METHODS FOR STUDYING COGNITIVE FUNCTIONS SCREENING SCALES
Verbal associations
Brief rating scale
mental status
Clock drawing test
Test “5 words”
Frontal Dysfunction Battery
Test for connecting letters and numbers

METHODS FOR RESEARCHING COGNITIVE FUNCTIONS

VERBAL ASSOCIATIONS
Literal: name in one minute as
as many words as possible starting with the letter C. Score - by
number of words (normally 20 words per minute)
Semantic categorical: name for
one minute as many animals as possible.
Score - by number of words (normally 20
words per minute)

CLINICAL SCALES

status
Orientation
–
–
–
–
–
year
time of year
month
number
day of the week
-country
-region
-city
-clinic
-floor
Registration: “Repeat and remember three words:
pencil, house, penny."
Serial counting: “From 100 subtract 7, from what
it will turn out to be 7 more and so on several times"
Five subtractions explored
Memory: “What words did I ask you to remember?”

General scale of violations

Brief Mental Rating Scale
status
Naming by display (pen, mobile phone,
watch)
Repeat the phrase: “There are no ifs, yeses, or buts.”
3-step command: “take a piece of paper
with your right hand, fold it in half and place it on
table"
Read and follow
close your eyes
write a proposal
copy the drawing

General scale of violations

Brief status assessment scale:
results
Time orientation = 0-5 points
Orientation in place = 0-5 points
Perception (word repetition) = 0-3 points
Attention (serial score) = 0-5 points
Memory (word recall) = 0 – 3 points
Naming = 0 – 2 points
Phrase = 0 – 1 points
Team = 0 – 3 points
Reading = 0 – 1 point
Letter = 0 – 1 point
Drawing = 0 – 1 point
OVERALL RESULT = 0-30 points

General scale of violations

Brief Mental Rating Scale
status: interpretation of results
30 points: normal
20-28 points: mild dementia (cognition died
violations)
15-19 points: moderate dementia
(severe cognitive impairment)
10-14 points: moderate-severe dementia
(true dementia)
less than 10: severe dementia (true
dementia)

General scale of violations

Brief Mental Rating Scale
status: typical difficulties
Negative patient attitude
The patient asks again
Errors in serial counting
Copying a drawing

General scale of violations

Brief Mental Rating Scale
status: drawing

10. General scale of violations

BATTERY OF FRONTAL DYSFUNCTION
Generalizations
– what is common between:
apple and banana (answer “fruit” = 1 point)
coat and jacket (answer “clothes” = 1 point)
table and chair (answer “furniture” = 1 point)
Associations (words starting with the letter “C”)
– more than 9 words 3 points
– from 7 to 9 words 2 points
– from 4 to 6 words 1 point
– less than 4 words 0 points

11. Clinical Dementia Rating Scale

BATTERY OF FRONTAL DYSFUNCTION
Dynamic Praxis
3 points - the patient performs three series together with the doctor and
2 times, three episodes each on your own
2 points - the patient performs three series together with the doctor and
three episodes on its own
1 point – performs three series together with a doctor
Choice reaction 1-1-2-1-2-2-2-1-1-2
– Simple (“if I hit once, you have to hit twice
times, and if I do it twice, then you do it once”)
– Complicated (if I hit once, you won’t do anything
do, and if I hit you twice in a row, you must
hit only once)
2 points - 1 error
1 point - 2 mistakes
0 points - echopraxia

12. Clinical Dementia Rating Scale

BATTERY OF FRONTAL DYSFUNCTION
Study of the grasping reflex
3 points – no reaction
2 points - the question “should I grab?”
1 point - there is a reflex, but the patient can do it
suppress
0 point - the patient cannot suppress the reflex
RESULT: 0-18 points

13. Clinical Dementia Rating Scale

BATTERY OF FRONTAL DYSFUNCTION:
INTERPRETATION OF RESULTS
18 points – norm
12-15 points - mild frontal
dysfunction
less than 12 points – dementia
frontal type

14. Clinical Dementia Rating Scale

"5 WORDS" TEST: RATIONALE
PATHOLOGY
HIPPOCAMPUS:
SUBCORTICAL-
FRONTAL SYNDROME
"INSTRUMENTAL
MEMORY DISORDERS"
"DYNAMIC
MEMORY DISORDERS"
Primary disorders
memorization
Failure
playback

15. Psychological research

“5 WORDS” TEST
CINEMA (building)
LEMONADE (drink)
GRASSHOPPER (insect)
SAUCER (dishes)
TRUCK (vehicle)

16. Objectives of psychological research

"5 WORDS" TEST: results
Direct playback:
0 – 5 points
Delayed playback:
0 – 5 points
TOTAL: 0 – 10 points

17. NEUROPSYCHOLOGICAL METHODS

"5 WORDS" TEST: interpretation
9 points or less – dementia
Alzheimer's
type

18. TEST SETS

CLOCK DRAWING TEST
11
12
1
2
10
3
9
4
8
7
5
6

19. SCREENING SCALES

CLOCK DRAWING TEST
10 - points - the norm, a circle is drawn, numbers in
correct places, arrows show
specified time
9 points - minor inaccuracies
arrow locations
8 points - more noticeable errors in
arrow location
7 points - arrows point perfectly
wrong time
6 points - shooters do not do their job
function (for example, the desired time is circled
circle)

20. VERBAL ASSOCIATIONS

CLOCK DRAWING TEST:
EXAMPLES OF IMPLEMENTATION

21. Brief Mental Status Rating Scale

CLOCK DRAWING TEST
5 points - incorrect placement of numbers on
dial: they appear in reverse order
(counterclockwise) or the distance between
numbers are not the same
4 points - the integrity of the clock and some of the numbers are lost
missing or located outside the circle
3 points - numbers and dial are not related to each other
friend
2 points - the patient’s activity shows that
it tries to execute the instruction, but
unsuccessfully
1 point - the patient does not even try
follow instructions

22. Brief Mental Status Rating Scale

CLOCK DRAWING TEST:
EXAMPLES OF IMPLEMENTATION

23. Brief status assessment scale: results

CLOCK DRAWING TEST:
EXAMPLES OF IMPLEMENTATION

- Emotional
violations
-Light cognitive
violations
Cognitive impairment
Syndromic diagnosis

29. BATTERY OF FRONTAL DYSFUNCTION

MAIN CAUSES OF DEMENTIA
Alzheimer's disease
Dementia with Lewy bodies
Frontotemporal degeneration (Niemann-Pick)
Primary progressive aphasia (semantic dementia)
Basal ganglia diseases
Parkinson's disease, progressive supranuclear palsy, chorea
Huntinton's disease, Wilson-Konovalov disease, corticobasal degeneration, etc.
Cerebrovascular insufficiency
Hypoxic encephalopathy
Traumatic brain injury
Brain tumors
Normal pressure hydrocephalus
Neuroinfection
syphilis, HIV, Creutzfeldt-Jakob disease, meningoencephalitis
Demyelinating diseases
multiple sclerosis, progressive multifocal
leukoencephalopathy
Dysmetabolic disorders
hypothyroidism, vitamin B12 deficiency, liver failure, etc.
Alcoholism and drug addiction
Chronic intoxication
aluminum, heavy metals, anticholinergics, benzodiazepines

30. BATTERY OF FRONTAL DYSFUNCTION: INTERPRETATION OF RESULTS

CONCLUSION
Psychometric study
necessary for diagnosing cognitive
violations, as it allows
objectify and evaluate the severity
cognitive disorders

In the clinical practice of a neurologist, the assessment of cognitive functions includes the study of orientation, attention, memory, counting, speech, writing, reading, praxis, and gnosis.

