Bedside Management of Neuropsychiatric Deficits in the Elderly

Vernon M Neppe MD, PhD,FRCPC, FFPsych, MMed
Director, Pacific Neuropsychiatric Institute

BRIEF INTRODUCTION TO THE BEHAVIORAL NEUROLOGICAL EXAMINATION

The neuropsychiatric mental status or behavioral neurological examination interfaces between psychiatry and neurology. Its object is to evaluate global and focal functions of the cerebral cortex. Never to be neglected on the one side is evaluation of the patient's mental status at a psychiatric level - such features as appearance, consciousness, orientation, intelligence, cognitive functions, affect, motoric behavior, motivation, behavior in the ward, interpersonal relations, insight, judgment and dangerousness.

On the other hand, particular areas of interface in the neurological examination are: level of consciousness, attention span, memory, presence or absence of primitive reflexes such as grasp, pout, snout, palmar mental reflexes, Babinski signs, and basic evaluations of the patient's power and tone. Evaluations of the person's emotions and reaction to stress are also fundamental.

The examples below are of items useful to use in your practice. Behavioral neurological examination consists specifically of the following headings:

Evaluations of:

Consciousness
Orientation for time, place, and space
Evaluation of speech, i.e. dysphasia, dysarthria, dysphonia
Evaluation of praxis
Evaluation of gnosis, i.e. recognition, interpretation and organization of percepts - agnosias
Evaluations of memory
Intelligence - verbal
Calculation
Melodic functions
Frontal-temporal functioning

Assessment of the neuropsychiatric mental status of the patient is vital in any patient who may exhibit features of possible coarse neurobehavioral disease. One rapid but very inadequate method has involved the 30 point Folstein Mini-Mental Status Examination which is loaded with regard to orientation and memory items (15 out of 30), and which requires very substantial impairment, generally easily clinically diagnosed before the patient scores the 21-23 out of 30 or less generally perceived as clinically relevant. In addition, patients with depression may commonly not score near the 29 or 30 out of 30 expected in the non-demented. Consequently it is neither sensitive nor specific.

A very promising instrument has been developed at the University of Washington, the BROCAS SCAN (Screening Cerebral Assessment of Neppe). This takes 15-30 minutes and involves 40 items. The B of the term BROCAS refers to behavior, and all facets of the Mental Status Examination are compared with the behavioral component. The ROCAS items are made up of two each of R-O-C-A-S: recall, recognition, orientation, organization, concentration, calculation, apraxia, agnosia, speech and sensory motor reflex. The typical items which are useful for students to apply are included below . The following brief behavioral examination exemplified by the Clinical BROCAS SCAN items can be performed:

Evaluation of the person's gait
Evaluation of his level of consciousness: this may require tests pertaining to variability of response, e.g. favorite color, favorite relation, favorite food.
Evaluation of orientation

Orientation for time: date, day of week, time of day, season
For space (geographic orientation in ward)
For place (name of ward, of hospital)

Orientation is a global cerebral function.

Evaluation of speech for aphasia
1. Examine fluency of speech, spontaneity of speech and word finding ability
2. Specific tasks like repeating "no ifs, ands, or buts about it," "Constitution of the State of Massachusetts," and "I am."
3. Identify and name certain objects in the room, certain body parts, certain colors.
4. Respond to a question requiring comprehension, i.e. "source of illumination," "through where does the wind blow into this room?"
5. Disturbances of speech may reflect pathology all the way through from Wernicke's area in the superior posterior temporal cortex through to Broca's area in the posterior-lateral frontal cortex. Fibers along the way may be impaired. Anomia or inability to name objects is a more non-specific function located generally in the posterior temporal-parietal areas. When there are visual inputs, then there may be occipital components to this. Specific localizations have been hypothesized for localization objects, body parts, and colors. Fluent aphasias generally reflect Wernicke's area pathology, non-fluent aphasias reflect expressive difficulties in the frontal lobe Broca's area.
Evaluations of apraxia

Ask the patient to copy a diagram; the diagrams may involve a Greek cross, and more complex figures, such as a triangle with a circle with certain distortions.
Ask the person to construct a clock, e.g. with the time 10 past 11. This involves both sides of the visual field, and the 10 has to be conceived as a 2 on the clock.
Tests of copying and construction while often cited as tests of praxis involve visuospatial perception and visuomotor integration - gnosis. Substantial skill is required to differentiate the site of the lesion.
Ask the person to perform the following task: with the middle finger of the right hand to touch his nose, and pull his left ear.

Tests such as middle finger of right hand involve testing of finger parts and testing of right and left orientation. When the right hand moves to touch the left ear, this shifts across the body mid-line involving cross-lateralization. This apparently simple task also involves touching the nose and then the ear and this requires sequential organization. These tasks therefore require additive evaluation in order to adequately interpret them. These functions therefore involve the perceptual, integrative, and executive functions. At the perceptual level, the patient would be agnosic, and this would predominantly reflect posterior parietal pathology. At the integrative-executive level, the patient would be apraxic, and this may reflect frontal lobe pathology. Fibers running between these areas and also leading inferiorly through to, for example, the cerebellum, and involving the motor system make these evaluations more difficult.

Memory function

Verbal memory function may be evaluated giving the patient four facts about the interviewer, e.g. name, origin, kind and color of car. Abstract words such as "peace, analyze, concept" can also be used.
Visual memory function can be assessed by retesting the copied drawing he did.
Verbal-visual function involves guessing five objects in the room, e.g. floor, table, window, shoe, pencil.

Memory function is complex

To test registration, the patient should be re-evaluated immediately.
If he is able to register this information, can he retain it?
Is he able to to appropriately recognize it?
Can he recall it spontaneously? Can he recall it with cues?

