Mse Cognition

Front 1

Cognition

Back 1

ability to know and think, using intellect, logic, reasoning, memory, and all of the higher cortical functions. Allows people to interact with others and negotiate daily life. Thus, appropriate communication and comprehension depend on speech/language abilities, absence of thought d/o, and brain fuctions relating to cognition and intellect, including language, memory, attention, perception, judgment, reasoning, and recognition.
MSE 121, 159

Front 2

Types of deficits affecting cognition and their clinical correlations

Back 2

Deficits in attention, memory, visuospatial ability, abstraction, Disorders include delirium, stroke, tumor, radiation necrosis, MS, HD, parkinsonism, Alzheimer's, head trauma, chronic alcoholism, infections, MR, learning disabilities.
MSE 121

Front 3

Intelligence - appraisal during psych interview

Back 3

Intelligence is a dimension of cognitive ability. Only a gross estimate can be obtained during a psych interview. Can rely on pt's verbal abilities as a clue to verbal intelligence. If pt has graduated from college, can assume he is of at least average (100) IQ, though converse is not true. In presence of other cognitive deficits, intelligence testing may not be possible.
MSE 122

Front 4

Cognition and competence

Back 4

If cognition is not intact, pt may not be fully competent to make medical/psych decisions. Competency involves not only intact cognition as a basic condition, but also an ability to comprehend the risks/benefits and consequences of an intervention
MSE 122-3

Front 5

Cognitive decline in the elderly - what skills are lost early? Late?

Back 5

The elderly tend to retain verbal skills better than so-called performance skills, such as visuomotor tasks and speed of performance. Have particular difficulty with timed tasks, and may perform them accurately if allowed more time. Few cognitive tests have normative values derived exclusively from/for older persons.
MSE 124

Front 6

Cognitive testing - basic/initial

Back 6

Can obtain some cognitive info from routine history taking, e.g. if pt remembered time/date/location of appt, likely to be oriented and have prospective memory intact. If pt does not know age, address, # years married, ages of children, demographic info, then cognitive impairment present.
MSE 124

Front 7

Cognitive testing - what to ask if pt doesn't know year

Back 7

ask pt's year of birth and age, and then ask "if you were born in1918 and you are 75 years old, then what year does that make it now?" This tests calculation and abstraction abilities.
MSE 124

Front 8

Cognitive testing - asking in a sensitive fashion

Back 8

This is especially important in case of dementia - pt may get defensive and hostile when confronted with cognitive decline, may become uncooperative. Can weave questions into history to test memory
MSE 124-5

Front 9

"Cognition grossly intact"

Back 9

Can say this when information from rest of history leaves examiner feeling confident of pt not having cognitive impairment. Should also write, "Cognition not formally tested"
MSE 125

Front 10

Cognitive testing in pt with language deficits

Back 10

Especially in deficit w/ comprehension (e.g. Wernicke's). Bypass verbal comprehensive/expressive language, e.g. Gestures, mimicry to describe tasks. Designs/objects can be used to test memory. Jigsaw puzzles can be used to assess problem-solving skills. Attention span - pointing to a series of written numbers. Referral to neuropsychologist for futher testing
MSE 125

Front 11

Prefacing cognitive testing to avoid awkwardness

Back 11

Don't say, "These are easy questions," because pt may be more impaired than is initially evident, and may feel worse for failing test then. Say, "I ask all my patients these questions. It's to test your memory and concentration. Have you noticed any problems with getting distracted or forgetting things?"
MSE 125

Front 12

Cognitive testing sequence - 6 steps

Back 12

1. Orientation 2. Attention/concentration 3. Registration and short-term memory (verbal and non-verbal) 4. Long-term memory (verbal and non-verbal) 5 Constructional and visuospatial ability 6. Abstraction and conceptualization
MSE 126

Front 13

Disorientation - order of loss of orientation

Back 13

Time lost first, then place, then person.
MSE 126

Front 14

Orientation to time - testing

Back 14

test by asking time of day,day of week, month, date of month, year, and season. Hospitalized patients should be clear on what part of the month it is.
MSE 126

Front 15

Orientation to place - testing

Back 15

ask pt name of hospital or clinic and floor. Ask city and state in which interview is taking place
MSE 126

Front 16

Orientation to person - testing

Back 16

to one's self, one's family, friends, those in contact w/ patient in hospital or clinic. Impairment usually begins with those least well known to the patient: the nurses, doctors, therapists. Names/functions may be forgotten, or they may be more commonly misidentified as hotel staff, old friends, torturers. Next, more familiar persons, e.g. neighbors, may be misidentified. Finally, pt may no longer known own identity - grave sign in delirious pt.
MSE 126

