10-14 Intro to Neuro; Cognitive Exam Flashcards
dementia
a generalized deterioration of intellectual or cognitive function, particularly
memory, without altered alertness or perception
amnesia
pure loss of memory without other cognitive loss
retrograde amnesia
loss of memory of events prior to a specific time
anterograde amnesia
loss of memory of events after a specific time
aphasia/dysphasia
language impairment
dysprosody/aprosody
loss or impairment of the use and understanding of inflection (impairment in aspects of non-verbal communication)
agnosia
inability to perceive/understand the import of sensory stimuli despite intact sensory
mechanisms
apraxia
inability to perform learned actions despite intact motor function
Components of the mental status exam?
A. Level of consciousness
B. Attention and concentration
C. Cognitive functions
- -C1. Language, Memory, Construction, Calculation
- -C2. Interpretation of sensory input
- -C3. Performance of complex learned activities
- -C4. Executive function
D. Thought processes
E. Thought content
F. Affect
confusion
acute thinking disorder
delirium
acute thinking disorder, with altered consciousness,
hyperactivity, irritability, etc.
encephalopathy
diffuse alteration in brain function generally including disordered thinking
Testing B. Attention and Concentration
digit span - give phone number and have them repeat it back
Spell WORLD forwards and backwards
Testing C1. Cognitive functions of: Language, Memory, Construction and Calculation
Language
Memory
Construction
Calculation
What are the different paraphasias one could see in while testing cognitive function C1 (language component)?
Paraphasia – production of well articulated, but incorrect, words
Semantic (verbal) paraphasia – substitute wrong word
Phonemic (literal) paraphasia – substitute wrong
sound Neologism – non-existent word
C1 language: Broca’s and Wernicke’s areas:
- -location?
- -function?
- -connection betwixt?
Broca’s: inferior precentral gyrus of the frontal lobe; MOTOR
Wernicke’s: superior temporal gyrus at the posterior end of the temporal lobe; COMPREHENSION
Connection: arcuate fasiculus = white matter tract in deep anterior-inferior parietal lobe
C1 language: Broca’s aphasia + localization?
~MOTOR PROBLEM: Dysfluent (<10 words/min), few connecting words, agrammatism (inability to speak in a grammatically correct fashion), phonemic mistakes, poor repetition, +/- naming, usually seen in the setting of R hemiparesis. Usually pt is very frustrated.
C1 language: Aphemia + localization?
a.k.a. “cortical dumbness”
Inability to produce speech despite intact comprehension, reading, writing
Localization = Broca’s area or prefrontal cortex
C1 language - types of aphasia: Wernicke’s aphasia + localization?
~WORD SALAD: (a.k.a.”receptive”, “jargon”, “fluent”)
Poor comprehension, poor repetition, poor naming, neologisms, paraphasias.
Often in the setting of R superior quadrantanopsia. Patient is often not concerned (vs. frustration seen in Broca’s).
–music therapy can help
C1 language - types of aphasia: Word deafness
Inability to comprehend words. Poor repetition, but normal fluency, naming, reading and writing.
localization - superior temporal gyrif
C1 language - types of aphasia: Conduction aphasia + localization?
Inability to repeat due to interruption of the arcuate fasciculus. Fluent, but with paraphasias. Comprehension may be OK.
C1 language - types of aphasia: Global aphasia + localization?
Inability to comprehend, produce, or repeat speech.
C1 language - types of aphasia: Transcortical aphasia + localization?
Difficulty with comprehension or fluency or both, with spared repetition
SEE Slide 18 for map of aphasias
transcort. sensory aphasia local - temporal
transcortical mixed aphasia localization - anterior and posterior border zones
QUESTION 1: 72 year old left-handed man was noted by his wife to be confused this morning. On exam he has some difficulty naming items as well as trouble following complex commands. He is noted to have atrial fibrillation on ECG. He is otherwise intact.
Where might you expect a lesion?
- L prefrontal cortex
- R prefrontal cortex
- L posterior temporal
- R posterior temporal
- Hippocampus
3
notes: even though left-handed, still likely L lang dominant; difficulty name = anomia; trouble following complex commands = impaired comprehension
C1 Memory - Define the components of memory
–which do we test?
Declarative (conscious, factual)
- -Episodic** – memory of events – med temporal (bilateral) – hippocampus, mammillary body
- -Semantic – knowledge of concepts – cortical association areas
Non-declarative (skills, habits)
- -Procedural – basal ganglia
- -Conditioning, priming – amygdala
Working memory** (“short-term” memory)
– several seconds of storage – frontoparietal regions
**Commonly tested portions
C1 Memory - How do you test for declarative episodic memory?
IR - repeat 3 items FRONTAL
STM - recall those items in 5 minutes MEDIOTEMP
LTM - breakfast, for dinner last night, news, progress more distantly MEDIOTEMP
C1 Calculation - Testing for acalculia?
serial 7s? (guessing go back and look-up)
C1 Memory - How do you test for semantic declarative memory?
more difficult to test (i.e. not commonly tested) – can ask pt to list items in a category
C2 Sensory Input - General definition of agnosia
dunno!
C1 Memory - Testing for procedural memory?
not commonly done - can assess learned abilities (see “apraxia”)
62 year old man was seen in the ED because of “altered mental status”. On exam he has some difficulty remembering events, and in fact seemed to make up some details to mask this problem. He was not well-oriented. Language was good. Where might you expect a lesion?
- Hippocampi
- Mamillary bodies
- L temporal
- R temporal
- Bitemporal
2 and 5
Korsakoff’s
C1 Calulation - Where is lesion in acalculia?
generally a dominant parietal lobe function, but can be seen in patients with frontal lesions
C2 Sensory Input - Anton’s Syndrome
Blindness without realizing it
C2 Sensory Input - Visual Agnosia
Definition: Inability to recognize objects despite normal vision.
