Cognitive neuropsychology/neurology in theory – functional neuroanatomy

1. Cognitive neuropsychology/neurology in theory – functional neuroanatomy MRCPsych Phase II Older Persons Mental Health (OPMHS) Module 16th June, 2011 Dr Rupert Noad Department of Neuropsychology, Derriford Hospital, Plymouth rupert.noad@nhs.net

2. Plan for the day 10.00 – 11-00 Functional Neuroanatomy 11.00 -11.15 Break 11.15 - 12.30 Cognitive Neuropsychology/Neurology – a clinical approach 12.30 – 1.00 : Lunch 1.00 – 16.00: Practical Session

3. Aims and objectives • Introduction to Neuropsychology • Functional Neuroanatomy • Cognitive disorders • Bedside cognitive assessment • Assessment of dementia

4. What is Neuropsychology? • Neuropsychology is concerned with the relationship between brain and behaviour – i.e. how brain functions are organised • Attempts to understand how mechanisms within the brain influence thinking, learning and emotions • Neuropsychologists are particularly interested in how brain damage changes behaviour • This tells us about normal brain functioning e.g. WWI – lots of focal injuries

5. Neuropsychologists….. • Aim to apply principles of brain-behaviour relationships to help patients understand their difficulties • Specialist neuropsychological assessments are used to test patients’ cognition and examine different brain functions • Neuropsychology knowledge is used as part of a psychological formulation of a patient’s difficulties

6. Clinical Psychology/Psychiatry understand models of… • Learning • Cognition • Development • Social • Psychodynamics • Scientific paradigms and language Neuropsychology adds • Biology • Medicine

7. Neuropsychologists work in…. • Acute neurosciences – neurology, neurosurgery • Neuro-rehabilitation – post-acute or community • Older Adults • Learning disability services • Adult Mental Health • Child services • Forensic and Health You do not need to be a ‘neuropsychologist’ to do neuropsychological assessment You do not have to do neuropsychological assessment to think ‘neuropsychologically’

8. The aim is to… • Have a good understanding of the way brain damage may impact on someone’s cognition • Have a good understanding of the way cognitive problems may affects someone's everyday functioning • What the psychological consequences of a disease may be and how they may manifest • What other explanations could be causing the cognitive symptoms being reported – in particular psychological difficulties

9. Where might ‘brain variables’ inform your psychiatric/psychological formulation? Child - Why is this child under achieving at school? Adult – Differential diagnosis where neurological condition is suspected e.g. early onset psychosis versus epilepsy? Older adult - Differential diagnosis e.g. dementia versus depression? LD - What is this person’s level of understanding Other health, forensic, Neurorehab

10. Key ideas • Patient presents with a symptom • You as a neuropsychologist are tasked with the idea of establishing what is going on • You want to assess their cognition: • Clinical Questions you ask • Tests of their cognition – either bedside or formal neuropsychological assessment • You do a psychological/psychiatric assessment • You put it all together in a formulation • You discuss this with the patient and base your treatment plan on this

11. So you need to be able to? • Understand their symptoms? • Understand their illness? • Understand the likely psychiatric consequences of their condition • Ask clinical questions to the patient and carer to understand their cognition • Gain a useful understanding from observing their behaviour • Use bedside neuropsychological test to measure their cognition

12. The challenge of neurological conditions Usually complex disorder involving triad of: • Biological e.g. chorea, weakness • Cognitive • Psychiatric difficulties But • Many other secondary consequences e.g. family dynamics, loss that can underpin individuals’ difficulties Biological Psychological Social

13. How do we understand Neuropsychological disorders? • Functional Neuroanatomy – what bit of brain has been affected and what does it do? • Cognitive Neuropsychology – how can the patients symptoms be understood within cognitive models? • Clinical Neurology – what do we know about this disease – are the symptoms typical? • Clinical Psychology – what do we know about the disease and its likely psychological consequences? What other factors, lifespan, systemic, childhood, financial etc. might be important?

14. A practical way of thinking… • Presence versus absence • Lateralisation • Focal versus diffuse • Acute/progressive versus chronic/static • Aetiology/prognosis/implications

15. Exercise: You have an orange, a newspaper and a pencil. How might you use these items to get an idea of someone’s cognitive abilities? What skills do you think you are able to test?

16. Cognitive abilities • Intelligence • Memory - amnesia • Language – Aphasia, anomia • Executive functions • Apraxia • Attention – hemispheric neglect • Visuospatial ability – agnosia • Other - alexia, agraphia, acalculia, anarithmetrica

17. Functional Neuroanatomy

18. parietal occipital frontal temporal cerebellum How is the brain organised?

