Frontal Lobar Function tests.pptx

Ppt on frontal lobe tests

1. LOBAR FUNCTION TEST Moderator :- Dr. S. Sengupta , AP Dr. S. A. Alam , SR Presenter :- Dr. Narendra P. S. Rajput,PGT Dept of psychiatry, LGBRIMH, Tezpur JULY 2015 Short topic

2. OUTLINE Introduction Different lobe functions Tests for frontal lobe Tests for temporal lobe Tests for parietal lobe Tests for occipital lobe References

3. Introduction- why to assess? Determine the cognitive deficits Evaluate the nature and scope of observed deficits Assist in diagnostic determination Aid in treatment and management To measure change over time

4. Frontal lobe functional anatomy

5. Functions Motor cortex:- specialized for controlling fine motor movement (hand & face) Premotor cortex:- these neuron forms three descending system-controlling limb movement, controlling body /axial movements, controlling eye movement. Prefrontal cortex:- it is involved in temporal organization of complex behavior . Sequencing Motivation and drive Executive function

6. Assessment of frontal lobe function- Motor subsystem:- Spastic hemiplegia contralaterally . Test includes test for basic motor function- (grip strength) finger tapping test (fine motor speed ). Premoto r lesions:- loss of “ Kinetic Melody”. Bedside test for alternating Motor Patterns Fist Palm Side Test Fist Ring Test Reciprocal Co-ordination Test Drawing zigzag line consisting of pointed and rectangular elements

7. Fist-ring test Test of reciprocal coordination Drawing zigzag line consisting of pointed and rectangular elements

8. In deep seated lesions of premotor cortex (in the test of kinetic melody ) patients will have “ compulsive automatism”. The patient has difficulty in ceasing the behavior

9. Frontal eye fields:- (BA8,9 ,6) Bedside test: Ask the patient to follow the movement of a finger from left to right and up and down. Ask the patient to look from left to right, up and down (with no finger to follow). Note inability to move or jerky movement

10. Supplementary motor area and anterior cingulate cortex Very much interconnected to other parts Involved in motivated behavior Initiation and goal directed behavior At present there are no office or neuropsychological tests can be tested along with other frontal lobe divisions

11. Left Generative Lesions: Impaired initiative, depression Right Inhibitory Lesions: impulsive mania, sociopathy Human PFC

12. It Includes - greater part of superior, middle and inferior frontal gyri , orbital gyrus , most of medial frontal gyrus , anterior half of cingulate gyrus LATERAL VIEW CUT SECTION OF BRAIN

13. Dorsolateral prefrontal cortex (DLPC):- (BA 9, 10, 46) Bedside tests: 1. Is the patient able to make an appointment and arrive on time? 2. Is the patient able to give a coherent account of current problems and the reason for the interview? Is there evidence of thought disorder? 3. ATTENTION & WORKING MEMORY :- Digit span, days of the week or months of the year backwards. Here the patient has to retain the task and the information, and then manipulate the information. Serial subtraction and test for Sustained attention

14. Test of Sustained attention Cancel 6 and 9 Right Wrong Total Time taken

15. 4. Controlled oral word association test ( COWAT ): Tests VERBAL FLUENCY A sked to produce as many words as possible, in one minute, starting with F, then A, then S. Proper nouns and be previously used words with a different suffix are prohibited Other categorical fluency tests include naming animals, fruits and vegetables 5. Executive function Wisconsin Card Sorting Tests Tower of L ondon test Trail making test

16. Wisconsin Card Sorting Test- Abstract thinking and set shifting; L>R “ Please sort the 60 cards under the 4 samples. I won’t tell you the rule, but I will announce every mistake. The rule will change after 10 correct placements.”

17. Tower of London Tests Planning Various levels of difficulty: e.g. “Please rearrange the balls on the pegs, so that each peg has one ball only. Use as few movements as possible”

18. Trail Making Test- Visuo -motor track, conceptualization, set shift A C 1 2 7 3 D 5 B 4 6 Various levels of difficulty: 1. “Please connect the letters in alphabetical order as fast as you can.” 2. “Repeat, as in ‘1’ but alternate with numbers in increasing order”

19. Abstract thinking and Judgement Proverb Testing Similarity testing Block design Tests construction ability abstract thinking. Blocks are kept in specific arrangement and also to shift them to the a particular form. Multi coloured cubes are given to the patient and asked to arrange them according to a specific design. Weigh colour – form sorting test, Object sorting Test Goldstein’s Scheerer Stick Test Insight :- reaction to own illness

20. Orbital and basal area ( Orbitofrontal cortex) Bedside tests: 1. Does the patient dress or behave in a way which suggests lack of concern with the feelings of others or without concern to accepted social customs. 2. Test sense of smell - coffee, cloves etc. 3. Go/no-go Test:- The patient is asked to make a response to one signal (the Go signal) and not to respond to another signal (the no-go signal). The most basic is to ask the patient to tap their knee when the examiner says, “Go” and to make no response when the examiner says, “Stop”.