Orientation

A study of the patient’s ability to navigate his own personality, place, time and current situation is carried out in parallel with an assessment of his state of consciousness.

• Orientation in one’s own personality: the patient is asked to state his name, residential address, profession, marital status.
• Orientation in place: the patient is asked to say where he is now (city, name of medical institution, floor) and how he arrived here (by transport, on foot).
• Time orientation: ask the patient to name the current date (date, month, year), day of the week, time. You can ask the date of the nearest upcoming or past holiday.

Further examination of the patient's mental functions is carried out if it is determined that he is clearly conscious and able to understand instructions and questions asked of him.

Attention

Human attention is understood as both the ability to comprehend many aspects of stimulating influences at any point in time, and a nonspecific factor in ensuring selectivity, selectivity of the course of all mental processes as a whole. Neurologists often use this term to describe the ability to focus on certain sensory stimuli, distinguishing them from others. It is customary to distinguish between fixation of attention, switching of attention from one stimulus to another, and maintenance of attention (necessary to complete a task without signs of fatigue). These processes can be voluntary or involuntary.

The ability to concentrate and maintain attention is grossly impaired in states of acute confusion, suffers to a lesser extent in dementia and, as a rule, is not impaired in focal brain lesions. Concentration is checked by asking the patient to repeat a series of numbers or, for some time, cross out a certain letter that is written on a piece of paper in random alternation with other letters (the so-called proofreading test). Normally, the subject correctly repeats 5-7 numbers after the researcher and crosses out the desired letter without errors. In addition, to assess attention, you can ask the patient to count to ten forward and backward; list the days of the week, months of the year in forward and reverse order; arrange the letters that make up the word “fish” in alphabetical order or pronounce this word by sounds in reverse order; report when the required one occurs among the sounds named in random order, etc.

Memory

Check

Disorders of counting and counting operations that occur in patients with organic brain damage are referred to as “acalculia.” Primary (specific) acalculia occurs in the absence of other disorders of higher brain functions and is manifested by a violation of ideas about number, its internal composition and place structure. Secondary (nonspecific) acalculia is associated with primary disorders of recognition of words denoting numbers and numbers, or with impaired development of an action program.

Assessment of numeracy in clinical neurological practice is most often limited to tasks on performing arithmetic operations and solving simple arithmetic problems.

• Serial counting: ask the patient to serially subtract seven from 100 (subtract seven from 100, then sequentially subtract seven from the remainder another 3-5 times) or three from 30. The number of errors and the time required for the patient to complete the task are noted. Errors when performing a test can be observed not only with acalculia, but also with attention disorders, as well as with apathy or depression.
• If the patient has impaired cognitive functions when solving the mentioned problems, he is offered simple addition, subtraction, multiplication, and division problems. You can also offer solutions to everyday problems with arithmetic operations: for example, calculate how many pears you can buy for 10 rubles, if one pear costs 3 rubles, how much change will be left, etc.

Ability to generalize and abstract

The ability to compare, generalize, abstract, form judgments, and plan belongs to the so-called “executive” mental functions of a person associated with the voluntary regulation of all other areas of mental activity and behavior. Various disorders of executive functions (for example, impulsivity, limited abstract thinking, etc.) in a mild form are possible in healthy individuals, therefore, the main importance in diagnosis is not given to determining the type of disorders of executive functions, but to assessing their severity. In neurological practice, only the simplest tests are used to assess executive functions. During the examination, it is important to obtain information about the premorbid characteristics of the patient. The patient is asked to explain the meaning of several well-known metaphors and sayings (“golden hands”, “don’t spit in the well”, “if you drive more quietly, you’ll keep going”, “ravenous appetite”, “a bee flies from a wax cell for a field tribute”, etc.). ), find similarities and differences between objects (apple and orange, horse and dog, river and canal, etc.).

Speech

When talking with the patient, they analyze how he understands the speech addressed to him (sensory part of speech) and reproduces it (motor part of speech). Speech disorders constitute one of the complex problems of clinical neurology; it is studied not only by neurologists, but also by neuropsychologists and speech therapists. Below we discuss only the basic issues of speech disorders that help topical diagnosis.

Speech may suffer relatively in isolation from other higher brain functions in focal brain lesions, or simultaneously with other cognitive impairments in dementia. Aphasia is a violation of already formed speech, which occurs with focal lesions of the cortex and adjacent subcortical region of the dominant hemisphere (left in right-handed people) and is a systemic disorder of various forms of speech activity with the preservation of elementary forms of hearing and movements of the speech apparatus (that is, without paresis of the speech muscles - lingual, laryngeal, respiratory muscles).

Classic motor aphasia (Broca's aphasia) occurs when the posterior parts of the inferior frontal gyrus of the dominant hemisphere are damaged, and sensory aphasia (Wernicke's aphasia) occurs when the middle and posterior parts of the superior temporal gyrus of the dominant hemisphere are damaged. With motor aphasia, all types of oral speech are impaired (spontaneous speech, repetition, automated speech), as well as writing, but the understanding of oral and written speech is relatively intact. With Wernicke's sensory aphasia, both the understanding of oral and written speech and the patient's own oral and written speech are affected.

In neurological practice, speech disorders are diagnosed by assessing spontaneous and automated speech, repetition, object naming, speech comprehension, reading and writing. These studies are carried out in patients with speech disorders. When examining a patient, it is important to determine the dominance of his hemispheres, that is, to find out whether he is right-handed or left-handed. It may be mentioned here that, according to neurophysiologists, the left hemisphere provides the functions of abstract thinking, speech, logical and analytical functions mediated by words. People whose functions of the left hemisphere predominate (right-handed people) gravitate towards theory, are goal-oriented, able to predict events, and are motorically active. In patients with functional dominance of the right hemisphere of the brain (left-handed), concrete thinking, slowness and taciturnity, a tendency to contemplation and memories, emotional coloring of speech, and an ear for music predominate. To clarify the dominance of the hemisphere, the following tests are used: determining the dominant eye in binocular vision, clasping the hands, determining the force of clenching into a fist with a dynamometer, folding the arms on the chest (“Napoleon’s pose”), clapping, pushing the leg, etc. In right-handed people, the dominant eye is the right one. , the thumb of the right hand, when folding the hands into a lock, is on top, the right hand is stronger, it is also more active when applauding, when folding the hands on the chest, the right forearm is on top, the right leg is a pusher, and for left-handed people it’s the other way around. A convergence of the functional capabilities of the right and left hands (ambidexterity) is often observed.

