Neurocognitive Screening - PowerPoint Presentation

Neurocognitive Screening Nicholas Kontos, MD Director of Fellowship in Consultation-Liaison Psychiatry – Massachusetts General Hospital Assistant Professor of Psychiatry – Harvard Medical School October 17, 2019

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Screening objectives To refine diagnostic hypotheses & further screening/testing To make more accurate diagnoses To protect our patients from misdiagnosis, misperceptions, and just being missed

What is bedside neuropsychological screening? A judiciously employed, systematic assessment of a pt’s arousal, cognitive, perceptual, and affective statuses/capabilities “Neuropsych TESTING” is for neuropsychologists More rigorously quantitative Less diagnostically oriented

Guiding Principles Find “the” lesion Catani & Thiebault de Schotten 2012

Guiding Principles Symptom/Sign-Lesion Connections Epicenters of distributed networks Single brain areas participate in multiple functions Multiple brain areas participate in single function No screen is “pure” (e.g. MOtYB ) Evident deficit ≠ actual deficit “memory” ≠ MemoryHOW pt errs as important as error itself

Hierarchy of Functions State-dependent vs Channel-dependent functions Alertness/Arousal ------------------ Attention, Motivation Language, Praxis, Object ID, Memory/Memories, Executive Fxn

The History Always assume pt will not participate in exam Much can be gleaned impressionistically Playing dumb Arousal, attention, language, praxis, recent recall Whether casually or “officially” screening, look out for: Suspiciousness Impending “catastrophic reaction” Denigrating your own exam (and patient’s performance)

Level of Arousal (State Dependent) Nothing useful until this is assessed Often escapes notice E.g., beware invocation of the “underlying depression” 3 parameters (avoid jargon) 1) What does it take to wake? 2) What level of arousal is achieved? 3) What sustains it (& for how long)?

Attention (State dependent) No attn w/o alertness, but alertness w/o attn Nothing next useful until this is assessed Selective vs Sustained vs Directed Attention vs Concentration vs Spatial

Attention Assessment often by interview alone Forward digit span (gold standard) Vigilance (sustained attention) Adult 7  Geriatric 5 Number/letter tapping Backwards digit span and reverse recitation of overlearned info (impure d/t working memory)

Motivation & Mood (State dependent) Aberrations of either can  false positives Esp. vulnerable to misinterpretation Assess by history & observation “Organic” mimics of idiopathic phenomena Depression vs Apathy/Abulia Blunted/inappropriate affect vs Dysprosodias Affective lability vs Pathological affect ASK pt Compare spontaneous vs elicited ( esp recent recall)

Channel Dependent Functions That Can Look State Dependent Language Speech ≠ Language (dysarthrias; modalities) Fluent/Non-Fluent ≠ Sensical/Nonsensical Observation, Commands, Absurdity Praxis Many types; ideomotor screened “Blow out a match,” “flip a coin,” etc. Errors: inability, perseveration, vocalization, simulation w/body part Filley 2011

Memory I - Content Declaritive/Explicit: semantic (facts), episodic (events) Medial temporal lobe bottleneck ? dissociable Implicit: procedural (skills); conditioning Striatum, amygdala, OFC, cerebellum, ?

Memory II: Timing Immediate: working “memory” DLPFC Recent: min-days Most vulnerable (hippocampal, thalamic bottleneck) Remote: weeks-years ConsolidatedPossible passing from meso- and sub- cortical to neocortical storage for declarative (w/continued hippocampal involvement) and procedural

Memory III – Experience/Exam Register  Consolidate  Retrieve Mere recall tasks do not discriminate Correct < chance w/cues suggests “true” anterograde amnesia (consolidation deficit) Correct w/cues likely = retrieval problem Retrograde/remote – autobio & public events Anterograde/recent – recent events, delayed recall

Beyond 3-item recall 3-Words, 3-Shapes Copy or 30sec Immediately reproduce (mult tries to get > 5) Reproduce at 5, 15, 30 or more minutes Weintraub 2000 Hidden $ variant

Executive function Planning & sequencing (DL)PFC-Parietal network Initiation also assoc w/ med PFC circuits Alternating sequences Luria maneuvers, figures Organizational abilities Clock Mega & Cummings 1994ERROR SIGNALS: perseveration, poor planning, pull to stimulus, poor initiation (incl in conversation)