19. Structural Neuroanatomy • Atom • Gene • Protein • Organelle • Neuron • Synapse • Neural network • Anatomical regions

20. Structural Neuroanatomy • Anatomical regions • Brain stem: medulla, pons, midbrain • Cerebellum • Diencephalon: thalamus/hypothal. • Basal ganglia • Cortex: • Lobes, gyri, sulci, Brodmann Areas • Limbic system • White matter tracts • Circulation

21. Ventricular System Body Posterior Horn Anterior Horn Atrium 3rd Ventricle Cerebral Aqueduct Amygdala 4th Ventricle Pons http://www.fisiobrain.com/web/nggallery/page-909/album-6/gallery-12

22. Brain Spotter Quiz…

24. Functions of the Frontal Lobe 5 key areas: • Motor area • Pre-motor area • Frontal eye fields • Broca’s area • Pre-frontal area (proper) Important for: Voluntary and planned motor behaviours • All higher order skills – such as executive functions and personality • Receives major afferents from the dorsomedial nucleus of the thalamus and basal ganglia

26. Frontal Lobe Syndrome • 3 Key area in the frontal lobes • Dorsolateral – reasoning, abstract thinking, problem solving, working memory • Orbitofrontal – social behaviour • Mesial – affect, emotion processing, motivation, initiation

27. Frontal lobe Disorders Degenerative • FTD, Picks Vascular • AnCoA • Subarachnoid haemorrhage Structural • Major closed head injury Differentiation from basal ganglia disorders • HD, Advanced PD, PSP, Wilsons disease

28. Symptoms of frontal Lobe lesions • Poor planning/organisation • Impaired judgement/reasoning • Poor short-term memory • Difficulty multi-tasking and dividing attention • Behaviour/personality change • Lack of inhibition/inappropriate behaviour • Emotional lability/inappropriate affect • Expressive/motor aphasia

29. * * A coronal section through the frontal lobes reveals extensive contusions involving the inferior gyri. This was a contracoup injury from a fall in the bathtub by an elderly person.

31. Functions of the Temporal Lobe TL is involved in Hearing, Memory, Emotional/affective behaviour and Wernicke’s area Impairments lead to: • Receptive dysphasia (superior) • Memory impairment – left verbal, right non-verbal (mesial) • Prosopagnosia and poor object recognition (posterior) • Anomia – (anterior) • Hearing deficits. • Hallucinations

32. Temporal Lobe Disorders Degenerative • Alzheimer’s disease Viral • Herpes simplex encephalitis Structural • Temporal Lobe Epilepsy

33. Alzheimer's disease leads to cerebral atrophy, characterized by narrowed gyri and widened sulci (mainly frontal and parietal). This is noticeable with dilation of the cerebral ventricles

35. Functions of the Parietal lobe • Main role integration of sensory information • From different modalities and to determine spatial locations of objects. • Important for aspects of somesthetic sensation (i.e. touch, kinesthesia, pain), taste, and other sophisticated perceptive abilities.

36. Parietal lobe disorders Commonly found in: • Stroke • Tumours Patients experience: • Conduction aphasia and tactile agnosia • Inability to locate and recognize parts of the body (neglect) – large lesion to non-dominant hemisphere • Severe - inability to recognize self • Disorientation of environment and space • Inability to write (agraphia) • Gerstmann’s syndrome and Balint’s syndrome

37. Gerstmann’s syndrome • Angular gyrus syndrome • Usually dominant hemisphere stroke • In order of frequency: • Dysgraphia • Dyscalculia • Left-right disorientation • Finger agnosia

38. Gerstmann syndrome Associated with lesion to the dominant (usually left) parietal lobe Characterized by four primary symptoms: • Dysgraphia/agraphia • Dyscaluculia/ acalculia • Finger agnosia • Left-right disorientation

39. Gerstamann’s syndrome • In 1924 he reported case of a 52yr old woman with L sided stroke • Unable to write or calculate • Unable to name/point to her own or examiner’s fingers • Unable to move named fingers

40. calcarine fissure

41. Functions of the Occipital Lobe Involved in sight and processing visual information Commonly found in: Stroke to posterior circulation Patient present with: Cortical Blindness

42. Visual Processing • First functional area is the primary visual cortex • This processes low-level information such as local orientation, spatial-frequency and colour then to extra-striate areas for further processing

43. Balint's syndrome Associated with bilateral lesions Characterised by: • Optic Ataxia - inability to accurately reach for objects) • Optic Apraxia – inability to voluntarily guide eye movements/ change to a new location of visual fixation) • Simultanagnosia - inability to perceive more than one object at a time, even when in the same place.

44. *

45. The Thalamus

46. Thalamus • Is a large mass of grey matter deeply situated in the forebrain • It relays to the cerebral cortex information received from diverse brain regions - 'last pit stop' for information before going to cortex • Axons from every sensory system (except olfaction) synapse here as the last relay site before information reaches the cerebral cortex • Most commonly impaired in Stroke

48. Thalamic lesions • Can cause memory problems • Frontal problems • Speech disturbance

49. parietal limbic lobe frontal corpus callosum occipital habenula fornix septum *paraolfactory gyrus thalamus * hypothalamus *orbital gyrus olfactory tract* cerebellum temporal

50. Limbic System Involved in: • Emotion • Motivation • Emotion associated with memory • Emotional responses to external stimuli