Front 17

Disorientation - clinical correlations

Back 17

MC in confusional states and severe amnestic syndromes. Also extensive damage to prefrontal cortex (usually b/l). Transient global amnesia, an unusual condition, involves tmporary disorientation and memory deficits, possibly related to temporal lobe dysfunction. Moderately to severely dementia. Sedation. Damage to frontal lobes from Trauma/surgery. Conversion, factitious disorders.
MSE 126-7, 161

Front 18

Attention and concentration - relationship

Back 18

Attention is ability to focus and direct cognitive processes while in a physiologically aroused state. Concentration is the ability to focus and sustain attention for a period of time.
MSE 127

Front 19

Attention - contributing brain regions

Back 19

Brainstem reticular activating system provides arousal as a precondition to attention. Subcortical areas such as cingulate gyrus, parts of thalamus, ascending noradrenergic, dopaminergic, and cholinergic brainstem pathways act w/ prefrontal cortex and nondominant inferior parietal lobe to subserve attentional functions.
MSE 127

Front 20

Intact attention, impaired concentration

Back 20

Is possible, even though the two are related. As in Alzheimer's Dz
MSE 127

Front 21

Aspects of attention

Back 21

include visual, auditory, verbal. Need to test each of these
MSE 127

Front 22

Attentional testing - Reasons for impairment

Back 22

pts who are agitated and generally distractible, anxious, sleep-deprived, actively psychotic, in pain, children with ADD. Deficits likely, especially in concentration
MSE 127

Front 23

Attention/Concentration - examples of tests

Back 23

Trail-making tests, Symbol Digit Test, Mesulam's Cancellation Tests, Stroop Color-Word Test
MSE 127

Front 24

Digit Span

Back 24

Attentional test. Digits recited to pt in series of increasing lengths. Pt to repeat aloud (writing not allowed). Recite in monotone, with last digit in lowered pitch (indicating end of series), slowly, clearly, one-second intervals. Until pt makes mistake. Do in reverse too, starting w/ two numbers.
MSE 128

Front 25

Digit Span - normal results, significance of abnormal results

Back 25

Forward - 6+/- 1 digit. Usually 1-2 higher than backward span. If backward is more than two fewer than forward - abnormal, implies impairment with problem in divided attention (attending while distracted by another mental task, as in changing order)
MSE 128

Front 26

Digit span - clinical correlation of abnormal results

Back 26

impaired in delirious, moderately demented, frontal/subcortical-lesioned patients, who may perform normally on the forward span but do poorly on backward span. L frontal lobe dysfunction can shorten forward digit span. Abulic pts perform slowly, may not complete task.
MSE 128

Front 27

Visual attention testing

Back 27

involve pictures w/ items, such as birds, hidden w/in a scene. Pt asked to point to and count aloud each bird he or she can find in the picture.
MSE 128

Front 28

Concentration testing - in elderly

Back 28

Can ask pt to count backwards from 65 to 49. Don't repeat instructions once started. Inattentive pts will continue past 49 or lose track of task. Good in elderly, in whom serial sevens may be too sensitive to effects of normal aging
MSE 128

Front 29

Serial sevens

Back 29

Concentration test. Look for maximum 5 correct. If pt makes mistake but then continues from there, correctly subtracting 7 each time, consider those correct responses. Consider results in context of educational background (also, may be too difficult if <=8 yrs education)
MSE 128

Front 30

Serial sevens - Alternatives

Back 30

Can subtract 7s from 101 or 13s from 100. Can subtract 3s from 20. Can add 3s to 1. Can do WORLD or EARTH backward. Letters must be in correct position to be correct. Can recite days/months backward
MSE 129

Front 31

Registration

Back 31

First step in learning. Capacity for immediate recall of new learning. Lasts only a few seconds. variously considered to precede memory or be the initial component of short-term memory. Prefrontal cortex probably plays an important role
MSe 129, 162

Front 32

Short-term memory - characteristics, requirements

Back 32

precedes consolidation of long-term memories, occurs successfully only if attention to and registration of information precede it. Short-term memory is temporary, lasting from seconds to a few minutes. Can be used immediately in decision making and/or passes into long-term memory. Limited capacity.
MSE 129-30

Front 33

Two types of long-term memory

Back 33

Procedural and declaritive
MSE 130

Front 34

Procedural memory

Back 34

Type of long-term memory. Involves remembering how to perform a set of skills, like driving, riding bicycle. After initial practice/mastery, these become implicit (not in conscious awareness).
MSE 130

Front 35

Procedural memory - in amnesia

Back 35

This remains intact in most amnestic patients, both for previously learned skills and for learning new skills. Phylogenetically old and not affected by dysfunction of temporal lobe-diencephalic areas known to be important for other types of long-term memory
MSE 130