• Spontaneous speech begins to be examined when meeting a patient, asking him questions: “What is your name?”, “What do you do?”, “What worries you?” etc. It is necessary to pay attention to the following disorders.
  • Changes in the speed and rhythm of speech, which manifests itself in slowing down, intermittency of speech or, conversely, in its acceleration and difficulty stopping.
  • Impaired melody of speech (dysprosody): it can be monotonous, inexpressive, or acquire a “pseudo-foreign” accent.
  • Speech suppression (complete absence of speech production and attempts at verbal communication).
  • The presence of automatisms (“verbal emboli”) - frequently, involuntarily and inappropriately used simple words or expressions (exclamations, greetings, names, etc.), the most resistant to elimination.
• Perseveration (“getting stuck”, repetition of an already spoken syllable or word, which occurs when attempting verbal communication).
• Difficulty in choosing words when naming objects. The patient's speech is hesitant, replete with pauses, and contains many descriptive phrases and words of a substitutive nature (such as “well, how is it there...”).
• Paraphasia, that is, errors in pronouncing words. Phonetic paraphasias are distinguished (inadequate production of language phonemes due to simplification of articular movements: for example, instead of the word “store” the patient pronounces “zizimin”); literal paraphasias (replacement of some sounds with others that are similar in sound or place of origin, for example “bump” - “kidney”); verbal paraphasia (replacement of one word in a sentence with another that resembles it in meaning).
• Neologisms (linguistic formations used by the patient as words, although there are no such words in the language he speaks).
• Agrammatisms and paragrammatisms. Agrammatism is a violation of the rules of grammar in a sentence. The words in the sentence do not agree with each other, syntactic structures (auxiliary words, conjunctions, etc.) are shortened and simplified, but the general meaning of the transmitted message remains clear. With paragrammatism, the words in the sentence are formally coordinated correctly, there are enough syntactic structures, but the general meaning of the sentence does not reflect the real relationships of things and events (for example, “Hay dries the peasants in June”), as a result, it is impossible to understand the transmitted information.
• Echolalia (spontaneous repetition of words spoken by a doctor or combinations thereof).
• To assess automated speech, the patient is asked to count from one to ten, list days of the week, months, etc.
  • To assess the ability to repeat speech, the patient is asked to repeat vowels and consonants after the doctor (“a”, “o”, “i”, “u”, “b”, “d”, “k”, “s” and etc.), oppositional phonemes (labial - b/p, front-lingual - t/d, z/s), words (“house”, “window”, “cat”; “moan”, “elephant”; “colonel” ”, “fan”, “ladle”; “shipwreck”, “cooperative”, etc.), a series of words (“house, forest, oak”; “pencil, bread, tree”), phrases (“Girl drinks tea "; "The boy is playing"), tongue twisters ("There is grass in the yard, there is firewood on the grass").
  • The ability to name objects is assessed after the patient names the objects shown to him (watch, pen, tuning fork, flashlight, sheet of paper, body parts).
• The following tests are used to assess understanding of spoken language.
  • Understanding the meaning of words: name an object (knocker, window, door) and ask the patient to point it out in the room or in the picture.
  • Understanding verbal instructions: the patient is asked to perform sequentially one-, two- and three-component tasks (“Show me your left hand”, “Raise your left hand and touch the fingers of this hand to your right ear”, “Raise your left hand, touch the fingers of this hand to your right ear” ear, stick out your tongue at the same time"). Instructions should not be supported by facial expressions or gestures. Evaluate the correct execution of commands. If the subject has difficulties, repeat the instructions, accompanying them with facial expressions and gestures.
  • Understanding of logical-grammatical structures: the patient is asked to follow a series of instructions containing genitive case constructions, comparative and reflexive forms of verbs, or spatial adverbs and prepositions: for example, show a key with a pencil, a pencil with a key; put a book under a notebook, a notebook under a book; show which object is more and which is less light; explain who is referred to in the expressions “mother’s daughter” and “daughter’s mother,” etc.
• To assess writing function, the patient is asked (provided with a pen and a piece of paper) to write his name and address, then take dictation of a few simple words (“cat”, “house”); sentence (“A girl and a boy are playing with a dog”) and copy the text from the sample printed on paper. In patients with aphasia, in most cases, writing also suffers (that is, agraphia is present - loss of the ability to write correctly while maintaining the motor function of the hand). If a patient can write but cannot speak, he most likely has mutism, but not aphasia. Mutism can develop in a wide variety of diseases: with severe spasticity, paralysis of the vocal cords, bilateral damage to the corticobulbar tracts, and is also possible with mental illness (hysteria, schizophrenia).
• To assess reading, the patient is asked to read a paragraph from a book or newspaper, or read and follow instructions written on paper (for example, “Go to the door, knock on it three times, come back”), and then evaluate the correctness of its execution.

For neurological diagnosis, the ability to distinguish motor aphasia from dysarthria, which is characteristic of bilateral lesions of the corticonuclear tracts or nuclei of the cranial nerves of the bulbar group, is of great importance. With dysarthria, patients say everything, but pronounce words poorly; the speech sounds “r”, “l”, and hissing are especially difficult to articulate. Sentence construction and vocabulary do not suffer. With motor aphasia, the construction of phrases and words is disrupted, but at the same time, the articulation of individual articulate sounds is clear. Aphasia also differs from alalia - underdevelopment of all forms of speech activity, manifested by speech impairment in childhood. The most important signs of various aphasic disorders are summarized below.

• With motor aphasia, patients generally understand someone else's speech, but find it difficult to choose words to express their thoughts and feelings. Their vocabulary is very poor and can be limited to only a few words (“emboli words”). When speaking, patients make mistakes - literal and verbal paraphasias, try to correct them and are often angry with themselves for not being able to speak correctly.
• The main signs of sensory aphasia include difficulty understanding the speech of others and poor auditory control of one's own speech. Patients make a lot of literal and verbal paraphasias (sound and verbal errors), do not notice them and get angry with the interlocutor who does not understand them. With severe forms of sensory aphasia, patients are usually verbose, but their statements are difficult to understand for others (“speech salad”). To identify sensory aphasia, you can use the experience of Marie (the patient is given three pieces of paper and asked to throw one of them on the floor, put the other on the bed or table, and return the third to the doctor) or Ged (the patient is asked to put a large coin in a small glass, and a small one - in a large one; the experiment can be complicated by placing four different glasses, the same number of coins of different sizes and asking the patient to place them).
• With lesions at the junction of the temporal, parietal and occipital lobes, one of the variants of sensory aphasia may occur - the so-called semantic aphasia, in which patients do not understand the meaning of individual words, but the grammatical and semantic connections between them. Such patients cannot, for example, distinguish between the expressions “father's brother” and “brother's father” or “the cat ate the mouse” and “the cat was eaten by the mouse.”
• Many authors identify another type of aphasia - amnestic, in which patients find it difficult to name the various objects shown, forgetting their names, although they can use these terms in spontaneous speech. It usually helps such patients if they are prompted with the first syllable of the word denoting the name of the object being shown. Amnestic speech disorders are possible with different types of aphasia, but most often they occur with lesions of the temporal lobe or parieto-occipital region. Amnestic aphasia should be distinguished from a broader concept - amnesia, that is, a memory disorder for previously developed ideas and concepts.

Praxis

Praxis is understood as the ability to perform successive complexes of conscious voluntary movements in order to perform purposeful actions according to a plan developed by individual practice. Apraxia is characterized by the loss of skills developed in the process of individual experience, complex purposeful actions (domestic, industrial, symbolic gestures, etc.) without pronounced signs of central paresis or impaired coordination of movements. Depending on the location of the lesion, several types of apraxia are distinguished.

