Rates of treatment response among the elderly are typically lower than those found in younger samples. This article discusses specific biological and psychological aspects of aging that may impact the effectiveness of treatments for late-life mood and anxiety disorders. Although empirical evidence for the role of executive skills in treatment outcome is currently quite limited, the small number of existing studies suggest that some older adults with deficits in executive skills may respond poorly to popular treatments for depression and anxiety compared with those with intact executive functions. However, there are likely to be additional mediating factors. This article provides a definition and description of executive functions, including a summary of popular assessment tools. The literature on treatment outcome is reviewed, and future directions are discussed.
Gallagher-Thompson D, Thompson L.Psychotherapy with older adults in theory and practice. In: Bongar B, Beutler L, eds. Comprehensive Textbook of Psychotherapy. Oxford, UK: Oxford University Press; 1995:359-379.
2.
Scogin F, McElreath L.Efficacy of psychosocial treatments for geriatric depression: a quantitative review. J Consult Clin Psychol. 1994;62:69-74.
3.
Stanley MA, Beck JG, Novy DM, et al.Cognitive behavioral treatment of late-life generalized anxiety disorder. J Consult Clin Psychol. 2003;71:309-319.
4.
Wetherell JL, Gatz M, Craske MG. Treatment of generalized anxiety disorder in older adults. J Consult Clin Psychol. 2003;71:31-40.
5.
Alexopoulos GS, Meyers BS, Young RC, et al.The “vascular depression” hypothesis. Arch Gen Psychiatry. 2000;57:285-290.
6.
Alexopoulos GS, Kiosses DN, Klimstra S, et al.Clinical presentation of the “depression-executive dysfunction syndrome” of late life. Am J Geriatr Psychiatry. 2002;10:98-106.
7.
Murphy CF, Alexopoulos GS:Longitudinal association of initiation/perseveration and severity of geriatric depression. Am J Geriatr Psychiatry. 2004;12:50-56.
8.
Alexopoulos GS, Myers BS, Young RC. Executive dysfunction increases the risk for relapse and recurrence of geriatric depression. Arch Gen Psychiatry. 2000;57:285-290.
9.
Alexopoulos GS, Raue P, Arean P.Problem-solving therapy versus supportive therapy in geriatric major depression with executive dysfunction. Am J Geriatr Psychiatry. 2003;11:1-7.
10.
Laidlaw K, Thompson LW, Dick-Siskin L, et al.Cognitive Behaviour Therapy With Older People. West Sussex, UK: Wiley; 2003.
Garden SE, Phillips LH, MacPherson SE. Midlife aging, open-ended planning, and laboratory measures of executive function. Neuropsychologia. 2001;15:472-482.
13.
Wegesin DJ, Stern Y:Neuroimaging and aging. In: Fu C, Senior C, Russell T, Weinberger D, Murray R, eds. Neuroimaging in Psychiatry. New York: Taylor & Francis; 2003:81-99.
14.
Norman DA, Shallice T.Attention to action: willed and automatic control of behavior. In: Davidson RJ, Schwarts GE, Shapiro D, eds. Consciousness and Self-Regulation: Advances in Research and TherapyNew York, NY: Plenum; 1986:1-18.
15.
Fuster JM. The Prefrontal Cortex. 3rd ed.Philadelphia, Pa: Lippincott-Raven; 1997.
16.
Stuss DT, Benson DF. The frontal lobes. New York, NY: Raven Press; 1986.
17.
Stuss DT, Alexander MP. Executive functions and the frontal lobes: a conceptual view. Psych Res. 2000;63:289-298.
18.
Burgess PW, Alderman N, Evans J, et al.The ecological validity of tests of executive function. J Int Neuropsychol Soc. 1998;4:547-558.
19.
Lezak MD. Neuropsychological Assessment. 3rd ed.New York, NY: Oxford University Press; 1995.
Pennington BF. Dimensions of executive functions in normal and abnormal development. In: Krasnegor NA, Lyon GR, Goldman-Rakic PS, eds. Development of the Prefrontal Cortex. Baltimore, Md: Brooks; 1997:265-281.