Objects usually can be recognized by touch or sound
Lesion is usually bilateral parieto-occipital cortex. Patients usually not aphasic (but receptive aphasia is possible)
C2 Sensory Input - Prosopagnosia
Definition - (a visual agnosia) – inability to recognize faces
Also includes difficulty recognizing individual items in a class (bird, but not robin)
Lesions usually in bilateral occipital lobes.
C2 Sensory Input - Simultanagnosia
Patients can recognize objects or details in their visual field but only one at a time. They cannot make out the full scene.
They literally cannot see the forest out of the trees.
Ask pt to name all the items in a scene:
“What objects do you see?” Pt will only see a few
C2 Sensory Input - Alexia: what sx accompany? DDx?
Definition - (a visual agnosia) – inability to read
Often accompanied by R hemianopsia, agraphia* and/or aphasia
Lesion in L temp-parieto-occipital region
DDx: •Visual impairment •Diplopia •Field defect - L •Simultanagnosia •Illiteracy
*Agraphia can actually be cured by closing your eyes
C2 Sensory Input - Alexia w/o agraphia
pure word blindness Lesion in anterior L occip, disconnecting Wernicke’s from both occip cortices
C2 Sensory Input - Astereognosia
Definition - inability to recognize objects by feel
Test - coins, pen
Lesion in contralateral parietal
C2 Sensory Input - Agraphesthesia
Definition - inability to recognize numbers traced on hand
Lesion in contralateral parietal
C2 Sensory Input - Auditory Agnosia
Definition: inability to recognize and identify specific sounds despite normal hearing
Examples – amusia**, cortical deafness
Lesion usually in non-dominant temporal lobe (side we do music on)
**total inabability to perceive music; can’t tell one tune from another
C2 Sensory Input - Anosognosia
Definition: Inability to understand the significance of one’s illness
Example: Lack of insight into hemiparesis, leading to falls
Lesion usually non-dom parietal lobe
::::Case – 82 y/o woman unaware of her L sided weakness or even that it is her left arm::::
C2 Sensory Input - Neglect syndromes: definition? types? and localization?
Definition: Inattention to or underuse of body part or surrounding space
Types: 1) Sensory neglect 2) Motor neglect 3) Visual neglect
–Lesion usually contralateral parietal lobe, esp R —Ventral thalamic lesions can produce neglect too –Visual neglect - parieto-occip lesions
C2 Sensory Input - Neglect syndromes:
Clock-drawing; cross out all the lines on a sheet of paper; circle all the A’s on this sheet
–C3. Performance of complex learned activities - constructional apraxia: definition, localization and testing
n/a
–C3. Performance of complex learned activities - ideomotor apraxia; def, example, local, seen usually with?
n/a
–C3. Performance of complex learned activities - Gait apraxia
n/a
–C3. Performance of complex learned activities - Apraxia, generally
Definition
Inability to carry out a motor task despite intact motor pathways; tested by having the pt do a task they were taught to do earlier in life
Types include: constructional, agraphia, Gerstmann’s Syndrome, Ideomotor Apraxia, Gait “Apraxia”
Location: (see slide 53) superoposterior to Wernicke’s area: post-central gyrus looping into angular gyrus
–C3. Performance of complex learned activities - Apgraphia: definition and location
Definition: inability to write
–C3. Performance of complex learned activities - Gerstmann’s Syndrome: sx and local
1) Agraphia
2) Finger agnosia
3) L/R disorientation
4) Acalculia
–C3. Performance of complex learned activities - abnormal gaits: Ataxia
Wide-based, unable to tandem
–C3. Performance of complex learned activities - abnormal gaits: Parkinsonian
Stooped, small steps, turns en bloc
–C3. Performance of complex learned activities - abnormal gaits: Foot drop
High knee-lift with foot slapping on affected side
–C3. Performance of complex learned activities - abnormal gaits: Spastic paresis
Stiff, short steps, scissoring
–C3. Performance of complex learned activities - abnormal gaits: Apractic
Slow and unsteady, magnetic
–C3. Performance of complex learned activities - abnormal gaits: Astasia-abasia
Wildly careening w/o falling
–C4. Executive function - Frontal “Release” signs/reflexes
[just guessing here; swearing loss of socially appropriate responses, etc.]
–C4. Executive function - general info
Executive functions include:
–C4. Executive function - Localization of frontal syndrome with sx: Social Inappropriateness,
disinhibition, euphoria, jocularity, abnormal sexual behavior
orbitofrontal
E. Thought content - Perceptual disturbances
Illusion, could also be full-blown hallucination
–C4. Executive function - Localization of frontal syndrome with sx: Apathy, akinetic, abulic
medial frontal
–C4. Executive function - Localization of frontal syndrome with sx: Irritability, inflexibility, reduced sexual interest,
loss of exec function
dorsolateral
–C4. Executive function - Front lobe testing
ASK PT’S FAMILY
D. Thought processes - possible abnormalities
Loose associations Tangentiality Flight of ideas Blocking Perseveration Word salad
E. Thought content - Abnormal findings
- -Delusions (Persecutory (paranoid), Somatic, Grandiose, Nihilistic, Jealous, Guilty)
- -Thought insertion/broadcasting
- -Suicidal or Homicidal Ideation
- -Obsessions
F. Affect - Mood vs. Affect?
Mood is like climate (What is happening) Affect is like weather (What we see)
F. Affect - Possible affect disturbances you could see
Blunted Restricted Labile Inappropriate affect Pathologic weeping, laughing
