1. Constructional ability refers to the capacity to draw or construct 2D and 3D figures and involves the integration of visual, sensory, and motor functions across different brain regions. 2. Tests of constructional ability can help detect subtle brain damage as even small early lesions frequently disrupt performance on tasks like copying simple line drawings. 3. Despite their clinical usefulness, constructional tasks are often omitted from mental status exams but can yield valuable information, especially in detecting dementia.

1. Constructional ability
Mental status examination in Neurology S & B chapter 7
Dr Amala Musti
Columbus hospital, Hyderabad

2. • Term constructional ability brings to our mind ability to draw some
geometrical designs/? some kind of drawing, which can be part of academic
learning as a memory, or part of professional learning and work
• Brain must be able to recognize, memorize a shape, figure out how to draw
and ability to held a pen to draw with hand

3. • Constructional ability can be defined as capacity to draw or
construct 2D/3D dimensional figures or shapes
• This high level, non verbal cognitive function is a very complex
perceptual(can be vision or sensory) motor task (we perceive the
design through vision or through sensation from hand, reproduce
through drawing by hand)…two activities are clubbed.
• Therefore involves integration of occipital(vision),
parietal(sensation) and frontal (drawing by hand) lobe functions.

4. • Because of this large surface area of cortex is needed to perform this task
and any small/early brain/tissue damage frequently/quickly/early disrupts
performance.
• In some pts, the unsuccessful attempt to copy simple line drawing can be
the only objective evidence suggesting organic brain damage.

5. • Despite their importance and proven clinical use, constructional tasks
are frequently not included(ignored) in bedside or op clinic mental
status testing, partly because very few pts actually complain of
constructional impairment.
• Feed for thought: What can be a construstional ability of a Christian
housewife or a hindu housewife.?

6. • Architects/engineers whose professions require such abilities, might notice
difficulty while performing professional tasks.
• Constructional tests take only few minutes to perform and can yield
valuable information
• Term “constructional ability” is used instead of “constructional praxis”
• Praxis in the strict sense, refers to motor integration used to execute
complex learned movements

7. • Reproduction of line drawings or block designs involve more than
organization of skilled hand movements
• Ie ??not solely dependent on hand movements
• Such ability requires 1. accurate visual perception 2. integration or encoded
as kinesthetic(?? To feel the structure) images 3. decoding or translation of
kinesthetic images into final motor pattern
• Pt donot have to recognize/name the figure, they only need to understand
a structure as a whole, develop a concept (gestalt).

8. • The relation of angle and sides, integration of parts into whole, orientation
in page and three dimentionality all be appreciated if accurate motor
integration is to be carried out.
• Final step requires adequate limb strength and coordination(that’s what
praxis part is)
• Failure to perform is described as constructional impairement rather than
constructional apraxia
• Term apraxia excludes the visual perception and organization part.

9. EVALUATION
• Warrington listed six basic types of tests for eliciting evidence of
constructional impairement
1. Two dimensional block designs
2. Three dimensional block constructions
3. Paper and pencil reproduction of geometric shapes
4. Spontaneous drawings
5. Stick pattern reproduction
6. Spatial analysis tasks that require the pt to shade in the portion of a
design that is common to two or more overlapping figures

10. • Drawings to command(?draw a cat) and reproduction drawings remain
most easily administered and interpreted
• To tap different aspects of constructional ability clinical examination must
ideally include several tests.
• Tests described further presumes normal vision and normal motor power
to hold pen pencil paper.(that means check them first)
• Deficits in either may impair performance, but does reflect in the higher
integrative cortical function.

11. • Inclusion of memory component may cause errors in interpretation,
impaired performance may be due to memory/ constructional
impairement/ both
• So testing/test items must assess a cognitive function as discrete as
possible

12. Reproduction drawings

14. Test items
• Simple and familiar
• Reproduced adequately by normal individuals
• Very sensitive to effects of brain disease
• Organised in the order of increasing difficulty and should be so
administered
• Both 2D and 3D drawings are used because frequent quantitative and
qualitative performance differences noted on these two tasks

15. • Using a standard pre drawn set of designs is best method
• Or draw on the left side of piece of blank white paper
• Separate sheets of paper for each design may be needed for pts who are highly
distractable
• Perceptualy confusing progress sheets/ consult sheets other handy papers must
be avoided.
• Two different colours or two felt-tip pens must me used to differentiate
examiner’s and pt’s drawing
• Instruction given as “please draw this design exactly as it looks to you”

16. • Scoring
0- Poor nonrecognisible
1- Fair moderately distorted/ rotated
2 –minimal distortion /rotation but less than perfect reproduction
3 –perfect
Following figures slides shows types of errors and scoring examples

23. Drawings to command
• Directions: pt is required to draw 3 pictures to verbal command.
• I would now like, you to draw some simple pictures on this paper.
Draw as good as possible
• Please draw a picture of clock with number and hands,
• A daisy in a flowerpot, a house in perspective so that you can see 2
sides and roof.

