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Examination Mary is sitting at the table. Small, shrunk and hunched over, she tries to behave as best as possible, carefully looking at the faces of the commission members - teachers or parents, examining. They say:
“Good afternoon, Mary. What is your name and how old are you, Mary?
Today we are all here [gathered] to help you.
By the way, what day is it today? What date is today?
Mary tries to remember the year and place where she is. (Right in front of everyone, half asleep after lunch and in the afternoon sun.)
“By the way, what did you have for lunch today, Mary? What is the name of our king, ...and queen?
Or maybe you remember the name of the Prime Minister?
Or what is the name of the capital of France? Mary is crying.
She cannot solve all these problems, draw a man and a bicycle, she cannot afford a single mistake, otherwise she will be punished, she must express her thoughts.
She's a good girl, please love her, she really tried her best.
And it doesn’t matter who she is or who these examiners are and what kind of test they are conducting and why.

Since the assessment of cognitive functions is very important for the psychiatric examination of elderly people, it is highlighted in a separate section below in this same chapter, but this is done only for convenience of presentation. In practice, it is probably best to place the cognitive test near the beginning of the conversation, or to spread the questions throughout the conversation, rather than presenting them in one block. The questioner needs to decide this for himself in advance. For a restless and distractible patient who is generally willing to cooperate, these questions should be asked first to obtain the most information: to ascertain the degree of cognitive impairment, if this is a likely diagnosis. On the other hand, a patient who is angry or suspicious about a doctor's visit may feel better if the doctor first focuses his efforts on getting to know and seeing the situation through the patient's eyes, and only then begins to ask questions that the patient finds difficult. and threatening.
If done judiciously, assessments of cognitive function are generally quite acceptable, and many people find them decidedly enjoyable. This is greatly facilitated by the statement of the interviewer at the beginning of the study that he asks such routine questions to everyone. This statement is reinforced by the use of pre-printed forms, which, surprisingly, seems to help reduce anxiety. If the patient is interested in what all these questions are for, then there will be nothing wrong if the person conducting the questioning explains to him that he is asking these questions to find out whether his memory is good now, after which the best thing is to immediately ask the patient himself for his opinion about his memory .
It is very important that the study is as pleasant and rewarding as possible for the patient. For all answers, both correct and incorrect, he should receive positive feedback. When the questioner can't say "That's right," he can always say "Thank you," or "Actually it's November, but you weren't far off the mark," or "Not bad, that was a tough question," etc. When the study is completed, the patient may ask: “How did I do?” In this case, you should answer honestly: “You remember most names and addresses, but not all. However, this is common. You name and read objects absolutely correctly. That is, it sounds like you have some difficulty with memory, but not with using words. Do you think this is really the case?
It happens that the patient is overly suspicious and shows indignation at any direct questions to assess cognitive functions: here it is better to remove the prepared questionnaire and rely on information gleaned from the answers that the patient deigns to give during a general conversation (internal consistency is especially important). He should also be given the opportunity to demonstrate orientation, praxis and verbal skills in a natural, hands-on way without sacrificing the relationship.

Domain of Cognitive Assessment

There are several areas of cognitive functioning that need to be covered: orientation to time, place and personality - attention and concentration - fixation of new material and its recall after distraction - simple counting - spatial awareness, including awareness of one’s own body - recognition of objects and persons - demonstration of adequate use of everyday objects - naming objects, receptive and expressive use of written and oral language - reproduction in memory of well-known facts, both historical and recent. There are many brief tests of cognitive function in the elderly described in the literature. Moreover, some of them are much more thoroughly validated than others. One of the first in this area was the Mental Test Score (Hodkinson, 1973), which mainly assessed memory and orientation. The Kew cognitive map (McDonald, 1969, modified by Hare, 1978) was the first to explicitly focus on the assessment of functions related to the activity of the parietal lobe of the brain and speech functions. The CAPE Cognitive Assessment Scale (Pattie and Gilleard, 1979) is one of the most structured and validated. The Mini-Mental State Examination (MMSE) (Folstein et al, 1975) is perhaps the most widely used test. A modification of the Rivermead Behavioral Memory Test (Cockbum and Collin) was developed to assess mild levels of memory impairment. They all have flaws and weaknesses. More detailed and comprehensive instruments have also been published: Cambridge Examination for Mental Disorders in the Elderly (CAMDEX) (Roth et al, 1988) - Geriatric Examination Framework mental state- GSIPS (Geriatric Mental State Schedule - GMSS) (Copeland et al, 1976) - Comprehensive Assessment and Referral Evaluation - BOOH (Comprehensive Assessment and Referral Evaluation) (Gurland et al, 1978). However, all of them were developed and are more suitable for research purposes rather than for everyday clinical practice.

Most geriatric psychiatric teams find it very useful to use one of the short standardized tests: the more familiar the interviewer is with the test, the more flexible they can be in using it. For example, he needs to know the weaknesses of the test and remember all the normative data with which the examination results of any patient are compared. All commonly used tests have limitations in the form of ceiling and floor effects, especially the latter. In other words, patients with very mild or very severe impairments fall outside the useful discriminatory range of tests. In all tests (except perhaps the Q test, which does not have an overall score), the sum of correct answers is less important than the types of violations and errors detected. Tests that rely primarily on language function as an assessment tool (even when testing nonverbal function) cannot be used in patients with dysphasia. In addition, they appear to underestimate cognitive decline in highly educated people and exaggerate it in low-educated people. This should be especially guarded against when examining a person who has never been able to read or write and does not want to discover this; his reluctance to answer some questions may not at all mean the presence of cognitive impairment. (An earlier history should alert one to this possibility. This is quite likely when the patient states, “I haven't studied much.”)
By citing these disclaimers, we in no way intend to dissuade the reader from using the standard sequence of questions. However, we would encourage the reader to be selective in the use of these diagnostic tools and to acquire the ability to ask a range of additional questions or tasks in cases where the rough screening of a standardized test reveals areas of impairment that require further investigation. Fraser's (1987) book on dementia contains a very useful section on formal mental state testing (pp. 113–128), where many short tests are presented and commented on; Black et al. (1990) comparisons of some of the most widely used tests can be found.
In the survey design below, we use the questions from the MIPS (not necessarily in the usual order) as a basis and supplement them with some of the other questions from above, which can be found in the brochure of the Medical Research Council (MRC) (1987).

Orientation

Personality orientation is not reflected in the MIPS: it includes the patient’s ability to correctly name given name(married women with memory impairment sometimes give their maiden name), recognize people around them by name or occupation, for example: “this is a doctor, and this is a nurse.” The inability of a person with dementia to recognize family members causes painful emotions. However, it is not always clear whether this inability is due to an impairment in facial recognition (prosopagnosia) or a more fundamental impairment in the ability to remember. specific person. The inability to identify a family member by relationship (e.g., “this is my father” instead of “my son”) again appears to be a complex disorder that may reflect both a language disorder and a recognition deficit equally.
The questions on orientation in time and space included in the MIPS must be asked carefully to avoid a series of demoralizing answers to the patient: “I don’t know.” If the patient appears to be confused about time, the first thing to ask is the month or season. If he is very mistaken in this, then it is unlikely that the correct answers will be given to other questions about time orientation, and therefore such questions can be omitted. An additional question about the time of day is useful: an approximately correct answer is not very informative, but a clearly incorrect answer convincingly indicates deep disorientation in time.

Naming objects

Such questions (name a pencil and a wristwatch) are too easy in the MIPS, and almost all patients answer them correctly (Brayne and Calloway, 1990). If there is any reason to suspect nominal dysphasia, additional questions about naming less common objects should be asked. For example, after showing a pen, you can ask to name the pen (rod) and cap; if the person asking the question is wearing a jacket, you can ask about the lapels; a wristwatch has hands, a winding head, and a strap with a buckle. With the help of such questions, you can effectively test your ability to name objects. The patient should also be asked to name body parts (eg, point to their own elbow or shoulder, as recommended by the MRC).

Speech understanding

MIPS uses a simple three-step command (“Please take this piece of paper in your right hand, fold it in half, place it on the floor”). In some later versions this wording is modified (for example, in "CAMDEX"). It is important that all parts of the command are communicated together and then the patient is allowed to follow them. This test is not only about comprehension, but also about praxis and memory. It turns out that some patients with severe memory loss forget the third step of the command before they reach it. However, at this stage the tester should not prompt, but only thank the patient and record the result accordingly. Next, according to MIPS, the patient is asked to follow the written command (“close your eyes”). This way you can effectively test your reading and comprehension abilities at the same time. It may be useful to examine these two aspects separately by asking the patient to read aloud a passage from a newspaper and then retell it. Sometimes a striking dissociation of abilities is revealed: the patient reads aloud with all expressiveness and appropriate intonation, and a minute later finds himself completely unable to repeat even a single word or thought from the passage read. The patient can also read written instructions, but at the same time he is not able to “translate” them into appropriate actions.

Remembering and reproducing new information

Typically, memory tests in relatively young people are limited to asking them to name and address. In MIPS, three objects are used for this purpose (initially not defined, but in the MRC and “CAMDEX” brochure - “apple - apple, table - table, coin - penny”). For many patients with dementia, it is too difficult to say their name and address; first of all, they cannot remember them correctly and, especially, remember them after a pause. It is therefore advisable to first use the "three objects", and if the patient copes satisfactorily, then ask him for his name and address. You should say to the patient: “Now I would like to ask you to remember three things that I will tell you. Here they are (for example): “apple, coin, table.” Can you repeat their names right now?” You need to choose ordinary, specific objects. Obviously, one-syllable words should be avoided because they are much more difficult for people with hearing loss to hear. Words must be pronounced clearly and measuredly. The immediate memory rate is recorded, and then all three words are presented again until the patient remembers everything. (If he cannot do this, there is no point in testing delayed recall, and the result is indicated by a zero.) When the patient remembers the words correctly, the tester says clearly and emphatically, “Please try to remember them, because I will ask them again later.” . After a pause, he continues: “In the meantime, I would like to ask something else,” and moves on to the distracting task. A minute or two later, the tester asks the patient if he can remember the three items that were mentioned earlier and counts the number of correct answers. If the patient cannot remember a single item, then he is allowed to suggest one of the three (of course, then it is not counted). However, in practice, a hint rarely helps the patient.
Checking memory for name and address is done in exactly the same way. Keep the name and address elements simple and familiar-sounding: unusual names are distracting. You need to remember six positions: first and last name, two-digit number (house), street and city name. For example: "John Green, 32 South Street, Manchester." The distracting task in the name and address test is not clearly defined, however, even in this test, before testing memory, it is necessary to take a five-minute break and switch attention.
In MIPS, distraction is achieved by taking a sequential subtraction test of sevens or by spelling the word “column” (originally “world”) in reverse order. Both methods have disadvantages. Sequentially subtracting sevens is definitely a test of concentration and mental arithmetic ability. For many patients it is too difficult and therefore disturbing. In addition, its results are highly dependent on educational level. An even better option is to use a counting test and ask the patient to perform a simple subtraction, such as 8 from 13. An alternative is to use a simple sum of money task. (Assessing numeracy is very important: people with sufficiently intact verbal skills may have serious violations in this area without overtly detecting them if they have the ingenuity to deal with problems, such as when shopping.) Spelling the word "pillar" backwards tests concentration - the ability to keep multiple parts of it in mind while processing information units. Patients are less discouraged by this method than the sequential subtraction of seven method. However, before using it, it is important to ensure that the patient can spell the word in a normal manner. This is a rather complex test - reproducing the names of the months in reverse order - a simpler test of concentration, but it is often performed without difficulty. Therefore, a test for pronouncing the word “pillar” in reverse order is useful to have in stock, even if the MIPS format is not strictly followed. (A minor disadvantage is the difficulty of consistently counting errors, which gives equal weight to omissions and letter reversals.) Of course, using a distractor task that is not tailored to the patient's ability means that the time taken to complete it will vary for different patients. , and the interval between memorization and playback is not always five minutes. The judgments made in a particular clinical situation are almost so general that this detail is of little importance.

Expression through speech

In MIPS there is no special test for expressing (thoughts) through speech, except for the “naming” test, and there is usually no need to develop a special test for this ability, since it is discovered during conversation. However, it is important to simply note the impairments that may occur in this area, such as mild difficulty finding words or paraphasia (almost correct words). In any patient with an expressive language disorder, it is especially important to accurately assess comprehension because it can easily be mistakenly assumed that the patient understands as little as he can communicate to others. In these cases, understanding can be assessed in part by carefully wording questions that elicit meaningful and unambiguous yes or no yes or no responses (if the patient is unable to use these words, nods or gestures may be used instead) , and partly by the patient's actions, asking him to demonstrate his understanding of questions such as: “Please, could you nod your head?” and “Please point first to the window and then to the door.” (Communication with a patient suffering from dysphasia is discussed again on page 168.)
MIPS has one test for proficiency in written language: the patient is asked to write any sentence he likes. To be counted as correct, it must contain a verb and some meaning. The beauty of this task is not in the good speech testing, but in the patient's choice of sentences. Sometimes these sentences are quite banal, but sometimes they convey the patient’s mood much more accurately and touchingly than any of the previous parts of the conversation. (For example, one lady who suffered from dementia with early age began, was brought to live together by her daughter from Wales. During the conversation, she talked about what a wonderful daughter she has and how well she takes care of her. However, after much thought, she wrote "I wish I was home in Wales now.")

