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HIGHER MENTAL FUNCTION EXAMINATION(PART1)
- 1. Dr. ASHUTOSH RATH DM NEUROLOGY RESIDENT GMCH,GUWAHATI 1
- 5. DORSAL CONVEXITY DYSEXECUTIVE SYNDROME ORBITOFRONTAL DISINHIBITION SYNDROME MEDIAL FRONTAL APATHETIC SYNDROME
- 6. FRONTAL DYSEXECUTIVE SYNDROME • POOR ORGANIZATION • PLANNING • IMPAIRED COGNITIVE RESPONSE • ABSRACTION AND JUDGEMENTS ORBITOFRONTAL DISINHIBITORY SYNDROME • SOCIALLY INAPPROPRIATE BEHAVIOUR • LOSS OF MANNERS AND DECORUM • IMPULSIVE RASH & CARELESS ACTIONS APATHETIC SYNDROME OF THE MEDIAL FRONTAL LOBE • LACK OF INTIATIVE AND REDUCED MOTIVATION • SOCIAL ISOLATION
- 7. • TOWER OF LONDON TEST • PROTEUS MAZE TEST 1.TEST OF PLANNING • STROOP • GO-NO-GO • ANTI-SACCADE TEST 2.TESTS OF RESPONSE INHIBITION • TRAIL B TEST(REITAN’S) • WISCONCIN CARD SORTING TEST 3.TESTS OF MENTAL FLEXIBILITY • WORD F • SEMANTIC F • DESIGN F 4.TESTS OF FLUENCY • GRAPHIC • MOTOR • CONCEPTUAL SERIES COMPLETION 5.TESTS OF SEQUENCING
- 8. • PROVERB INTERPRETATION 6.ABSTRACT THINKING • TAP ‘A’ TEST • RANDOM LETTER CANCELLATION TEST 7.ATTENTION & CONCENTRATION • DIGIT BACKWARD TEST • LETTER NUMBER SPAN TEST 8.WORKING MEMEORY • MOTOR IMPERSISTENCE • MOTOR PERSEVERATION • ECHOPRAXIA 9.TESTS OF INTENTIONAL MOTOR SYSYTEM
- 9. TOWER OF LONDON TEST • Build a tower according to specified arrangements • Fewest number of possible steps • Move one piece at a time
- 11. PROTEUS MAZE TEST • Plan strategy for route finding • Pts with deficits make numerous errors • Increasingly difficult mazes are used • Error- new cleaner version is given • Pts with executive dysfunction will repeat the identical route they used initially
- 13. StRoop test • Response inhibition 1. Distraction 2. Selective attention 3. Response conflict
- 15. “Go-no-go test “of Luria • Response inhibition & initiation • Raise 2 fingers on hearing 1 tap • Raise 1 finger on hearing 2 taps Modifications : • Eg.Tap your feet on hearing “A”
- 16. WISCONSIN CARD SORTING TEST • Grant & Berg • Mental flexibility and set shifting • 3 stimulus parameters 1. Colour 2. Shape 3. Number INSTRUCTION: • respondents are told to match the cards but not how to match. • But he will be told if he is right or wrong
- 19. REITAN’S TRAIL MAKING TEST • Trail A(25 encircled numbers ): Processing speed • Trail B(25 encircled numbers & letters) Set shifting(mental flexibility) Attention Scanning Sequencing Shifting Execute & modify plan Maintain 2 train of thoughts
- 22. FLUENCY TESTS
- 24. • PHONEMIC VERBAL FLUENCY(FAS TEST)PVF As many words beginning with a single letter as possible in 1 min(F A S) Norm: 14±5 • SEMANTIC (CATEGORY)VERBAL FLUENCY(SVF) Eg.animals or fruits or birds in 1 min Norm: 14 ± 5
- 25. FLUENCY TESTS(cont…) DESIGN FLUENCY TEST • As many designs possible with the given set of dots within a fixed time limit.
