Littell, R. C. (1987). SAS System for Elementary Statistical Analysis. Cary, NC: SAS Institute Inc.
Seidel, D., Brayne, C. and Jagger, C. (2011). Limitations in physical functioning among older people as a predictor of subsequent disability in instrumental activities of daily living. Age and Ageing, 40, 463469. doi: 10.1093/ageing/afr054.
Shallice, T. I. M. and Burgess, P. W. (1991). Deficits in strategy application following frontal lobe damage in man. Brain, 114, 727741.
Song, H. J., Meade, K., Akobundu, U. and Sahyoun, N. R. (2014). Depression as a correlate of functional status of com- munity-dwelling older adults: utilizing a short-version of 5-item geriatric depression scale as a screening tool. Journal of Nutrition, Health & Aging, 18, 765770. doi: 10.1007/s12603-014-0452-1.
Sperling, R. A. et al. (2011). Toward defining the preclinical stages of Alzheimer's disease: recommendations from the national institute on aging-Alzheimer's association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimer's & Dementia, 7, 280292. doi: 10.1016/j.jalz.2011.03.003.
Spinnler, H. and Tognoni, G. (1987). Standardizzazione italiana e taratura di test neuropsicologici. Italian Journal of Neurological Sciences. Milan: Masson Italia Periodici.
Synn, A. et al. (2018). Mental states in moving shapes: distinct cortical and subcortical contributions to theory of mind impairments in dementia. Journal of Alzheimer's Disease, 61, 521535. doi: 10.3233/JAD-170809.
Tabert, M. H. et al. (2002). Functional deficits in patients with mild cognitive impairment: prediction of AD. Neurology, 58, 758764.
Tomaszewski, F. S. et al. (2009). Longitudinal changes in memory and executive functioning are associated with longitudinal change in instrumental activities of daily living in older adults. Clinical Neuropsychologist, 23, 446461. doi: 10.1080/13854040802360558.
Villemagne, V. L. et al. (2013). Amyloid β deposition, neurodegeneration, and cognitive decline in sporadic Alzheimer's disease: a prospective cohort study. Lancet Neurology, 12, 357367. doi: 10.1016/S1474-4422(13)70044-9.
Wilson, B. A., Alderman, N., Burgess, P. W., Emslie, H. and Evans, J. J. (1996). BADS: Behavioural Assessment of the Dysexecutive Syndrome. Bury St. Edmonds, UK: Thames Valley Test Company.
Wood, R. L. and Liossi, C. (2007). The relationship between general intellectual ability and performance on ecologically valid executive tests in a severe brain injury sample. Journal of the International Neuropsychological Society, 13, 9098.
Yoshita, M. et al. (2006). Extent and distribution of white matter hyperintensities in normal aging, MCI, and AD. Neurology, 67, 21922198. doi: 10.1212/01.wnl.0000249119.95747.1f.


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