COGNITIVE TESTING

IN THE FRANZCP
EXAMINATIONS
Mark Walterfang MBBS Hons FRANZCP
Neuropsychiatry Unit, Royal Melbourne Hospital
Cognitive Neuropsychiatry Research & Academic Unit, University of
of
Melbourne
Mental Health Research Institute, Victoria

April 12th 2003

 Why do we cognitively assess?
• To globally aid diagnosis, guide
investigations, and inform management &
rehabilitation
• To assist differentiation between “functional”
and “non-functional” disorders – e.g.
depression versus dementia; or between
“organic” and “non-organic” disorders –
e.g. neurological versus somatoform illnesses
• Identify co-morbid impairment inherent in
some illnesses (e.g. schizophrenia)
• To screen high-risk individuals
Why do we cognitively assess in
the exam?
• To pass
• To provide a thorough, holistic assessment
that integrates all aspects of history and
examination
• To assist in generating, and sorting, a
differential diagnosis list – and to ensure you
don’t miss the diagnosis
• To inform & guide investigations,
management, or neuropsychological
assessment
 Myths About Testing

• Cognitive testing is difficult to learn

• Cognitive testing is onerous
• Cognitive testing is hard to interpret
• Cognitive testing is not relevant
• Cognitive testing is someone else’s job
Basic Schema for
Cognitive Testing
 Watch-Talk-Test
• All fields of medicine start at the end of
the bed and work in
• Much valuable information can be
gained prior to or in absence of formal
testing
• Progression from
behavioural/observational to historical
to direct challenge/assessment
 Watch
• Degree of co-operation, motivation
• Level of psychomotor activity
• Gait & neurological signs,
dysmorphology
• Behaviour – judgement, inhibition,
planning, utilisation
• Grooming
• Remembering/making appointment,
requiring assistance
 Talk
• Lack of an informant does not mean
that interview lacks substance
• Information (memory, language,
attention, executive) can be gained
throughout course of “normal” ? i/v
• Cognitive history/systems review – think
first in terms of deficits in domains, then
illness types
• Cognitive risk factors (HI, ECT, vascular,
medication, substances)
 Talk
• Establishing sense of baseline –
age, education
• Clues: course, and first symptom of
onset; each aids in diagnosis
 Test
• Systematic approach best based on
set of items you:
– Are comfortable in doing
– Understand their interpretation
– Know their limitations
• Ensure that your collection of items is
broad enough to cover most domains
• basic, high yield items; low-yield,
specific items; knowledge of n? tests
 Models

• Lower-order to higher-order functions

(e.g. attention, psychomotor speed to
language, construction to executive)
• Regional (temporal, parietal, frontal)
• Illness-based (Alz, scz, FTD, subcortical)
/ targeted
 From Bedside to
Neuropsychological Testing
• Cognitive testing items vary in their degree
of “bluntness” of dissection of
neuropsychological functions
• E.g. memory
recall of three objects - blunt
recall of brief story/passage - medium
paired associate learning - fine
• The finer the item, the more sensitive,
specific and reliable
• Beware of assuming a blunt tool is fine
 Distributed Function
• Cognitive testing tends to focus on
functions performed by relatively
specific zones of the brain
• These zones are not entirely
independent; they are semi-
independent, and inter-dependent
• Example: memory (frontal), calculation
to command (language), praxis
(interhemispheric)
 SUGGESTED
APPROACH
BASIC BEDSIDE (blunt)
(ALWAYS DO AT LEAST ONE)

BEYOND BEDSIDE (medium)

(DO IF ABNORMALITIES IN BASIC TESTING, OR IF TIME AVAIL)

NEUROPSYCHOLOGICAL (fine)
(BE AWARE OF & ABLE TO TALK ABOUT THEIR ROLE)
ATTENTION
 Attention: Basic Bedside
• Serial 7’s – in the MMSE; difficult for
elderly/poorly numerate; intact
dominant parietal lobe required;
familiar word backwards – better
• Overlearned sequence in reverse
(days of week, months of year)
• Orientation – time is most sensitive, esp
time of day and duration of stay in
hospital; date v. unreliable
 Attention: Beyond Bedside
• Digit span – less dependent on
memory (other than WM). Normally 6
±1. Reverse span usually one less
usually one less
– Be aware that forward span ends to test
freedom from distractibility, reverse tests
working memory
– Anxiety may reduce score but disappears
with practice
 Attention: Neuropsychological
• Letter/star cancellation tests* - also
useful for inattention

