COGNITIVE TESTING IN THE FR.PPT [Read-Only]andrewmallett.net/practicenursing/instruments/Cognitive Testing.pdf · COGNITIVE TESTING IN THE FRANZCP ... “Pick up this piece of paper

COGNITIVE TESTING COGNITIVE TESTING IN THE FRANZCP IN THE FRANZCP EXAMINATIONSEXAMINATIONS

Mark Mark WalterfangWalterfang MBBS MBBS HonsHons FRANZCPFRANZCPNeuropsychiatry Unit, Royal Melbourne HospitalNeuropsychiatry Unit, Royal Melbourne Hospital

Cognitive Neuropsychiatry Research & Academic Unit, University oCognitive Neuropsychiatry Research & Academic Unit, University of f MelbourneMelbourne

Mental Health Research Institute, VictoriaMental Health Research Institute, Victoria

April 12April 12thth 20032003

Why do we cognitively assess?Why do we cognitively assess?

•• To globally aid diagnosis, guide To globally aid diagnosis, guide investigations, and inform management & investigations, and inform management & rehabilitationrehabilitation

•• To assist differentiation between “functional” To assist differentiation between “functional” and “nonand “non--functional” disorders functional” disorders –– e.g. e.g. depression versus dementia; or between depression versus dementia; or between “organic” and “non“organic” and “non--organic” disorders organic” disorders ––e.g. neurological versus somatoform illnessese.g. neurological versus somatoform illnesses

•• Identify coIdentify co--morbid impairment inherent in morbid impairment inherent in some illnesses (e.g. schizophrenia)some illnesses (e.g. schizophrenia)

•• To screen highTo screen high--risk individualsrisk individuals

Why do we cognitively assess in Why do we cognitively assess in the exam?the exam?

•• To passTo pass•• To provide a thorough, holistic assessment To provide a thorough, holistic assessment

that integrates all aspects of history and that integrates all aspects of history and examinationexamination

•• To assist in generating, and sorting, a To assist in generating, and sorting, a differential diagnosis list differential diagnosis list –– and to ensure you and to ensure you don’t miss the diagnosis don’t miss the diagnosis

•• To inform & guide investigations, To inform & guide investigations, management, or neuropsychological management, or neuropsychological assessmentassessment

Myths About TestingMyths About Testing

•• Cognitive testing is difficult to learnCognitive testing is difficult to learn•• Cognitive testing is onerousCognitive testing is onerous•• Cognitive testing is hard to interpretCognitive testing is hard to interpret•• Cognitive testing is not relevantCognitive testing is not relevant•• Cognitive testing is someone else’s jobCognitive testing is someone else’s job

Basic Schema for Basic Schema for Cognitive TestingCognitive Testing

WatchWatch--TalkTalk--TestTest

•• All fields of medicine start at the end of All fields of medicine start at the end of the bed and work inthe bed and work in

•• Much valuable information can be Much valuable information can be gained prior to or in absence of formal gained prior to or in absence of formal testingtesting

•• Progression from Progression from behavioural/observational to historical behavioural/observational to historical to direct challenge/assessmentto direct challenge/assessment

WatchWatch

•• Degree of coDegree of co--operation, motivationoperation, motivation•• Level of psychomotor activityLevel of psychomotor activity•• Gait & neurological signs, Gait & neurological signs,

dysmorphologydysmorphology•• Behaviour Behaviour –– judgementjudgement, inhibition, , inhibition,

planning, planning, utilisationutilisation•• GroomingGrooming•• Remembering/making appointment, Remembering/making appointment,

requiring assistancerequiring assistance

TalkTalk

•• Lack of an informant does not mean Lack of an informant does not mean that interview lacks substancethat interview lacks substance

•• Information (memory, language, Information (memory, language, attention, executive) can be gained attention, executive) can be gained throughout course of “normal” throughout course of “normal” ?? i/vi/v

•• Cognitive history/systems review Cognitive history/systems review –– think think first in terms of deficits in domains, then first in terms of deficits in domains, then illness typesillness types

•• Cognitive risk factors (HI, ECT, vascular, Cognitive risk factors (HI, ECT, vascular, medication, substances)medication, substances)

TalkTalk

•• Establishing sense of baseline Establishing sense of baseline ––age, educationage, education

•• Clues: course, and first symptom of Clues: course, and first symptom of onset; each aids in diagnosisonset; each aids in diagnosis

TestTest

•• Systematic approach best based on Systematic approach best based on set of items you:set of items you:–– Are comfortable in doingAre comfortable in doing–– Understand their interpretationUnderstand their interpretation–– Know their limitationsKnow their limitations

•• Ensure that your collection of items is Ensure that your collection of items is broad enough to cover most domainsbroad enough to cover most domains

