Sunday, September 5, 2010

Bedside testing of frontal lobes

Kramer JH, Quitania L in Miller BL, Cummings JL.  The Human Frontal Lobes functions and disorders.

Published tests:
EXIT-  Executive Interview

bedside tests
fluency -- give F, A, S test and in alternate form give D only. Measure not only number of words produced, but also rule violations (giving responses with a different letter, and proper nouns) and repetitions.  Subjects who do worse on category fluency have more likelihood of temporal involvement, and those with letter fluency only are more likely to have frontal involvement.  Nonverbal analogue to letter fluency is design fluency. Show a box with five dots and ask them to create in one minute that have four lines that connect the dots. Several variations are used, one is d-kefs.

Mental flexibility-- on Trails B, Stuss et al. enhance the test by counting errors on Part B, which correlates best with DLPFC right sided injury. On DKEFS Trails, subjects alternate with letters and numbers.  Older patients maybe asked to shift between numbers and days of the week, with a record of time to complete task and how many sequencing errors are made.  Patients who cannot read may get Color Trails instead, connecting colored circles alternating between pink and yellow circles.  Alternate form of Trails:  Patients get one minute to create, from an array of dots (alternating half filled dots, half unfilled), as many designs as possible with four straight lines connecting dots.  In first form, they are asked only to use unfilled dots, in the second, to alternate between filled and unfilled dots. Design and rule violations (ie failure to shift) are recorded.

Abstract reasoning:    a) similarities between word pairs (dog/lion, table/chair. anger / joy)   and b) proverbs- eg. " An old ox plows a straight row" and "Shallow brooks are noise" and " A beard well lathered is half shaved."  Give credit for abstract and accurate answers.

Response inhibition:  a) Stroop-- tabulate correct responses in 60 seconds, and the number of inhibition errors.  b)  Salient responses :  Tell patient to to point to his chin while examiner touches nose, or tell patient to point to the ceiling while extending his hand   c) Opposite-- when I tap once, you tap twice, and vice versa.

Working memory-- backwards digit span, spelling "world" backwards, serial sevens, saying days of week backwards, months in reverse order.

primitive reflexes-- snout, suck and grasp and glabellar

Complex motor programs
1) fist palm edge task-- perform 10 times, record the number of trials to learn the task, the number of perseverations, and the fluency of the movements.
2)  Graphomotor sequences-- alternate m and n (cursive) elicit perseveration, micrographia.
3)  Rhythm test-- ask patient to imitate finger taps in complex patterns.

Behavior-- observe and record, use a modified Manchester Behavior Questionnaire to survery based on both information and report.  NPI and NPI-Q (short version) can be used (link to certification test: use the Dysexecutive Questionnaire (DEX), Frontal Behavior Inventory (FBI) , and Frontal Systems Behavior Scale (FrSBE)

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