Bedside Cognitive Assessment – a practical workshop Friday 6 th June, 2014 Dr Rupert Noad Department of Neuropsychology, Derriford Hospital, Plymouth [email protected] MRCPsych Training Programme
Apr 01, 2015
Bedside Cognitive Assessment – a practical workshop
Friday 6th June, 2014
Dr Rupert NoadDepartment of Neuropsychology, Derriford Hospital, [email protected]
MRCPsych Training Programme
Aims and objectives
• Introduction to Neuropsychology• Understanding of the role cognitive assessment
can play in clinical work• Understanding of different cognitive domains• Understanding of a clinical approach to assessing
cognition• Experience of administering a bedside cognitive
assessment battery
What is Neuropsychology?
• Neuropsychology is concerned with the relationship between brain and behaviour – i.e. how brain functions are organised
• Attempts to understand how mechanisms within the brain influence thinking, learning and emotions
• Neuropsychologists are particularly interested in how brain damage changes behaviour
• This tells us about normal brain functioning e.g. WWI – lots of focal injuries
Neuropsychologists…..
• Aim to apply principles of brain-behaviour relationships to help patients understand their difficulties
• Specialist neuropsychological assessments are used to test patients’ cognition and examine different brain functions
• Neuropsychology knowledge is used as part of a psychological formulation of a patient’s difficulties
The aim is to…
• Have a good understanding of the way brain damage may impact on someone’s cognition
• Have a good understanding of the way cognitive problems may affects someone's everyday functioning
• What the psychological consequences of a disease may be and how they may manifest
• What other explanations could be causing the cognitive symptoms being reported – in particular psychological difficulties
Child - Why is this child under achieving at school?Adult – Differential diagnosis where neurological
condition is suspected e.g. early onset psychosis versus epilepsy?
Older adult - Differential diagnosis e.g. dementia versus depression?
LD - What is this person’s level of understanding
Other health, forensic, Neurorehab
Where might ‘brain variables’ inform your psychiatric/psychological formulation?
Typical questions• Does this person have cognitive difficulties and if so what
is the severity?• Is this patient declining in ability? • Establishing the effects of treatment - surgery or
radiotherapy• Are the person’s cognitive difficulties more related to
psychological factors such as depression• To validate patients’ experiences• Capacity for consent, work, school, and independent living• Medically Unexplained symptoms?• Adjustment, depression, anger, anxiety related to a
condition e.g. PD or Cavernoma
Biopsychosocial approachBrain disorders are complex involving triad of:• Physical • Cognitive • Emotional
Biological
Psychological Social
ButMany other secondary consequences e.g. family dynamics, loss that can underpin individuals’ difficulties
How do we understand Neuropsychological disorders?• Functional Neuroanatomy – what area of brain has been
affected and what does it do?• Cognitive Neuropsychology – how can the patient’s
symptoms be understood within cognitive models?• Clinical Neurology – what do we know about this disease
– are the symptoms typical?• Psychiatry/Clinical Psychology – what do we know about
the disease and its likely psychological consequences? What other factors, lifespan, systemic, childhood, financial etc. might be important?
A practical way of thinking…
• Presence versus absence• Lateralisation• Focal versus diffuse• Acute/progressive versus chronic/static• Aetiology/prognosis/implications
Exercise:
You have an orange, a newspaper and a pencil. How might you use these items to get an idea of someone’s cognitive abilities? What skills do you think you are able to test?
Cognitive abilities• Orientation• Intelligence• Memory - amnesia• Language – Aphasia, anomia• Executive functions• Apraxia• Attention – hemispheric neglect• Visuospatial ability – agnosia• Other - alexia, agraphia, acalculia, anarithmetrica
Making sense of cognition
Following the video…• 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 clinical approach…..
A framework for assessing cognition5 steps:• The questions you ask the patient and carer• What you observe in the room• Informal tests of cognition• Bedside tests of cognition• Neuropsychological tests
Domain e.g. memory
Stage 1: Questions for patient/carerStage 2: Observations in the room of amnesia?Stage 3: Informal tests of memory e.g. recent events,
teaStage 4: Bedside cognitive assessments e.g. address
from ACE-R, MMSEStage 5: Formal Neuropsychological assessment e.g.
Camden, WMS
The Bedside Cognitive Assessment Tool (BCAT)
BCAT – Attention
• Months of the year– Forwards– Backwards
Attention
• Critical to establish basic attention before any cognitive assessment
• For example, critical for memory• Will be affected in disorders such as delirium,
head injury, sub-cortical disorders
BCAT – Orientation
• Date, Month, Year, Day• City, Building, Floor/Level
Orientation
Need to establish orientation to Person, Place, Time and Situation
What causes poor orientation?
Causes of poor orientation
• Delirium• Post traumatic amnesia• Drug effects• Amnesia – e.g.. Alzheimer's disease• Frontal lobe impairment• General confusion – e.g. unwell• Institutionalisation• Others…..
Memory
BCAT – Episodic Memory• Name and Address:
– Linda Clark59 Meadow CloseMilfordSurrey
• Word List:– FACE, VELVET, CHURCH, DAISY, RED
• Figure Copy
• Faces
BCAT - FACES
BCAT – Facial recognition memory
BCAT – Remote Memory
• Dead or Alive:– ELVIS PRESLEY– TONY BLAIR– MARTIN LUTHER KING JR.– MADONNA
BCAT – Semantic Memory
• What do the following words mean?– UMBRELLA– STAPLER– BREAKFAST
BCAT – Working Memory
• Digit Span– Forwards– Backwards
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
In clinic – episodic memory
In clinic• Recall of what had for main meal yesterday• Recall of what did for 17th birthday• What did you do on your last holiday?
