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Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 195-199

Frontal Executive Function Assessment in Patients with Parkinson Disease Using Frontal Assessment Battery (FAB) at a Tertiary Care Center in Western India

1 Department of Neurology, JLN Medical College, Ajmer, Rajasthan, India
2 Department of Medicine, JLN Medical College, Ajmer, Rajasthan, India

Date of Submission15-May-2022
Date of Decision13-Jun-2022
Date of Acceptance15-Jun-2022
Date of Web Publication3-Oct-2022

Correspondence Address:
Pankaj Kumar Saini
Assistant Professor, Department of Neurology, JLN Medical College, Ajmer, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnpnd.ijnpnd_26_22

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Background: Cognitive impairment in Parkinson disease (PD) primarily consists of executive dysfunction. Frontal Assessment Battery (FAB), composed of six subsets to explore different functions related to the frontal lobe is a validated and easily performed tool for executive function assessment. Aims and Objectives: We performed this study to evaluate the clinical utility of the FAB for the assessment of executive dysfunction in PD and to study the correlation of FAB with other tests of executive functions such as fluency tests (lexical and semantic) and trail making tests (TMT A and B) in a group of Indian patients with PD. Material and Methods: We included 60 patients diagnosed with PD per the UK PD Brain Bank criteria. Our study included 40 healthy age, sex, and education-matched controls. We recorded clinical characteristics of patients [age, sex, disease duration, Hoehn and Yahr stage, and Unified Parkinson disease Rating Scale (UPDRS) scores] and Mini-Mental State Examination (MMSE) and FAB scores of both patients and controls in a prescribed pro forma. Results: In the study group, mean age was 52.53 ± 10.42 years, mean disease duration was 5.77 ± 3.27 years, mean MMSE was 28.4 ± 1.53, and mean FAB was 11.53 ± 2.30, and they had significantly decreased mean FAB scores as compared to controls. FAB scores also correlated significantly with age, disease duration, Hoehn and Yahr stage, UPDRS score, MMSE, fluency tests, and TMT. Conclusion: FAB is an easily performed bedside screening test for executive function assessment in PD, and it can be used to detect early and subtle cognitive impairments in PD.

Keywords: executive functions, fluency tests, frontal assessment battery, MMSE, parkinson disease

How to cite this article:
Saini PK, Gupta GK. Frontal Executive Function Assessment in Patients with Parkinson Disease Using Frontal Assessment Battery (FAB) at a Tertiary Care Center in Western India. Int J Nutr Pharmacol Neurol Dis 2022;12:195-9

How to cite this URL:
Saini PK, Gupta GK. Frontal Executive Function Assessment in Patients with Parkinson Disease Using Frontal Assessment Battery (FAB) at a Tertiary Care Center in Western India. Int J Nutr Pharmacol Neurol Dis [serial online] 2022 [cited 2022 Dec 5];12:195-9. Available from:

Key Message:

Executive dysfunction is the fundamental cognitive element involved in Parkinson disease. Frontal Assessment Battery (FAB) is an easily performed test consisting of six subtests to explore different frontal lobe functions. FAB also has good discriminant and concurrent validity, so it is superior in identifying early cognitive impairment (executive dysfunction) in Parkinson disease.

   Introduction Top

Parkinson disease (PD) is a hypokinetic movement disorder manifested by tremors at rest, rigidity, bradykinesia, and postural disturbances.[1]

Recently, nonmotor symptoms of PD, such as anxiety, depression, fatigue, apathy, cognitive impairment, and dementia, have gained particular attention. The neuropsychological deficits in PD range from mild executive impairment in the early stages to mild cognitive impairment and dementia in advanced stages.[2],[3] The development of cognitive impairment is associated with rapid disability progression and increased risk for nursing home placement.[4]

So, appropriate neuropsychological tests are required to detect subtle cognitive deficits. The principal cognitive impairment in patients with PD is executive function impairment.[5] Executive dysfunction may cause impairment in complex attention, reasoning, memory, and visuospatial functions.[6] Executive functions primarily consist of planning, response inhibition, goal-directed action, abstract thinking, resistance to interference, problem-solving, strategy development, self-monitoring, and self-regulation.[7] Frontal Assessment Battery (FAB) is an easily and quickly performed and validated tool for assessing executive functions in patients with PD.[8],[9]

So, we performed this study to evaluate the usefulness of FAB in executive dysfunction assessment in patients with idiopathic PD, and also to evaluate the relationship between FAB scores and age, education, disease duration, Hoehn and Yahr stage, Unified Parkinson disease Rating Scale (UPDRS), and Mini-Mental State Examination (MMSE) scores in patients with PD.

