Bedside cognitive examination –
beyond the MMSE
Dr Richard Perry
Dept of Neurosciences
Imperial College
Overview
• Initial observations
• Cognitive rating scales
• Assessing cognitive domains
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Memory
Language
Visuospatial function
Praxis
Executive function and social behaviour
Initial observations
• Initial presentation – self presentation, or brought
• How they walk
– Gait pattern, speed of movement
• Head turning sign
• First symptom
• Behaviour and personality changes – interview
informant
Cognitive rating scales
• MMSE
• ACE-R
• MoCA
Mini Mental State Examination
Folstein et al 1975
• Most widely used screening
tool
• Takes 8 – 10 minutes
Advantages
Disadvantages
Ease of administration
Poor on speed of processing and
executive function
Comparable across testing centres
Minimal assessment of memory
Suitable for longitudinal assessment
Ceiling effect in MCI or FTD
Quick
Limited inter and intra rater
reliability
Addenbrooke’s Cognitive Examination - Revised
• Includes subtests of MMSE but expanded to include more
detailed tests to provide domain scores for memory, attention
and orientation, fluency, language, and visuospatial function
• Scored / 100
• 20-25 minutes to administer
• Cut-off score of 88 has sensitivity for dementia of 94% and
specificity of 89%
• Lower cut-off score of 82% has higher specificity without major
loss of sensitivity
• Combination of ACE-R plus 2 epsodic memory tests has good
predictive power for conversion of aMCI to AD
ACE-R
Montreal Cognitive Assessment (MoCA)
• 10-15 minutes
• Score / 30
• Better sensitivity than MMSE for
MCI
• Needs more clarity about cutoff
scores?
• Mean score of normal population
26-27
• Cutoff at 26 gives high sensitivity
but low specificity
• Suggested guide is <22 for MCI,
AD < 17
Assessing different cognitive domains
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Memory
Language
Visuospatial function
Praxis
Executive function
Social behaviour
cortical or subcortical
Cortical
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Episodic memory
Praxis
Language
Visuospatial
Executive function
Subcortical
• Processing speed
• Working memory
• Executive function
Orientation
• Orientation section of MMSE adequate for space and
time
• Note disorientation to person suspicious for nonorganic disorder
– Catch is severely and suddenly aphasic patients
Memory
- memory is not a unitary process
Declarative memory
Anterograde memory
Working memory
Retrograde memory
Explicit memory
Recall memory
Semantic memory
Implicit memory
Long-term memory
Procedural memory
Episodic memory
Short-term memory
Episodic Memory
memory
explicit
implicit
long term
short term
episodic semantic working
Episodic Memory
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65 yr old man attended with his wife
Two year history of gradual onset
difficulty in memory for day-to-day
things.
Forgets to take messages
Forgets where car parked
Wife thinks that he is more repetitive
Continues to work part time, manages
hobbies and finances
• Bedside testing
• History
• MMSE poor
• ACE and MoCA better
CANTAB Mobile memory screening tool
•Episodic memory test – PAL
(Paired Associates Learning)
•Geriatric Depression Scale
•Activities of Daily Living
•Can be administered by nonmedical staff in 10 mins
•Sensitive to MCI
•Visual modality
•Different languages
Working memory
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Refers to the ability to temporarily maintain and manipulate information
that one needs to keep on-line
Traditionally divided into components that process phonologic
information (e.g phone number in head) and components that process
visual (mentally following a route) with ‘central executive’
• Overlap with attention
• Overlap with episodic memory – poor working memory leads to faulty encoding
• Bedside task – digit span, forwards and back
Semantic memory
• General store of conceptual and factual knowledge
– e.g. Colour of a banana, name of the Prime Minister, capital of
France
– Not person or time specific – culturally shared
– Spared in pure amnesic states such as Korsakoffs’ syndrome
– Inferolateral and anterior
temporal lobe neocortex a
key substrate for semantic
memory
Semantic memory
65 yr old priest
2 yr history of difficulty remembering
what things are called
Day-to-day memory intact e.g
conversations, appointments, recent family
events
Speech fluent but empty – thing, place,
doing etc
Unable to remember the names of the
twelve disciples or books of New Testament
Diagnosis: Semantic Dementia – a progressive
neurodegenerative condition characterised by
progressive loss of semantic memory
Testing semantic memory at the bedside
– Observation of speech – fluent, empty,
circumlocutions
– Naming objects, line drawings, providing
semantic information about them
– Verbal fluency for categories e.g. animals,
tools, fruit etc.
– Direct questions - e.g. what colour is
grass, where do elephants live
– Reading irregular words – surface
dyslexia
– Knowledge of famous faces
Language
Listen for:
– Aphasia vs Dysarthria
– Fluent or non-fluent
– Grammatically correct
– Paraphasic errors – semantic,
phonemic
– Impairment of prosody
Language
• Testing at bedside
– Comprehension – single and multiple stage commands
– Repetition – simple words such as toaster, then more
complicated words such as catastrophe, then sentences e.g.
the Chinese emperor’s new fan
– Naming – objects or drawings
– Reading – note educational factors
– Writing and spelling
Progressive aphasia
Non-fluent
Adynamic
Behaviour and
personality
Think:
FTD (Pick’s)
PSP
Fluent
Empty, anomic
Behaviour
Think: SD
Non-fluent
Logopaenic
Agrammatic
Acalculia
Apraxia
Gerstman’s
Think:
AD
CBD
Dot counting
Visuospatial function
Scene description
Copying line drawings
Naming objects
Naming faces
Degraded letters
Visuospatial function
62 yr old man
Difficulty in proof reading
Difficulty in telling time from
clock
Digital clock OK
Couldn’t see things right in
front of him
18 F FDG PET
11C PIB PET
Praxis and apraxia
• Inability to perform skilled motor movements in the absence of
deficit of power or sensation
• Although usually associated with lesions in the left parietal lobe,
apraxia may also be seen after lesions to the right parietal lobe,
frontal lobes and subcortical structures in the basal ganglia.
• Terminology of subtypes of apraxia confusing and not often
relevant in clinical practice
Praxis and apraxia
Praxis is a predominantly cortical function
Should be normal in psychiatric disease
Look for associated myoclonus
Look for extrapyramidal features
Executive function
• not synonymous with frontal lobe
function
• at the bedside:
– verbal fluency - letters and
categories
– backward digit span
– proverbs
– cognitive estimates
– go-no-go tasks
– alternating hand-movements
– Luria 3-step
Summary and conclusions
• Possible to get quantative assessment at
bedside of many cognitive and behavioural
functions with minimum props
• Keep in mind which brain areas are affected
• Keep question of cortical or subcortical in
mind
• Keep question of organic / functional or
neurological / psychiatric in mind
Acknowledgements
• Dr Angus Kennedy, CXH, London
• Dr Paul Bentley, CXH, London
• Dr Peter Garrard and Dementia Research Group, NHNN,
London
• Dr Bruce Miller, University of California, San Francisco
• Dr Bob Levenson, University of California, Berkeley