These functions can be tested individually, and should be. Test global memory functions by interrupting the task and retesting a few minutes later. Visual memory impairment may reflect non-dominant hemispheric involvement, verbal memory dominant hemispheric involvement. Generally these memory functions all reflect particularly hippocampal functioning.

Intelligence

Verbal intelligence can be evaluated by usage of words, by vocabulary, comprehension, digits span forwards and backwards, general knowledge and information, proverb interpretation, ability to perceive similarities and differences.

Calculation

Tests of calculation reflect specifically defects which are disproportionate to the person's general verbal intelligence. Ask the patient simple addition and subtraction (under 100). Test the limits of his ability. If calculation is disproportionately disturbed, this may reflect parietal lobe functioning, specifically left parietal functioning. At times, however, dyscalculia due to incapacity for spatial organization and numerical operations is more common with right sided lesions.
Melodies or testing for aprosodia is useful in that this may reflect non-dominant frontal temporal lobe pathology, in parallel with speech organization. Screen this by the patient's ability to:

spontaneously hear, and
repeat tunes

These tests are, however, poor screens.

Tests for frontal lobe functioning relates specifically to

Tapping abilities and
Abilities to perform repetitive complex movements such as "fist, flat of hand, side of hand," and the ability to change cognitive set.
At a verbal level this may involve counting in three's, and subtracting back in two's, and spelling words such as "world" forward and backward.

Tests for temporal lobe functioning involve screening for visual fields. Other frontal-temporal signs are noted behaviorally, and many temporal lobe features are obtained on history, or using structured instruments such as the Inventory of Neppe of Symptoms of Epilepsy and the Temporal Lobe (INSET).

Useful BROCAS SCAN (Screening Cerebral Assessment of Neppe) Items

"Would you please remember the following about a friend? His name is Peter Smythe. He comes from Minneapolis, Minnesota, and he drives a blue Toyota."
"Please copy the following drawing." The patient is given a square with a triangle inside and a distorted Greek cross. "What are the differences between your drawing and mine? Please repeat this drawing now from memory."
Ask the patient to repeat the following sequence, showing him the sequence with your hands: side, flat, fist; side, flat, fist.
Repeat the following sentences. "Constitution of the State of Massachusetts." "No ifs, ands or buts about it."
"Who is the current Vice-President?"
"With the little finger of your right hand, please touch your nose and then your left cheek."
Observe subject's gait and shake hands with him.
"What does 'Many hands make light work' mean?"
"Subtract nine from 98, and continue downwards."
"Repeat the following digits: six, eight, one, four, two, three."
"Now repeat the following backwards: seven, eight, four, two, five."
"What is your favorite book, your favorite vegetable, your favorite member of family?"
Check the patient's pout reflex, and glabella tap, and planter responses.
"Draw a clock with the time 25 past nine."
Test the patient's visual fields. Test to see that he can observe movement on both sides simultaneously.
"Please give me as many words as you can that begin with the letter D in a period of 30 seconds."
"Repeat again the information about the friend."
"Draw the original drawing again."
Check for variability of response with regard to favorite book, favorite vegetable and favorite member of family.
Test tactile two-point discrimination in the the palmar surface of the middle finger of both right and left hands.
"What date (day, month, year) is it? What is the time? Where are you?"

THE GERIATRIC CONTEXT: ORGANIC AND NEUROBEHAVIORAL

Organic mental disorders are a class of disorders of mental functioning and behavior caused by transient or permanent dysfunction of the brain. As these disorders are a heterogeneous group, no single description can characterize them. The differences in clinical presentation reflect differences in localization, mode of onset, progression, duration and nature of underlying pathophysiological processes. There are a great many potential causes of cerebral dysfunction. The underlying cerebral disease or disorder may be primary, such as a brain tumor, or secondary to a systemic dysfunction. Organic mental disorders may occur at any age, but many are more prevalent in the population over 60 years of age.

As psychiatry becomes more biological, it is assumed that all AXIS I disorders have some organic basis. When we used the term Organic Mental Disorder in DSM - III R, we are talking about relative degrees of organicity. The organicity in these disorders involves a clear-cut organic element, sometimes called coarse neurobehavioral syndrome. Clearly these occur at all ages. However, the elderly is a particularly important group. DSM -1V dropped the term organic for such descriptions as "symptomatic" or "due to medical conditions."

Neurobehavioral is a term which is commonly used, particularly in behavioral neurology, and in neuropsychiatry. This term is particularly relevant in describing not only the coarse chronic disorders above, but demarcating a specific lack in DSM IIIR namely episodic or paroxysmal neurobehavioral disorders relating to episodic conditions deriving from a specified condition in the brain such as temporal lobe disorder linked with "spells" of marked lability of affect over hours or episodic rage. "Neurobehavioral" in this context may be perceived as a substitute for "organic", but will not be part of the official terminology. Other possible synonyms that still appear in books and should be recognized are "organic cerebral syndromes", "organic brain syndromes" and "organic psychosis."

The term organic is used in current psychiatric nomenclature, namely DSM-I11R. However, the term organic will not be used in DSM-IV. This is so because most psychiatric illness is based on organic abnormalities - biochemical, anatomic or physiologic: For example, schizophrenia and affective illness are also "organically" based, so the term organic is ambiguous. Instead, in DSM-IV, the broad term "cognitive impairment" will be used. The cognitive impairment disorders include coarse neurobehavioral disorders like dementia and delirium. For those conditions in DSM-IV that have specific etiologies, the term "symptomatic" will be used, so that we talk of symptomatic delusional disorder when Vitamin B-12 deficiency may be causing a delusional condition (as opposed to the current organic delusional disorder).