24. • Scoring
• 0 –Poor nonrecognizable drawings or gross distortion
• 1 –Fair Recognizable but moderate distortion or rotation
• 2 –Adequate integration on all pictures (house should contain some
evidence of 3dimensionality and contain basic elements of a house
• 3 –Excellent perfect or near perfect

28. Block designs
• Although important test, considered ancilliary
• Requires only four multicoloured cubes ( from Wechsler’s Adult
Intelligence Scale, WAIS-R) and four stimulus designs.

31. Interpreting Test Performance
• Normal individuals score almost perfect scores on simple
reproduction or command drawings, but there is modest yet
significant drop with age.
• 3d cube and house are the most difficult for most people

32. • Pathognomonic signs of brain damage are
1. Rotation >45degrees or disorientation
2. Perservation or repetetion
3. Fragmentation or omission of parts
4. integration or arrangement of parts
5. Substitution or addition
Occurrence of any of these errors should raise a strong question of brain
dysfunction.

33. ANATOMY
• Parietal lobe is the area of primary sensory cortex and it is the
principal area involved in visuo motor integration.
• Visual cortex and frontal motor area are necessary for completion of
all tests
• But it is the association cortex of parietal lobe that is responsible
complex integration

34. • Kinesthetic analysis of visual pattern is the initial task of association
area
Dynamic kinesthetic imagery is the cognitive creation of the
feeling of movements while physically moving
Kinesthetic imagery implies muscular sensation when performing an
imaginary moving action that leads to event-related desynchronization
(ERD) of motor-associated brain rhythms. (something which conscious
brain cannot identify :-|)

35. • Simply understood visual pattern is break up/decoded into movement
(path) pattern.
• Kinesthetic images are then translated into motor patterns by involving
the perirolandic premotor area.

36. CLINICAL IMPLICATIONS
• Although leisons in any quadrant can disrupt constructional ability,but
parital lobe dysfunction can be strongly suspected
• The incidence and severity of frontal lobe leisons are small.
• Most constructional impairement is seen in pts with cortical damage
posterior to Rolandic fissure.
• Constructional ability is not a function exclusive to the right parietal
lobe, either of the lobes can show constructional impairement.

37. • Subtle differences are observed with
right and left parietal lobe lesion in
qualitative performance.
• In right hemisphere lesion
frequently loose the basic outline of
the design and “string out” the
blocks
Make scattered and fragmented
drawings that show loss of spatial
relations and orientation on the page.

38. • Pts with left hemisphere leisons show
more coherent block designs, with
maintenance of external configuration
but loss of accurate internal detail 3rd
diagram in adjacent pic.
• Their drawings tend to be simplifications
of the model lacking details but
preserved general spatial relationships
• When pt’s constructional ability is
grossely impaired, in the face of normal
language, right hemisphere dysfunction
is strongly suggested

39. • Lesions that are confined to parietal lobes will often show evidence of
significant constructional impairement on mental status testing yet
will fail to demonstrate abnormalities on standard neurologic
examination.
• Therefore the presence of errors on constructional testing should lead
to more complete neurodiagnostic workup
• The most dramatic(very prominent to see, even identified by LKG kid)
examples of constructional impairement occur in pts with b/l cortical
disease.

40. • In cerebral atrophy, well demonstrated.
• Dementia most common Alzheimer's seen in early stage of disease.
• Pts with multiple infarct dementia show other abnormal neurologic
signs( eg upper motor neuron signs) along with constructional
difficulty.

41. • Pts in delirium from toxic and metabolic factors frequently demonstrate
constructional impairement due reversible physiologic of the cortex rather
than structural damage
• Because of high incidence of constructional impairement in dementia such
tasks are very good screening tests in pts of advancing age who present
with vague psychiatric or neurologic complaints.
• Relatively effortless performance on simple drawing tests is expected by
age 10-12.
• There is usually relatively high correlation with constructional performance
and measured intelligence in children.

42. • As with any skilled motor activity, both initial exposure and repeated
practice affect the ability to reproduce the paper and pencil designs or
complete block constructions.
• Social deprivation and a lack of academic experience do, therefore have
detrimental effect on constructional performance
• Therefore be careful in interpreting performance in retarted or poor
academic background