MRCPsych Phase II
Older Persons Mental Health (OPMHS) Module
Cognitive neuropsychology/neurology
in theory - a clinical approach
16th June, 2011
Dr Rupert Noad
Department of Neuropsychology, Derriford Hospital, Plymouth
rupert.noad@nhs.net
Making sense of cognition
Watch this video of this woman being
interviewed
• What cognitive difficulties is she experiencing?
• How can you make sense of these?
• Which area of her brain may be being
affected?
• What condition might cause this
presentation?
A framework for assessing
cognition
3 steps:
• The questions you ask
• Bedside tests
• Neuropsychological tests
Domain e.g. memory
Stage 1: Questions for patient/carer
Stage 2: Observations in the room of amnesia?
Stage 3: Informal tests of memory e.g. recent events,
tea
Stage 4: Bedside cognitive assessments e.g. address
from ACE-R, MMSE
Stage 5: Formal Neuropsychological assessment e.g.
Camden, WMS
Orientation
Time, place and person.
• time: time of day, date, length of time in hospital
• Place: name of building, name of town, hospital
• Person: name, age, date of birth.
What causes poor orientation?
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Delirium
Post traumatic amnesia
Drug effects
Amnesia – e.g.. Alzheimer's disease
Frontal lobe impairment
General confusion – e.g. unwell
Institutionalisation
Others…..
Memory
• The most common reasons for referral.
• Divided into several domains;
• Episodic- personally experienced events.
• Semantic- word meaning and general knowledge.
• Working Memory- the limited capacity by which
we retain information for a few seconds.
Memory
• Amnesia is a severe impairment in memory with intact
perception and intellectual functions
Memory impairments are causes by:
Korsakoff's Syndrome
• Alcoholic Blackout
• Closed Head Injury
• Electroconvulsive Therapy (ECT)
• Transient Global Amnesia
• Encephalitis
• Dementia
• Temporal Lobe Removals
• Hysterical Amnesia
Episodic Memory
• Depends upon the hippocampal-diencephalic
system.
• Divided into anterograde and retrograde
components.
– Anterograde memory refers to the ability to recall newly
encountered information.
– Retrograde memory refers to the ability to recall past
events.
Disorders of Episodic Memory
• Generally both anterograde and retrograde
memory loss occur in parallel e.g. Alzheimer’s
disease or head injury.
• Dissociations occur e.g. hippocampal damage
may lead to anterograde amnesia e.g. herpes
simplex encephalitis, focal lobe tumours or
infarction.
Clinical Clips
• 1.4.4 – what type of memory problem is this
man describing?
• 1.4.5 – what about this man?
What are the differences between the two types
of problems they report?
Clinical Clips
1.4.4
Confabulation (and drifting into irrelevant material)
• The falsification of memory occurring in clear
consciousness in association with an organically derived
amnesia. It may be:
• Provoked (momentary/fleeting) – evident only on
probing, as with this example
• Spontaneous (sustained/grandiose) – evident in general
conversation
(this patient was in the acute aftermath of traumatic brain
injury)
Clinical Clip: 1.4.5
• Patient had suffered a documented Wernicke’s
encephalopathy. He is being interviewed two
months after the event. The interview takes
place on a Monday in November 1991
Clinical Clips
1.4.5
Korsakoffs
• Impairment of recall e.g. reasons for
admission/name of prime minster and date of
general election
• Preserved alertness and language
• Time disorientation, faulty judgment of passage of
time
Other features of Korsakoff’s
• Confirm impairment in new learning on formal testing
• Seek to establish length of retrograde amnesia
• Confirm other cognitive functions are substantially intact
i.e. a disproportionate loss of memory
Korsakoff’s syndrome is a classic example of a focal
persistent amnesic syndrome where memory and new
learning are affected out of proportion to other cognitive
functions in an otherwise alert and responsive patient.
