Focal Cognitive Impairments

Stephen A. Ujano
References: Harrisons Principles of Internal Medicine 18th ed
Bates Guide to Physical Examination and History Taking 11th ed
MEMORY FUNCTION AND AMNESTIC DISORDERS

Description

Comprehensio
n
Repetition
Naming
Fluency
LANGUAGE APHASIA

Comprehension is impaired for spoken and written language,

for single words as well as sentences
Many function words but few substantive nouns or verbs
Language output is fluent but is highly paraphasic and circumlocutious.
Strings of neologisms JARGON APHASIA
Gestures and pantomime do not improve communication.
Patient is unaware of condition (language deficit)
Posterior portion of the language network and tends to involve at least parts of
Wernickes area MOST COMMON LESION SITE
Embolus to the inferior MCA (posterior temporal or angular branches) MOST
COMMON ETIOLOGY
Impaired
Impaired
Impaired
Preserved or Increased

a. Wernickes Aphasia

b. Brocas Aphasia
Description

Comprehension

Speech is nonfluent, labored, interrupted by many word-finding pauses, and

usually dysarthric.
Less function words but rich in substantive nouns and verbs
Abnormal word order and inappropriate deployment of bound morphemes
- AGRAMMATISM
Speech is telegraphic and pithy but quite informative; reduced to a grunt or
single word emitted in different intonations
Comprehension deficit for function words and syntax
Patient is aware of the condition
Brocas area (inferior frontal convolution) and surrounding anterior
perisylvian and insular cortex - MOST COMMON LESION SITE
Infarction of Brocas area and occlusion of the superior MCA MOST
COMMON ETIOLOGY
Preserved except grammar

Repetition
Naming
Fluency

Impaired
Impaired
Decreased

c. Global Aphasia
Description

Comprehension
Repetition
Naming
Fluency

Combined dysfunction of Brocas and Wernickes areas

Speech output is nonfluent, and comprehension of spoken
language is severely impaired.
Naming, repetition, reading, and writing also are impaired.
Patient is unaware of the condition
Middle cerebral artery (left hemisphere)- MOST COMMON
LESION SITE
Stroke MOST COMMON ETIOLOGY
Impaired
Impaired
Impaired
Decreased

d. Anomic Aphasia
Description

D
E
S
C
R
I
P
T
I
O
N
---C
A
U
S
E
S

Single most common language disturbance seen in head

trauma, metabolic encephalopathy, and Alzheimers disease .
The minimal dysfunction syndrome of the language network
Articulation, comprehension, and repetition are intact, but
APHASIA
DYSARTHRIA
confrontation
naming, word finding, APHONIA/DYSPHONIA
and spelling are impaired
Aphasia refers to a Less function
Dysarthria
refers
a in substantive
Aphonia
refers
toverbs
a loss of
words
but to
rich
nouns
and
disorder in producing or
defect
in theismuscular
voice that
accompanies
Language
output
fluent but paraphasic,
circumlocutious,
understanding language.
control of the speech
disease affecting the
and uninformative.
apparatus
tongue,by word-finding
larynx orhesitations.
its nerve supply.
Fluency
may be (lips,
interrupted
palate,
or pharynx).
Words
Dysphonia refers to less
Patient
is aware
of the condition
may
bebe
nasal,
slurred,
or the severe
impairment
in the
Lesions
can
anywhere
within
left hemisphere
language
indistinct,
butthe
themiddle
centraland inferior
volume,
quality,gyri
or pitch of
network
including
temporal
symbolic aspect of
the voice. For example, a
Comprehension
Preserved
language remains intact.
person may be hoarse or
Repetition
Preserved
only able to speak in a
Naming
Impaired
whisper.
Fluency
Preserved except for word-finding pauses

Dominant
cerebral
hemisphere
(LEFT) lesion

Central or
peripheral nervous
system motor
lesions
Parkinsonism
Cerebellar disease

Laryngitis
Laryngeal tumors
Unilateral vocal
cord paralysis (CN
X)

CORTICAL DISORDERS OF VISUAL FUNCTION AND HEMISPATIAL NEGLECT

A. Parietofrontal Network for Spatial Orientation
Adaptive orientation to significant events within the extrapersonal
space is subserved by a large-scale network containing three major
cortical components.
1. cingulate cortex provides access to a motivational mapping of the extrapersonal space
2. posterior parietal cortex to a sensorimotor representation of salient extrapersonal events
3. frontal eye fields to motor strategies for attentional behaviors
Subcortical components of this network include the striatum and the thalamus.
Three behavioral components of neglect:
1. Sensory events (or their mental representations) within the neglected hemispace have a lesser
impact on overall awareness,
2. There is a paucity of exploratory and orienting acts directed toward the neglected hemispace
3. The patient behaves as if the neglected hemispace were motivationally devalued.
Model of Spatial Cognition
The right hemisphere directs attention within the entire extrapersonal space, whereas the left
hemisphere directs attention mostly within the contralateral right hemispace

