Brain, Vol. 122, No. 3, 383-404,
March 1999
© 1999 Oxford University Press
Review Article |
Attention and executive deficits in Alzheimer's disease
A critical review
1 University of Cambridge Neurology Unit, Addenbrooke's Hospital and 2 MRC Cognition and Brain Sciences Unit, Cambridge, UK
Correspondence to:
Professor John R. Hodges, MRC CBU, 15 Chaucer Road, Cambridge CB2 2EF, UK E-mail: john.hodges{at}mrc-cbu.cam.ac.uk
In this review we summarize the progress that has been made in the research on attentional and executive deficits in Alzheimer's disease. Like memory, attention is now recognized as consisting of subtypes that differ in their function and anatomical basis. We base our review upon a classification of three subtypes of attention: selective, sustained and divided. This model derives from lesion studies, animal electrophysiological recordings and functional imaging. We examine how these subcomponents of attention can be reconciled with neuropsychological models of attentional control, particularly the Supervisory Attentional System and the Central Executive System of Shallice and Baddeley, respectively. We also discuss the relationship of attention to the concept of executive function. Current evidence suggests that after an initial amnesic stage in Alzheimer's disease, attention is the first non-memory domain to be affected, before deficits in language and visuospatial functions. This is consistent with the possibility that difficulties with activities of daily living, which occur in even mildly demented patients, may be related to attentional deficits. It appears that divided attention and aspects of selective attention, such as set-shifting and response selection, are particularly vulnerable while sustained attention is relatively preserved in the early stages. The phenomenon of cognitive slowing in Alzheimer's disease and normal ageing emphasizes the need to discriminate quantitative changes in attention dysfunction from qualitative changes which may be specifically related to the disease process. The neuropathological basis of these attentional deficits remains unsettled, with two competing hypotheses: spread of pathology from the medial temporal to basal forebrain structures versus corticocortical tract disconnection. Finally we discuss the difficulties of comparing evidence across studies and look at the implications for the design of future studies and future directions that may be fruitful in the research on attention in Alzheimer's disease.
Alzheimer's disease; attention; executive function
CDR = Clinical Dementia Rating Scale; CES = Central Executive System; CMRglc = cerebral metabolic rate for glucose; DRS = Dementia Rating Scale; ERP = event-related potential; MMSE = Mini-Mental State Examination; rCBF = regional cerebral blood flow; RT = reaction time; SOA = stimulus onset asynchrony; SPECT = single photon emission computed tomography; WCST = Wisconsin Card Sorting Test
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