- 27. SEQUENCE TESTS OF LURIA MOTOR SEQUENCING: 1 hand at a time 1. Fist edge palm 2. Fist ring test 3. Finger counting
- 28. SEQUENCE TESTS OF LURIA(cont..) GRAPHIC SEQUENCING
- 29. SEQUENCE TESTS OF LURIA(cont..) • SERIES COMPLETION TEST • Eg.1,3,5………………… • Cat-tac,man-nam,big-………………. • A1,B2,C3…………………
- 30. ABSTRACT THINKING 1. PROVERB INTERPRETATION 2. SIMILARITIES (table & chair, mango & banana)
- 31. LETTER NUMBER SPAN TEST
- 32. TAP A TEST • ATTENTION & CONCENTRATION • Pt is read a series of random letters • Tap when you hear A
- 33. RANDOM LETTER CANCELLATION TEST • Attention • Visual search and mental speed
- 35. TESTS OF INTENTIONAL MOTOR SYSTEM • MOTOR PERSEVERATION Luria motor,graphic,tap a etc • MOTOR IMPERSISTENSE 1. Hold the arm outstretched for 20 seconds 2. Protrude your tongue 3. Grip my finger with your hand 4. Maintaining the conjugate fixed in a particular direction.
- 36. TESTS OF INTENTIONAL MOTOR SYSTEM(CONT…) • ECHOPRAXIA Show 2 fingers when I show 1 finger and 1 finger I show 2 fingers Pt repeats whatever the examiner does
- 37. MEMORY
- 39. FILLING CLERK RECENT FILE CAB REMOTE MEMORY
- 40. (IMMEDIATE)WORKING MEMORY FORWARD DIGIT SPAN 1. Repeat non-sequential numbers (e.g not even numbers or not in any known pattern) 2. Start with 1 digit and after the patient successfully repeats it, is asked to repeat increasing number of digits 3. Repetition upto 5 digits is considered as normal BACKWARD DIGIT SPAN 1. 1 & 2 same 2. Repetition upto 3 digits is considered as normal
- 43. RECENT MEMORY • 3-5 Mins Word Recall • Details Of Breakfast, Admission Date Etc • Retrieving A STORY/ADDRESS After 3-5 Mins. VISUAL MEMORY: • 5 easily recognizable objects are hidden in the vicinity while the pt is observing • Distraction • Ask to locate them after 3-5 mins
- 45. Cues for recall
- 46. PAIRED ASSOCIATION MEMORY • ASSESSMENT OF NEW LEARNING ABILITY • Pt is p/w 4 word pairs • 2 related & 2 unrelated • After presentation the examiner repeats the 1 st word of each pair • <70 yrs: 2 related and atleast 1 unrelated pair EG: BOOK-PAGE SCHOOL-TAPE GLASS-WATER PENCIL-SPOON
- 47. REMOTE MEMORY • Details of schooling • Years of passing examinations • Date of retirement SEMANTIC MEMORY • Facts, concepts & gen.Knowledge. Color of elephant No.Of days in a week Author of ramamyana 1st prime minister of india
- 48. LANGUAGE
- 49. TERMINOLOGIES • Complex system of articulation & phonation of thoughts inside our mind.LANGUAGE • Disorder of language AQUIRED secondary to brain damage.APHASIA • DEVELOPEMENTAL language disordersDYSPHASIA • Articulation & phonation of language sounds.SPEECH • DISORDERS OF ARTICULATION of single sounds.DYSARTHRIA
- 50. • Smallest unit of sound • Eg. Ba & tPHONEMES • Smallest meaningful unit of language. • Eg. BatMORPHEMES • Rules applied to construction of phrases and sentencesSYNTAX • word?/phrase meaningSEMANTICS • Internal dictionary/vocabulary of a person LEXICON • Meaning in the contextPRAGMATICS • Intonation of speechPROSODY
- 52. LINGUISTIC ABNORMALITIES AGRAMMATISM • Difficulty with grammatical morpheme eg. Rapidly vs rapid (usage and understanding) • Better with lexical morphemes.eg. Rapid • CONTENT WORDS are fine(noun,verbs- cats ,dog,bat) • FUNCTIONAL WORDS bad(on,at,shall, may) • SEMANTIC MAINTAINED,GRAMMAR IMPAIRED • Telegraphic speech • Eg.Broca’s aphasia PARAGRAMMATISM • Overuse of grammatical elements • More functional words and less content words (no meaning) • Defining limits of sentences absent.(exceessive verbal output) • Eg. Wernicke’s aphasia
- 53. PHONEMIC PARAPHASIAS • one /few phonemes substituteD • Literal paraphasia • More than half of intended word produced • HEN for PEN NEOLOGISM • Multiple phonemic substitutions • Less than half of intended word produced • Meaningless • HIPPOPOTAMUS - TIKKOTOKKAGUS VERBAL PARAPHASIAS • SEMANTIC paraphasia • Meaningful but nearly wrong word • CAR for VAN PARAPHASIAS • Substitution within a language
- 54. APHASIAS Aquired disturbance of comprehension and formulation of language caused by dysfunction of language areas.