•• basic, high yield items; lowbasic, high yield items; low--yield, yield, specific items; knowledge of nspecific items; knowledge of n?? tests tests

ModelsModels

•• LowerLower--order to higherorder to higher--order functions order functions (e.g. attention, psychomotor speed to (e.g. attention, psychomotor speed to language, construction to executive)language, construction to executive)

•• Regional (temporal, parietal, frontal)Regional (temporal, parietal, frontal)•• IllnessIllness--based (based (AlzAlz, , sczscz, FTD, , FTD, subcorticalsubcortical) )

/ targeted/ targeted

From Bedside to From Bedside to Neuropsychological TestingNeuropsychological Testing

•• Cognitive testing items vary in their degree Cognitive testing items vary in their degree of “bluntness” of dissection of of “bluntness” of dissection of neuropsychological functionsneuropsychological functions

•• E.g. memoryE.g. memoryrecall of three objects recall of three objects -- bluntbluntrecall of brief story/passagerecall of brief story/passage -- mediummediumpaired associate learningpaired associate learning -- finefine

•• The finer the item, the more sensitive, The finer the item, the more sensitive, specific and reliablespecific and reliable

•• Beware of assuming a blunt tool is fineBeware of assuming a blunt tool is fine

Distributed FunctionDistributed Function

•• Cognitive testing tends to focus on Cognitive testing tends to focus on functions performed by functions performed by relativelyrelativelyspecific zones of the brainspecific zones of the brain

•• These zones are not entirely These zones are not entirely independent; they are semiindependent; they are semi--independent, and interindependent, and inter--dependent dependent

•• Example: memory (frontal), calculation Example: memory (frontal), calculation to command (language), praxis to command (language), praxis ((interhemisphericinterhemispheric))

SUGGESTEDSUGGESTEDAPPROACHAPPROACH

BASIC BEDSIDE (blunt)BASIC BEDSIDE (blunt)(ALWAYS DO AT LEAST ONE)(ALWAYS DO AT LEAST ONE)

BEYOND BEDSIDE (medium)BEYOND BEDSIDE (medium)(DO IF ABNORMALITIES IN BASIC TESTING, OR IF TIME AVAIL)(DO IF ABNORMALITIES IN BASIC TESTING, OR IF TIME AVAIL)

NEUROPSYCHOLOGICAL (fine)NEUROPSYCHOLOGICAL (fine)(BE AWARE OF & ABLE TO TALK ABOUT THEIR ROLE)(BE AWARE OF & ABLE TO TALK ABOUT THEIR ROLE)

ATTENTIONATTENTION

Attention: Basic BedsideAttention: Basic Bedside

•• Serial 7’s Serial 7’s –– in the MMSE; difficult for in the MMSE; difficult for elderly/poorly numerate; intact elderly/poorly numerate; intact dominant parietal lobe required; dominant parietal lobe required; familiar word backwards familiar word backwards –– betterbetter

•• OverlearnedOverlearned sequence in reverse sequence in reverse (days of week, months of year)(days of week, months of year)

•• Orientation Orientation –– time is most sensitive, time is most sensitive, espesptime of day and duration of stay in time of day and duration of stay in hospital; date v. unreliablehospital; date v. unreliable

Attention: Beyond BedsideAttention: Beyond Bedside

•• Digit span Digit span –– less dependent on less dependent on memory (other than WM). Normally 6 memory (other than WM). Normally 6 ±1. Reverse span usually one less ±1. Reverse span usually one less usually one lessusually one less–– Be aware that forward span ends to test Be aware that forward span ends to test

freedom from distractibility, reverse tests freedom from distractibility, reverse tests working memoryworking memory

–– Anxiety may reduce score but disappears Anxiety may reduce score but disappears with practicewith practice

Attention: NeuropsychologicalAttention: Neuropsychological

•• Letter/star cancellation tests* Letter/star cancellation tests* -- also also useful for inattentionuseful for inattention

•• PASAT PASAT –– paced auditory serial addition paced auditory serial addition test; set of digits at different speeds test; set of digits at different speeds that subject has to name (2that subject has to name (2--88--66--11--9 9 becomes 10..14…7..10..); v. useful in TBIbecomes 10..14…7..10..); v. useful in TBI

Attention: NeuropsychologicalAttention: Neuropsychological•• Digit symbol tests (e.g. Symbol Digit Modalities Test)Digit symbol tests (e.g. Symbol Digit Modalities Test)--

has key of symbols, patient required to fill in spaces has key of symbols, patient required to fill in spaces according to key. Good measure of psychomotor according to key. Good measure of psychomotor speed, used in MS. Also speed, used in MS. Also reqsreqs visual searching, new visual searching, new learninglearning

