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5th Congress of the European Academy of Neurology
Oslo, Norway, June 29 - July 2, 2019
Teaching Course 18
Testing of cognitive functions by the neurologist (Level 1)
Testing cognitive functions with a view on anatomy
Armin Schnider Geneva, Switzerland
Email: [email protected]
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Testing cognitive functions
with a view on anatomy
Armin Schnider, MD
Chairman, Division of Neurorehabilitation
University Hospitals of Geneva / Switzerland
EAN 2019, Oslo
Teaching Course 18:
Testing of cognitive functions by the neurologist
EAN 2019, Oslo Teaching Course 18
Testing of cognitive functions by the neurologist
Testing cognitive functions with a view on anatomy
Armin Schnider, Geneva, Switzerland
Clinical dementia testing: methods and meaning
Eric Salmon, Liège, Belgium
How to explore confused patients
Jacques Luauté, Lyon, France
When standardized neuropsychological testing is needed
Lisa Cipolotti, London, UK
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Testing cognitive functions
with a view on anatomy
I have
nothing to declare
Armin Schnider, MD
Chairman, Division of Neurorehabilitation
University Hospitals of Geneva / Switzerland
EAN 2019, Oslo
Teaching Course 18:
Testing of cognitive functions by the neurologist
Focal cognitive disorders
L frontal lobe syndromes
distractability, perseveration, ...
hyperverbali-
R
lack of drive sation
aphasia
alexia
agraphia
1 hemispatial
neglect
apraxia 2 acalculia
amnesia
4
visuoconstructive 2 failures
finger agnosia
R-L-confusion 3 topographagnosia
object agnosia prosopagnosia
color agnosia
visual recognition failures
Schnider A.
Verhaltensneurologie,
2. Aufl. Thieme, 2004
Neurologie du
Comportement.
Elsevier-Masson, 2008
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not good good
Writing (first name)
Reticular
formation
& ARAS
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Tests of attention
Service de Neurorééducation Département des neurosciences cliniques
Digit span "Serial 7's" Spelling bckwd: "WORLD"
Situation Time Place
Perseveration
good
Luria's loops
not good
Luria's alternating
sequences
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Frontal haemorrhage
R L
Focal cognitive disorders
L frontal lobe syndromes
distractability, perseveration, ...
hyperverbali-
R
lack of drive sation
aphasia
alexia
agraphia
1 hemispatial
neglect
apraxia 2 acalculia
amnesia
4
visuoconstructive 2 failures
finger agnosia
R-L-confusion 3 topographagnosia
object agnosia prosopagnosia
color agnosia
visual recognition failures
Schnider A.
Verhaltensneurologie,
2. Aufl. Thieme, 2004
Neurologie du
Comportement.
Elsevier-Masson, 2008
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Frontal failure: Grasping
„Do nothing with your hands.“
Schnider A. Verhaltensneurologie. Thieme 1997
Cognitive perseveration
Perseveration - 2 Perseveration - 1 Model
Motor perseveration
New task
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Severe amnesia Frontal lobe dysfunction normal
(≥12/min)
Word production, "verbal fluency"
(Words starting with "S", "A" … but no proper names of people or places)
Traumatic brain injury Frontal dementia
Figural fluency – Production of ideas – 5 point test (Regard)
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Figural fluency – Production of ideas – 5 point test (Regard)
Traumatic brain injury
Isolated personality change after frontopolar lesion
Schnider A. Verhaltensneurologie. Thieme 1997/2004 - Neurologie du Comportement. Masson-Elsevier 2008
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Frontal Tests
Service de Neurorééducation Département des neurosciences cliniques
Describe your observations !
Stroop
Verbal fluency
5-point (Regard)
Proverb interpr.
Alternating seq.: Luria's loops
Category fluency
Language-associated disorders
L frontal lobe syndromes
distractability, perseveration, ...
hyperverbali-
R
lack of drive sation
aphasia
alexia
agraphia
1 hemispatial
neglect
apraxia 2 acalculia
amnesia
4
visuoconstructive 2 failures
finger agnosia
R-L-confusion 3 topographagnosia
object agnosia prosopagnosia
color agnosia
visual recognition failures
Schnider A.
Verhaltensneurologie,
2. Aufl. Thieme, 2004
Neurologie du
Comportement.
Elsevier-Masson, 2008
vis
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sp
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l dis
ord
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lan
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sso
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dis
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Fluent aphasia - Jargon (Wernicke’s aphasia)
Describe this picture, please.
Fluent aphasia - Jargon (Wernicke’s aphasia)
Describe this picture, please.
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Wernicke‘s aphasia: writing
“Write a sentence,please.”
“Write the word…”
“…‘électricité’ [electricity].”
“…‘hôpital’ [hospital].”
“…‘voiture’ [car].”
Testing language comprehension
Close your eyes.
Touch your nose.
Where is your left ear?
...
Where could I wash my hands?
...
Show me the door after showing me the ceiling
...
Touch your right ear with your left index finger.
Com
ple
xity
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Reading
If you easily succeed in
reading this text correctly,
then you have no alexia.
Aphasic alexia: according to the aphasia
Letter-by-letter reading: pure alexia (alexia without
agraphia)
Naming
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Ideomotor apraxia
Ideomotor apraxia: Body-part-as-object error (BPO)
„Show how you use a tooth brush.“
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Apraxia testing: Upper limbs
Transitive movements
• Use a toothbrush
• Use a comb
• Turn a key in a lock
• Throw a piece of money
• Open a bottle
• Use a screwdriver
Intransitive movements
• Signal bye-bye with your hand
• Hitchhike
• Indicate “hallo” from distance
• Greet like a soldier
• indicate “come here” with the
hand
• stop!
