Transcript Neurological Testing - The Cambridge MRCPsych Course

Neurological Testing
Dr Anna Adlam
Clinical Lecturer/Clinical Psychologist
University of East Anglia
5 November 2009
Overview
• Historical context
• Purpose of neurological/ neuropsychological
assessment
• Distributed cognitive functions - disorders &
tests
• Localised cognitive functions - disorders &
tests
• Cognitive & neuropsychiatric history taking
• Practise EMQs & MCQs
Historical context
Historical context
(see Benson, 1993;1996)
• Behavioural neurology
– Neuropsychiatry (see Martin, 2002; Kendler, 2005 for
discussion)
– Neuropsychology (brain-behaviour relationships, Benton,
2002)
• Three contributing avenues
– Clinical neuroscience
• Broca, Wernicke, & Geschwind studied language disorders
• First and second world war survivors with brain damage (e.g.,
Goldstein, 1939; Luria, 1973), Middle East (Larry Squire, today)
– Educational psychology
• Spearman (1904) and Binet & Simon (1908) developed tests of
“intelligence”.
– Cognitive psychology
• Animal studies, ‘normal’ participants, survivors of brain injury,
imaging studies (MRI, PET, DTI)
Purpose of neurological/
neuropsychological
assessment
Neuropsychological assessment
• Diagnosis
– Psychiatric vs. neurological symptoms, localise
lesions - BUT, now more sensitive neuroimaging
techniques
• Patient care
– Management, planning
• Treatment
– Identifying treatment needs
– Evaluation of treatment efficiency
• Research
• Forensic (e.g., medicolegal work)
Questions/areas that can be
assessed
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Is there evidence of cognitive/intellectual impairment?
Severity of cognitive impairments?
What is the likely diagnosis? Brain areas involved?
Predicted level of premorbid function?
Awareness of cognitive difficulty?
Strengths and weaknesses?
Changes over time: improvement or deterioration?
Comparison with others? (e.g., age)
Malingering?
How might this person be best supported at
school/home/work/on the ward?
• How might this person respond to ‘talking therapy’? (e.g.,
distractibility, attention/concentration, impulsivity, perseveration,
problem-solving, confabulation, planning, response to novel
situations, empathy, ability to generate alternatives etc.).
Distributed vs. localised
functions
Distributed vs. localised functions
• Distributed
– Bilateral involvement
• attention/concentration (reticular activating system - brain
stem/thalamus - prefrontal, & parietal areas)
• memory (limbic & frontal)
• executive function & social cognition (frontal lobe)
• Localised
– Lateralised lesions
• Left (dominant) hemisphere - e.g., spoken language,
reading, writing (aphasia), calculation (acalculia), higher
motor control (apraxia)
• Right (non-dominant) hemisphere - e.g., spatial attention
(neglect), visuo-perceptual skills (agnosia), prosodic
components of language (tone, melody, intonation)
Brain-behaviour relationship
Working memory;
Planning
Spatial attention
Emotion perception;
Set-shifting; Decision
making
Semantic & Episodic memory;
Higher order visuospatial
processing
Distributed cognitive functions
- Attention & arousal
Distributed functions (1)
Attention & Arousal
• Attention & arousal
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Arousal (wakefulness, responsivity)
Sustained attention (maintain attention)
Divided attention (respond to more than one task)
Selective attention (focus on one stimulus while
suppressing awareness of competing stimuli)
• e.g., driving a car while conversing with a
passenger and having to overtake
Disorders of Attention & Arousal
• Impairments in attention can lead to distractibility
(frontal or parietal damage)
• Marked impairments can lead to disorientation in
time/place
• Deficits in global attention at processing is referred to
as the acute confusional state (delirium)
– Transient (duration rarely exceeds weeks)
– If severe, consciousness is diminished due to depression of
basic arousal processes (ascending reticular activating
system)
• Attention deficits common in Alzheimer’s disease,
dementia with Lewy bodies, early stage Parkinson’s
disease, traumatic brain injury, and stroke.