Front 36

Declarative memory

Back 36

Part of long-term memory, affected in amnestic patients, involves data or facts that can be verbal or nonverbal. Explicit - remembered information should be retrievable into conscious awareness, unless there is damage to brain areas involved in storage/retrieval (i.e. amnestic syndrome) or there is a psychologic defense mechanism interfering (e.e. repression, dissociation, denial)
MSE 130

Front 37

Declarative memory - brain regions

Back 37

Phylogenetically more recent, located in medial temporal lobe, hippocampus, diencephalon, ventromedial frontal lobe. Continues to be consolidated over time, or can decay over time. Hypothesized that various types of short-term memory (verbal, visual, auditory) are located in same brain areas as their long-term counterparts. Medial temporal particularly important during learning, and for consolidation. Retrieval from LT memory involves coordination b/w medial temporal area and various storage sites in the cortex.
MSE 131

Front 38

Retrograde amnesia

Back 38

loss of LT memories that were consolidated prior to insult or event producing amnesia
MSE 131

Front 39

Anterograde amnesia

Back 39

loss of ability to learn, store, and retrieve memories subsequent to insult
MSE 131

Front 40

Amnesia in head trauma

Back 40

often have some degree of retrograde amnesia, usually for hours or days prior to accident, as well as anterograde amnesia for information about accident and from a period after trauma that lasts for hours or days. In some cases, anterograde amnesia extends indefinitely - becomes amnestic syndrome.
MSE 131

Front 41

Memory - Korsakoff's

Back 41

diencephalic dysfunction w/ profound anterograe LT memory deficits and variable retrograde amnesia (often remote memories are intact), but w/ preservation of registration and ST memory. Thus, able to recall newly presented information for a few seconds or minutes, not hours or days.
MSE 131

Front 42

Memory - [non-]Dominant temporal lobe lesions

Back 42

dominant - predominantly affect verbal memory; nondominant lesions affect visual memory
MSE 131

Front 43

Memory - temporal lobe lesions

Back 43

b/ cause more severe amnesia than unilateral; greatly impair new learning (anterograde memorY). Attention span is normal, however, as is ST memory, and recent LT memory often more impaired than very remote LT memory (retrograde amnesia)
MSE 131

Front 44

Memory - other causes of b/l lesions and amnesia

Back 44

viral encephalitis (commonly herpes), infarctions due to posterior cerebral artery compromise, and hypoxia (e.g. cardiac arrest or CO poisoning); anoxic encephalopathy, diencephalic damage following rupture anterior communicating artery aneurysm, tumors of 3rd ventricle can also produce amnestic syndrome
MSE 131, 158

Front 45

Pseudodementia vs. dementia - findings

Back 45

Pseudodementia - term used in describing pts whose memory deficits are presumably due to physiologic perturbations associated w/ psychiatric disturbance, rather than structural brain damage. Show pattern of "spotty" deficits and inconsistent performance on most memory testing, related to attentional deficits and inconsistent motivation. Truly demented pts have difficulty with LT memory, usually more than w/ remote info, until later in dz, when both are impaired.
MSE 131

Front 46

Memory - frontal lobe damage

Back 46

deficits in temporal memory (or prospective memory), which is remembering to remember. Not consequence of true amnesia, but related to inability to shift mental sets from one topic to another in order to focus on newly presented information and then remember it, and to deficits in planning and organization abilities. Can affect orientation. W/ sufficient focusing and rehearsal, can remember information once volitional/motivational impairments overcome
MSE 131

Front 47

Registration - testing

Back 47

via immediate recall (within seconds). Repeat three words that will be tested again in a few minutes. Note number of trials needed. More than two suggests inadequate registration. Particularly important to determine if registration has occurred in inattentive, poorly motivated, or depressed pts
MSE 132

Front 48

Short Term Memory - testing

Back 48

Present 3-4 unrelated words to be remembered after five minute delay. Check for registration, then do rest of MSE, then test ST memory. Note how many words remembered, and prompt with category (if word is brown, say "it's a color"), and then with a list of words if necessary. No points for word recalled after cuing, but note that cuing was helpful.
MSE 132-3

Front 49

Short Term Memory - testing, alternate

Back 49

Can read a paragraph long vignette aloud. Preface by explaining to the patient that he/she will be expected to retell the story from memory. E.g. George/ is a TV / news reporter. / He was covering an earthquake / in LA. / He interviewed / a woman / named Carol / whose car / was parked on a street / which caved in / during the tremors. / The car / disappeared / into the earth. 15 ideas expressed. Normal is >=8
MSE 133

Front 50

Word List Recall

Back 50

Tests ST memory. Read aloud at 1word/sec rate, 15 related words and 15 unrelated words, with immediate repetition by patient. Do twice (different order for second trial. One point for each correct. Sum both trials for each list. Can ask again after 20 min for LT verbal memory
MSE 133-4

