Cognitive Testing & Localization 1
COGNITIVE TESTING AND LOCALIZATION MADE RIDICULOUSLY SIMPLE
David F. Tang-Wai MDCM FRCPC
Assistant Professor (Neurology & Geriatric Medicine), University of Toronto
Geriatric Refresher Day, University of Western Ontario, London ON May 2, 2012
1. Cognitive testing involved examination of the various cognitive domains
•
Cognitive domains as examined on the Mini-Mental Status Examination (MMSE) and the Montreal Cognitive Assessment (MoCA)
Cognitive Domain
•
MMSE
MoCA
Orientation
Yes
Yes
Memory - Learning/Delayed recall
Yes
Yes
Attention
Yes
Yes
Language
Yes
Yes
Visuospatial
Yes
Yes
Executive Function
Yes
Yes
Neuropsychological testing involves detailed assessments of each cognitive domain
Cognitive Domain
Examples of Specific Neuropsychological Tests
Orientation
Memory - Learning/Delayed recall
Logical (story) memory, California adult verbal learning test
(CVLT), Free-cued recall
Attention
Reverse digit span, letter cancellation
Language
Boston Naming Test, Token Test (comprehension)
Visuospatial
Rey-O complex figure, block design
Executive Function
Wisconsin card sorting, Stroop, Trails Making Test
Cognitive Testing & Localization 2
2.
Each cognitive domain can be localized to a specific lobe in the brain
Executive Function
Memory
Language
Visuospatial
Arithmetic
Praxis
Facial
Recognition
Frontal
Temporal
Left Hemisphere
Biparietal &
occipial lobes
Left Parietal
Left parietal
Right temporal
Lobe in
brain
Figure
Sample
tests that
can examine
domain
3.
•
•
•
•
•
Modified Trails B
Digit span
WORLD/serial 7s
Verbal fluency
Letter cancelation
• Orientation
• Learning &
delayed recall
•
•
•
•
•
•
Reading
Writing
Naming
Comprehension
Repetition
Semantic
fluency
• Cube copy
• Pentagons
copy
• Calculations
(simple
arithmetic)
• Ask patient to
show how to...
• Identify famous
faces
Localization can be further refined to a specific area within a lobe of the brain
Memory
Reading, wRiting,
aRithmetic
Facial recognition
Ideomotor praxis
Lobe
Temporal
Left parietal
Right temporal
Left parietal lobe
Where in
lobe
Hippocampus & Papez
circuit
Angular & supramarginal
gyrus
Inferior fusiform & lingual gyrus
Inferior parietal lobule
Disorders
to consider
if first
presenting
symptom
Alzheimer’s dementia
Alzheimer’s dementia
(posterior cortical atrophy)
Frontotemporal dementia - right
temporal variant
Corticobasal syndrome
Cognitive Testing & Localization 3
Memory
Reading, wRiting,
aRithmetic
Facial recognition
Ideomotor praxis
Figure
Language Localization (left hemisphere)
Repetition
Lobe
Left perisylvian area
Comprehension
Left parietal/temporal
Fluency
Spontaneous speech - Left
frontal lobe
Letter fluency (green)
Semantic fluency (red)
Figure
Naming
Left temporal
Writing
Left parietal (see
previous)
Cognitive Testing & Localization 4
Frontal lobe syndromes
Dorsolateral
Function
• Poor organizational strategies, problem
solving, planning, shifting and maintaining
sets, verbal working memory, and reduced
verbal fluency
Orbitofrontal
Anterior Cingulate
• Personality change: tactlessness,
obsessive compulsive disorder;
decreased empathy, socially
inappropriate behavior;
impulsive behavior; inappropriate
jocular affect; emotional lability;
poor judgment & insight;
distractibility; increased sweets
• Apathy, little display of emotions,
decreased motivated behavior/
creative thought, failure of response
initiation/suppression, poor response
inhibition; lack of concern of
personal hygiene, appearing
unkempt
Figure
4.
Guidelines to interpret cognitive testing - determining patterns
1.1.
Look at the affected cognitive domains in addition to the total score - this will help determine the pattern of impairment and localization
within the brain
1.2.
Recall where the cognitive domains are localized within the brain
Executive function
Localization
1.3.
