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THE CLINICAL NEUROLOGIC EXAMINATION
Audio-Digest Neurology
Volume 04, Issue 16
August 21, 2013

Mental status examination; Elemental neurologic examination; Evaluation for dementia – Richard Restak, MD
  
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The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.

Neurology Program Info  Accreditation InfoCultural & Linguistic Competency Resources

The Clinical Neurologic Examination

Richard Restak, MD, Clinical Professor of Neurology, George Washington University School of Medicine and Health Sciences, Washington, DC, and Past President of the Neuropsychiatric Association

Educational Objectives

The goal of this program is to improve the execution of clinical neurologic examinations. After hearing and assimilating this program, the clinician will be better able to:

1. Carry out a mental status evaluation.

2. Evaluate a patient’s verbal fluency and perform a detailed evaluation of memory.

3. Test for functions of the left and right hemispheres.

4. Perform a neurologic examination of function of the cranial, motor, and sensory nerves.

5. Evaluate patients for cortical and subcortical dementia and determine whether additional testing is needed.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Restak and the planning committee reported nothing to disclose.

Mental Status Examination

Observations at first contact with patient: important to greet patient in waiting room; appearance — dressed neatly or untidily; sitting, standing, or pacing (possible sign of akathisia); social interaction — good eye contact; firm or limp handshake; dry or moist palm; tremor when arm and hand extended; to evaluate social skills, ask whether patient had any trouble finding office; signs of weaknesseg, placement of hands on thighs and pressing upward (semi-Gowers maneuver) upon rising from chair; gait — stand behind patient during walk to examining room; look for symmetric movements of both arms (disturbed in Parkinson disease [PD]), or focal weakness (unilateral; bilateral and symmetrical weakness in PD); does patient use smooth 2-step process to turn with weight shifted unhesitatingly or multiple steps; does gait have wide base; stand behind patient, direct verbally, and observe ability to follow directions

Chief complaint: determine first to guide neurologic examination; find out whether visit generated by patient or compelled by others; if brought by others, ask whether patient feels problem exists; if patient denies problem, ask whether problem might exist (provides early measure of insight); typically patients with moderate to advanced Alzheimer disease (AD) brought to consultation; those with early AD may recognize problem with memory or cognitive function

Mental status evaluation: begin by emphasizing that questions asked of all patients; prepare patient that some questions easy and others difficult; encourage patient to relax

Attention: other findings invalid if attention deficient; ask days of week and months of year backwards; have patient repeat increasingly long (ie, 5 to 7) digit spans; Trail Making Test — available on internet; both parts have 25 circles distributed over sheet of paper; in part A, patient draws line to connect numbers in circles in ascending order; in part B, circles include numbers (1 to 13) and letters (A to L); patient draws lines to connect circles in ascending pattern, alternating numbers and letters as quickly as possible without lifting pen; unnecessary to continue test if patient cannot complete both parts in <5 min; part A normally takes <30 sec; trail B takes ≈75 sec; attention impaired in confusional states, delirium, dementia, or executive function failures

Short Test of Mental Status (STMS): available on internet; Mini-Mental State Examination good but does not include as many cognitive functions; Montreal Cognitive Assessment also useful; select on basis of clinician’s comfort and familiarity with test

Orientation: ask name, address, current location, city, state, day or date, month, and year; up to 8 points given for correct answers

Attention: ask to listen and repeat 5- to 7-digit numbers; tell patient not to think about numbers but to listen and repeat; not everyone able to recall 7 digits; score corresponds to number of digits correctly repeated

Learning and immediate recall: give 4 unrelated words (apple, Mr. Johnson, charity, and tunnel); ask patient to repeat and advise that question will be repeated later

Calculation: multiplication, subtraction, division, and addition, eg, 5×13, 65-7, 58÷2, 29+11; score of 4 points if all correct

Abstraction and similarity: ask similarities between orange and banana (fruit), dog and horse (animals), and table and bookcase (furniture); may provide hints and give partial score if patient answers correctly after hint

Information: ask names of current president, first president, number of weeks per year, and definition of island; worth 4 points

Construction: copy Necker cube; draw clock face showing, eg, 11:10, 11:15

Total score: maximum 38; 34 to 38 considered normal; 29 to 33 suggests mild cognitive impairment; <29 suggests early dementia

Verbal fluency test: speaker adds to STMS to evaluate semantic and lexical fluency; semantic — count number of animals named in 1 min; lexical — think of words beginning with f, s, or a; 17 to 20 animals or words considered normal; understanding — ask names of objects in environment; ask patient to follow simple commands, name objects, body parts, and colors, read passage from newspaper and write sentence of dictation

Detailed evaluation of memory: ask whether patient has problems learning and remembering new things, difficulty finding correct words, or lack of memory of previous conversations; test for 3 stages — ability to encode revealed by learning and immediate recall section of STMS; request for repetition 4 min later evaluates storage and retrieval; if hint helpful, information stored but not retrieved; if hint not helpful, information not stored; frontal lobes responsible for acquiring, storing, and retrieving information; hippocampus important in storage; ask patient to repeat Babcock sentence; test for recent events (tests for early dementia); test for remote events (eg, years of World War II, names of previous presidents)

