2 The neurological examination
Higher centres
The neurological examination is broken down into three components:
Higher centre function testing
1 The patient is given a six-item name and address (for example, William Bourke, 61 Griffith Avenue, Waverley) and asked to repeat it correctly on three consecutive attempts and until it is correctly repeated three times. The number of times the initial material needs to be offered should be scored. The average person should not require more than ten repetitions of the data to repeat it three times correctly. This tests immediate recall and allows transfer from the metaphoric RAM (random accessed memory) to hard drive. Once the material is correctly repeated three times, the patient is advised that an alarm has been set and they will be asked why it was set when it goes off in five minutes. The reason will be to see if the patient can remember that the alarm was set for a reason, what that reason was, and then repeat the six-item name and address. Most people can remember why the alarm was set, and personal experience suggests the average patient will recall three or four out of the six items. This tests immediate memory, five-minute recall, compliance and cooperation. It does contain a cultural element as the name and address is Australian based, but the recall of why the alarm was set does not reflect cultural bias.
2 Once Step 1 has been completed and the backwards timer is set, the remainder of the higher centre function testing can take place. This distracts the patient to allow proper five-minute recall rather than the patient practising and thus only testing immediate recall rather than five-minute recall.
3 Within the Australian context the patient is asked the name of the prime minister, state premier, day and date. This tests orientation in time and place as well as awareness of current affairs with an element of memory testing. Most will know at least day and date, and many will offer politicians’ family names if prompted with given names.
4 The next test is ‘Serial 7s’. Patients are asked to sequentially deduct 7 from 100, 7 from the response (i.e. 93) and 7 from that—until asked to stop. Once the patient reaches ‘30’ the sequence recurs, thus if the patient correctly states 100, 93, 86, 79, 72, 65, 58, 51, 44, 37, 30, it is my practice to stop at 30. The average person loses concentration when the answer is ‘44’. The most common error is 100, 93, 84 but this still shows good arithmetic skills: (a) the patient correctly subtracts 100 – 7 to achieve 93; (b) then subtracts 3 from 93 to achieve the 80s; (c) then subtracts 3 from 7 to get 4; (d) but rather than subtracting 4 from 90 the patient adds 4 to 80, hence the answer 84. This demonstrates anxiety rather than dyscalculia. Serial 7s test calculation (eloquent dominant hemisphere function), visual spatial orientation (spatial non-dominant hemisphere function) and the connections between the hemispheres to coordinate both hemispheres (corpus callosum). It also assesses concentration and anxiety levels. It is important to determine which of these factors has provoked an error if one occurs, as demonstrated above with the ‘84’ response.
5 The patient is then asked to manipulate 29 × 3 to achieve 87. Once the correct answer is given the patient is asked for the method used. The intelligent, sophisticated calculation is 30 × 3 = 90 – 3 = 87. This demonstrates capacity for lateral thinking and equates to proverb testing. The traditional method of long multiplication 9 × 3 = 27; 20 × 3 = 60; 60 + 27 = 87 demonstrates a degree of concrete thinking.
6 Next in higher centre testing is 5-digit repeat and reverse. The patient is given a 5-digit number and asked to repeat the number in the sequence given and then to recite it in reverse order. As part of the instructions the patient is provided the example of 1, 2, 3, 4, 5 followed by 5, 4, 3, 2, 1 to demonstrate what is expected. The average patient should be able to complete the process with no more than ten attempts. Should the patient have trouble giving the number in its correct forward order, the number should be repeated for the patient before the next attempt. The failure to perform the task is recorded as one of the attempts, and the attempt after the repetition of the number constitutes the next attempt. The number of times the base number is provided should also be recorded but does not constitute one of the ten attempts. This tests immediate recall, visual spatial orientation, concentration and may also provide the best indicator of organic pathology if there is a perseverative error; for example, the reverse of 1, 2, 3, 4, 5 is repeatedly given incorrectly as 4, 3, 5, 2, 1 despite being advised that this was incorrect. If the patient successfully completes the 5-digit repeat and reverse sequence then a 7-digit number is provided. The average patient can repeat the 7-digit number but cannot correctly reverse it, even after ten attempts.
7 The next step is to test dominant parietal lobe function by asking the patient to name: a watch, strap, clasp and hands of a wristwatch. Other questions include the lapel of a jacket and the cuff of a sleeve. These test for nominal dysphasia, but such items as the lapel of a jacket may be culturally and socio-economically reflective so this needs to be considered.
8 Receptive dysphasia and right/left dissociation is tested by asking the patient to place the right hand over the left ear and then the left hand over the right eye.
9 Finger agnosia and right/left dissociation is tested by asking the patient to indicate the right index finger, the left middle finger and so on. This also further tests receptive dysphasia.
10 Constructional dyspraxia and visual/spatial orientation is tested by asking the patient to draw a clock face (analogue) with the hands set at 10:45 hours (Fig 2.1). The reason for selecting this time is because it further tests receptive dysphasia as it is somewhat more complex and further it requires both the hands to be set on the left-hand half of the clock face, thereby further testing non-dominant hemisphere function due to the potential for left-sided neglect. Clock drawing tests constructional dyspraxia as well as left-sided neglect.
11 Within the Australian context, the final test is to ask the patient to draw a map of Australia with a capital letter identifying each capital city at an appropriate spot on the map. This tests educational standard, visual/spatial orientation and constructional dyspraxia (Fig 2.2).
It is not enough to know which tests to perform as it is equally important to appreciate what is being tested and what the results mean. The above tool describes both the test and the modality tested. It also offers suggested limits of normality based on experience of the average patient (see Box 2.1 on p. 10). A patient achieving below average for a test has demonstrated a localised problem, such as memory problem with possible temporal lobe dysfunction. This helps direct further investigations.
Box 2.1 Testing cognition
Summary