Front 51

Word List Recall - example

Back 51

List A: Dog, Chicken, Horse, Cat, Elephant, Book, Magazine, Newspaper, Pamphlet, File, Knife, Dish, Pan, Spatula, Grill
List B: Vacuum, Truck, Movie, Conference, Envelope, Fire, Election, Moon, Refrigerator, Shovel, House, Lemonade, Town, Wallet, Lamp
MSE 133-4

Front 52

Word List Recall - Significance of results

Back 52

Normal - 16 or more for each; similar performance in related/unrelated lists. Amnestic - do not group words of category together, perform similarly on both. Depression-induced pseudodementia - fairly well on A, less well on B b/c of reduced motivation/impaired attention to more challenging task. True dementia - poorly on both
MSE 134

Front 53

Nonverbal Short Term Memory - Testing

Back 53

Visual ST memory - test by showing pt picture of six simple designs for five seconds, and then have them draw what they remember.
MSE 134

Front 54

Nonverbal Short Term Memory - Testing, addressing confounding factor

Back 54

Drawing is involved, so visual or visuospatial deficit might interfere w/ ability to test this memory. Have a trial to simply copy designs following the failed recall trial. Alternatively, can choose several drawings from larger list, e.g. Mesulam's Three Shapes Test.
MSE 134

Front 55

Auditory Short Term Memory - Testing

Back 55

Tap out pattern of loud and soft sounds and ask pt to repeat. Start with simple patterns and progress to more complicated ones.
MSE 134

Front 56

Long Term Memory - time periods

Back 56

Recent and remote. Remote is from many years ago, e.g. from childhood.
MSE 135

Front 57

Long Term Memory - subtypes of declarative long term memory

Back 57

episodic and semantic
MSE 135

Front 58

Episodic Memory and its testing

Back 58

these are time tagged, personalized, and experiential knowledge. Pt asked to describe important personal events, such as a wedding, PMH, etc., and to identify when these occurred. Examiner should verify from other sources data gathered.
MSE 135

Front 59

Memory - confabulation

Back 59

Be wary of this. Pts with memory deficits may go on and on with interesting stories with no basis in fact. Particularly grandiose/unbelievable stories may indicate spontaneous confabulation
MSE 135

Front 60

Semantic Memory and testing

Back 60

Involves recall of general information that a person could reasonably be expected to have learned. E.g. name of last five presidents, when did WWII end, what famous college is in Cambridge MA, where do Steelers play? Or can ask pt to list as many items from grocery store as possible in one min. Normal is at least 18 different things
MSE 135-6

Front 61

Constructional ability - prerequisites

Back 61

Prerequisites are intact vision, motor coordination, strength, praxis, and tactile sensation. Those who fail construction tests should be tested for other d/o inc. visual deficits, writing apraxia, and visual agnosia. Vision tested by Snellen and confrontational visual field test. Then test writing ability.
MSE 136

Front 62

Constructional ability and visuospatial function - needed for?

Back 62

driving, maneuvering in kitchen to cook, use a computer, vacuum a room, climb the stairs, read a map, solve mazes, etc. Even so, pts may not be able to specifically describe deficits. May complain of not recognizing previously familiar faces, no longer being able to knit, do puzles w/ children, etc.
MSE 136

Front 63

Constructional ability - brain regions

Back 63

nondominant hemisphere is particularly important for visuospatial function, both have capacity for imagery, both contribute to visuoconstruction. ND hemisphere, esp. parietal area - perceive overall form or Gestalt. D hemisphere discerns detail.
MSE 136-7

Front 64

Constructional/visuospatial testing- L hemisphere impairment

Back 64

typically draw coherent by simplified image w/o details but w/ correct overall spatial orientation/relations.
MSE 137

Front 65

Visual agnosia - constructional testing deficits

Back 65

may make it difficult for pts to recognize things visually, though they can feel and identify object. May confound visuospatial testing.
MSE 137

Front 66

Posterior parietal (e.g. Alzheimer's) - effect in construction testing

Back 66

alters constructional ability.
MSE 137

Front 67

Constructional/visuospatial testing - Right Hemisphere deficits

Back 67

loss of spatial relations, incorrect orientation, scattered and fragmented components, new lines added to correct drawing.
MSE 137

Front 68

Constructional testing - example

Back 68

Draw 3D cube or intersecting pentagons. If too difficult, move to simpler shapes, e.g. trianges, circles, squares. Pattern of alternative shapes (i.e. graphomotor sequences - line that includes alternating tops of circles and triangles) can detect motor perseveration. If too difficult, have pt draw its simpler components, the circle and triangle.
MSE 138-9

