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CHAPTER 26 Last modified: July 1, 2006
HIGHER CORTICAL FUNCTIONS
Introduction
In psychiatry and neurology, the term cognition is synonymous with higher cortical
functions (HCF). In psychology the term cognition has been used to mean thinking
and process of knowing, and incorporates some of the topics covered in earlier
chapters.
The HCFs are: 1) memory, 2) orientation, 3) concentration, 4) language, 5)
recognition of stimuli (examined by tests for agnosia), and 6) performance of learned
skilled movements (examined by tests for apraxia).
Only the first four (memory, orientation, concentration, language) are components of
the regular psychiatric assessment. Language is a component in so far as we focus
particular attention on the form of thought. It is also a focus of attention in the Mini
Mental State Examination (MMSE; Folstein et al, 1975, see Chapter 20), the most
widely used screening test for cognition/HCF. Some additional aspects of language
are listed toward the end of this chapter for reference purposes.
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Recognition of stimuli (agnosia) and performance of skilled movements (apraxia) are
not components of the regular psychiatric assessment, but form a part of the fuller
examination (along with the other 4) used when indicated, and believed to be specific
to the “organic” disorders.
The term organic disorder is problematic. It was coined at a time when investigative
technologies were crude compared to those of the early 21st century. At the time it
was assumed that if no organic basis could be demonstrated (with the technology of
the day), none existed. Those conditions for which no physical explanation could be
found were termed “functional”, which implied that organs were healthy, but not
functioning properly.
With technological advances, the boundaries of “organic” should be moved.
Schizophrenia, for example, was considered to be a functional disorder, but imaging
and genetic studies have recently demonstrated a physical basis. The same applies to
many other psychiatric disorders.
The term organic, therefore, says as much about the technology of the day as it does
about pathology. It can be argued that psychiatry is generally concerned with
pathology at a molecular level (e.g., neurotransmitters) and other branches of
medicine are concerned with supra-molecular pathology (e.g., abnormal cells, as in
tumour), but not without debate.
Putting confusing terminology aside: HCF testing is a valuable means of detecting
conditions which may present as psychiatric disorders but which require the services
of other branches of medicine. For example, patients may present with a picture
suggestive of schizophrenia or depression which is secondary to space occupying
lesions, toxic, endocrine or metabolic abnormalities, conditions in which HCF testing
frequently reveal abnormal result.
In general, if memory, orientation, concentration and language are intact, recognition
and performance of learned skilled movements will also be intact. Thus, the former
may be regarded as a screening test, such that if the former are intact, the latter need
not be tested.
MMSE deserves special mention. This is a standardised, widely accepted screening
test of HCF. It examines orientation in some detail and then briefly touches on
registration and recall, attention/concentration, language and constructional abilities.
Brevity is its strength (allowing a wide breadth examination) and its weakness (not
allowing in depth examination). This is a screening test which may indicate a need for
more extensive testing.
Memory
Memory is the ability to revive past thoughts and sensory experiences. It includes
three basic mental processes: registration (the ability to perceive, recognise, and
establish information in the central nervous system) retention (the ability to retain
registered information) and recall (the ability to retrieve stored information at will).
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Short-term memory (which for this discussion includes what has been called
immediate memory by others) has been defined as the reproduction, recognition or
recall of perceived material within a period of up to 30 seconds after presentation.
Long term memory can be split into recent memory (events occurring during the past
few hours or days), recent past memory (events occurring during the past few months
and remote (events occurring in past years).
Memory can be influenced by many factors. In addition to physical lesions,
intoxication, emotional arousal, psychomotor retardation, thought disorder and
motivation must be considered.
Tests of memory
During the psychiatric interview some information about memory will be available
from the history and initial conversation with the patient. Memory tests are required
for quantitative assessment. Three levels of memory are specifically tested.