• Gradient from recent events to remote events
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.
Semantic memory
• Semantic memory is your total store of knowledge about yourself and the world
• Often loss of autobiographical information can be an indicator of a non-organic cognitive disorder
• However, there is semantic dementia as we have seen and retrograde memory loss e.g. post encephalitis can result in loss of semantic memory
• Tests in clinic - General knowledge, Dead or Alive test• Bits from pyramids and palm trees
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.
Language
BCAT – Expressive Aphasia
• Naming:– “What is this?”
BCAT – Repetition
• Repeat after me:– PROSPER– GARDEN– PORCUPINE– ECCENTRICITY
• “Above, beyond and below”• “Today is a sunny and windy day”
BCAT – Receptive Aphasia
• Single Word Comprehension:– Point to:
• The source of illumination• Object used to tell the time• Object to sit on• Surface that you walk on• Entrance to the room
BCAT – Auditory Comprehension
• Answer YES or NO:– Is a hammer good for cutting wood?– Does a stone sink in water?– Do dogs fly?– Do you put on your socks after your shoes?– Do you peal a banana before eating it?
• Syntax– With the pencil touch the pen– Touch the pencil with the pen– With the pen touch the pencil– Touch the pen with the pencil
Language
Divided into different processes;• Expressive language - production• Receptive language - comprehension
• Plus reading and writing
Disease affecting language
• Stroke• Frontal temporal dementia• Corticobasal degeneration• Head Injury
Need to differentiate dysarthria from dysphasia
Expressive aphasia in clinic
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)
Bedside tests• 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”
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?
Bedside tests• 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?”
Apraxia
BCAT – Apraxia
• Melokinetic– “Touch each finger tip of your right hand with the thumb
of your right hand.”• Buccolingual
– “Lick your lips”– “Blow up your cheeks”
• Ideomotor– Observe any clumsy action with pen use– Interlocking Finger Test
• Ideational– “Fold this piece of paper in half, write your name on it and
place it inside this book.”
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
Can be:• Ideomotor – inability to draw or construct simple
configurations • Ideational - inability to create a plan for or idea of a
specific movement, for example, "pick up this pen and write down your name”
Ideomotor apraxiaIn clinicDoes patient have difficulty with tasks such as using a knife and
fork?Does patient have difficulty with dressing?
Bedside tests• 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)
Copyright ©2005 BMJ Publishing Group Ltd.
Kipps, C M et al. J Neurol Neurosurg Psychiatry 2005;76:i22-30i
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.
Agnosia
• Patient cannot recognise the meaning of visually presented objects
• Recognition sometimes better for real rather than imagined or lined drawings
• It is particularly associated with lesions of the left occipital lobe and temporal lobes
BCAT – Prosopagnosia
• Can you tell me who these people are?
Prosopagnosia
• A specific deficit in recognising familiar faces, sometimes even including own
• Patients can often appreciate the aspects of faces, such as age, gender or emotional expression.
Visual inattention/NeglectNeglect of extrapersonal spacePatients 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/AnosognosiaIn its most profound form, patients deny the presence of
hemiplegia despite evidence to the contrary.
BCAT – Neglect
• Clock Drawing• Image Copy
Copyright ©2005 BMJ Publishing Group Ltd.
Kipps, C M et al. J Neurol Neurosurg Psychiatry 2005;76:i22-30i
Figure 2 Impaired clock face drawings in dementia.
Frontal Lobes/Executive
BCAT – Executive Functioning• Fluency
– ANIMALS & ‘B’• Proverbs
– A stitch in time saves nine– People in glass houses shouldn’t throw stones
• Conflicting instructions– Tap twice when I tap once– Tap once when I tap twice
• Go-No-Go tasks– Tap once when I tap once– DON’T Tap when I tap twice
BCAT – Executive Functioning (cont.)
• Multiple Loops
• Alternating Sequence
• M’s and N’s
BCAT – Executive Functioning (cont.)
• Hayling Test– Complete these sentences with the appropriate
word:• I put my shoes on and I tie my ………• It was raining cats and ………
– Complete these sentences with an inappropriate word:
• John bought candy at the ………• An eye for and eye, a tooth for a ………• I washed my clothes with water and ………
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.• Brain 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).
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.
Don’t forget the psychiatric perspective!
Cognitive symptoms associated with mental health disorders:
• Anxiety• Low mood/depression • PTSD• Psychosis
Summary
• Cognitive assessment can be very helpful• It can give you new types of data over and
above a clinical interview• However, the data is ‘soft’ and is dependent
upon the interpretation of the clinician• Neuropsychological assessment should be
FORMULATION driven not DATA driven
The science/art
To be able to use cognitive data to help in the conceptualisation/diagnosis of a patients clinical problem
Biological
PsychologicalSocial
Can you remember?...
• The name and address• The list of words• The three figures you copied
• Cognitive assessment for Clinicians – 2nd Ed (2007). John Hodges (in fact anything by John Hodges)
• Neuropsychological Neurology: The Neurocognitive Impairments of Neurological Disorders – Andrew J Larner
• Cognitive assessment for Clinicians (2001). Kipps and Hodges (JNNP) Supplement
• Concise Guide to Neuropsychiatry and Behavioral Neurology (second Ed) - Cummings and Trimble.
Great Resources
Thank YouAny questions?