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Based on ……
• AAN- Continuum Journal
• Interesting area
• Does it help in localizing lesions
• Explain symptoms
• Important to know for rehabilitation
– May seem complex (perceived need of props)– Time consuming
– Patients may not cooperate
– Not that useful- waste of time?– Not knowing how to do it – not covered well in med school– Not able to interpret even if knows how to do it
• Patient with a cognitive complaint
• Suspected of dementia
• Stroke/ head injury/ encephalitis etc
Aim
• Single domain
• Multiple domain
• Degree
• Can we localize to a particular region of the brain?
Spheres of cognition
MEMORY
3 aspects1. Encoding
2. Storage
3. Retrieval
• Defect in 1 or more of these processes -amnesia
Modalities of memory
Memory
Explicit
SemanticEpisodic
Short-term
Long-term
anterograde
retrograde
Implicit
Procedural Priming
Recall of past events with a sense of familiarity
Memory of general information such as vocabulary or arithmetic facts
Explicit memory is the conscious, intentional recollection of previous experiences and information. We use explicit memory throughout the day, such as remembering the time of an appointment or recollecting an event from years ago.
Episodic memory is the memory of autobiographical events (times, places, associated emotions, and other contextual knowledge) that can be explicitly stated.
Semantic memory refers to the memory of meanings, understandings, and other concept-based knowledge unrelated to specific experiences.
Implicit memory is a type of memory in which previous experiences aid in the performance of a task without conscious awareness of these previous experiences.
Procedural memory –(motor learning) – phenomenon whereby repeated performance of a motor act enhances and automates future skill of the same act. Slow acquisition but resistant to forgetting
Priming – short lived enhancement of perceptually based performance after recent exposure to visually similar material
• 25 year old
sustained a head injury after a fight where he was struck on the head.
He was confused after the accident.
CT showed a basal skull #
Assault
Day 4
4 months later
Retrograde amnesia Anterograde amnesia
Evaluation
History
Mental status examination
History ……….
• Attention– Is the patient easily distracted?– Able to stay on task?
• Memory– ask the same question repeatedly?– remember recent conversations?
• Language– trouble recalling names of long time acquaintances?– trouble summoning words?– mispronounce or use the wrong words in conversation– stopped reading?– hand writing deteriorated?
History …….
• Visuospatial fn– difficulty driving?– get confused or disoriented in crowded stores?– Trouble finding the car in a crowded parking lot– Get lost easily
• Executive fn– Personality changed?– Done any thing embarrassing/inappropriate in a gathering– Difficulty managing hygiene, home and finances– Negative evaluations at work– Cry more often than used to
• Praxis– Difficulty using household items– Trouble dressing
• Before proceeding to assess mental status better to test
level of consciousness
attention
comprehension
Level of consciousness
• Alert - obtunded - stuporous - coma
• GCS
Attention
1. Orientation to time• Day of the week• Month of the year• Year• Clock time• Calendar date
2. Forward digit span
3. A-vigilance (1 minute)
Disorientation – impaired global attention or severe anterograde amnesia; in latter A-vigilance task will be normal
Forward digit span
• 4,6,9,5,3,5,6
• Normal - 5-9
A vigilance test
• D,A,G,D,R,A,T,E,X,A,S,H,A,Q,W,E,F,G,A,F,A,G,B,F,D,M,N,D,S,W,AS,D,D,Q,F,A……………..
• Tap the table each time u hear letter A or raise hand if in bed
• (1 letter per second for 60 sec)
• Error of ommision Attention deficit• Perseveration Executive dysfn• Errors of commission Executive dysfn
Impaired repetitionImpaired comprehension
Impaired fluency
Conduction
Broca
Wernicke
Global
TCSA
TCMA
Language
1. Observation of spontaneous speech
2. Speech comprehension1. Yes/ No questions2. Token test
3. Verbatim repetition
4. One minute category fluency
5. Visual naming to confrontation
Yes/No questions
• Please answer yes or no
– Is this a hotel?
– Is the door closed?
– Am I wearing a tie?
– Do I have black shoes?
– Are u on the bed?
– Is there a cat in the room?
Only indicated if patient is acutely ill or there is suggestion of impaired comprehension
Token test
– Point to the comb
– Point to the key
– Point to the black pen
– Point to the large coin
– Point to the key and then the comb
– Put the large pen on the key
– Touch the key and touch a coin
– Touch the key with the black pen
Normal token test means speech comprehension is normal
Verbatim repetition
• Please repeat exactly what I say:I got home from work.Near the table in the dining room.They heard him speak on the radio last night.