Praxis

The MIPS only tests for constructive apraxia, and it is a very complex test in which the patient is asked to copy a drawing of two connected pentagons. Many patients who fail this test should be given a simpler task, such as drawing a square, as in the Q test (Hare, 1978), or at home. An informative test is drawing a dial: the doctor draws a circle and asks the patient to place the numbers. If this part is done correctly, the subject can be asked to draw arrows so that they show the time called by the leader - thus the test is useful for assessing a wide range of abilities. Praxis testing can be expanded by asking the patient to demonstrate how he uses a comb, key, or pen; more complex actions (eg, getting dressed) are better assessed in a different setting or indirectly from people providing information about the patient.

Gnosis

When testing object recognition, a second aspect of cognitive function must be used to prove that it has occurred. The patient must name the objects or show how he uses them. Consequently, if these abilities (speech and praxis) are impaired, the test for agnosia is difficult. In people with less severe impairments, a variety of tests can detect different types of agnosia. The MRC brochure (1987) includes picture recognition (three monochromatic images of everyday objects from unusual viewing angles). (A more complete series of pictures is used in CAMDEX.) Unless the patient has visual impairment, misrecognition of MRC pictures is telling, since older adults with intact cognitive abilities usually recognize them immediately. Facial recognition can be verified from photographs famous people(for example, members of the royal family) or from family photographs, if there is information necessary to assess the correct recognition of the patient's relatives. Tactile recognition can be tested by using coins of various denominations or other small objects (for example, a key or a comb, which the patient picks up one by one without looking and tries to identify. A complex test including accurate recognition of body parts, right/left direction, speech ability and praxis is the face-hand test (Fink et al, 1952- Kahn et al., 1960).The patient sitting opposite the doctor is asked to gradually place his hands on his knees, touch the right ear with the right hand, touch the left ear with the left hand, then touch the left with the right hand, and the left - the right. It is the last two tasks that are most difficult for people who confuse the right and left sides, which indicates a possible dysfunction of the parietal lobe of the dominant hemisphere. If such a suspicion exists, then it is also necessary to look for sensory disturbances in the visual and tactile modalities. More detailed descriptions of this aspect of assessment can be found in the neuroscience literature.

Awareness

MIPS does not have a test for awareness of events, both current and historical. Many people question how important it is for assessing cognitive function because there is no definitive way to find out whether this information was previously known to the patient. There is a long tradition of asking about the dates of the Second World War, on behalf of the current Prime Minister. However, the meaning of these two tasks is completely different: the first depends on how well the material that was presented a long time ago has been memorized, and the latter on how closely the patient follows current events.

Higher cognitive functions

Many brief tests of cognitive function do not include items that test more complex intellectual skills that are thought to be mediated by the frontal lobe. Abstraction can be tested by questions like: “What do a banana and an apple have in common?” However, it appears that the ability to answer such a question in an abstract rather than concrete manner depends in part on the patient's education. During a conversation, it is necessary to monitor perseverations (in speech or motor skills), which are a sign of damage frontal lobes brain
A test of oral fluency originally described by Isaacs and Kennie (1973) as a dementia test called the Set test is useful. Nowadays it is often used in a simplified form, for example: “Please name as many animals as you can remember, I mean animals of any kind - birds, fish, etc. (The instructions in KEMDEX are slightly different.) Then count the number different animals named in one minute (excluding repetitions). It can be surprising to find that a patient with apparently no impairment in other aspects of cognitive functioning futilely recalls new animal names and cannot, like healthy people, use the strategy of moving from one group (farm animals, pets, jungle mammals, game, fish, etc.) d.) to another. Alternative categories are words starting with a certain letter of the alphabet, names, items that can be bought in a store. Tests that require the patient to make alternative or conditioned responses (eg, “Tap the table if I hold up one finger, but don't knock if I hold up two”) involve assessing the ability to inhibit an unwanted response, which also depends on the functioning of the frontal lobes . Tasks to complete complex instructions, involving spatial or grammatical relationships (e.g., “Touch the tip of the green pencil that is closest to the red pencil,” “Move the smaller of the two pencils to the right”) may reveal difficulties not detected by simpler cognitive tests.
A comprehensive and detailed study of mild cognitive impairment requires the participation of a psychologist who is a specialist in this field. However, broadly covering different areas of cognitive functioning using simple questions is within the competence of any professional working with older and older people. old age, and significantly enriches his understanding of their problems. As described here, these tests may seem laborious and time-consuming, but in practice, performing the MIPS with a patient at the clinic takes about 10 minutes, with slightly more time (perhaps 15-20 minutes) required in cases where additional questions or special problems arise in interaction with the patient.
Cognitive assessment should be practiced on an ongoing basis, in a relaxed manner and alongside other routine assessments, and with the aim of making the assessment process as enjoyable as possible for both participants. When the interviewer directs his efforts to friendly and attentive observation, and not to imposing his will on the patient, then it is always possible to obtain useful information, even if the obsessive desire to write down the answer to every question remains unsatisfied.

Neurological diseases are among the most common and socially significant diseases both in Ukraine and in the world. Among the causes of organic brain damage, the leading place belongs to cerebrovascular diseases and especially their most severe form - strokes. Frequent consequences of stroke, in addition to neurological deficits, are cognitive impairment (CI), which is observed in 30-80% of patients in the first 6 months from the onset of the disease.

When studying cognitive processes, it is necessary to answer the following questions:

— Does the patient have CI?

— When did they arise and how did they develop?

— What cognitive functions are impaired and to what extent?

— What disease most likely underlies the cognitive deficit?

Conversation with the patient

Importance careful collection history for the correct study of higher mental functions can hardly be overestimated. History is the cornerstone of clinical practice and is vital to the focus of all further investigations. It’s better to start by finding out the premorbid level of intelligence (education, work, hobbies, etc.), the duration and course of the disorders. Severe CIs lead to changes in the patient’s quality of life. In CI, high-level skills such as using household appliances, driving, managing finances, and adhering to medication are affected earlier, compared with cooking, walking, personal hygiene, and sphincter control. Sometimes relatives can provide more information than the patient himself. Even with moderate CI, it is recommended to talk with someone close to the patient, and it is better to do this in the absence of the patient. By talking with the patient face to face, it is easier to assess his speech, language, attention, orientation, memory, and thinking. Difficulty speaking, paraphasia, inappropriate behavior help in understanding the nature of CI. In the documentation, it is advisable to illustrate all deviations with specific examples. An indicative assessment in a conversation with the patient is no less important than the formal testing discussed below.

During the study mental (mental) status it is customary to characterize appearance and behavior, orientation, attention and concentration, emotional state, thinking and cognitive processes(memory, reasoning, language and speech, perception, praxis and executive functions). The concept that generalizes all cognitive functions (CF) is intelligence. Observing the patient in the first minutes allows you to get an impression of the level of general motor activity, facial expressions, grooming, demeanor and conversation. Before directly studying CF, it is necessary to determine whether there is a decrease in the level of wakefulness (stunning, drowsiness) and changes in the content of consciousness. They explore orientation in place (city, district, institution, floor), time (time of day, date, day of week, month, year) and self (name, gender, age). If the patient does not know what time it is, you can ask how long he has been here. The level of attention is assessed using the following simple tests:

- counting from 20 to 1, listing the months of the year or the letters of the specified word in reverse order;

- detection of 2 identical objects among 10 similar ones;

- an indication of all the objects that are superimposed on each other in the picture;

- finding a shaded object in the drawing;

— following instructions under distractions.

Sometimes the patient expresses concern about his condition, the presence of obsessive thoughts, and expresses inadequate ideas about the causes, nature and prognosis of the disease. The medications used can have a significant impact on mental status. Severe attention deficit and/or disorientation, especially if developed over a short period of time, indicate severe brain damage. This situation limits the study of CF.

Study of blocks of cognitive functions

Assessing CF is important for several reasons. Firstly, the diagnosis of dementia is based specifically on the assessment of CI. Second, most types of dementia can be diagnosed by characteristic patterns of behavior and CI. Third, it is very important to identify patients in the prodromal period of CI who have not yet reached the level of dementia.

It is important for a neurologist to be able to conduct general research CF in all of their patients. If CI is suspected, the patient should be referred to a specialist with training in neuropsychology, who, in addition to a global assessment, conducts a study of individual blocks (modules) of CI: memory, speech and executive functions. For correct assessment situation, you need to know the discrete characteristics of CF and their topographic localization in the brain. The study of the main cognitive blocks (modules), and primarily memory, is of practical importance.

Memory

If CI is suspected, it is necessary to systematically examine memory. Memory functions include the ability to remember, store and reproduce information. When talking about memory disorders, it is important to determine what type of memory we are talking about. Memory is divided into explicit (requiring awareness) and implicit (dynamic stereotypes, motor skills). Typically, only explicit memory is examined in the clinic, the structure of which can be divided into several subtypes.

RAM - immediate fixation and retention of new information for several seconds, it is associated with the function of the dorsolateral prefrontal cortex. Disorders of working memory, as well as decreased attention and ability to concentrate (the patient forgets what he wanted to say or why he entered the room) are more often observed due to age-related changes, depression or anxiety.

Memory for current events in the present (anterograde) or in the past (retrograde). It is associated with the function of the diencephalic-hippocampal structures.

Short-term memory (anterograde) - a type of memory that ensures the memorization of received information for a short time (5-7 minutes), after which the information can be completely forgotten or go into long-term memory.

Impairment of short-term memory is manifested by anterograde amnesia, which can be suspected based on information about the loss of objects, repetition of the same questions, the need to write everything down, if the patient regularly forgets about an appointment, it is difficult for him to follow the content of films or find the way to the house. The study of short-term memory is carried out using verbal and/or non-verbal tests. A verbal test typically asks you to memorize 5-10 words or numbers and then name them after a few minutes. When conducting nonverbal tests, the patient can be shown 3 objects, placed around the room, and a little later asked to point to these objects. In another version of the nonverbal test, the patient is shown several drawn geometric shapes and after a few minutes is asked to reproduce the ones that he was able to remember.

Long-term memory (retrograde) ensures that information is remembered for a long time. This type of memory is characterized by an almost unlimited storage time and volume of stored information. Impaired long-term memory - retrograde amnesia - can be suspected in cases where the patient cannot remember episodes of his life (what year he graduated from school, what his school number was, the name of his first teacher, what he ate for lunch yesterday, what the last book he read was about) and so on.).

Retrograde and anterograde amnesia usually occur together, as in Alzheimer's disease (AD) or traumatic brain injury, but dissociations sometimes occur. Relatively isolated anterograde amnesia develops in encephalitis caused by a virus herpes simplex, tumors and infarctions of the temporal lobe. Transient amnesia (mostly anterograde) is characteristic of transient global amnesia, and repeated short episodes of memory loss are typical of transient epileptic amnesia. Amnesia as a leading syndrome is not typical for vascular CI (VC), which is based on cerebrovascular diseases. With asthma, on the contrary, in the early stages the patient cannot remember words spoken a few minutes ago. The 5-word memory test detects AD with a sensitivity of 91% and specificity of 87%.

Semantic memory (knowledge about the meanings and meaning of words, general knowledge) is associated with the function of the anterior temporal lobes. A decrease in semantic memory is manifested by a depletion of vocabulary. The patient cannot find the right word, often uses words like “this one”, “this thing”, instead of the name of the object he talks about its purpose (instead of the word “pen” he says “well, this one with which you write”). Ideas about the meaning of concepts also suffer (he is unable to name the parts of a bicycle: wheels, steering wheel, pedals). Most people experience some difficulty in finding the right word in old age and with anxiety and depressive disorders, but this is not constantly noted and is not associated with impaired comprehension. A striking example of impairments in naming objects or selecting the right words (anomia) is semantic dementia, which has a progressive course and occurs with atrophy of the anterior parts of the temporal lobe, usually the left.

Ability to conceptualize and resolve problem situations

An important part intellectual activity human beings are consistent and logical reasoning, the ability to find a way out of difficult situations through abstraction and an abstract search for a solution. These disorders manifest themselves when the brain is damaged at various locations, which leads to significant difficulties in performing professional and everyday duties. A classic example of such disorders is insufficient abstract thinking. Judgment tests can be verbal or non-verbal.

Verbal tests include tasks to explain the figurative meaning of proverbs (“When they cut down a forest, the chips fly,” “An apple doesn’t fall far from the tree,” etc.), to find commonality in various objects (an apple and a banana). The correct answer in the last task is “fruits”, not “they are yellow” (the latter answer does not demonstrate generalization ability).

