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Bedside Cognitive Assessment – a practical workshop

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1 Bedside Cognitive Assessment – a practical workshop
MRCPsych Training Programme Bedside Cognitive Assessment – a practical workshop Friday 6th June, 2014 Dr Rupert Noad Department of Neuropsychology, Derriford Hospital, Plymouth

2 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

3 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

4 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

5 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

6 Where might ‘brain variables’ inform your psychiatric/psychological formulation?
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 6

7 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

8 Biopsychosocial approach
Brain disorders are complex involving triad of: Physical Cognitive Emotional Biological But Many other secondary consequences e.g. family dynamics, loss that can underpin individuals’ difficulties Social Psychological

9 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?

10 A practical way of thinking…
Presence versus absence Lateralisation Focal versus diffuse Acute/progressive versus chronic/static Aetiology/prognosis/implications

11 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?

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

13 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?

14 A clinical approach…..

15 A framework for assessing cognition
5 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

16 Domain e.g. memory Stage 1: Questions for patient/carer
Stage 2: Observations in the room of amnesia? Stage 3: Informal tests of memory e.g. recent events, tea Stage 4: Bedside cognitive assessments e.g. address from ACE-R, MMSE Stage 5: Formal Neuropsychological assessment e.g. Camden, WMS

17 The Bedside Cognitive Assessment Tool (BCAT)

18 BCAT – Attention Months of the year Forwards Backwards

19 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

20 BCAT – Orientation Date, Month, Year, Day City, Building, Floor/Level

21 Orientation Need to establish orientation to Person, Place, Time and Situation What causes poor orientation?

22 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…..

23 Memory

24 BCAT – Episodic Memory Name and Address: Linda Clark 59 Meadow Close
Milford Surrey Word List: FACE, VELVET, CHURCH, DAISY, RED Figure Copy Faces


26 BCAT – Facial recognition memory

27 BCAT – Remote Memory Dead or Alive: ELVIS PRESLEY TONY BLAIR

28 BCAT – Semantic Memory What do the following words mean? UMBRELLA

29 BCAT – Working Memory Digit Span Forwards Backwards

30 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.

31 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

32 In clinic – episodic memory
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

33 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.

34 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


36 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) 36

37 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.

38 Language

39 BCAT – Expressive Aphasia
Naming: “What is this?”

40 BCAT – Repetition Repeat after me: “Above, beyond and below”
PROSPER GARDEN PORCUPINE ECCENTRICITY “Above, beyond and below” “Today is a sunny and windy day”

41 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

42 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

43 Language Divided into different processes;
Expressive language - production Receptive language - comprehension Plus reading and writing

44 Disease affecting language
Stroke Frontal temporal dementia Corticobasal degeneration Head Injury Need to differentiate dysarthria from dysphasia

45 Expressive aphasia 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”

46 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?”

47 Apraxia

48 BCAT – Apraxia Melokinetic Buccolingual Ideomotor Ideational
“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.”

49 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”

50 Ideomotor apraxia In clinic
Does 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)


52 Figure 1: Hand movements in apraxia. Reproduced from: Goldberg G
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. Kipps, C M et al. J Neurol Neurosurg Psychiatry 2005;76:i22-30i Copyright ©2005 BMJ Publishing Group Ltd.

53 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

54 BCAT – Prosopagnosia Can you tell me who these people are?

55 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.

56 Visual inattention/Neglect
Neglect of extrapersonal space Patients 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/Anosognosia In its most profound form, patients deny the presence of hemiplegia despite evidence to the contrary.

57 BCAT – Neglect Clock Drawing Image Copy

58 Figure 2 Impaired clock face drawings in dementia.
Kipps, C M et al. J Neurol Neurosurg Psychiatry 2005;76:i22-30i Copyright ©2005 BMJ Publishing Group Ltd.

59 Frontal Lobes/Executive

60 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

61 BCAT – Executive Functioning (cont.)
Multiple Loops Alternating Sequence M’s and N’s

62 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 ………

63 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.

64 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).

65 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.

66 Don’t forget the psychiatric perspective!
Cognitive symptoms associated with mental health disorders: Anxiety Low mood/depression PTSD Psychosis

67 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

68 The science/art To be able to use cognitive data to help in the conceptualisation/diagnosis of a patients clinical problem Biological Psychological Social

69 Can you remember?... The name and address The list of words
The three figures you copied

70 Great Resources 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.

71 Thank You Any questions?

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