• Motor (kinetic, efferent) apraxia is manifested by the fact that sequential switching of movements is disrupted and disorders in the formation of motor units that create the basis of motor skills occur. Characterized by a disorder in the smoothness of movements, “getting stuck” on individual fragments of movements and actions (motor perseverations). Observed with a lesion in the lower parts of the premotor region of the frontal lobe of the left (in right-handed) hemisphere (if the precentral gyrus is damaged, central paresis or paralysis develops, in which apraxia cannot be detected). To identify motor apraxia, the patient is asked to perform the “fist-edge-palm” test, that is, hit the table surface with a fist, then with the edge of the palm, and then with the palm with straightened fingers. This series of movements is asked to be repeated at a fairly fast pace. A patient with damage to the premotor area of ​​the frontal lobe experiences difficulty performing such a task (gets lost in the sequence of movements, cannot complete the task at a fast pace).
• Ideomotor (kinesthetic, afferent) apraxia occurs when the inferior parietal lobule is damaged in the region of the supramarginal gyrus, which is classified as a secondary field of the kinesthetic analyzer cortex. In this case, the hand does not receive afferent feedback signals and is not able to perform fine movements (at the same time, a lesion in the region of the primary fields of the postcentral gyrus causes a gross disturbance of sensitivity and afferent paresis, in which the ability to control the opposite hand is completely lost, but this disorder does not cause apraxia attributed). Apraxia is manifested by a violation of fine differentiated movements on the side opposite to the lesion: the hand cannot take the position necessary to perform a voluntary movement, or adapt to the nature of the object with which specified manipulations are performed (the “shovel hand” phenomenon). The search for the required posture and errors are typical, especially if there is no visual control. Kinesthetic apraxia is detected when performing simple movements (both with real objects and when simulating these actions). To identify it, you should ask the patient to stick out his tongue, whistle, show how to light a match (pouring water into a glass, using a hammer, holding a pen to write with, etc.), dial a telephone number, comb his hair. You can also invite him to close his eyes; put his fingers into some simple figure (for example, “goat”), then destroy this figure and ask him to restore it himself.
• Constructive apraxia (spatial apraxia, apractognosia) is manifested by impaired coordination of joint movements of the hands, difficulty in performing spatially oriented actions (difficulty making the bed, getting dressed, etc.). There is no clear difference between performing movements with open and closed eyes. This type of disorder also includes constructive apraxia, which manifests itself in the difficulty of constructing a whole from individual elements. Spatial apraxia occurs when the focus is localized at the junction of the parietal, temporal and occipital regions (in the area of ​​the angular gyrus of the parietal lobe) of the cortex of the left (in right-handed people) or both hemispheres of the brain. When this zone is damaged, the synthesis of visual, vestibular and cutaneous-kinesthetic information is disrupted and the analysis of action coordinates deteriorates. Tests that reveal constructive apraxia involve copying geometric figures, drawing a clock face with the arrangement of numbers and hands, and building structures from cubes. The patient is asked to draw a three-dimensional geometric figure (eg, a cube); draw a geometric figure; draw a circle and arrange the numbers in it as on a watch dial. If the patient has completed the task, he is asked to arrange the arrows so that they show a certain time (for example, “a quarter to four”).
• Regulatory (“prefrontal”, ideational) apraxia includes disturbances in the voluntary regulation of activities directly related to the motor sphere. Regulatory apraxia manifests itself in the fact that the performance of complex movements is impaired, including the performance of a series of simple actions, although the patient can perform each of them individually correctly. The ability to imitate is also preserved (the patient can repeat the doctor’s actions). At the same time, the subject is not able to draw up a plan of sequential steps necessary to perform a complex action, and is not able to control its implementation. The greatest difficulty is in simulating actions with missing objects. So, for example, the patient finds it difficult to show how to stir sugar in a glass of tea, how to use a hammer, comb, etc., while he performs all these automatic actions with real objects correctly. Starting to perform an action, the patient switches to random operations, getting stuck on fragments of the started activity. Echopraxia, perseveration and stereotypy are characteristic. Patients are also characterized by excessive impulsiveness of reactions. Regulatory apraxia occurs when the prefrontal cortex of the frontal lobe of the dominant hemisphere is damaged. To identify it, patients are asked to take a match out of a matchbox, light it, then put it out and put it back in the box; open the tube of toothpaste, squeeze a column of paste onto the toothbrush, screw the cap on the tube of paste.

Gnosis

Agnosia is a disorder of recognition of objects (objects, faces) while maintaining the elementary forms of sensitivity, vision, and hearing. There are several types of agnosia - visual, auditory, olfactory, etc. (depending on within which analyzer the violation occurred). In clinical practice, optical-spatial agnosia and autotopagnosia are most often observed.

• Optical-spatial agnosia is a violation of the ability to perceive spatial features of the environment and images of objects (“further-closer”, “more-less”, “left-right”, “top-bottom”) and the ability to navigate in external three-dimensional space. Develops with damage to the superior parietal or parieto-occipital parts of both hemispheres or the right hemisphere of the brain. To identify this form of agnosia, the patient is asked to draw a map of the country (approximately). If he cannot do this, they draw a map on their own and ask him to mark on it the location of five large, poorly known cities. You can also ask the patient to describe the route from home to hospital. The phenomenon of ignoring one half of space is considered a manifestation of optical-spatial agnosia (one-sided visual-spatial agnosia, one-sided spatial neglect, hemi-spatial neglect, hemi-spatial sensory inattention). This syndrome manifests itself in difficulty perceiving (ignoring) information coming from one hemisphere of the surrounding space, in the absence of a primary sensory or motor deficit in the patient, including hemianopsia. For example, the patient eats only the food that is on the right side of the plate. The phenomenon of neglect is associated mainly with damage to the parietal lobe, although it is also possible with temporal, frontal and subcortical localization of the pathological process. The most common phenomenon is ignoring the left half of space when the right hemisphere of the brain is damaged. To identify neglect syndrome, the following tests are used (it must be emphasized that they are applicable only if the patient does not have hemianopia).
  • The patient is given a lined notebook sheet and asked to divide each line in half. With ignoring syndrome, a right-handed person will place marks not in the middle of the lines, but at a distance of three quarters from its left edge (that is, he divides only the right half of the lines in half, ignoring the left).
  • The patient is asked to read a paragraph from a book. If ignored, he can only read the text located on the right half of the page.
• Autotopagnosia (asomatagnosia, body diagram agnosia) is a violation of recognition of parts of one’s body and their location in relation to each other. Its variants include finger agnosia and impaired recognition of the right and left halves of the body. The patient forgets to put clothes on the left limbs and wash the left side of the body. The syndrome most often develops when the superior parietal and parieto-occipital regions of one (usually the right) or both hemispheres are affected. To identify autotopagnosia, the patient is asked to show the thumb of the right hand, the index finger of the left hand, touch the left ear with the right index finger, and touch the right eyebrow with the index finger of the left hand.

anesthesia psyche cognitive

To assess cognitive functions, different authors use different research methods. Thus, to study the typological properties of the nervous system (strength of the nervous system, balance of nervous processes, mobility of nervous processes), the technique of E.P. is used. Ilyina (1978). To increase the reliability of diagnosing the typological characteristics of the nervous system, the study is repeated at least four times; if there is no variation in the results, the patient is assigned to a specific typological group.

