Case 10 Flashcards

Question

what are two-pore domain K+ channels? what anaesthetics are they affected by? and how?

Answer 1

- also known as 'leak channels' - inhalation inducing agents directly activate these channels, causing hyperpolarisation, thus reducing membrane excitability - this may contribute to the analgesic, hypnotic and immobilising effects of these agents - these channels are not affected by intravenous inducing agents

Answer 2

- enhance tonic inhibition (through enhancing the actions of GABA) - reduce excitation (opening K+ channels - hyperpolarisation) - inhibit excitatory synaptic transmission (by depressing transmitter release and inhibiting ligand-gated ion channels)

Answer 3

- most sensitive appear to be the midbrain reticular formation, thalamic sensory relay nuclei and, to a lesser extent, parts of the cortex - inhibition of these regions results in unconsciousness and analgesia

Answer 4

particularly volatile ones, cause inhibition at the spinal level, producing a loss of reflex responses to painful stimuli

Answer 5

- all brain functions are progressively affected | - at high enough doses, all anaesthetics cause death by loss of cardiovascular reflexes and respiratory paralysis

Answer 6

- they are all small, lipid-soluble molecules that readily cross alveolar membranes

Answer 7

the rates of delivery of drug to and from the lungs, via (respectively) the inspired air and bloodstream

Answer 8

Properties of the anaesthetic: - blood:gas partition coefficient (solubility in blood) - speed of induction/recovery - oil:gas partition coefficient (solubility in fat) - potency Physiological factors: - alveolar ventilation rate - cardiac output

Answer 9

as the minimal alveolar concentration (MAC) - it is the concentration of vapour in the lungs that is needed to prevent movement (motor response) in 50% patients in response to surgical (pain-incision) stimulus

Answer 10

with increasing lipid solubility (the higher the lipid solubility is the lower the MAC)

Answer 11

- an intravenous anaesthetic agent used for induction of general anaesthesia, after which anaesthesia may be maintained using a combination of medications - it has a rapid onset of action (30s) and a rapid rate of distribution - it is very rapidly metabolised to inactive metabolites - therefore giving rapid recovery with a small hangover effect - 60L/kg (healthy adults) - positive modulation of inhibitory function of GABA through GABA-A receptor - less frequent side effects than other intravenous anaesthetic agents - major side effects: - hypotension and bradycardia - respiratory depression - pain with injection - involuntary movement and adrenocortical suppression - nausea and vomiting - can also be given as a continuous infusion to maintain surgical anaesthesia without the need for any inhalation agent

Answer 12

- the most widely used volatile anaesthetic - inhalation inducing agent - used for maintenance of general anaesthesia - always administered with air/pure oxygen and nitric oxide mechanism of action: - remains incompletely understood - likely binds to GABA, glutamates (NMDA) and glycine receptors, but has different effects on each receptor - relatively free from side effects - major side effects: - hypotension - coronary vasodilator - exacerbate cardiac ischaemia in patient with coronary disease - respiratory suppression

Answer 13

- a potent necrotic analgesic - similar actions to morphine but with a more rapid onset and shorter duration of action - 0.05 mg/mL intravenous mechanism of action: - strong agonist at the u-opioid receptor - upon binding, it inhibits adenylate cyclase which causes an inhibition in the release of nociceptive substances such as substance P, GABA, dopamine etc.

Answer 14

- clinically, neuromuscular block is used only as an adjunct to anaesthesia, when artificial ventilation is available; it is not a therapeutic intervention - the drugs work postsynaptically, either: - blocking ACh receptors - activating ACh receptors and thus causing persistent depolarisation - apart from suxamethonium, all of the drugs used clinically are non-depolarising agents

Answer 15

Mechanism of action: - act as competitive antagonists at the ACh receptors of the motor endplate - also block facilitatory presynaptic autoreceptors and thus inhibit the release of ACh during repetitive stimulation of the motor neurone Pharmocokinetics: - most are metabolised by the liver or excreted unchanged in the urine; exceptions being atracurium, which hydrolyses spontaneously in plasma Effects: - motor paralysis - help facilitate endotracheal intubation Major side effects: - hypotension - bronchospasm - due to histamine release - ganglion block

Answer 16

- non-depolarising neuromuscular blocking agent - muscle relaxant - short duration of action - clinical advantage because of the decreased cardiovascular effects and decreased dependency on good kidney function - optimum conditions - low pH (acidosis) and high temperature - elimination is reduced due to respiratory acidosis