21. The Stroop Test :- Examines attention and the ability of the patient to inhibit responses. Patients are asked to state the color in which words are printed rather than the words This task is made difficult by presenting the name of colors printed in different colored ink RED BLUE ORANGE YELLOW GREEN RED PURPLE RED GREEN YELLOW BLUE RED YELLOW ORANGE RED GREEN BLUE GREEN PURPLE RED

22. Frontal Release Reflexes As the CNS matures, frontal lobe cells develop and begin to inhibit the primitive reflexes which are present in normal babies. These may reappear with brain damage or disease Grasp Sucking (pout, snout, rooting) Palmar -mental Glabella Tap Apraxia , aphasia and memory disturbances also occur in frontal lobe lesions. Test described with other lobes

23. Orbitofrontal syndrome ( disinhibited ) Frontal convexity syndrome (apathetic) Medial frontal syndrome ( akinetic ) Disinhibited , impulsive behavior ( pseudopsychopathic ) Inappropriate jocular affect, euphoria Emotional lability Poor judgment and insight Distractibility Perseveration Apathy Indifference Psychomotor retardation Motor perseveration and impersistence Loss of self Stimulus-bound behavior Discrepant motor and verbal behavior Motor programming deficits Poor word list generation Poor abstraction and categorization Segmented approach to visuospatial analysis Paucity of spontaneous movement and gesture Disturbance of will Catatonic signs- gegenhalten ,waxy flexibility Alien hand, forced grasping, compulsive utilization, Sparse verbal output (repetition may be preserved) Lower extremity weakness and loss of sensation Incontinence

24. Test and lesions (Stuss2002) Left DLPFC FAS WCST Stroop Naming List Learning TMT Semantic Fluency Inferior Medial List learning Semantic Fluency Right DLPFC WCST TMT Semantic fluency Superior Medial FAS WCST Stroop Incongruent TMT Semantic Fluency

25. Test for temporal lobe Sensory:- auditory n visual perception Memory Comprehension & understanding spoken language Emotion and behaviour

26. NEUROPSYCHOLOGICAL ASSESSMENT 1-Testing for auditory processing capacity- DICHOTIC TESTING TASK 2- Testing for visual processing capacities- Mc Gill picture anomalies tests 3—Test for verbal memory— Wechsler memory scale 4—Test for visual memory Rey complex figure/ Rey- Osterrieth Test 5—Test for language comprehension Token test

27. Some terms related to language disorders :- Aphasia- a true language disturbance due to impairment in the production and/or comprehension of spoken language. Dysarthria - a specific disorder of articulation in which basic language( grammar, word choice and comprehension) are intact. Dysprosody - an interruption of speech melody. Speech inflection and rhythm are disturbed Buccofacial or oral Apraxia - is the inability to perform skilled movements of the face and speech musculature in the presence of normal comprehension, muscle strength, and coordination. Amusia – inability to identify musical themes Pure word deafness ( aphemia )– can not recognise spoken word despite speech, reading n writing being normal.

28. Aphasias Global :- M/C , Spontaneous speech is absent or reduced to a few stereotyped words or sounds. Comprehension is absent/reduced. Broca ‘s:- Nonfluent , comprehension good , poor repetition. Wernicke’s :- fluent, poor comprehension & repetition. Conduction:- poor repetition, paraphagic , fluent speech comprehension relatively spared Transcortical :- retained repetition but subdivided according to fluency & comprehension as transcortical motor/ sensory Anomic Aphasia- There is word finding difficulty and an inability to name objects , speech is spontaneous, fluent, grammatically rich but contains many word finding pauses Subcortical Aphasia- fluent/ articulary disturbances Repetition is intact/impaired impaired comprehension