Non-verbal tests include tasks to find commonality between the depicted objects, arrange them in order, continue the visual sequence, etc.

Speech functions (language and speech)

Disorders of speech functions are of greatest clinical importance. They may result from dementia, delirium, aphasia or mental illness (eg psychosis). The study of speech functions implies a mandatory assessment of the following aspects: expression (spontaneous speech production, writing), reception (understanding of speech and text), repetition of words and sentences, naming of objects. In SCI, especially after strokes, the ability to name an object is often affected, which requires the integration of visual perception, semantic and phonetic modules. The following main types of speech disorders are distinguished.

Mutism is a refusal of speech communication in the absence of organic lesions of the speech apparatus. The patient is conscious but does not attempt to speak or make sounds. More often this is a consequence of mental disorders, but it also occurs with lesions in the area of ​​the anterior wall of the third ventricle and bilateral lesions of the posteromedial surface of the frontal lobes.

Aphasia (dysphasia) is a systemic speech disorder caused by local damage to the dominant (in 95% of cases left) hemisphere. Aphasia is often accompanied by alexia and almost always agraphia. First, it is necessary to clarify the ethnic origin and native language of the patient, whether he is right-handed or left-handed (if right-handed, then was he retrained in childhood), and whether he could read, write and count before. In almost all right-handers, speech centers are localized in the left hemisphere, while in left-handers the left (in about 60%), right, or both hemispheres may be dominant.

When assessing aphasic disorders, you first need to listen carefully to the patient's speech, inviting him to talk about the development of his disease or asking the patient to describe the plot picture shown to him. Is he fluent? Is speech smooth? Are the words and sentences constructed correctly? Does this make sense? Does he use words that do not quite fit the meaning (paraphasia), neologisms, repetitions (perseveration)? Are complex constructions used to hide difficulties in finding words? All aphasic disorders can be divided into cases:

- with fluent and fluent speech (the lesion is usually posterior to the Sylvian fissure), speech is replete with paraphasias and neologisms;

- with stuttering, fragmentary speech (the lesion is usually anterior to the Sylvian fissure), dysarthria is often noted.

Then they examine the understanding of addressed speech (by simple questions or asking them to point to certain objects in the room and follow commands), the ability to name the shown objects (using about 20 objects, starting with simple objects such as a watch, a comb, a pen, then moving on to their parts : strap, prong, cap), repeat the phrase, read and write a sentence (sometimes the patient retains the ability to write his name or address, but is not able to correctly compose a sentence, for example, about his job), add small numbers.

Aphasias are divided into several types depending on the severity of expressive and receptive disorders, although in clinical practice Mixed types of violations are the rule rather than the exception. The classification of aphasia given below, currently accepted in the international neurological literature, is somewhat different from the classification of aphasia in Russian neuropsychology.

— Motor (Broca's) aphasia- speech production is impaired. The patient understands the spoken speech, but cannot convey the content of his thoughts due to the loss of the skills of complex movements that determine speech. The focus is in the cortex of the posterior part of the third (inferior) frontal gyrus on the left.

— Sensory (Wernicke) aphasia- speech understanding is impaired. The patient loses the ability to understand speech in a language familiar to him, perceives it as a set of incomprehensible sounds, and does not understand questions or tasks. He does not understand his own speech, loses the ability to control it, allowing the replacement of letters in a word (literal paraphasia) and the replacement of words in a sentence (verbal paraphasia). Speech becomes incorrect, incomprehensible, and can be a meaningless set of words and sounds. The focus is in the cortex of the posterior part of the first (superior) temporal gyrus on the left.

— Global (total) sensorimotor aphasia- sensory and motor aphasia.

— Conductive aphasia— repetition of phrases is impaired, paraphasia appears. The focus is in the area of ​​the inferior parietal lobule and the supramarginal gyrus with damage to the arcuate fibers connecting Broca's and Wernicke's areas.

— Transcortical aphasia— repetition is preserved, but speech production is impaired (motor transcortical dysphasia, focus is anterior to the Sylvian fissure, but above Broca’s area) or speech understanding (sensory transcortical dysphasia, focus is posterior to the Sylvian fissure, but below and/or caudal to Wernicke’s area).

— Stuttering occurs more often in children (usually boys), the causes are usually psychogenic, but can be associated with retraining left-handers; in adults it often occurs with mild dysphasia, including in the process of speech restoration after aphasia.

— Echolalia- repetition of heard words and phrases. The lesion is located in the parietotemporal region.

— Amnestic aphasia, or anomie, - the patient forgets the name of familiar objects and names, cannot name the object shown to him, but can describe its purpose. At the same time, he freely repeats the prompted title or name and rejects the incorrect clue. The focus is in the parieto-temporo-occipital region of the cerebral cortex.

— Apraxia of speech- the patient does not speak himself, but can pronounce words with outside help, for example, the researcher asks to count out loud and says “one, two...”, the patient continues “three”.

— Subcortical aphasia- atypical forms of speech disorders that occur with damage to the basal ganglia, thalamus and deep parts of the white matter of the hemispheres.

Dysphonia (aphonia) - the patient cannot speak loudly enough due to damage to the vocal cords, bulbar or neurotic disorders.

Dysarthria — the patient speaks loudly enough, but it is difficult to understand his speech due to poor articulation (distortion of sounds and syllables). Tests for dysarthria include repeating words and phrases with complex articulation, reading fragments of text, and pronouncing tongue twisters. The following types of dysarthria are distinguished:

- spastic with damage to the central motor neuron (the patient says “through his teeth”, axial signs are revealed);

- rigid with extrapyramidal disorders (speech is monotonous, words and sentences suddenly begin and end);

- ataxic with a focus in the cerebellum (speaks like a drunk, sometimes loudly, sometimes quietly, irregularly, sounds are “blurred”);

— sluggish with damage to peripheral motor neurons and muscles;

- myasthenic (normal articulation at the beginning of a sentence and distorted at the end).

When discussing CI, the identification of aphasia is of greatest importance, as this allows localization of the lesion and can help in making a diagnosis. There are special sets of tests for a detailed study of speech functions.

Perception and design ability

To understand the world around us, the ability to correctly perceive it is extremely important. Neuropsychological studies include tests to assess visual, auditory and tactile perception. Some perceptual disturbances, such as neglect, are diagnostically valuable. Sensory perception is not a passive process; it depends on many factors, including attention and memory.

Visual perception , including color vision, are examined using tests for the ability to recreate visual images, the ability to recognize an object and separate an image from the background. Color vision is tested using standard Rabkin tables or special methods. The ability to recognize visual images can be assessed using a facial recognition test (Benton test). The patient is shown a portrait and asked to find it on a page where 6 different faces are presented. The task can be complicated by using photographs that differ in lighting or clothing details. An example would be sorting pictures according to the plot or composing images from parts (puzzles).

Spatial perception and neglect assessed by the following tests: split a segment into 2 equal halves, read a fragment, find a specific letter in the text, etc. If the patient regularly “does not perceive” some half of the picture, then a violation of visual-spatial perception can be suspected. It usually occurs in the left half of the visual field. This is explained by the fact that the left hemisphere monitors only the right half, and right hemisphere- both halves of the field of view. Therefore, with lesions in the left hemisphere, disturbances in visual-spatial perception do not occur, but with damage to the right hemisphere (usually the parietal lobe), left-sided hemi-ignorance is noted. With this pathology, the left side of the segment will be significantly larger than the right, and when reading, the patient will miss words in the left half of the line. For example, if the visual perception of half the space is impaired, the patient does not care for one half of his body or leaves food on one half of the plate. To study spatial perception, a test is used in which the subject is asked to depict a watch dial (Fig. 1, 2).

Auditory perception includes hearing acuity, perception of sounds and rhythms, including comparison of two similar samples.

Tactile perception usually assessed by complex types of sensitivity in the hands (graphesthesia, stereognosis) and by alternating touches to one or both hands or halves of the face. In the case of tactile neglect, touch is normally perceived when touched alternately from the right and left, but when touched simultaneously from both sides, the patient perceives irritation only on one (usually the right) half of the body.

Praxis

Apraxia is the inability to perform an action familiar to the patient, despite the absence of motor, sensory and coordination disorders. Several types of apraxia are described in the literature, but their division is of little clinical importance. It is more important to indicate the type and area (oromandibular, hand) of the disorders. The greatest role in the occurrence of apraxia is played by lesions of the frontal (premotor area) and parietal lobes on the left. With lesions of the anterior parts of the corpus callosum due to disruption of connections between the hemispheres, apraxia is observed in the left limbs. With motor aphasia (Broca's), oromandibular apraxia is often observed, caused by damage to the lower parts of the frontal lobe and insula on the left. Isolated progressive apraxia in the limbs is characteristic of corticobasal degeneration.

Praxis is explored through simple commands (wave goodbye, point your right leg with a finger), the use of imaginary objects (show combing hair, brushing teeth), simple oromandibular movements (stick out tongue, blow out candle, lick lips) and more complex actions ( alternately clench your fists: one hand is clenched into a fist, the other is straightened; alternately place one hand, palm down, on the table, and the other, palm up, on your knee; the sequence “fist, palm, rib”).

Gnosis

Agnosia is the inability to name normally perceived external stimuli. Visual agnosia is more common. Visual information from the occipital lobes is transmitted in two directions. Direction "Where?" connects the visual areas of the cortex with the centers of spatial orientation in the parietal lobes (more on the right), the direction “what?” - with a repository of semantic knowledge in the temporal lobes of the brain (more in the left). Visual agnosia can be total (often in ischemic-anoxic encephalopathy) or selective (failure to recognize letters or faces) and can develop in isolated lesions in the temporal lobes of the brain. Wernicke's aphasia can to some extent be classified as verbal agnosia.

Executive and motor functions

Executive functions (from the English executive functions) are also called regulatory, or organizational. They are associated with a variety of mental processes (concentration, memory, logical reasoning) and cover the perception and processing of incoming information, setting goals, planning actions to achieve these goals, the ability to evaluate the effectiveness of tactics and implement plans. Executive functions are traditionally associated with the frontal lobes of the brain. It is the frontal cortex, according to classical theory A.R. Luria and modern ideas, controls conceptualization, abstract thinking, mental flexibility, drawing up and implementing a program of voluntary activities, selective suppression of internal impulses and the dependence of behavior on external stimuli. Impairments of executive functions are manifested by a decrease in speech activity, verbal stereotypes, echolalia and perseverations, difficulties in remembering, attention deficit, concrete thinking and sometimes dysinhibition (impaired control of the frontal lobes with maladjustment, impulsive and antisocial behavior).

To study executive functions There are several tests: Wisconsin Card Sorting Test, Path Finding Test, Stroop Test, etc. Planning ability is assessed by the time it takes to find a way to the exit in a drawn maze (each dead end is considered an error). Flexibility of the mind can be explored with the task of drawing as many figures as possible consisting of 4 lines (straight or curved) in 4 minutes. Age standards have been developed for this test. The productivity of searching for successful tactics can be studied in a test with the generation of new words: in 1 minute you need to name as many words as possible that start with a certain letter or belong to a certain category (animals, vegetables). Similar words are not allowed. It is considered pathological if the patient names less than 8-10 words (with the norm being at least 10-15). Impulsivity, which more often indicates damage to the basal parts of the frontal lobes, is characterized by the following tests: “forward - stop - forward”, “clap once when I clap twice, and not once if I clap once”, word and color interference test Stroop, which allows us to study the ability to selectively suppress incorrect impulses. It consists of 3 parts: the patient is asked to first read the names of the colors printed in black font, then, as quickly as possible, name the color of the dots in the picture and, finally, name the color of the letters in which the names of the colors are printed (the color of the letters and the meaning of the word do not match, for example, the word "red" is printed in green font). Working memory: the patient is shown increasingly longer series of numbers and asked to reproduce these numbers in the same or reverse order. Mobility of nervous processes and ability to switch: the patient is shown a diagram in which each number has its own symbol, and then is asked, moving along a series of numbers, to draw as many suitable symbols as possible in 90 seconds.

Study of motor productivity is especially important for assessing the functional usefulness of the extrapyramidal system in relation to small movements. Speed, strength and manual dexterity are examined separately. Speed ​​can be tested with a simple task - tapping your index finger on the table as quickly as possible for 5 or 10 seconds. Age-specific norms were developed for this study. A significant difference between the right and left hands suggests disturbances in the corresponding cerebral hemisphere. Strength is assessed by a handshake and a standard neurological examination. Dexterity can be characterized by the success of placing matches or other objects in a specific order with each hand separately.

Grade executive (organizational) functions and motor productivity are especially important for patients with suspected SCI and AD, as well as after traumatic brain injuries, with leukodystrophies and demyelinating processes. Often the first manifestations of SCI are a decrease in overall productivity due to the fact that it has become difficult to concentrate and switch from one type of activity to another. For example, decreased performance (a frequent patient complaint) is directly related to impaired planning, suppression of impulsive responses, or implementation of plans.

