L1.

Dementia and Neurodegenerative Disorders: Mental Status Exam, Aphasia,

Neglect

The depth of the mental status exam (how detailed/broad you go) depends on:
§ Patient’s level of consciousness (e.g. comatose patient – unable to assess…)
§ Patient’s ability to understand/speak (e.g. aphasic patient – they can’t repeat a sentence)
§ Chief complaint (e.g. patient tells you I’m forgetful à DEFINITELY conduct MSE)
§ Present illness:
o Personality changes, decreased motivation (apathy, abulia), psychiatric symptoms …
o Forgetfulness, repeats statements, misplaces objects…
o Altered daily living despite no motor impairment: can’t take meds, can’t perform job…
§ Physical exam:
o Can’t follow orders…either they don’t understand, or can’t…
o Hyperreflexia above the neck:
§ jaw jerk (touch chin – temporalis and masseter muscles at work)
§ frontal release signs: glabellar, palmomental, grasp, snout reflexes
§ paratonia (Gegenhalten)

A comprehensive mental exam covers many aspects of a person’s functioning, including:

§ Attention: ability to concentrate on a task (examine attentive vs inattentive/distractible)
§ Formal testing: problem is that it’s dependent on a person’s literacy status
§ Digit span: give patient 3-8 numbers and ask them to repeat them
§ Forward (3 to 8 numbers)
§ Backward (2 to 5 numbers)
§ Serial 7s or 3s
§ Spell backward (5-letter word)
§ List days of the week backward
§ Inattention often occurs in encephalopathies:
§ metabolic (renal or hepatic)
§ drug-induced

§ Memory:
§ Short-term memory: After minutes/hours/days/months
§ Testing:
§ Remember 3 words for a few minutes
§ “What did you have for breakfast” (hours)
§ Recent national or international major events (days or months)
§ Long-term (remote) memory: Events from years ago
§ Birthdays, past schools, past personal/medical history

§ Judgement: Ability to compare alternative ideas to decide on a course of action

§ “what would you do if you find an unconscious person on the floor?”
§ “what would you do if you find a stamped letter on the floor?”
§ “what do you do with fruits that you just bought from the grocery store before eating
them?”

§ Thought:
§ Processing: how you think (sequence, logic, coherence, relevance of thought toward a
goal – blocking, echolalia, confabulation, neologisms… etc.
§ Content: WHAT you think – compulsions, obsessions, phobias, delusions…etc.
§ Orientation: depends on memory and attention – tested by asking:
§ Time: day of week, day of month, month of year, time of the day
§ Place: address of home or hospital, which floor we’re on
§ Persons: immediate family, hospital staff (not really to self b/c don’t need more than 10
neurons to be able to recognize yourself; if you cannot recognize your own self then
you’re either aphasic or psychogenic/faking it)
§ Situation: “why are you in the hospital?”
§ Right-to-left orientation
§ Neglect: usually hemi-neglect
§ refers to neglect of the left side (contralateral side) of a space/body due to
SPATIAL INATTENTION (not perception problem in eyes/feeling)
§ if you touch patient to neglected side, they can sense that you touched it but not
able to localize where (if they didn’t see)
§ Typically, due to non-dominant hemispheric lesions (i.e. on left MCA in most)
§ Caused by deficits in:
§ Vigilance System:
§ It is the ability to sustain attention in periods of low stimulation
§ Mediated by NE projections of locus coeruleus to parietal
cortex and primary/secondary sensory regions
§ Spatial Attention System:
§ It is the ability to attend to relevant stimuli and filter out
irrelevant stimuli
§ Mediated by distributed cortical and subcortical system that
includes:
§ superior/inferior parietal cortex
§ dorsal frontal cortex
§ pulvinar nucleus and superior colliculus
§ Both these systems lateralize to the right hemisphere in humans
§ left hemi-neglect is due to overactivation of left hemispheric lesions (so
left hemisphere only cares about what itself sees and ignores the rest
e.g. right side of face, ignoring left side – left hemi-neglect
§ lesion in left hemisphere à improves hemo-neglect
§ Most common lesion causing neglect:
§ right inferior parietal/temporal cortex
§ right ventral frontal cortex
§ right thalamus
§ right caudate
§ What are the signs associated with hemineglect?
§ Left visual hemifield cut
§ Hemi-sensory loss
§ Anosognosia (no recognition of illness)
§ Neglect is one of the WORST prognostic factors for stroke recovery
§ How do we test for hemineglect? BEDSIDE TESTING: draw a clock, bisect a line…
(e.g. ask draw house – ignore the left side of it, although can still see)

