Presentation on theme: "Bedside Cognitive Assessment – a practical workshop"— Presentation transcript:
1 Bedside Cognitive Assessment – a practical workshop MRCPsych Training ProgrammeBedside Cognitive Assessment – a practical workshopFriday 6th June, 2014Dr Rupert NoadDepartment of Neuropsychology, Derriford Hospital, Plymouth
2 Aims and objectives Introduction to Neuropsychology Understanding of the role cognitive assessment can play in clinical workUnderstanding of different cognitive domainsUnderstanding of a clinical approach to assessing cognitionExperience 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 organisedAttempts to understand how mechanisms within the brain influence thinking, learning and emotionsNeuropsychologists are particularly interested in how brain damage changes behaviourThis 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 difficultiesSpecialist neuropsychological assessments are used to test patients’ cognition and examine different brain functionsNeuropsychology 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 cognitionHave a good understanding of the way cognitive problems may affects someone's everyday functioningWhat the psychological consequences of a disease may be and how they may manifestWhat 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 understandingOther health, forensic, Neurorehab6
7 Typical questionsDoes 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 radiotherapyAre the person’s cognitive difficulties more related to psychological factors such as depressionTo validate patients’ experiencesCapacity for consent, work, school, and independent livingMedically 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:PhysicalCognitiveEmotionalBiologicalButMany other secondary consequences e.g. family dynamics, loss that can underpin individuals’ difficultiesSocialPsychological
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 absenceLateralisationFocal versus diffuseAcute/progressive versus chronic/staticAetiology/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?
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?
15 A framework for assessing cognition 5 steps:The questions you ask the patient and carerWhat you observe in the roomInformal tests of cognitionBedside tests of cognitionNeuropsychological 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, teaStage 4: Bedside cognitive assessments e.g. address from ACE-R, MMSEStage 5: Formal Neuropsychological assessment e.g. Camden, WMS
27 BCAT – Remote Memory Dead or Alive: ELVIS PRESLEY TONY BLAIR MARTIN LUTHER KING JR.MADONNA
28 BCAT – Semantic Memory What do the following words mean? UMBRELLA STAPLERBREAKFAST
29 BCAT – Working MemoryDigit SpanForwardsBackwards
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 MemoryAmnesia is a severe impairment in memory with intact perception and intellectual functionsMemory impairments are causes by:Korsakoff's SyndromeAlcoholic BlackoutClosed Head InjuryElectroconvulsive Therapy (ECT)Transient Global AmnesiaEncephalitisDementiaTemporal Lobe RemovalsHysterical Amnesia
32 In clinic – episodic memory Recall of what had for main meal yesterdayRecall of what did for 17th birthdayWhat 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 memorySemantic memory is your total store of knowledge about yourself and the worldOften loss of autobiographical information can be an indicator of a non-organic cognitive disorderHowever, there is semantic dementia as we have seen and retrograde memory loss e.g. post encephalitis can result in loss of semantic memoryTests in clinic - General knowledge, Dead or Alive testBits from pyramids and palm trees
36 Working MemoryThis refers to the very limited capacity which allows us to retain information for a few secondsUses 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.
39 BCAT – Expressive Aphasia Naming:“What is this?”
40 BCAT – Repetition Repeat after me: “Above, beyond and below” PROSPERGARDENPORCUPINEECCENTRICITY“Above, beyond and below”“Today is a sunny and windy day”
41 BCAT – Receptive Aphasia Single Word Comprehension:Point to:The source of illuminationObject used to tell the timeObject to sit onSurface that you walk onEntrance 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?SyntaxWith the pencil touch the penTouch the pencil with the penWith the pen touch the pencilTouch the pen with the pencil
43 Language Divided into different processes; Expressive language - productionReceptive language - comprehensionPlus reading and writing
44 Disease affecting language StrokeFrontal temporal dementiaCorticobasal degenerationHead InjuryNeed 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 testsWord 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 testsUse 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?”
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”IdeomotorObserve any clumsy action with pen useInterlocking Finger TestIdeational“Fold this piece of paper in half, write your name on it and place it inside this book.”
49 ApraxiaInability to perform a movement with a body part despite intact sensory and motor function - due to deficits in higher cortical control of movementCan be:Ideomotor – inability to draw or construct simple configurationsIdeational - 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 testsImitation 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)
53 AgnosiaPatient cannot recognise the meaning of visually presented objectsRecognition sometimes better for real rather than imagined or lined drawingsIt is particularly associated with lesions of the left occipital lobe and temporal lobes
54 BCAT – ProsopagnosiaCan you tell me who these people are?
55 ProsopagnosiaA specific deficit in recognising familiar faces, sometimes even including ownPatients can often appreciate the aspects of faces, such as age, gender or emotional expression.
56 Visual inattention/Neglect Neglect 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 sideBodily neglect/AnosognosiaIn its most profound form, patients deny the presence of hemiplegia despite evidence to the contrary.
60 BCAT – Executive Functioning FluencyANIMALS & ‘B’ProverbsA stitch in time saves ninePeople in glass houses shouldn’t throw stonesConflicting instructionsTap twice when I tap onceTap once when I tap twiceGo-No-Go tasksTap once when I tap onceDON’T Tap when I tap twice
62 BCAT – Executive Functioning (cont.) Hayling TestComplete 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 injuryAlzheimer’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:AnxietyLow mood/depressionPTSDPsychosis
67 Summary Cognitive assessment can be very helpful It can give you new types of data over and above a clinical interviewHowever, the data is ‘soft’ and is dependent upon the interpretation of the clinicianNeuropsychological assessment should be FORMULATION driven not DATA driven
68 The science/artTo be able to use cognitive data to help in the conceptualisation/diagnosis of a patients clinical problemBiologicalPsychologicalSocial
69 Can you remember?... The name and address The list of words The three figures you copied
70 Great ResourcesCognitive assessment for Clinicians – 2nd Ed (2007). John Hodges (in fact anything by John Hodges)Neuropsychological Neurology: The Neurocognitive Impairments of Neurological Disorders – Andrew J LarnerCognitive assessment for Clinicians (2001). Kipps and Hodges (JNNP) SupplementConcise Guide to Neuropsychiatry and Behavioral Neurology (second Ed) - Cummings and Trimble.