There should be concern for the patient’s comfort and dignity, but there should not be
indecision or inappropriate apology. After some general conversation, the examiner
may say something like, “Thank you Mr X, I understand what you have been saying. I
now need to test your memory.” Then proceed directly to, “I am going to give you
three things which I want you to remember.......” or similar words, according to the
test the examiner wishes to apply.
When a patient who has been treated respectfully refuses cognitive testing, there is
probably cognitive impairment.
History and conversation
The patient should be able to give a clear account of his/her life from the remote to
the recent past.
The presenting complaint is important. Where memory function is the primary
problem the patient may not be able to remember why he/she is present. The patient
should be able to give details of who made the arrangements for the interview, how
the patient was conveyed from home or work, at what time did the patient depart
home or work, at what time did he/she arrive and how long the journey took. Thus,
the history gives the opportunity for a real life test of the recent memory.
Assessment of the remote memory may prove difficult as the examiner does not have
confirmed facts. The internal consistency of the personal history gives important
information, that is, matching the dates, ages and events when the patient is describing
his/her past life. The names and current ages of children and siblings are often useful.
Short-term (immediate) memory test
The most common test is to ask the patient to repeat sequences of digits. Three digits
are given first and the patient is asked to repeat them. If this is performed
successfully, four digits are given and so on, until the patient makes mistakes. A
normal person of average intelligence is usually able to repeat seven digits correctly.
Strictly speaking, this is not memory, as this information is kept in mind and does not
have to be retrieved. This test is often omitted.
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Recent memory test
A common testing method is to ask the patient to learn three or four unrelated words.
The patient is advised that he/she will be given some words to remember, and that
later in the interview he/she will be asked to recall them. The words are said (e.g., car,
tree, sock, bucket) at the rate of about one second per second. The patient is asked to
repeat each word after they are said, to ensure that they have been registered properly.
The interview then proceeds so that the patient is distracted. Some minutes later the
patient is asked to recall the words. If any words cannot be recalled, the test can be re-
administered using a different set of words.
Remote memory test
The examiner usually does not have extensive knowledge of the patient’s early life
against which to check his/her answers. Individual differences in intelligence and
education make it difficult to know what questions on past world events it reasonable
to ask.
The date of birth is often available to the examiner. However, this is very highly
learned material, it is among the last pieces of information to be lost and its retention
does not exclude moderately advanced memory problems.
The names and dates of birth of the patient’s children may also be available, as might
the patient’s wife’s (in the case of a married male) and mother’s maiden names.
It is reasonable to ask the capital cities of Australia, England and USA, and perhaps
the dates of the first and second world wars - taking care to take account of
intelligence and education.
It is reasonable to ask the name of the current Prime Minister or President. Often
patients with memory problems give the name of a Prime Minister or President from
the past – in this case, in clinical experience, the more remote in time the eminent
person, the greater the memory problems.
Loss of memory/Amnesia - clinical pictures
Loss of memory of physical origin
Dementia
Dementia (see Chapter 20) is a global deterioration in intellectual functioning, a
central feature of which is memory problems. It is usually of gradual onset, although
it may follow sudden events such as head injury. In general, the more recently stored
the more rapidly lost; those stored long ago are lost last. However, this is a relative
matter and the remote memory of patients with dementia is usually significantly
impaired compared to that of non-demented persons or comparable age. There is also
impairment in abstract thinking, judgement, other cortical functions and personality
change.
Amnestic disorder (Korsakoff’s psychosis/syndrome)
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Korsakoff’s amnestic disorder is characterised by the inability to learn new
information, while HCFs are retained. Lack of motivation and flat affect are common.
Patients frequently lack insight or deny difficulties. Confabulation (untrue experiences
which the patient believes) may occur in the early stages but usually disappears with
time. The patient is severely disabled, being incapable of independent living.
The most common cause of amnestic disorder is thiamine deficiency secondary to
alcohol use - in which case onset may be gradual, or more apparently rapid if it arises
in a setting of acute Wernicke's encephalopathy. Head injury, cerebral neoplasm,
carbon monoxide poisoning and herpes simplex encephalitis are other causes.