§ Sensory Perceptions:
§ Illusions: misinterpretations of real external stimulus
§ Psychotic symptoms: perceptions in absence of external stimuli
§ Hallucinations: visual, auditory, gustatory (e.g. in some focal seizures), tactile or
olfactory (e.g. smell rubber burning)
§ Delusions: paranoid, grandiose, … (unshakeable beliefs)
§ Insight: recognizing that you have that illness or deficit à lack of insight: things worse
§ Psychotic illness: retained vs without insight
§ Insight into own illness or actions
§ Higher cognitive functions:
§ Vocabulary
§ Fund of information: Last 5 presidents, national and international events, job-related
information …
§ Abstract thinking (~ age of 12 years):
§ Generalizations: test for similarities
§ hypotheses, theories, logical reasoning: proverbs, handling a letter
§ Future planning, assess risk and possibilities
§ Calculation: simple (3+5) and complex (15+37, 3x15)
§ Copy/Construction: diamond, intersecting pentagons (2D), 3D cube, clock drawing
(patients with Alzheimer have problems drawing clocks even before diseases manifests!)

§ Mood and Affect:

§ Mood: how you feel overall
§ Affect: observable immediate feelings à Reflected in voice, face, demeanor
§ Both may be cheerful, anxious, depressed, apathetic/flat, angry, evasive/paranoid,
euphoric …
§ Depression may manifest as pseudodementia (depressed + don’t want to do the exam)

§ Level of consciousness: patient’s alertness and awareness of environment, assessed via:

§ General Appearance
§ LOC testing in the following order:
1. Alert (eyes open)
2. Response to visual stimuli
3. Response to verbal command
4. Response to touch
5. Response to shaking
6. Response to pain
§ Levels of Consciousness:
§ Normal: Alert, awake, aware of environment, respond to external stimuli
§ Delirium: agitation, confusion, fear, hallucinations
§ Drowsiness/Obtundation/Lethargy: not fully alert, impaired attention, slow to
respond, decreased spontaneous movements, response to verbal stomili but fall
asleep easily
§ Stupor: needs vigorous/painful stimuli to response
§ Coma: Unconscious, cannot be awakened even w/ pain, pay have non-purposeful
activity/reflexes

§ Speech: Voice vs Articulation vs Language

§ Dysphonia: voice impairment in larynx/vocal cords (no effect on writing)
§ impaired volume, quality or pitch of voice
§ Hoarse, breathy, strained voice
§ Hypophonia (low volume), diplophonia (talking in 2 sound frequencies)
§ Extreme dysphonia: aphonia

§ Dysarthria: impairment in articulation (no effect on writing)

§ Slurred speech vs nasal speech
§ May affect differentially consonants
§ Facial problem (buccals/lips) à problem with m, b, p
§ Hypoglossal problem (linguals,tongue) à problem with d, t, l
§ Vagal problem (gutterals/pharunx) à problem with k, g
§ Extreme dysarthria: anarthria
 § Oral Apraxia: impaired planning movements of the tongue, lips, and pharynx (no effect
on writing)

§ Mutism: no verbal utterance due to aphonia, anarthria, oral apraxia or aphasia

§ Aphasia: language impairment (content of language itself) – must have at least one
problem out of this list:
§ Fluency: within this category, we aim to examine:
§ Rate of words per minute:
§ slow, hesitant or effortful
§ logorrhea (non-stop speech)
§ ungrammatical speech: no prepositions, adverbs, adjectives
§ Paraphasia: word or letter substitutions that can happen via:
§ Phonologic (by sound): "restrant" instead of “restaurant”
§ Semantic (by meaning): "day" instead of "night”
§ Neologism: invented words
§ Jargon aphasia (excessive paraphasic and/or neologistic speech)
§ Verbal Comprehension (understanding what you hear)
§ Naming
§ Repetition
§ Writing
§ Reading Comprehension:
à Differentiate from previous problems by writing challenge; Avoid confusing it with
dysphasia (which is a developmental speech impairment in children).