VISUOSPATIALVISUOSPATIAL

VisuospatialVisuospatial: Basic Bedside: Basic Bedside

•• Drawing reproduction Drawing reproduction –– simple to more simple to more complex figurescomplex figures

•• Praxis Praxis –– limb, trunk, limb, trunk, buccalbuccal (different (different tracts)tracts)

•• L/R orientation (patient, yours, crossed)L/R orientation (patient, yours, crossed)•• Clock drawing Clock drawing –– correct number correct number

placement, drawing hands to placement, drawing hands to commandcommand

VisuospatialVisuospatial: Beyond Bedside: Beyond Bedside

•• Calculation Calculation –– simple, difficult, simple, difficult, conceptual; written or verbalconceptual; written or verbal

•• SomatosensorySomatosensory neglect neglect -- extinctionextinction•• Line bisectionLine bisection•• Copying flower (doubleCopying flower (double--header)header)•• Drawing a house, bicycleDrawing a house, bicycle

VisuospatialVisuospatial: : NeuropsychologicalNeuropsychological

•• BenderBender--Gestalt test Gestalt test ––also has projective also has projective qualities; nine figures to qualities; nine figures to be reproduced. be reproduced. Hundreds of different Hundreds of different scoring systems exist. scoring systems exist. Sensitive to R par. Sensitive to R par. lesionslesions

VisuospatialVisuospatial: : NeuropsychologicalNeuropsychological

•• Complex figure of Complex figure of ReyRey (…Taylor, etc). Scoring systems; also (…Taylor, etc). Scoring systems; also timed. Can be used qualitatively to compare L timed. Can be used qualitatively to compare L vsvs R lesions, R lesions, and frontal impairmentand frontal impairment

Taylor FigureTaylor Figure

•• Block designBlock design: part of the WAIS, simple to : part of the WAIS, simple to complexcomplex

MEMORYMEMORY

Memory: Basic BedsideMemory: Basic Bedside

•• Recalling three items; one or twoRecalling three items; one or two--stage stage cueing; unrelated words best. Standard cueing; unrelated words best. Standard deviation in deviation in normalsnormals significant (0.8 of 3significant (0.8 of 3--4 4 words over 10 min). Cueing suggests words over 10 min). Cueing suggests retrieval retrieval vsvs storage problemstorage problem

•• Remote memory & fund of knowledgeRemote memory & fund of knowledge•• AppleApple--tabletable--penny copyrighted!penny copyrighted!•• Reproducing drawing after delayReproducing drawing after delay•• L L vsvs R hemispheric storage verbal R hemispheric storage verbal vsvs spatialspatial

Memory: Beyond BedsideMemory: Beyond Bedside

•• Verbal: story to immediate recall (it Verbal: story to immediate recall (it wsawsa julyjuly/and the Rogers/had packed /and the Rogers/had packed up/their four children/in the station up/their four children/in the station wagon/and were off/on vacation)wagon/and were off/on vacation)

•• Spatial Spatial –– hidden objects; found & hidden objects; found & namednamed

Memory: NeuropsychologicalMemory: Neuropsychological

•• WMSWMS--R R –– Wechsler Memory Scale; battery Wechsler Memory Scale; battery most frequently administered. Paragraph most frequently administered. Paragraph recall, paired associates, visual pairs, visual recall, paired associates, visual pairs, visual design reproduction; visual digit spandesign reproduction; visual digit span

•• RAVLT RAVLT –– ReyRey Auditory Verbal Learning Test Auditory Verbal Learning Test ––word lists learnt; documents primacy and word lists learnt; documents primacy and recencyrecency effects, interference, intrusion, effects, interference, intrusion, confabultationconfabultation

•• Benton Visual Retention Test Benton Visual Retention Test –– recall of line recall of line drawings after brief delaydrawings after brief delay

EXECUTIVEEXECUTIVE

Executive: Basic BedsideExecutive: Basic Bedside

•• Proverbs Proverbs –– abstraction abstraction vsvsconcreteness. Be aware of cultural concreteness. Be aware of cultural and epoch biases. Similarities & and epoch biases. Similarities & differences betterdifferences better

•• Motor sequencing Motor sequencing –– LuriaLuria 33--stepstep•• Categorical fluency Categorical fluency –– naming animals; naming animals;

1818--2222

Executive: Beyond BedsideExecutive: Beyond Bedside

•• Inhibition & interference Inhibition & interference –– gogo--nono--gogo•• FAS from the Controlled Oral Word FAS from the Controlled Oral Word

Association test (COWA) Association test (COWA) –– three onethree one--minute trials, minute trials, exlucingexlucing plurals/proper plurals/proper nouns. ~15 for each; total <30 nouns. ~15 for each; total <30 definitely abnormaldefinitely abnormal

