The document outlines the assessment of higher mental functions, including consciousness levels, signs of delirium and dementia, and speech impairments such as aphasia. It describes various states of consciousness from normal alertness to coma, and details cognitive assessment techniques, including the Mini-Mental State Examination (MMSE) and tests for memory, intelligence, and speech. Additionally, it addresses higher mental functions like apraxia and agnosia, providing guidelines for evaluating abnormal behaviors and cognitive decline.

1. CNS examination - higher
mental
function,Sensorium,speech
By Gauri Chikhalkar

2. Higher Mental Function

3. CONSCIOUSNESS
• Consciousness Level of consciousness is the patient’s relative state of
awareness of the self and the environment, and ranges from fully awake to
comatose.
• Sleep is a state of physical and mental inactivity from which patient can
be aroused to normal consciousness
• Catatonia is a state during which rigid plastic postures of limbs for long
hours are assumed .
• Akinetic Mutism- state during which patient remains immobile , making
no sound , follows movement slowly with his eyes and allow himself to be
fed and nursed.
• Drowsiness is a pathological state that resembles normal sleep. Patient
can be aroused with an external stimulus , but reverts back to drowsy state
on withdrawal of the stimulus

4. • Semicoma a pathological state , which requires stronger stimulation
to arouse the patient , though his reflexes are normal
• Stupor considered synonymous to semicoma , whereas some
doctors regard it as a state between drowsiness and semicoma
• Coma deepest level of unconsciousness. Patient is immobile , all
reflexes are absent and plantar response is extensor

5. GLASGOW COMA SCALE(GCS)

6. ORIENTATION
• Time - What time of the day is it? (Do not ask - is it day or night -
leading question)
• Place - where are you presently?
• Person - who am I or who is the attendee with you?
In the given order , do not ask leading questions

7. DELIRIUM
• defined as a relatively acute decline in cognition that fluctuates over
hours or days
• 2 subtypes- hypoactive and hyperactive
• Reversibility of dementia
• Assess mental status , fluctuation “sundowning”

9. DEMENTIA
• defined as an acquired deterioration in cognitive abilities that impairs
the successful performance of activities of daily living.
• Episodic memory, the ability to recall events specific in time and place,
is the cognitive function most commonly lost.

11. • MMSE - MINI MENTAL STATE EXAMINATION
Score<21 in educated person=severe dementia
for screening and progress of dementia
Total score= 30
Score<21 in educated person=severe dementia.

12. MEMORY
analyzed according to three main time scales:
(1) immediate memory is assessed by saying a list of three items and
having the patient repeat the list immediately
(2) short-term memory is tested by asking the patient to recall the same
three items 5 and15 mins later
(3) long-term memory is evaluated by determining how well the patient is
able to provide a coherent chronologic history of his or her illness or
personal events.

13. INTELLIGENCE
• Abnormalities of insight and judgment detected during the patient
interview; a more detailed assessment can be elicited by asking the
patient to describe how he or she would respond to situations having a
variety of potential outcomes (e.g., “What would you do if you found a
wallet on the sidewalk?”).
• Abstract thought can be tested by asking the patient to describe
similarities between various objects or concepts (e.g. apple and orange)
or to list items having the same attributes (e.g. a list of four-legged
animals).
• Calculation ability is assessed by having the patient carry out a
computation that is appropriate to the patient’s age and education (e.g.,
serial subtraction of 7 from 100 or 3 from 20; or word problems involving
simple arithmetic).

14. NEURO-PSYCHIATRIC EXAMINATION
• Delusion
• Emotional status

15. Speech
• APHASIA - is an impairment,affecting production or
comprehension of speech and the ability to read and write

16. Testing for Aphasia
• Establish if the patient is right or left handed
• Discover the patients first language

17. COMPREHENSION
ASSESS UNDERSTANDING
Ask the patient a simple question -
• What is your name/address?
• What is your job?
• Where do you come from?

18. UNDERSTANDING
• Ask questions with yes /no answers
• Give a simple command
• If successful try more complicated command

19. NAMING
Show an object to patient, ask him to name it.
NAMING DEFICITS
• TWO WAY(semantic)-cannot name even on clues
• ONE WAY(Retrieval based)- can point to the right object
• Circumlution - Patient fails to come up with the appropriate word ,may provide a circumlutious
description of the object(eg - tells the function of the object - pen shown to patient and asked to
name it - patient says it is used for writing )

20. PARAPHASIA - patient offers incorrect but related word
2 types:
• Semantic- pt knows function of the object , tells a related word eg- pencil
shown-pt calls it “pen”
• Phonemic - pt is phonetically incorrect eg-pencil shown -PT calls it “pentil”

21. REPETITION
• Asking PT to repeat single words ,short sentences,or string of words
such as ‘No ifs,ands,or buts’
• Test of repetition with tongue twisters such as “hippopotamus”
provides a better assessment of dysarthria.

22. FLUENCY
Talk with the patient about a familiar topic preferably in patient’s first
language
For spontaneous speech:
• Fluent -if it maintains appropriate output volume,phrase length
• Non-fluent -if it is sparse and halting and average utterance length is
below four words
The examiner also should note the integrity of grammar as manifested
by word order (syntax), tenses, suffixes, prefixes, plurals, and
possessives

27. Other important higher mental
functions
• APRAXIA - inability to do skilled motor activity.
Eg- ask or to uncap and again cap the pen and keep it back .
1. Ideational
2. Constructive
3. Dressing
4. Ideomotor
5. Speech

28. • AGNOSIA- inability to recognise an object in spite of normal
sensory ,motor and cerebellar function
1. Auditory
2. Tactile
3. Visual

29. PROFORMA
Higher functions are normal with MMSE
Score of ___/30, well oriented to time,
place , person, normal behavior, memory,
intelligence, unaffected speech, and no
perceptual or emotional abnormality .