Basic Circuitry of Aphasia:

§ Angular Gyrus: contains Wernicke’s area (library)
§ Wernicke’s Area: word COMPREHENSION
§ Broca’s Area: word GENERATION (writing/speech)
§ Arcuate Fasciculus: connection b/w two areas

Expressive vs Receptive Aphasia

Broca’s Aphasia (Expressive) Wernicke’s Aphasia (Receptive)

Fluency Non-fluent (can’t say, intact insight Fluent (paraphasia, neologisms, no
into speech errors) insight into speech errors)
Verbal Comprehension Normal Impaired
Naming Impaired (can’t say/can recognize) Impaired (can’t recognize)
Repetition Impaired (can’t say) Impaired (can’t recognize)
Writing Impaired (can’t find word) Normal (if spontaneous only)
Reading Comprehension Normal Impaired (can’t recognize/understand)
Location of Lesion Perisylvian Fissure Perisylvian Fissure
§ Frontal Lobe § Inferior Parietal Lobe
§ Insula § Posterior Temporal Lobe
§ Anterior Temporal Lobe
Associated Symptoms § Facial Weakness § Agitation
§ Right arm weakness (If left- § No muscle weakness
dominant)
Lesions causing aphasia:
1. Perisylvian
a. Broca’s area: Frontal, Insula, and Anterior Temporal Lobe
b. Wernicke’s area: Inferior Parietal and Posterior Temporal Lobes
2. Extrasylvian
a. Transcortical MOTOR: Prefrontal Cortex – preparing the speech
b. Transcortical SENSORY: Temporal Occipital Lobe – library of words
à lesions to these transcortical areas present the same as their corresponding perisylvian area,
except that repitition is INTACT b/c broca’s area, arcuate fasciculus, and wernicke’s area are fine

Transcortical Aphasias (Motor vs Sensory)

Transcortical Aphasia (MOTOR) Transcortical Aphasia (SENSORY)

Fluency Non-fluent (can’t say, intact insight Fluent (paraphasia, neologisms, no
into speech errors) insight into speech errors)
Verbal Comprehension Normal Impaired
Naming Impaired (can’t say/can recognize) Impaired (can’t recognize)
Repetition Normal Normal
Writing Impaired (can’t find word) Normal (if spontaneous only)
Reading Comprehension Normal Impaired (can’t recognize/understand)
Location of Lesion Anterior Extrasylvian region Posterior Extrasylvian region (inferior
(prefronal/medial frontal cortex) temporo-occipital cortex)

Associated Symptoms No face/arm weakness § Agitation

§ No muscle weakness

If patient can repeat then automatically assume aphasia is transcortical.

Other Restricted Aphasias:

Conduction Aphasia Anomia

Fluency Intact (b/c Broca’s area intact) but Intact
may have paraphasia (no feedback)
Verbal Comprehension Intact (b/c in Intact
Naming Impaired (can recognize but can’t Impaired (patient does not recognize
send order to speak what you see) object)
Repetition Impaired Intact
Writing Intact Intact
Reading Comprehension Intact Intact
Location of Lesion Arcuate Fasciculus Non-localizing, but probably dominant
(left) angular gyrus

Other Aphasias: (due to large lesions)

1. Global Aphasia:
§ Injury to entire perisylvian region: broca’s + wernicke’s + arcuate fasciculus
§ Usually accompanied by right hemiparesis
§ Example would be a large left MCA stroke
2. Mixed transcortical aphasia:
§ Injury to entire extrasylvian region: prefrontal + temporo-occipital area
§ Example would be dementia (degenerating diseases)
§ Repitition would be intact (echolalia: patients keep repeating what you say)
Mini-mental status examination (MMSE) – Folstein’s exam
§ Useful when you don’t have 2 hours to test a patient
§ Takes 5-10 minutes
§ Non-demented patient – can be done in 4 minutes
§ 75% sensitive in picking up dementias
§ Heavily weighted towards cortical dementias (like Alzheimer’s dementia)

Montreal Cognitive Assessment (MOCA) Much more advanced

MMSE
§ 30/30 : normal
§ <26 : abnormal
§ 26 to 29 : NOT normal but not
dementia (although depends
on age)
MOCA
§ 30/30 : normal
§ 26 to 29: MCI
§ 25 to 20: mild dementia
§ 19 to 10: moderate dementia
§ <10 : severe

MOCA is a little better than MMSE in picking up dementias.