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
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:
- Orientation for time, place, and space
- Evaluation of speech, i.e. dysphasia, dysarthria,
- Evaluation of praxis
- Evaluation of gnosis, i.e. recognition, interpretation
and organization of percepts - agnosias
- Evaluations of memory
- Intelligence - verbal
- 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
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,
- 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
- Examine fluency of speech, spontaneity
of speech and word finding ability
- Specific tasks like repeating "no ifs,
ands, or buts about it," "Constitution of
the State of Massachusetts," and "I am."
- Identify and name certain objects in the
room, certain body parts, certain colors.
- Respond to a question requiring comprehension,
i.e. "source of illumination," "through where
does the wind blow into this room?"
- 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
- 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.
- 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
- 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.
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.
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
- 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
- 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
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
- "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'
- "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
- "Please give me as many words as you can
that begin with the letter D in a period of 30
- "Repeat again the information about the
- "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
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).