Assessment of cognitive (cognitive) functions using scales

Neuropsychological testing in SCI should be multifaceted and sensitive to a wide range of impairments, but the investigator should focus on deficits in executive functioning. The most commonly used method worldwide for screening for CI is the Mini-Mental State Examination (MMSE). From sections of MMSE with mild or initial form Dementia will primarily affect delayed word recall, the ability to subtract 7s, and drawing and naming the letters of a word in reverse order. To clarify, you can ask the patient to remember 5-7 words instead of 3, additionally draw a clock face, find commonalities and differences between objects, and perform calculations. If a patient fails to score on a test, he should be asked to perform a similar task to clarify the nature of the error. For example, if the figures are copied incorrectly, you can suggest drawing a watch dial. One way or another, an MMSE score of less than 28 in young people and less than 24 in older people indicates a significant likelihood of CI and serves as an indication for in-depth neuropsychological research. There is debate as to whether MMSE is an appropriate method for assessing SCI. To make a final decision, the use of the MMSE is not recommended, since the scale does not reflect executive dysfunction well enough and contains only a 3-word memory test, which is not sufficient to identify the initial stages of amnesia. In recent years, the modified MMSE has been increasingly used, which is more informative and can detect dementia with a sensitivity of 94-96% and a specificity of 92%.

A short protocol for neuropsychological testing is proposed, requiring about 5 minutes, which is more suitable for practical use in neurology (www.mocatest.org): memorization of 5 words, orientation (of 6 points) and a test for generating words starting with a given letter. Additionally, you can use other sections of the cognitive test (generating animal names, test for connecting random numbers and letters with lines) or MMSE, which is performed 1 hour before or 1 hour after the above tests. .

There are also a number of small test tasks that have certain advantages. The Blessed Orientation-Memory-Concentration Test Short Form (http://www.strokecenter.org/trials/scales/somct.html) includes only 6 items and does not involve writing or drawing, making it convenient for use over the telephone. However, its memory component is also too short. The strength of the MMSE is its greater examination of abstract thinking. To monitor the dynamics of cognitive functions, the Brief Cognitive Rating Scale (BCRS) is convenient, which allows you to determine the stage according to the Global Deterioration Scale (GDS) (www.geriatric-resources.com).

Relationship between cognitive impairment and emotional disorders

In all patients with CI, it is necessary to assess the behavior and emotional and psychological state. CFs are closely interrelated with a person’s emotional state and behavior. Cases of pseudodementia due to depression have been described. In AD, apathy (72%), aggression/agitation (60%), anxiety and depression (48%) are common. Anxiety and depressive disorders are often found in cerebrovascular diseases and negatively affect CP. With appropriate alertness, the presence of depression or anxiety can always be suspected during the first conversation with the patient. If the patient has felt depressed or helpless for more than 2 weeks, and has lost interest in previous hobbies, the likelihood of a depressive disorder is very high. Anxiety is a fairly common emotional disorder characterized by a subjective feeling of discomfort and fear. Generalized anxiety disorder is indicated by a tendency to constantly worry, experience unreasonable bad premonitions, fussiness, constant internal tension, inability to completely relax, poor sleep, frequent headaches, random dizziness, “fog in the head,” dry mouth. With cortical and subcortical lesions, frequent mood swings, called emotional lability, are sometimes observed.

Identifying affective disorders is extremely important because, on the one hand, they affect the course and outcome of many diseases, and on the other, they can be successfully treated. In addition, the assessment of emotional disturbances is important for differentiating organic diseases from functional neurological disorders, which underlie almost 1/3 of symptoms, including all types of somatoform disorders. The main methods for confirming emotional disturbances are the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), Beck's Depression and Anxiety Inventories, Geriatric Depression Scale, Hospital Depression Scale and anxiety (Hospital Anxiety and Depression Scale - HADS).

Conclusion

In the international literature you can find information about a large number of tests, questionnaires and scales used to identify and assess cognitive deficits. However, we believe that a busy clinician should have in his arsenal a set of tests that allow him to obtain basic information about the state of CF in a short time. If there is a need for an in-depth study of CF, it is advisable to carry it out together with a clinical psychologist or neuropsychologist, using methods that have proven themselves in international practice. We hope that the creation of a set of tests that will provide the necessary and sufficient amount of information about cognitive impairment for clinical practice will become one of the areas of activity of both academic institutions and professional associations.

The authors express their sincere gratitude to the head of the department of medical psychology of the Institute of Neurology, Psychiatry and Narcology of the Academy of Medical Sciences of Ukraine, Professor L.F. Shestopalova for her assistance in preparing the text of this review.

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Catad_tema Mental disorders - articles

Neuropsychological tests. Necessity and possibility of application

V.V.Zakharov
Department of Nervous Diseases of the First Moscow State Medical University named after. I.M.Sechenova

Identification and analysis of clinical features of cognitive function disorders (synonyms: higher cerebral, higher mental, higher cortical, cognitive - Table 1) is of great importance for diagnosis and differential diagnosis neurological diseases. Many neurological diseases, especially in childhood and old age, manifest almost exclusively as cognitive impairment (CI). The presence and severity of CI largely determine the prognosis and tactics of patient management for a number of common nervous diseases.

Table 1. Cognitive functions

It is important to emphasize that the most objective impression of the state of the patient’s cognitive abilities is formed by comparing information obtained from all three of these sources. Dynamic monitoring of the patient also plays an important role, which allows for a differential diagnosis between transient cognitive difficulties, often of a functional nature, and stationary or progressive disorders associated with organic brain damage.

Analysis of patient complaints

Suspicion of a patient's cognitive impairment should arise if there are complaints of:

• decreased memory compared to the past;
• deterioration of mental performance;
• difficulty concentrating or concentrating;
• increased fatigue during mental work;
• heaviness or feeling of “emptiness” in the head, sometimes unusual, even pretentious sensations in the head;
• difficulties in choosing a word in a conversation or expressing one’s own thoughts;
• decreased vision or hearing in the absence or insignificant severity of eye and hearing diseases;
• awkwardness or difficulty performing habitual actions in the absence of muscle weakness, extrapyramidal and discoordination disorders;
• the presence of difficulties in professional activities, social activity, interaction with other people, in everyday life and in self-care.

Any of the above complaints is the basis for an objective assessment of the state of cognitive functions (see figure) using neuropsychological research methods (Appendix 1).

It should be noted that the most important are the patient’s active complaints, which are expressed by him independently, without a leading question. It is known that many healthy individuals are dissatisfied with their memory and other cognitive abilities, therefore, in response to a doctor’s question, many, even completely cognitively intact individuals, will complain of poor memory. Therefore, priority attention should be given to spontaneous complaints. It also makes sense to clarify whether the patient has always had poor memory or whether it has significantly worsened over time. Lately.

On the other hand, the absence of cognitive complaints does not mean the absence of objective CIs. It is known that in most cases, progressive CIs are accompanied by a decrease in criticism, especially at the stage of dementia (Appendix 4). The patient may consciously dissimulate his existing disorders for fear of receiving an unwanted diagnosis and associated restrictions in professional and social spheres. Therefore, the patient’s self-assessment must always be compared with objective information.

Neuropsychological research methods

Neuropsychological testing is an objective way to assess the state of cognitive functions and is advisable in the following situations:

• in the presence of active cognitive complaints on the part of the patient;
• if the doctor, in the process of communicating with the patient, develops his own suspicion of the presence of CI (for example, due to difficulties in collecting complaints, medical history, failure to follow recommendations);
• in case of unusual behavior of the patient, decreased criticism, sense of distance, or the occurrence of psychotic disorders in old age;
• if third parties (relatives, colleagues, friends) report a decrease in the patient’s memory or other cognitive abilities.

To assess memory status tasks for memorizing and reproducing words, visual images, motor series, etc. are used. The most commonly used tests are auditory-verbal memory: memorizing a list of words, two competitive series of 2-3 words each, sentences, a fragment of text. The most specific technique is considered to be indirect memorization of words: the patient is presented with words to memorize, which he must sort into semantic groups (for example, animals, plants, furniture, etc.). The name of the semantic group is used as a hint during reproduction (for example: “You memorized another animal,” etc.). According to the generally accepted point of view, thanks to this procedure, memory impairments associated with attention deficit are leveled.

To assess the state of perception They study the patient’s recognition of real objects, their visual images, and other stimulus material of various modalities. The perception of one's own body schema is examined using Head tests.

For the praxis scene the patient is asked to perform one or another action (for example: “Show how to comb your hair, how to cut paper with scissors, etc.). Constructive praxis is assessed in drawing tests: the patient is asked to draw independently or redraw a three-dimensional image (for example, a cube), a clock with hands, etc.

For speech assessment attention should be paid to the understanding of the addressed speech, fluency, grammatical structure and content of the patient’s statements. They also examine the repetition of words and phrases after the doctor, reading and writing, and a test for naming objects (nominative function of speech).

For the skit of intelligence generalization tests can be used (for example: “Please tell me what is common between an apple and a pear, a coat and a jacket, a table and a chair”). Sometimes they are asked to interpret a proverb, give a definition of a particular concept, or describe a plot picture or a series of pictures.

In everyday clinical practice, standard test kits with formalized (quantitative) assessment of results have proven themselves well, allowing for rapid assessment of several cognitive functions in a limited time.

Mini-Cog technique: advantages and disadvantages

Of the above standard test kits for outpatient practice, we can recommend the Mini-Cog method (Appendix 5). This technique includes a memory task (memorizing and recalling 3 words) and a clock drawing test. The main advantage of the Mini-Cog technique is its high information content with simultaneous simplicity and speed of implementation. The test takes no more than 3-5 minutes. The interpretation of the test results is also extremely simple: if the patient cannot reproduce at least one of three words or makes significant errors when drawing a clock, high degree It is likely that he has impaired cognitive functions. The test results are assessed qualitatively: if there are violations, there are no violations. The methodology does not provide for scoring, as well as grading CI according to the degree of severity. The latter is carried out according to the severity of the functional defect.

The Mini-Cog technique can be used both for the diagnosis of vascular and primary degenerative CIs, as it includes memory tests and “frontal” functions (clock drawing test). The main disadvantage of this technique is its low sensitivity: being very simple, it detects only quite severe disorders of cognitive functions, such as dementia. At the same time, patients with mild and moderate CI in most cases cope with the described test without difficulty. However, a small number of patients with moderate CI syndrome make mistakes in drawing clocks.

Montreal Cognitive Assessment Scale or Moka Test: advantages and disadvantages

If the doctor has time, for example, when examining inpatients, you can use a more detailed and, accordingly, more sensitive battery of tests - the Montreal Cognitive Function Rating Scale or the Moka test (Appendix 2). This scale is currently recommended by most modern experts in the field of CI for widespread use in everyday clinical practice.

The Montreal Cognitive Assessment Scale was developed for rapid assessment of mild cognitive dysfunction. It assesses various cognitive domains: attention and concentration, executive functions, memory, language, visual constructive skills, abstract thinking, numeracy and orientation. The test time is approximately 10 minutes. The maximum possible number of points is 30, 26 or more is considered normal.

Like the Mini-Cog technique, the Moka test evaluates various aspects of cognitive activity: memory, “frontal” functions (letter-number connection test, speech fluency, generalization, etc.), nominative speech function (naming animals), visuospatial praxis (cube, clock). Therefore, the technique can be used to diagnose both vascular and primary degenerative CIs. However, the sensitivity of the Moka test is significantly higher than that of the Mini-Cog, so the Montreal Cognitive Scale is suitable for identifying not only severe, but also moderate CIs. At the same time, the formalized assessment system of the Mock Test itself does not provide for a gradation of the severity of violations depending on the score. The assessment of the severity of CI is based on the degree of functional limitation in everyday life, which is determined mainly through conversation with relatives. Other neuropsychological tests can be used to assess CI (Appendices 3, 6-7).

Evaluation of neuropsychological testing results

Neuropsychological testing is the most objective method for diagnosing CI, but it is still not completely reliable. In some cases (however, quite rarely), neuropsychological testing gives a false positive or false negative result.

False positive result neuropsychological testing may lead to overdiagnosis of CI. In these cases, the patient scores low on tests, below the norm for the corresponding age, despite the absence of true CIs. Main reasons false positive result testing are:

• low educational level and social status of the patient, illiteracy, lack of general knowledge, long-term isolation from society;
• situational absent-mindedness and inattention (for example, if at the time of testing the patient is upset or preoccupied with something), as well as high situational anxiety at the time of the neuropsychological study;
• state of intoxication at the time of the study or the day before, severe fatigue of the patient at the time of the study or lack of sleep the night before;
• has an indifferent or negative attitude towards testing, does not make the necessary efforts to perform cognitive tasks, since he does not understand the purpose and significance of the neuropsychological research method, and considers it unnecessary. Sometimes, even having formally agreed to the study, the patient, due to an internal negative attitude, consciously or unconsciously resists the assessment of the state of his cognitive functions.

