Bedside Cognitive Assessment – a practical workshop

Friday 6th June, 2014

Dr Rupert NoadDepartment of Neuropsychology, Derriford Hospital, Plymouthrupert.noad@nhs.net

MRCPsych Training Programme

Aims and objectives

• Introduction to Neuropsychology• Understanding of the role cognitive assessment

can play in clinical work• Understanding of different cognitive domains• Understanding of a clinical approach to assessing

cognition• Experience of administering a bedside cognitive

assessment battery

What is Neuropsychology?

• Neuropsychology is concerned with the relationship between brain and behaviour – i.e. how brain functions are organised

• Attempts to understand how mechanisms within the brain influence thinking, learning and emotions

• Neuropsychologists are particularly interested in how brain damage changes behaviour

• This tells us about normal brain functioning e.g. WWI – lots of focal injuries

Neuropsychologists…..

• Aim to apply principles of brain-behaviour relationships to help patients understand their difficulties

• Specialist neuropsychological assessments are used to test patients’ cognition and examine different brain functions

• Neuropsychology knowledge is used as part of a psychological formulation of a patient’s difficulties

The aim is to…

• Have a good understanding of the way brain damage may impact on someone’s cognition

• Have a good understanding of the way cognitive problems may affects someone's everyday functioning

• What the psychological consequences of a disease may be and how they may manifest

• What other explanations could be causing the cognitive symptoms being reported – in particular psychological difficulties

Child - Why is this child under achieving at school?Adult – Differential diagnosis where neurological

condition is suspected e.g. early onset psychosis versus epilepsy?

Older adult - Differential diagnosis e.g. dementia versus depression?

LD - What is this person’s level of understanding

Other health, forensic, Neurorehab

Where might ‘brain variables’ inform your psychiatric/psychological formulation?

Typical questions• Does this person have cognitive difficulties and if so what

is the severity?• Is this patient declining in ability? • Establishing the effects of treatment - surgery or

radiotherapy• Are the person’s cognitive difficulties more related to

psychological factors such as depression• To validate patients’ experiences• Capacity for consent, work, school, and independent living• Medically Unexplained symptoms?• Adjustment, depression, anger, anxiety related to a

condition e.g. PD or Cavernoma

Biopsychosocial approachBrain disorders are complex involving triad of:• Physical • Cognitive • Emotional

Biological

Psychological Social

ButMany other secondary consequences e.g. family dynamics, loss that can underpin individuals’ difficulties

How do we understand Neuropsychological disorders?• Functional Neuroanatomy – what area of brain has been

affected and what does it do?• Cognitive Neuropsychology – how can the patient’s

symptoms be understood within cognitive models?• Clinical Neurology – what do we know about this disease

– are the symptoms typical?• Psychiatry/Clinical Psychology – what do we know about

the disease and its likely psychological consequences? What other factors, lifespan, systemic, childhood, financial etc. might be important?

A practical way of thinking…

• Presence versus absence• Lateralisation• Focal versus diffuse• Acute/progressive versus chronic/static• Aetiology/prognosis/implications

Exercise:

You have an orange, a newspaper and a pencil. How might you use these items to get an idea of someone’s cognitive abilities? What skills do you think you are able to test?

Cognitive abilities• Orientation• Intelligence• Memory - amnesia• Language – Aphasia, anomia• Executive functions• Apraxia• Attention – hemispheric neglect• Visuospatial ability – agnosia• Other - alexia, agraphia, acalculia, anarithmetrica

Making sense of cognition

Following the video…• What cognitive difficulties is she experiencing?• How can you make sense of these?• Which area of her brain may be being

affected?• What condition might cause this

presentation?

A clinical approach…..

A framework for assessing cognition5 steps:• The questions you ask the patient and carer• What you observe in the room• Informal tests of cognition• Bedside tests of cognition• Neuropsychological tests

Domain e.g. memory

Stage 1: Questions for patient/carerStage 2: Observations in the room of amnesia?Stage 3: Informal tests of memory e.g. recent events,

teaStage 4: Bedside cognitive assessments e.g. address

from ACE-R, MMSEStage 5: Formal Neuropsychological assessment e.g.

Camden, WMS

The Bedside Cognitive Assessment Tool (BCAT)

BCAT – Attention

• Months of the year– Forwards– Backwards

Attention

• Critical to establish basic attention before any cognitive assessment

• For example, critical for memory• Will be affected in disorders such as delirium,

head injury, sub-cortical disorders

BCAT – Orientation

• Date, Month, Year, Day• City, Building, Floor/Level

Orientation

Need to establish orientation to Person, Place, Time and Situation

What causes poor orientation?

Causes of poor orientation

• Delirium• Post traumatic amnesia• Drug effects• Amnesia – e.g.. Alzheimer's disease• Frontal lobe impairment• General confusion – e.g. unwell• Institutionalisation• Others…..