•• Written sequencingWritten sequencing

Executive: NeuropsychologicalExecutive: Neuropsychological•• Trails A & B (from HalsteadTrails A & B (from Halstead--ReitanReitan battery); battery);

must shift set in part B must shift set in part B –– sensitive to frontal sensitive to frontal impairmentimpairment

•• Wisconsin Card Sorting Test Wisconsin Card Sorting Test –– tests settests set--shifting; one of four symbols printed in one of shifting; one of four symbols printed in one of four four colourscolours on cards and match to stimulus on cards and match to stimulus cards according to principles. Good for left cards according to principles. Good for left frontal lesions. Subject places pack of 64 frontal lesions. Subject places pack of 64 cards in four piles under 4 stimulus cards cards in four piles under 4 stimulus cards according to principles, that must detect according to principles, that must detect from examiner’s responsesfrom examiner’s responses

•• Raven’s Progressive Matrices Raven’s Progressive Matrices –– test of test of general intellectual ability; initially pattern general intellectual ability; initially pattern matching, then problem solving. In matching, then problem solving. In absence of absence of visuospatialvisuospatial deficits, tests deficits, tests executive executive functionfunction

StroopStroop EffectEffect•• StroopStroop –– it’s all about it’s all about

interferenceinterference•• Both congruent and Both congruent and

incongruent conditions incongruent conditions presentedpresented

•• Incongruent > Incongruent > congruent latencycongruent latency

•• Try it online:Try it online:•• www.dcity.org/braingawww.dcity.org/brainga

mes/stroopmes/stroop

•• CLOX TESTCLOX TEST•• RoyallRoyall et al et al –– JNNP 64: 588JNNP 64: 588--

594, 1998594, 1998•• Scored version of simple Scored version of simple

clockfaceclockface (insert numbers, (insert numbers, place hands)place hands)

•• To discriminate between To discriminate between executive impairment & executive impairment & nonnon--executive consexecutive cons--tructionaltructional impairmtimpairmt

A TALE OF NINE CLOCKSA & B - dementa with prominent frontal deficits

C – early dementia

D & E – frontal dementia

F – moderate Alzheimer’s

G – vascular dementia & neglect

H - cerebellar stroke

I – Pick’s disease

LANGUAGELANGUAGE

Language: Basic BedsideLanguage: Basic Bedside

•• Reading & comprehension Reading & comprehension –– written written and verbal, simple and complexand verbal, simple and complex

•• Repetition of words, phrases, Repetition of words, phrases, sentences (simple to complex, sentences (simple to complex, common to rare)common to rare)

•• Writing to command/spontaneousWriting to command/spontaneous

Language: Beyond BedsideLanguage: Beyond Bedside

•• Naming to confrontation; high and low Naming to confrontation; high and low frequencyfrequency

•• WordWord--finding (subjective)finding (subjective)•• Conceptual Conceptual –– “is a ball square?”; “if “is a ball square?”; “if

the lion is killed by the tiger, which one the lion is killed by the tiger, which one survives?”survives?”

Language: NeuropsychologicalLanguage: Neuropsychological

•• Boston Naming Test Boston Naming Test –– identifying 60 identifying 60 large drawings large drawings –– from tree & pencil from tree & pencil through to sphinx & trellis through to sphinx & trellis –– sensitive to sensitive to aphasicsaphasics

•• Aphasia batteries such as Multilingual Aphasia batteries such as Multilingual Aphasia Examination (MAE), Boston Aphasia Examination (MAE), Boston battery use validated battery use validated normednormed versions versions of most above tasksof most above tasks

COGNITIVE SCREENING & COGNITIVE SCREENING & ASSESSMENT TOOLSASSESSMENT TOOLS

AMTS/MSQAMTS/MSQ

•• Standard emergency dept test Standard emergency dept test –– ten ten items; relies heavily on memory/ items; relies heavily on memory/ orientationorientation

•• Good testGood test--retest reliabilityretest reliability•• Not particularly sensitive or specificNot particularly sensitive or specific•• Misses range of other cognitive Misses range of other cognitive

functions/disordersfunctions/disorders

MiniMini--Mental State ExaminationMental State Examination

•• MiniMini--Mental Status Examination: developed Mental Status Examination: developed by by FolsteinFolstein & & FolsteinFolstein in 1975in 1975–– widely used in medical settings widely used in medical settings –– available in number of languagesavailable in number of languages–– widely used in research including ECA as part of widely used in research including ECA as part of

DISDIS

•• Developed to differentiate functional from Developed to differentiate functional from organic illness in psychiatric patients. organic illness in psychiatric patients.