False negative result neuropsychological testing means a formally normal test score (within the average age norm) despite the presence of CI in the patient’s status. Usually observed in patients with the earliest signs of cognitive impairment, however, in rare cases, even patients with dementia successfully cope with the presented cognitive tasks. The likelihood of a false negative test result directly depends on the complexity (and therefore sensitivity) of the method used. Thus, in the same sample of patients, when using the Mini-Cog technique, a significantly larger percentage of individuals will formally correspond to the norm than when using the Moka test.

However, the use of even the most complex and sensitive research methods does not provide a complete guarantee against a false negative result. Observations of patients with so-called subjective cognitive impairment (cognitive complaints not confirmed by the results of neuropsychological tests) indicate that some of them will develop objective cognitive decline in the near future. Obviously, in these cases we are talking about the most early manifestations cognitive impairment, not recorded using available neuropsychological tests, but noticeable (with intact criticism) for the patient himself.

In other cases, subjective CIs are a manifestation of emotional disorders of the anxiety-depressive series. Therefore, in patients with active cognitive complaints with a negative result of neuropsychological testing, a thorough examination of the emotional state is necessary. In some cases, it is advisable to prescribe antidepressants ex juvantibus. Thus, active cognitive complaints are always a pathological symptom that requires correction even in the case of normal results of neuropsychological tests. However, in some cases, complaints of decreased memory and mental performance should be considered as evidence of emotional rather than CI.

Considering the possibility of an erroneous test result in doubtful cases, repeated neuropsychological studies are advisable. In some cases, the diagnosis can be established only during dynamic monitoring of the patient.

Assessment of the patient's cognitive status and degree of functional limitation by third parties

The most complete and correct idea of ​​the presence, structure and severity of cognitive impairment is formed by comparing the patient’s complaints, the results of a neuropsychological study and information received from people who have been in constant communication with the patient for a long time, who can observe him in everyday life - family members, close relatives, friends, colleagues, etc. (Table 2).

Table 2. Assessment of the patient’s functional independence in conversation with third parties

Professional activity	Is the patient still working? If not, is leaving work related to CI? If so, is he doing his job as well as before?
Activities outside the home	Has the patient developed new (not previously noted) difficulties in one or more of the following areas: social activities, services, financial transactions, shopping, driving, using public transport, hobbies and interests. How are these difficulties related to memory and intelligence impairments?
Activity at home	What household duties did the patient traditionally perform (cleaning, cooking, washing dishes, laundry, ironing, childcare, etc.)? Does he continue to deal with them? If not, what is the reason for this (forgotten, decreased motivation, physical difficulties, for example, pain, motor limitations, etc.)?
Self-service	Does the patient need assistance with self-care (dressing, hygiene procedures, eating, using the toilet)? Does he need reminders or prompts when performing self-care? What are the causes of self-care difficulties (forgotten, forgotten how to do things, doesn’t know how to perform certain actions, decreased motivation, physical difficulties, for example, pain)?

Relatives or other close persons of the patient should be asked targeted questions to assess the state of cognitive functions: for example, how often the patient forgets events, the content of conversations, necessary things to do, and whether there is forgetfulness of names and faces. Relatives may pay attention to changes in the patient’s speech, difficulties in understanding spoken speech, choosing words in a conversation, and incorrect construction of phrases. They may also notice unexpected difficulties when performing usual activities, for example, when preparing food, minor household repairs, cleaning, etc. You should ask how the patient navigates space and time, whether he has difficulties in determining the date and when traveling, remains Is he as smart and reasonable as he always was?

Information about the patient's cognitive status obtained from the patient's relatives and other close associates is usually objective. However, sometimes it can be distorted by misconceptions of the informant himself. It is no secret that many people without medical education consider it normal for a decline in memory and intelligence in old age, and therefore may not pay due attention to these changes. Emotional attachment or, on the contrary, hidden negative attitude may also affect the objectivity of the information, which must be taken into account by the attending physician.

Relatives and other close people are an important source of information about the patient’s emotional state and behavior in everyday life.

In a conversation with relatives, it is necessary to clarify how often they see the patient sad and depressed or excited and worried, whether he expressed dissatisfaction with his life, or complained of fear or anxiety. Relatives and other close people can report on the patient's behavior and how it has changed recently. Targeted questions should be asked regarding aggressive behavior, eating habits, the sleep-wake cycle, the presence of incorrect thoughts and ideas, including ideas of harm, jealousy, increased suspicion, and illusory-hallucinatory disorders.

Without information received from relatives and other close people, it is impossible to get a correct idea of ​​the degree of functional limitation, and therefore the severity of CI. Traditionally, there are 3 degrees of severity of CI: mild, moderate and severe (Table 3).

Table 3. Characteristics of CI syndromes by severity

Basis for assessment	Lungs	Moderate	Heavy
Patient complaints of a cognitive nature	Usually there is	Usually there is	Usually absent
Neuropsychological tests	Violations are detected only by the most sensitive methods	Violations are detected	Violations are detected
Information from third parties	Violations are not noticeable	Impairments are noticeable but do not lead to functional limitations	Impairments lead to functional limitations

Light KN are characterized by rare and mild symptoms that do not lead to any functional limitations. Typically, mild CIs are not noticeable to others, including those who constantly communicate with the patient, but can be noticeable to the patient himself, being the subject of complaints and a reason to see a doctor. The most characteristic manifestations of mild cognitive impairment are episodic forgetfulness, rare difficulties in concentrating, fatigue during intense mental work, etc. Mild CI can be objectified only with the help of the most complex and sensitive neuropsychological techniques.

Moderate CI characterized by regular or persistent cognitive symptoms, more significant in severity, but with no or minimal severity of functional limitation. There may be slight but almost constant forgetfulness, frequent difficulty concentrating, and increased fatigue during normal mental work. Moderate CIs are usually noticeable not only to the patient himself (reflected in complaints), but also to third parties who report this to the attending physician. Neuropsychological tests (eg, Moka test) usually reveal deviations from normative indicators. At the same time, the patient retains independence and independence in most life situations, copes with his work, social role, family responsibilities, etc. Only sometimes there may be difficulties in complex and unusual activities for the patient.

Heavy KN lead to a greater or lesser degree of functional limitation (see Table 3), partial or complete loss of independence and autonomy.

Treatment

Treatment for CI depends on its cause and severity. In most nosological forms (Alzheimer's disease, cerebrovascular insufficiency, degenerative process with Lewy bodies and some others), the presence of severe CI is an indication for the prescription of acetylcholinesterase inhibitors and/or NMDA glutamate receptor antagonists. For mild and moderate CI, Pronoran (piribedil) is used - an agonist dopamine and α2-blocker), vasoactive and metabolic drugs.

Applications.

Additional neuropsychological tests

Appendix 1. Diagnostic algorithm

Suspicion of CI (active complaints of the patient, his unusual behavior during the conversation, information from third parties. risk factors)
↓
Neuropsychological tests
↓	↓
No violations	There are violations
↓	↓	↓
Dynamic observation	Functional status assessment
	↓	↓
	There are violations	No violations
	↓	↓
	Heavy KN	Mild to moderate CI

Appendix 2. Mock test. Instructions for use and evaluation

1. Test “Connecting numbers and letters.”

The examiner instructs the subject: “Please draw a line from the number to the letter in ascending order. Start here (point to number 1) and draw a line from number 1 to letter A, then to number 2 and so on. Finish here (point D).”

Score: 1 point is awarded if the subject successfully draws a line as follows: 1-A-2-B-3-C-4-D-5-D without crossing the lines.

Any error that is not immediately corrected by the test taker himself earns 0 points.

2.Visuospatial skills (cube)

The researcher gives the following instructions, pointing to the cube: “Copy this drawing as accurately as you can in the space below the drawing.”

Score: 1 point is awarded if the drawing is accurately executed:

• the drawing must be three-dimensional;
• all lines are drawn;
• no extra lines;
• the lines are relatively parallel, their length is the same.

No point is given if any of the above criteria are not met.

3.Visuospatial skills (clock)

Point to the right third of the blank space and give the following instructions: “Draw a clock. Arrange all the numbers and indicate the time: 10 minutes past twelve.”

Scoring: Points are awarded for each of the following three items:

• contour (1 point): the dial should be round, only slight curvature is allowed (i.e. slight imperfection when closing the circle);
• numbers (1 point): all numbers on the clock must be presented, there should be no additional numbers; the numbers must be in the correct order and placed in the appropriate quadrants on the dial; Roman numerals are allowed; the numbers can be located outside the contour of the dial;
• arrows (1 point): there must be 2 arrows jointly showing right time; the hour hand must be obviously shorter than the minute hand; The hands should be positioned in the center of the dial, with their junction close to the center.

No score will be awarded if any of the above criteria are not met.

4. Naming

Starting on the left, point to each shape and say, “Name this animal.”

Score: 1 point is assigned for each of the following answers - camel or dromedary camel, lion, rhinoceros.

5. Memory

The researcher reads a list of 5 words at a rate of 1 word per second. The following instructions should be given: “This is a memory test. I will read a list of words that you need to remember. Listen carefully. When I finish, tell me all the words that you remember. It doesn't matter in what order you name them." Make a mark in the space provided for each word as the subject names it on the first try. When the subject indicates that he has finished (named all the words) or cannot remember any more words, read the list a second time with the following instructions: “I will read the same words a second time. Try to remember and repeat as many words as you can, including the words you repeated the first time." Place a mark in the space provided for each word that the test taker repeats on the second try. At the end of the second attempt, inform the subject that he or she will be asked to repeat the given words: “I will ask you to repeat these words again at the end of the test.”

Scoring: No points will be awarded for the first or second attempt.

6. Attention

Repeating numbers. Give the following instructions: “I’m going to say a few numbers and when I’m done, repeat them exactly as I said them.” Read 5 numbers in sequence with a frequency of 1 number per 1 s.

Repeat numbers backwards. Give the following instructions: “I will say a few numbers, but when I finish, you will need to repeat them in reverse order.” Read a sequence of 3 numbers with a frequency of 1 number per 1 second.

Grade. Award 1 point for each sequence repeated exactly (N.B.: exact answer for counting backwards 2-4-7).

Concentration. The researcher reads a list of letters with a frequency of 1 letter per 1 s, after the following instructions: “I will read you a series of letters. Every time I say the letter A, clap your hand once. If I say another letter, I don’t need to clap my hand.”

Score: 1 point is assigned if there are no errors or there is only 1 error (an error is considered if the patient claps his hand when naming another letter or does not clap when naming the letter A).

Serial account(100-7). The researcher gives the following instructions: “Now I will ask you to subtract 7 from 100, and then continue subtracting 7 from your answer until I say stop.” Repeat the instructions if necessary.

Score: 3 points are assigned for this item, 0 points - if there is no correct count, 1 point - for 1 correct answer, 2 points - for 2-3 correct answers, 3 points - if the subject gives 4 or 5 correct answers. Count each correct subtraction by 7s, starting from 100. Each subtraction is scored independently: if the participant gives an incorrect answer but then continues to accurately subtract 7s from it, give 1 point for each accurate subtraction. For example, a participant might answer "92-85-78-71-64", where "92" is incorrect, but all subsequent values ​​are subtracted correctly. This is 1 error, and 3 points are assigned for this item.

7. Repeating a phrase

The researcher gives the following instructions: “I will read you a sentence. Repeat it exactly as I say (pause): “All I know is that Ivan is the one who can help today.” Following the answer, say: “Now I will read you another sentence. Repeat it exactly as I say (pause): “The cat always hid under the sofa when the dogs were in the room.”

Scoring: 1 point is awarded for each sentence repeated correctly. The repetition must be precise. Listen carefully to look for errors due to omissions of words (for example, omission of “only”, “always”) and substitutions/adding (for example, “Ivan is the only one who helped today”; substitution of “hiding” instead of “hiding”, use of plurals, etc. .d.).

8. Fluency

The researcher gives the following instructions: “Tell me as many words as possible that begin with a specific letter of the alphabet, which I will now tell you. You can name any kind of word, with the exception of proper names (such as Peter or Moscow), numbers or words that begin with the same sound, but have various suffixes, for example love, lover, love. I'll stop you in 1 minute. You are ready? (Pause) Now tell me as many words as you can think of that start with the letter L. (time 60 s). Stop".

Score: 1 point is awarded if the subject names 11 words or more in 60 seconds. Write your answers at the bottom or side of the page.

9. Abstraction

The researcher asks the subject to explain: “Tell me what an orange and a banana have in common.” If the patient answers in a specific way, say only 1 more time: “Tell me how else they are similar.” If the subject does not give the correct answer (fruit), say, “Yes, and they are both fruits.” Do not give any other instructions or explanations. After a trial attempt, ask: “Now tell me what a train and a bicycle have in common.” After answering, give the second task by asking: “Now tell me what the ruler and the clock have in common.” Do not give any other instructions or hints.

