Ppt on frontal lobe tests

1. LOBAR FUNCTION TEST
Moderator :- Dr. S. Sengupta, AP
Dr. S. A. Alam, SR
Presenter :- Dr. Narendra P. S. Rajput,PGT
Dept of psychiatry, LGBRIMH, Tezpur
JULY 2015
Short topic

2. OUTLINE
• Introduction
• Different lobe functions
• Tests for frontal lobe
• Tests for temporal lobe
• Tests for parietal lobe
• Tests for occipital lobe
• References

3. Introduction- why to assess?
• Determine the cognitive deficits
• Evaluate the nature and scope of observed
deficits
• Assist in diagnostic determination
• Aid in treatment and management
• To measure change over time

8. Frontal lobe functional anatomy

9. Functions
• Motor cortex:- specialized for controlling fine motor
movement (hand & face)
• Premotor cortex:- these neuron forms three descending
system-controlling limb movement, controlling body /axial
movements, controlling eye movement.
• Prefrontal cortex:- it is involved in temporal organization of
complex behavior.
• Sequencing
• Motivation and drive
• Executive function

10. Assessment of frontal lobe function-
• Motor subsystem:- Spastic hemiplegia contralaterally.
• Test includes test for basic motor function- (grip strength)
finger tapping test (fine motor speed).
• Premotor lesions:- loss of “Kinetic Melody”.
• Bedside test for alternating Motor Patterns
1. Fist Palm Side Test
2. Fist Ring Test
3. Reciprocal Co-ordination Test
4. Drawing zigzag line consisting of pointed and rectangular
elements

11. Fist-ring test
Test of reciprocal coordination
Drawing zigzag line consisting of pointed and rectangular elements

12. • In deep seated lesions of premotor cortex (in
the test of kinetic melody ) patients will have
“compulsive automatism”.
• The patient has difficulty in ceasing the
behavior

13. Frontal eye fields:- (BA8,9 ,6)
• Bedside test:
1. Ask the patient to follow the movement of a
finger from left to right and up and down.
2. Ask the patient to look from left to right, up
and down (with no finger to follow).
• Note inability to move or jerky movement

14. Supplementary motor area and anterior
cingulate cortex
• Very much interconnected to other parts
• Involved in motivated behavior
• Initiation and goal directed behavior
• At present there are no office or neuropsychological
tests can be tested along with other frontal lobe
divisions

15. Left
Generative
Lesions:
Impaired initiative,
depression
Right
Inhibitory
Lesions:
impulsive
mania,
sociopathy
Human PFC

16. It Includes - greater part of superior, middle and inferior frontal
gyri, orbital gyrus, most of medial frontal gyrus, anterior half of
cingulate gyrus
LATERAL VIEW CUT SECTION OF BRAIN

17. Dorsolateral prefrontal cortex (DLPC):-
(BA 9, 10, 46)
• Bedside tests:
1. Is the patient able to make an appointment and arrive
on time?
2. Is the patient able to give a coherent account of current
problems and the reason for the interview? Is there
evidence of thought disorder?
3. ATTENTION & WORKING MEMORY :-
• Digit span, days of the week or months of the year
backwards. Here the patient has to retain the task and
the information, and then manipulate the information.
• Serial subtraction and test for Sustained attention

18. Test of Sustained attention
Cancel 6 and 9 Right Wrong
Total
Time taken

19. 4. Controlled oral word association test (COWAT):
Tests VERBAL FLUENCY
• Asked to produce as many words as possible, in one
minute, starting with F, then A, then S.
• Proper nouns and be previously used words with a
different suffix are prohibited
• Other categorical fluency tests include naming animals,
fruits and vegetables
5. Executive function
I. Wisconsin Card Sorting Tests
II. Tower of London test
III. Trail making test

20. Wisconsin Card Sorting Test-
Abstract thinking and set shifting; L>R
“Please sort the 60 cards under the 4 samples. I won’t tell you the rule, but I
will announce every mistake. The rule will change after 10 correct
placements.”

21. Tower of London Tests
Planning
Various levels of difficulty:
e.g. “Please rearrange the balls on the pegs, so that each peg has
one ball only. Use as few movements as possible”

22. Trail Making Test-
Visuo-motor track, conceptualization, set shift
A
C
1
2
7
3 D
5 B
4
6
Various levels of difficulty:
1. “Please connect the letters in alphabetical order as fast as you can.”
2. “Repeat, as in ‘1’ but alternate with numbers in increasing order”

23. Abstract thinking and Judgement
• Proverb Testing
• Similarity testing
• Block design
1. Tests construction ability abstract thinking.
2. Blocks are kept in specific arrangement and also to shift
them to the a particular form.
3. Multi coloured cubes are given to the patient and asked
to arrange them according to a specific design.
• Weigh colour – form sorting test, Object sorting Test
• Goldstein’s Scheerer Stick Test
• Insight :- reaction to own illness

24. Orbital and basal area (Orbitofrontal cortex)
• Bedside tests:
1. Does the patient dress or behave in a way which suggests
lack of concern with the feelings of others or without
concern to accepted social customs.
2. Test sense of smell - coffee, cloves etc.
3. Go/no-go Test:-
The patient is asked to make a response to one signal (the
Go signal) and not to respond to another signal (the no-go
signal).
The most basic is to ask the patient to tap their knee when
the examiner says, “Go” and to make no response when
the examiner says, “Stop”.