   Material and Methods Top

Patients suffering from PD were taken from the neurology outdoor clinic and ward based on random sampling. We included 60 patients diagnosed with PD per the Hughes’ UK PD Society Brain Bank criteria.[10] PD severity was scored using the UPDRS.[11] Hoehn and Yahr stage was used for scoring the disease severity.[12]

We excluded patients with depression or any psychiatric illness, history of drug or alcohol abuse, history of head injury, and MMSE score < 24. In addition, the patient’s age, sex, disease duration, Hoehn and Yahr stage, and UPDRS scores were noted. Finally, we excluded other diagnoses of Parkinsonism by thorough neurologic examination and radiologic evaluation.

We included 40 healthy age, sex, and education-matched controls in our study, selected from the attendants of the patients. All patients gave written informed consent for the study.

MMSE[13] and FAB scores[8] were calculated for PD patients and healthy controls. FAB primarily incorporates six subtests: (i) conceptualization: to test abstract reasoning by asking about similarities between two items, (ii) mental flexibility: tested by lexical fluency task, in which the patient has to recall as many words as he can beginning with a given letter in 1 minute, (iii) motor programming: tested by Luria motor series (fist-edge-palm), (iv) sensitivity to interference: tested by conflicting instructions, (v) inhibitory control: tested by go–no go test, and (vi) environmental autonomy: tested by prehension behavior. It is easily applicable and takes only 10 minutes to perform. Each subtest is given scoring from zero to three, and the total score ranges from 18 to 0.

Fluency tests (lexical and semantic fluency) and trail making tests (TMT A and B) were done for cases.[14]

The IBM SPSS (Jaipur, Rajasthan) statistical package was used for statistical analysis. The unpaired t test and χ2 were used to compare FAB scores of patients with PD with those of healthy participants. The Pearson correlation test was done by comparing FAB scores with age, education, disease duration, MMSE, Hoehn and Yahr stage, and UPDRS scores. We considered a P-value < 0.05 to be statistically significant.

   Results Top

Clinical characteristics of PD patients and healthy controls are depicted in [Table 1]. The mean age was 52.53 ± 10.52 in cases and 53.85 ± 9.94 in controls (P = 0.53). There was statistically no significant difference in education level and MMSE scores of cases and controls. The total FAB score in patients with PD was 11.53 ± 2.30 and 14.25 ± 1.51 in controls, which was statistically significant (P < 0.001). It establishes that FAB has good discriminant validity [Table 1].
Table 1 Clinical characteristics of patients with PD and healthy controls

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The correlation of FAB scores with age, sex, education, disease duration, Hoehn and Yahr stage, and UPDRS in cases is shown in [Table 2]. FAB scores correlated with age (P = 0.001), disease duration (P = 0.04), and Hoehn and Yahr stage (P = 0.03) in patients with PD.
Table 2 Correlation of FAB with clinical parameters in patients with PD

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[Table 3] shows the frequency distribution of scores of the subtests of FAB in patients with PD. All patients scored a maximum (score 3) on the environmental autonomy test.
Table 3 Frequency distribution of scores of the subtests of FAB for patients with PD

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In subgroup analysis of FAB, performance of patients with PD was worse in go–no go test (PD = 1.23 ± 0.72; controls = 1.93 ± 0.47, P < 0.001), conceptualization (PD = 1.38 ± 0.78; controls = 2.23 ± 0.42, P < 0.001), phonemic fluency (PD = 1.65 ± 0.66; controls = 1.98 ± 0.42, P = 0.006), and conflicting instructions (PD = 1.90 ± 0.66; controls = 2.38 ± 0.49, P = 0.001) [Table 4].
Table 4 FAB subtests scores in patients with PD and healthy controls

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A significant correlation was noted between MMSE and total FAB scores in patients with PD (r = 0.695, P < 0.001) [Table 5].
Table 5 Correlation of total FAB scores with mean scores on neuropsychological tests in patients with PD

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We analyzed the concurrent validity of FAB by calculating its correlation with other tests of executive function assessment (fluency tests and TMT). All measures showed a significant correlation with the total FAB score [Table 5].

