6/10- Testing of Higher Cortical Function Flashcards
What’s on the DDx for things causing dementia?
- Alzheimer’s Dz (most common)
- FTLD (with variants: behavioral, semantic, progressive non-fluent aphasia, logopenic progressive aphasia)
- LBD
- PSP
- Corticobasal degeneration
- Parkinson’s dz demetnia
- Vascular dementia
- Normal pressure hydrocephalus
- HIV dementia
- Huntington’s dz dementia
- Dementia due to MS
- Post-traumatic encephalopathy including chronic traumatic encephalopathy
- Mixed dementias
Purpose of cognitive testing? Types?
Determine the extent and profile of cognitive impairment so we are able to facilitate diagnosis of specific cognitive disorders as well as monitor disease progression and response to treatment.
Types:
- Bedside
- Formal neuropsychological testing
What is the first step of assessment?
What factors should be considered?
Determining if cognitive impairment is present by measuring cognitive ability and comparing result with an individual’s expected performance/baseline
Consider:
- Years of education and occupation (allows estimate premorbid cognitive ability and baseline)
- Age: MMSE expected test result decreases significantly with age (usually cut off is under 26, but 23 for 80)
What is the second step of assessment after determining if cognitive impairment is present?
Determine the profile of cognitive impairment in regards to basic cognitive functions:
- Attention and concentration
- Language
- Executive functions
- Memory
- Praxis
- Gnosis
- VIsuospatial construction
Pattern of impairment helps clinician figure out the localization and the etiology
Diagnostic characteristics of the Folstein MMSE (for bedside mental status testing)
- Sensitivity:
- Specificity:
- Strengths:
- Shortcomings:
Sensitivity: 0.81
Specificity: 0.89
Strengths:
- Widely used
- Norms available
Shortcomings:
- Does not test executive function
- Can have some non-AD dementias and have normal or near normal MMSE
The MMSE focuses a lot on language, but not too much on things in the R hemisphere
Score is meant to be taken as a whole (although may provide hints of where problem may be)
Diagnostic characteristics of the Montreal Cognitive Assessment (MOCA) (for bedside mental status testing)
- Sensitivity:
- Specificity:
- Strengths:
- Shortcomings:
(for detecting MCI):
Sensitivity: 0.89
Specificity: 0.75
Strengths: appears to have tests of executive function
Shortcomings:
- Cut off score is too high for non-college educated people
- No improved sensitivity/specificity from MMSE
Score is meant to be taken as a whole (although may provide hints of where problem may be)
What are the broad levels of consciousness?
- Clouding of consciousness
- Confusional state
- Lethargy
- Obtundation
- Stupor
- Coma
What is clouding of consciousness?
Very mild form of altered mental status in which the pt has inattention and reduced wakefulness
What is confusional state?
More profound deficit that includes disorientation, bewilderment, and difficulty following commands
What is lethargy?
Consists of severe drowsiness in which the pt can be aroused by moderate stimuli and then drift back to sleep
What is obtundation?
State similar to lethargy in which the pt has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states
What is stupor?
Only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the pt will immediately lapse back to the unresponsive state
What is coma?
A state of unarousable unresponsiveness
Parts of the MOCA?
- Visuospatial/executive (connecting letters/numbers, copy cube, draw clock)
- Naming (animals)
- Memory
- Attention
- Language
- Abstraction
- Delayed Recall
- Orientation
What is the clock drawing test? What does it test?
(It’s part of the MOCA exam)
Ask patient to draw a clock
- If don’t know/remember what a clock is or where to start (possible aphasia)
- If all numbers are on right side (hemi-neglect)
- General assessment of planning and coordination (executive function)
What tests can be used to test attention and concentration?
- Serial 7s
- WORLD backwards
- Digit span forward and backwards (backwards no more than -2, normal 6-8 forward)
- Vigilance test (“tap every time I say A”)
What is the Wisconsin card sorting test?
- Matching shape/color/number
- Change rules and see if they adjust
What is executive function?
- Complex set of cognitive abilities that are involved in planning and multitasking.
- These functions operate in non-routine situations and exert a top-down, volitional control over cognition and behavior
- Also refers to the ability to be aware of environmental input and to change cognition or behavior if required
- Preservation results from an inability to change
- Generating thoughts and actions are also implicated in executive functioning and impairment manifests with lack of initiation or apathy
What are some tests of executive function?