22.
Stuss DT, Shallice T, Alexander MP, et al.A multidisciplinary approach to anterior attentional functions. Ann N Y Acad Sci. 1995;769:191-211.
23.
Goldapple K, Segal Z, Garson MAet al.Modulation of cortical-limbic pathways in major depression. Arch Gen Psychiatry. 2004;61:34-41.
24.
Elias JW, Treland J.Executive function in Parkinson’s disease and subcortical disorders. Semin Clin Neuropsychiatry. 1999;4:34-40.
25.
Sohlberg MM, Mateer CA. Cognitive Rehabilitation: An Integrative Neuropsychological Approach. New York, NY: Guilford; 2000.
26.
Goldman-Rakic PSCircuitry of primate prefrontal cortex and regulation of behavior by representational memory. In: Plum F, Mountcastle V, eds. Handbook of Physiology-The Nervous System. Washington DC: American Physiological Society; 1987:373-413.
27.
Goldman-Rakic PS. Working memory and the mind. Sci Am. 1992;267:110-117.
28.
Damasio A.Descartes Error: Emotion, Reason, and the Human Brain. New York, NY: Avon Books; 1994.
29.
Grafman J.Experimental assessment of adult frontal lobe function. In: Miller BL, Cummings JL, eds. The Human Frontal Lobes: Functions and Disorders. New York, NY: Guilford; 1999:321-344.
30.
Craik FIM, Anderson ND, Kerr SA, et al.Memory changes in normal aging. In: Baddeley AD, Wilson BA, Watts FN, eds. Handbook of Memory Disorders. Chichester, UK: Wiley; 1995:211-242.
31.
Boone KB, Miller BL, Lesser IM, et al.Neuropsychological correlates of white matter lesions in healthy elderly subjects. Arch Neurol. 1992;49:549-554.
32.
Albert MS. Age related changes in cognitive function. In: Albert ML, Knoefel JE, eds. Clinical Neurology of Aging. New York, NY: Oxford University Press; 1994:314-328.
33.
West RL. An application of prefrontal cortex function theory to cognitive aging. Psychol Bull. 1996;120:272-292.
34.
Kray J, Eber J, Lindenberger U.Age differences in executive functioning across the lifespan: The role of verbalization in task preparation. Acta Psychol. 2003;115:143-165.
35.
Zelazo PD, Craik FIM, Booth L.Executive function across the lifespan. Acta Psychol. 2003;115:167-183.
36.
Hachinski VC, Potter P, Merskey H.Leuko-araiosis. Arch Neurol. 1987;44:21-23.
37.
Goldman-Rakic PS, Brown RM. Regional changes of monoamines in cerebral cortex and subcortical structures of aging rhesus monkeys. Neuroscience. 1981;6:177-187.
38.
Kemper TL. Neuroanatomical and neuropathological changes during aging and in dementia. In: Albert ML, Knoepfel EJE, eds. Clinical Neurology of Aging. New York, UK: Oxford University Press; 1994:3-67.
39.
Kimberg DY, D’Esposito M, Farah MJ. Cognitive functions in the prefrontal cortex-working memory and executive control. Curr Dir Psychol Sci. 1997;6:185-192.
40.
Willis SL, Schaie KW. Training the elderly on the ability factors of spatial orientation and inductive reasoning. Psychol Aging. 1986;1:239-247.
41.
Carstensen LL, Gross J, Fung H.The social context of emotional experience. In: Schaie KW, Lawton MP, eds. Annual Review of Geriatrics and GerontologyNew York, NY: Springer; 1997:325-352.
42.
Rabbitt P, Lowe C.Patterns of cognitive aging. Psychol Res. 2000;63:308-316.
43.
Derryberry D, Rothbart MK. Arousal, affect, and attention as components of temperament. J Pers Soc Psychol. 1988;55:958-966.
44.
Posner MI, Rothbart MK. Attention, self-regulation, and consciousness. Philos Trans R Soc Lond. 1998;B353:1915-1927.
45.