- 57. AUDITARY PHONEME PERCEPTION SYSTEM • SUPERIOR TEMPORAL GYRUS • 1st stage • Analyze phoneme independent of word meaning • Bilateral representation INTERNAL SEMANTIC SYSTEM • ANTEROLATERAL TEMPORAL LOBE & ANGULAR GYRUS • 2nd stage • Word meaning system PHONOLOGICAL/LEXICAL RETRIEVAL SYATEM • CLASSICAL WERNICKES AREA & SUPRAMARGINAL GYRUS OF PARIETAL LOBE(22 & 40) • Actiavating knowledge about the sequence of phonemes . • Final Mental stage prior to the motor speech
- 61. Anterior language area • Brocas area is constituted by 44,45, (posterior part of the inferior frontal gyrus)surrounding frontal area , underlying frontal white matter and the caudate nucleus.
- 62. TEST INCLUDED 1. SPONTANEOUS SPEECH(fluency) 2. COMPREHENSION 3. REPETITION 4. NAMING 5. READING 6. WRITING
- 63. SPONATANEOUS SPEECH 1. Fluency: Q. reason for hospitalization/interpretation of cookie theft picture/ten statements about a pen 1. 50-115/min-normal 2. >200-logorrheic 3. <50-non fluent 2. Prosody(INTONATION OF SPEECH) 3. Grammar & syntax 4. Phrase length(is it telegraphic) 5. Paraphasia 6. Circumlocution & word finding difficulty 7. Initiation difficulty 8. Content of speech
- 65. COMPREHENSION • 1,2,3 STEP COMMANDS 1. Point to a fan 2. Point to the fan and then the switch 3. Take a pencil wrap it in a paper and throw AVOID ORDERS THAT INVOLVES AXIAL MOVEMENTS • MARIE’S THREE PAPER TEST: • HERE ARE THREE PAPERS(BIG,MEDIUM & SMALL) 1. Crumple the big one and throw it on the ground 2. Give the medium one to me 3. Keep the small in your pocket
- 66. REPETITION • Single words • Sentence with min 3 words • Non-sense words: a word or sentense in another language • Nb: no.Of words should not exceed pts attention span
- 67. NAMING • Reasonably unfamiliar objects • If familiar object is used name the unfamiliar parts. Eg.Nib of pen, locket of a chain
- 70. DIAGNOSING APHASIA’S 1. FLUENT OR NON FLUENT?? 2. How’s the COMPREHENSION?? 3. How’s the REPETATION??