Loss of memory of psychological basis
Psychogenic amnesia
In psychogenic amnesia the predominant disturbance is an episode of sudden inability
to recall important personal information, which is not due to an organic mental
disorder. (The usual presentation is in contrast to Korsakoff’s amnesia where the
difficulty is in learning new information). Onset is sudden and there is usually some
precipitating emotional trauma. The psychogenic amnesias are reversible.
The clinical presentation is compounded by the combination of unconscious
forgetting and active avoidance of painful material. The memories lost and the
understanding of the patient of their condition usually varies with time and
circumstances. Malingering must be excluded.
Orientation
In the psychiatric examination, orientation means awareness of one's relationships and
surroundings in time, place and person. Insofar as disorientated people are frequently
given orienting information by other individuals, but remain disorientated, the
condition has a memory component. Other important components may include
attentional difficulties, apraxia and agnosia.
Orientation in time
Orientation in time is the first dimension to be lost and the last to return. The patient is
asked to give the year, month, day of the week and date. As with memory, it is the
recent, more precise information which is lost first.
Even more fine-grained information is the time of day. Clinical experience is that
disorientated patients often give answers which are inconsistent with the evidence.
They may contend it is evening even when the sun is blazing through the window, and
may not change their contention when these inconsistencies are pointed out. When
trying to help the patient with the time of day the examiner may ask which meals of
the day the patient has eaten. This is a test of memory, but can be used this way - the
disorientated patient may claim that it is late afternoon - but that breakfast has not yet
been served.
Orientation in place
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The MMSE contains some good questions on this topic. At the “big picture” end, the
questions are about identifying the city and the county. If a patient knows the city,
knowing the county is a matter of memory, rather than orientation.
Going on from other questions the examiner can say something like, “Well, thank you
for answering those questions, Mrs Z. Now, I would like to ask you, can you please
tell me, the name of the city (or building) we are in?”
If the patient is not able to give the name of the building, or gives an incorrect answer
it is important to determine whether they can benefit from the cues around them. If
they answer that they are in their own home, it is reasonable to say something like,
“I'm not sure this is your house. Is this your furniture? There seem to be other people
walking around. Are you sure this is your home?”
If the patient says he/she does not know where he/she is, the same sort of questions as
in the above paragraph should be asked. It is reasonable to say something like, “Mr Y,
we are in a public building. It could be a police station, a railway station, a fire station
or a hospital. Have a look around. Look at the beds and the people walking around. In
which one of those places do you think we are?”
The patient gives the name of the facility/hospital correctly, he/she should then be
asked to name the ward. If this cannot be given, the patient should be asked what type
of cases are treated on this ward. If there are difficulties with this question, ask the
patient to look around, “You are right about this being a ward of the Royal Hospital.
But, what type of ward is this? Have a look around, the patients don’t seem to be in
bed here. Do you think this is a surgical ward where people are recovering from
operations?”
Orientation in person
Orientation in person requires various abilities, including the capacity to recognise
faces (prosopagnosia being agnosia for faces) and memory. Thus, failure in
orientation in person is a general rather than specific indicator of pathology.
Under this heading the examiner assesses the patient’s ability to identify him/herself,
but more importantly, others. A common mistake is to report only that the patient's
ability to give his/her own name.
The patient may then asked to identify the examiner, who will have introduced
him/herself earlier (and may have been known from previous meetings) and to
indicate the type of work the examiner performs. The patient may say that he/she has
a poor head for names. In this case it is better to move to the examiners function, by
saying something like, “Yes, I’m not much good on names myself. But we’ve been
talking about different things for a few minutes, Mr X.....Can you tell me what sort of
work I do?”
When testing orientation in person it is often worth asking the patient to identify by
name and occupation, any available nursing staff who have had dealing with him/her
and to identify any available relatives.
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Attention (Concentration)
The term concentration has traditionally been used in the standard psychiatric
assessment. This is being replaced by the term attention, as this is being used in the
research literature.
