Mse in neurology lesson 8

1. Higher cognitive
functions
Mse in neurology S & B chpter 8

2. • Included within category are manipulation of well learned material, abstract thinking,
problem solving, arithmetic computations and so forth.
• Most evolved functioning, which is highly susceptible to the effects of neurologic disease
• Often demonstrates the early effects of cortical damage
• Ability to perform on large part depends on large part by an individual’s adequacy
• Also gives information regarding social and vocational prognosis

3. Evaluation
• Most intelligence tests target assessing higher cognitive functions
• Higher cognitive functions can be categorized into hierarchy groups
1. Fund of acquired information
2. Manipulation of old knowledge (eg., calculations or problem solving)
3. Social awareness and judgement
4. Abstract thinking

4. • The store of basic acquired information is assessed by simple verbal tests
of vocabulary, general information and comprehension
• Specific examples of these kinds of tests may be seen on any basic
intelligence tests.
• General intelligence, education and social exposure influence the
performance.

5. • Manipulation of old knowledge is a more active active process
• Involves both an intact fund of general information and ability to apply this information
to a new or unfamiliar situation
• Assessed by questions concerning social comprehension and calculation.
• Social comprehension and problem solving may be evaluated by questions
concerning the knowledge of environmental situations and how to deal with them
effectively eg what person should do if sees smoke in grocery

6. ❑Social judgement more complex process (different from problem solving of a
hypothetical situation) includes
• Basic knowledge of social situations,
• The socially appropriate response in such situation
• Ability to personally apply the correct response
❑Because it is a reality based test, difficult to assess validly in an abstract test situation
❑A pt may give a response in a test situation may respond differently in actual situation
❑Therefore pt’s social judgement must be collaborated with family members information
who have witnessed the pts actual performance in dealing with day to day activities

7. • Abstract thinking , highest level of cognition assessed by proverbs,
conceptual series or analogy interpretation.

8. Fund of information
• Presented in order of increasing difficulty
• Less difficult question can be omitted if pt is of above average intelligence
• Continue until failed three successive questions or test has completed
• Can repeat question but no paraphrasing
• If pt’s reponse is unclear can ask him or her to explain fully

9. Test items
Questions
• 1. How many weeks are in a year?
• 2. Why do people have lungs?
• 3. Name four people who have been
president of the United States since 1940.
• 4. Where is Denmark?
• 5. How far is it from New York to Los
Angeles?
Acceptable responses
• 52
• To transfer oxygen from air to blood; to
breath
• Any appropriate presidents
• Scandinavia, NorthernEurope
• Any answer between 2300and 3000 miles.

10. Questions Acceptable responses
6. Why are light-colored clothes cooler in the
summer than dark-colored clothes?
Light-colored clothes reflect heat from the
sun whereas dark-colored clothes absorb
heat
7. What is the capital of Spain? Madrid
8. What causes rust? Oxidation: a chemical reaction of metal,
oxygen,and moisture
9. Who wrote the Odyssey? Homer
10.What is the Acropolis? Site of the Parthenon in Athens, Greece;
ancient city on a hill in Athens

11. Scoring
• Pt’s response must be either exact or very closely approximate the
acceptable answer
• Less adequate response may denote
Inadequate social and educational exposure/ retardation/ dementia
Average 6 answers adequate

12. CALCULATIONS
• Directions : calculations are complex neuropsychologic functions
• Involves components such as
i. Rote tables eg addition substraction and multiplication
ii. Basic arithmetic concept of borrowing and carrying
iii. Recognition of signs (+,-,×,÷)
iv. Correct spatial alignment for written calculations

13. • When evaluating calculations, it is important to require, pt actually
calculate and not merely recite rote tables(eg 4+4=8 or 3×5=15)
• This allows the observation of many different types of errors and provides
additional clinical data of nature of the deficit and for providing
neuroanatomic implications.
• Performance is closely related to educational experience

14. Verbal rote examples
1.Addition 3. Multiplication
4+6 = (10)
7+9 = (16)
2×8=(16)
9×7=(63)
2.Subtraction 4.Division
8-5 = (3)
17-9 = (8)
9÷3=(3)
56÷8=(7)

15. Verbal complex
examples
1. Addition 3.Multiplication
14+17= (31) 21×5=(105)
2.Subtraction 4.Division
43-38=(5) 128÷8=(16)
Allow only 20secs.