•• UUnitarynitary measure made up of 30 itemsmeasure made up of 30 items•• Generally administered in under ten Generally administered in under ten

minutes; portable & easy to administerminutes; portable & easy to administer

MiniMini--Mental State ExaminationMental State Examination

•• LLimitations, imitations, –– unitary measure, limited testing of many unitary measure, limited testing of many

cognitive spheres, lack of executive function cognitive spheres, lack of executive function testing, lack of graded scoringtesting, lack of graded scoring

–– American Neuropsychiatric Association American Neuropsychiatric Association recommends supplementrecommends supplementationation with spatial with spatial functions, delayed recall & executive function functions, delayed recall & executive function testingtesting

•• Significant ceiling effects; significant age & Significant ceiling effects; significant age & educationeducation--related biases; lack of related biases; lack of standardised instructionsstandardised instructions

RMH Neuropsychiatry Unit Mini-Mental State Exam (After Folstein, Folstein & McHugh, 1975.)

What is the: year, season, date, day, month? ___/5 What: country, state, town, hospital, ward are we in? ___/5 Name 3 objects (apple, table, penny), one second apart; ask subject to recall all three after you have said them. One point for each correct answer. Then repeat until subject learns all three. ___/3 Ask subject to subtract 7 from 100, and provide the answer, then continue to subtract 7 from each answer given five times. (93, 86, 79, 72, 65). Score one point for each correct answer. Alternatively, or if subject unable to undertake serial 7's, ask to spell word WORLD backwards (spell it forwards first), with one mark for each correct letter. ___/5 Ask subject to recall 3 objects, one point for each recalled. ___/5 Ask subject to name your watch and pen/pencil. ___/2 Ask subject to repeat: “No ifs, ands or buts”. ___/1 “Pick up this piece of paper with your right hand, fold it in half, and place it in your lap.” ___/1 Ask patient to read & obey the following:

CLOSE YOUR EYES. ___/1 Ask patient to write a sentence – of their choice, containing a noun & verb, below.

___/1 Ask patient to copy this design in the space to its right. ___/1

TOTAL SCORE ___/30

Name: ………………………………………………………….. Date: …./…./…. UR: ………………………. Examiner: …………………………………………………….

NCSENCSE

•• Neurobehavioral Cognitive Screening Neurobehavioral Cognitive Screening ExaminationExamination ((Kiernan et al in 1987Kiernan et al in 1987))

•• EEightight years of experience in Cyears of experience in C--L role to L role to neurosurgical unitneurosurgical unit

•• Designed to address issues with MMSE & Designed to address issues with MMSE & other toolsother tools–– introduced multiintroduced multi--dimensional scoring & dimensional scoring &

screen’n’metricscreen’n’metric approachapproach–– standardized instructionsstandardized instructions

•• “P“Patternattern” of cognitive function across ” of cognitive function across multiple domains taps into key medical skill multiple domains taps into key medical skill of patternof pattern--matching matching

NCSENCSE

•• LimitationsLimitations–– Screen & metric approach Screen & metric approach hashas lack of lack of

specificity & suitability of screen items specificity & suitability of screen items –– ??estimates of brevity claimed by authorsestimates of brevity claimed by authors

•• NCSE in psychiatric populations NCSE in psychiatric populations –– limited specificity and poor predictive limited specificity and poor predictive

power as regards presence of cognitive power as regards presence of cognitive disturbance, whilst retaining moderate disturbance, whilst retaining moderate sensitivitysensitivity

ACEACE

•• AddenbrookeAddenbrooke Cognitive ExaminationCognitive Examination•• Published by Cambridge team 2000 Published by Cambridge team 2000

((BerriosBerrios, , MathuranathMathuranath, Nestor, Hodges), Nestor, Hodges)•• Includes MMSE as well as more Includes MMSE as well as more

extensive language, visuospatial & extensive language, visuospatial & memory testingmemory testing

•• Scores out of 100 & score out of 30Scores out of 100 & score out of 30•• Limited executive function testingLimited executive function testing

ACEACE

FABFAB

•• Frontal Assessment Battery published in 2000 Frontal Assessment Battery published in 2000 by by SaltpetriereSaltpetriere group (Dubois et al)group (Dubois et al)

•• Includes common bedside cognitive Includes common bedside cognitive function tests function tests inclincl sequencing, interference, sequencing, interference, inhibition, similarities, verbal fluencyinhibition, similarities, verbal fluency

•• Very much like the executive scale of the Very much like the executive scale of the NuCOGNuCOG! !