Front 69

Clock drawing - anosognosia

Back 69

pts w/ neglect may only draw one side, or squeeze all parts onto one side. If given a pair of gloves, may only put one on.
MSE 139

Front 70

Clock drawing - visuospatial defects

Back 70

space numbers unevenly, put them outside the circle, or otherwise distort clockface. hands may not point ot correct time
MSE 139

Front 71

Clock drawing - perseveration

Back 71

Motor perseveration may impede finishing task, w/ pt stuck in one area, drawing it over and over.
MSE 139

Front 72

Clock drawing - hemispheric contributions

Back 72

LH - contributes to capacity to draw details like position of hands and size of numbers. RH perceives rotatiosn or distortions of whole shape or layout and spatial relationship and proportionality among components
MSE 139

Front 73

Clock drawing - what to test if severely impaired in this

Back 73

May need to test separately ability to write numbers or to count out loud.
MSE 139

Front 74

Hooper Visual Test - purpose, brain regions

Back 74

example of using a puzzle to test constructional ability. Pt has to imagine what whole object would look like without moving the pieces. RH and frontal lobe functions important in performance of this test.
MSE 139

Front 75

Match figures - cognitive testing

Back 75

Can use red-tipped matchstick figures and have pt replicate designs. Shape and subtle positioning of red tips should be replicated. If done after delay, LT visual memory tested.
MSE 139

Front 76

Map drawing

Back 76

Can test visuospatial function and general information (semantic memory) at same time. Have pt draw map of US and label NY, SF, Boston, Miami, Dallas, Chicago, San Diego. Alaska and Hawaii should not be forgotten. Proportions and shape should be proper. Cities and oceans should be located. Allow for tremors, chorea, etc.
MSE 139-41

Front 77

Frontal lobe functions

Back 77

Involved in attention, prospective memory (remembering to remember), conceiving and organizing for the future (tmeporal relationships), motivation, spontaneity, creativity, abstract thought, ability to initiate activity, executive functions
MSE 142

Front 78

Executive functions - what are they, brain region?

Back 78

regulate complex and novel thinking, judgments, and behaviors. Frontal lobe. in dominant hemisphere, frontal lobe also imporatnt for language, e.g. Broca's area
MSE 142

Front 79

Prefrontal cortex - importance

Back 79

part of an interconnected cortical and subcortical network that includes association areas in the temporal and parietal lobes, limbic regions, and subcortical nuclei. Thus, deficits in executive functions can occur because of lesions or degeneration of basal cholinergic and midbrain dopaminergic nuclei, caudate nuclei, or medial dorsal thalamic nuclei, or because of multiple subcorctical white matter lesions that disrupt corticocortical connections, or multiple cortical lesions outside the frontal lobe.
MSE 143

Front 80

Executive functions - other deficits that can interfere with this

Back 80

Memory, attention, visuospatial ability integrate with frontal executive ability in production of abstract thinking and sophisticated conceptualization. Deficits in any of these cognitive abilities, or in language, can affect executive functions.
MSE 143

Front 81

Abstract thinking

Back 81

capacity to conceptualize menaings of words beyond literal (concrete) interpretation. Includes ability to analyze info according ot themes, generalize according to categories, appreciate double meanings, make comarisons, hypothesize, and to reason using deductive and inductive thinking. Corresponds to Piaget's formal operations
MSE 143

Front 82

Abstract thinking - what affects this?

Back 82

education, intelligence, cultural factors, developmental level in children.
MSE 143

Front 83

Abstract thinking - Hemispheric contributions

Back 83

L - capacity to formulate verbal concepts, using rules of hierarchy and logic. R - capacity to appreciate an overall, integrated image of the spatial , emotional (e.g. humor) and practical components.
MSE 143

Front 84

Abstraction - assessment

Back 84

Identifying similarities and interpreting proverbs are common ways
MSE 143

Front 85

Similarities testing

Back 85

abstraction testing. ask pt ot conceptualize categories to which two belong. Apple/orange/fruit, car/boat/modes of transport, shirt/coat/clothing, table/chair/furniture. Dog/tree/living (to say they both have bark is literal, almost a pun)
MSE 143

Front 86

Proverb interpretation

Back 86

test for abstraction. Also measures divergent reasoning. Proverbs are intrinsically significant when generalized or abstracted, rather than in literal interpretation.
MSE 143-4

Front 87

Proverbs - simple examples

Back 87

The grass is greener on the other side (Things that seem better elsewhere are not necessarily so) Don't count your chickens before they hatch (Don't be prematurely expecting something that might not happen), A stitch in time saves nine (take action today to avoid consequences or complications tomorrow)
MSE 144

Front 88

Proverbs - more difficult examples

Back 88

Rome wasn't built in a day. People who live in glass houses shouldn't throw stones. Loose lips sink ships. Every cloud has a silver lining. A rolling stone gathers no moss.
MSE 144