25. 4. The Stroop Test:- Examines attention and the ability of the
patient to inhibit responses.
• Patients are asked to state the color in which words are printed
rather than the words
• This task is made difficult by presenting the name of colors printed
in different colored ink
– RED BLUE ORANGE YELLOW
– GREEN RED PURPLE RED
– GREEN YELLOW BLUE RED
– YELLOW ORANGE RED GREEN
– BLUE GREEN PURPLE RED

26. Frontal Release Reflexes
• As the CNS matures, frontal lobe cells develop and
begin to inhibit the primitive reflexes which are
present in normal babies.
• These may reappear with brain damage or disease
1. Grasp
2. Sucking (pout, snout, rooting)
3. Palmar-mental
4. Glabella Tap
• Apraxia, aphasia and memory disturbances also
occur in frontal lobe lesions. Test described with
other lobes

27. Orbitofrontal syndrome
(disinhibited)
Frontal convexity
syndrome (apathetic)
Medial frontal
syndrome (akinetic)
 Disinhibited, impulsive
behavior
(pseudopsychopathic)
 Inappropriate jocular affect,
euphoria
 Emotional lability
 Poor judgment and insight
 Distractibility
 Perseveration
 Apathy
 Indifference
 Psychomotor
retardation
 Motor perseveration
and impersistence
 Loss of self
 Stimulus-bound
behavior
 Discrepant motor and
verbal behavior
 Motor programming
deficits
 Poor word list
generation
 Poor abstraction and
categorization
 Segmented approach to
visuospatial analysis
 Paucity of spontaneous
movement and gesture
 Disturbance of will
 Catatonic signs-
gegenhalten ,waxy
flexibility
 Alien hand, forced
grasping, compulsive
utilization,
 Sparse verbal output
(repetition may be
preserved)
 Lower extremity
weakness and loss of
sensation
 Incontinence

28. Test and lesions (Stuss2002)
Left DLPFC
• FAS
• WCST
Stroop Naming
List Learning
TMT
• Semantic Fluency
Inferior Medial
List learning
Semantic Fluency
Right DLPFC
• WCST
• TMT
• Semantic fluency
Superior Medial
• FAS
• WCST
Stroop Incongruent
• TMT
• Semantic Fluency

29. Test for temporal lobe
• Sensory:- auditory n
visual perception
• Memory
• Comprehension &
understanding spoken
language
• Emotion and behaviour

30. NEUROPSYCHOLOGICAL ASSESSMENT
1-Testing for auditory processing capacity-
• DICHOTIC TESTING TASK
2- Testing for visual processing capacities-
• Mc Gill picture anomalies tests
3—Test for verbal memory—
• Wechsler memory scale
4—Test for visual memory
• Rey complex figure/ Rey-Osterrieth Test
5—Test for language comprehension
• Token test

31. • Some terms related to language disorders :-
• Aphasia- a true language disturbance due to impairment in the
production and/or comprehension of spoken language.
• Dysarthria- a specific disorder of articulation in which basic
language( grammar, word choice and comprehension) are intact.
• Dysprosody- an interruption of speech melody. Speech inflection
and rhythm are disturbed
• Buccofacial or oral Apraxia- is the inability to perform skilled
movements of the face and speech musculature in the presence of
normal comprehension, muscle strength, and coordination.
• Amusia – inability to identify musical themes
• Pure word deafness (aphemia)– can not recognise spoken word
despite speech, reading n writing being normal.

32. Aphasias
• Global :-M/C ,Spontaneous speech is absent or reduced to a few
stereotyped words or sounds. Comprehension is absent/reduced.
• Broca ‘s:- Nonfluent , comprehension good , poor repetition.
• Wernicke’s:- fluent, poor comprehension & repetition.
• Conduction:- poor repetition, paraphagic , fluent speech
comprehension relatively spared
• Transcortical:- retained repetition but subdivided according to
fluency & comprehension as transcortical motor/ sensory
• Anomic Aphasia- There is word finding difficulty and an inability
to name objects , speech is spontaneous, fluent, grammatically rich
but contains many word finding pauses
• Subcortical Aphasia- fluent/articulary disturbances Repetition
is intact/impaired impaired comprehension