The generally accepted psychometric methods include the following: attention span and concentration are studied using a proof test; switching attention - using the Schulte technique; selectivity of attention - using the Munsterberg technique; voluntary attention - a technique for arranging numbers; RAM - Wechsler method; short-term memory and memory for images - Ebbinghaus method; logical thinking is studied using the method of regularities in the number series; To study intellectual lability, the method of intellectual lability is used, and the ability to classify and analyze is determined using the method of eliminating concepts. The asthenic state is assessed using the E.V. scale. Malkova (1980), neuropsychic stress - according to the questionnaire of T.A. Nemchina (1983).

In clinical practice, to assess cognitive functions in elderly people, methods are most often used that make it possible to quickly and quickly determine the state of various mental processes in this category of patients. Such techniques include:

• · methods of E. Kraepelin and Schulte for studying the characteristics of attention, performance, cognitive pace;
• · A. Luria’s technique for studying auditory-verbal memory;
• · clock drawing test to study visual memory;
• · techniques for eliminating concepts, classification, simple and complex analogies for studying the characteristics of thinking.

These methods are quite simple to use and informative, but their significant drawback when working with elderly people is the lack of standard indicators for this age group.

Abroad, the determination of cognitive abilities in gerontological patients is carried out mainly using those intelligence tests that are used in the examination of younger age groups, however, as a rule, these tests have a rating scale for older age. These are the Wechsler Intelligence Test for Adults, designed for people under the age of 74, the Brief Test of the General Level of Information Processing with a scale for assessing results up to 65 years, the Raven's Progressive Matrices test, which is widely used in working with older people, especially in cases where they have neurological and speech disorders.

The Raven's Progressive Matrices test was used as the main psychodiagnostic tool for assessing the cognitive functions of older people in our clinic.

This technique has a number of advantages compared to those traditionally used in the clinic for diagnosing cognitive characteristics in older people:

• · This technique is valid, reliable, easy to carry out and does not require special training of a clinician to conduct the study.
• · It is standardized for the elderly.
• · This technique belongs to the category of non-verbal, which makes it possible to use it when examining elderly people with any linguistic and sociocultural background.
• · When performing test tasks, mental processes such as perception, attention, and thinking are manifested, which makes it possible to obtain a fairly complete overall picture of the state of a person’s higher mental functions and to evaluate his non-verbal intelligence.
• · The technique makes it possible to obtain a qualitative assessment of cognitive indicators and their dynamics when performing tasks of various categories of complexity.

The Raven's Progressive Matrices test consists of 60 matrices, or compositions with missing elements. The test is built on the principle of progression, which means that completing previous tasks is like preparing the subject to perform more difficult test programs. As a result of testing, a person is prepared and trained to solve complex test tasks.

The test consists of 5 series, each of which performs its own diagnostic function, ranging from assessing the characteristics of a person’s perception to assessing his analytical and synthetic thought processes.

To conduct a study of cognitive functions in elderly people in our clinic, this technique was divided into 2 variants of equal complexity in order to eliminate learning tasks and getting used to them during repeated studies. In addition, the Raven's test rating scale was modified taking into account a number of features of this patient population and for a more differentiated analysis of the state of cognitive functions in older people in different postoperative periods.

Thus, the scale for assessing cognitive functions in the elderly received the following criteria:

• · 90% or more correctly solved tasks - a very high level of indicators of mental processes;
• · 75-89% of correctly solved tasks - high level;
• · 55-74% - the level of indicators of mental processes is above average;
• · 45-54% - average level;
• · 25-44% - the level of indicators of mental processes is below average;
• · 10-24% - low level of indicators of mental processes;
• · 0-9% - very low level.

In addition, to assess the nature of the disturbance of mental processes and the dynamics of their recovery, we conducted a qualitative analysis of the errors made by patients when performing test tasks.

The following types of errors were identified:

• · Errors in attention and perception associated with the visual ability to distinguish one-dimensional changes in an image.
• · Errors in complex perception associated with the ability to differentiate linearly and find relationships between elements of figures.
• · Errors in drawing specific conclusions associated with the ability to study smooth changes in space.
• · Errors in constructing abstract conclusions associated with the ability to comprehend the pattern of complex changes in space.
• · Errors in constructing the highest form of abstraction and dynamic synthesis, associated with the ability for analytical-synthetic mental activity.

In order to identify the impact on the state of cognitive functions in patients of both the type of anesthesia itself and the pharmacological drugs used (to assess their neuroprotective effect), the above criteria were determined before surgery (initial background) and after surgery in the early and early long-term postoperative periods:

• · Before surgery.
• · On the 5th day after surgery.
• · On the 10th day after surgery.
• · On the 30th day after surgery.

Neuroprotective therapy began before surgery or in the first minutes after its completion, depending on the pharmacological drug used.

Catad_tema Mental disorders - articles

Neuropsychological tests. Necessity and possibility of application

V.V.Zakharov
Department of Nervous Diseases of the First Moscow State Medical University named after. I.M.Sechenova

Identification and analysis of clinical features of cognitive dysfunction (synonyms: higher cerebral, higher mental, higher cortical, cognitive - Table 1) is of great importance for the diagnosis and differential diagnosis of neurological diseases. Many neurological diseases, especially in childhood and old age, manifest almost exclusively as cognitive impairment (CI). The presence and severity of CI largely determine the prognosis and tactics of patient management for a number of common nervous diseases.

Table 1. Cognitive functions

It is important to emphasize that the most objective impression of the state of the patient’s cognitive abilities is formed by comparing information obtained from all three of these sources. Dynamic monitoring of the patient also plays an important role, which allows for a differential diagnosis between transient cognitive difficulties, often of a functional nature, and stationary or progressive disorders associated with organic brain damage.

Analysis of patient complaints

Suspicion of a patient's cognitive impairment should arise if there are complaints of:

• decreased memory compared to the past;
• deterioration of mental performance;
• difficulty concentrating or concentrating;
• increased fatigue during mental work;
• heaviness or feeling of “emptiness” in the head, sometimes unusual, even pretentious sensations in the head;
• difficulties in choosing a word in a conversation or expressing one’s own thoughts;
• decreased vision or hearing in the absence or insignificant severity of eye and hearing diseases;
• awkwardness or difficulty performing habitual actions in the absence of muscle weakness, extrapyramidal and discoordination disorders;
• the presence of difficulties in professional activities, social activity, interaction with other people, in everyday life and in self-care.

Any of the above complaints is the basis for an objective assessment of the state of cognitive functions (see figure) using neuropsychological research methods (Appendix 1).

It should be noted that the most important are the patient’s active complaints, which are expressed by him independently, without a leading question. It is known that many healthy individuals are dissatisfied with their memory and other cognitive abilities, therefore, in response to a doctor’s question, many, even completely cognitively intact individuals, will complain of poor memory. Therefore, priority attention should be given to spontaneous complaints. It also makes sense to clarify whether the patient has always had poor memory or whether it has significantly worsened recently.