ErrorsNot able to repeat – aphasiaInability to remember phrases beyond a certain
length (working memory)
One-minute category fluency
• I want u to say aloud all of the things you can think of that u can buy from a grocery store, as fast as u can, I am going to time u, ready go!
• Sugar, flour, milk, jam, rice, soap, toothpaste, etc…
Amnesia - repeatExecutive dysfn - fail to maintain set and shift to other categoriesClouded sensorium - fail to maintain taskSlow – subcortical
Normal<70 >1670-80 >14> 80 >10
ContentNumber
Visual naming to confrontation
CuffHemSleeve
Cap
Point
Clip
Dial
Buckle
Band
In the setting of other signs of aphasia, impaired naming adds little additional import. In the absence of these findings – left extrasylvian language areas- left anterior and inferior temporal lobe
Memory
Working memory
– Reverse digit span• Normal is =5 ; 2 less than the forward digit span
– Serial subtraction- depends more on level of education
Anterograde memory
– Registration and delayed recall of 3 items (screening)
– Serial word list learning test
Serial word list learning test
• Write down 10 frequent 1-2 syllable concrete nouns, in a column
• Explain to patient ‘I am going to read u a list of words. When I finish I want u to tell me immediately as many as u can’
• Record the number of items the patient recalls
Trial
1 2 3 4 5 Delayedrecall
(5 min)
Orange
Table
Shirt
Fish
Bag
Book
Shoe
Paper
Pen
Eraser
Total 6 7 7 8 9 7
Signs of executive dysfunction
Positive Negative
Impaired decision makingDistractibilityInstability of emotionSocial disinhibitionPerseverationImpulsivenessHyperphagia
Limited behaviour initiationRestricted emotionDeficient empathyLack of planningFailure to complete tasksLack of awareness or concern
Executive function screening
1. Observe pt- frontal lobe
2. Luria 3 step test (‘fist-edge-palm’ test)Complex task- checks premotor, prefrontal, parietal and
visual memory
3. Grasp response
4. Imitation behaviour
Luria’s 3 step test (fist-edge-palm)
Grasp response
Imitation behaviour
• Clapping once
• Slapping each knee in turn
• Crossing your arms across your chest
Sensory disorders
• Visual
• Somatosensory
• Auditory
• Disorders of sensory processing
• Disorders of sensory integration
Dorsal - whereVentral - what
Disorders of sensory integration
Visuospatial disorders ‘Body-schema’ disorders
Spatial neglect Finger agnosia(inability to identify one’s own fingers or of another’s)
Impaired visuoconstruction Autotopagnosia(impairment of identification of all body parts- lateral left parietal lobe)
Right- Left disorientation Anosognosia
• Before higher vision check visual acuity and visual fields
Higher vision screening
1. Cookie theft picture
2. Figure copyCube/ intersecting pentagons
3. Finger constructions
4. Clock drawing
• Check R/parietal function
‘Cookie theft’ picture
A patient with neglect
L R
Line bisection
Normal
Patient with left sided neglect
Line cancellation test
Normal Patient with left neglect
Figure copy
Clock drawing
Finger constructions
Cortical sensation
• Stereognosis
• Graphaesthesia
• 2 point discrimination
Apraxia
• Disorder of skilled movement
in the absence of elementary – Motor
– Extrapyramidal
– Cerebellar disorders
Types of apraxias
• True apraxias– Ideomotor apraxia
• Limb apraxia• Oral apraxia
– Ideational apraxia– Conceptual apraxia– Callosal apraxia– Ocular apraxia
• Other apraxias– Constructional – Dressing– Gait
Ideomotor apraxia
• Cannot pantomime a skilled movement to command even though they understand the request and have no primary motor deficit
• Results from left hemisphere damage (infparietal lobe)
• Presence of aphasia or hemiparesis may mask the presence of apraxia
Oral apraxia
• Stick out your tongue
• Cough
• Blow out a match
• Lick your lips
• Show me how you would whistle
Limb apraxia
• Wave good-bye
• Use a comb
• Use scissors
• Use toothbrush
• Use a key to open a door
Body part as object responses are incorrect
Ideational apraxia
• Inability to formulate and execute a series of acts that are necessary to achieve a goal– Eg mail a letter
What we use often
• Mini Mental State Examination (MMSE)– 11 questions
– 30 points
– ~ 10 min
MMSE
Orientation in time
Orientation in place
Registration and recall
Attention
Speech
Higher visual fn
Advantages and disadvantages of MMSE
Easy to administer Does not take much time Reproducible
It is good to follow progression
More weight-age on verbally mediated abilities than on memory Only 1 point for visually mediated performance None for executive functions (insensitive to diagnose some types of
dementia) Absence of timed items (subcortical) Early AD- sensitivity 50-60%
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