Declining Executive Control in Normal Aging Predicts Change in Functional Status: The Freedom House Study

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Abstract
Objectives: To assess the contribution of executive control function (ECF) to functional status. Design: Three‐year longitudinal cohort study. Setting: A comprehensive‐care retirement community. Participants: Five hundred forty‐seven noninstitutionalized septuagenarians. Measurements: The Mini‐Mental State Examination (MMSE) and Executive Interview (EXIT25). Functional status was assessed using instrumental activities of daily living (IADLs). Latent growth curves of MMSE, EXIT25, and IADL were modeled. The rate of change in IADLs (ΔIADL), adjusted for baseline IADLs and cognition, was regressed on the rate of change in each cognitive measure (adjusted for baseline cognition). Models were also adjusted for baseline age, level of care, and comorbid illnesses. Results: Baseline test scores were within normal ranges, but mean EXIT25 scores reached the impaired range by the second follow‐up. There was significant variability around the baseline means and slopes for all variables. The rate of change in EXIT25 was strongly correlated with ΔIADL (r=−0.57, P<.001). This remained significant after adjusting for baseline EXIT25 scores, IADLs, age, comorbid disease, and level of care. The effect of the EXIT25 on ΔIADL was stronger than those of age, baseline IADLs, comorbid disease, or level of care. The rate of change in MMSE scores was not significantly associated with ΔIADL. Conclusion: ECF is a significant and independent correlate of functional status in normal aging. Traditional dementia case finding is likely to underestimate cognition‐related disability. Neither a normal baseline MMSE score nor stable MMSE scores over time preclude functionally significant changes in ECF.