Answer 17

- depolarising neuromuscular blocking agent - muscle relaxant - duration of action lasts between 3-5 minutes mechanism of action: - 'persistent' depolarisation of neuromuscular junction - caused by mimicking the effect of ACh but without being rapidly hydrolysed by acetylcholinesterase - the constant depolarisation leads to desensitisation - suxamethonium is hydrolysed by plasma cholinesterase (butyrycholinesterase (BuChE)) - rapid recovery that follows its withdrawal Major side effects: - bradycardia and hyperkalaemia - increased intraocular pressure - postoperative pain

Answer 18

1. acetylcholinesterase (AChE) - mainly membrane-bound - relatively specific for acetylcholine - responsible for rapid acetylcholine hydrolysis at cholinergic synapses 2. butyrylcholinesterase (BuChE) - relatively non-selective - occurs in plasma and many tissues - cholinesterase inhibitors affect peripheral as well as central cholinergic synapses Cinical uses of anticholinesterase drugs: - to reverse the action of non-depolarising neuromuscular blocking drugs at the end of an operation (neostigmine) - atropine/glycopyrrolate must be given to limit parasympathomimetic effects - to treat myasthenia gravis (neostigmine) Autonomic side effects: - bradycardia - hypotension - bronchoconstriction Muscular side effects: - muscle fasciculation - twitch tension - depolarisation block

Answer 19

- acts to reverse effects of muscle relaxants Mechanism of action: - blocks acetylcholinesterase - increases ACh in the neuromuscular junction (both nicotinic and muscarinic receptors) - increases muscular contraction

Answer 20

- these antagonise the muscarinic receptor and thus inhibit cholinergic transmission - atropine can cross the blood-brain-barrier, whereas glycopyrrolate cannot - they are used to limit parasympathomimetic effects caused by neostigmine - it prevents neostigmine's muscarinic effects such as bradycardia

Answer 21

- osmotic diuretic - inert in humans but it occurs naturally - drug used to treat raised intracranial pressure (e.g. cerebral oedema) Mechanism of action: - these are pharmacologically inert substances that are filtered in the glomerulus but not reabsorbed by the nephron - they cause diuresis because they increase the solute content of the fluid in the proximal tubule and collecting tubules - this draws fluid from the body into the proximal tubule, thus decreasing the volume of fluid inside the body - the result of this is that less water is reabsorbed and also less sodium - this leads to a decrease in extracellular fluid volume - also, they increase the plasma osmolality - this increases the flow of water from tissues (brain and CSF included) into the interstitial fluid and plasma - this reduces the intracranial pressure

Answer 22

a state of physiological reversible unconsciousness

Answer 23

- the change from sleep to wakefulness is mediated by the reticular activating mechanism - the change from wakefulness to sleep is also an active process affected by an arousal inhibitory mechanism based on a partial blockade of the thalamus and upper brainstem - the cognitive change between sleep and wakefulness is accompanied by changes in the autonomic system, the cerebral blood flow and cerebral metabolism

Answer 24

instant awareness - defined as the ability to integrate all sensory information from the external environment and the internal environment of the body

Answer 25

- a function of the thalamo-cortical network in the cerebral hemispheres, which forms the final path of the sleep/wake mechanism - an essential component of total consciousness - defined as continuous awareness of the external and internal environment, both past and present, together with the emotions arising from it

Answer 26

short-term and explicit memory and intact emotional responses

Answer 27

- human sleep occurs with circadian periodicity - the biological clock detects decreases in light levels as night approaches - ganglion cells containing melanopsin are depolarised by light - projections run via axons running the retino-hypothalamic tract, which projects to the suprachiasmatic nucleus (SCN) of the anterior hypothalamus, the site of the circadian control of homeostatic functions Activation of SCN: - activation evokes responses in neurones whose axons first synapse int he paraventricular nucleus (PVN) of the hypothalamus - these neurones descend to the preganglionic sympathetic neurones in the intermediolateral zone (IML) in the lateral horns of the thoracic spinal cord - these preganglionic neurones modulate neurones in the superior cervical ganglia (SCG), whose postganglionic axons project to the pineal gland - this causes secretion of melatonin in the bloodstream - melatonin increases as the light in the environment decreases

Answer 28

the pineal gland produces less melatonin

Answer 29

it governs other functions that are synchronised with the sleep-wake cycle, including body temperature, hormone secretion, blood pressure, and urine production