Wells A, Mathews G.Modelling cognition in emotional disorder: The S-REF model. Behav Res Ther. 1996;34:881-888.
46.
Frijda NH. Emotions are functional, most of the time. In: Ekman P, Davidson RJ, eds. The Nature of Emotion: Fundamental Questions. New York, NY: Oxford University Press; 1994:112-122.
47.
Levenson RW. Human emotion: a functional view. In: Ekman P, Davidson RJ, eds. The Nature of Emotion: Fundamental Questions. New York, NY: Oxford University Press; 1994:123-126.
48.
Beauregard M, Levesque J, Bourgouin P.Neural correlates of conscious self-regulation of emotion. J Neurosci. 2000;21:1-6.
49.
Hariri AR, Bookheimer SY, Mazziotta JC. Modulating emotional responses: effects of a neocortical network on the limbic system. NeuroReport. 2000;11:43-48.
50.
Abercrombie HC, Schaefer SM, Larson CL, et al.Medial pre-frontal and amygdala glucose metabolism in depressed and control subjects. An FDG-PET study. Psychophysiology. 1996;33:S17.
51.
Amaral DG, Price JL, Pitkanen A, et al.Anatomical organization of the primate amygdaloid complex. In Aggleton JP, ed. The Amygdala: Neurobiological Aspects of Emotion, Memory and Mental Dysfunction. New York, NY: Wiley; 1992:1-66.
52.
Davidson RJ. Anxiety and affective style: role of prefrontal cortex and amygdala. Biol Psychiatry. 2002;51:69-80.
53.
Barlow DH. Anxiety and Its Disorders. New York, NY: Guilford;2004.
Heaton RK, Chelune GJ, Talley JL, et al.Wisconsin Card Sorting Test Manual: Revised and Expanded. Odessa, Fla: Psychological Assessment Resources; 1993.
56.
Mohlman J, Mangels J, Craske MG. The Spider Phobia Card Sorting Test: executive functioning in the presence of fear cues. Cognition and Emotion. 2005;18:939-960.
57.
Palmer BW, Boone KB, Lesser IM, Wohl MA. Base rates of “impaired” neuropsychological test performance among healthy older adults. Arch Clin Neuropsychol. 1998;13:503-511.
58.
Lezak MD, Howieson DBLoring DW. Neuropsychological Assessment. New York, NY: Oxford University Press; 2004.
59.
Spreen O, Strauss E.A Compendium of Neuropsychological Tests. 2nd ed.New York, NY: Oxford University Press; 1998.
60.
Mitrushina MN, Boone BB, D’Elia LF. Handbook of Normative Data for Neuropsychological Assessment.2nd ed.New York, NY: Oxford University Press; 2005.
61.
Martin DJ, Oren Z, Boone K.Major depressives’ and dysthymics’ performance on the Wisconsin Card Sorting Test. J Clin Psychol. 1991;47:684-690.
62.
Stroop JR. Studies of interference in serial verbal reactions. J Exp Psychol. 1935;225:643-662.
Armitage SG. An analysis of certain psychological tests used for the evaluation of brain injury. Psychol Monogr. 1946;60:1-47.
65.
Benton AL, Hamsher KD. Multilingual Aphasia Examination. Iowa City, Iowa: University of Iowa; 1976.
66.
Braswell D, Hartry A, Hoornbeek S, et al.Profile of the Executive Control System. Wake Forest, NC: Lash; 1993.
67.
Boyd TM, Sautter S, Bailey MB, et al.Reliability and validity of a measure of everyday problem solving. Paper presented at: the annual meeting of the International Neuropsychological Society; February 1987; Washington, DC.
68.
Owen AM, Downes JJ, Sahakian BJ, et al.Planning and spatial working memory following frontal lobe lesions in man. Neuropsychologia. 1990;28:1021-1034.
69.
Shallice T.Specific impairments in planning. Philos Trans R Soc Lond. 1982;298:199-209.
Marson DC, Dymek MP, Duke LW, Harrell L.Subscale validity of the Mattis Dementia Rating Scale. Arch Clin Neuropsychol. 1997;12:269-275.