29. Bedside tests Handedness :- 99% of right hander's have left hemispheric dominance for language. left hander's, 67% left hemispheric language, 33% have either mixed or right hemispheric language dominance. Spontaneous speech :- fluent / non fluent Comprehension:- answers to normal Qs. Naming objects Repetition Reading writing

30. Memory assessment Immediate memory :- 3 unrelated words ask to repeat , digit span test. Recent /short term- recall of 3 words after 5 min , recent events of day * Orientation – time/place/person * Verbal memory- word list test * Visuo -spatial memory- reproduce drawings Remote /Long term :- personal / historic events of past. Confabulation ;- making up stories to fill up the gaps ; Korsakov’s psychosis

31. The Kluver-Bucy syndrome Tameness : loss of fear/anxiety or diminished aggression Dietary changes: indiscriminate dietary behavior Altered sexuality : greatly increased autoerotic, homosexual, or heterosexual activity or inappropriate sexual object choice Hypermetamorphosis : a tendency to attend to and react to every visual stimulus Hyperorality : a tendency to examine all objects by mouth Psychic blindness : visual agnosia Gastaut-Geschwind syndrome combinations of hyposexuality , hyperreligiosity , hypergraphia , interpersonal “stickiness,” circumstantiality

32. Temporal lobe Lesions Dominant Dysphasia Dyslexia Poor memory Complex hallucinations (smell, sound, vision) Superior quadrantanopia Non-dominant Poor non-verbal memory Loss of musical skills Complex hallucinations

33. Parietal lobe Integrating somatosensory with visual and auditory information to construct ‘body schema’ and its relation to extrapersonal space. Also in the execution of voluntary complex motor acts. Comprehension of verbal and written language. The recognition and utilization of numbers, arithmetic principles and calculations.

34. Some terms Stereognosis : ability to recognize and identify objects by feeling them. The absence of this ability is termed astereognosis . Graphesthesia : ability to recognize symbols written on the skin. The absence of this ability is termed graphanesthesia . Two-point discrimination: ability to recognize simultaneous stimulation by two blunt points. Measured by the distance between the points required for recognition. Touch localization ( topognosis ): ability to localize stimuli to parts of the body. Topagnosia is the absence of this ability. Double simultaneous stimulation: ability to perceive a sensory stimulus when corresponding areas on the opposite side of the body are stimulated simultaneously. ( sensory extinction ) Alexia- Loss of reading ability in a previously literate person. Agraphia - An acquired disturbance in writing. Acalculia - Inability to manipulate figures

35. Classical Test of parietal lobe functions 1) Steriognosia and graphesthesia , 2) Calculating 3) Left – Right orientation 4) Writing 5) Reading aloud 6) Spatial recognition 7) Recognizing ones illness 8) Copying Geometric s shapes Sensory and perceptual disturbances - Somatic sensation is touch, pain, temperature, body position sense, kinesthesia , and vibration.

36. Two-point discrimination Ordinarily, only the fingerpads are tested but other areas of the body can be tested. According to DeJong (1967), the following are the normal distances at which two points can be discriminated on various body parts: Tongue tip: 1 mm Fingertip: 2 to 4 mm Dorsum of fingers: 4 to 6 mm Palm: 8 to 12 mm Dorsum of hand: 20 to 30 mm Topognosis Ask the patient to describe or point to various parts of the body tested with tactile stimulation. This can be done with tactile testing. Double simultaneous stimulation Patients with parietal lobe lesions may recognize stimuli on one side of the body when applied independently but not recognize or distinguish that stimulus when bilateral stimuli are applied.(extinction )

37. Apraxia Inability carry out skilled movement in the absence of impaired motor functioning or paralysis. Type – Left hemisphere injury: ideomotor , ideational, buccal facial apraxia . Right hemispherer injury: constructional and dressing apraxia . Method of testing- 1 st make sure that if there is any weakness, sensory deficit or ataxia. Patient understands instructions. Ideomotor – Buccofacial - Blow out a match, Protrude your tongue & drink through straw. Limb command—How to solute, Use a brush, Flip a coin, Hammer a nail, comb your hair, kick a ball & crush out cigarette. Whole body command- - Stand like boxer, Swing a baseballs bat Ideational Apraxia —Carring out the whole of a complex act is defective, though the execution of different part of the complete act may be normal.