Confabulation is not invariably found
Memory problems arise with damage
to
• Mammilary Bodies and Dorsomedial Nucleus
of Thalamus (Midline diencephalon)
• Medial temporal lobe including hippocampus,
amygdala, connections to surrounding cortex
Assessing memory in clinic
• Specific questions about route to hospital or events
on wards
• Recall of a name and address, or 3 items.
• Copy and recall of geometric shapes (anterograde
non-verbal memory)
• recalling details of past holidays, operations, jobs,
and past homes? (reterograde memory)
• vocabulary, names of people, places and things and
general factual knowledge (history, geography,
politics, etc)? (semantic memory)
Neuropsychological tests of memory
1. Wechsler Memory Scale – 3rd Edition (1997)
2. Adult Memory and Information Processing Battery
(AMIPB) (1985)
3. Doors and People Test (1994)
4. Recognition Memory Test (1984)
5. Camden Memory Tests (1996)
6. Rivermead Behavioural Memory Test (2003)
Examples of Neuropsychological tests
Verbal Memory - Story Recall & List Learning
“Mrs Angela Harper was sitting in her bedroom mending the curtains when
she heard a noise coming from the kitchen. She rushed to investigate
and found a boy climbing out of the window with her handbag….”
Visual Memory - Figure Recall
Recognition Memory for Faces
50 faces, 50 distractors, white male.
Semantic Memory
• Memory for word meaning, and general knowledge.
• Key neural substrate is the anterior temporal lobe
• Patients complain of loss of words, may substitute
“thing”
• Parallel impairment in understanding meaning of
individual words, beginning with unusual words and
progressing onto familiar words.
Disorders of Semantic Memory
• Word finding difficulties are common in both
anxiety and ageing but in these cases present
as being more variable and not associated
with impaired comprehension.
• Semantic dementia is relentlessly progressive
and associated with atrophy of the anterior
temporal lobe, usually on the left.
Assessing semantic memory in clinic
 Does the patient have problems with
vocabulary, names of people, places and
things and general factual knowledge (history,
geography, politics, etc)?
 Asking both the patient and accompanying
informant to give a memory rating out of 10
may be helpful, amnesic patients less likely to
give low scores of 0 or 1 than those with
depression or anxiety.
Working Memory
• This refers to the very limited capacity which
allows us to retain information for a few
seconds
• Uses the dorsolateral prefrontal cortex.
• Often appears as lapses in concentration and
attention (going into a room and forgetting
the purpose)
Disorders of Working Memory
• Lapses in working memory are common and
increase with age, depression and anxiety.
• Diseases which affect basal ganglia and white
matter may present with predominantly
working memory deficits.
Assessing working memory in clinic
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Days of the week forwards
Days of the week backwards
Months of the year forwards
Months of the year backwards
Serial ‘7’s or ‘5’s or ‘3’s or ‘2’’s
Digit span
Mental arithmetic
Language
Divided into different processes;
• Expressive language - production
• Receptive language - comprehension
• Naming
• Plus reading and writing
Aphasia
• Is an impairment in language
• Caused by damage to perisylvian region of left
cerebral hemisphere.
• Affects higher language functions - difficulties not
able to be accounted for by impairment in motor
systems involved in language production i.e.
dysarthria
• Deficits can be revealed by listening to a patient’s
recounting of their history
Clinical Clips
• What language abnormalities are being
demonstrated in each excerpt?
• 1.3.3
• 1.3.2
• 1.3.5
1.3.2 Wernicke’s (‘fluent’) aphasia
- Speech is fluent with normal syntax
- Lack of meaningful content – reflects defective
appreciation of the meaning of words
• Marked impairment of comprehension with fluent paraphasic
speech (incorrectly chosen words, disorganised syntax).
• May be appropriate use of articles, pronouns and
prepositions.
• Anomia is severe or complete (failure to elicit a naming
response to a stimulus)
• Can be increased speech rate and hyperfluency
• Lesion affects posterior portion of superior temporal gyrus
and spares anterior speech zone.
1.3.3 Broca’s (‘non-fluent’)
aphasia
• Difficulty with mechanisms by which words are chosen
and articulated and sentences constructed.