Memory

BCAT – Episodic Memory• Name and Address:

– Linda Clark59 Meadow CloseMilfordSurrey

• Word List:– FACE, VELVET, CHURCH, DAISY, RED

• Figure Copy

• Faces

BCAT - FACES

BCAT – Facial recognition memory

BCAT – Remote Memory

• Dead or Alive:– ELVIS PRESLEY– TONY BLAIR– MARTIN LUTHER KING JR.– MADONNA

BCAT – Semantic Memory

• What do the following words mean?– UMBRELLA– STAPLER– BREAKFAST

BCAT – Working Memory

• Digit Span– Forwards– Backwards

Memory

• The most common reasons for referral.• Divided into several domains;

• Episodic- personally experienced events.• Semantic- word meaning and general knowledge.• Working Memory- the limited capacity by which

we retain information for a few seconds.

Memory• Amnesia is a severe impairment in memory with intact

perception and intellectual functions

Memory impairments are causes by: Korsakoff's Syndrome • Alcoholic Blackout • Closed Head Injury • Electroconvulsive Therapy (ECT) • Transient Global Amnesia • Encephalitis • Dementia • Temporal Lobe Removals • Hysterical Amnesia

In clinic – episodic memory

In clinic• Recall of what had for main meal yesterday• Recall of what did for 17th birthday• What did you do on your last holiday?

• Gradient from recent events to remote events

Episodic Memory

• Depends upon the hippocampal-diencephalic system.

• Divided into anterograde and retrograde components.– Anterograde memory refers to the ability to recall newly

encountered information.– Retrograde memory refers to the ability to recall past

events.

Semantic memory

• Semantic memory is your total store of knowledge about yourself and the world

• Often loss of autobiographical information can be an indicator of a non-organic cognitive disorder

• However, there is semantic dementia as we have seen and retrograde memory loss e.g. post encephalitis can result in loss of semantic memory

• Tests in clinic - General knowledge, Dead or Alive test• Bits from pyramids and palm trees

Working Memory

• This refers to the very limited capacity which allows us to retain information for a few seconds

• Uses the dorsolateral prefrontal cortex.• Often appears as lapses in concentration and

attention (going into a room and forgetting the purpose)

Disorders of Working Memory

• Lapses in working memory are common and increase with age, depression and anxiety.

• Diseases which affect basal ganglia and white matter may present with predominantly working memory deficits.

Language

BCAT – Expressive Aphasia

• Naming:– “What is this?”

BCAT – Repetition

• Repeat after me:– PROSPER– GARDEN– PORCUPINE– ECCENTRICITY

• “Above, beyond and below”• “Today is a sunny and windy day”

BCAT – Receptive Aphasia

• Single Word Comprehension:– Point to:

• The source of illumination• Object used to tell the time• Object to sit on• Surface that you walk on• Entrance to the room

BCAT – Auditory Comprehension

• Answer YES or NO:– Is a hammer good for cutting wood?– Does a stone sink in water?– Do dogs fly?– Do you put on your socks after your shoes?– Do you peal a banana before eating it?

• Syntax– With the pencil touch the pen– Touch the pencil with the pen– With the pen touch the pencil– Touch the pen with the pencil

Language

Divided into different processes;• Expressive language - production• Receptive language - comprehension

• Plus reading and writing

Disease affecting language

• Stroke• Frontal temporal dementia• Corticobasal degeneration• Head Injury

Need to differentiate dysarthria from dysphasia

Expressive aphasia in clinic

In Clinic• Is the patient as fluent and articulate as normal? Has there

been a deterioration in grammar?• Is there a misuse of words (paraphasias -)? (semantic - clock

for watch) or phonemic - baby flitter for baby sitter)

Bedside tests• Word repetition: Use a series of words of increasing

complexity e.g hippopotamus, emerald, perimeter. Listen for phonemic paraphasias.

• Sentence repetition: use well known phrase “no ifs, ands or buts”

Receptive aphasia

In clinic• Does the patient have difficulty following complex

instructions?• Does he/she struggle to keep track of group conversations?• Does he/she find using the telephone particularly difficult?

Bedside tests• Use several common items (coin, pen, key) and ask patient to

point to one to assess single word comprehension.• Test sentence comprehension and syntax commands with

common items and commands e.g. “touch the pen” or “if the lion ate the tiger, who remained?”

Apraxia

BCAT – Apraxia

• Melokinetic– “Touch each finger tip of your right hand with the thumb

of your right hand.”• Buccolingual

– “Lick your lips”– “Blow up your cheeks”

• Ideomotor– Observe any clumsy action with pen use– Interlocking Finger Test

• Ideational– “Fold this piece of paper in half, write your name on it and

place it inside this book.”

Apraxia

Inability to perform a movement with a body part despite intact sensory and motor function - due to deficits in higher cortical control of movement

Can be:• Ideomotor – inability to draw or construct simple

configurations • Ideational - inability to create a plan for or idea of a

specific movement, for example, "pick up this pen and write down your name”

Ideomotor apraxiaIn clinicDoes patient have difficulty with tasks such as using a knife and

fork?Does patient have difficulty with dressing?