Score: Only the last 2 pairs of words are taken into account. 1 point is given for each correct answer. The following answers are considered correct: train-bicycle = means of transportation, means of travel, both can be ridden; clock ruler=measuring tools, used for measuring. The following answers are not considered correct: train-bicycle = they have wheels; ruler-clock=there are numbers on it.

1O. Delayed playback

The researcher gives the following instructions: “I previously read you a series of words and asked you to remember them. Tell me as many words as you can remember.” Make a note for each word correctly named without prompting in the specially designated space.

Scoring: 1 point is awarded for each word named without any prompts.

Optionally, after a delayed attempt to recall words without a hint, give the subject a hint in the form of a semantic categorical key for each unprompted word. Make a mark in the space provided if the subject recalled the word using a categorical or multiple choice prompt. Prompt in this way all the words that the subject did not name. If the subject does not name the word after the categorical prompt, he/she should be given a multiple-choice prompt using the following instructions: “Which word do you think was named: nose, face, or hand?” Use the following categorical and/or multiple choice clues for each word:

• face: categorical clue - part of the body, multiple choice - nose, face, hand;
• velvet: categorical prompt - type of fabric, multiple choice - gin, cotton, velvet;
• church: categorical clue - type of building, multiple choice - church, school, hospital;
• violet: categorical clue - type of flower, multiple choice - rose, tulip, violet;
• red categorical clue - color; multiple choice - red, blue, green.

Scoring: No points are awarded for recalling prompted words. Clues are used for clinical informational purposes only and may provide the test interpreter with additional information about the type of memory impairment. When memory is impaired due to retrieval impairment, performance is improved by cueing. When memory is impaired due to impaired encoding, test performance after prompting does not improve.

11. Orientation

The researcher gives the following instructions: “Give me today’s date.” If the subject does not give a complete answer, then give the appropriate hint: “Name the year, month, date and day of the week.” Then say: “Now tell me this place and the city in which it is located.”

Scoring: 1 point is awarded for each correctly named item. The subject must name the exact date and place (name of hospital, clinic, clinic). No point is awarded if the patient makes an error in the day of the week or date.

Total score: All points are summed up in the right column. Add 1 point if the patient has 12 years of education or less, to a possible maximum of 30 points. A final total score of 26 or more is considered normal.

Appendix 2. Montreal Cognitive Assessment Scale - Moka Test (from the English Montreal Cognitive Assessmnet, abbreviated MoCA). Z. Nasreddine MD et al., 2004. www.mocatest.org. (translation by O.V. Posokhin and A.Yu. Smirnov). Instructions included.
Name:
Education:					Date of Birth:
Floor:					Date of:
Visual-constructive/executive skills					Draw a CLOCK (10 minutes past twelve - 3 points)			Points
					Circuit	Numbers	Arrows
Naming								_/3
Memory	Read the list of words and the subject must repeat them. Make 2 attempts. Ask to repeat the words after 5 minutes		face	velvet	church	violet	red	no points
		Attempt 1
		Attempt 2
Attention	Read a list of numbers (1 digit in 1s)	The subject must repeat them in direct order 2 1 8 5 4						_/2
		The subject must repeat them in reverse order 7 4 2 /2
Read a series of letters. The test taker must clap his hand for each letter A. No points if there are more than 2 errors		F B A V M N A A J K L B A F A K D E A A A F M O F A A B						_/1
Serial subtraction of 7 from 100			93 86 79 72 65					_/3
4–5 correct answers – 3 points; 2–3 correct answers – 2 points; 1 correct answer – 1 point; 0 correct answers – 0 points
Speech	Repeat: All I know is that Ivan is the one who can help today.							_/2
	The cat always hid under the sofa when the dogs were in the room.
Speech fluency. In 1 minute, name the maximum number of words starting with the letter L (N≥11 words)								_/1
Abstraction	What do words have in common, for example: banana – apple = fruit			train – bike		clock - ruler		_/2
Delayed playback	You need to name words without prompting	face	velvet	church	violet	red	Points only for words without prompting	_/5
Additionally upon request	Category hint
	Multiple Choice
Orientation		date	Month	Year	Day of the week	Place	City	_/6
Norm 26/30				Number of points				_/30
				Add 1 point if education ≤12
© Z.Nasreddine MD Version 7.1 Norm 26/30

Tests to assess the general state of cognitive functions

Appendix 3 Instructions

1. Orientation in time. Ask the patient to fully state today's date, month, year, season and day of the week. The question must be asked slowly and clearly, the rate of speech should be no more than one word per second. The maximum score (5) is given if the patient independently and correctly gives a complete answer.

2. Orientation in place. The question is asked: “Where are we?” The patient must name the country, region (for regional centers it is necessary to name the city district), city, institution in which the examination is taking place, floor (or room number). Each error or lack of answer reduces the score by 1 point.

3. Memorization. The instruction is given: “Repeat and try to remember 3 words: pencil, house, penny.” Words should be pronounced as clearly as possible at a speed of 1 word per 1 second. Correct repetition of a word by the patient is scored 1 point for each word. Words should be presented as many times as necessary for the subject to repeat them correctly. However, only the first repetition is scored.

4. Attention and counting. They are asked to sequentially subtract 7 from 100. The instructions may be approximately as follows: “Please subtract 7 from 100, from what you get, 7 again, and so on several times.” 5 subtractions are studied. Each correct subtraction is worth 1 point.

5. Playback. The patient is asked to remember the words that were memorized in step 3. Each correctly named word is scored 1 point.

6. Speech. They show a pen and ask: “What is this?”, similarly - a watch. Each correct answer is worth 1 point. The patient is asked to repeat a complex phrase. Correct repetition is scored 1 point. A command is given orally, which requires the sequential performance of 3 actions. Each action is worth 1 point. A written command is given; the patient is asked to read it and complete it. The command must be written in fairly large block letters on a blank sheet of paper. Then the verbal command is given: “Write a sentence.” Correct execution of the command requires that the patient independently write a meaningful and grammatically complete sentence.

7. Constructive praxis. For correct execution of each command, 1 point is given. For correct execution of the drawing, 1 point is given. The patient is given a sample (2 intersecting pentagons with equal angles). If spatial distortions or unconnected lines occur during redrawing, the execution of the command is considered incorrect.

The test result is determined by summing the scores for each item. You can score a maximum of 30 points in this test, which corresponds to the highest cognitive abilities. The lower the test result, the more severe the cognitive deficit. Patients with dementia of the Alzheimer's type score less than 24 points, with subcortical dementia - less than 26 points.

Appendix 3. Brief Mental Status Rating Scale

Try	Score (points)
Time orientation:
Give the date (day, month, year, season, day of the week)	0-5
Orientation to the place:
Where are we located (country, region, city, clinic, floor)?	0-5
Memorization:
Repeat three words: pencil, house, penny	0-3
Attention and account:
Serial count (“subtract 7 from 100”) 5 times	0-5
Playback
Remember 3 words (see paragraph “Perception”)	0-3
Speech
Naming (show the pen and watch and ask what it is called)	0-2
Ask to repeat the sentence “One today is better than two tomorrow”	0-1
Running a 3-step command:	0-3
“Take a piece of paper with your right hand, fold it in half and place it on the next chair.” Read and follow:
close your eyes	0-1
Write a proposal	0-1
Constructive praxis Copy the drawing	0-1
Total score	0-30

Appendix 4. Comparative characteristics of mild cognitive impairment and dementia

Criteria	Mild cognitive impairment	Dementia
Daily Activities	Not impaired (only the most complex actions are limited)	Patients “cannot cope with life” due to an intellectual defect and require outside help
Flow	Variable: along with progression, long-term stabilization and spontaneous regression of the defect are possible	In most cases it is progressive, but sometimes it is stationary or reversible
Cognitive defect	Partial, may involve only one cognitive function	Multiple or diffuse
Mini-Mental Status Scale score	Can range from 24 to 30 points	Often below 24 points
Behavior Changes	Cognitive defect is not accompanied by pronounced changes in behavior	Behavioral changes often determine the severity of a patient's condition
Criticism	Safe, disturbances are more of a concern to the patient himself	Sometimes reduced, violations worry relatives more

Appendix 5. Mini-Cog technique

1. Instructions: “Repeat 3 words: lemon, key, ball.” Words must be pronounced as clearly and legibly as possible, at a speed of 1 word per second. After the patient has repeated all 3 words, we ask: “Now remember these words. Repeat them 1 more time." We ensure that the patient independently remembers all 3 words. If necessary, repeat the words up to 5 times.
2. Instructions: “Please draw a round clock with numbers on the dial and hands.” All numbers must be in place, and the arrows must point to 13 hours 45 minutes. The patient must independently draw a circle, arrange numbers and draw arrows. Hints are not allowed. The patient should not look at a real clock on his hand or wall. Instead of 13 hours 45 minutes, you can ask to set the hands at any other time.
3. Instructions: “Now let’s remember the 3 words that we learned at the beginning.” If the patient cannot remember the words on his own, then you can offer a hint, for example: “Did you remember some other fruit, instrument, geometric figure.”
The inability to remember at least 1 word after a hint or errors when drawing a clock indicate the presence of clinically significant CIs.

Appendix 6. Memory self-assessment questionnaire

1. I forget the phone numbers I call regularly.

2. I don’t remember what I put where

3. When I stop reading, I can’t find the place I was reading.

4. When I shop, I write down on paper what I need to buy so I don’t forget anything.

5. Forgetfulness causes me to miss important meetings, dates, and activities.

6. I forget things I plan on the way home from work.

7. I forget the first and last names of people I know.

8. I find it difficult to concentrate on the work I am doing.

9. It’s difficult for me to remember the content of a TV show I just watched.

10. I don't recognize people I know

11. I lose the thread of conversation when communicating with people.

12. I forget the first and last names of people I meet.

13. When people say something to me, it’s hard for me to concentrate.

14. I forget what day of the week it is

15. I have to check and double-check that I closed the door and turned off the stove.

16. I make mistakes when writing, typing, or using a calculator.

17. I often get distracted

18. I need to listen to instructions several times to remember them.

19.ohm what am I reading

20. I forget what I was told

21. I have trouble counting change in the store.

22. I do everything very slowly

23. My head feels empty

24. I forget what date it is

How to interpret test results The McNair and Kahn questionnaire must be completed by the patient. This will allow you to assess his CI in everyday life. Each question must be scored from 0 to 4 points (0 - never, 1 - rarely, 2 - sometimes, 3 - often, 4 - very often). A total score >43 suggests the presence of CI.

Appendix 7. Tests for assessing regulatory functions

Battery of "frontal" tests

1. Similarity (conceptualization)

“Banana and orange. What do these objects have in common? If there is a complete or partial inability to name the common thing (“there is nothing in common” or “both are covered with peel”), you can provide the hint “both a banana and an orange are...”; but the test is scored 0 points; do not help the patient answer the following 2 questions: “Table and chair”, “Tulip, rose and daisy”.

Evaluation: only the category names (fruits, furniture, flowers) are evaluated as correct:

• 3 correct answers - 3 points;
• 2 correct answers - 2 points;
• 1 correct answer - 1 point;
• no correct answer - 0 points.

2. Speech activity

“Name as many words as possible that begin with the letter L, excluding names or proper names.”

If the patient does not respond within the first 5 s, you should say: “For example, a tray.” If the patient is silent for 10 seconds, you should stimulate him by repeating: “Any word starting with the letter L.” The test execution time is 60 s.

Rating [repeated words or their variations (love, lover), titles or names are not taken into account):

• more than 9 words - 3 points;
• from 6 to 9 words - 2 points;
• from 3 to 5 words - 1 point;
• less than 3 words - 0 points.

3. Serial movements

“Watch carefully what I do.” The examiner, sitting in front of the patient, performs the Luriev series of fist-rib-palm movements with his left hand 3 times. “Now with your right hand, repeat the same series of movements, first with me, then on your own.” The examiner performs the series 3 times with the patient, then tells him: “Now do it yourself.”

• the patient independently performs 6 consecutive series of movements - 3 points;
• the patient performs at least 3 correct consecutive series of movements - 2 points;
• the patient is not able to perform series of movements independently, but performs 3 consecutive series together with the researcher - 1 point;
• the patient is unable to perform 3 correct consecutive series even with the researcher - 0 points.

In the clinical practice of a neurologist, assessment of cognitive functions includes the study of orientation, attention, memory, counting, speech, writing, reading, praxis, and gnosis.

Orientation

A study of the patient's ability to navigate his own personality, place, time and current situation is carried out in parallel with an assessment of his state of consciousness.

• Orientation in one’s own personality: the patient is asked to state his name, residential address, profession, marital status.
• Place orientation: ask the patient to say where he is now (city, name medical institution, floor) and how he arrived here (by transport, on foot).
• Time orientation: ask the patient to name the current date (date, month, year), day of the week, time. You can ask the date of the nearest upcoming or past holiday.

Further examination of the patient's mental functions is carried out if it is determined that he is clearly conscious and able to understand instructions and questions asked of him.

