Descriptive Psychopathology: The Signs and Symptoms of ...

313 Chapter 13: Testing and psychopathology of cognitive dysfunctionThe consultant suggested the group move to a larger room and asked thepatient if he knew the room with “the piano” and could he lead the group to it.The inpatient unit was shaped like an H, with the patient’s room at the bottomof the lower left section and the piano room in the top of the upper rightsection. With a perfectly normal, smooth gait the patient led the team out ofhis room. He immediately turned to his left, walked to the transept, turnedright, crossed to the other hallway, turned left and walked to the piano roomwhere he pointed to the piano. As the team was getting settled to observe theconsultant’s “bedside” cognitive testing, he turned to the patient’s geriatricpsychiatrist and whispered, “Well, I’ve just completed most of my evaluation.The patient does not have Alzheimer’s disease.” Further assessment wasconsistent with the clinical interpretation and indicated the patient hadmodest impairment on tasks associated with frontal lobe disease. Functionalimaging confirmed mild primary frontal lobe atrophy without evidence ofvascular disease.Patient 13.2 had been in slow decline for six years. Although there is an earlyonsetform of Alzheimer’s disease it is virulent, associated with a strong familyhistory for the illness, and about 30% of sufferers will have associated increasedmuscle tone or rigidity. Alzheimer’s disease typically begins with problems invisual–spatial functioning and new learning. Patient 13.2’s facial recognition ofhis physicians, learning the unit’s floor plan and being able to easily negotiate itsconfiguration, remembering where the piano was, and being able to lead the teamto the correct room with a smooth gait, eliminated Alzheimer’s disease fromserious consideration. 12 Accomplishing all that while still maintaining socialgraces further indicated that Patient 13.2’s cognitive decline associated with hisapathetic syndrome was likely to be modest. Functional imaging, other historyand examination findings also demonstrated that the apathy was not due tovascular disease or depressive illness.Many behaviors signal specific cognitive difficulties and their presence shapethe choice of standardized tasks. Table 13.1 displays the more common ofsignature behaviors. Along with the assessment for patterns of abnormal motorfeatures, bedside cognitive testing helps identify the circumscribed brain lesionsthat may underlie the behavioral syndrome.Principles of bedside cognitive assessmentReasons for assessmentTable 13.2 displays reasons for cognitive assessment. Relying on screening batteriessuch as The Mini Mental State Examination (MMSE) is of modest utility only