Attention is a multifaceted mental function, but in general, it denotes the capacity of
an individual to focus the mind on some aspect of the environment or the contents of
the mind itself (Cutting, 1992).
Tests of attention
Testing of attention can seamlessly follow on from the testing of memory.
History and conversation
Patients often lack insight into their difficulties with attention. However, insight may
be present, especially in psychiatric disorders such as depression, anxiety disorder or
schizophrenia. The experience of poor attention is often unpleasant. Patients are more
familiar with the word concentration. Where the symptom is suspected, it is
reasonable to ask, “Mr X, how is your concentration at the moment. Are you able to
watch a show on TV and concentrate all the way through?” (Alternatively, “Are you
able to concentrate on reading the newspaper?”)
Where there are marked difficulties with attention, this will be obvious during
conversation. The patient will be unable to give a clear account of the reasons for
presentation, will wander off the topic and will be distracted by the external
environment and his/her own thoughts. It may, in the early stages, be difficult to
distinguish from the person with schizophrenia and severe formal thought disorder
from the person with delirium.
Subtraction
A common test is to ask the patient to take seven from one hundred and keep
subtracting seven from the answer. There is no accepted standard for the number of
mistakes and the amount of time allowed. A written record of the performance may be
useful if the ability is re-tested at another time. Even without an agreed standard, it is
often possible to identify impaired ability. The patient may not even get the first
subtraction correct. Quite often an impaired patient will subtract a number of times
(usually with mistakes), then make some additions.
If the patient has had little numerical education, it may be appropriate to give an
easier task. Subtracting three from twenty down to zero is easier. Subtracting two
from twenty is easier again. It is important only that the task taxes the patient so that
his/her ability to attend and to sustain attention can be evaluated.
Reversing components
Reversing a series of numbers is a commonly suggested test. The examiner reads the
numbers to the patient slowly and clearly. Again, it is not clear what constitutes a
normal and a pathological performance.
Reversing the letters of a “world” is stated to be an alternative to the 100 minus 7 test
in the MMSE. However, in this test the patient should be comfortable with the
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forward arrangement of the letters, so the examiner should first say the word, and
have the patient spell the word forwards before attempting to reverse the letters.
Reversing the months of the year is another recommended test. A problem with this is
test is that some students learn this task by rote at school while others do not - for
those without rote learning, reversing the months of the year is quite a difficult
exercise. An easier task is to reverse the days of the week. This may too easy - it can
be made more taxing by asking the patient to reverse the days of the week for a
fortnight.
Other HCFs
Medical students and trainee psychiatrists should be competent in the above. The
material from this point on, however, is more esoteric and forms part of a more
comprehensive assessment. Various experts may be involved in such an assessment:
psychiatrist, neuropsychiatrist, neurologist, behavioural neurologist,
neuropsychologist and speech pathologist. The following is included for reference
purposes.
Language
As mentioned above, language is assessed in the standard psychiatric assessment
through attention to the form of thought, and is a significant component of the
MMSE. Thus, language could be place in the group above, but the aspects of
language mentioned below are not part of the standard psychiatric assessment.
Aphasia
Aphasia is defined as the loss or impairment of language caused by brain damage
(Benson, 1992). The specific mention of the presence of brain damage prohibits the
use of this term in the so-called functional disorders. Another definition is interesting:
a disorder of the symbolic functions of speech. This would make aphasia
indistinguishable from the formal thought disorder of schizophrenia – this is a path
which is best avoided.
Broca's aphasia
In Broca's aphasia the output is sparse, effortful, dysarthric, dysprosodic, short-
phrased and agrammatic. There is disturbance in repetition and naming.
Comprehension is relatively preserved. The patient may be aware of and frustrated by
his/her expressive difficulties. This form is associated with dominant frontal
opercular involvement.