Examples of frontal-subcortical network dysfunction findings

Comportment (judgment, motivational direction, social graces, response inhibition) OFC, mPFC (ant cingulate) circuit epicenters Talk talk but don’t walk walk Observation, collateral, no discrete screens Imitation Utilization (Lhermitte 1986)

Other channel-dependent functions Construction/visuospatial R hemisphere & parietal – “big picture” L hemisphere & frontal – details Neglect ----- 2x simultaneous stimulation Gnosis Distinguished from anomia by ability to use objects

Standardized screens MMSE MOCA Orientation x10: Mixed function of attention, short term memory Registration x3: Attention Calculation/WORLD x5: attention/working memory Recall x3: Short term memory Language x5: name, repeat, read, write Construction x1 Praxis x3

Bedside screening in action Dementia Subtype Hypothesizing Executive Comportment Attention Anterograde amnesia Visuospatial (Anomia) Alzheim . Vs Subcort’l, FTD  (FTD incl language)

What’s next? You may be done Imaging EEG (for fine-grained delirium questions) Formal NPT Use findings to formulate questions & make predictions

References Baddeley A: Working memory. Science 255:556-559, 1992. Catani M, Thiebaut de Schotten M. Atlas of Human Brain Connections . Oxford University Press. 2012. Filley CM. Neurobehavioral Anatomy 3 rd Edition. University Press of Colorado. 2011.Harris, L, Humphreys K, Migo EM, Kopelman MD. Memory disorders. In: Hussain M, Schott JM, eds: Oxford Textbook of Cognitive Neurology and Dementia. Oxford University Press. 2016.Jefferson Al, Cosentino SA, Ball SK, et al: Errors produced on the Mini-mental State Examination and neuropsychological test performance in Alzheimer ’ s disease, ischemic vascular dementia, and Parkinson ’ s disease. J Neuropsychiatry Clin Neurosci 14:311-320, 2002.Kontos N. Neuropsychiatric dysfunction. In: Stern TA, Herman JB, Rubin DH (eds): Massachusetts General Hospital Psychiatry Update and Board Preparation. MGH Psychiatry Academy, 2018.Kontos N, Querques J. Psychiatric consultation to medical and surgical patients. In: Stern TA, Fava M, Wilens TE, Rosenbaum JF (eds): Massachusetts General Hospital Comprehensive Clinical Psychiatry. Mosby, 2016.Lhermitte F: Human autonomy and the frontal lobes. Part II: Patient behavior in complex and social situations: The “environmental dependency syndrome.” Ann Neurol 19:335-343, 1986.Malloy PF, Richardson ED: Assessment of frontal lobe functions. J Neuropsychiatry Clin Neurosci 6:399-410, 1994.Mega MS, Cummings JL: Frontal-subcortical circuits and neuropsychiatric disorders. J Neuropsychiatry Clin Neurosci 6:358-370, 1994.Nasreddine ZA, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 53: 695-699, 2005.Robbins TW: Dissociating executive functions of the prefrontal cortex. Phil Trans R Soc Lond B 351:1463-1471, 1996.Royall DR, Cordes JA, Polk M: CLOX: An executive clock drawing task. J Neurol Neurosurg Psychiatry 64:588-594, 1998. Shallice T, Evans ME: The involvement of the frontal lobes in cognitive estimation. Cortex 14:294-303, 1978.Sporns O. Networks of the Brain. MIT Press. 2011Squire LR: Mechanisms of memory. Science 232:1612-1319, 1986. Staffaroni AM, Stephens ML, Kramer JL. Bedside frontal lobe testing. In: Miller BL, Cummings JL (eds): The Human Frontal Lobes 3 rd Edition . Guilford. 2018. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet 2: 81-4, 1974. Weintraub S: Neuropsychological Assessment of Mental State. In: Mesulam MM (ed): Principles of Behavioral and Cognitive Neurology . New York: Oxford University Press, pp. 121-173, 2000. Voyer P, Champoux N, Desrosiers J, et al. Assessment of inattention in the context of delirium screening: one size does nto fit all. Int Psychogeriatr 23: 1-9, 2016. Weintraub S, Peavy GM, O ’ Connor M, et al. Three words-three shapes: a clinical test of memory. J Clin Exp Neuropsychol 22: 267-278; 2000.