Higher cognitive functions

1. HIGHER COGNITIVE FUNCTIONS

2. INTRODUCTION
• Attention,language and memory serves as the
building blocks for higher intelectual
functions.
• Higher cognitive functions are manipulation of
well learned matiriel ,abstract
thinking, problem solving, arithematic
computations.
• Above functions are the highest level
intellectual functions often the earliest
markers of cortical dysfunction.

3. • These can be readily assesed by carefully
history taking about his job
performance, management of
finances, problem solving and over all
judgement.

4. • Behaviour :
• a. the aggregate of all the responses made by
an organism in any situation
• b. a specific response of a certain organism to
a specific stimulus or group of stimuli
• c. the action, reaction, or functioning of a
system, under normal or specified
circumstances

5. • Personality :
• The pattern of collective
character, behavioral, temperamental, emotio
nal and mental traits of a person.

6. EVALUATION
• Categorised in the following groups:
– Fund of acquired information.
– Manipulation of old knowledge.
– Social awareness and judgement.
– Abstract thinking.
• Fund of information is acomplished by simple
verbal tests of vocabulary, general information
and comprehension.

7. • Manipulation of old knowledge is tested by
social comprehension and caluculation.
• Abstract thinking is a more complex function
assesed by proverb interpretation, conceptual
or anology interpretation.

8. Fund of information
• A series of 10 questions are asked in order of
increasing difficulty till the patient unable to
answer 3 succesive questions or test is
completed.
• If the patients answer is unclear should be
asked to explain again.
• Examiner can repeat the question but should
not paraphase or spell or explain words.

9. Table of questions
How many weeks are there in 52
a year
Why do people have lungs ? respiration
Name three prime ministers appropriate answer
of india whom you remember
Where is culcutta West bengal
How far is Tirupathi to 400 to 500km
vijayawada
Why light colored clothes Appropriate answer
cooler than dark ones in
summer
What is capital of pakisthan islamabad
What causes rust Appropriate answer
Who wrote ramayana valmiki
Why is Tajmahal constructed Appropriate answer

10. • Scoring
– Average patient should answer minimum of six
questions.
– Less adequate performance indicate reduced
inteligence, limited social and education exposure
or significant dementia.
– Stable over a wide age range.
– Impaired early in alzeimers disease.

11. • Caliculations are complex neuropsychologic
testing that requires distinct components of
number sense and manipulation.
– Rote tables(addition, substraction and
multiplication)
– Basic arithmatic concepts(carrying and borrowing)
– Recognition of signs.
– Correct spatial alignment of written caliculation.

12. • Verbal note examples:
– Read each example in a clear voice and record
patients response.
1. Addition : 4+6=10, 7+9=16
2. Substraction : 8-5=3, 17-9=8
3. Multiplication : 2 8=16, 9 7=63
4. Division : 9/3 = 3, 56/8 =7

13. • Verbal complex examples:
– Allow only 20 sec for a response.
– Failure to respond in time –considered as a failure
Addition : 24+26=50, 27+49=76
Substraction : 18-15=3, 17-9=8
Multiplication : 25 8= 200
Division : 128/8 = 16

14. • Written complex examples:
– Allow sufficient time to respond( 30 sec)
– If patient is inattentive , try using individual cards for each
sum.
– Failure to complete each task should be noted(even after
time).
– Record errors in alignment as well.
Addition : 124+526,
Substraction : 218-75
Multiplication : 108 38
Division : 559/43

17. PROVERB INTERPRETATION:
• Directions : proverbs are presented in ascending
order of difficulty .
– The instructor should tell the patient that I am going
tell you a saying you may or may not have heard
explain in your own words what that means.
• Scoring:
– abstract-2, semiabstract-1,concrete-0.
– Total of ten points.

18. • Test items:
1. Don’t cry over spilled milk
2. Rome wasn't built in a day
3. A drowning man will clutch at straw
4. Golden hammer can break down an iron door
5. Hot coal burns ,the cold one blackens
• A total score of less than 5 is significant.

21. • Simalarities :
– Requires analysis of relationships, formation of
verbal concept and logical thinking.
• Directions: tell the patient that I am going to
tell some pairs of objects .each pair is alike in
some way. Please tell me how they are alike.

22. • Test items:
– Turnip-cauliflower.
– Car-airplane.
– desk-book case.
– Poem-novel.
– Horse-apple.
• Non retarded patient with a normal
educational status should obtain a score of 5
or 6 in this test.

23. • Equal impairment on this and fund of
informations suggests educational deprivati
on rather than specific deficit in abstract
thinking.

