This presentation briefs out the approach of dementia assessment in line with consideration of recent advances. Now the pattern of assessment has evolved towards examining each individual domain rather than lobar assessment.

1. Presenter: Dr. Kshitij Bansal
Senior Resident
Department of Neurology
Government Medical College, Kota
DOMAIN ASSESSMENT IN DEMENTIA

2. SCHEME OF PRESENTATION
 Introduction
 Scales
 Attention
 Language
 Memory
 Visuospatial function
 Praxis
 Executive Function

4. HMF GUIDELINES
General Principles
 Specific cognitive testing: Brief screening Mental Status Examination.
 Scales: MMSE and MOCA
 Neuropsychological testing
 Test each area with more than one task.
 Normal or abnormal if > 3 /4 examples.
 Confounding variables (Assess sensory deficits).
 Hierarchical (attention impacts memory)

5. SCALES

6. Scoring below the level of education-adjusted
cut-off on the MMSE may indicate cognitive
impairment. Generally, a score of 24 to 30 is
normal depending on education among total
MMSE score = 30.
 Education levels of 7th grade or lower:
MMSE score of 22 or below
 Education level till only high school: MMSE
score of 24 or below
 Education level of high school graduate:
MMSE score of 25 or below
 Education level of college or higher: MMSE
score of 26 or below
CRUM RM, ANTHONY JC, BASSETT SS, FOLSTEIN MF. POPULATION-BASED NORMS FOR THE MINI-
MENTAL STATE EXAMINATION BY EDUCATIONAL LEVEL. JAMA. 1993 MAY 12;269(18):2386-91.

8. KONSTANTOPOULOS K, VOGAZIANOS P, DOSKAS T. NORMATIVE DATA OF THE MONTREAL COGNITIVE ASSESSMENT IN THE GREEK POPULATION AND PARKINSONIAN DEMENTIA. ARCHIVES OF
CLINICAL NEUROPSYCHOLOGY. 2016 MAY 1;31(3):246-53.

9. DOMAINS OF COGNITIVE ASSESSMENT

10.  Attention: Digit span, Serial reversals (months of year), continuous performance (“A” test).
 Language: Observed and semantic fluency, Comprehension, naming, repetition and write.
 Memory: AVLT screening for remote memory with current / historical events.
 Visuospatial / Perceptual: 2D and 3D construction, Search / Cancellation.
 Praxis: UE mime, imitation gesture comprehension.
 Executive function

11. ATTENTION

12. DIGIT FORWARD AND BACKWARD TEST
Attention:
 Digit Span: Direction: Tell the patient, “I am going to read a list of
numbers. Listen carefully and when I am finished, repeat same
numbers after me.” Present the digital in a normal tone of voice at a
rate of one digit per second.
 “A” Test: Direction: Tell the patient, “I am going to read you a long
series of letters. Whenever you hear the letter A, indicate by tapping
the desk.” Read the following letter list in a normal tone at a rate of
one letter per second.
(Read only line 1 unless you need a larger sample)
Omissions: _____
Commissions: _____

13. MONACO M, COSTA A, CALTAGIRONE C, CARLESIMO GA. FORWARD AND BACKWARD SPAN FOR VERBAL AND VISUO-SPATIAL DATA: STANDARDIZATION AND NORMATIVE DATA FROM AN ITALIAN
ADULT POPULATION. NEUROLOGICAL SCIENCES. 2013 MAY;34:749-54.

14. ATTENTION
Attention:
DIGIT VIGILANCE TEST, SUSTAINED ATTENTION:
Say “cancel digit 6 and 9 as fast as he can. Do not cancel any other digit and do not miss any target
digit”. Note down the time and errors.
Time:
Errors of omission:
Errors of commission:

15. DIGIT VIGILANCE TEST
 Age range: 20 to 80 years
 Admin time: 10 minutes (Timed)
 Respondents are asked to find and cross out either sixes
and nines, which appear randomly within 59 rows of
single digit on two separate pages.
LIN GH, WU CT, HUANG YJ, LIN P, CHOU CY, LEE SC, HSIEH CL. A RELIABLE AND VALID ASSESSMENT OF SUSTAINED ATTENTION FOR
PATIENTS WITH SCHIZOPHRENIA: THE COMPUTERIZED DIGIT VIGILANCE TEST. ARCHIVES OF CLINICAL NEUROPSYCHOLOGY. 2018
MAR;33(2):227-37.