On the other hand, the absence of cognitive complaints does not mean the absence of objective CIs. It is known that in most cases, progressive CIs are accompanied by a decrease in criticism, especially at the stage of dementia (Appendix 4). The patient may consciously dissimulate his existing disorders for fear of receiving an unwanted diagnosis and associated restrictions in the professional and social spheres. Therefore, the patient’s self-assessment must always be compared with objective information.

Neuropsychological research methods

Neuropsychological testing is an objective way to assess the state of cognitive functions and is advisable in the following situations:

• in the presence of active cognitive complaints on the part of the patient;
• if the doctor, in the process of communicating with the patient, develops his own suspicion of the presence of CI (for example, due to difficulties in collecting complaints, medical history, failure to follow recommendations);
• in case of unusual behavior of the patient, decreased criticism, sense of distance, or the occurrence of psychotic disorders in old age;
• if third parties (relatives, colleagues, friends) report a decrease in the patient’s memory or other cognitive abilities.

To assess memory status tasks for memorizing and reproducing words, visual images, motor series, etc. are used. The most commonly used tests are auditory-verbal memory: memorizing a list of words, two competitive series of 2-3 words each, sentences, a fragment of text. The most specific technique is considered to be indirect memorization of words: the patient is presented with words to memorize, which he must sort into semantic groups (for example, animals, plants, furniture, etc.). The name of the semantic group is used as a hint during reproduction (for example: “You memorized another animal,” etc.). According to the generally accepted point of view, thanks to this procedure, memory impairments associated with attention deficit are leveled.

To assess the state of perception They study the patient’s recognition of real objects, their visual images, and other stimulus material of various modalities. The perception of one's own body schema is examined using Head tests.

For the praxis scene the patient is asked to perform one or another action (for example: “Show how to comb your hair, how to cut paper with scissors, etc.). Constructive praxis is assessed in drawing tests: the patient is asked to draw independently or redraw a three-dimensional image (for example, a cube), a clock with hands, etc.

For speech assessment attention should be paid to the understanding of the addressed speech, fluency, grammatical structure and content of the patient’s statements. They also examine the repetition of words and phrases after the doctor, reading and writing, and a test for naming objects (nominative function of speech).

For the skit of intelligence generalization tests can be used (for example: “Please tell me what is common between an apple and a pear, a coat and a jacket, a table and a chair”). Sometimes they are asked to interpret a proverb, give a definition of a particular concept, or describe a plot picture or a series of pictures.

In everyday clinical practice, standard test kits with formalized (quantitative) assessment of results have proven themselves well, allowing for rapid assessment of several cognitive functions in a limited time.

Mini-Cog technique: advantages and disadvantages

Of the above standard test kits for outpatient practice, we can recommend the Mini-Cog technique (Appendix 5). This technique includes a memory task (memorizing and reproducing 3 words) and a clock drawing test. The main advantage of the Mini-Cog technique is its high information content with simultaneous simplicity and speed of implementation. The test takes no more than 3-5 minutes. The interpretation of the test results is also extremely simple: if the patient cannot reproduce at least one of three words or makes significant errors when drawing a clock, it is highly likely that he has impaired cognitive functions. The test results are assessed qualitatively: if there are violations, there are no violations. The methodology does not provide for scoring, as well as grading CI according to the degree of severity. The latter is carried out according to the severity of the functional defect.

The Mini-Cog technique can be used both for the diagnosis of vascular and primary degenerative CIs, as it includes memory tests and “frontal” functions (clock drawing test). The main disadvantage of this technique is its low sensitivity: being very simple, it detects only quite severe disorders of cognitive functions, such as dementia. At the same time, patients with mild and moderate CI in most cases cope with the described test without difficulty. However, a small number of patients with moderate CI syndrome make mistakes in drawing clocks.

Montreal Cognitive Assessment Scale or Moka Test: advantages and disadvantages

If the doctor has time, for example, when examining inpatients, you can use a more detailed and, accordingly, more sensitive battery of tests - the Montreal Cognitive Function Rating Scale or the Moka test (Appendix 2). This scale is currently recommended by most modern experts in the field of CI for widespread use in everyday clinical practice.

The Montreal Cognitive Assessment Scale was developed for rapid assessment of mild cognitive dysfunction. It assesses various cognitive domains: attention and concentration, executive functions, memory, language, visual constructive skills, abstract thinking, numeracy and orientation. The test time is approximately 10 minutes. The maximum possible number of points is 30, 26 or more is considered normal.

Like the Mini-Cog technique, the Moka test evaluates various aspects of cognitive activity: memory, “frontal” functions (letter-number connection test, speech fluency, generalization, etc.), nominative speech function (naming animals), visuospatial praxis (cube, clock). Therefore, the technique can be used to diagnose both vascular and primary degenerative CIs. However, the sensitivity of the Moka test is significantly higher than that of the Mini-Cog, so the Montreal Cognitive Scale is suitable for identifying not only severe, but also moderate CIs. At the same time, the formalized assessment system of the Mock Test itself does not provide for a gradation of the severity of violations depending on the score. The assessment of the severity of CI is based on the degree of functional limitation in everyday life, which is determined mainly by talking with relatives. Other neuropsychological tests can be used to assess CI (Appendices 3, 6-7).

Evaluation of neuropsychological testing results

Neuropsychological testing is the most objective method for diagnosing CI, but it is still not completely reliable. In some cases (however, quite rarely), neuropsychological testing gives a false positive or false negative result.

False positive result neuropsychological testing may lead to overdiagnosis of CI. In these cases, the patient scores low on tests, below the norm for the corresponding age, despite the absence of true CIs. The main reasons for a false positive test result are:

• low educational level and social status of the patient, illiteracy, lack of general knowledge, long-term isolation from society;
• situational absent-mindedness and inattention (for example, if at the time of testing the patient is upset or preoccupied with something), as well as high situational anxiety at the time of the neuropsychological study;
• state of intoxication at the time of the study or the day before, severe fatigue of the patient at the time of the study or lack of sleep the night before;
• has an indifferent or negative attitude towards testing, does not make the necessary efforts to perform cognitive tasks, since he does not understand the purpose and significance of the neuropsychological research method, and considers it unnecessary. Sometimes, even having formally agreed to the study, the patient, due to an internal negative attitude, consciously or unconsciously resists the assessment of the state of his cognitive functions.

False negative result neuropsychological testing means a formally normal test score (within the average age norm) despite the presence of CI in the patient’s status. Usually observed in patients with the earliest signs of cognitive impairment, however, in rare cases, even patients with dementia successfully cope with the presented cognitive tasks. The likelihood of a false negative test result directly depends on the complexity (and therefore sensitivity) of the method used. Thus, in the same sample of patients, when using the Mini-Cog technique, a significantly larger percentage of individuals will formally correspond to the norm than when using the Moka test.

However, the use of even the most complex and sensitive research methods does not provide a complete guarantee against a false negative result. Observations of patients with so-called subjective cognitive impairment (cognitive complaints not confirmed by the results of neuropsychological tests) indicate that some of them will develop objective cognitive decline in the near future. Obviously, in these cases we are talking about the earliest manifestations of cognitive failure, not recorded using available neuropsychological tests, but noticeable (with intact criticism) for the patient himself.