Answer 30

- increases arousal and mediates wakefulness | - flows from the brainstem, through the thalamus, hypothalamus, and basal forebrain to the cerebral cortex

Answer 31

1. through the thalamus to the cerebral cortex - these projections activate relay neurones and reticular nuclei (in the thalamus) essential for thalamocortical transmission - two cholinergic structures (PPT - peduculopontine / LDT - laterodorsal tegmental) in the brainstem and basal forebrain serve as the origin of these projections - PPT/LDT neurones are most active during wakefulness and rapid eye movement (REM) sleep and discharge more slowly during non-REM (NREM) sleep, a period when cortical activity is reduced - transmission to the reticular nucleus promotes a state of excitability and wakefulness ('reticular activating system') - projections to the thalamus use acetylcholine

Answer 32

2. through the lateral hypothalamus and basal forebrain to the cerebral cortex It comprises a number of monoaminergic cell populations, including: - noradrenergic neurones of the locus coeruleus - serotoninergic (5-HT) dorsal and median raphe nuclei - dopaminergic neurones of the ventral periaqueductal grey matter - histaminergic neurones from TMN - neurones in these monoaminergic systems have broad action potentials, discharging most rapidly during wakefulness, slowing during NREM sleep, and showing little activity during REM sleep

Answer 33

a neurotransmitter that regulates arousal, wakefulness and appetite wakefulness: - orexin neurones strongly excite various brain nuclei with important roles in wakefulness, including the dopamine, norepinephrine, histamine and acetylcholine systems - orexin system also helps stabilise wakefulness and sleep - during REM sleep, the activity of orexin neurons is reduced

Answer 34

sleep is a readily reversible state of reduced responsiveness to, and interaction with, the environment coma and general anaesthesia are not readily reversible and so do not qualify as sleep

Answer 35

sleep consists of non-REM stages that vary clinically with a REM stage during which the EEG (electroencephalogram) cycles between a desynchronised state and a synchronised state

Answer 36

one passes through non-REM sleep and then through REM sleep: - there are usually 4-6 sleep cycles in an 8 hr period of sleep - 80% of a sleep cycle is spent in non-REM sleep; the amount of time spent in non-REM sleep decreases with each cycle - 20% of a sleep cycle is spent in REM sleep; the amount of time spent in REM sleep increases with each cycle

Answer 37

induced by: - 'non-REM-on' GABA neurones in the hypothalamus - serotonin from the raphe nuclei - during non-REM sleep, brainstem noradrenergic neurones show decreased activity - characterised by progressively synchronised EEG

Answer 38

awake: - eyes open, alert, active mental concentration - eyes closed but awake - beta (highest frequency, lowest amplitude) - alpha (for eyes closed?) NREM 1: - light sleep - this is the stage between wakefulness and sleep - EEG = 4-7 Hz waves - theta NREM 2: - deeper sleep, bruxism (involuntary habitual grinding of teeth) - EEG = 10-15 Hz waves - theta + sleep spindles & K complexes NREM 3 + 4: - deepest NREM sleep, sleepwalking, night terrors, bedwetting - 'slow-wave sleep' - the sleeper is less responsive to the environment; many environmental stimuli no longer produce any reactions - EEG = < 3.5 Hz waves - delta (lowest frequency, highest amplitude)

Answer 39

- skeletal muscles relax but maintain their tone - the parasympathetic nervous system is active and promotes gastric motility and a decrease in heart rate and blood pressure

Answer 40

It's characterised by a sudden conversion from a synchronised to a desynchornised EEG, resembling that of the awake state combined with a loss of muscle tone (atonia), which results in an active nervous system in an inactive body

Answer 41

- commences only after non-REM sleep progresses through stages 1-4 and back to stage 2, a cycle that lasts about 90 minutes - brainstem cholinergic neurones in the ascending arousal system act as 'REM-on' cells that initiate REM sleep - during REM sleep, inhibitory medullary reticulospinal neurones are activated, causing skeletal muscles to become flaccid and muscle stretch reflexes to be absent - only the ocular, respiration and middle ear muscles remain active - during REM sleep, all sensory systems are inhibited - there is an increase in blood pressure, metabolism, and blood flow to the brain - penile and clitoral erections are features - REM sleep is associated with rapid saccadic conjugate eye movements - most dreams occur during REM sleep, and the visual images perceived during dreaming are associated with PGO waves in the EEG - near the end of a REM sleep period, noradrenergic and serotonergic neurones act as 'REM-off' cells, initiating a transition from REM sleep back to non-REM sleep