• vanish!
Language & associated functions
Calculation Finger recognition R/L-discrimination
Praxia
Reading Writing
Repetition
Comprehension
Naming
Spontaneous expr.
Verbal fluency Category fluency
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Left hemispatial neglect
Visuo-spatial disorders
L frontal lobe syndromes
distractability, perseveration, ...
hyperverbali-
R
lack of drive sation
aphasia
alexia
agraphia
1 hemispatial
neglect
apraxia 2 acalculia
amnesia
4
visuoconstructive 2 failures
Topograph-
finger agnosia agnosia
R-L-confusion 3
object agnosia prosopagnosia
color agnosia
visual recognition failures
Schnider A.
Verhaltensneurologie,
2. Aufl. Thieme, 2004
Neurologie du
Comportement.
Elsevier-Masson, 2008
vis
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Copying a cube: Hemispatial neglect
Copying a cube: Beginning Alzheimer’s dementia
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Clock drawing (hemispatial neglect)
"Write the digits of a clock and put the hands to 10 past 10."
Beginning Alzheimer’s Frontal ablation after TBI
Clock drawing
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Line cancellation
Line bisection
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Disturbed Gestalt perception (apperceptive agnosia)
74 yo. M, bilateral posterior brain damage after cardio-pulmonary arrest
“Soll das ein Wort sein?” ["Is this supposed to be a word?"]
“... Baum?” [… Tree?]
[House] “Haus”
Visual recognition disorders
L frontal lobe syndromes
distractability, perseveration, ...
hyperverbali-
R
lack of drive sation
aphasia
alexia
agraphia
1 hemispatial
neglect
apraxia 2 acalculia
amnesia
4
visuoconstructive 2 failures
finger agnosia
R-L-confusion 3 topographagnosia
object agnosia prosopagnosia
color agnosia
visual recognition failures
Schnider A.
Verhaltensneurologie,
2. Aufl. Thieme, 2004
Neurologie du
Comportement.
Elsevier-Masson, 2008
vis
uo
sp
atia
l dis
ord
ers
lan
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sso
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dis
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Disturbed Gestalt perception (apperceptive agnosia)
75 yo. F, right posterior stroke (hobby: painting)
Apperceptive agnosia sensu strictu
Right parietal / parieto-temporal / parieto-occipital lesion
(Severe form: bilateral lesion)
Stroke, inflammation, traumatic brain injury, hypoxia …
Apperceptive agnosia = failure of automatic extraction
(or closure) of visual forms
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Associative visual agnosia
Cortex 1994; 30: 445-457
Model Copy
L R
Left posterior stroke (M, 72 yrs)
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Reading
If you have no difficulty in
reading this text, you
have neither alexia nor
aperceptive agnosia.
63 yo. woman: misidentification of two select faces
L R
Right posterior stroke: Failure to recognize faces
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± OK. gestört ± .K.
Confusion of two faces
Nyffeler et al. Neurology 2001; 57: 556-7
Nyffeler et al. Neurology 2001; 57: 556-7 (“disturbed”, “O.K.”: in comparison to other faces)
± O.K. disturbed ± O.K. disturbed
Confusion of two faces (almost a prosopagnosia)
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Visual
"battery" handkerchief thunderstorm
Reading of
masked words
Kanisza (illusory contours)
Color naming
Street (fragmented
designs)
Poppelreuter (overlaid
drawings)
Famous faces
Masked animal
pictures
Schnider A.
Verhaltensneurologie,
2. Aufl. Thieme, 2004
Neurologie du
Comportement.
Elsevier-Masson, 2008
finger agnosia
R-L-confusion 3 topographagnosia
object agnosia prosopagnosia
color agnosia
visual recognition failures
visuoconstructive 2 failures
amnesia
4
apraxia 2 acalculia
hemispatial
neglect
1 aphasia
alexia
agraphia
sation lack of drive
R frontal lobe syndromes
distractability, perseveration, ...
hyperverbali-
L
Memory disorders
vis
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shoulder
duck
window
Verbal long term memory
Long delay free recall
(≥20') Cued recall
Learning trials 1-5 Recognition
2 3 4 5
Recent events:
Names of grand children:
The lazy version (only 5 words)
tulip
17
belt
Toyota
fog
normal
Rappel différé Copie
“Non-verbal” memory failures (Rey figure)
nombre insuffisant
d'éléments
rotation
confabulation
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Take home messages
1. Every patient is testable
2. Think about what you are testing
3. Just do it !
Focal cognitive disorders
L frontal lobe syndromes
distractability, perseveration, ...
hyperverbali-
R
lack of drive sation
aphasia
alexia
agraphia
1 hemispatial
neglect
apraxia 2 acalculia
amnesia
4
visuoconstructive 2 failures
finger agnosia
R-L-confusion 3 topographagnosia
object agnosia prosopagnosia
color agnosia
visual recognition failures
Schnider A.
Verhaltensneurologie,
2. Aufl. Thieme, 2004
Neurologie du
Comportement.
Elsevier-Masson, 2008
vis
uo
sp
atia
l dis
ord
ers
lan
gu
ag
e a
sso
cia
ted
dis
ord
ers
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Schnider A. Neuropsychology - Bedside approaches. In: Goldenberg G and Miller BL, eds.
Handbook of Clinical Neurology. Neuropsychology and Behavioral Neurology. Vol 88
(3rd series). Edinburgh: Elsevier Science, 2008, pp. 137-154.
[email protected]