16. STROOP TEST
MACLEOD CM, MACDONALD PA. INTERDIMENSIONAL INTERFERENCE IN THE STROOP EFFECT: UNCOVERING THE COGNITIVE AND NEURAL ANATOMY OF ATTENTION. TRENDS IN COGNITIVE SCIENCES. 2000
OCT 1;4(10):383-91.

17. TRAIL A AND TRAIL B TEST
WECHSLER, D. MANUAL FOR THE WECHSLER ADULT INTELLIGENCE SCALE, 3RD ED, THE
PSYCHOLOGICAL CORPORATION, SAN ANTONIO 1997.

18. LANGUAGE / SPEECH

19. LANGUAGE
Spontaneous Speech
 “Tell me about your illness” – Observe articulation, prosody, fluency, grammar and paraphasia and
neologisms.
 Normal Fluency: 100-150 words / miutes
 Sentence length: > 7 words
 Verbal fluency test: Animal or vegetable naming test (60 sec) < 13 impaired.
 Phonemic fluency: Say as many words as you can which begins with KA, PA, MA (give 60 seconds for
each sound) – no repletion of words, no names of person or places or derivations of same word.

20. VERBAL FLUENCY TEST
 Phonemic (letter): (eg. Letter D or S, or FAS):
 Sensitive to frontal lobe lesions
 Normal 10-11 / min.
 Semantic (Category): (eg. Animals, grocery items)
 Sensitive to frontal and temporal lobe function
 Normal 17-18 (more sensitive to age and education)
 Reflects integrity of DMN / semantic processing networks (MTL, posterior cingulate, anterior / lateral temporal
regions)
*Also may provide insight into executive control
LOONSTRA AS, TARLOW AR, SELLERS AH (2001). "COWAT METANORMS ACROSS AGE, EDUCATION, AND GENDER". APPL NEUROPSYCHOL. 8 (3): 161–6.
ARDILA, A.; OSTROSKY-SOLÍS, F.; BERNAL, B. (2006). "COGNITIVE TESTING TOWARD THE FUTURE: THE EXAMPLE OF SEMANTIC VERBAL FLUENCY (ANIMALS)". INTERNATIONAL JOURNAL OF
PSYCHOLOGY. 41 (5): 324–332.

21. LANGUAGE
 A) Pointing: Ask for at least 4 objects or body parts.
 B) Yes or No responses: ask at least 7 questions (eg. Is it a hotel? Is it a rainy day?
 C) Complex Commands: The lion was killed by the tiger? Which animal is dead? The boy was slapped by
the girl? Who got hit?

22. LANGUAGE
Repetition
 Airplane
 Community Hospital
 Ganga Jamuna Saraswati
 Saraswati Shishu Bal Vidhya Mandir
 Type of errors: Addition / Omission / Paraphasis / Grammatical

23. LANGUAGE
Naming and Word Finding
 Color: Red, Blue, Yellow, Pink
 Body Parts: Eye, Leg, Teeth, Thumb
 Clothing and room objects: Door, Watch, Shoe, Shirt
 Parts of Objects: Chain of a wrist watch, buckle of the belt, shoe laces, nib of a pen
 Less than 4 in any category is abnormal
 Impression:

24. LANGUAGE
Reading (Aloud)
 Letters: G, D, E, Q, M, O, P, X, B, A
 Numbers: 5, 8, 9, 6, 23, 59, 678, 321
 Give a paragraph to read
Reading Comprehension (Ask something about a written sentence)
‘The boy and the girl walked in the sun’
Question: Did the boy go alone?
Question: Was it raining when the boy and the girl went for a walk?

25. LANGUAGE
Writing
 Dictate Letters and numbers
 Names of common objects or body parts
 Write a sentence about a job or the weather.