Front 89

Proverb - testing (initial)

Back 89

First explain to pt that a proverb is a saying with a broader meaning. Start by finding an example of which the pt has already heard, e.g. save for a rainy day. Then proceed with easy and progressively harder proverbs as pt correctly interprets them.
MSE 144

Front 90

Proverbs - significance of inability to interpret

Back 90

Possible explanations - inadequate education (<8 years), acute psychosis, dementia, delirium, head injury, frontal lobe damage, low IQ (including MR), and lack of cultural applicability of proverb. Easy proverbs and interpretations are often memorized by patients who cannot reason out unfamiliar ones.
MSE 144

Front 91

Switching Mental sets

Back 91

Test of conceptualization. E.g. b/w letters and numbers (Trailmaking B test) or b/w symbols and numbers (Stroop test) or between motor tasks. This can be tested by having pt squeeze examiner's hand whenever he/she says "green" and to relax when he/she says "red" - a Go-No go paradigm. Impulsive and prefrontal cortex-lesioned pts are particularly apt to make errors of omission, commission, and perseveration on such tasks.
MSE 144

Front 92

IQ Testing - WAIS, changes with aging, factors making performance difficulties > verbal difficulties

Back 92

Wechsler Adult Intelligence Scale. Its info and vocab subtests are believed to be good indicators of premorbid intellectual abilities. Verbal aspects of intelligence may remain relatively constant through aging. Performance aspects appear more vulnerable to effects of aging, as well as to conduct d/o, alcohol abuse, head trauma, etc. Normally the two subscores should be w/in ten points of each other. With aging and these disorders, the spread can increase.
MSE 145-6

Front 93

IQ testing - WAIS - verbal difficulties > performance difficulties

Back 93

Can be worse in ADHD, in some conduct d/o pts (perhaps the inadequate verbal skills make them more likely to "act out" their feelings in the form of behavioral problems rather than to think/talk through their feelings/frustrations). Dyslexics do worse on many verbal subtests than performance ones.
MSE 146

Front 94

Mini-Mental - limitations

Back 94

Max score = 30. Normals average 28. 24 or less is abnormal, indicating diffuse cognitive dysfunction. Less sensitive than specific. Abnormal score highly suggests that a problem is present, but pts with milder forms of delirium or dementia may score 25 or more points. This kind of false positive more likely in highly intelligent pts with early dementia. Low scores in pts with <8 years education require cautious interpretation.
MSE 146

Front 95

Mattis Dementia Rating Scale - use, limitations

Back 95

screening test for pts expected to be incapable of performing challenging tests, e.g. demented or brain-injured pts. Max 144 pts. <124 usually considered abnormal. Total score less informative than five subscores: attention, construction, memory, initiation/perseveration, conceptualization. Deficient in language problem screening. Stronger in testing visuospatial abilities, memory, attention. Tests for perseveration. Assesses conceptualization using similarities and other abstraction tasks. Saves time by placing most difficult test in any section first.
MSE 146

Front 96

Trailmaking Tests Parts A and B; use? purpose? upper limits of normal? Part B is especially sensitive in detecting what?

Back 96

Screening test for sustaining attention. Also assess visuospatial and motor integrative functions and cognitive flexibility (probably prefrontal cortex function), both of which are required to switch quickly from numbers to letters. Timed in seconds. Different norms for different age groups. For adults <70, 34s is upper limit for normal in Part A, 89 for part B. Part A is just number, Part B numbers and letters. Part B is especially sensitive in detecting diffuse cognitive dysfunction.
MSE 148-9

Front 97

Symbol Digit Modalities Test

Back 97

Test of concentration. Has a key made of a row of symbols corresponding to numbers 1-9. Timed test testing accuracy of translating symbols into numbers in 90s. Pts who can't write can say numbers aloud. Normative scores for age groups, as education and age affect scores
MSE 149-51

Front 98

Stroop Color-Word Test

Back 98

Challenging test of selective attention and concentration. First page - color words. Second - xx's in different colors. Third - color words in non-matching color ink. Pt has to read as many words (first page) and colors (2-3 pages) as possible in 45 seconds. Impulsive patients make many errors. Alternate administration/scoring system = timing how long it takes to correctly read 100 items.
MSE 151-2

Front 99

Rey-Osterrieth Complex Figure

Back 99

Test of constructional ability and visual memory. Also evaluates organization and perceptuomotor skills. Pt asked to copy as accurately as possible in 5min. How drawing is begun and executed is observed.
MSE 152

Front 100

Rey-Osterrieth Complex Figure - normals vs. brain-damaged, R hemispheric lesioned

