Cognitive Testing & Localization 1

COGNITIVE TESTING AND LOCALIZATION MADE RIDICULOUSLY SIMPLE

David F. Tang-Wai MDCM FRCPC
Assistant Professor (Neurology & Geriatric Medicine), University of Toronto
Co-Director, University Health Network Memory Clinic
7th Canadian Conference on Dementia, Vancouver BC, October 4, 2013

1. Cognitive testing involved examination of the various cognitive domains

• Cognitive domains as examined on the Mini-Mental Status Examination (MMSE) and the Montreal Cognitive Assessment (MoCA)
Cognitive Domain MMSE MoCA

Orientation Yes Yes

Memory - Learning/Delayed recall Yes Yes

Attention Yes Yes

Language Yes Yes

Visuospatial Yes Yes

Executive Function Yes Yes

• Neuropsychological testing involves detailed assessments of each cognitive domain

Cognitive Domain Examples of Specific Neuropsychological Tests

Orientation

Memory - Learning/Delayed recall Logical (story) memory, California adult verbal learning test
(CVLT), Free-cued recall

Attention Reverse digit span, letter cancellation

Language Boston Naming Test, Token Test (comprehension)

Visuospatial Rey-O complex figure, block design

Executive Function Wisconsin card sorting, Stroop, Trails Making Test

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2. Each cognitive domain can be localized to a specific lobe in the brain
Executive Function Memory Language Visuospatial Arithmetic Praxis Facial
Recognition

Lobe in Frontal Temporal Left Hemisphere Biparietal & Left Parietal Left parietal Right temporal
brain occipial lobes

Figure

Sample • Modified Trails B • Orientation • Reading • Cube copy • Calculations • Ask patient to • Identify famous
tests that • Digit span • Learning & • Writing • Pentagons (simple show how to... faces
can examine • WORLD/serial 7s delayed recall • Naming copy arithmetic)
domain • Verbal fluency • Comprehension
• Letter cancelation • Repetition
• Semantic
fluency

3. Localization can be further refined to a specific area within a lobe of the brain
Memory Reading, wRiting, Facial recognition Ideomotor praxis
aRithmetic

Lobe Temporal Left parietal Right temporal Left parietal lobe

Where in Hippocampus & Papez Angular & supramarginal Inferior fusiform & lingual gyrus Inferior parietal lobule
lobe circuit gyrus

Disorders Alzheimer’s dementia Alzheimer’s dementia Frontotemporal dementia - right Corticobasal syndrome
to consider (posterior cortical atrophy) temporal variant
if first
presenting
symptom
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Memory Reading, wRiting, Facial recognition Ideomotor praxis

aRithmetic

Figure

Language Localization (left hemisphere)

Repetition Comprehension Fluency Naming Writing

Lobe Left perisylvian area Left parietal/temporal Spontaneous speech - Left Left temporal Left parietal (see
frontal lobe previous)

Letter fluency (green)

Semantic fluency (red)

Figure
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Frontal lobe syndromes
Dorsolateral Orbitofrontal Anterior Cingulate

Function • Poor organizational strategies, problem
solving, planning, shifting and maintaining
sets, verbal working memory, and reduced
verbal fluency
• Personality change: tactlessness,
obsessive compulsive disorder;
decreased empathy, socially
inappropriate behavior;
impulsive behavior; inappropriate
jocular affect; emotional lability;
poor judgment & insight;
distractibility; increased sweets
• Apathy, little display of emotions,
decreased motivated behavior/
creative thought, failure of response
initiation/suppression, poor response
inhibition; lack of concern of
personal hygiene, appearing
unkempt

Figure

4. Guidelines to interpret cognitive testing - determining patterns

1.1. Look at the affected cognitive domains in addition to the total score - this will help determine the pattern of impairment and localization
within the brain

1.2. Recall where the cognitive domains are localized within the brain

Executive function Memory Language Visuospatial

Localization Frontal lobe Temporal lobe (hippocampus/ Left hemiphere Mainly right temporoparietal
Papez circuit) lobes