27. THE RESIDENT APHASIA KIT

28. COLOURS
Identify Colours
Black
Green
Red
Blue

29. IDENTIFY COLOURS

31. DRAWING

32. SHAPES
Circle Triangle
Quadrangle

34. OBJECTS
PLEASE WRITE THE NAME OF THE OBJECTS

36. ACTIONS
To
Read
To
Sleep
To Eat

37. ACTIONS
To Cut To Run To Fall

38. WRITING
 Please write the name of the object
 Please write your name and address
 Write the serial number from 11 to 20
 Write what I say
 Go
 Come
 Boy
 Book
 Door

39. CALCULATIONS
 4 + 3 = ______ a) 8 b) 4 c) 9 d) 7
 9 -5 = _______ a) 5 b) 3 c) 9 d) 4
 5 – 2 = _______ a) 6 b) 3 c) 8 d) 4
 4 x 2 = _______ a) 6 b) 8 c) 10 d) 12
 6 x 3 = _______ a) 10 b) 18 c) 12 d) 14
 9 / 3 = _______ a) 5 b) 6 c) 3 d) 9
 30 / 5 = _______ a) 6 b) 8 c) 4 d) 10

42. READING

43. SENTENCE COMPREHENSION

44. MEMORY

45. MEMORY FUNCTION
 Memory is receiving, processing, maintaining and retrieving information.
 Registration (Encoding and Acquisition)
 Retention(Storage or Consolidation)
 Retrieval (Recall or Decoding)
 Temporal stages of memory
 Sensory
 Immediate
 Recent and
 Remote
 Three memory functions: Immediate recall, learning ability and retrieval.

46. MEMORY
 Short-term Memory
 AKA working memory, immediate memory
 Ability to hold information across an undistracted delay
 Prefrontal cortex
 Long-term Memory
 Memory not lost by distraction
 Hippocampus and Papez circuit
 Remote Memory
 Memory of events many months ago
 Semantic knowledge, procedural skill
 Distributed in cortex, not dependent on hippocampus for retrieval.

48. BUDSON AE, PRICE BH. MEMORY DYSFUNCTION. NEW ENGLAND JOURNAL OF MEDICINE. 2005 FEB 17;352(7):692-9.

49. A FILING ANALOGY OF EPISODIC MEMORY
BUDSON AE, PRICE BH. MEMORY DYSFUNCTION. NEW ENGLAND JOURNAL OF MEDICINE. 2005 FEB 17;352(7):692-9.

50. RECENT MEMORY
 Left Temporal: verbal memory
 Rey’s Auditory Verbal Learning test
 UCLA Memory test
 Paired Associate Learning Test
 Right Temporal: Visual Memory
 Benton Visual Memory Test
 Hide 5 objects in front of patient and ask him after 5 minutes about the name and its location (< 4 abnormal).

51. RAVLT

52. PAIRED ASSOCIATIVE LEARNING TEST
Read the first presentation at the rate of one
pair every 2 seconds. After reading the first
presentation, test for recall by presenting the
first recall list. Give the first word of a pair and
allow 5 seconds for a response. If the patient
gives a correct response, say "That's right" and
proceed with the next pair. If the patient gives
an incorrect response, say "No," provide the
correct word, and proceed to the next pair.
After the first recall has been completed, allow
a la-second interval and give the second
presentation list, proceeding as before.

53. UCLA MEMORY TEST

54. BENTON VISUAL MEMORY TEST

55. VERBAL EPISODIC MEMORY- “WORD LIST LISTENING’
Three-Step Process
 Encoding: Processing information
 “Repeat 3 words: X, Y, Z”
 Storage: retain information over time
 Retrieval: Access information
 “What were the three words?”
If recall < 3, is it a storage or retrieval problem?
Retrieval deficit aided by clue or multiple choice.

56. SEMANTIC MEMORY
Semantic Memory
 Historical facts
 Independence day?
 Who built Taj Mahal?
 Name the colours in Indian flag
 When do we celebrate Gandhi Jayanti
For Uneducated
 Sita was wife of?
 Who killed Ravan?
 When do we celebrate Christmas?

57. VISUO-SPATIAL FUNCTION

58. REPRODUCTION DRAWINGS

60. DRAWINGS TO COMMAND

63. RIGHT-LEFT DISORIENTATION
The following outline, which is in ascending order of difficulty, may be used to test for right-left disorientation.
TEST ITEMS
1. Identification on self
Show me your right foot.
Show me your left hand.
2. Crossed commands on self
With your right hand touch your left shoulder.
With your left hand touch your right ear.
3. Identification on examiner (with examiner facing patient)
Point to my left knee.
Point to my right elbow.
4. Crossed commands on examiner (with examiner facing patient)
With your right hand point to my left eye.
With your left hand point to my left foot.
Most normal persons will successfully accomplish all items without difficulty, although a significant percentage of the normal population
(9% of males and over 17% of females) has demonstrable difficulty on right-left testing.