• PASAT – paced auditory serial addition

test; set of digits at different speeds
that subject has to name (2-8-6-1-9
becomes 10..14…7..10..); v. useful in TBI
 Attention: Neuropsychological
• Digit symbol tests (e.g. Symbol Digit Modalities Test)-
has key of symbols, patient required to fill in spaces
according to key. Good measure of psychomotor
speed, used in MS. Also reqs visual searching, new
learning
VISUOSPATIAL
 Visuospatial: Basic Bedside
• Drawing reproduction – simple to more
complex figures
• Praxis – limb, trunk, buccal (different
tracts)
• L/R orientation (patient, yours, crossed)
• Clock drawing – correct number
placement, drawing hands to
command
Visuospatial: Beyond Bedside
• Calculation – simple, difficult,
conceptual; written or verbal
• Somatosensory neglect - extinction
• Line bisection
• Copying flower (double-header)
• Drawing a house, bicycle
 Visuospatial:
Neuropsychological
• Bender-Gestalt test –
also has projective
qualities; nine figures to
be reproduced.
Hundreds of different
scoring systems exist.
Sensitive to R par.
lesions
 Visuospatial:
Neuropsychological
• Complex figure of Rey (…Taylor, etc). Scoring systems; also
timed. Can be used qualitatively to compare L vs R lesions,
and frontal impairment
Taylor Figure
• Block design: part of the WAIS, simple to
complex
MEMORY
 Memory: Basic Bedside
• Recalling three items; one or two-stage
cueing; unrelated words best. Standard
deviation in normals significant (0.8 of 3-4
words over 10 min). Cueing suggests
retrieval vs storage problem
• Remote memory & fund of knowledge
• Apple-table-penny copyrighted!
• Reproducing drawing after delay
• L vs R hemispheric storage verbal vs spatial
 Memory: Beyond Bedside
• Verbal: story to immediate recall (it
wsa july/and the Rogers/had packed
up/their four children/in the station
wagon/and were off/on vacation)
• Spatial – hidden objects; found &
named
Memory: Neuropsychological
• WMS-R – Wechsler Memory Scale; battery
most frequently administered. Paragraph
recall, paired associates, visual pairs, visual
design reproduction; visual digit span
• RAVLT – Rey Auditory Verbal Learning Test –
word lists learnt; documents primacy and
recency effects, interference, intrusion,
confabultation
• Benton Visual Retention Test – recall of line
drawings after brief delay
EXECUTIVE
 Executive: Basic Bedside
• Proverbs – abstraction vs
concreteness. Be aware of cultural
and epoch biases. Similarities &
differences better
• Motor sequencing – Luria 3-step
• Categorical fluency – naming animals;
18-22
 Executive: Beyond Bedside