Neuroanatomy of Attention & Arousal
Cortical areas
Thalamus
Prefrontal, posterior parietal, and
limbic areas (top-down)
Intralaminar and reticular nuclei
Dopaminergic, cholinergic, and
serotinergic pathways
Brain-stem
nuclei
Reticular formation, midline raphe,
locus coeruleus, and tegmental
nuclei (bottom-up)
Tests of Attention
• Orientation in time & place (also dependent on
episodic memory)
• Digit span esp. backwards (also dependent on
working memory)
• Recitation of months of the year or days of the week
backwards or serial subtraction of 7s (also working
memory component)
• Alternation tasks, such as Trails B (also executive
function)
• The Stroop Test of response inhibition (also executive
function)
• Test of Everyday Attention (standardised assessment)
Example: Test of Everyday Attention
Distributed cognitive functions
- Memory
Distributed functions (2) Memory
Memory
Long-term
Explicit/
declarative
Episodic
Short-term/ working
memory
Implicit/ nondeclarative
Semantic
Motor skills
Classical
conditioning
Priming
Disorders of Memory (1)
• Duration
– Short-term = a few seconds
– immediate = a few minutes
– long-term = > 20 minutes, days, months, years
• Stages
– Encoding
– Storage
– Retrieval (recall vs. recognition)
• Short-term or working memory impairments
– e.g., inability to retain verbal information over a few seconds,
difficulty with dual-task performance, poor visuo-spatial shortterm memory
• Long-term memory impairments
– Anterograde vs. retrograde
Disorders of Memory (2)
• Amnesic syndrome
– Preserved intellectual abilities (MQ < IQ) and semantic
memory
– Preserved short-term/working memory
– Preserved procedural (implicit) memory
– Korsakoff’s syndrome - executive function impairments,
encoding < storage
– Limbic damage - executive function usually intact
– Frontal lobe damage - confabulation, recall < recognition
– Anterograde amnesia - impaired acquisition of new episodic
memory (verbal vs. nonverbal, recall vs. recognition)
– Retrograde amnesia - impaired memory for past events
(temporal gradient?)
Disorders of Memory (3)
• Transient amnesia
– Transient global amnesia
• 60-70 years, poor anterograde and patchy retrograde memory,
disorientated, repetitive, no impaired consciousness, typically
lasts after 4 - 6 hours - amnesic gap for duration of the attack cause unknown (migraine, distress)
– Transient epileptic amnesia (TEA)
• Brief episodes of confusion and disorientation, repetitive
questioning, typically shorter duration than TGA (a few minutes),
attacks often occur after waking, recurrent episodes, poor
retrograde memory
– Psychogenic fugue states
• Rare, precipitated by significant life events, profound retrograde
amnesia encompassing whole life including loss of personal
identity but sometimes without significant anterograde memory
impairment.
Neuroanatomy of Memory
Control
Case 1
Tests of Memory
• Short-term/ working memory
– Digit span, block span, letter-number sequencing (WAIS)
• Anterograde episodic memory
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Story recall and recognition (WMS), word list learning (RAVLT)
Recognition of words/faces (Warrington’s Recognition Memory Test)
Geometric figures (Rey-Osterrieth Figure, WMS-III)
Test batteries - WMS-III, RBMT, Doors & People
• Retrograde episodic memory
– Autobiographical Memory Interview (personal facts, events)
• Semantic memory
– Types of dementia, herpes simplex virus encephalitis, vascular
lesions of temporal lobe
– Tests of general knowledge (WAIS subtests)
– Category fluency, object naming, Pyramids & Palm Trees test
Example: Rey Figure
Copy
Delayed recall (40 mins)
13 year old control
Jon
Kate
Distributed cognitive functions
- frontal lobe function
Distributed functions (3)
Frontal lobe function
• Executive function
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DLPfC
Planning
Goal maintenance
Self-monitoring (e.g.,