•• NUCOG is both ACE & FABNUCOG is both ACE & FAB

CAMDEXCAMDEX•• art of the CAMDEX (Roth et al, Cambridge art of the CAMDEX (Roth et al, Cambridge

University) University) –– specifically designed for the specifically designed for the diagnosis of dementia in the elderly; diagnosis of dementia in the elderly; incorporates the MMSE within the batteryincorporates the MMSE within the battery

•• Advantages: sensitive and specific, high Advantages: sensitive and specific, high interinter--rater reliability, sensitive to mild degrees rater reliability, sensitive to mild degrees of dementia, good detection of impairment of dementia, good detection of impairment across all spheresacross all spheres

•• Disadvantages: not as widely available, Disadvantages: not as widely available, some floor effects, poorly sensitive to frontal some floor effects, poorly sensitive to frontal lobe dysfunction, impaired abstraction or lobe dysfunction, impaired abstraction or attentionattention

•• Less Less generalizablegeneralizable to treatment populations to treatment populations other than the elderly/dementedother than the elderly/demented

ADASADAS--COGCOG

•• DementiaDementia--specific, 21specific, 21--item test item test designed to detect classical areas of designed to detect classical areas of deficit in SDAT (memory, orientation, deficit in SDAT (memory, orientation, language, praxis). Scores out of 70 language, praxis). Scores out of 70 (cognitive) and 50 (non(cognitive) and 50 (non--cognitive cognitive ––mood, behaviour), and monitors mood, behaviour), and monitors change with less floor/ceiling effectschange with less floor/ceiling effects

Neuropsychological Tests of Neuropsychological Tests of Intelligence/IQIntelligence/IQ

•• WAIS WAIS –– battery multiple performance & battery multiple performance & verbal subtests to yield Fullverbal subtests to yield Full--Scale IQ. General Scale IQ. General knowledge, comprehension, arithmetic, knowledge, comprehension, arithmetic, similarities, digit span, vocabulary, digit similarities, digit span, vocabulary, digit symbol, picture completion, block design, symbol, picture completion, block design, picture arrangement, object assessmentpicture arrangement, object assessment

•• NART NART –– developed by Nelson & O’Connell as developed by Nelson & O’Connell as measure of measure of premorbidpremorbid IQ when IQ when deterioration expected (e.g. early SADT). 50 deterioration expected (e.g. early SADT). 50 irregular words, graded frequency; for IQ 90irregular words, graded frequency; for IQ 90--130130

NEUROPSYCHIATRY UNITNEUROPSYCHIATRY UNITINSTRUMENTSINSTRUMENTS

(Test (Test –– Talk Talk –– Watch)Watch)

NUCOGNUCOG

•• 1515--20 minutes complete20 minutes complete•• Includes MMSE patchIncludes MMSE patch•• 5 domains 5 domains –– attention, memory, attention, memory,

executive, language, executive, language, visuoconstructionalvisuoconstructional

•• Cognitive profileCognitive profile

NUCOG ScheduleNUCOG Schedule

NUCOG ScoringNUCOG Scoring

NUCOG Subject SheetNUCOG Subject Sheet

NUCOG Cognitive ProfileNUCOG Cognitive Profile

The NUCOG “Patch”The NUCOG “Patch”

•• Designed to allow Designed to allow MMSEMMSE--equivalent score equivalent score to be extracted from to be extracted from NUCOGNUCOG

•• Two additional items Two additional items asked, takes <3 asked, takes <3 minutes, provides minutes, provides MMSE scoreMMSE score

•• Possible to score 30 on Possible to score 30 on MMSE & have MMSE & have significant NUCOG significant NUCOG deficitsdeficits

NUCOG.COMNUCOG.COM

Case OneCase One

•• 22 year old student with catatonic state22 year old student with catatonic state•• Preceding history of presumed encephalitis, Preceding history of presumed encephalitis,

supported by MRI & EEG data supported by MRI & EEG data –– left (dominant) left (dominant) temporotemporo--parietal regionparietal region

•• No pathogen identifiedNo pathogen identified•• Initially mute, catatonic & psychotic Initially mute, catatonic & psychotic ––

occasional aggressionoccasional aggression•• As recovered As recovered –– significant residual significant residual

organisationalorganisational & expressive language difficulties& expressive language difficulties

Case One ProfileCase One Profile

Case Two ProfileCase Two Profile

•• 49 year old executive 49 year old executive with impairment in work with impairment in work function necessitating function necessitating stopping workstopping work

•• Significant reductions in Significant reductions in all areas of executive all areas of executive functionfunction

•• Family history Family history –– father & father & paternal uncle paternal uncle –– early early onset onset dementingdementing illnessillness

•• MMSE score of 30/30MMSE score of 30/30

Case Three ProfileCase Three Profile

•• 52 year old 52 year old hypertensive chronic hypertensive chronic alcoholic malealcoholic male

•• Previous dysphasia Previous dysphasia following CVA 2y agofollowing CVA 2y ago

•• Recent R MCA infarct Recent R MCA infarct ––neglect, impaired neglect, impaired spatial memory, spatial memory, constructional constructional dyspraxiadyspraxia; overlaid on ; overlaid on marked disinhibition & marked disinhibition & perseverationperseveration