38. Constructional Apraxia / Amorphosynthesis — Basic type of tests are- Spontaneous drawing, Paper and pencil. Production of geometric shape, Two dimensional block design, Three dimensional block design, Stick pattern reproduction, Spatial analysis task—patient is asked to shade in the portion of a design that is common to two or more overlapping figures. 7) Reconstruction of puzzles e.g. Benson & Benson and object assembly subset of WAIS.

39. Patient should have adequate vision & sufficient motor ability. Constructional Apraxia —Presents in 27% of right hemispheric lesion and absent in 17% of cases while in left hemispheric lesion it is seen in 17% and absent in 27% of cases. Other tests- 1) Bender Gestalt Test, 2) Ravens Progressive Matrices, 3) Minnesota Perception- Diagnostic Test,4) Hooper Visual Organization Drawing to command →human figure drawing→bicycle drawing.  

40. Laterality of the lesion and characteristics of drawing Right hemisphere —1) Scattered and fragmented, 2) Loss of spatial relations, 3) Faulty orientation, 4) Energetic drawing, 5) Addition of the line to try to make drawing correct. Left hemisphere —1) Coherent but simplified, 2) Preservation of spatial relations, 3) Correct orientation, 4) Slow and laborious, 5) Gross lack of detail. Constructional apraxia TESTS frontal parietal n occipital lobes

41. Unilateral Spatial Neglect – The syndrome consists of a tendency to neglect one half of extra personal space in such task as drawing and reading. More prominent with right hemispheric lesions.

42. Dressing Apraxia — How patient manipulates to buttons, how he takes off his coat or jacket and puts them on again. It is usually due to right hemisphere lesion involving parietal region Left sided or Unilateral apraxia :- Unable to initiate or perform certain movements with their left hand (but not right). Geographic Disorientation — Describe evidence of disorientation from history, Map localization—to locate well-known cities on a map, Orientation of self in hospital.

43. Disorder of body schema :-- Anosognosia — Failure to perceive one side of body e.g. for hemiplegia ( Babinsky syndrome), Autotopognosia —Inability to identify any part of body. Finger agnosia — Inability to recognize name and point to individual finger on oneself and on others Right—Left disorientation Gerstmann’s Syndrome — Left or dominant parietal lesion. (angular gyrus ) Consists four major component – ---Finger agnosia --Right-left disorientation --- Dysgraphia , agraphia --Dyscalculia Additionally constructional impairment and mild aphasia may exist. It indicates damage of dominant parietal lobe/ bilateral lobe.

44. Dominant side Functions Calculation- simple/complex Language Planned movement Appreciation of size, shape, weight and texture Lesions Dyscalculia Dysphasia Dyslexia Apraxia / Agnosia / Homonymous- Hemianopia Non-dominant side Functions Spatial orientation Constructional skills Lesions Neglect of non-dominant side Spatial disorientation Constructional apraxia Dressing apraxia Homonymous- Hemianopia

45. Occipital lobe Analysis of vision Prospagnosia :- Inability to recognise familiar faces e.g ; family photograph ,popular figures Visual memory :- 5 hidden objects, score <4 abnormal Hemianopia with macular sparing Ballint ‘s syndrome :- Simultagnosia Oculomotor apraxia Optic ataxia

46. Anton- Babinski syndrome) – Inability to recognise part of one’s own body. It includes a somatosensory defect that encompasses loss of the stored body schema as well as conceptual negation of paralysis and a disturbed visual perception and neglect of the body. Patients with visual spatial impairment have great difficulty localizing objects in two and three dimensional space. Stereopsis (binocular depth perception) is often impaired. Unilateral anosognosiais associated with additional abnormalities like blunted emotionality, confusion, and allocheiria .

47. References Bickerstaff’s Neurological Examination in Clinical practice 7 th adapted edition 2013. Richard L. Strub , F. Willium Black, The Mental Status Examination in Neuology , 4 th edition 2003. JN Vyas , Niraj Ahuja,Textbook of Postgraduate Psychiatry, 2 nd edtion 2003. B.J. Sadock , V.A. Sadock , Biology of Memory, Chapter 3.4, Comprehensive Textbook Of Psychiatry 9th, (2009), p658. psych.theclinics.com Pridmore S. Download of Psychiatry, Chapter 27. Last modified: April, 2007 Neuropsychologic Assessment of Frontal Lobe Dysfunction,Elkhonon Goldberg, PhD*, Dmitri Bougakov , PhD, Psychiatr Clin N Am 28 (2005) 567–580. Google images

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