monitoring errors)
– Failure to inhibit
response
– Perseveration
– Leads to poor problemsolving
• Social cognition
– VMPfC
– ‘Personality and
behaviour’
– Phineas Gage
– Emotion-based decisionmaking (Damasio’s
somatic marker
hypothesis)
– Theory of mind
– Aggression and
regulation of mood
– Motivation
Disorders of Frontal Lobe Function
• Degenerative
– Frontotemporal dementia (Pick’s disease)
– Alzheimer’s diease
• Vascular
– Bilateral anterior cerebral artery infarction
– Subarachnoid haemorrage (anterior communicating artery
aneurysms)
• Structural
– Closed head injury
– Tumours
– Surgery
• Deafferentation from basal ganglia
– Huntingdon’s disease
– Parkinson’s disease
– Progressive supranuclear palsy
Tests of Frontal Lobe Function
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Verbal fluency (category and letter)
Problem-solving (e.g., Tower of Hanoi)
Trail Making Test
Set-shifting tests (WCST)
Motor sequencing (e.g., alternating hand movements,
fist-palm-palm-fist, Luria three-step test, fist-edgepalm)
• Decision-making tests (Iowa Gambling)
• Test batteries
– Behavioural Assessment of the Dysexecutive Syndrome (BADS)
– Hayling and Brixton Test
– Delis-Kaplan Executive Function System (D-KEFS)
Example: WCST
Localised cognitive functions left hemisphere
Localised functions (1)
Left hemisphere
• Disorders of language
– Aphasia - loss or impairment of language function caused by
brain damage
• Dysarthria - impaired speech (not necessarily language
impairments)
• Phonology (speech sounds), semantics (meaning), syntax
(structure), prosody (expression of tone, emotion)
• Causes
– Focal lesions, dementia, psychiatric disorders (mutism)
– Dyslexia - reading impairments
• Peripheral dyslexia - impaired visual decoding of written script
(letter-by-letter reading, errors reading part of word)
• Central dyslexia - impairment in deriving meaning (affects oral
spelling), surface (loss whole word), deep (loss sound-based
reading), phonological (non-word reading)
– Dysgraphia - disorders of writing
Localised functions (2)
Left hemisphere
• Disorders of calculation
– Acalculia - inability to comprehend or write numbers
– Anarithmetria - inability to perform number manipulations
– Spatial dyscalculia - difficulty aligning columns of figures, or
performing carrying tasks
– Gerstmann’s syndrome
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Angular gyrus syndrome (rare)
Agraphia (written oral spelling)
Acalculia (number reading, writing, calculations)
Right-left disorientation
Finger agnosia (naming, pointing/moving named finger, unable
to recognise touch)
Localised functions (3)
Left hemisphere
• Disorders of praxis
– Apraxia - inability to carry out complex motor acts despite
intact motor and sensory systems
– Limb kinetic (basal ganglia, supplementary motor areas) finger movements for fine motor tasks, unable to copy
meaningless hand movements
– Ideomotor (left parietal) - unable to conduct motor acts to
command, difficulty with selection, sequencing, spatial
orientation, and movements
– Ideational or conceptual (left temporal) - inability to conduct a
complex sequence of co-ordinated movements, or mime use
of objects
– Orobuccal (left inferior) - difficulty performing skilled
movements of face, lips, tongue, cheeks, larynx on command
(e.g., pretend to blow out a match)
Localised cognitive functions right hemisphere
Localised functions (4)
Right hemisphere
• Neglect
– Impairments of spatially directed attention
– Personal neglect - extreme cases behave as if one half of the
body has ceased to exist
– Motor and sensory neglect - fail to move a limb, failure in
awareness of stimuli on affected side
– Extrapersonal neglect - line bisection, cancellation tasks,
draw or copy pictures
• Dressing apraxia
– Impairment in orientating body parts in relation to garments
because of visuo-spatial deficits.