Wernicke's aphasia
In Wernicke's aphasia there is fluent verbal output with normal word count and phrase
length and no effort or articulatory problems, but there is difficulty in word finding
and frequent paraphasia (unintentional syllables, words or phrases during speech).
The patient may be unaware of his/her difficulties and frustrated by the failure of
others to respond appropriately. This form is associated with lesions of the posterior
superior temporal lobe of the dominant hemisphere.
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Nominal aphasia
In anomic aphasia the primary problem is with word finding. There are frequent
pauses and a stumbling output. There may be reading and writing disturbance. Output
may be fluent and comprehension good, but with naming significantly disturbed. This
is often the residuum when other aphasias have largely resolved.
Other forms of aphasia
Additional forms include conductional aphasia and transcortical aphasia.
Examining aphasia
Observations are made during introductory conversation and history gathering. If
indicated, the following may be tested.
Dysarthria
Dysarthria (speech disorder due to organic disorders of the speech organs or nervous
system) is a mechanical problem. It is not a form of aphasia, but as it frequently co-
exists with aphasia, it is convenient to include it here. Dysarthria may coexist Broca's
aphasia, or alone, as in cerebellar damage or bulbar palsy.
The patient is asked to produce the vowel ah steadily for as long as possible, and to
produce a sting of consonants (puh-puh-puh.....). “Tongue twisters” may also be used.
Any tongue twister will do, a traditional favourite of neurologists is, “Around the
rugged rocks, the ragged rascals ran”.
Comprehension
When testing comprehension, the examiner stays alert to the possibility that apraxia
and agnosia may be complicating factors. The patient may be asked to, “Close your
eyes” and be given some information such as a short story and asked to repeat it in
his/her own words. Comprehension should be tested both verbally and in written
language (mentioned again later).
Repetition
The patient is asked to repeat verbatim, short passages of normal speech.
Naming
The patient is asked to name objects on the examiner’s person or around the room,
such as, watch, tie, pencil pillow and chair.
Writing ability
The patient is given equipment and asked to write a sentence (as in the MMSE).
Educational background is taken into account.
Reading ability
The patient is asked to read a passage aloud.
Diagnostic implications of aphasia
Aphasia is rarely difficult to distinguish from schizophrenic thought disorder.
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Aphasia, by definition, a symptom of organic disorder, is commonly found with
vascular and space occupying lesions.
Other language disorders
The following are rare. They are included here for the sake of completeness and
because of they illustrate the difficulties of the functional/organic distinction.
Amelodia (aprosodia)
Amelodia is characterised by flat, monotonous verbal output, decreased facial
movement, and reduced use of gesture (Benson, 1992). It can be tested by having the
patient hum a familiar tune such as Happy Birthday, a nursery rhyme, or the national
anthem.
It has been described as the result of pathology of the right frontal opercular area.
Depressive disorder and schizophrenia manifest similar symptoms.
Verbal dysdecorum
Verbal dysdecorum is not, in fact, a problem of the symbolic use of language, but a
loss of control of the contents of verbal output. The patient speaks too freely,
discusses improper topics, argues and is 'otherwise disagreeable' (Benson, 1992).
There may or may not be physical impropriety.
Verbal dysdecorum is associated with pathology of the right frontal lobe. Hypomania
has similar symptoms and would need to be considered.
Skilled movement (and apraxia)
Apraxia is a disorder of learned skilled movements not attributable to elementary
sensory or motor dysfunction. Four types are described and will be briefly mentioned.
Dressing apraxia
Dressing apraxia is difficulty in orienting articles of clothing with reference to the
body. The obvious test is to ask the patient to put on an article of clothing.
It is seen in dementia and right parietal lobe lesions, and is common in confusional
states.
Constructional apraxia
Unsurprisingly, constructional apraxia denotes difficulties with “constructions”. In the
testing situation the patient is asked to copy a drawing on paper or an arrangement of
blocks or other physical objects.
It is seen in posterior lesions of left or right, or diffuse brain damage.