64. FINGER AGNOSIA
Finger agnosia is the inability to recognize, name, and point to individual fingers on oneself and on others
TEST ITEMS
1. Nonverbal finger recognition
Directions: With the patient's eyes closed, touch one finger. Have the patient open his or her eyes and then
point to the same finger on the examiner's hand.
2. Identification of named fingers on examiner's hand
Directions: The examiner's hand should be placed in various positions (e.g., palm down on the table facing
the patient; hand held vertically in the air with the palm facing the patient; and hand held horizontally in the
air with the palm facing the examiner). The examiner should say "Point to my middle finger," and so forth.
3. Verbal identification (naming) of fingers on self and examiner
Directions: The patient's and examiner's hands should be placed in the various positions as described earlier.
The examiner points to the patient's index finger and says, ''What is the name of this finger?" and so forth.

65. PROSOPAGNOSIA

66. APRAXIA

67. TESTING FOR LIMB APRAXIA
1. Pantomime to verbal command
 Transitive: Associated with tool or instrument use- demonstrate how to comb their hair, brush their teeth
or use a pair of scissors.
 Intransitive: Associated with communicative gestures- demonstrate how to wave goodbye, beckon
somebody to come, say Namaste, Salute, victory sign.
 Testing involves the right and left limbs independently.
 Observes the patient’s responses for the presence of temporal- spatial or content errors.
 If the patient has difficulty pantomiming movements- tests their ability to imitate gestures.

68. TESTING FOR LIMB APRAXIA
2. Imitation of Gestures
 Performs both transitive and intransitive movements and asks the patient to copy the movements.
 Also include meaningless / non-representational gestures such as interlocking circles made with the
thumb and index finger on each hand.
 Disturbed meaningless gestures.
 Either an inability to apprehend spatial relationships involving the hands and arms in parietal-variant
ideomotor apraxia.
 Basic disturbances in idiokinetic movements.

69. TESTING FOR LIMB APRAXIA
3. Gesture Knowledge
 Perform the same transitive and intransitive gestures and asks the patient to identify the gesture.
 Patient must identify the gesture and discriminate between those that are well and poorly performed.
4. Sequential Actions
 Patient must perform tasks that require several motor acts in sequence, such as making a sandwich or
preparing a letter for mailing.
5. Conceptual Knowledge
 Patient is shown pictures of tools or objects or the actual tools or objects themselves.
 The examiner then requests the patient to pantomime the action associated with the tool or object.

70. TESTING FOR LIMB APRAXIA
6. Limb Kinetic Movements
 Examiner checks for fine finger movements by asking the patient to do repetitive tapping, picking up a
coin with a pincer grasp and twirling the coin.
7. Real Object Use
 If limb apraxia is present, test with real object use.
 Most limb apraxias improve when using real objects for transitive actions and when gesturing
spontaneously with intransitive actions.
 Any impairment in the patient’s ability to use real objects indicates marked severity of the limb apraxia.

71. ß

72. EXECUTIVE FUNCTIONING

73. OBJECITVE EVALUTATION
 Working Memory: Complex tasks like digit span backwards and trail making test part B.
 Verbal Fluency: Letter fluency more closely associated than category fluency.
 Design Fluency:

74. OBJECTIVE EVALUTATION
 Motor Programming: Luria’s “Fist – edge - palm” test
 Response Inhibition: “Go– no – go” test
 Abstract Reasoning: Eg. Proverb Interpretation

75. REFERENCES
 Bradley and Daroff’s Neurology in Clinical Practice, 8th Edition.
 The Mental Status Examination in Neurology, Richard L. Strub, 4th Edition.
 Budson, A. E., & Price, B. H. (2005). Memory dysfunction. New England Journal of Medicine, 352(7), 692-699.
 Konstantopoulos, K., Vogazianos, P., & Doskas, T. (2016). Normative data of the Montreal Cognitive Assessment
in the Greek population and parkinsonian dementia. Archives of Clinical Neuropsychology, 31(3), 246-253.
 Ardila, A., Ostrosky‐Solís, F., & Bernal, B. (2006). Cognitive testing toward the future: The example of Semantic
Verbal Fluency. International Journal of Psychology, 41(5), 324-332.
 MacLeod, C. M., & MacDonald, P. A. (2000). Interdimensional interference in the Stroop effect: Uncovering the
cognitive and neural anatomy of attention. Trends in cognitive sciences, 4(10), 383-391.

76. MENTAL STATUS EXAMINATION RECORDING
FORM