• Circumlocution is evident, shown by the patient not
being able to find the correct word and talking around
the point using gestures
• Severe restriction of speech output, laborious articulation,
short utterances, spared auditory comprehension.
• Restricted vocabulary access
• Agrammatism is common
• Writing reduced to few common words
Clinical Clips
1.3.5
• Nominal Dysphasia
• Difficulty lies in evoking names at will
• improves with cueing, and patient retains knowledge of
what each object is used for. e.g. patient can still use a
pen.
• This is one of the commonest manifestations of
dysphasia.
Conduction Aphasia
• Damage to the arcuate fasciculus results in
conduction aphasia in which a person cannot repeat
what is said by another
• Phonemic paraphasic errors predominate, with
attempts at self correction
• Single word repetition may be possible, but phrase or
sentence repetition is impaired. Particularly for
unfamiliar or meaningless items.
• Comprehension and verbal fluency remain intact.
Assessing expressive aphasisa in clinic
• Is the patient as fluent and articulate as normal? Has
there been a deterioration in grammar?
• Is there a misuse of words (paraphasias -)? (semantic
- clock for watch) or phonemic - baby flitter for baby
sitter)
• Is a word-finding difficulty apparent?
• Broad responses such as ‘animal’ for ‘camel’ can be
seen in semantic dementia
• Notable frequency effect - use less common objects
to test the patient
Assessing receptive aphasia in clinic
• Does the patient have difficulty following complex
instructions?
• Does he/she struggle to keep track of group
conversations?
• Does he/she find using the telephone particularly
difficult? (this is the case for patients with any
degree of comprehension deficit, because all the
usual gestural and contextual cues to meaning are
absent.)
• Is understanding of individual words affected? (as in
patients with temporal lobe damage or progressive
degenerative diseases)
continued
• Use several common items (coin, pen, key) and ask
patient to point to one to assess single word
comprehension.
• Test sentence comprehension and syntax commands
with common items and commands e.g. “touch the
pen” or “if the lion ate the tiger, who remained?”
• Conceptual comprehension (understanding) and
semantic store can use same objects. E.g. which item
is used to record the passage of time?
Repetition
• Word repetition: Use a series of words of
increasing complexity e.g hippopotamus,
emerald, perimeter. Listen for phonemic
paraphasias.
• Sentence repetition: use well known phrase
“no ifs, ands or buts”
Neuropsychological tests of language
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Graded Naming test
Boston Naming Test
Western Aphasia Battery
Vocabulary
Token Test
Description Naming test
Apraxia
• Inability to perform a movement with a body part
despite intact sensory and motor function - due to
deficits in higher cortical control of movement
• I.e. an inability to carry out a motor command e.g.
"act as if you are brushing your teeth" or "salute"
• It can be useful to provide a description of impaired
performance, recording both spatial and sequencing
errors on different tasks
Apraxia
Also can be:
• Ideational - inability to create a plan for or
idea of a specific movement, for example,
"pick up this pen and write down your name
• Constructional – inability to draw or construct
simple configurations
Other apraxias include:
• Limb kinetic
• Whole body
- test by commanding to stand up/turn around
• Dressing
- note for muddling clothes and difficulty dressing
Assessing apraxia in clinic
• Imitation of gestures, and gestures to command (e.g.
wave, salute)
• Use of imaginal objects (comb your hair, brush your
teeth). Common error is to use body part as a tool
(e.g. finger for toothbrush)
• Oral apraxia (blow out a candle, stick out your
tongue)
• Sequencing task: Luria three step command (fist,
edge, palm) or alternating hand movements.
Figure 1 Hand movements in apraxia. Reproduced from: Goldberg G. Imitation and matching of
hand and finger postures. Neuroimage 2001;14:S132-6, with permission from Elsevier.
Kipps, C M et al. J Neurol Neurosurg Psychiatry 2005;76:i22-30i
Copyright ©2005 BMJ Publishing Group Ltd.