Working memory: ie, tracking, retrieving, and manipulating information (manipulation key); ask for names of presidents from Obama to Roosevelt (tests general memory); then ask for names of Democratic and Republican presidents and to list them in alphabetical order (tests working memory)

Left hemisphere function: look for problems with language and calculation; look for anomalies in fluency and spontaneous speech, word retrieval, substitutions, or paraphasias; listen for sparse, effortful, or laconic speech, short phrase length, and absence of melodic intonation (telegraphic or nonfluent speech suggests Broca aphasia); right-sided weakness often present; speech in Wernicke aphasia effortless, melodic, normal or slightly increased in rate, but incomprehensible; patient also cannot understand speech of others or follow commands; patients may become agitated or paranoid; important to differentiate from word salad of schizophrenia (very rare)

Language function: ask patient to repeat phrase, eg, “no ifs, ands, or buts”; ask patient to point to nose or forehead (comprehension); ask patient to perform maneuvers that cross midline; ask patient to comply with 3-part commands; ask more complex questions

Reading (alexia) and writing (agraphia): ask patient to read from magazine and write dictated sentences

Praxia: ask patient to demonstrate movements and follow commands

Goal of examination: identify patients who need additional neurologic work-up

Right hemisphere: prosodyie, conveyance of information by means other than word choice or order by, eg, tone, pitch, intonation, melody, cadence, loudness, tempo, stress, accent, timing and placement of pauses; to test for dysprosody, ask patient to speak in angry voice and identify emotional tones in speech of others; visual constructive defectsie, problems with spatial analysis; ask patient to draw circle, cross, and cube; draw and ask patient to identify square; ask patient to identify triangle drawn on top of square and circle drawn on top of all; ask patient to fill in area common to all 3 items; visual memory — ask patient to describe path taken to office, and path from office to local landmark; facial recognition — in prosopagnosia, patient cannot recognize familiar faces without nonvisual cues (rare); patients with environmental agnosia cannot identify familiar scenes but can sense familiarity

Elemental Neurologic Examination

Cranial nerves

Olfactory: affected early in AD; ask patients to identify samples of coffee, cloves, vanilla, and mint by smell; inability to respond correctly may involve impaired language ability rather than olfactory nerve problem

Optic: observe shape, size, and symmetry of eyes and pupils; determine visual acuity with Snellen chart; test visual field by moving objects into view from 4 quadrants while patient looks straight ahead; test direct response by noting restriction of pupil when shining light into eye; consensual response causes fellow pupil to constrict; dilation when light shown into fellow pupil indicates problem with optic nerve on that side; examine macula for optic pallor (sign of multiple sclerosis) or swelling of nerve head (sign of raised intracranial pressure)

Oculomotor, trochlear, and abducens: look for smooth symmetric movement of eyes as finger moved from side to side, and up and down; evaluate voluntary saccades while patient looks left, right, up, and down; observe convergence response

Trigeminal: test sensation in upper face, maxillary, and mandibular areas; test strength of masseter by placing hands on side of jaw while patient chews; speaker does not usually test jaw jerk or reflex (sign of problems with upper motor neuron)

Facial: ask patient to wrinkle forehead and to open and close eyes against resistance; observe symmetry of nasolabial fold; voluntary smile; ability to purse lips and inflate cheeks

Vestibulocochlear: test hearing by rubbing forefinger against thumb ≈1 in away from ear

Glossopharyngeal and vagus: ask patient to say “ahh” and evaluate symmetry of elevation of palate (deviation may occur to strong side); ask patient to say “eee” to check for opposition of vocal cords; bulbar palsy characterized by nasal speech, weak palate, and decreased gag reflex; pseudobulbar palsy characterized by exaggerated gag reflex

Spinal accessory: have patient push chin against hand and shrug shoulders to evaluate sternocleidomastoid and trapezius muscles

Hypoglossal: look for atrophy, fasciculations, and abnormal involuntary movements of tongue; on protrusion, deviation of tongue to weak side indicates problem

Motor examination: look for atrophy or hypertrophy of muscles and fasciculations (possibly caused by benign fasciculation syndrome rather than motor neuron disease); look for abnormal involuntary movements (eg, tremors, choreas); check resistance (eg, spasticity, rigidity, cogwheeling)

Reflexes: important to test before strength because motor activation can exaggerate reflexes; test biceps, brachioradialis, triceps, knee, and ankle reflexes; if knee and ankle reflexes suppressed because of anxiety, have patients lock fingers and pull hands apart (Jendrassik maneuver) to release reflex; grading — assign score of 0 to 4 (0, absent; 1, normal; 4, brisk with several muscle groups involved); associated nerves — triceps, C7; biceps, C8; brachioradialis, C6; reflexes of lower extremities include patellar (primary roots L2-L4) and Achilles (primary root S1); abnormal reflexes — Hoffmann reflex (thumb moves when distal phalanx of middle finger flicked); Babinski sign (big toe moves up if foot touched along lateral aspect and across below toes)