1.3. Common patterns seen on cognitive testing and representative dementing disorders
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Problems Seen on Testing Pattern Suggestive Of Examples of Disorders

Orientation Amnestic • Amnestic mild cognitive impairment

Delayed word recall • Alzheimer’s dementia

Attention Executive dysfunction • Vascular cognitive impairment

3-step command Frontosubcortical • Parkinson’s disease
Learning (many trials) • Dementia with Lewy bodies
Trials B (MoCA)
Letter fluency

Intersecting pentagons Visuospatial • Posterior cortical atrophy

Necker cube • Alzheimer’s dementia
• Dementia with Lewy bodies

Naming Aphasia • Primary progressive aphasia

Semantic fluency • Semantic dementia
Writing
Comprehension

Normal cognitive testing but change in behaviour Disinhibition or apathy behaviour • Behavioural variant frontotemporal dementia

1.4. In addition to the clinical history and the pattern of cognitive testing, a diagnosis can be made
Sample Cases Cognitive Testing Result Diagnosis

Case 1: 58 year-old man with 2 year history of
progressive memory loss and impairment with his
instrumental activities of daily living
MMSE = 22/30
Orientation 7/10; Learning 3/3 in 1 trial; Attention
5/5; Recall 0/3; Language 8/8; Pentagon copy 1/1
Alzheimer’s dementia
Cognitive testing revealed a primary amnestic
pattern. Given the history of anterograde memory
impairment with functional impairment, the clinical
scenario is one of Alzheimer’s dementia.

Case 2: 88 year-old woman with 5 year history of
progressive memory impairment, getting lost,
unable to cook and balance the finances. No
cerebrovascular risk factors or history of stroke.
MMSE = 18/30
Orientation 7/10; Learning 3/3 in 2 trials; Attention
2/5 (WORLD); Recall 0/3; Language 6/8; Pentagon
copy 0/1
Alzheimer’s dementia - severe
Cognitive testing revealed deficits in multiple
domains. Given the history of anterograde memory
impairment and other cognitive impairments
associated with functional impairment, the clinical
scenario is one of a moderate-to-severe
Alzheimer’s dementia.

Sample Cases
Case 3: 56 year-old with 5 year history of
progressive apathy, emotional blunting, mental
rigidity and dismissed from his job for “slacking off”
Case 4: 74 year-old woman presenting with visual
hallucinations, slowness in thought, shuffling gait,
and “memory” problems of 1 year in duration
Case 5: 78 year-old math teacher with known
Alzheimer’s disease presents with acute confusion.
Cognitive Testing Result
MMSE = 30/30
MMSE = 25/30
Orientation 10/10; Learning 3/3 in 5 trials; Attention
3/5 (WORLD); Recall 3/3; Language 8/8; Pentagon
copy 0/1
Previous MMSE 26/30 days prior to ictus
Orientation 9/10; Learning 3/3 in 1 trials; Attention
5/5 (serial 7’s); Recall 0/3; Language 8/8; Pentagon
copy 1/1
MMSE on admission = 20/30
Orientation 9/10; Learning 3/3 in 1 trials; Attention
0/5 (serial 7’s); Recall 0/3; Language 8/8; Pentagon
copy 0/1
Cognitive Testing & Localization 6
Diagnosis
Frontotemporal dementia - behavioural variant
Cognitive screening was normal. The clinical
history is primarily a change in personality and
behaviour and is associated with an impairment
with his iADLs (work). In FTD, especially the
behavioural and executive dysfunction
presentations, the cognitive testing can be normal
or mildly impaired early in the disease.
Dementia with Lewy Bodies
Cognitive testing revealed intact memory but
difficulties with attention/executive function
(WORLD), frontosubcortical slowing (excess
number of trials to learn 3 words), and visuospatial
dysfunction. With the history of parkinsonism,
visual hallucinations and some cognitive
impairment, the clinical scenario is consistent with
DLB.
Acute left parietal stroke
Repeat cognitive testing revealed sudden decline
with visuospatial and serial 7s (a crude measure of
calculations). These functions localize to the left
parietal lobe. Given the sudden change, this man
had a stroke in the same area.
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