Visuospatial ability
• Information from the visual cortex is directed
towards the temporal or parietal cortex via
one of two streams:
– Dorsal (‘where’) stream links visual info with
spatial position and orientation in the parietal
lobe
– Ventral (‘what’) stream links this information to
store of semantic knowledge in temporal lobes
Agnosia
• Agnosia is a ‘loss of ability to recognize objects,
persons, sounds, shapes or smells’
• It is particulrly associated with lesions of the left
occipital lobe and temporal lobes
• Prosopagnosia is a specific deficit in recognising
familiar faces, sometimes even including own
Visual Object Agnosia
• Patient cannot recognise the meaning of visually
presented objects
• Recognition sometimes better for real rather than
imagined or lined drawings
– Apperceptive: patient cannot demonstrate adequate
perception of objects through drawing, copying or
matching tasks.
– Associative: drawing or copying tasks bring more success,
though performance is “slavish”. More generalised
semantic memory impairment.
Prosopagnosia
• Patient is unable to recognise the identity of
viewed faces
• Patients can often appreciate the aspects of
faces, such as age, gender or emotional
expression.
Clinical Clips
1.5.1
• What condition do you think this woman has?
Clinical Clip
1.5.1: Visuospatial agnosia and hemi-neglect
• visual neglect shown by omissions in images
copied i.e. the numbers of the clock are
crowded onto the right hand side, and one half
of the flower is missing.
• This patient had right hemisphere stroke with
resulting left-sided hemiplegia
Neglect phenomena
Neglect of extrapersonal space
Patients with focal right hemisphere lesions often fail to
respond to stimuli in the opposite half of
extrapersonal space.
May manifest as a failure to talk to visitors on the left
side of the bed, a tendency to ignore food on the left
half of the plate, constantly bumping into objects on
the neglected side
Bodily neglect
In its most profound form, patients deny the presence
of hemiplegia despite evidence to the contrary. Less
dramatic versions, consisting of a tendency to ignore
or under use one side are more frequent.
Bedside tests of visuospatial ability
Neglect
• Letter and star cancellation tasks are used.
• Object centred neglect patients fail to copy
one side of an object
• Copying a 2 headed flower
• Line bisection
• Clock drawing
Figure 2 Impaired clock face drawings in dementia.
Kipps, C M et al. J Neurol Neurosurg Psychiatry 2005;76:i22-30i
Copyright ©2005 BMJ Publishing Group Ltd.
Visuospatial functioning
• In order for sensations to be fully appreciated and consciously
recognised they have to be perceived, discriminated and
associated with existing knowledge.
• Stimuli have to be processed (apperception) to from a conscious
perception of something
• These conscious elements then need to be associated (linked)
with other elements (e.g. memory traces) which give them
meaning.
• Abnormality in the higher level process leads to agnosia, a
disorder of perceptual recognition (not attributed to a primary
sensory deficit or general intellectual impairment)
• Thus perceptual disorders can be subdivided into appreceptive
and associative agnosisa
1.5.2
• What abnormalities does this man describe?
1.5.2
• Prosopagnosia (improving)
- inability to recognise faces
• Topographical disorientation
(this patient has encephalitis)
Assessing visuospatial skills in clinic
Dressing
Does patient have an impairment in the ability to dress him/herself? - apraxia
Does the patient mis-sequence garments when dressing?(sometimes the case
in the context of frontal brain damage).
Constructional abilities - rarely evident without formal testing.
For patients with particular skills or professions, is there any complaint of
difficulty drawing or in three-dimensional construction?
Has a specific decline been noticed in practical abilities such as DIY or
drawing?
Spatial orientation and route-finding
Topographical disorientation is a common accompaniment of moderately
advanced dementia. It may also indicate focal right hemisphere
pathology. It may be due to poor spatial memory or a failure to recognize
landmarks.
Neuropsychological tests of
visuospatial ability
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Rey Complex figure
Block Design
VOSP
Benton
BIT
BORB
CVST
VOSP
VOSP
Frontal Lobe functioning
• Generally thought to be a (dorsolateral)
frontal lobe function, although this set of skills
is probably more widely distributed in the
brain.