Answer 42

can get along without REM sleep but need non-REM sleep to survive

Answer 43

both awake and aware - this means that they have an intact ascending reticular activating system (awake) in the brainstem, and a functioning cerebral cortex (aware)

Answer 44

a reversible state of unconsciousness that lasts for only a brief amount of time, without any structural or pathological alteration

Answer 45

a profound state of unconsciousness that is associated with depressed cerebral activity from which the individual cannot be aroused - it generally occurs when there is dysfunction or injury involving both cerebral hemispheres or the reticular formation

Answer 46

when they are unconscious and unable to respond to verbal command - they might be able to show motor responses to painful stimuli

Answer 47

if they are unconscious but can be roused by verbal command or painful stimuli for short periods and produce verbal responses

Answer 48

- its used to assess depression of consciousness - it's also essential to record: - pupillary responses to light - reflex eye movements in horizontal and vertical plane - blood pressure, respiratory rate, pulse and temperature

Answer 49

it's a clinical condition in which the patient is unaware of self or surroundings, breathes spontaneously and has stable circulation and shows patterns of eye closure and opening that may stimulate sleep - however, there is no intelligent communication coming from the patient - a persistent vegetative state is irreversible - a person is said to be in a persistent vegetative state if they are still in one 12 months after a head injury

Answer 50

the most extreme form of synchronous brain activity, they are always a sign of pathology