• Inhibition & interference – go-no-go

• FAS from the Controlled Oral Word
Association test (COWA) – three one-
minute trials, exlucing plurals/proper
nouns. ~15 for each; total <30
definitely abnormal
• Written sequencing
 Executive: Neuropsychological
• Trails A & B (from Halstead-Reitan battery);
must shift set in part B – sensitive to frontal
impairment
• Wisconsin Card Sorting Test – tests set-
shifting; one of four symbols printed in one of
four colours on cards and match to stimulus
cards according to principles. Good for left
frontal lesions. Subject places pack of 64
cards in four piles under 4 stimulus cards
according to principles, that must detect
from examiner’s responses
• Raven’s Progressive Matrices – test of
general intellectual ability; initially pattern
matching, then problem solving. In
absence of visuospatial deficits, tests
executive function
 Stroop Effect
• Stroop – it’s all about
interference
• Both congruent and
incongruent conditions
presented
• Incongruent >
congruent latency
• Try it online:
• www.dcity.org/brainga
mes/stroop
• CLOX TEST
• Royall et al – JNNP 64: 588-
594, 1998
• Scored version of simple
clockface (insert numbers,
place hands)
• To discriminate between
executive impairment &
non-executive cons-
tructional impairmt
A TALE OF NINE
CLOCKS
A & B - dementa with prominent
frontal deficits
C – early dementia
D & E – frontal dementia
F – moderate Alzheimer’s
G – vascular dementia & neglect
H - cerebellar stroke
I – Pick’s disease
LANGUAGE
 Language: Basic Bedside
• Reading & comprehension – written
and verbal, simple and complex
• Repetition of words, phrases,
sentences (simple to complex,
common to rare)
• Writing to command/spontaneous
 Language: Beyond Bedside
• Naming to confrontation; high and low
frequency
• Word-finding (subjective)
• Conceptual – “is a ball square?”; “if
the lion is killed by the tiger, which one
survives?”
Language: Neuropsychological
• Boston Naming Test – identifying 60
large drawings – from tree & pencil
through to sphinx & trellis – sensitive to
aphasics
• Aphasia batteries such as Multilingual
Aphasia Examination (MAE), Boston
battery use validated normed versions
of most above tasks
COGNITIVE SCREENING &
ASSESSMENT TOOLS
 AMTS/MSQ
• Standard emergency dept test – ten
items; relies heavily on memory/
orientation
• Good test-retest reliability
• Not particularly sensitive or specific
• Misses range of other cognitive
functions/disorders
 Mini-Mental State Examination
• Mini-Mental Status Examination: developed
by Folstein & Folstein in 1975
– widely used in medical settings
– available in number of languages
– widely used in research including ECA as part of
DIS
• Developed to differentiate functional from
organic illness in psychiatric patients.
• Unitary measure made up of 30 items
• Generally administered in under ten
minutes; portable & easy to administer
 Mini-Mental State Examination
• Limitations,
– unitary measure, limited testing of many
cognitive spheres, lack of executive function
testing, lack of graded scoring
– American Neuropsychiatric Association
recommends supplementation with spatial
functions, delayed recall & executive function
testing
• Significant ceiling effects; significant age &
education-related biases; lack of
standardised instructions
RMH Neuropsychiatry Unit Name: …………………………………………………………..

Mini-Mental State Exam Date: …./…./…. UR: ……………………….

Examiner: …………………………………………………….
(After Folstein, Folstein & McHugh, 1975.)

What is the: year, season, date, day, month? ___/5

What: country, state, town, hospital, ward are we in? ___/5

Name 3 objects (apple, table, penny), one second apart; ask subject to recall all three after you have
said them. One point for each correct answer. Then repeat until subject learns all three.
___/3

Ask subject to subtract 7 from 100, and provide the answer, then continue to subtract 7 from each
answer given five times. (93, 86, 79, 72, 65). Score one point for each correct answer. Alternatively,
or if subject unable to undertake serial 7's, ask to spell word WORLD backwards (spell it forwards
first), with one mark for each correct letter.
___/5

Ask subject to recall 3 objects, one point for each recalled. ___/5

Ask subject to name your watch and pen/pencil. ___/2

Ask subject to repeat: “No ifs, ands or buts”. ___/1

“Pick up this piece of paper with your right hand, fold it in half, and place it in your lap.”
___/1

Ask patient to read & obey the following:

CLOSE YOUR EYES. ___/1

Ask patient to write a sentence – of their choice, containing a noun & verb, below.