Case Four ProfileCase Four Profile•• 81 year old woman 81 year old woman

with prior R MCA with prior R MCA aneurysm clipping, aneurysm clipping, presenting with global presenting with global cognitive impairment cognitive impairment +/+/-- ?acute ischemic ?acute ischemic eventevent

•• CT showing CT showing widespread vascular widespread vascular pathology cortically & pathology cortically & subcorticallysubcortically

•• Marked Marked perseverationperseverationon most tests on most tests

COGRISKCOGRISK

BATCHBATCH

EXAMINATIONEXAMINATIONISSUESISSUES

Not Enough TimeNot Enough Time

•• Strategy if you run out: something general Strategy if you run out: something general (orientation), something high(orientation), something high--yield (clock yield (clock face), something illness specific; also discuss face), something illness specific; also discuss obervationalobervational data (general knowledge, data (general knowledge, vocabulary, recall of recent/remote history vocabulary, recall of recent/remote history etc)etc)

•• Discuss what you would have liked to have Discuss what you would have liked to have done, and whydone, and why

•• Generally not excusable in the highGenerally not excusable in the high--risk for risk for cognitive impairment (elderly, clearly cognitive impairment (elderly, clearly dementingdementing, , neurodegenneurodegen disorders)disorders)

Complex PatientComplex Patient

•• Difficulty where obvious evidence of Difficulty where obvious evidence of psychiatric disability (e.g. depression, psychiatric disability (e.g. depression, psychosis) copsychosis) co--incident with significant incident with significant impairment (e.g. executive dysfunction, impairment (e.g. executive dysfunction, memory impairment)memory impairment)

•• Best approach is to hold two chief Best approach is to hold two chief possibilities possibilities –– cognitive impairment related to cognitive impairment related to disease (intrinsic, medication, ECT), or is codisease (intrinsic, medication, ECT), or is co--morbid; be prepared to discuss bothmorbid; be prepared to discuss both

Quantitative Quantitative vsvs QualitativeQualitative

•• Important skill of psychiatrist Important skill of psychiatrist –– to to integrate findings from all spheres of integrate findings from all spheres of assessmentassessment

•• NEVER rely on numbers alone; NEVER rely on numbers alone; qualitative data MORE importantqualitative data MORE important

•• E.g. young male with first psychosis E.g. young male with first psychosis MMSE 19/30 MMSE 19/30 –– is he demented?is he demented?

Blunt DissectionsBlunt Dissections

•• Be aware of the limitations of the tools you Be aware of the limitations of the tools you are using; their specificity and sensitivityare using; their specificity and sensitivity

•• Most cognitive tools in clinical practice have Most cognitive tools in clinical practice have limitations and are relatively bluntlimitations and are relatively blunt

•• Important to be aware of role and necessity Important to be aware of role and necessity for further neuropsychological assessmentfor further neuropsychological assessment

•• When neuropsychological assessment When neuropsychological assessment required required –– a set of key questions is useful: “is a set of key questions is useful: “is this the pattern of memory impairment seen this the pattern of memory impairment seen in chronic alcoholism?” “is this man’s poor in chronic alcoholism?” “is this man’s poor motivation and motivation and organisationalorganisational difficulty difficulty indicative of frontal lobe disease?”indicative of frontal lobe disease?”

Pretend Neuropsychological Pretend Neuropsychological TestingTesting

•• At least one examiner’s bugbear!At least one examiner’s bugbear!•• Examples Examples –– using Trails or complex using Trails or complex

figures without following standard rules figures without following standard rules or test designs; then assuming that or test designs; then assuming that “test’s poor cousin” performs as well as “test’s poor cousin” performs as well as the test itselfthe test itself

Taking a Cognitive “History”Taking a Cognitive “History”

•• One other examiner: candidates more One other examiner: candidates more likely to ask about ideas of selflikely to ask about ideas of self--harm harm than about leaving the gas on in atthan about leaving the gas on in at--risk risk patientspatients

•• Taking a basic cognitive systems Taking a basic cognitive systems review is often neglected; beware the review is often neglected; beware the “pseudo“pseudo--impaired”/overimpaired”/over--reporting reporting patient (somatoform, anxiety, patient (somatoform, anxiety, depressed, personality variables)depressed, personality variables)

““Functional” Syndromes & Functional” Syndromes & Cognitive ImpairmentCognitive Impairment

•• Many “functional” syndromes have Many “functional” syndromes have cognitive concomitantscognitive concomitants

•• Dementia Dementia vsvs depressiondepression•• Depression Depression –– reduced processing reduced processing

speed, attentional functionspeed, attentional function•• Schizophrenia Schizophrenia –– reduced global reduced global

function, (spatial) working memory, function, (spatial) working memory, dysexecutivedysexecutive functionfunction

