Bedside Evaluation of Neurobehavioral Disorders Yong Jeong, M.D., Duk L. Na, M.D. Department of Neurology, Samsung Medical Center, School of Medicine,

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1 Bedside Evaluation of Neurobehavioral Disorders Yong Jeong, M.D., Duk L. Na, M.D. Department of Neurology, Samsung Medical Center, School of Medicine, Sungkyunkwan University This article provides clinical practice guidelines for neurologists in the assessment of neurobehavioral and neurocognitive deficits. It has been known that cognitive functions lie mainly in the cortex and that different cortical areas mediate different cognitive functions. Therefore, the evaluation of cognitive and neurobehavioral symptoms helps localize these symptoms. This article describes the bedside history taking and clinical examinations for patients with neurobehavioral and cognitive dysfunctions. It includes the assessment of aphasia, apraxia, Gerstmann syndrome, visuospatial dysfunctions, neglect syndrome, memory disturbances, and frontal lobe dysfunctions. This guideline will offer better approaches to patients with cognitive deficits and neurobehavioral problems. J Korean Neurol Assoc 20(4):325~338, 2002 Key Words : Behavioral, Cognitive, Bedside Duk L. Na, M.D. Copyright 2002 by the Korean Neurological Association 325

2 Table 1. Cognitive dysfunctions associated with left versus right hemisphere and anterior versus posterior region injury Left hemisphere Aphasia, alexia, agraphia Acalculia Right-left disorientation Finger agnosia Ideomotor apraxia Verbal memory loss Anterior half (frontal lobe) Abulia, akinetic mutism Disinhibition Executive dysfunction Motor impersistence Right hemisphere Neglect syndrome Visuospatial dysfunction - Visuoperceptual dysfunction - Geographical disorientation - Constructional apraxia Dressing apraxia Aprosodia Visual memory loss Posterior half (parietal, temporal, occipital lobes) Visual agnosia - object (visual object agnosia) - face (prosopagnosia) - color (color agnosia) Balint syndrome 326 J Korean Neurol Assoc / Volume 20 / July, 2002

3 Table 2. Classification of aphasia Nonfluent (NF) aphasia Fluent (F) aphasia Broca TM Global MT Wernicke TS Conduction Anomic Spontaneous speech NF NF NF NF F F F F Comprehension good good poor poor poor poor good good Repetition poor good poor good poor good poor good Naming poor poor poor poor poor poor poor poor TM; transcortical motor, MT; mixed transcortical, TS; transcortical sensory J Korean Neurol Assoc / Volume 20 / July,

4 Table 3. Representative items for assessment of ideomotor apraxia Limb-Intransitive Limb-Transitive ( ) ( Buccofacial-Intransitive ) 10. Buccofacial-Transitive ( ) 10. ( ) 328 J Korean Neurol Assoc / Volume 20 / July, 2002

5 Figure 1. Judgment of Line Orientation : a test for visuoperceptual ability. The subject is to find the same angle in B that is presented in A. Figure 2. Examples of visuoconstructive dysfunction. Left: A copying of interlocking pentagon; Right: A copying of Rey-Osterrieth Complex Figure. J Korean Neurol Assoc / Volume 20 / July,

Figure 3. Block design Figure 4. Line bisection test. Patients with right hemisphere injury, for instance, bisect to the right from the true midline. A

6 Figure 3. Block design Figure 4. Line bisection test. Patients with right hemisphere injury, for instance, bisect to the right from the true midline. A B Figure 5. A. Line cancellation task (Top) and an example of left hemispatial neglect (Bottom). B. Star cancellation task (Top) and an example of left hemispatial neglect (Bottom). 330 J Korean Neurol Assoc / Volume 20 / July, 2002

7 A B C Figure 6. Examples of left hemispatial neglect on copying tasks. A. Two daisy, B. modified Ogden picture, C. Clock Drawing. J Korean Neurol Assoc / Volume 20 / July,

8 332 J Korean Neurol Assoc / Volume 20 / July, 2002

9 J Korean Neurol Assoc / Volume 20 / July,

If the examiner raises two fingers, the patient is to raise one finger(b). A B Figure 8. Go-No-Go test.