36. Bedside tests
• Handedness :-
• 99% of right hander's have left hemispheric dominance for
language.
• left hander's, 67% left hemispheric language, 33% have either
mixed or right hemispheric language dominance.
• Spontaneous speech :- fluent / non fluent
• Comprehension:- answers to normal Qs.
• Naming objects
• Repetition
• Reading
• writing

37. Memory assessment
• Immediate memory:- 3 unrelated words ask to repeat , digit
span test.
• Recent /short term- recall of 3 words after 5 min , recent
events of day
* Orientation – time/place/person
* Verbal memory- word list test
* Visuo -spatial memory- reproduce drawings
• Remote /Long term:- personal / historic events of past.
• Confabulation ;- making up stories to fill up the gaps ;
Korsakov’s psychosis

38. • The Kluver-Bucy syndrome
• Tameness: loss of fear/anxiety or diminished aggression
• Dietary changes: indiscriminate dietary behavior
• Altered sexuality: greatly increased autoerotic, homosexual,
or heterosexual activity or inappropriate sexual object choice
• Hypermetamorphosis: a tendency to attend to and react to
every visual stimulus
• Hyperorality: a tendency to examine all objects by mouth
• Psychic blindness: visual agnosia
• Gastaut-Geschwind syndrome
• combinations of hyposexuality, hyperreligiosity, hypergraphia,
interpersonal “stickiness,” circumstantiality

39. Temporal lobe Lesions
Dominant
• Dysphasia
• Dyslexia
• Poor memory
• Complex hallucinations
(smell, sound, vision)
• Superior quadrantanopia
Non-dominant
• Poor non-verbal
memory
• Loss of musical skills
• Complex hallucinations

40. Parietal lobe
• Integrating somatosensory with visual and auditory
information to construct ‘body schema’ and its relation to
extrapersonal space.
• Also in the execution of voluntary complex motor acts.
• Comprehension of verbal and written language.
• The recognition and utilization of numbers, arithmetic
principles and calculations.

41. Some terms
• Stereognosis: ability to recognize and identify objects by feeling
them. The absence of this ability is termed astereognosis.
• Graphesthesia: ability to recognize symbols written on the skin.
The absence of this ability is termed graphanesthesia.
• Two-point discrimination: ability to recognize simultaneous
stimulation by two blunt points. Measured by the distance
between the points required for recognition.
• Touch localization (topognosis): ability to localize stimuli to parts
of the body. Topagnosia is the absence of this ability.
• Double simultaneous stimulation: ability to perceive a sensory
stimulus when corresponding areas on the opposite side of the
body are stimulated simultaneously. (sensory extinction)
• Alexia- Loss of reading ability in a previously literate person.
• Agraphia- An acquired disturbance in writing.
• Acalculia- Inability to manipulate figures

42. Classical Test of parietal lobe functions
1) Steriognosia and graphesthesia, 2) Calculating
3) Left – Right orientation 4) Writing
5) Reading aloud 6) Spatial recognition
7) Recognizing ones illness 8) Copying Geometric
s shapes
Sensory and perceptual disturbances-
• Somatic sensation is touch, pain, temperature, body position
sense, kinesthesia, and vibration.

43. Two-point discrimination
• Ordinarily, only the fingerpads are tested but other areas of the body
can be tested. According to DeJong (1967), the following are the
normal distances at which two points can be discriminated on various
body parts:
• Tongue tip: 1 mm
• Fingertip: 2 to 4 mm
• Dorsum of fingers: 4 to 6 mm
• Palm: 8 to 12 mm
• Dorsum of hand: 20 to 30 mm
Topognosis
• Ask the patient to describe or point to various parts of the body tested
with tactile stimulation. This can be done with tactile testing.
Double simultaneous stimulation
• Patients with parietal lobe lesions may recognize stimuli on one side of
the body when applied independently but not recognize or distinguish
that stimulus when bilateral stimuli are applied.(extinction )

44. Apraxia
• Inability carry out skilled movement in the absence of impaired motor
functioning or paralysis.
Type – Left hemisphere injury: ideomotor, ideational, buccal facial apraxia.
• Right hemispherer injury: constructional and dressing apraxia.
Method of testing-
• 1st make sure that if there is any weakness, sensory deficit or ataxia.
• Patient understands instructions.
Ideomotor –
• Buccofacial- Blow out a match, Protrude your tongue & drink through
straw.
• Limb command—How to solute, Use a brush, Flip a coin, Hammer a nail,
comb your hair, kick a ball & crush out cigarette.
• Whole body command- - Stand like boxer, Swing a baseballs bat
Ideational Apraxia—Carring out the whole of a complex act is defective,
though the execution of different part of the complete act may be
normal.