In other cases, subjective CIs are a manifestation of emotional disorders of the anxiety-depressive series. Therefore, in patients with active cognitive complaints with a negative result of neuropsychological testing, a thorough examination of the emotional state is necessary. In some cases, it is advisable to prescribe antidepressants ex juvantibus. Thus, active cognitive complaints are always a pathological symptom that requires correction even in the case of normal results of neuropsychological tests. However, in some cases, complaints of decreased memory and mental performance should be considered as evidence of emotional rather than CI.

Considering the possibility of an erroneous test result in doubtful cases, repeated neuropsychological studies are advisable. In some cases, the diagnosis can be established only during dynamic monitoring of the patient.

Assessment of the patient's cognitive status and degree of functional limitation by third parties

The most complete and correct idea of ​​the presence, structure and severity of cognitive impairment is formed by comparing the patient’s complaints, the results of a neuropsychological study and information received from people who have been in constant communication with the patient for a long time, who can observe him in everyday life - family members, close relatives, friends, colleagues, etc. (Table 2).

Table 2. Assessment of the patient’s functional independence in conversation with third parties

Professional activities	Is the patient still working? If not, is leaving work related to CI? If so, is he doing his job as well as before?
Activities outside the home	Has the patient developed new (not previously noted) difficulties in one or more of the following areas: social activities, services, financial transactions, shopping, driving, using public transport, hobbies and interests. How are these difficulties related to memory and intelligence impairments?
Activity at home	What household duties did the patient traditionally perform (cleaning, cooking, washing dishes, laundry, ironing, childcare, etc.)? Does he continue to cope with them? If not, what is the reason for this (forgotten, decreased motivation, physical difficulties, for example, pain, motor limitations, etc.)?
Self-service	Does the patient need assistance with self-care (dressing, hygiene procedures, eating, using the toilet)? Does he need reminders or prompts when performing self-care? What are the causes of self-care difficulties (forgotten, forgotten how to do things, doesn’t know how to perform certain actions, decreased motivation, physical difficulties, for example, pain)?

Relatives or other close persons of the patient should be asked targeted questions to assess the state of cognitive functions: for example, how often the patient forgets events, the content of conversations, necessary things to do, and whether there is forgetfulness of names and faces. Relatives may pay attention to changes in the patient’s speech, difficulties in understanding spoken speech, choosing words in a conversation, and incorrect construction of phrases. They may also notice unexpected difficulties when performing usual activities, for example, when preparing food, minor household repairs, cleaning, etc. You should ask how the patient navigates space and time, whether he has difficulties in determining the date and when traveling, remains Is he as smart and reasonable as he always was?

Information about the patient's cognitive status obtained from the patient's relatives and other close associates is usually objective. However, sometimes it can be distorted by misconceptions of the informant himself. It is no secret that many people without medical education consider it normal for a decline in memory and intelligence in old age, and therefore may not pay due attention to these changes. Emotional attachment or, conversely, a hidden negative attitude may also affect the objectivity of the information, which must be taken into account by the attending physician.

Relatives and other close people are an important source of information about the patient’s emotional state and behavior in everyday life.

In a conversation with relatives, it is necessary to clarify how often they see the patient sad and depressed or excited and worried, whether he expressed dissatisfaction with his life, or complained of fear or anxiety. Relatives and other close people can report on the patient's behavior and how it has changed recently. Targeted questions should be asked regarding aggressive behavior, eating habits, the sleep-wake cycle, the presence of incorrect thoughts and ideas, including ideas of harm, jealousy, increased suspicion, and illusory-hallucinatory disorders.

Without information received from relatives and other close people, it is impossible to get a correct idea of ​​the degree of functional limitation, and therefore the severity of CI. Traditionally, there are 3 degrees of severity of CI: mild, moderate and severe (Table 3).

Table 3. Characteristics of CI syndromes by severity

Basis for assessment	Lungs	Moderate	Heavy
Patient complaints of a cognitive nature	Usually there is	Usually there is	Usually absent
Neuropsychological tests	Violations are detected only by the most sensitive methods	Violations are detected	Violations are detected
Information from third parties	Violations are not noticeable	Impairments are noticeable but do not lead to functional limitations	Impairments lead to functional limitations

Light KN are characterized by rare and mild symptoms that do not lead to any functional limitations. Typically, mild CIs are not noticeable to others, including those who constantly communicate with the patient, but can be noticeable to the patient himself, being the subject of complaints and a reason to see a doctor. The most characteristic manifestations of mild cognitive impairment are episodic forgetfulness, rare difficulties in concentrating, fatigue during intense mental work, etc. Mild CI can be objectified only with the help of the most complex and sensitive neuropsychological techniques.

Moderate CI characterized by regular or persistent cognitive symptoms, more significant in severity, but with no or minimal severity of functional limitation. There may be slight but almost constant forgetfulness, frequent difficulty concentrating, and increased fatigue during normal mental work. Moderate CIs are usually noticeable not only to the patient himself (reflected in complaints), but also to third parties who report this to the attending physician. Neuropsychological tests (eg, Moka test) usually reveal deviations from normative indicators. At the same time, the patient retains independence and independence in most life situations, copes with his work, social role, family responsibilities, etc. Only sometimes there may be difficulties in complex and unusual activities for the patient.

Heavy KN lead to a greater or lesser degree of functional limitation (see Table 3), partial or complete loss of independence and independence.

Treatment

Treatment for CI depends on its cause and severity. In most nosological forms (Alzheimer's disease, cerebrovascular insufficiency, degenerative process with Lewy bodies and some others), the presence of severe CI is an indication for the prescription of acetylcholinesterase inhibitors and/or NMDA glutamate receptor antagonists. For mild and moderate CI, Pronoran (piribedil) is used - an agonist dopamine and α2-blocker), vasoactive and metabolic drugs.

Applications.

Additional neuropsychological tests

Appendix 1. Diagnostic algorithm

Suspicion of CI (active complaints of the patient, his unusual behavior during the conversation, information from third parties. risk factors)
↓
Neuropsychological tests
↓	↓
No violations	There are violations
↓	↓	↓
Dynamic observation	Functional status assessment
	↓	↓
	There are violations	No violations
	↓	↓
	Heavy KN	Mild to moderate CI

Appendix 2. Mock test. Instructions for use and evaluation

1. Test “Connecting numbers and letters.”

The examiner instructs the subject: “Please draw a line from the number to the letter in ascending order. Start here (point to number 1) and draw a line from number 1 to letter A, then to number 2 and so on. Finish here (point D).”

Score: 1 point is awarded if the subject successfully draws a line as follows: 1-A-2-B-3-C-4-D-5-D without crossing the lines.

Any error that is not immediately corrected by the test taker himself earns 0 points.

2.Visuospatial skills (cube)

The researcher gives the following instructions, pointing to the cube: “Copy this drawing as accurately as you can in the space below the drawing.”

Score: 1 point is awarded if the drawing is accurately executed:

• the drawing must be three-dimensional;
• all lines are drawn;
• no extra lines;
• the lines are relatively parallel, their length is the same.

No point is given if any of the above criteria are not met.

3.Visuospatial skills (clock)

Point to the right third of the blank space and give the following instructions: “Draw a clock. Arrange all the numbers and indicate the time: 10 minutes past twelve.”