Answer 51

``` generalised = involves the entire cerebral cortex of both hemispheres partial = involves only a limited area of the cortex, but it can spread ```

Answer 52

the neurones within the affected areas fire with a synchrony that never occurs during normal behaviour - therefore, seizures are usually accompanied by very large EEG patterns

Answer 53

when a person experiences repeated seizures

Answer 54

drugs that block GABA receptors withdrawal of chronic depressant drugs, such as alcohol or barbiturates, may also trigger seizures

Answer 55

variety of ways: - prolonging the inhibitory actions of GABA (e.g. barbiturates, benzodiazepines) - decreasing the tendency for certain neurones to fire high-frequency action potentials (e.g. phenytoin, carbamazepine)

Answer 56

- virtually all cortical neurones participate, so behaviour is completely disrupted for many minutes - consciousness is lost, while all muscle groups may be driven by tonic (ongoing) activity or by clonic (rhythmic patterns), or by both in sequence = tonic-clonic seizures

Answer 57

- partial seizures can be instructive - if they begin in a small area of motor cortex, they can cause clonic movement of part of a limb - if seizures begin in a sensory area, they can trigger an abnormal sensation, or 'aura', such as an odd smell or sparkling lights - most bizarre are the partial seizures that elicit more well-formed auras such as deja vu or hallucinations - sometimes involving the cortex of the temporal lobes, including the hippocampus and amygdala, they can impair memory, thought, and consciousness - in some cases, partial seizures may spread uncontrollably and become generalised seizures

Answer 58

- early signs include drowsiness and a diminished level of consciousness - neuroimaging may reveal evidence of oedema and mass effect - late signs are coma and unilateral pupillary changes - they require immediate intervention

Answer 59

by intubation and hyperventilation, which causes vasoconstriction (oxygen lack theory) and reduces cerebral blood volume hyperventilation is best used for short periods of time until a more definitive treatment can be instituted

Answer 60

measurement of ICP

Answer 61

high-dose barbiturates (causes cerebral vasoconstriction and reduced metabolic demands?), decompressive hemicraniectomy, or hypothermia - although these have significant side effects and have not been proven to improve outcomes

Answer 62

vasogenic oedema = the influx of fluid and solutes into the brain through an incompetent blood-brain barrier (BBB) cytotoxic oedema = cellular swelling

Answer 63

a combination of vasogenic and cellular components

Answer 64

1. elevate head 30* 2. intubate and hyperventilate - reduce cerebral blood flow due to vasoconstriction 3. IV mannitol - osmotic diuretic 4. ventricular drainage - removal of CSF decreases intracranial pressure

Answer 65

this is the surgical removal of part of the cranium, performed to expose brain and meninges for inspection or biopsy or to relieve excessive intracranial pressure

Answer 66

- the hair is shaved, the scalp is cleaned with iodine solution, and an incision is then made to expose the skull - burr holes are drilled through the skull at several locations - the burr holes are then joined together - the bone flap is removed, exposing the dura - the dura is hen carefully opened and folded back

Answer 67

the blood supply of the scalp is via five pairs of arteries, two from the internal carotid and three from the external carotid internal carotid: - supratrochlear artery to the midline forehead - branch of the ophthalmic branch of the ICA - supraorbital artery to the lateral forehead and scalp as far as the vertex - branch of ophthalmic branch of ICA external carotid: - superficial temporal artery gives off frontal and parietal branches to supply much of scalp - occipital artery runs posteriorly to supply much of posterior aspect of scalp - posterior auricular artery ascends behind the auricle to supply the scalp above and behind the auricle

Answer 68

they are firmly attached to the fibrous tissue of the superficial fascial layer, hence cut ends of vessels here do not readily retract; even a small scalp wound may bleed profusely

Answer 69

a break in one or more of bones of the skull caused by a head injury

Answer 70

they are not very serious injuries but the presence of a skull fracture can indicate that a significant enough force was applied to cause brain trauma - the broken fragments of a skull can lacerate or bruise the brain or damage blood vessels - bone fragments can cause a penetrating head injury (i.e. breaching the dura mater)

Answer 71

compound (open) fracture = fracture in which the skin is also broken

Answer 72

linear: - most common - caused by widely distributed force - they occur when the area that is impacted bends inwards causing the area around it to bend outwards diastatic: - the fracture line transverses one or more sutures of the skull, causing a widening of the suture depressed: - the broken bones are displaced inwards - carries a high risk of increasing intracranial pressure, crushing delicate tissue - require surgery to life the pieces of bone off the brain if they are causing pressure on it basilar: - breaks in bones at the base of skull - more force is required to cause these than with cranial vault fractures - has some characteristic signs; blood in the sinuses, CSF leaking from the nose or ears

Answer 73

simple: - ask whether patient is able to move and react to physical stimuli - if so, see whether patient can respond in a meaningful way to questions and commands - if so, patient is asked name, current location, and current day and time - a patient who can answer all of these questions is said to be 'oriented three times' (sometimes denoted Ox3 on a medical chart), and is usually considered fully conscious Complex: - a formal neurological examination runs through a precisely delineated series of tests, beginning with tests for basic sensorimotor reflexes, and culminating with tests for sophisticated use of language

Answer 74

- intellectual functioning - problem solving, abstract/verbal reasoning, speed of processing, concentration, spatial awareness - perception - the processes by which information about the external environment is analysed and made meaningful - first stage of memory memory - mental process of recalling and reproducing that which has been learned and retained - 3 stages - 1 = perception, 2 = storage, 3 = retrieval - mood - speech & language

Answer 75

1. descriptive - type and severity of problem | 2. predictive - to explain causes and consequences of deficit

Answer 76