___/1
Ask patient to copy this design in the space to its right.

___/1

TOTAL
SCORE ___/30
 NCSE
• Neurobehavioral Cognitive Screening
Examination (Kiernan et al in 1987)
• Eight years of experience in C-L role to
neurosurgical unit
• Designed to address issues with MMSE &
other tools
– introduced multi-dimensional scoring &
screen’n’metric approach
– standardized instructions
• “Pattern” of cognitive function across
multiple domains taps into key medical skill
of pattern-matching
 NCSE
• Limitations
– Screen & metric approach has lack of
specificity & suitability of screen items
– ?estimates of brevity claimed by authors
• NCSE in psychiatric populations
– limited specificity and poor predictive
power as regards presence of cognitive
disturbance, whilst retaining moderate
sensitivity
 ACE
• Addenbrooke Cognitive Examination
• Published by Cambridge team 2000
(Berrios, Mathuranath, Nestor, Hodges)
• Includes MMSE as well as more
extensive language, visuospatial &
memory testing
• Scores out of 100 & score out of 30
• Limited executive function testing
ACE
 FAB
• Frontal Assessment Battery published in 2000
by Saltpetriere group (Dubois et al)
• Includes common bedside cognitive
function tests incl sequencing, interference,
inhibition, similarities, verbal fluency
• Very much like the executive scale of the
NuCOG!
• NUCOG is both ACE & FAB
 CAMDEX
• art of the CAMDEX (Roth et al, Cambridge
University) – specifically designed for the
diagnosis of dementia in the elderly;
incorporates the MMSE within the battery
• Advantages: sensitive and specific, high
inter-rater reliability, sensitive to mild degrees
of dementia, good detection of impairment
across all spheres
• Disadvantages: not as widely available,
some floor effects, poorly sensitive to frontal
lobe dysfunction, impaired abstraction or
attention
• Less generalizable to treatment populations
other than the elderly/demented
 ADAS-COG
• Dementia-specific, 21-item test
designed to detect classical areas of
deficit in SDAT (memory, orientation,
language, praxis). Scores out of 70
(cognitive) and 50 (non-cognitive –
mood, behaviour), and monitors
change with less floor/ceiling effects
 Neuropsychological Tests of
Intelligence/IQ
• WAIS – battery multiple performance &
verbal subtests to yield Full-Scale IQ. General
knowledge, comprehension, arithmetic,
similarities, digit span, vocabulary, digit
symbol, picture completion, block design,
picture arrangement, object assessment
• NART – developed by Nelson & O’Connell as
measure of premorbid IQ when
deterioration expected (e.g. early SADT). 50
irregular words, graded frequency; for IQ 90-
130
NEUROPSYCHIATRY UNIT
INSTRUMENTS
(Test – Talk – Watch)
 NUCOG
• 15-20 minutes complete
• Includes MMSE patch
• 5 domains – attention, memory,
executive, language,
visuoconstructional
• Cognitive profile
NUCOG Schedule
NUCOG Scoring
NUCOG Subject Sheet
NUCOG Cognitive Profile
 The NUCOG “Patch”
• Designed to allow
MMSE-equivalent score
to be extracted from
NUCOG
• Two additional items
asked, takes <3
minutes, provides
MMSE score
• Possible to score 30 on
MMSE & have
significant NUCOG
deficits
NUCOG.COM
 Case One
• 22 year old student with catatonic state
• Preceding history of presumed encephalitis,
supported by MRI & EEG data – left (dominant)
temporo-parietal region
• No pathogen identified
• Initially mute, catatonic & psychotic –
occasional aggression
• As recovered – significant residual
organisational & expressive language difficulties
Case One Profile
 Case Two Profile
• 49 year old executive
with impairment in work
function necessitating
stopping work
• Significant reductions in
all areas of executive
function
• Family history – father &
paternal uncle – early
onset dementing illness
• MMSE score of 30/30
 Case Three Profile
• 52 year old
hypertensive chronic
alcoholic male
• Previous dysphasia
following CVA 2y ago
• Recent R MCA infarct –
neglect, impaired
spatial memory,
constructional
dyspraxia; overlaid on
marked disinhibition &
perseveration
 Case Four Profile
• 81 year old woman
with prior R MCA
aneurysm clipping,
presenting with global
cognitive impairment
+/- ?acute ischemic
event
• CT showing
widespread vascular
pathology cortically &
subcortically
• Marked perseveration
on most tests
COGRISK
BATCH
EXAMINATION
ISSUES
 Not Enough Time
• Strategy if you run out: something general
(orientation), something high-yield (clock
face), something illness specific; also discuss
obervational data (general knowledge,
vocabulary, recall of recent/remote history
etc)
• Discuss what you would have liked to have
done, and why
• Generally not excusable in the high-risk for
cognitive impairment (elderly, clearly
dementing, neurodegen disorders)
 Complex Patient
• Difficulty where obvious evidence of
psychiatric disability (e.g. depression,