72.
Norris G, Tate RL. The Behavioural Assessment of the Dysexecutive Syndrome (BADS): ecological, concurrent, and construct validity. Neuropsychol Rehabil. 2000;10:33-45.
73.
Folstein SE, Folstein MF, McHugh PR. Mini-mental state.A practical method for grading the mental state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.
74.
Royall DR. Precis of executive dyscontrol as a cause of problem behavior in dementia. Exp Aging Res. 1994;20:73-94.
75.
Dywan J, Segalowitz SJ. Self and family ratings of adaptive behavior after traumatic brain injury: psychometric scores and frontally generated ERPs. J Head Trauma Rehabil. 1996;11:79-95.
76.
Sohlberg MM, McLaughlin K, Pavese A, et al.Evaluation of attention process training and brain injury education in persons with acquired brain injury. J Clin Exp Neuropsychol. 2000;22:656-676.
77.
Squires KC, Wickens C, Squires NK, et al.The effect of stimulus sequence on the waveform of the cortical event-related potential. Science. 1976;193:1142-1146.
78.
Bosco CM, Gratton G, Kramer AF, et al.Information extraction and components of the event-related potential. Psychophysiology. 1986;23:426.
79.
Donchin E, Kramer AF, Wickens C.Applications of event-related brain potentials to problems in engineering psychology. In: Coles MGH, Donchin M, eds. Psychophysiology: Systems, Processes, and Applications, New York, NY: Guilford; 1986:702-718.
Coles MG, Gratton G, Fabiana M.Event-related brain potentials. In: Cacioppo J, Tassinary L, eds. Principles of Psychophysiology. Cambridge, UK: Cambridge University Press; 1995:413-455.
82.
Donchin E, Coles MG. Is the P300 component a manifestation of context updating?Behav Brain Sci. 1988;11:357-427.
83.
Gunning-Dixon FM, Raz N.The cognitive correlates of white matter abnormalities in normal aging. Neuropsychology. 2000;14:224-232.
84.
Martin SD, Martin E, Santoch SR, et al.Brain blood flow changes in depressed patients treated with interpersonal therapy of venlafaxine hydrochloride. Arch Gen Psychiatry. 2001;58:64-648.
85.
Baxter LR, Schwartz JM, Bergman KS, et al.Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive compulsive disorder. Arch Gen Psychiatry. 1992;49:681-689.
86.
Brody AL, Saxena S, Stoessel P, et al.Regional brain metabolic changes in patients with major depression treated with either paroxetine or interpersonal therapy. Arch Gen Psychiatry. 2001;58:631-640.
87.
Channon S.Frontal lobe dysfunction and everyday problem-solving: social and nonsocial contributions. Acta Psychol. 2004;115:235-254.
88.
Hartley A.The cognitive ecology of problem solving. In: Poon LW, Rubin DC, Wilson BA, eds. Everyday Cognition in Adulthood and Late Life. New York, NY: Cambridge University Press; 1989:300-329.
89.
Channon S, Crawford S.Problem-solving in real-life-type situations: the effects of anterior and posterior lesions on performance. Neuropsychologia. 1999;37:757-770.
90.
Goel V, Grafman J.Are the frontal lobes implicated in “planning” functions? Interpreting data from the Tower of Hanoi. Neuropsychologia. 1995;33:623-642.
91.
Braver TS, Cohen JD, Barch DM. The role of prefrontal cortex in normal and disordered cognitive control: a cognitive neuroscience perspective. In: Stuss DT, Benson R, eds. Principles of Frontal Lobe Function. New York, NY: Oxford University Press; 1986:428-447.
92.
Salthouse TA:What and when of cognitive aging. Curr Dir Psychol Sci. 2004;13:140-144.
93.
Kalayam B, Alexopoulos GS. Prefrontal dysfunction and treatment response in geriatric depression. Arch Gen Psychiatry. 1999;36:713-718.
94.
Alexopoulos GS, Meyers BS, Young RC, et al.Executive dys-function and long-term outcomes of geriatric depression. Arch Gen Psychiatry. 2000;57:285-290.