intellectual functioning: - higher executive functioning (WAIS-R) - reduced accuracy / or speed in time pressure processing - reduced concentration span - executive functioning (planning, organisation, decision making) - initiate and maintain and also disengage from goal-directed behaviour perception: - visuo-perceptual (object recognition) - audition (sound recognition, localisation) - hallucinations - altered olfactory, kinaesthetic or gustatory experiences memory: - impaired recent memory - frequency estimation - sequencing - delayed response task - verbal memory - working memory mood: - lability (swings) - aggression - depression - anxiety behaviour: - sexual disinhibition - aggression - uncharacteristic responses language: - receptive and expressive language functions - verbal knowledge - reading skills

Answer 77

1st level: basic neurological examination 2nd level: interview, observation, assessment 3rd level: full measurement using standardised measures -> rehabilitation plan

Answer 78

1. memory, hearing, language understanding, info processing 2. additional damage to residual tissue 3. on-going disability, consequences 4. stigma, additional demand on coping, dependent

Answer 79

- pharmacology - behavioural therapy - social retaining - physical retaining - family therapy - cognition therapy

Answer 80

- esteem support = other people increase one's own self-esteem - informational support = other people available to offer advice - companionship = involves support through activities - instrumental support = involves physical help

Answer 81

- midbrain reticular formation - mesencephalic nucleus (midbrain) - thalamic intralaminar nucleus - dorsal hypothalamus - tegmentum

Answer 82

- Physiology: stop smoking, loosing weight, improve exercise tolerance - Pharmacology: diabetes, heart failure, COPD, asthma, angina - Psychological: awareness, information, anticipation, mindset

Answer 83

- Peripheral limbs – can just block the nerves that are going in e.g. block the left brachial plexus - Lower abdomen - Supplied by a distinct set of nerves

Answer 84

- Hypnosis (posh word for sleep) - intravenous agents: propofol, barbiturates (thiopenton), benzodiazepines - Analgesia (inability to feel pain) - opiates: synthetic or natural - non-opiates - Muscle relaxation - depolarising e.g. suxamethonium - non-depolarising

Answer 85

- For different agents, depending on their physical characteristics, the rate at which the blood concentration increases (alveolar concentration increases), depends on how soluble these agents are - If you take an agent that is very soluble, e.g. halothane, you can give a lot, but it all becomes solution and that is not effective – you need the agents in the gaseous phase for them to have a physiological effect on the brain - Therefore, with less soluble agents, e.g. N2O, desflurane, sevoflurane, isoflurane, the effect tends to come on much faster than with agents that are highly soluble, e.g. halothane - How quickly an inhalational anaesthetic agent’s effect comes on, is determined by blood-gas solubility coefficient or Ostwald coefficient ‘ - Cb/Cg – when the partial pressure in both compartments are equal - More soluble agents have a higher coefficient -> agents with a lower coefficient have a faster onset and faster emergence

Answer 86

- Related to lipid solubility – if highly soluble in lipid, then it can reach the brain in high concentrations, and therefore tends to be a lot more potent - Measured by oil-gas partition coefficient - Not related to blood-gas solubility coefficient – that’s to do with how quickly the effect comes on, not to do with potency - An inherent property of the agent itself - N2O has low potency - MAC (minimum alveolar concentration) – an inverse indicator of potency - Halothane > isoflurane > sevoflurane > desflurane > N2O

Answer 87

- PONV – post-operative nausea and vomiting - Cardiovascular depression - negatively inotropic – these agents weaken the force of muscular contractions - variable action on heart rate - Arrhythmogenesis - Hypotension: vasodilatation - Loss of airway tone: airway obstruction - Malignant hyperthermia - Bronchial muscle relaxation & impaired cough reflex - Agitation and confusion – particularly in elderly – takes much longer to get back to original state - Nephrotoxicity: RBF, GFR, UOP…vs. fluoride-induced nephrotoxicity - Nephrotoxicity: halothane hepatitis

Answer 88

- Natural - morphine - dihydro-morphine - codeine - Opiate analogues (opiate-like substances) - tramadol - Synthetic or semisynthetic - pethidine - fentanyl - alfentanyl - remifentanyl

Answer 89

Analgesia and respiratory depression are mediated via the u receptors - u1: analgesia - u2: respiratory depression - u3: vasodilatation

Answer 90

structurally similar to opiates but binds to opiate receptors much more rapidly but it’s not as potent, therefore patients will wake up – the naloxone displaces the morphine

Answer 91

the study of the relationship between the brain and the mind

Answer 92

Frontal lobe: Emotional control, self-awareness, motivation, judgement, problem-solving, talking, movement and initiation Parietal lobe: sense of touch, awareness of spatial relationships and academic functions such as reading Temporal lobe: memory, hearing, understanding, language, and processing information Occipital lobe: vision Cerebellum: balance, coordination, skilled motor activity Brainstem: breathing, hear rate, arousal and consciousness, sleep and wake cycles

Answer 93

Perception: - Object recognition (visuo-perceptual skills) - Sound recognition/localisation (auditory processing) - Block design test, picture completion task (visual-spatial and constructional skills) Memory: - Visual reproductions (impaired recent memory, visual learning) - Delayed recall tasks (auditory & visual declarative memory) - Digit span tests (repeat string of digits of increasing length), vigilance and continuous performance tests (working memory) - Spatial working memory tests Language: - Vocabulary knowledge tests (‘crystallised’ verbal knowledge) - Reading comprehension tasks and aurally presented instruction (receptive language)) - Naming tests and letter fluency tasks (expressive language) Intellectual ability: - Card sorting task (attention, executive functioning) - Digit symbol task, trail making task (mental processing and psychomotor speed) - WAIS-IV (IQ test), Stroop task (executive functioning) OTHER COMPONENTS OF ASSESSMENT - Alongside standardised tests of cognitive function - Also assessing other factors: e.g. assessment of personal, interpersonal and contextual factors - Assessment may include history taking, interviewing, tests of motor functioning