- 73. Aphasia rules • FLUENT APHASIA’S: wernicke’s, transcortical sensory, conduction & anomic • NON-FLUENT: broca’s, transcortical motor, global ,transcortical mixed • COMPREHENSION INTACT: broca’s ,transcortical motor, conduction, anomic • REPETITION INTACT: all transcortical aphasia’s & anomic • (Brocas + wernicke’s) PROBLEMS- global • (Brocas + wernicke’s) SOLUTIONS-conduction
- 74. Points to ponder…. BROCA’S APHASIA • AGRAMMATISM hallmark • Apraxia of speech • Comprehension is preserved???(eg. Ravana was killed by Ram) • True Broca’s –anterior language areas • Damage restricted to Broca’s l/t- APHEMIA WERNICKE’S APHASIA • FLUENT PARAPHASIC SPEECH(neologism- jargon/devil’s speech) • Involvement of all three posterior language systems. • Unaware of the problem
- 75. • BROCA’S + WERNICKES • Spontaneous speech , naming & repetition limited to a single PERSEVERSTIVE word • Non-fluent GLOBAL PAHASIA • Wernicke’s with relatively preserved comprehension • TIP OF THE TONGUE anomia • Arcuate fasciculus?? • PERISYLVIAN AREA(PHONEMIC/LEXICAL RETRIEVAL AREA) CONDUCTION APHASIA Aphasia: A clinical perspective DF Benson, DF Benson, A Ardila - 1996
- 77. INTACT REPETITION……… TRANSCORTICAL MOTOR • BROCA’S with preserved repetition • Lesions surrounding Broca’s area TRANSCORTICAL SENSORY • WERNICKE’S with preserved repetition • damage TO THE INTERNAL SEMANTIC SYATEM MIXED TRANSCORTICAL • GLOBAL with intact sentence repetition • Appear Echolalic • Lesions surrounding Broica’a & Wernicke’s but sparing both.(ISOLATION OF SPEECH AREAS)
- 79. PURE WORD DEAFNESS(PWD) • Auditory VERBAL AGNOSIA • Damage To Bilateral auditory phoneme identification system(hence rare) • CAN NOT HEAR WORDS • CAN HEAR non- verbal sounds • Read them & write them too PWD
- 80. APRAXIA OF SPEECH • Slow ,deliberate, effortful, dysprosodic speech • Trying to find the correct pronunciation by trial & error APRAXIA OF SPEECH • Monosyllable repetitions good • Polysyllable impaired • Inconsistent mispronunciation DYSARTHRIA • Word distortion irrespective of length • Mispronunciation is consistent
- 81. SUBCORTICAL APHASIAS MARIE’S QUADRILATERAL SPACE APHASIAS • Acute mutism • Ext capsule,claustrum,putamen & insula STRIATOCAPSULAR APHASIA • Head of caudate and putamen-dysarthria • AL of IC-Aphemia(broca’s) • PL of IC-wernicke’s like THALLAMIC APHASIA • Transcortical sensory aphasia
- 82. READING AND WRITING : ALEXIA and AGRAPHIA • VWFA-visual word form area • Equivalent to Auditory phoneme perception area. • Left occipito-temporal sulcus & left fusiform gyrus.
- 83. VWFA
- 84. Reading with comprehension • Visual information from the left occipital lobe reaches directly the left fusiform gyrus. • From the rt occipital lobe has to cross over to (corpus callosum)reach the left fusiform GYRUS. • ANGULAR GYRUS- interpreetation of visual- verbal materials.
- 85. Reading aloud
- 86. ALEXIA WITHOUT AGRAPHIA • PURE/POSTERIOR ALEXIA • CAN NOT : read and understand • CAN UNDERSTAND: words spelled aloud, written on the palm • Visual function intact(Naming objects) • left occipital lobe with splenium • Left PCA infarcts ALEXIA WITH AGRAPHIA • CENTRAL ALEXIA • Aquired illiteracy • Unable to read or write • Dominant ANGULAR gyrus
- 87. Al-Ag
- 89. Al+Ag
- 90. Third alexia • Inability to comprehend syntax • “Ravana was killed by rama” vs “ Rama killed Ravana” • Seen in Broca’s aphasia
- 91. Other alexias SURFACE ALEXIA • Grapheme to phoneme conversion problem • Irregular orthography • CAN read: mint,dog,cat • CAN NOT read: pint, dough, laugh • PARALEXIA(DEEP) • Problem of READIN ALOUD • SEMANTIC paralexia –m.c • Eg: infant read as baby
- 92. Agraphia • anterior(BROCA’s)-agrammatism with spelling mistakes • Posterior(WERNICKE’S)-unintelligible & non- sensical Aphasic agraphia • Correct letters and words • Problem with orientation • eg,. Moving on to the next line, wider space on one side Visuospatial agraphia • Language fromation is correct along with spatial arrangement • Handwriting loses its personal characters. Apraxic agraphia
Editor's Notes
- Ventral part: social cognition DLPFC:selective attention working memory MEDIAL PFC: motivation & initiation
- FDS subcortical dementia. Does not necessarily mean that the lesion has to be in the frontal lobe. Executive function: goal oriented activity thet requires planning,initiation,response inhibition, mental flexibility(SET SHIFTING), working memory and fluency.