Large frontoparietal
lesion in the right hemisphere
Left Hemispatial Neglect

Degenerative Dementia

Simultanagnosia
inability to integrate visual information
in the center of gaze with more
peripheral information
misses the forest for the trees.
Most dramatic component of Balints
syndrome
Occipitotemporal Network for Face and
Object Recognition

Associative Prosopagnosia
cannot recognize familiar faces, including, sometimes, the reflection of his or her own face in
the mirror; can extend to the recognition of individual members of larger generic object groups
intact perception
recognizes voice
modality-specific (visual input)

Visual Object Agnosia

When recognition problems become more generalized and extend to the generic identification
of common objects
Unable either to name a visually presented object or to describe its use
Apperceptive agnosia

Face and object recognition disorders also can result from the simultanagnosia of
Balints syndrome
Alexia
Describes an inability to either read aloud or comprehend single words and simple sentences
A.K.A. Visual aphasia or word blindness.
It is caused by severe damage to the left side of the brain (the occipital and temporal lobes. strokenetwork.org
Focal Cognitive Impairment 2

DAILY BASIS
Examples of Long Term Memory
Episodic Memory
Birthday celebrations in the past.
Most favorite place visited.
Most memorable moments in the last 10 years.
Most traumatic experience.
NOTE:
o
o

Schools attended.
Previous jobs.
SSS ID etc.

Responses should be validated by a close relative or significant other.

Testing semantic and procedural memory is usually outside the realm of the generalist, but if deficits in these
systems are suspected, further tests are warranted.

Clinical Testing
Mini-Mental Status Examination - Orientation and Three-Word Recall
Free Recall Episodic Memory Peformance
The participants were asked to learn two lists of 16 short sentences (e.g. lift the pen). Each sentence was visually
presented on an index card for 8 s. For one of the lists, the participants were asked to enact each presented sentence,
whereas no enactment was required for the other list. Each list presentation was immediately followed by
administration of a free recall test. These tasks are referred to as free recall of sentences with enactment (SPTB) and
without enactment (VTB). The second free recall test was followed by a cued recall test of the nouns presented in each
of the two lists. This provided us with two additional measures of episodic memory performance: cued recall for
sentences that were initially learned with enactment (SPTCRC) and for sentences initially learned without enactment
(VTCRC)
Conclusion: two free recall-based tests of episodic memory function may be useful for detecting individuals at risk of
developing dementia 10 years prior to clinical diagnosis
Boraxbekk, C.J. et.al. Dement Geriatric Cognitive Disorders Extra. 2015 May-Aug; 5(2): 191202.
DAILY BASIS
Examples of Short Term Memory
Working Memory
First thing you do every morning upon
waking up
Car you usually drive

Bet among the candidates for

Presidency
Place visited last Monday and activities
done

Todays weather

Clinical Testing
More of test of attention

Digit Span
Explain that you would like to test the patients ability to concentrate, perhaps adding that this can be difficult
when people are in pain, ill, or feverish. Recite a series of digits, starting with two at a time and speaking each number clearly at
a rate of about one per second. Ask the patient to repeat the numbers back to you. If this repetition is accurate, try a series of three
numbers, then four, and so on as long as the patient responds correctly. Jot down the numbers as you say them to ensure your own
accuracy. If the patient makes a mistake, try once more with another series of the same length. Stop after a second failure in a
single series.
When choosing digits, use street numbers, zip codes, telephone numbers, and other numerical sequences that
are familiar to you, but avoid consecutive numbers, easily recognized dates, and sequences that are familiar to the patient.
Now, starting again with a series of two, ask the patient to repeat the numbers to you backward.
Normal - repeat correctly at least five digits forward and four backward.

Serial 7s
Instruct the patient, Starting from a hundred, subtract 7, and keep subtracting 7. . . . Note the effort required
and the speed and accuracy of the responses. Writing down the answers helps you keep up with the arithmetic. Normally, a
person can complete serial 7s in 1 minutes, with fewer than four errors. If the patient cannot do serial 7s, try 3s or counting
backward.

Spelling Backward
This can substitute for serial 7s. Say a five-letter word, spell it, for example, W-O-R-L-D, and ask the patient to spell it
backward.