Back 100

Normals notice large rectangle, draw it, subdivide it, then add details, b/c this keeps design proportionate. Brain-damaged pts usually have a great deal of difficulty copying the drawing. R hemisphere lesions - miss overall form and focus on smaller details, drawing disproportionate figure. Severely brain-damaged pts, esp. those with non-dominant hemisphere lesions, will draw something w/ little or no resemblance to design.
MSE 152

Front 101

Rey-Osterrieth figure - memory testing

Back 101

Can ask pt to redraw design after brief delay. This recall task is sensitive to non-dominant temporal-lobe dysfunction. Tests ST visual memory. After 30 minutes, tests LT visual memory. Specific scoring for this test found in Spreen and Strauss (1991)
MSE 152-3

Front 102

Mini Object Test

Back 102

used to test for anomia, agnosia, apraxia. Uses children's game Jack Straws - miniature plastic objects including wrench, pitchfork, ladder, rifle, paddle, shovel, ax, and saw. Pt asked to name each and demonstrate how it should be used. If pt can't visually recognize, allowed to feel it. 30 point scale. Differentiates demented from depressed/schizophrenic pts. Can be useful in naming portion of language assessment.
MSE 153

Front 103

Mini Object Test - anomics

Back 103

impaired in naming objects, though can demonstrate their use
MSE 153

Front 104

Mini Object Test - Agnosics

Back 104

Can neither recognize nor describe use of objects
MSE 153

Front 105

Mini Object Test - Apraxics

Back 105

Can name and describe use of objects, but can't demonstrate
MSE 153

Front 106

Cognitive test results - only memory defects

Back 106

perhaps amnestic syndrome, early dementia
MSE 156

Front 107

Cognitive test results - mostly attentional deficits, inconsistent performance performance w/in even a particular area

Back 107

motivational problem, e.g. depression-induced pseudodementia, mild/subclinical delirium
MSE 156

Front 108

Cognitive test results - many different areas of impairment, inc. orientation, attention, calculations, working memory, LT memory

Back 108

consider delirium, dementia
MSE 156

Front 109

Cognitive test results - older person w/ difficulty naming objects, memory deficits, visuospatial problems in drawing or constructional tasks

Back 109

suggests early Alzheimer's dementia
MSE 156

Front 110

Cognitive test results - inattention on most tasks and short attention span

Back 110

suggest attention deficit disorder
MSE 156

Front 111

Abstraction impairment - lesions where?

Back 111

prefrontal cortices and/or their subcortical connections in the basal ganglia and thalamus
MSE 157

Front 112

Agnosia

Back 112

Inability to recognize an object or a nonverbal symbol even though primary sensory pathways, e.g. vision and hearing, are intact. Perceptual problem, not verbal. Can't comprehend object's function, even though it was previously familiar. Can be visual, tactile, auditory, for faces, colors. Differentiate from anomia
MSE 157

Front 113

Agnosia - responsible lesions?

Back 113

finger, color and visual-object agnosia caused by lesions in L hemisphere
MSE 157

Front 114

Neural basis of memory function

Back 114

Not completely understood but probably involves temporal lobes, frontal lobes, and limbic system, w/ ascending connections from brainstem.
MSE 157

Front 115

Memory - affect of concussion

Back 115

produces retrograde and anterograde amnesia, which may be only temporary
MSE 158

Front 116

Amnesias - differentiate from?

Back 116

Differentiate amnesias from structural/physiological causes from hysterical causes, e.g. conversion d/o and fugue states, and from psychologic repression of a memory
MSE 158

Front 117

Deficit in attention (distractibility) causes

Back 117

include delirium, depression, fatigue, drug intoxication, ADD, stroke, head trauma, anxiety, and dementias
MSE 158

Front 118

Attentional mechanisms - neuroanatomy

Back 118

involves ascending brainstem pathways, cingulate gyrus, thalamus, frontal lobes, parietal lobes
MSE 158

Front 119

Calculation ability - requires?

Back 119

ability to understand and utilize mathematical constructs and symbols, in contrast to verbal symbols and words. Calculating requires visual and cognitive recognition of symbols and figures, remembering tables of mathematical procedures, and sequencing the order of numbers
MSE 158

Front 120

acalculia (dyscalculia)

Back 120

inability to solve mathematical problems
MSE 158

Front 121

localization of acalculia

Back 121

depends on deficit involved: disturbed spatial ability, difficulty appreciating numbers as symbols, comprehension problems, etc. L hemisphere lesions cause dyscalculia related to loss of arithmetic sense or alexia. R cause dyscalculia related to loss of spatial relations sense
MSE 158-9

Front 122

Concentration deficits - causes, lesions

Back 122

can be impaired by organic brain dysfunction, depression, head injury, any conditions that disrupt attentional ability. It can be affected by damage to the parietal and frontal lobes, cingulate gyrus, and ascending brainstem neuronal pathways.
MSE 159

Front 123

Concrete thinking is normal in?