• Constructional disorders
– Impaired copying of visually a presented model (either by
drawing or building)
Localised functions (5)
Right hemisphere
• Complex visuo-perceptual abilities
– Recognising objects from ‘unusual views’, identify overlapping
drawings, judge line orientation
– Visual Object and Space Perception battery (VOSP)
• Visual object agnosia
– Failure to recognise objects
– Apperceptive agnosia unable to recognise objects from vision but
can recognise objects if held, poor copy of shapes
– Associative agnosia - unable to recognise objects in all modalities
(semantic loss)
– Tests include object naming, object miming use, name to
description, tactile naming
• Prosopagnosia
– Inability to recognise familiar faces but can recognise person by
voice, posture, gait etc
– Tests include naming photographs of familiar faces
Localised functions (6)
Right hemisphere
• Disorders of colour perception
– Achromatopia - inability to discriminate between colours (“everything
is washed out, like black-and-white TV”)
– Colour agnosia - impaired reteival of colour information (e.g., “what
colour is a banana?”)
– Colour anomia - inability to name colours but presevred colour
perception and knowledge
• Balient’s syndrome
– Inability to direct voluntary eye movements to visual targets
– Inability to reach for, or point to, visual targets (unable to locate
objects in relation to self)
– Visual attentional deficits, where only one stimulus at a time is
perceived (‘simultanagnosia’), unable to synthesise parts in to the
whole
– Functionally blind
• Topographical disorientation
– Unable to navigate familiar routes due to not knowing the
relationship between objects and landmarks
Case examples
Frontotemporal dementia - PNFA
• Clip of person with progressive non-fluent
aphasia
– Left > right
– Inferior frontal and insula damage
Frontotemporal dementia - SD
• Clip of person with semantic dementia
– Left > right
– Inferior anterior temporal lobe damage
Cognitive and
Neuropsychiatric History
Taking
Initial interview
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Need context in order to interpret test results
Build rapport, assess motivation for testing, generate further
hypotheses from data gathered
Interview client and informant separately (with consent)
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demographic data (handedness)
description of current difficulties (include mood checks/hours of sleep)
medical history (any physical impairments to consider?)
psychiatric history
educational and vocational background (good for estimating premorbid
function)
birth history and early development (developmental disorder?)
family background (neurological disorders? LD?)
legal history/substance use
current situation
Selecting measures
– Reliable, valid, age-appropriate normative data - refer for
neuropsychological assessment by psychologist
Check list for assessment (1)
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Memory
– Attention, concentration
– Anterograde (recall new events), retrograde (previous public and personal
events), semantic memory (vocabulary, names of objects, general factual
knowledge)
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Language
– Expressive - word-finding, grammar, word errors (paraphasias), writing
(spelling/motor)
– Receptive - comprehension, reading
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Numerical skills
– Handling money, shopping, bills
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Executive function
– Planning, organising, problem-solving, flexibility
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Visuo-spatial
– Dressing, constructional abilities
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Neglect
– Bodily neglect, extrapersonal space
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Visual perception
– Recognising people, objects, colours
Check list for assessment (2)
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Route findings and landmarks
– Recognition of known landmarks, learning new routes
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Personality and social conduct
– Empathy, disinhibition, sexual behaviour, grooming, personal hygiene
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Eating
– Appetite, food preferences, manners
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Mood
– Depression, mania, anxiety, irritability
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Motivation
– Drive, energy
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Delusions
Hallucinations
Practise EMQs and MCQs
See handout
Key references
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Hebben, N., & Milberg, W. (2002). Essentials of Neuropsychological
Assessment. New Jersey, USA: John Wiley & Sons.
Hodges, J.R. (2007). Cognitive assessment for clinicians (Second
edition). Oxford: Oxford University Press.
Lezak, M.D., Howieson, D.B., Loring, D.W. (2004). Neuropsychological
assessment (Fourth edition). New York: Oxford University Press.
Strauss, E., Sherman, E.M.S., & Spreen, O. (2006). A compendium of
neuropsychological tests: administration, norms, and commentary (Third
edition). New York: Oxford University Press.
Tulsky, D., Saklofske, D., Chelune, G., Heaton, R., Ivnik, R., Bornstein,
R., Prifitera, A., Ledbetter, M. (2003). Clinical interpretation of the WAISIII and WMS-III. London: Academic Press.