- Luria hand movement tests (show, do it with them, do alone; e.g. fist -> hand -> flat -> fist…)
- Verbal fluency tests
—- Category or semantic fluency: animal words in 1 min
—- Phonemic or lexical fluency- “f” or “s” words in 1 min
- Go-No-Go Task: tap once if I tap once but don’t tap at all if I tap twice
- Alternating sequence: trailmaking test (1-A-2-B-3-C etc.)
- Months of the year backwards
- Abstraction- similarities (e.g. fly and human;
What are some categories/ways to test language at the bedside?
Fluency- ask open ended questions
Comprehension- ask to follow every more complex commands
- Point to the ceiling
- Point to the ceiling and then the window
- ….. and then the floor
- ….. and then the door
Naming (overlaps with visual agnosia)- objects or pictures of objects (use high and low frequency objects appropriate to pt’s life experience)
Repetition: “no ifs, ands, or buts”
Reading: individual words including irregulars and sentence
Writing: write a sentence
What are the categories for selected memory systems (broad)?
Length of memory storage in each?
Types of awareness?
Episodic memory
- min-yrs
- Explicit, declarative awareness
Semantic memory
- min-yrs
- Explicit, declarative awareness
Procedural memory
- min- yrs
- Explicit or implicit; nondeclarative awareness
Working memory
- s- min; info actively rehearsed or manipulated
- Explicit, declarative type of awareness
What are the major anatomical structures involved and examples of episodic memory?
Structures:
- Medial or temporal lobe
- Anterior or thalamic nucleus
- Mammillary body
- Fornix
- Pre-frontal cortex
Examples:
- Word recall (e.g. remember an address, 3 word, 10 word)
- Remembering a short story
- What you had for dinner last night
- What you did on your last birthday
What are the major anatomical structures involved and examples of semantic memory?
(Fund of knowledge)
Structures:
- Inferolateral temporal lobes
Examples:
- Knowing who the 1st president of the US was
- Capital of the US
- Color of a lion
- How a fork differs from a comb
What are the major anatomical structures involved and examples of procedural memory?
Structures:
- Basal ganglia
- Cerebellum
- Supplementary motor area
Types of awareness:
- Driving a car with a standard transmission (explicit)
- Learning the sequence of numbers on a touch-tone phone without trying (implicit)
What are the major anatomical structures involved and examples of working memory?
Structures (phonologic)
- Prefrontal cortex
- Broca’s area
- Wernicke’s area
Structures (spatial)
- Prefrontal cortex
- Visual-association areas
Examples:
- Phonologic: keeping a phone number in your head before dialing
- Spatial: mentally following a route or rotating an object in your mind
What is praxis?
The ability to translate an idea into action and to execute the action
What is apraxia?
The inability to perform purposeful movements in the presence of normal elementary motor and sensory function
What localized areas are responsible for movement planning (early and late)?
- Initially done with words in the posterior aspect of the dominant hemisphere (left parietal cortex)
- The plans are moved to the frontal cortex, supplementary motor area, and motor cortex for final movement; primary motor
How can you assess apraxia at the bedside?
Ideomotor apraxia:
- Mime a task
- Mimic a hand motion/position
Other apraxias:
- Ideational: complex multistep activities
- Limb-kinetic: finely coordinated movements
- Dressing (visuospatial dysfunction due to right parietal issue): copy cube; intersecting pentagons
- Oral-mouth movement issues: blow out candles, lick crumbs off limps
What is agnosia? How can it be tested?
Impairment of perceptual functioning due to a breakdown in higher order stimuli
Tests: naming or objects seen, heard, or touched
Localization of agnosia?
Higher order sensory function is processed in the association cortices.
This involves the parietal lobes and sensory association areas of the occipital and temporal lobes
What tests comprise Formal Neuropscyhological Testing?
- Rey Osterrieth Complex Figure (picutre)
- Stroop test (word name vs. color of words)
- Symbol Digit test (draw particular symbol under numbers)
- Boston Naming Test (30 in increasing difficulty)
- California verbal learning test (two different lists with 16 words, 4 words from 4 different categories in pseudo random manner. A x 5, B x 1 immediately after; presentation recall)
- Block Design