16. Written Complex
Examples
1.Addition
108
+79
____
3.Multiplication
108
×36
____
2.Subtraction
605
-86
____
4.Division
559÷43

17. • If the pt is inattentive and distractable present at a time one task
• When written on a single sheet examples written should be widely separated
• Allow a reasonable amount of time, delay of 30 seconds must be noted
• Scoring :
• Comparing each computation subtest, area adequacy and deficit can be determined

18. • Errors specific to a particular aspect of computation(eg division) or to a modality of
presentation ( verbally/ written) to be noted.
• Errors involving borrowing and alignment on written examples should be recorded.
• Calculation ability is stable across all age groups
• Performance in early dementia is not significantly impaired.
• Performance deteriorates dramatically in 2nd and 3rd stages of the disease

19. Proverb interpretation
• Directions : to interpret accurately
• Requires : intact fund of general information
• Ability to think in the abstract
• Ability to apply this knowledge to unfamiliar situations
• **Read each proverb as written, do not paraphrase or otherwise explain**
• Continue only until the pt fails on two successive proverbs.

20. • If the response is concrete or unable to interpret it, examiner must supply correct and
explain that this is the expected type of response.
• Test items
1. Don’t cry over spilled milk
2. Rome wasn’t built in a day
3. A drowning man will clutch at a straw
4. A golden hammer breaks an iron door
5. The hot coal burns; the cold one blackens ( meaning : extremes are detrimental/ there
may be aspects to things that appear good.

21. • Scoring : Scoring criterion degree of abstraction demonstrated while explaining the
proverb
• Abstract 2 points , semi abstract 1 point concrete 0
• For difficult proverbs minimally semiabstract response
• Except for retarted or illiterate pt, concrete responses are pathologic.
• Illetrate persons may give semi abstract when prompted.
• Examiner must be cautious in interpreting a low score

22. Similarities
• Directions : Verbal ability requires analysis of relationships, formation of verbal
concepts and logical thinking.
• I am going to tell you some pairs of objects, each pair is alike in some way
• Please tell how they are similar or alike.
• If the mentions a difference or fails to respond or states they are different
score item 0.
• Give no help on succeeding items

23. Test items
• 1. Turnip- Cauliflower
• 2.Car- Airplane
• 3.Desk- Bookcase
• 4.Poem- Novel
• 5. Horse- Apple

24. • 2points for abstract ability
• One point for responses for specific properties that constitute a relevant similarity
• 0 for properties which share no similarity/ concrete to the each items
• ITEM 1 – 2points –Vegetables 1point- Food
• ITEM 2 - 2points – transportation 1point –drive with both of them
• ITEMS 3 -2points – furniture 1 point household objects
• ITEM 4 – 2points – literary work 1 point write them both
• ITEM 5 -2points – both grow, have skin

25. Conceptual series completion
• It is a test of verbal abstraction
• Test ability to solve unfamiliar and complex verbal problems and the ability
to reason at higher level
• Tell the pt I am going to show some numbers, letters or words in series.
• Each series will be incomplete and needs an additional word, letter or
number to complete it.

27. • Each __ calls for either a number or letter to fill in.
• Take each item in order, if you don’t understand don’t spend too much
time.

28. ANATOMY
• Higher cognitive functions rely on intact cerebral cortex.
• But are not as well localized as language or constructional ability.
• Abstract thinking, ability to manipulate old knowledge, calculation ability
and similar functions are probably widespread.
• Subcortical structures are also important in carrying out these highly abstract
functions.
• impairement can be seen due to various parts of the brain.
• Impairement is prominent in widespread bilateral disease.

29. • It is likely that these cognitive functions are localized posterior than frontal
areas of brain.
• Verbal reasoning and abstraction are primarily dominant hemisphere
function with very close relationships with language.
• Thus dominant hemisphere lesions frequently interefere with these high
level manipulations.
• Impaired performance of calculations can be seen in dominant/
nondominant, right/left hemispheres.

30. • Dominant left hemisphere lesion has more severe impairement of calculations.
• A significant dyscalculia often accompanies aphasia.
• Dyscalculia is a significant component of gerstmann’s syndrome which is secondary to
dominant parietal lobe lesion.
• Though defects focal to frontal, temporal and occipital are described in specific
calculation defects.

31. • Impaired calculation ability due to focal leisons in the parietal lobes are
more common.
• It is characterized by loss of ability to understand the meaning of numbers
and numeric concepts (eg larger or smaller) and by the inability to align
numbers correctly on the pg owing to visual- spatial deficits.
• The malalignment in complex computations can often be the most striking
feature in the dyscalculia seen in pts with parietal lobe leisons.

32. CLINICAL IMPLICATIONS
• Deficits with higher cognitive function is seen with widespread brain disease.
• Focal dominant parietal lobe lesions , may produce defects in verbally mediated
functions and also considered in differential diagnosis of pts with loss of abstract
ability or impaired calculations
• Frontal lobe leisons impair social awareness and judgement

33. • Schizophrenia with impaired abstract ability is different from organic brain disease
e.g., symbolic interpretations incorporating pt’s delusions
• We are studying about recent changes in higher intellectual functions therefore
must exclude mental retardation
• Must take premorbid intelligence and education background while interpreting
the performance