Muscle strength: pronator drift (palms turn slowly downward when hands held out with palms up) indicates weakness (arm going down indicates psychogenic limb weakness); graded by assigning score of 0 (no movement), 5 (normal movement), 2 or 3 (full range of motion against gravity), or 4 (full range of motion but decreased strength); determine whether weakness proximal (sign of myopathy) or distal (sign of neuropathy)

Sensory examination: test 2-point discrimination with pin ≈6 mm apart (parietal area); coordination — evaluate sides separately; finger-to-nose test with eyes open and closed; repetitive or rapidly alternating movement (eg, opening and closing hand); gait — ask patient to toe-walk, heel-walk, and tandem gait

Evaluation for Dementia

Cortical type: signs — aphasia, language disturbance, apraxia, agnosia, amnesia, and visual spatial defects; primitive reflexes — palmomental reflex in which mentalis muscle of chin puckers in response to object drawn across palm; snout and rooting reflex elicited by tapping lip; disturbance of muscle toneeg, gegenhalten (tone increased on passive movement of limb)

Subcortical type: signs — mental slowness, bland look, tremor, and bradykinesia

Executive function: always affected in dementia; includes generation of several response alternatives, maintenance of focus and goal, flexibility in responses, integration of parts into whole, maintenance of insight, and self-monitoring of errors; tests — verbal fluency (semantic and lexical); look for perseveration (performing same action repetitively and not changing when necessary); test for right-left orientation, calculation, similarities, cognitive estimates, and proverb interpretation

Frontal systems to asses: orbital — disturbances characterized by disinhibition, impulsivity, angry outbursts, or inappropriate speech or behavior; distinguish from late-life mania (cognitive function generally intact); system dampens emotional responses of limbic system (especially amygdala); medial — disturbances result in apathy, social withdrawal, and decreased socialization; important to differentiate from depression; dorsolateral — disturbances result in inability to keep checkbook, attend meetings on time, cook meal, or carry out activities with linked steps; difficult to identify; patients appear distracted or absentminded

Tests for executive syndrome: perseveration — fist-edge-palm test (patient places hand on table with fist closed, opens hand, strikes table with side of hand, and turns hand downward); alternating fist-palm-down position test; difficulty shifting back and forth indicates perseveration; go-no-go test (ask patient to raise 1 finger when clinician raises 2 and vice versa without mirroring actions); ask patient to repeat clinician’s actions (must not mirror); verbal fluency tests evaluate executive function; nonverbal tests — ask patient to draw as many abstract designs as possible (≈15 normal); ramparts design (quickly copy alternating pattern of squares and triangles loosely connected on straight line) tests for perseveration

Results of examination: signs of executive dysfunction suggest dementia (loss of intellectual function caused by brain disease) and indicate further evaluation needed; focal or lateralizing signs of any kind require prompt investigation for neurologic disorders; abnormal examination results indicate need for structural imaging studies

Suggested Reading

Desikan RS et al: An expanded role for neuroimaging in the evaluation of memory impairment. AJNR Am J Neuroradiol Jun 13, 2013 [Epub ahead of print]; Kaiser NC et al: What dementia reveals about proverb interpretation and its neuroanatomical correlates. Nueropsychologia Jun 5, 2013 [Epub ahead or print]; Karrasch M et al: CERAD test performance and cognitive impairment in Parkinson’s disease. Acta Neurol Scand May 14, 2013 [Epub ahead of print]; Kaufman LD et al: Executive deficits detected in mild Alzheimer’s disease using the antisaccade task. Brain Behav 2:15, 2012; Kudlicka A et al: Pattern of executive impairment in mild to moderate Parkinson’s disease. Dement Geriatr Cogn Disord 36:50, 2013; Okahashi S et al: A virtual shopping test for realistic assessment of cognitive function. J Neuroeng Rehabil 10:59, 2013; Peters ME et al: Neuropsychiatric symptoms as risk factors for progression from CIND to dementia: the Cache County Study. Am J Geriatr Psychiatry Feb 6, 2013 [Epub ahead of print]; Pulsipher DT et al: Clinical utility of the Neuropsychological Assessment Battery (NAB) after unilateral stroke. Clin Neuropsychol May 20, 2013 [Epub ahead of print]; Sewell MC et al: Detection of mild cognitive impairment and early stage dementia with an audio-recorded cognitive scale. Int Psychogeriatr May 2, 2013 [Epub ahead or print]; Sikaroodi H et al: Cognitive impairments in patients with cerebrovascular risk factors: a comparison of Mini Mental Status Exam and Montreal Cognitive Assessment. Clin Neurol Neurosurg Jan 2, 2013 [Epub ahead of print]; Skodda S: Aspects of speech rate and regularity in Parkinson’s disease. J Neurol Sci 310:231, 2011; Weissberger GH et al: Which neuropsychological tests predict progression to Alzheimer’s disease in Hispanics? Neuropsychology 27:343, 2013; Zgaljardic DJ et al: Naming test of the Neuropsychological Assessment Battery: reliability and validity in a sample of patients with acquired brain injury. Arch Clin Neuropsychol May 27, 2013 [Epub ahead of print].


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