- Antisaccades test
- Read the words Read the colours
- Image cam scanner
- Image camscanner
- Comon mistakes performed by pts. Not shifting from numbers
- Levels of increasing difficulty
- Image camscanner
- Bedside testing , 4 dots can be given
- Demonstrate them . Perform it with me..1-2 times…do it on ur own
- Mountain valleys plateau Spirals M & N Mountains & plateaus. No.of mountains can be increased sequentially
- LEFT MEDIAL FRONTAL LOBE
- Mistakes like : they re the same thing,start describing the objects Instead of saying they are fruits they say both are yellow
- IMAGE CAM SCANNER
- Cancel or circle all the c’s
- DEMONSTRATE
- SENSORY MEMORY is the shortest-term element of memory. It is the ability to retain impressions of sensory information after the original stimuli have ended. ... For example, the ability to look at something and remember what it looked like with just a second of observation is an example of sensory memory Working memory: remembering the phone no before dialling or remembering the OTP before entering them
- Filling clerk is the –PFC guides the storage and retrieval of memory Recent memory file cabinet-medial temporal lobe (storage of recent memory) Remote memory-cortex. Long term storage.
- TESTS REGISTRATION
- PROCEDURE FOR STORY RETRIEVAL.
- Lexical morphemes: dog, fast Grammatical morphemes: affix-faster,connectors- neither
- AG-39,SMG-40,PMA-41,WA-22,BA-44,45
- Conventionally means wernickes area. But functional neuroimaging have found otherwise
- Bilateral localization hence difficult to destroy Location and function of the three areas Fusiform gyrus serves as the phoneme perception system for visual language while reading
- Mapping of the phoneme sesequences to their meaning in the internal semantic system Repetition : input from the phoneme perception system directly to the phoneme retrieval system bypassing the internal semsntic system justifying the fact we don’t have to understand words inorder to tepeat them
- Similarly reading aloud involves phoneme percetion visually through the fusiform gyrus(the visual counterpart for the auditory phoneme system) Again this does no require understanding and is lot like repeatition in the circuitry For sponataneous speech retrieval of the word meaning from the semantic system onto the phonological retrieval system Naming also involves a similar path.
- Brocas area is constituted by 44,45, (posterior part of the inferior frontal gyrus)surrounding frontal area , underlying frontal white matter and the caudate nucleus. Exners writing area: posterior part of the middle frontal gyrus
- ABILITY TO UNDERSTAND.
- 3 animals & 3 musical instruments
- Boat,goat, boot,coat,bone,kite
- Naming is impaired in all.
- Mild transient speech disturbance with impaired prosody nd articulatory agility Why is repetition impaired in Broca;s then. Bcoz it’s the final pathwAY for speech output & the articulatory speech agility is impaired here.
- Conduction aphasia: logopenic variant of the PPA Phonemic/lexical retrieval area Hence comprehensiin is preserved
- Where is echolalia seen?
- Conventionally means wernickes area. But functional neuroimaging have found otherwise
- ALSO important in color integration and facial recognition.
- Visual information from the left occipital lobe reaches directly the left fusiform gyrus. From the rt occipital lobe has to cross over to (corpus callosum)reach the left fusiform GYRUS. ANGULAR GYRUS- interpreetation of visual-verbal materials.
- paralexia
- Copies written language as if it was a foreign language. Color naming impaired
- Explaination:
- Like wernicke’s where reading is impaired more than auditory perception
- Aquired abnormalities of writing: agraphia
- They have been asked to describe the cookie jar picture.