24. • INSIGHT AND JUDGEMENT:
Insight is once ability to understand oneself or
external situation.
Judgement is a complex mantal process where by a
person forms a opinion makes a decision or plan
action or respond after analyzing the issue and
comparing choices with acceptable social
behaviour.

25. • ANATOMY:
– Higher cortical function rely on intact cerebral
cortex though subcortical lesions can effect
performance.
– Except for caliculating ability these functions are
not localised particular area.
– Abstract thinking is widely represented in cortical
and subcortical areas
– Social judgement is affected in frontal lobe
lesions.

26. – Verbal reasoning and abstraction are primarily
dominent hemisphere lesions because of close
relation ship with language.
– Left hemispheric lesions show more severe
impairment of caliculation.
– Malalighnment of numbers in complex
caliculations is a feature of right parietal lobe
lesion.

27. • CLINICAL IMPLICATIONS :
– Testing for higher cognitive functions helps in
detection of early disease because these are
affected well before the basic aminities of
language , attention, memory.
– Results of the tests depends upon educational
status and social ex posure of the patient.

28. • Results to be compared with patients social
judgement and history of family members
and patients performance in day today
events for arriving at accurate diagnosis.

29. RELATED COGNITIVE FUNCTIONS

30. • Apraxia and visual agnosia which were
previously classified along with aphasias and
higher cortical functions now cosidere
seperately as related cognitive functions.
• apraxia is ahigh level motor disturbance.
• Visual agnosia is a high level perceptual
disturbance.

31. • APRAXIA:
– An acquired disorder learned skilled
sequential motor events that can not be
accounted for elementary disturbances in
strength, coordination, sensation, or lack of
comprehension or attention.
– Defect in motor planning.

32. • IDEOMOTOR APRAXIA:
– Most common type of apraxia.
– Patient fails to perform a previously learned motor
act accurately.
• Buccofacial apraxia.
• Limb apraxia.
• Truncal apraxia.

33. • EVALUATION:
– Hiararchy of difficulty in performing the motor
task.
– 1 st step most difficult perform a action on verbal
command.
– 2 nd step performing the action and asked to
immitate.
– 3 rd step provide actual object and ask him to
follow thecommand.

34. CLINICAL IMPLICATIONS

37. • IDEATIONAL APRAXIA:
– Also known as conceptual apraxia.
– Disturbance in complex motor planning of higher
order.
– Difficulty in performing a task having a series of
different but related steps.
– Examples : postal envolope, ligting a
candle, placing tooth paste over tooth brush.

38. • Clinical implications:
– Patients with ideational apraxia have elements of
ideomotor apraxia, constructional impairment and
spatial orientation.
– Associated with wide spread intellectual seen in
patients of dementia.

39. • VISUAL OBJECT AGNOSIA:
– Failure to recognize objects by vision with
preserved ability to recognize them through touch
or hearing and in the absence of impaired primary
visual perception or dementia.

40. • Apperceptive visual agnosia:
– Perceived elements of object are synthesized to
whole image.
– Pick out features of the object correctly such as
lines, angles,colors or movement but fail to
appreciate the whole object.
– Examples : spectacles, forest.
– Right hemisphere particularly lingual gyrus
involved in global processing of the object.

41. • Left hemisphere occipital cortex invoved in
more local processing.

42. • ASSOCIATED VISUAL AGNOSIA:
– Is more closely related to than primary disorder of
vision.
– Patients can copy and match the drawing of
objects but can not name them.
– They can be identified by tactile or auditary
modality.
– have associated color agnosia and prosagnosia.

43. – Bilateral posterior hemispheric lesions involving
occipitotemporal gyrus some times lingual gyri
and adjacent white matter.

44. BALINT SYNDROME
• Charecterised by
– Simultagnosia is a disorder of visual attention
especially to peripheral field associated inability to
perform orderly visual scanning of the
environment and attention to other sensory
stimuli are intact.
– Optic ataxia is the loss of hand eye co-ordination
with difficulty in touching or reaching the objects
under visual guidance.

45. – Optic apraxia is inability project gaze voluntarily in
the peripheral field despite intact occulomotor
movements.

46. BALINT SYNDROME

47. GERSTMANN SYNDROME
• Charesteristic features:
– Dyscaliculia.
– Dysgraphia.
– Finger agnosia [ in ability to point out, recognize
and name fingers of one self or others ]
– Right-left confusion [ inability to distinguish right
left of one self or others ]

48. Gerstmann syndrome