Frontal lobe
Memory
Temporal lobe (hippocampus/
Papez circuit)
Language
Left hemiphere
Common patterns seen on cognitive testing and representative dementing disorders
Visuospatial
Mainly right temporoparietal
lobes
Cognitive Testing & Localization 5
Problems Seen on Testing
Orientation
Delayed word recall
Pattern Suggestive Of
Amnestic
Examples of Disorders
• Amnestic mild cognitive impairment
• Alzheimer’s dementia
Attention
3-step command
Learning (many trials)
Trials B (MoCA)
Letter fluency
Executive dysfunction
Frontosubcortical
Intersecting pentagons
Necker cube
Visuospatial
• Posterior cortical atrophy
• Alzheimer’s dementia
• Dementia with Lewy bodies
Aphasia
• Primary progressive aphasia
• Semantic dementia
Naming
Semantic fluency
Writing
Comprehension
Normal cognitive testing but change in behaviour
1.4.
Disinhibition or apathy behaviour
• Vascular cognitive impairment
• Parkinson’s disease
• Dementia with Lewy bodies
• Behavioural variant frontotemporal dementia
In addition to the clinical history and the pattern of cognitive testing, a diagnosis can be made
Sample Cases
Cognitive Testing Result
Diagnosis
Case 1: 58 year-old man with 2 year history of
progressive memory loss and impairment with his
instrumental activities of daily living
MMSE = 22/30
Orientation 7/10; Learning 3/3 in 1 trial; Attention
5/5; Recall 0/3; Language 8/8; Pentagon copy 1/1
Alzheimer’s dementia
Cognitive testing revealed a primary amnestic
pattern. Given the history of anterograde memory
impairment with functional impairment, the clinical
scenario is one of Alzheimer’s dementia.
Case 2: 88 year-old woman with 5 year history of
progressive memory impairment, getting lost,
unable to cook and balance the finances. No
cerebrovascular risk factors or history of stroke.
MMSE = 18/30
Orientation 7/10; Learning 3/3 in 2 trials; Attention
2/5 (WORLD); Recall 0/3; Language 6/8; Pentagon
copy 0/1
Alzheimer’s dementia - severe
Cognitive testing revealed deficits in multiple
domains. Given the history of anterograde memory
impairment and other cognitive impairments
associated with functional impairment, the clinical
scenario is one of a moderate-to-severe
Alzheimer’s dementia.
Cognitive Testing & Localization 6
Sample Cases
Cognitive Testing Result
Diagnosis
Case 3: 56 year-old with 5 year history of
progressive apathy, emotional blunting, mental
rigidity and dismissed from his job for “slacking off”
MMSE = 30/30
Frontotemporal dementia - behavioural variant
Cognitive screening was normal. The clinical
history is primarily a change in personality and
behaviour and is associated with an impairment
with his iADLs (work). In FTD, especially the
behavioural and executive dysfunction
presentations, the cognitive testing can be normal
or mildly impaired early in the disease.
Case 4: 74 year-old woman presenting with visual
hallucinations, slowness in thought, shuffling gait,
and “memory” problems of 1 year in duration
MMSE = 25/30
Orientation 10/10; Learning 3/3 in 5 trials; Attention
3/5 (WORLD); Recall 3/3; Language 8/8; Pentagon
copy 0/1
Dementia with Lewy Bodies
Cognitive testing revealed intact memory but
difficulties with attention/executive function
(WORLD), frontosubcortical slowing (excess
number of trials to learn 3 words), and visuospatial
dysfunction. With the history of parkinsonism,
visual hallucinations and some cognitive
impairment, the clinical scenario is consistent with
DLB.
Case 5: 78 year-old math teacher with known
Alzheimer’s disease presents with acute confusion.
Previous MMSE 26/30 days prior to ictus
Orientation 9/10; Learning 3/3 in 1 trials; Attention
5/5 (serial 7’s); Recall 0/3; Language 8/8; Pentagon
copy 1/1
Acute left parietal stroke
Repeat cognitive testing revealed sudden decline
with visuospatial and serial 7s (a crude measure of
calculations). These functions localize to the left
parietal lobe. Given the sudden change, this man
had a stroke in the same area.
MMSE on admission = 20/30
Orientation 9/10; Learning 3/3 in 1 trials; Attention
0/5 (serial 7’s); Recall 0/3; Language 8/8; Pentagon
copy 0/1
Cognitive Testing & Localization 7