Attention

Human attention is understood as both the ability to comprehend many aspects of stimulating influences at any point in time, and a nonspecific factor in ensuring selectivity, selectivity of the course of all mental processes as a whole. Neurologists often use this term to describe the ability to focus on certain sensory stimuli, distinguishing them from others. It is customary to distinguish between fixation of attention, switching of attention from one stimulus to another, and maintenance of attention (necessary to complete a task without signs of fatigue). These processes can be voluntary or involuntary.

The ability to concentrate and maintain attention is grossly impaired in states of acute confusion, suffers to a lesser extent in dementia and, as a rule, is not impaired in focal brain lesions. Concentration is tested by asking the patient to repeat a series of numbers or cross out numbers for some time. a certain letter, which is written on a piece of paper in random alternation with other letters (the so-called proof test). Normally, the subject correctly repeats 5-7 numbers after the researcher and crosses out the desired letter without errors. In addition, to assess attention, you can ask the patient to count to ten forward and backward; list the days of the week, months of the year in forward and reverse order; arrange the letters that make up the word “fish” in alphabetical order or pronounce this word by sounds in reverse order; report when the required one occurs among the sounds named in random order, etc.

Memory

Check

Disorders of counting and counting operations that occur in patients with organic brain damage are referred to as “acalculia.” Primary (specific) acalculia occurs in the absence of other disorders of higher brain functions and is manifested by a violation of ideas about number, its internal composition and place structure. Secondary (nonspecific) acalculia is associated with primary disorders of recognition of words denoting numbers and numbers, or with impaired development of an action program.

Billing assessment in clinical neurological practice most often limited to tasks on performing arithmetic operations and solving simple arithmetic problems.

• Serial counting: ask the patient to serially subtract seven from 100 (subtract seven from 100, then sequentially subtract seven from the remainder another 3-5 times) or three from 30. The number of errors and the time required for the patient to complete the task are noted. Errors when performing a test can be observed not only with acalculia, but also with attention disorders, as well as with apathy or depression.
• If the patient has impaired cognitive functions when solving the mentioned problems, he is offered simple addition, subtraction, multiplication, and division problems. You can also offer solutions to everyday problems involving arithmetic operations: for example, calculate how many pears you can buy for 10 rubles, if one pear costs 3 rubles, how much change will be left, etc.

Ability to generalize and abstract

The ability to compare, generalize, abstract, form judgments, and plan belongs to the so-called “executive” mental functions human, associated with the voluntary regulation of all other areas of mental activity and behavior. Various disorders of executive functions (for example, impulsivity, limited abstract thinking, etc.) in a mild form are possible in healthy individuals, therefore, the main importance in diagnosis is not determined by the type of disorders of executive functions, but by assessing their severity. In neurological practice, only the simplest tests are used to assess executive functions. During the examination, it is important to obtain information about the premorbid characteristics of the patient. The patient is asked to explain the meaning of several well-known metaphors and sayings (“golden hands”, “don’t spit in the well”, “if you drive more quietly, you’ll keep going”, “ravenous appetite”, “a bee flies from a wax cell for a field tribute”, etc.). ), find similarities and differences between objects (apple and orange, horse and dog, river and canal, etc.).

Speech

When talking with the patient, they analyze how he understands the speech addressed to him (sensory part of speech) and reproduces it (motor part of speech). Speech disorders constitute one of the complex problems of clinical neurology; it is studied not only by neurologists, but also by neuropsychologists and speech therapists. Below we discuss only the basic issues of speech disorders that help topical diagnosis.

Speech may suffer relatively in isolation from other higher brain functions in focal brain lesions, or simultaneously with other cognitive impairments in dementia. Aphasia is a violation of already formed speech, which occurs with focal lesions of the cortex and adjacent subcortical region of the dominant hemisphere (left in right-handed people) and is a systemic disorder of various forms of speech activity with the preservation of elementary forms of hearing and movements of the speech apparatus (that is, without paresis of the speech muscles - lingual, laryngeal, respiratory muscles).

Classic motor aphasia (Broca's aphasia) occurs when the posterior parts of the inferior frontal gyrus of the dominant hemisphere are damaged, and sensory aphasia (Wernicke's aphasia) occurs when the middle and posterior parts of the superior temporal gyrus of the dominant hemisphere are damaged. With motor aphasia, all types of oral speech are impaired (spontaneous speech, repetition, automated speech), as well as writing, but the understanding of oral and written speech is relatively intact. With Wernicke's sensory aphasia, both the understanding of oral and written speech and the patient's own oral and written speech are affected.

In neurological practice, speech disorders are diagnosed by assessing spontaneous and automated speech, repetition, object naming, speech comprehension, reading and writing. These studies are carried out in patients with speech disorders. When examining a patient, it is important to determine the dominance of his hemispheres, that is, to find out whether he is right-handed or left-handed. It may be mentioned here that, according to neurophysiologists, left hemisphere provides the functions of abstract thinking, speech, logical and analytical functions mediated by words. People whose functions of the left hemisphere predominate (right-handed people) gravitate towards theory, are goal-oriented, able to predict events, and are motorically active. In patients with functional dominance of the right hemisphere of the brain (left-handed), concrete thinking, slowness and taciturnity, a tendency to contemplation and memories, emotional coloring of speech, and an ear for music predominate. To clarify the dominance of the hemisphere, the following tests are used: determining the dominant eye in binocular vision, clasping the hands, determining the force of clenching into a fist with a dynamometer, folding the arms on the chest (“Napoleon’s pose”), clapping, pushing the leg, etc. In right-handed people, the dominant eye is the right one. , the thumb of the right hand, when folding the hands into a lock, is on top, the right hand is stronger, it is also more active when applauding, when folding the hands on the chest, the right forearm is on top, the right leg is a pusher, and for left-handed people it’s the other way around. A convergence of the functional capabilities of the right and left hands (ambidexterity) is often observed.

• Spontaneous speech begins to be examined when meeting a patient, asking him questions: “What is your name?”, “What do you do?”, “What worries you?” etc. It is necessary to pay attention to the following disorders.
  • Changes in the speed and rhythm of speech, which manifests itself in slowing down, intermittency of speech or, on the contrary, in its acceleration and difficulty stopping.
  • Impaired melody of speech (dysprosody): it can be monotonous, inexpressive, or acquire a “pseudo-foreign” accent.
  • Speech suppression (complete absence of speech production and attempts at verbal communication).
  • The presence of automatisms (“verbal emboli”) - frequently, involuntarily and inappropriately used simple words or expressions (exclamations, greetings, names, etc.), the most resistant to elimination.
• Perseveration (“getting stuck”, repetition of an already spoken syllable or word, which occurs when attempting verbal communication).
• Difficulty in choosing words when naming objects. The patient's speech is hesitant, replete with pauses, and contains many descriptive phrases and words of a substitutive nature (such as “well, how is it there...”).
• Paraphasia, that is, errors in pronouncing words. Phonetic paraphasias are distinguished (inadequate production of language phonemes due to simplification of articular movements: for example, instead of the word “store” the patient pronounces “zizimin”); literal paraphasias (replacement of some sounds with others that are similar in sound or place of origin, for example “bump” - “kidney”); verbal paraphasia (replacement of one word in a sentence with another that resembles it in meaning).
• Neologisms (linguistic formations used by the patient as words, although there are no such words in the language he speaks).
• Agrammatisms and paragrammatisms. Agrammatism is a violation of the rules of grammar in a sentence. The words in the sentence do not agree with each other, syntactic structures (auxiliary words, conjunctions, etc.) are shortened and simplified, but the general meaning of the transmitted message remains clear. With paragrammatism, the words in the sentence are formally coordinated correctly, there are enough syntactic structures, but the general meaning of the sentence does not reflect the real relationships of things and events (for example, “Hay dries the peasants in June”), as a result, it is impossible to understand the transmitted information.
• Echolalia (spontaneous repetition of words spoken by a doctor or combinations thereof).
• To assess automated speech, the patient is asked to count from one to ten, list days of the week, months, etc.
  • To assess the ability to repeat speech, the patient is asked to repeat vowels and consonants after the doctor (“a”, “o”, “i”, “u”, “b”, “d”, “k”, “s” and etc.), oppositional phonemes (labial - b/p, front-lingual - t/d, z/s), words (“house”, “window”, “cat”; “moan”, “elephant”; “colonel” "", "fan", "ladle"; "shipwreck", "cooperative", etc.), a series of words ("house, forest, oak"; "pencil, bread, tree"), phrases ("Girl drinks tea "; "The boy is playing"), tongue twisters ("There is grass in the yard, there is firewood on the grass").
  • The ability to name objects is assessed after the patient names the objects shown to him (watch, pen, tuning fork, flashlight, sheet of paper, body parts).
• The following tests are used to assess understanding of spoken language.
  • Understanding the meaning of words: name an object (knocker, window, door) and ask the patient to point it out in the room or in the picture.
  • Understanding verbal instructions: the patient is asked to perform sequentially one-, two- and three-component tasks (“Show me your left hand”, “Raise your left hand and touch the fingers of this hand to your right ear”, “Raise your left hand, touch the fingers of this hand to your right ear” ear, stick out your tongue at the same time"). Instructions should not be supported by facial expressions or gestures. Evaluate the correct execution of commands. If the subject has difficulties, repeat the instructions, accompanying them with facial expressions and gestures.
  • Understanding logical-grammatical structures: asking the patient to follow a series of instructions containing structures genitive case, comparative and reflexive forms of verbs or spatial adverbs and prepositions: for example, show a key with a pencil, a pencil with a key; put a book under a notebook, a notebook under a book; show which object is more and which is less light; explain who is referred to in the expressions “mother’s daughter” and “daughter’s mother,” etc.
• To assess writing function, the patient is asked (provided with a pen and a piece of paper) to write his name and address, then take dictation of a few simple words (“cat”, “house”); sentence (“A girl and a boy are playing with a dog”) and copy the text from the sample printed on paper. In patients with aphasia, in most cases, writing also suffers (that is, agraphia is present - loss of the ability to write correctly while maintaining the motor function of the hand). If a patient can write but cannot speak, he most likely has mutism, but not aphasia. Mutism can develop in a wide variety of diseases: with severe spasticity, paralysis of the vocal cords, bilateral damage to the corticobulbar tracts, and is also possible with mental illness(hysteria, schizophrenia).
• To assess reading, the patient is asked to read a paragraph from a book or newspaper, or read and follow instructions written on paper (for example, “Go to the door, knock on it three times, come back”), and then evaluate the correctness of its execution.

For neurological diagnosis, the ability to distinguish motor aphasia from dysarthria, which is characteristic of bilateral lesions of the corticonuclear tracts or nuclei of the cranial nerves of the bulbar group, is of great importance. With dysarthria, patients say everything, but pronounce words poorly; the speech sounds “r”, “l”, and hissing sounds are especially difficult to articulate. Sentence construction and vocabulary do not suffer. With motor aphasia, the construction of phrases and words is disrupted, but at the same time, the articulation of individual articulate sounds is clear. Aphasia also differs from alalia - underdevelopment of all forms of speech activity, manifested by speech impairment in childhood. Below are summarized the most important signs various aphasic disorders.

• With motor aphasia, patients generally understand someone else's speech, but find it difficult to choose words to express their thoughts and feelings. Their vocabulary is very poor and can be limited to only a few words (“emboli words”). When speaking, patients make mistakes - literal and verbal paraphasias, try to correct them and are often angry with themselves for not being able to speak correctly.
• The main signs of sensory aphasia include difficulty understanding the speech of others and poor auditory control of one's own speech. Patients make a lot of literal and verbal paraphasias (sound and verbal errors), do not notice them and get angry with the interlocutor who does not understand them. With severe forms of sensory aphasia, patients are usually verbose, but their statements are difficult to understand for others (“speech salad”). To identify sensory aphasia, you can use the experience of Marie (the patient is given three pieces of paper and asked to throw one of them on the floor, put the other on the bed or table, and return the third to the doctor) or Ged (the patient is asked to put a large coin in a small glass, and a small one - in a large one; the experiment can be complicated by placing four different glasses, the same number of coins of different sizes and asking the patient to place them).
• With lesions at the junction of the temporal, parietal and occipital lobes, one of the variants of sensory aphasia may occur - the so-called semantic aphasia, in which patients do not understand the meaning of individual words, but the grammatical and semantic connections between them. Such patients cannot, for example, distinguish between the expressions “father's brother” and “brother's father” or “the cat ate the mouse” and “the cat was eaten by the mouse.”
• Many authors identify another type of aphasia - amnestic, in which patients find it difficult to name the various objects shown, forgetting their names, although they can use these terms in spontaneous speech. It usually helps such patients if they are prompted with the first syllable of the word denoting the name of the object being shown. Amnestic speech disorders are possible with different types of aphasia, but most often they occur with lesions of the temporal lobe or parieto-occipital region. Amnestic aphasia should be distinguished from a broader concept - amnesia, that is, a memory disorder for previously developed ideas and concepts.

