Higher Centres and Speech

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1. Note the stem (important to commit to memory)
   1. ​"assess this patient for the presence of dementia or cognitive impairment"
   2. perform higher function testing in this patient
2. Greet patient, noting any obvious weakness
3. Ask patient if they are right or left handed to establish dominant lobe
4. General inspection
5. Test orientation
   1. Patients name (person)
   2. Place of examination (place)
   3. Time
6. Speech
   1. Get the patient to describe the scene in the picture printout
      1. determine whether it is a fluent or non fluent aphasia
         1. in non fluent aphasia the patient's speech takes considerable effort and may be slurred, with short sentences that lack words such as 'and', 'so', 'the'. There is often an absence of grammatical structure
         2. in fluent aphasia the words flow freely, but what is said is difficult to understand and words are used incorrectly
            1. paraphasias where wrong words are used
            2. neologisms, where a word is substituted with a non existant word
      2. test repetition "no ifs, ands or buts"
      3. assess comprehension for signs of receptive aphasia
         1. one step commands - touch your nose, close your eyes
         2. two step commands - point to the ceiling after you have pointed to the floor
            1. note that many patients with aphasia can follow one step commands but not two step commands
   2. Nominal aphasia by naming objects
      1. patient may use long sentences to overcome this - circumlocution
   3. Assess for dysarthria (causes include spasticity - pseudobulbar palsy, motor neuron disease; lower motor neuron weakness - eg NMD, progressive bulbar palsy, GBS; cerebellar disorders)
      1. words are slurred but language content is OK
      2. ask them to repeat words that are difficult to say
         1. red lorry yellow lorry
         2. British constitution
         3. west register street
         4. Irish constabulary 
      3. repetition of sounds
         1. lips 'puh'
         2. tongue 'tuh'
         3. palate 'kuh 
7. Temporal lobe
   1. Memory - check recall 
   2. test visual fields (temporal lobe defect causes an upper quadrantic hemianopia)
   3. receptive dysphasia if dominant lobe
8. Pariental lobe
   1. Dominant hemisphere
      1. acalculia
         1. serial 7's, or more simple calculations such as 5 + 7, 2 + 6
      2. agraphia
         1. inability to write a sentence
      3. left-right disorientation
      4. finger agnosia
         1. asking patient to name the fingers
   2. non dominant - testing cortical sensation (not really localising)
      1. graphaesthesia
      2. tactile extinction
      3. astereognosis - inability to recognise objects when placed in hand
      4. constructional apraxia - asking patient to draw a 2D representation of a house
      5. spatial neglect - draw a clock face and look for crowding
9. Frontal lobe function
   1. Assess primitive reflexes
      1. presence of multiple primitive reflexes are associated with diffuse disease
      2. grasp reflex
      3. palmomental reflex - stroke thenar eminence firmly with a key or thumb nail - contraction of mentalis with protrusion and lifting of lower lip
      4. pout and snout reflex
   2. interpretation of a proverb "a rolling stone gather's no moss​

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