Bedside tests• Imitation of gestures, and gestures to command (e.g. wave,

salute)• Use of imaginal objects (comb your hair, brush your teeth).

Common error is to use body part as a tool (e.g. finger for toothbrush)

• Oral apraxia (blow out a candle, stick out your tongue)

Copyright ©2005 BMJ Publishing Group Ltd.

Kipps, C M et al. J Neurol Neurosurg Psychiatry 2005;76:i22-30i

Figure 1: Hand movements in apraxia. Reproduced from: Goldberg G. Imitation and matching of hand and finger postures. Neuroimage 2001;14:S132-6, with permission from Elsevier.

Agnosia

• Patient cannot recognise the meaning of visually presented objects

• Recognition sometimes better for real rather than imagined or lined drawings

• It is particularly associated with lesions of the left occipital lobe and temporal lobes

BCAT – Prosopagnosia

• Can you tell me who these people are?

Prosopagnosia

• A specific deficit in recognising familiar faces, sometimes even including own

• Patients can often appreciate the aspects of faces, such as age, gender or emotional expression.

Visual inattention/NeglectNeglect of extrapersonal spacePatients with focal right hemisphere lesions often fail to respond

to stimuli in the opposite half of extrapersonal space. May manifest as a failure to talk to visitors on the left side of the

bed, a tendency to ignore food on the left half of the plate, constantly bumping into objects on the neglected side

Bodily neglect/AnosognosiaIn its most profound form, patients deny the presence of

hemiplegia despite evidence to the contrary.

BCAT – Neglect

• Clock Drawing• Image Copy

Copyright ©2005 BMJ Publishing Group Ltd.

Kipps, C M et al. J Neurol Neurosurg Psychiatry 2005;76:i22-30i

Figure 2 Impaired clock face drawings in dementia.

Frontal Lobes/Executive

BCAT – Executive Functioning• Fluency

– ANIMALS & ‘B’• Proverbs

– A stitch in time saves nine– People in glass houses shouldn’t throw stones

• Conflicting instructions– Tap twice when I tap once– Tap once when I tap twice

• Go-No-Go tasks– Tap once when I tap once– DON’T Tap when I tap twice

BCAT – Executive Functioning (cont.)

• Multiple Loops

• Alternating Sequence

• M’s and N’s

BCAT – Executive Functioning (cont.)

• Hayling Test– Complete these sentences with the appropriate

word:• I put my shoes on and I tie my ………• It was raining cats and ………

– Complete these sentences with an inappropriate word:

• John bought candy at the ………• An eye for and eye, a tooth for a ………• I washed my clothes with water and ………

Frontal Lobe functioning

• Generally thought to be a (dorsolateral) frontal lobe function, although this set of skills is probably more widely distributed in the brain.

• Impairments relate to planning, judgement, problem solving, impulse control and abstract reasoning.

Disorders of Executive and frontal lobe function.• Brain injury• Alzheimer’s disease, even in early stages.• The majority of the frontal lobe is subcortical white

matter and the leucodystrophies, demyelination and vascular pathology all cause executive dysfunction.

• Basal ganglia disorders also impair executive skills e.g. progressive supranuclear palsy (PSP).

Exploring executive dysfunction in the clinical interview.• There are a broad range of skills encompassed by “executive

function” so it is worth testing in a number of different ways.• Has there been a drop off in performance at work or in

household tasks and hobbies? (reflecting impairment in sequencing and planning)

• Have any perseverative behaviours been noticed?• Are there any reports of poor judgement or an inability to

modify behaviour according to changing situations.• Appreciation of jokes and puns also depends on complex

abstracting ability and so is frequently affected.

Don’t forget the psychiatric perspective!

Cognitive symptoms associated with mental health disorders:

• Anxiety• Low mood/depression • PTSD• Psychosis

Summary

• Cognitive assessment can be very helpful• It can give you new types of data over and

above a clinical interview• However, the data is ‘soft’ and is dependent

upon the interpretation of the clinician• Neuropsychological assessment should be

FORMULATION driven not DATA driven

The science/art

To be able to use cognitive data to help in the conceptualisation/diagnosis of a patients clinical problem

Biological

PsychologicalSocial

Can you remember?...

• The name and address• The list of words• The three figures you copied

• Cognitive assessment for Clinicians – 2nd Ed (2007). John Hodges (in fact anything by John Hodges)

• Neuropsychological Neurology: The Neurocognitive Impairments of Neurological Disorders – Andrew J Larner

• Cognitive assessment for Clinicians (2001). Kipps and Hodges (JNNP) Supplement

• Concise Guide to Neuropsychiatry and Behavioral Neurology (second Ed) - Cummings and Trimble.

Great Resources

Thank YouAny questions?