psychosis) co-incident with significant
impairment (e.g. executive dysfunction,
memory impairment)
• Best approach is to hold two chief
possibilities – cognitive impairment related to
disease (intrinsic, medication, ECT), or is co-
morbid; be prepared to discuss both
 Quantitative vs Qualitative
• Important skill of psychiatrist – to
integrate findings from all spheres of
assessment
• NEVER rely on numbers alone;
qualitative data MORE important
• E.g. young male with first psychosis
MMSE 19/30 – is he demented?
 Blunt Dissections
• Be aware of the limitations of the tools you
are using; their specificity and sensitivity
• Most cognitive tools in clinical practice have
limitations and are relatively blunt
• Important to be aware of role and necessity
for further neuropsychological assessment
• When neuropsychological assessment
required – a set of key questions is useful: “is
this the pattern of memory impairment seen
in chronic alcoholism?” “is this man’s poor
motivation and organisational difficulty
indicative of frontal lobe disease?”
 Pretend Neuropsychological
Testing
• At least one examiner’s bugbear!
• Examples – using Trails or complex
figures without following standard rules
or test designs; then assuming that
“test’s poor cousin” performs as well as
the test itself
 Taking a Cognitive “History”
• One other examiner: candidates more
likely to ask about ideas of self-harm
than about leaving the gas on in at-risk
patients
• Taking a basic cognitive systems
review is often neglected; beware the
“pseudo-impaired”/over-reporting
patient (somatoform, anxiety,
depressed, personality variables)
 “Functional” Syndromes &
Cognitive Impairment
• Many “functional” syndromes have
cognitive concomitants
• Dementia vs depression
• Depression – reduced processing
speed, attentional function
• Schizophrenia – reduced global
function, (spatial) working memory,
dysexecutive function
Integration (Or Lack Thereof)
• Integration of cognitive findings into history,
mental state examination, and physical
examination critical
• Role of psychiatrist in most settings is
uniquely integrational – the buck often stops
with you! Examiners will expect you to play
this role
• Try to understand, not just report, your
cognitive findings. How do you understand
its origins? How does it relate to their mental
illness? What does it mean for treatment
planning?
 The Role of Baseline
• Understanding of baseline (inferred from
work history, vocabulary, education,
presentation) critical
• High-flyer who may present well cross-
sectionally but be significantly declined;
beware as you are not allowed access to
the informant!
• The chronically cognitively impaired person
who presents cross-sectionally poor but may
have “been like this for many years” – e.g.
mild mental retardation, developmental
disorders
Semi-independence of Domains
• Most cognitive functions are
distributed to a significant degree
• Function does not necessarily equal
location
• Understanding component functions
of any item or domain critical;
undertaking range of items will allow
for pattern to appear
 Regional Specialisation
• L/R - left hemisphere specialized for
language & processing verbally coded
information (regardless of how info
acquired); right hemisphere processes
primarily nonverbal information – faces,
music - & feeling states, as well as
perception of bodies in space
(intra/extrapersonal)
• Posterior portions dedicated to perception
of body & world beyond it; anterior portions
comprise effector systems, specialized for
execution of behaviour
 Patterns of Syndromes
• Subcortical vs cortical – processing
speed, frontal de-afferentiation,
extrapyramidal signs
• LBD – course specifiers & psychosis
• Dementia in other disorders (MS, ETOH)
 The Good Candidate…
• … integrates into possible DDx or Rx
implications
• …understands regional syndromes &
laterality
• …understands how different disorders
present different patterns
• …understands limitation of their assessment
• …understands cognitive risk factors
• …understands the role of neuropsychology
 The Poor Candidate…
• …doesn’t do (enough) cognitive
assessment
• …focuses on “the numbers”
• …doesn’t integrate findings into other
elements of the assessment
• …the opposite of everything in the
previous slide
SOME GOOD
REFERENCES
Strub & Black

The Mental Status

Examination in
Neurology, 3rd
edition

Strub RL, Black FW

FA David & Co,

Philadelphia, 1993

ISBN: 0-8036-8212-3
Hodges

Cognitive
Assessment for
Clinicians

Hodges JR

Oxford University
Press, Oxford, 1994

ISBN: 0-1926-2394-X
 Take-Home Messages
• Have a suite of cognitive tools,
understand their limitations
• Practice your assessments, present
them frequently, and get used to the
“act of integration”
• Peace
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