Circa 1970, the renowned Russian neuropsychologist Alexander Luria together with Karl Pribram from Stanford University and other neuroscientists of that era introduced the term “executive functions” into the scientific lexicon to denote complex behaviors such as attention and awareness. They identified the frontal lobe — the front of the brain — as the “executive of the brain” responsible for these behaviors based on their experiments with primates and patients with specific brain injuries.
Over time, the concept evolved to include mental processes needed to focus, concentrate, and pay attention when challenged by multiple simultaneous sources of information to weigh options and make informed decisions as opposed to impulsive ones.
Executive functions encompass core components that include behavioral self-control, attention, mental flexibility (the ability to move from one topic to another), and working memory (capability of keeping information in mind so that it is readily accessible). It also includes complex human thinking, such as the ability to effectively reason, solve problems, and make decisions. Self-control refers to managing one’s emotions — specifically not acting reflexively and impulsively without thinking through the consequences of one’s actions. Finally, executive functions broadly encompass self-awareness, including the capacity to monitor one’s own behavior and detect when errors are being made.
Executive functions have obvious implications for decision-making in all areas but especially in the public policy realm, where the impact can be far reaching. One would hope that major policymaking is based on thoughtful deliberations and sound reasoning. However, if the process is untethered to the frontal lobe and executive functions, we risk entering an unpredictable dystopia.
The term “executive functions” has also become a business metaphor, and the title of chief executive officer colloquially denotes the head of a complex entity whose job requires several essential elements including long-term strategic planning, coordinating, and analyzing information from multiple departments and domains. It involves mentally separating “the signal from the noise” and making informed decisions on a regular basis. In addition to analyzing and prioritizing information, the CEO must also prospectively confront the realities and challenges facing the organization and apply sound insight and judgment in responding to them.
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The CEO could be the head of a university, a private corporation, or a nation state — the same principles of higher-order mental processing, prioritization, and behavior apply.
The consulting company McKinsey highlights several leadership traits needed to excel in today’s competitive corporate environment. These include positive energy and inspiration, selflessness, continuous learning, grit, levity, and stewardship.
These skills, which are critical for leadership, rely on an intact frontal lobe and executive functions.
The frontal lobe occupies about 40% of the brain, was the last to evolve, and is much larger than that of our nonhuman primate relatives. The frontal lobe has extensive connections with other parts of the brain, and it is this network that gives the region its privileged role of coordinating input from multiple areas and coordinating a response.
Luria documented how damage to the frontal lobe could lead to “dysexecutive syndrome” — a compromise in behavioral and cognitive functions that depend on the integrity of the frontal lobe and its connections. These include difficulty organizing and planning for the future, an inability to multitask, decreased self-awareness, mood swings, and lack of concern for other people, as well as the inability to learn from past actions, denial that there is a problem, volatility, and socially inappropriate behavior. Executive function impairment rarely occurs in a vacuum and is compromised in a variety of conditions that affect the brain across the lifespan.
While these abilities gradually decline with age there can be dramatic changes in executive function-related behaviors after brain changes resulting from common brain disorders like stroke, degenerative brain disorders (e.g., Alzheimer’s disease), and vascular dementia (secondary to compromised blood supply to the brain). Indeed, behavioral change may be the first clinical presentation of an underlying dementia, especially if the initial loss of brain cells (atrophy) occurs primarily in the frontal lobe.
Erratic behavior including disinhibition, coarseness, near-total lack of empathy, and poor judgment — either occurring for the first time in later life or a substantial amplification of prior behaviors — should also alert one (and/or their family and colleagues) to the possibility of an underlying dementia.
A comprehensive evaluation of late-onset behavioral change should include a complete neuropsychiatric assessment together with neuropsychological testing of executive functions, memory, language, and spatial functions. It should also include brain scans to rule out strokes and other structural abnormalities. A recently available screening blood test for amyloid (a protein biomarker of Alzheimer’s disease) and a positron emission tomography scan to examine the brain for high levels of amyloid would complete the workup of an elderly individual being worked up for executive function impairment.
Executive function impairment can be subtle and elusive especially when compared with other cognitive domains like memory and language. It may be prematurely dismissed as benign “personality change” occurring with aging. That would be a mistake. The consequences of executive function impairment can be profound and far reaching, especially if the individual is in a major leadership role where the ripple effects of bad decisions are widespread.
When a CEO develops acquired executive dysfunction (e.g., from a stroke or neurodegenerative change) yet remains in their role, the challenges become immediately apparent. It is critical to determine the root cause of the impairment to tailor management strategies more precisely.
The goal may shift from restoring peak cognition to preserving decision quality, reducing risk, and scaffolding daily behavior through reliance on the aid of others. Depending on the cause, the most effective approaches combine cognitive rehabilitation principles (simplifying and reducing the cognitive demands on the individual), behavioral/environmental structuring (reducing distractions), and organizational safeguards including error protection protocols.
If the underlying condition is an irreversible dementia, one should prepare for an inevitable worsening of the mental state over time.
While the road ahead may be long and difficult, intellectual honesty, objectivity, and a thorough workup are the first steps in this process. There can be no compromise. The risks are too great.
Anand Kumar is the head of the Department of Psychiatry at the University of Illinois at Chicago and past president of the American Association for Geriatric Psychiatry. Neil Pliskin, Ph.D., is director of neuropsychology services at University of Illinois Health and the past president of the Society of Clinical Neuropsychology.