Back 123

latency-age children (pre-pubertal)
MSE 159

Front 124

Concrete thinking - seen in?

Back 124

pts with schizophrenia, MR, delirium, dementia, frontal lobe damage
MSE 159

Front 125

Spontaneous confabulation - characteristics? cause?

Back 125

One of two types of confabulation (other is provoked). Wide-ranging and grandiose, resembles delusions, occurs w/ severe lesions of frontal lobes.
MSE 159

Front 126

Provoked confabulation - characteristics? causes?

Back 126

one of two types of confabulation (other is spontaneous) - in response to questions about forgotten information. Occurs w/ lesions of temporal and limbic areas
MSE 159

Front 127

Confabulation - differentiate from?

Back 127

fluent aphasia
MSE 159

Front 128

Confabulation - lesions

Back 128

damage to temporal lobes, frontal lobes, and limbic system/thalamus, or to pathways that interconnect them. Tumor, stroke, aneurysm, and chronic alcohol abuse are common causes
MSE 159-60

Front 129

Constructional ability, lobar/hemispheric contributions

Back 129

ability to draw, construct, or manipulate shapes and figures in 2D and 3D. Requires integration of occipital, parietal, and frontal lobe function. L hemisphere contributes to ability to draw details or specific things. R perceives spatial configurations of whole image.
MSE 160

Front 130

Dementia - definition

Back 130

global deterioration of cognitive and intellectual functions. Dx, not single sign or Sx, usually involves more Sx than simply cognitive decline, e.g. personality change, mood change, psychosis.
MSE 160

Front 131

Dementia - early course of diffuse cognitive dysfunction

Back 131

can start with focal type of cognitive deficit, then progress to involve multiple functions. Specific early focal deficits and course vary with type of dementia
MSE 160

Front 132

Cortical pattern of dementia associated w/?

Back 132

cortical pathology plays a major role in Alzheimer's Pick's and multiinfarct dementias
MSE 160

Front 133

Subcortical pattern of dementia associated w/?

Back 133

progressive supranuclear palsy, Huntington's disease, and parkinsonian dementias
MSE 160

Front 134

Graphesthesia

Back 134

the ability, without looking, to perceive, recognize, and identify numbers or letters traced on the palm of the hand or palmar surface of the fingertips, through tactile stimulation. Tested separately in each hand, usually using numbers 0-9
MSE 161

Front 135

Agraphesthesia - definition, significance

Back 135

inability to identify numbers with graphesthesia. Soft neurological sign. If unilaterally impaired, suggests dysfunction fo contralateral parietal lobe.
MSE 161

Front 136

Disorientation in psychotic pts?

Back 136

Psychotic pts usually retain reasonably good orientation, unless impaired by marked disorganization of thought processes or marked preoccupation w/ delusions/hallucinations.
MSE 126-7

Front 137

Pseudodementia - Causes

Back 137

Generally results from inattention, concentration deficits, and/or poor motivation to perform cognitive tasks. May be named for condition causing it, e.g. depression-induced dementia or dementia syndrome of depression. Can be seen in mania and in other psych conditions, e.g. conversion, as well.
MSE 162

Front 138

Soft neurologic signs

Back 138

variety of motor or sensory impairments that are subtler than gross neuro impairments, indicative of CNS dysfunction, often of subcortical origin. Low specif for predicting neuro dz, often developmentally based. More often used by psychiatrists than neurologists.
MSE 163

Front 139

Soft neurological signs - examples

Back 139

include mirror movements, motor impersistence, agraphesthesia, astereognosis, extinction to bilateral simultaneous stimulation.
MSE 163

Front 140

Soft neurological signs - use/significance

Back 140

may be useful in detecting dysfunction of frontal or parietal lobes in the absence of more robust deficits, and can be combined w/ detected cognitive deficits for possible localization of neuroanatomic lesions.
MSE 163

Front 141

Visuospatial ability

Back 141

perceptual ability to comprehend visually relationships of designs or structures in space, and to reproduce them. Adequate visual acuity is a prerequisite
MSE 163

Front 142

Steregonosis - ability, test, significance

Back 142

ability to perceive, recognize, and identify objects placed in hand on basis of tactile sensing w/o seeing shape. Tested in each hand separately. Inability to perform is called astereognosis. Tests parietal lobe function
MSE 163

Front 143

Word-finding difficulties, clinical correlation

Back 143

inability to recall words or names of things spontaneously during conversations or during confrontational naming. Occur in Alzheimer's, anxiety d/o, various other causes of inattentiveness, e.g. sleep deprivation.
MSE 163