COGNITIVE TESTING AND LOCALIZATION MADE RIDICULOUSLY SIMPLE 1. Cognitive testing involved examination of the various cognitive domains • Cognitive domains as examined on the Mini-Mental Status Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) Cognitive Domain MMSE MoCA Orientation Yes Yes Memory - Learning/Delayed recall Yes Yes Attention Yes Yes Language Yes Yes Visuospatial Yes Yes Executive Function Yes Yes • Neuropsychological testing involves detailed assessments of each cognitive domain Cognitive Domain Examples of Specific Neuropsychological Tests Orientation Memory - Learning/Delayed recall Logical (story) memory, California adult verbal learning test (CVLT), Free-cued recall Attention Reverse digit span, letter cancellation Language Boston Naming Test, Token Test (comprehension) Visuospatial Rey-O complex figure, block design Executive Function Wisconsin card sorting, Stroop, Trails Making Test Cognitive Testing & Localization 1 Assistant Professor (Neurology & Geriatric Medicine), University of Toronto 7th Canadian Conference on Dementia, Vancouver BC, October 4, 2013 David F. Tang-Wai MDCM FRCPC Co-Director, University Health Network Memory Clinic
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1. Cognitive testing involved examination of the various ... · 4. Guidelines to interpret cognitive testing - determining patterns 1.1. Look at the affected cognitive domains in
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COGNITIVE TESTING AND LOCALIZATION MADE RIDICULOUSLY SIMPLE
1. Cognitive testing involved examination of the various cognitive domains• Cognitive domains as examined on the Mini-Mental Status Examination (MMSE) and the Montreal Cognitive Assessment (MoCA)
Cognitive Domain MMSE MoCA
Orientation Yes Yes
Memory - Learning/Delayed recall Yes Yes
Attention Yes Yes
Language Yes Yes
Visuospatial Yes Yes
Executive Function Yes Yes
• Neuropsychological testing involves detailed assessments of each cognitive domain
Cognitive Domain Examples of Specific Neuropsychological Tests
Orientation
Memory - Learning/Delayed recall Logical (story) memory, California adult verbal learning test (CVLT), Free-cued recall
Attention Reverse digit span, letter cancellation
Language Boston Naming Test, Token Test (comprehension)
Visuospatial Rey-O complex figure, block design
Executive Function Wisconsin card sorting, Stroop, Trails Making Test
Cognitive Testing & Localization 1
Assistant Professor (Neurology & Geriatric Medicine), University of Toronto
7th Canadian Conference on Dementia, Vancouver BC, October 4, 2013
David F. Tang-Wai MDCM FRCPC
Co-Director, University Health Network Memory Clinic
2. Each cognitive domain can be localized to a specific lobe in the brainExecutive Function Memory Language Visuospatial Arithmetic Praxis Facial
Recognition
Lobe in brain
Figure
Sample tests that can examine domain
Frontal Temporal Left Hemisphere Biparietal & occipial lobes
• Apathy, little display of emotions, decreased motivated behavior/creative thought, failure of response initiation/suppression, poor response inhibition; lack of concern of personal hygiene, appearing unkempt
4. Guidelines to interpret cognitive testing - determining patterns1.1. Look at the affected cognitive domains in addition to the total score - this will help determine the pattern of impairment and localization
within the brain
1.2. Recall where the cognitive domains are localized within the brain
Normal cognitive testing but change in behaviour Disinhibition or apathy behaviour • Behavioural variant frontotemporal dementia
1.4. In addition to the clinical history and the pattern of cognitive testing, a diagnosis can be made
Sample Cases Cognitive Testing Result Diagnosis
Case 1: 58 year-old man with 2 year history of progressive memory loss and impairment with his instrumental activities of daily living
MMSE = 22/30Orientation 7/10; Learning 3/3 in 1 trial; Attention 5/5; Recall 0/3; Language 8/8; Pentagon copy 1/1
Alzheimer’s dementiaCognitive testing revealed a primary amnestic pattern. Given the history of anterograde memory impairment with functional impairment, the clinical scenario is one of Alzheimer’s dementia.
Case 2: 88 year-old woman with 5 year history of progressive memory impairment, getting lost, unable to cook and balance the finances. No cerebrovascular risk factors or history of stroke.
MMSE = 18/30Orientation 7/10; Learning 3/3 in 2 trials; Attention 2/5 (WORLD); Recall 0/3; Language 6/8; Pentagon copy 0/1
Alzheimer’s dementia - severeCognitive testing revealed deficits in multiple domains. Given the history of anterograde memory impairment and other cognitive impairments associated with functional impairment, the clinical scenario is one of a moderate-to-severe Alzheimer’s dementia.
Cognitive Testing & Localization 5
Sample Cases Cognitive Testing Result Diagnosis
Case 3: 56 year-old with 5 year history of progressive apathy, emotional blunting, mental rigidity and dismissed from his job for “slacking off”
MMSE = 30/30 Frontotemporal dementia - behavioural variantCognitive screening was normal. The clinical history is primarily a change in personality and behaviour and is associated with an impairment with his iADLs (work). In FTD, especially the behavioural and executive dysfunction presentations, the cognitive testing can be normal or mildly impaired early in the disease.
Case 4: 74 year-old woman presenting with visual hallucinations, slowness in thought, shuffling gait, and “memory” problems of 1 year in duration
MMSE = 25/30Orientation 10/10; Learning 3/3 in 5 trials; Attention 3/5 (WORLD); Recall 3/3; Language 8/8; Pentagon copy 0/1
Dementia with Lewy BodiesCognitive testing revealed intact memory but difficulties with attention/executive function (WORLD), frontosubcortical slowing (excess number of trials to learn 3 words), and visuospatial dysfunction. With the history of parkinsonism, visual hallucinations and some cognitive impairment, the clinical scenario is consistent with DLB.
Case 5: 78 year-old math teacher with known Alzheimer’s disease presents with acute confusion.
Previous MMSE 26/30 days prior to ictusOrientation 9/10; Learning 3/3 in 1 trials; Attention 5/5 (serial 7’s); Recall 0/3; Language 8/8; Pentagon copy 1/1
MMSE on admission = 20/30Orientation 9/10; Learning 3/3 in 1 trials; Attention 0/5 (serial 7’s); Recall 0/3; Language 8/8; Pentagon copy 0/1
Acute left parietal strokeRepeat cognitive testing revealed sudden decline with visuospatial and serial 7s (a crude measure of calculations). These functions localize to the left parietal lobe. Given the sudden change, this man had a stroke in the same area.