Integration (Or Lack Thereof)Integration (Or Lack Thereof)

•• Integration of cognitive findings into history, Integration of cognitive findings into history, mental state examination, and physical mental state examination, and physical examination criticalexamination critical

•• Role of psychiatrist in most settings is Role of psychiatrist in most settings is uniquely uniquely integrationalintegrational –– the buck often stops the buck often stops with you! Examiners will expect you to play with you! Examiners will expect you to play this rolethis role

•• Try to understand, not just report, your Try to understand, not just report, your cognitive findings. How do you understand cognitive findings. How do you understand its origins? How does it relate to their mental its origins? How does it relate to their mental illness? What does it mean for treatment illness? What does it mean for treatment planning? planning?

The Role of BaselineThe Role of Baseline

•• Understanding of baseline (inferred from Understanding of baseline (inferred from work history, vocabulary, education, work history, vocabulary, education, presentation) criticalpresentation) critical

•• HighHigh--flyer who may present well crossflyer who may present well cross--sectionallysectionally but be significantly declined; but be significantly declined; beware as you are not allowed access to beware as you are not allowed access to the informant!the informant!

•• The chronically cognitively impaired person The chronically cognitively impaired person who presents crosswho presents cross--sectionallysectionally poor but may poor but may have “been like this for many years” have “been like this for many years” –– e.g. e.g. mild mental retardation, developmental mild mental retardation, developmental disordersdisorders

SemiSemi--independence of Domainsindependence of Domains

•• Most cognitive functions are Most cognitive functions are distributed to a significant degreedistributed to a significant degree

•• Function does not necessarily equal Function does not necessarily equal locationlocation

•• Understanding component functions Understanding component functions of any item or domain critical; of any item or domain critical; undertaking range of items will allow undertaking range of items will allow for pattern to appearfor pattern to appear

Regional Regional SpecialisationSpecialisation

•• L/R L/R -- left hemisphere specialized for left hemisphere specialized for language & processing verbally coded language & processing verbally coded information (regardless of how info information (regardless of how info acquired); right hemisphere processes acquired); right hemisphere processes primarily nonverbal information primarily nonverbal information –– faces, faces, music music -- & feeling states, as well as & feeling states, as well as perception of bodies in space perception of bodies in space (intra/(intra/extrapersonalextrapersonal))

•• Posterior portions dedicated to perception Posterior portions dedicated to perception of body & world beyond it; anterior portions of body & world beyond it; anterior portions comprise comprise effectoreffector systems, specialized for systems, specialized for execution of behaviourexecution of behaviour

Patterns of SyndromesPatterns of Syndromes

•• SubcorticalSubcortical vsvs cortical cortical –– processing processing speed, frontal despeed, frontal de--afferentiationafferentiation, , extrapyramidalextrapyramidal signssigns

•• LBD LBD –– course course specifiersspecifiers & psychosis& psychosis•• Dementia in other disorders (MS, ETOH)Dementia in other disorders (MS, ETOH)

The Good Candidate…The Good Candidate…

•• …… integrates into possible integrates into possible DDxDDx or Rx or Rx implications implications

•• …understands regional syndromes & …understands regional syndromes & lateralitylaterality

•• …understands how different disorders …understands how different disorders present different patternspresent different patterns

•• …understands limitation of their assessment…understands limitation of their assessment•• …understands cognitive risk factors…understands cognitive risk factors•• …understands the role of …understands the role of neuropsychologyneuropsychology

The Poor Candidate…The Poor Candidate…

•• ……doesn’t do (enough) cognitive doesn’t do (enough) cognitive assessmentassessment

•• …focuses on “the numbers”…focuses on “the numbers”•• …doesn’t integrate findings into other …doesn’t integrate findings into other

elements of the assessmentelements of the assessment•• …the opposite of everything in the …the opposite of everything in the

previous slideprevious slide

SOME GOOD SOME GOOD REFERENCESREFERENCES

The Mental Status Examination in Neurology, 3rd

edition

Strub RL, Black FW

FA David & Co, Philadelphia, 1993

ISBN: 0-8036-8212-3

StrubStrub & Black& Black

HodgesHodges

Cognitive Assessment for Clinicians

Hodges JR

Oxford University Press, Oxford, 1994

ISBN: 0-1926-2394-X

TakeTake--Home MessagesHome Messages

•• Have a suite of cognitive tools, Have a suite of cognitive tools, understand their limitationsunderstand their limitations

•• Practice your assessments, present Practice your assessments, present them frequently, and get used to the them frequently, and get used to the “act of integration”“act of integration”

•• PeacePeace

Our SponsorsOur Sponsors