Praxis

Praxis is understood as the ability to perform successive complexes of conscious voluntary movements in order to perform purposeful actions according to a plan developed by individual practice. Apraxia is characterized by the loss of skills developed in the process of individual experience, complex purposeful actions (everyday, industrial, symbolic gestures, etc.) without pronounced signs central paresis or impaired coordination of movements. Depending on the location of the lesion, several types of apraxia are distinguished.

• Motor (kinetic, efferent) apraxia is manifested by the fact that sequential switching of movements is disrupted and disorders in the formation of motor units that create the basis of motor skills occur. Characterized by a disorder in the smoothness of movements, “getting stuck” on individual fragments of movements and actions (motor perseverations). Observed with a lesion in the lower parts of the premotor region of the frontal lobe of the left (in right-handed) hemisphere (if the precentral gyrus is damaged, central paresis or paralysis develops, in which apraxia cannot be detected). To identify motor apraxia, the patient is asked to perform the “fist-edge-palm” test, that is, hit the table surface with a fist, then with the edge of the palm, and then with the palm with straightened fingers. This series of movements is asked to be repeated at a fairly fast pace. A patient with damage to the premotor area of ​​the frontal lobe experiences difficulty in performing such a task (gets lost in the sequence of movements, cannot complete the task at a fast pace).
• Ideomotor (kinesthetic, afferent) apraxia occurs when the inferior parietal lobule is damaged in the region of the supramarginal gyrus, which is classified as a secondary field of the kinesthetic analyzer cortex. In this case, the hand does not receive afferent feedback signals and is not able to perform fine movements (at the same time, a lesion in the region of the primary fields of the postcentral gyrus causes a gross disturbance of sensitivity and afferent paresis, in which the ability to control the opposite hand is completely lost, but this disorder does not cause apraxia attributed). Apraxia is manifested by a violation of fine differentiated movements on the side opposite to the lesion: the hand cannot take the position necessary to perform a voluntary movement, or adapt to the nature of the object with which specified manipulations are performed (the “shovel hand” phenomenon). The search for the required posture and errors are typical, especially if there is no visual control. Kinesthetic apraxia is detected when performing simple movements (both with real objects and when simulating these actions). To identify it, you should ask the patient to stick out his tongue, whistle, show how to light a match (pouring water into a glass, using a hammer, holding a pen to write with, etc.), dial a telephone number, comb his hair. You can also invite him to close his eyes; put his fingers into some simple figure (for example, “goat”), then destroy this figure and ask him to restore it himself.
• Constructive apraxia (spatial apraxia, apractognosia) is manifested by impaired coordination of joint movements of the hands, difficulty in performing spatially oriented actions (difficulty making the bed, getting dressed, etc.). There is no clear difference between performing movements with open and closed eyes. This type of disorder also includes constructive apraxia, which manifests itself in the difficulty of constructing a whole from individual elements. Spatial apraxia occurs when the focus is localized at the junction of the parietal, temporal and occipital regions (in the area of ​​the angular gyrus of the parietal lobe) of the cortex of the left (in right-handed people) or both hemispheres of the brain. When this zone is damaged, the synthesis of visual, vestibular and cutaneous-kinesthetic information is disrupted and the analysis of action coordinates deteriorates. Tests that reveal constructive apraxia involve copying geometric figures, drawing a clock face with the arrangement of numbers and hands, and building structures from cubes. The patient is asked to draw a three-dimensional geometric figure (eg, a cube); draw a geometric figure; draw a circle and arrange the numbers in it as on a watch dial. If the patient has completed the task, he is asked to arrange the arrows so that they show a certain time (for example, “a quarter to four”).
• Regulatory (“prefrontal”, ideational) apraxia includes disturbances in the voluntary regulation of activities directly related to the motor sphere. Regulatory apraxia manifests itself in the fact that the performance of complex movements is impaired, including the performance of a series of simple actions, although the patient can perform each of them individually correctly. The ability to imitate is also preserved (the patient can repeat the doctor’s actions). At the same time, the subject is not able to draw up a plan of sequential steps necessary to perform a complex action, and is not able to control its implementation. The greatest difficulty is in simulating actions with missing objects. So, for example, the patient finds it difficult to show how to stir sugar in a glass of tea, how to use a hammer, comb, etc., while he performs all these automatic actions with real objects correctly. Starting to perform an action, the patient switches to random operations, getting stuck on fragments of the started activity. Echopraxia, perseveration and stereotypy are characteristic. Patients are also characterized by excessive impulsiveness of reactions. Regulatory apraxia occurs when the prefrontal cortex of the frontal lobe of the dominant hemisphere is damaged. To identify it, patients are asked to take a match out of a matchbox, light it, then put it out and put it back in the box; open the tube of toothpaste, squeeze a column of paste onto the toothbrush, screw the cap on the tube of paste.

Gnosis

Agnosia is a disorder of recognition of objects (objects, faces) while maintaining the elementary forms of sensitivity, vision, and hearing. There are several types of agnosia - visual, auditory, olfactory, etc. (depending on within which analyzer the violation occurred). In clinical practice, optical-spatial agnosia and autotopagnosia are most often observed.

• Optical-spatial agnosia is an impairment in the ability to perceive spatial cues environment and images of objects (“further-closer”, “more-less”, “left-right”, “top-bottom”) and the ability to navigate in external three-dimensional space. Develops with damage to the superior parietal or parieto-occipital parts of both hemispheres or the right hemisphere of the brain. To identify this form of agnosia, the patient is asked to draw a map of the country (approximately). If he cannot do this, they draw a map on their own and ask him to mark on it the location of five large, poorly known cities. You can also ask the patient to describe the route from home to hospital. The phenomenon of ignoring one half of space is considered a manifestation of optical-spatial agnosia (one-sided visual-spatial agnosia, one-sided spatial neglect, hemi-spatial neglect, hemi-spatial sensory inattention). This syndrome manifests itself in difficulty perceiving (ignoring) information coming from one hemisphere of the surrounding space, in the absence of a primary sensory or motor deficit in the patient, including hemianopia. For example, the patient eats only the food that is on the right side of the plate. The phenomenon of neglect is associated mainly with damage to the parietal lobe, although it is also possible with temporal, frontal and subcortical localization of the pathological process. The most common phenomenon is ignoring the left half of space when the right hemisphere of the brain is damaged. To identify neglect syndrome, the following tests are used (it must be emphasized that they are applicable only if the patient does not have hemianopsia).
  • The patient is given a lined notebook sheet and asked to divide each line in half. With ignoring syndrome, a right-handed person will place marks not in the middle of the lines, but at a distance of three quarters from its left edge (that is, he divides only the right half of the lines in half, ignoring the left).
  • The patient is asked to read a paragraph from a book. If ignored, he can only read the text located on the right half of the page.
• Autotopagnosia (asomatagnosia, body diagram agnosia) is a violation of recognition of parts of one’s body and their location in relation to each other. Its variants are considered to be finger agnosia and impaired recognition of the right and left halves of the body. The patient forgets to put clothes on the left limbs and wash the left side of the body. The syndrome most often develops when the superior parietal and parieto-occipital regions of one (usually the right) or both hemispheres are affected. To identify autotopagnosia, the patient is asked to show the thumb of the right hand, the index finger of the left hand, touch the left ear with the right index finger, and touch the right eyebrow with the index finger of the left hand.

Relevance. Cognitive functions (CF) are the most complex (higher) functions of the brain, with the help of which the process of rational cognition of the world and interaction with it is carried out. Being the most complexly organized, CFs are at the same time very vulnerable to various pathological conditions. CF disturbances are observed both in primary organic brain damage (for example, neurodegeneration processes in Parkinson's disease) and in encephalopathy secondary to various somatic or endocrine diseases (for example, Hashimoto's encephalopathy). Therefore, CF disorders are an interdisciplinary problem that is regularly encountered not only by neurologists and psychiatrists, but also by therapists, endocrinologists, cardiologists and doctors of other specialties.

At the same time, an analysis of the patient’s CF status is necessary both to establish a diagnosis (including to establish the stage of the disease, for example, in chronic cerebral ischemia) and to clarify the characteristics of the disease, and to develop optimal tactics for managing the patient (therapeutic and medical-social). It should also be remembered that in the absence of timely prescribed therapy, acute CI may eventually develop into chronic form- dementia and become a heavy burden for the patient’s relatives ([ !!! ] an individually developed management plan for patients with CI allows in many cases to reduce the severity of existing disorders and prevent or delay the onset of dementia).

note! Impaired CF (or cognitive impairment [CI]) can occur at any age but is most common in older adults. In this regard, brief screening for CI is necessary in [all] patients (especially those hospitalized) in the older age group. At the outpatient (polyclinic) level, the basis for analyzing the patient’s CF status is complaints about decreased memory or decreased mental performance, which (complaints) can come both from the patient himself and from his relatives, friends, colleagues (information from this circle of people is important a diagnostic sign, since the patient’s assessment of the state of his CFs is not always objective).

KN research, as a rule, is carried out in two stages. [ 1 ] At the first stage, the attending physician, regardless of specialty, conducts a brief screening (from the English “screening” is a concept that includes a number of measures to identify and prevent diseases), the purpose of which is to identify patients who are likely to have CI. [ 2 ] At the second stage [CN research], a [detailed] neuropsychological study is carried out, for which a neuropsychologist is usually involved - he evaluates various cognitive functions and makes a conclusion about the degree and qualitative features of the identified disorders, as well as their impact on the patient’s daily life. These findings allow a diagnosis of dementia or mild CI (MCI) to be made.

One of the most widely used tests for assessing cognitive function is the Mini-Mental State Examination, which consists of 9 tasks, 30 questions. The test is conventionally divided into 2 parts: the first evaluates orientation, attention, perception and memory, the second - speech. The maximum score for the test is 30 points, the borderline value, according to various authors, is 24 - 25 points. The disadvantages of the MMSE include the fact that it does not include an assessment of executive functions, it takes on average about 8 minutes, among the tasks there are those that require drawing, which is problematic with visual impairments and muscle weakness; it is of little use in diagnosing MCI (a more sensitive tool for diagnosing MCI is the Montreal Cognitive Rating Scale - [instructions]). There are reports that very low scores on the MMSE (less than 10 points out of a possible 30) in patients who did not suffer from overt dementia before hospitalization indicate the development of acute CI as part of delirium.

read also the post: Delirium in somatic medicine(to the website)

note! In acute CI, it is usually sufficient to use brief scales, such as the method for assessing confusion in intensive care units (), together with data from anamnesis, objective and laboratory-instrumental studies.

As stated, the use of MMSE (and MoCA) requires a relatively long time (8 - 10 minutes), which is not always possible in outpatient practice. In this regard, it is important for the doctor to know shorter scales for assessing CI, the use of which takes 2 to 3 minutes (including those that can be used in a hospital at the patient’s bedside, without interrupting the usual round).

To identify gross (pronounced) cognitive impairment (i.e., dementia) in general somatic practice, the optimal screening tool is the Mini-Cog(Mini-Cog), proposed by S. Borson et al. (2000) and included simple memory tasks and a clock drawing test.

There is also the following option for interpreting test results: [ 1 ] if the patient remembered all three words, then there are no gross cognitive impairments, if he did not remember a single one, that is; [ 2 ] if the patient remembers two or one word, then at the next stage the drawing of the clock is analyzed; [ 3 ] if the drawing is correct, then there are no gross cognitive impairments; if it is incorrect, that is (only the position of the numbers and arrows is assessed, but not the length of the arrows).

The main advantage of the Mini-Cog technique is its high information content while being simple and fast, which is very important for non-specialized specialists. The sensitivity of the test is 99%, specificity is 93%. The test takes about 3 minutes for the patient to complete, and the interpretation of the results is extremely simple - the test results are assessed qualitatively, in other words [ + ] the patient has impairments or [ - ] No. The technique does not provide a score, nor does it provide a gradation of cognitive impairment by severity, which is not the task of endocrinologists and general practitioners. The Mini-Cog technique can be used to diagnose both vascular and primary degenerative cognitive disorders, as it includes tests of memory and “frontal” functions (clock drawing test). The test can be used quite easily in persons with speech impairments or language barriers. The main disadvantage of this technique is its low sensitivity for mild and moderate cognitive impairment. To diagnose them, more sophisticated tools should be used, such as the MMSE or MoCA scale.

You can read about all the brief methods for screening for CI that can be used by a therapist in everyday practice in the article “Identification of cognitive deficits in a therapist’s practice: a review of screening scales” by M.A. Kutlubaev, Republican Clinical Hospital named after. G.G. Kuvatova", Ufa (magazine "Therapeutic Archives" No. 11, 2014) [read]

Read also:

article “Diagnostics of cognitive dysfunction in patients in intensive care units” by A.A. Ivkin, E.V. Grigoriev, D.L. SHUKEVICH; Federal State Budgetary Institution "Research Institute of the Communist Party of the Soviet Union", Kemerovo; FSBEI HE "KemSMU", Kemerovo (magazine "Bulletin of Anesthesiology and Reanimatology" No. 3, 2018) [read];

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