45. Constructional Apraxia / Amorphosynthesis—
• Basic type of tests are-
1) Spontaneous drawing,
2) Paper and pencil. Production of geometric shape,
3) Two dimensional block design,
4) Three dimensional block design,
5) Stick pattern reproduction,
6) Spatial analysis task—patient is asked to shade in the portion of a
design that is common to two or more overlapping figures.
7) Reconstruction of puzzles e.g. Benson & Benson and object
assembly subset of WAIS.

48. • Patient should have adequate vision & sufficient motor ability.
• Constructional Apraxia—Presents in 27% of right hemispheric
lesion and absent in 17% of cases while in left hemispheric lesion
it is seen in 17% and absent in 27% of cases.
• Other tests-
1) Bender Gestalt Test, 2) Ravens Progressive Matrices,
3) Minnesota Perception- Diagnostic Test,4) Hooper Visual
Organization
• Drawing to command →human figure drawing→bicycle drawing.

49. Laterality of the lesion and characteristics of drawing
• Right hemisphere—1) Scattered and fragmented, 2) Loss
of spatial relations, 3) Faulty orientation, 4) Energetic
drawing, 5) Addition of the line to try to make drawing
correct.
• Left hemisphere—1) Coherent but simplified, 2)
Preservation of spatial relations, 3) Correct orientation, 4)
Slow and laborious, 5) Gross lack of detail.
• Constructional apraxia TESTS frontal parietal n occipital
lobes

50. Unilateral Spatial Neglect – The syndrome consists of a tendency to neglect
one half of extra personal space in such task as drawing and reading. More
prominent with right hemispheric lesions.

51. Dressing Apraxia—
• How patient manipulates to buttons, how he takes off
his coat or jacket and puts them on again. It is usually
due to right hemisphere lesion involving parietal region
• Left sided or Unilateral apraxia :- Unable to initiate or
perform certain movements with their left hand (but
not right).
• Geographic Disorientation— Describe evidence of
disorientation from history, Map localization—to locate
well-known cities on a map, Orientation of self in
hospital.

52. Disorder of body schema:--
• Anosognosia— Failure to perceive one side of body e.g. for
hemiplegia (Babinsky syndrome),
• Autotopognosia—Inability to identify any part of body.
• Finger agnosia— Inability to recognize name and point to
individual finger on oneself and on others
• Right—Left disorientation
• Gerstmann’s Syndrome—
• Left or dominant parietal lesion. (angular gyrus)
• Consists four major component –
---Finger agnosia --Right-left disorientation
---Dysgraphia, agraphia --Dyscalculia
• Additionally constructional impairment and mild aphasia may exist. It
indicates damage of dominant parietal lobe/ bilateral lobe.

53. • Dominant side
Functions
• Calculation-
simple/complex
• Language
• Planned movement
• Appreciation of size, shape,
weight and texture
Lesions
• Dyscalculia
• Dysphasia
• Dyslexia
• Apraxia /Agnosia/
Homonymous-Hemianopia
• Non-dominant side
Functions
• Spatial orientation
• Constructional skills
Lesions
• Neglect of non-dominant side
• Spatial disorientation
• Constructional apraxia
• Dressing apraxia
• Homonymous-Hemianopia

54. Occipital lobe
• Analysis of vision
• Prospagnosia :- Inability to recognise familiar faces e.g;
family photograph ,popular figures
• Visual memory :- 5 hidden objects, score <4 abnormal
• Hemianopia with macular sparing
Ballint ‘s syndrome :-
• Simultagnosia
• Oculomotor apraxia
• Optic ataxia

55. • Anton-Babinski syndrome)–
• Inability to recognise part of one’s own body.
• It includes a somatosensory defect that encompasses loss of the
stored body schema as well as conceptual negation of paralysis
and a disturbed visual perception and neglect of the body.
• Patients with visual spatial impairment have great difficulty
localizing objects in two and three dimensional space. Stereopsis
(binocular depth perception) is often impaired.
• Unilateral anosognosiais associated with additional abnormalities
like blunted emotionality, confusion, and allocheiria.

56. References
• Bickerstaff’s Neurological Examination in Clinical practice 7 th
adapted edition 2013.
• Richard L. Strub, F. Willium Black, The Mental Status Examination
in Neuology, 4 th edition 2003.
• JN Vyas, Niraj Ahuja,Textbook of Postgraduate Psychiatry, 2nd
edtion 2003.
• B.J. Sadock, V.A. Sadock, Biology of Memory, Chapter 3.4,
Comprehensive Textbook Of Psychiatry 9th, (2009), p658.
• psych.theclinics.com
• Pridmore S. Download of Psychiatry, Chapter 27. Last modified:
April, 2007
• Neuropsychologic Assessment of Frontal Lobe
Dysfunction,Elkhonon Goldberg, PhD*, Dmitri Bougakov, PhD,
Psychiatr Clin N Am 28 (2005) 567–580.
• Google images

57. Thank you