Patients who had higher FAB scores performed fast on TMT A (r = −0.32, P = 0.01) and TMT B (r = −0.31, P = 0.02), and also performed better on lexical fluency (r = 0.38, P < 0.05) and semantic fluency (r = 0.35, P < 0.05) tasks.

On analyzing the total FAB score with its subtests, conceptualization, phonemic fluency, motor Luria series, conflicting instructions, and go–no go test correlated significantly with total FAB scores.

   Discussion Top

In this study, we analyzed the utility of FAB for executive function assessment in patients with PD (discriminant validity). We also studied the correlation of FAB with other tests of executive function assessment, including fluency tests (lexical and semantic fluency) and TMT A and B to establish the concurrent validity of FAB. We found lower FAB scores in patients with PD than healthy controls, thus establishing its fair discriminant validity. Our study also established the concurrent validity of FAB, as FAB correlated well with other tests of executive function assessment. These results are same as the study done by Lima et al.[9]

We obtained a significant correlation between MMSE and total FAB scores in patients with PD (r = 0.695, P < 0.001). A study by Lima et al.[9] and Beato et al.[15] also obtained similar results. This correlation could be explained by the fact that MMSE also does some executive function assessment (e.g., attention, calculation, and three-step command task) but lacks principal motor and reasoning functions. However, more studies may be required to explain this correlation.

In subtests analysis of FAB, patients with PD performed poorly on conceptualization, phonemic fluency, conflicting instructions, and the go–no go test compared to controls, thus indicating the better discriminative capacity of these four tests. Lima et al.[9] also found the superiority of these tests. Appollonio et al.[16] found conceptualization and phonemic fluency more discriminative.

The test for environmental autonomy (prehension behavior) was found to have the lowest discriminative value. All participants, including patients with PD and healthy controls, scored maximum in this test in our study. Previous studies by Appollonio et al.[16] and Kenangil et al.[17] also obtained similar results.

Dubois et al.[8] described FAB for frontal executive function assessment. The six subtests of FAB identify conceptualization, motor programming, mental flexibility, sensitivity to interference, inhibitory control, and environmental autonomy. These functions reflect the integrity of thalamocortical and corticostriatal connections.[18],[19]

We did not find a correlation between FAB scores and education level in patients with PD. Similar results were obtained by the previous study by Kenangil et al.[17] However, this result might have occurred due to the small group study population.

We observed a significant correlation of total FAB scores with disease duration, Hoehn and Yahr stage, and UPDRS. Similar results were obtained in a study by Cohen et al.[20]We found a lack of sensitivity to environmental autonomy (prehension behavior) in patients with PD. Previous studies obtained a similar result.[9],[20] However, Lipton et al.[21] reported that environmental autonomy well discriminated between Alzheimer disease and frontotemporal lobar degeneration. The cognitive processes assessed by the FAB may not be specific to frontal lobe function but instead require the integrity of other brain regions. This possibility is supported by the report that the FAB cannot differentiate frontal dementia from Alzheimer disease dementia.[22] Involvement of different areas is also supported by the finding that the left inferior parietal lobule and the left supramarginal gyrus demonstrate reduced perfusion in patients with PD who have a low FAB scoring, therefore giving evidence of dysfunction of the parietal lobe also, in addition to frontal lobe dysfunction.[23]

   Conclusion Top

The FAB is an easily and quickly performed bedside test, and it may serve as a valuable tool in assessing initial cognitive dysfunction in patients with PD. It may be of particular importance in patients with PD with a preserved memory, in whom MMSE does not reveal any deficit. In addition, frontal executive dysfunction in PD may start long before the start of other cognitive deficits. Therefore, identification of early executive dysfunction may have the potential for early treatment of these deficits. FAB scores also correlated with other measures of executive dysfunction, including the fluency tests and TMT, so it is superior in detecting cognitive dysfunction. It has added value over MMSE, particularly among patients with PD who have an intact memory. So, FAB should be incorporated in evaluating early cognitive dysfunction in patients with PD.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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Appollonio I, Leone M, Isella V et al. The Frontal Assessment Battery (FAB): normative values in an Italian population sample. Neurol Sci 2005;26:108-16.  Back to cited text no. 16
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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