Medical Decision Making

A primary application of neurocognitive assessment in behavioral medicine involves the role of certain cognitive functions in a patient's medical decision making. Here we conceptualize medical decision making broadly, including health behaviors and health behavior changes relevant to diet, exercise, substance use, and medical treatment adherence. We also focus on executive function, as this domain has been linked most often to patients' medical decision making.

By definition, all health behaviors and health behavior changes involve executive functions (Williams and Thayer, 2009), as they require the planning of strategies for future behavior, the initiation and execution of these strategies, and the ability to troubleshoot ineffective strategies and implement new ones. Emotion regulation is also relevant to the maintenance of health behaviors and implementation of behavior changes. As an example, an obese individual interested in losing weight must initiate, execute, and maintain a weight loss plan in order to successfully achieve his or her goal. Furthermore, good problemsolving strategies and effective regulation of emotional reactions to this process may increase chances of success.

In their review of executive functions and changing substance use behavior, Blume and Marlatt (2009) point out that the conceptual relation between executive function and substance use behavior is reciprocal. That is, poor executive function contributes to poor substance-related decisions, such as excessive or illegal substance use. In turn, substance use behavior may result in further decrements in executive function through temporary or permanent damage to relevant brain circuits. Such deficits in executive function then become significant barriers to successful behavior change. Importantly, this cycle may be easily applied to the range of health behaviors described above, including diet and fitness. In fact, Sabia and colleagues (2009) show evidence of an association between a number of unhealthy behaviors (including smoking, alcohol abstinence, low physical activity, and low fruit and vegetable consumption) and likelihood of poor executive functioning. Specifically, individuals with three to four unhealthy behaviors were more likely to have poor executive function, and this association grew stronger with increasing age.

Similarly, executive functioning deserves consideration in the context of management of chronic illness and adherence to medical treatment regimens. As noted above, on average, individuals with obesity, diabetes, hypertension, peripheral vascular disease, renal dysfunction, pulmonary disease, HIV/AIDS, and other illnesses demonstrate poorer executive function than individuals without these diseases. Deficits in executive function may result directly from disease or indirectly through treatments of disease (via mechanisms such as hypoperfusion of the brain or systemic inflammation). Moreover, these decrements in executive function are associated with poor treatment adherence, which may serve to perpetuate or exacerbate the disease processes. For example, executive function has been associated with poor adherence to medication regimens for cholesterol lowering (Stilley et al, 2004) and HIV/AIDS (Hinkin et al, 2003). Other cognitive functions, such as attention, prospective memory, and visuospatial-constructional ability, are also implicated in poor adherence to medication regimens (Hinkin et al, 2003; Stilley et al, 2004; Woods et al, 2008). Decisions to adhere poorly to prescribed treatments should therefore be understood as potential end-products of decrements in various cognitive functions.

Chronic pain, a common treatment target for behavioral medicine practitioners, provides a final example of the relevance of the neu-rocognitive examination to medical decision making. In their review of executive functions, self-regulation, and chronic pain, Solberg et al (2009) propose a model in which executive functions and associated decrements in self-regulation cause and maintain chronic pain disorders. Specifically, the cognitive, emotional, social, behavioral, and physiological challenges associated with chronic pain are more poorly managed in the context of poor executive function. Optimally designed chronic pain interventions may therefore require components aimed at improving executive functions and self-regulatory capacity, such as cognitive techniques and physical activity.

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