• Impairments relate to planning, judgement,
problem solving, impulse control and abstract
reasoning.
Disorders of Executive and frontal lobe
function.
• Head Injury.
• Alzheimer’s disease, even in early stages.
• The majority of the frontal lobe is subcortical white
matter and the leucodystrophies, demyelination and
vascular pathology all cause executive dysfunction.
• Basal ganglia disorders also impair executive skills
e.g. progressive supranuclear palsy (PSP).
Clinical Clips
1.7.1
• What abnormalities of frontal lobe functioning
are demonstrated and what might account for
her different presentation the second time
you see her?
Clinical Clip
1.7.1
• Impaired verbal fluency
• Irritability
• Disinhibited social behaviour
• Patient had a frontal meningioma
• Had surgery - post operative improvement - regained a more
balanced composure and engages in the tests with willingness and
humour.
• Verbal fluency remains poor.
1.7.2
• What frontal test is being shown and what
does it highlight?
1.7.2
• Abstract thinking tested with proverb
interpretation i.e. people in glass houses
• The patient shows literal/concrete thinking
even with encouragements he cant generalise
• Patient had a traumatic brain injury secondary
to severe assault
Exploring executive dysfunction in the
clinical interview.
• There are a broad range of skills encompassed by “executive
function” so it is worth testing in a number of different ways.
• Has there been a drop off in performance at work or in
household tasks and hobbies? (reflecting impairment in
sequencing and planning)
• Have any perseverative behaviours been noticed?
• Are there any reports of poor judgement or an inability to
modify behaviour according to changing situations.
• Appreciation of jokes and puns also depends on complex
abstracting ability and so is frequently affected.
Bedside tests of frontal functions
Memory – learn and recall a name and address with recognition
Attention – arithmetic, digit span
Frontal measures
• Verbal fluency – ‘b’ or animals
• Proverb interpretation/Similarities
• Cognitive estimates
• Luria – alternating sequence/spirals
• Frontal Assessment Battery (FAB)
• Carer report measure – e.g. frontal behavioural inventory
Also focus on the manner of completion – clinical presentation rather than absolute performance e.g. MMSE
Neuropsychological tests of executive
functioning
Attention
TEA, Trail Making Test
Working memory
Digit Span/Arithmetic
Executive functioning
Proverbs/Similarities
Stroop/Fluency/Trail Making Test, WCST, The Hayling and Brixton
Test
Other domains to think about
• Alexia – reading
• Agraphia – Writing
• Acalculia- the inability to read, write and
comprehend numbers.
• Anarithmetrica- the inability to perform
arithmetical calculations.
For discussion
What about
• Eye movements?
• Gait?
• Frontal release signs?
• Rigidity/stiffness/balance?
Are these the role of the
psychiatrist/neuropsychologist?
Don’t forget the psychological
perspective!
People will often report cognitive
problems underpinned by
psychological/psychiatric
phenomenon
Mental health difficulties are
common in neurological conditions
• Eg: in Huntington's Disease
• Depression – 40-50%
• Psychosis – 5-15%
• Mania – 2%
• Anxiety and obsessions seem to be important
Some symptoms that could accompany the
psychological challenge of HD
• Anxiety – palpitations, tightness in throat
• Loss/grief – loss weight, increased fatigue,
loss energy, increased restlessness
• Low mood – despondency, low motivation,
withdrawal from work,
absentmindness/forgetfulness, Inability to
concentrate
• Relationship issues - Irritability, anger
• Reaction to having HD gene- risky behaviour,
Great Resources
• Cognitive assessment for Clinicians – 2nd Ed
(2007). John Hodges (in fact anything by
John Hodges)
• Cognitive assessment for Clinicians (2001).
Kipps and Hodges (JNNP) Supplement
• Neuropsychiatry and Behavioural
Neurology (second Ed). Cummings and
Trimble.
Thank You
Any questions?