Transcript MRCPsych workshop Bedside cognitive assessment Dr R Noad

MRCPsych Training Programme
Bedside Cognitive Assessment – a
practical workshop
Thursday 7th March, 2012
Dr Rupert Noad
Department of Neuropsychology, Derriford Hospital, Plymouth
[email protected]
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
Where might ‘brain variables’ inform your
psychiatric/psychological formulation?
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
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 approach
Brain disorders are complex involving triad of:
• Physical
• Cognitive
• Emotional
But
Many other secondary consequences
e.g. family dynamics, loss that can
underpin individuals’ difficulties
Biological
Psychological
Social
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…
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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
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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
cognition
5 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/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
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
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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
BCAT – Episodic Memory
• Name and Address:
– Linda Clark
59 Meadow Close
Milford
Surrey
• 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:
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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:
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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
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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
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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 apraxia
In clinic
Does 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)
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.
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/Neglect
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/Anosognosia
In its most profound form, patients deny the presence of
hemiplegia despite evidence to the contrary.
BCAT – Neglect
• Clock Drawing
• Image Copy
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.
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
Psychological
Social
Can you remember?...
• The name and address
• The list of words
• The three figures you copied
Great Resources
• 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.
Thank You
Any questions?