10 A B Figure 7. Contrasing programming. If the examiner raises one finger, the patient is to raise two fingers (A). If the examiner raises two fingers, the patient is to raise one finger(b). A B Figure 8. Go-No-Go test. If the examiner raises one finter, the patient is to raise two fingers(a). If the examiner raises two fingers, the patient is to do nothing(b). 334 J Korean Neurol Assoc / Volume 20 / July, 2002

11 Figure 9. The stimulus for the alternating square and triangle (Top), and an example of perseveration shown by a patient (Bottom). Figure 10. Lurial loop (the first stimulus) and an example of perseveration shown by a patient (the right six drawings). J Korean Neurol Assoc / Volume 20 / July,

12 A B C Figure 11. Fist-edge-palm. The patient is asked to repeat the hand gestrues in the order of fist(a), edge(b), and palm(c). A B Figure 12. Alternating hand movements 336 J Korean Neurol Assoc / Volume 20 / July, 2002

13 16. Heilman KM, Valenstein E. Frontal lobe neglect in man. Neurology 1972;22: Hier DB, Davis KR, Richardson ET, Mohr JP. Hypertensive putaminal hemorrhage. Ann Neurol 1977;1: Watson RT, Heilman KM. Thalamic neglect. N e u r o l o g y 1979;29: Oh JY, Kwon JC, Chin J, Kim JI, Lee JH, Choi KK, et al. Retrograde amnesia following anterior thalamic infarction. 01. Kim H, Na DL. PARADISE Korean version-the J Korean Neurol Assoc 2002 (in press). Western Aphasia Battery (PARADISEK - W A B ). Seoul: 20. Squire LR, Clark RE, Knowlton BJ. Retrograde amnesia. Paradise Welfare Foundation, Institute for Children with Hippocampus 2001;11: Disabilities, Kroll NEA, Markowitsch HJ, Knight RT, Cramon Y. 02. Kim H, Kwon MS, Na DL, Choi SS, Lee KH, Chung CS. Retrieval of old memories: the temporofrontal hypothesis. Decision making in fluency measures of aphasic sponta- Brain 1997;120: neous speech. Korean J Communication Disorders 1998;3: Kim H, Na DL. Korean - Boston Naming Test( K - B N T ). Seoul: Hakji Co., Heilman KM Apraxia, In: Heilman KM and Valenstein E. Clinical Neuropsychology. 3rd ed. New York; Oxford University Press, 1993; Kwon JC, Na DL, Kim H, Kim GM, Kang Y. Errors of ideomotor apraxia in Alzheimer s disease. J Korean Neurol Assoc 1997;15: Choi SH, Na DL, Kang E, Lee KM, Lee SW, Na DG. Functional magnetic resonance imaging during pantomiming tool-use gesture. Exp Brain Res. 2001;139: Raade AS, Rothi LJ, Heilman KM.. The relationship between buccofacial and limb apraxia. Brain 1991;16: Benton AL, Hamsher K, Varney NR, Spreen O. Contributions to Neuropsychological Assessment. N e w York: Oxford University Press Benton AL, Tranel D. Visuoperceptual, visuospatial, and visuoconstructive disorders. In: Heilman KM and Valenstein E. Clinical Neuropsychology. 3rd ed. New York; Oxford University Press, 1993; Benton AL. Differential behavioral effects in frontal lobe disease. Neuropsychologia 1968;6: Son Y, Na DL. Stroke and neglect syndrome. Korean J Stroke 1999;1: Lee BH, Lee KS, Yoon SJ, Lee YM, Kim H, Kwon JC, Kang SJ, Na DL. Horizontal versus vertical reading in neglect dyslexia-a case study. J Korean Neurol Assoc 2002;20: Lee BH, Kang SJ, Park JM, Son Y, Lee KH, Adair JC, et al. The character-line bisection task: A new test for hemispatial neglect. Neurology 2002;58(Suppl.3):A Bowen A, McKenna K, Tallis R. Reasons for variability in the reported rate of occurrence of unilateral spatial neglect after stroke. Stroke 1999;30: Feinberg TE, Haber LD, Leeds NE. Verbal asomatognosia. Neurology 1990;40: J Korean Neurol Assoc / Volume 20 / July,

14 22. Mumby DG, Glenn MJ. Anterograde and retrograde memory for object discriminations and places in rats with periphinal cortex lesion. Behav Brain Res ; : Absher JR, Cummings JL. Neurobehavioral examination of frontal lobe functions. Aphasiology 1995;9: Cummings JL. Frontal-subcortical circuits and human behavior. Arch Neurol 1993 ;50: Tranel D. Acquired sociopathy : the development of sociopathic behavior following focal brain damage. P r o g Exp Pers Psychopathol Res 1994; Eslinger PJ, Damasio AR. Severe disturbance of higher cognition after bilateral frontal lobe ablation: patient EVR. Neurology 1985;35: Yoon SJ, Jeong JH, Kang SJ, Na DL. Compulsive behaviors and presenting symptoms of frontotemporal dementia. J Korean Neurol Assoc 2000;18: Kang Y, Chin JH, Na DL, Lee H, Park JS. A normative study of the Korean version of Controlled Oral Word Association Test (COWAT) in the elderly. Korean J Clinical Psychology 2000;19: J Korean Neurol Assoc / Volume 20 / July, 2002

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