95.
Butters MA, Bhalla RK, Mulsant BH, et al.Executive functioning, illness course, and relapse/recurrence in continuation and maintenance treatment of late life depression. Am J Geriatr Psychiatry. 2004;12:387-394.
96.
Nezu CM, Nezu AM, Arean, P.Assertiveness and problem-solving training for mildly mentally retarded persons with dual diagnosis. Res Dev Disabil. 1991;12:371-386.
97.
Jeste DV, Lohr JB, Goodwin FK. Neuroanatomical studies of major affective disorders. Br J Psychiatry. 1988;153:444-459.
98.
Hauser P, ed. Brain Imaging in Affective Disorders. Washington, DC: American Psychiatric Association; 1991.
99.
Bearden CE, Hoffman KM, Cannon TD. The neuropsychology and neuroanatomy of bipolar affective disorder: a critical review. Bipolar Disord. 2001;3:106-150.
100.
Young RC, Murphy CF, DeAsis JM, et al.Executive dysfunction and treatment outcome in geriatric mania. Paper presented at American Psychiatric Association; May 2001; New Orleans, La.
101.
Wylie ME, Mulsant BH, Pollock B, et al.Age-at-onset in geriatric bipolar disorder. Am J Geriatr Psychiatry. 1999;7:77-83.
102.
van Gorp WG, Altshuler L, Theberge DC, Mintz J.Cognitive impairment in euthymic bipolar patients with and without prior alcohol dependence. Arch Gen Psychiatry. 1999;55:41-46.
103.
Mohlman J, Gorman JM. The role of executive functioning in CBT: a pilot study with anxious older adults. Behav Res Ther. In press.
104.
LeDoux J.The Emotional Brain. New York, NY: Simon & Schuster; 1996.
105.
Gorman JM, Kent JM, Sullivan GM, Coplan JD. Neuroanatomical hypothesis of panic disorder, revised. Am J Psychiatry. 2000;157:493-505.
106.
Mayberg H.Neural circuits in anxiety and depression: evidence from neuroimaging studies. Paper presented at: the 23rd annual conference of the Anxiety Disorders Association of America; May 2003; Toronto, Ont.
Carmin CN, Wiegartz PS, Yunus U, et al: Treatment of late-onset OCD following basal ganglia infarct. Depress Anxiety. 2002;15:87-90.
109.
Arco L, Cohen L, Geddes K.Verbal self regulation of impulsive behavior of persons with frontal lobe injury. Behav Ther. 2004;35:605-619.
110.
Reeder C, Newton E, Frangou S, et al: Which executive skills should we target to affect social functioning and symptom change? A study of a cognitive remediation therapy program. Schizophr Bull. 2004;30:87-100.
111.
Kalayam B, Alexopoulos GS. A preliminary study of left frontal region error negativity and symptom improvement in geriatric depression. Am J Psychiatry. 2003;160:2054-2056.
112.
George MS, Ketter TA, Post RM. Prefrontal dysfunction in clinical depression. Depression. 1994; 2:59-72.
113.
Lisanby SH, Morales O, Payne N, et al.New developments in electroconvulsive therapy and magnetic seizure therapy. CNS Spectr. 2003;8:529-536.
114.
Cattan R, Barry P, Mead G.Electroconvulsive therapy in octogenarians. J Am Geriatr Soc. 1990;38:753-758.
115.
Mulsant B, Alexopoulos G., Reynolds CF III, et al.The PROSPECT Study Group: pharmacological treatment of depression in older primary care patients. Int J Geriatr Psychiatry. 2001;16:585-592.
116.
Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES. Interpersonal Psychotherapy of Depression. New York, NY: Basic Books; 1984.
117.
Verhaeghen P, Marcoen A, Goossens L.Improving memory performance in the aged through mnemonic training: a meta-analytic study. Psych Aging. 1992;7:242-251.
118.
Salthouse T.Theoretical Perspectives on Cognitive Aging. Hillsdale, NJ: Lawrence Erlbaum; 1991.