Ideomotor apraxia
Ideomotor apraxia is the inability to perform single actions. Such actions may be
performed automatically, as with shaking hands on meeting friends. Thus, the
inability may only be revealed if the patient is asked to demonstrate actions or to
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imitate the actions of the examiner. In the testing situation the patient may be asked to
“wave good-bye”, “blow a kiss” or “show how to use a toothbrush”.
Ideomotor apraxia may result from disconnection of the language area from the motor
area – the idea cannot be sent to the appropriate area.
Ideational apraxia
Ideational apraxia is the inability to perform a series of actions because of difficulty
with sequencing the movements. The “idea” of the actions is disrupted. In the MMSE
the patient is asked to take a piece of paper in the right hand, fold it in half and place
it on the floor.
Ideational apraxia is commonly a feature of confusional states or severe dementia,
however, it may accompany focal callosal, left parietal and biparietal lesions.
Recognition of stimuli (and agnosia)
Agnosia is the inability to recognise stimuli, which is not attributable to impaired
sensory processing, intellectual functioning, or naming ability (Rosen, 1991). It is
most frequently specific to one modality.
Visual object agnosia
Visual object agnosia is the inability to recognise a familiar object which can be seen.
In the test situation the patient is asked to identify objects which make no noise, such
as a pen, a coin or a dressing.
It is seen in left occipital lobe lesions.
Agnosia for faces (prosopagnosia)
Prosopagnosia is the inability to recognise faces of people well known or newly
introduced to the patient.
It is most frequently the result of bilateral lesions of the mesial cortex of occipital and
temporal lobes.
Tactile agnosia
Tactile agnosia is the inability to recognise objects by touch. In the test situation the
patient is asked to identify by touch, items such as a key, a coin, or a pen.
It results from unilateral or bilateral lesions of the postcentral gyrus.
Auditory agnosia
Auditory agnosia is the inability to recognise non-verbal acoustic stimuli. In the test
situation the patient may be asked to identify the sound of keys jangling, water
running from a tap, or the clapping of hands.
It is associated with unilateral or bilateral temporal lesions.
Spatial agnosia
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Spatial agnosias include disorders of spatial perception and loss of topographical
memory (Rosen, 1991). Some include spatial agnosia and constructional apraxia
under “visuospatial function” (Ovsiew, 1992). In testing the patient may be asked to
locate significant geographical locations on an unmarked map and orient him/herself
in space using the available cues.
It is associated with bilateral cortical lesions.
Corporal agnosia and anosognosia
Corporal agnosia is the inability to recognise parts of the body (one form of which is
finger agnosia) or that a part of the body is affected by disease (anosognosia).
Agnosia limited to finger identification may be found in left parietal lesions (in right
handed people), while anosognosia is associated with right parietal lesions.
References
Benton A. Neuropsychiatric aspects of aphasia and related language impairments. In
The American Psychiatric Press Textbook of Neuropsychiatry, Eds S Yudovsky, R
Hales. Washington: American Psychiatric Press. 1992. pp. 311-328.
Cutting J. Neuropsychiatry aspects of attention and consciousness: stupor and coma.
In, The American Psychiatric Press Textbook of Neuropsychiatry, Eds S Yudovsky, R
Hales. Washington: American Psychiatric Press. 1992. pp. 227-290.
Folstein M, Folstein S, McHugh P. Mini-mental state: a practical method for grading
the cognitive state of patients for the clinician. Journal of Psychiatric Research 1975;
12:189-198.
Ovsiew F. Bedside neuropsychiatry: eliciting the clinical phenomena in
Neuropsychiatric illness. In, The American Psychiatric Press Textbook of
Neuropsychiatry, Eds S Yudovsky, R Hales. Washington: American Psychiatric
Press. 1992. pp. 89-126.
Rosen W. Higher cortical processes. In, Foundations of psychiatry, Eds, K Davis, H
Klar, J Coyle. Philadelphia: W B Saunders, pp. 199-207.