Scoring: Points are awarded for each of the following three items:

• contour (1 point): the dial should be round, only slight curvature is allowed (i.e. slight imperfection when closing the circle);
• numbers (1 point): all numbers on the clock must be presented, there should be no additional numbers; the numbers must be in the correct order and placed in the appropriate quadrants on the dial; Roman numerals are allowed; numbers can be located outside the contour of the dial;
• arrows (1 point): there must be 2 arrows, together showing the correct time; the hour hand must be obviously shorter than the minute hand; The hands should be positioned in the center of the dial, with their junction close to the center.

No score will be awarded if any of the above criteria are not met.

4. Naming

Starting on the left, point to each shape and say, “Name this animal.”

Score: 1 point is assigned for each of the following answers - camel or dromedary camel, lion, rhinoceros.

5. Memory

The researcher reads a list of 5 words at a rate of 1 word per second. The following instructions should be given: “This is a memory test. I will read a list of words that you need to remember. Listen carefully. When I finish, tell me all the words that you remember. It doesn't matter in what order you name them." Make a mark in the space provided for each word when the test taker says it on the first try. When the subject indicates that he has finished (named all the words) or cannot remember any more words, read the list a second time with the following instructions: “I will read the same words a second time. Try to remember and repeat as many words as you can, including the words you repeated the first time." Place a mark in the space provided for each word that the test taker repeats on the second try. At the end of the second attempt, inform the subject that he or she will be asked to repeat the given words: “I will ask you to repeat these words again at the end of the test.”

Scoring: No points will be awarded for either the first or second attempt.

6. Attention

Repeating numbers. Give the following instructions: “I’m going to say a few numbers and when I’m done, repeat them exactly as I said them.” Read 5 numbers in sequence with a frequency of 1 number per 1 s.

Repeat numbers backwards. Give the following instructions: “I will say a few numbers, but when I finish, you will need to repeat them in reverse order.” Read a sequence of 3 numbers with a frequency of 1 number per 1 second.

Grade. Award 1 point for each sequence repeated exactly (N.B.: exact answer for counting backwards 2-4-7).

Concentration. The researcher reads a list of letters with a frequency of 1 letter per 1 s, after the following instructions: “I will read you a series of letters. Every time I say the letter A, clap your hand once. If I say another letter, I don’t need to clap my hand.”

Score: 1 point is assigned if there are no errors or there is only 1 error (an error is considered if the patient claps his hand when naming another letter or does not clap when naming the letter A).

Serial account(100-7). The researcher gives the following instructions: “Now I will ask you to subtract 7 from 100, and then continue subtracting 7 from your answer until I say stop.” Repeat the instructions if necessary.

Score: 3 points are assigned for this item, 0 points - if there is no correct count, 1 point - for 1 correct answer, 2 points - for 2-3 correct answers, 3 points - if the subject gives 4 or 5 correct answers. Count each correct subtraction by 7s, starting from 100. Each subtraction is scored independently: if the participant gives an incorrect answer but then continues to accurately subtract 7s from it, give 1 point for each accurate subtraction. For example, a participant might answer "92-85-78-71-64", where "92" is incorrect, but all subsequent values ​​are subtracted correctly. This is 1 error, and 3 points are assigned for this item.

7. Repeating a phrase

The researcher gives the following instructions: “I will read you a sentence. Repeat it exactly as I say (pause): “All I know is that Ivan is the one who can help today.” Following the answer, say: “Now I will read you another sentence. Repeat it exactly as I say (pause): “The cat always hid under the sofa when the dogs were in the room.”

Scoring: 1 point is awarded for each sentence repeated correctly. The repetition must be precise. Listen carefully to look for errors due to omissions of words (for example, omission of “only”, “always”) and substitutions/adding (for example, “Ivan is the only one who helped today”; substitution of “hiding” instead of “hiding”, use of the plural, etc. .d.).

8. Fluency

The researcher gives the following instructions: “Tell me as many words as possible that begin with a specific letter of the alphabet, which I will now tell you. You can name any kind of word, with the exception of proper names (such as Peter or Moscow), numbers or words that begin with have the same sound, but have different suffixes, for example love, lover, love. I'll stop you in 1 minute. Are you ready? (Pause) Now tell me as many words as you can think of that start with the letter L. (time 60 s). Stop".

Score: 1 point is awarded if the subject names 11 words or more in 60 seconds. Write your answers at the bottom or side of the page.

9. Abstraction

The researcher asks the subject to explain: “Tell me what an orange and a banana have in common.” If the patient answers in a specific way, say only 1 more time: “Tell me how else they are similar.” If the subject does not give the correct answer (fruit), say, “Yes, and they are both fruits.” Do not give any other instructions or explanations. After a trial attempt, ask: “Now tell me what a train and a bicycle have in common.” After answering, give the second task by asking: “Now tell me what the ruler and the clock have in common.” Do not give any other instructions or hints.

Score: Only the last 2 pairs of words are taken into account. 1 point is given for each correct answer. The following answers are considered correct: train-bicycle = means of transportation, means of travel, both can be ridden; clock ruler=measuring tools, used for measuring. The following answers are not considered correct: train-bicycle = they have wheels; ruler-clock=there are numbers on it.

1O. Delayed playback

The researcher gives the following instructions: “I previously read you a series of words and asked you to remember them. Tell me as many words as you can remember.” Make a note for each word correctly named without prompting in a specially designated place.

Scoring: 1 point is awarded for each word named without any prompts.

Optionally, after a delayed attempt to recall words without a prompt, give the subject a hint in the form of a semantic categorical key for each unprompted word. Make a mark in the space provided if the subject recalled the word using a categorical or multiple choice prompt. Prompt in this way all the words that the subject did not name. If the subject does not name the word after the categorical prompt, he/she should be given a multiple-choice prompt using the following instructions: “Which word do you think was named: nose, face, or hand?” Use the following categorical and/or multiple choice clues for each word:

• face: categorical clue - part of the body, multiple choice - nose, face, hand;
• velvet: categorical prompt - type of fabric, multiple choice - gin, cotton, velvet;
• church: categorical clue - type of building, multiple choice - church, school, hospital;
• violet: categorical clue - type of flower, multiple choice - rose, tulip, violet;
• red categorical clue - color; multiple choice - red, blue, green.

Scoring: No points are awarded for recalling prompted words. Clues are used for clinical informational purposes only and may provide the test interpreter with additional information about the type of memory impairment. When memory is impaired due to retrieval impairment, performance is improved by cueing. When memory is impaired due to impaired encoding, test performance after prompting does not improve.

11. Orientation

The researcher gives the following instructions: “Give me today’s date.” If the subject does not give a complete answer, then give the appropriate hint: “Name the year, month, date and day of the week.” Then say: “Now tell me this place and the city in which it is located.”

Scoring: 1 point is awarded for each correctly named item. The subject must name the exact date and place (name of hospital, clinic, clinic). No point is awarded if the patient makes an error in the day of the week or date.

Total score: All points are summed up in the right column. Add 1 point if the patient has 12 years of education or less, to a possible maximum of 30 points. A final total score of 26 or more is considered normal.

Appendix 2. Montreal Cognitive Assessment Scale - Moka Test (from the English Montreal Cognitive Assessmnet, abbreviated MoCA). Z. Nasreddine MD et al., 2004. www.mocatest.org. (translation by O.V. Posokhin and A.Yu. Smirnov). Instructions included.
Name:
Education:					Date of birth:
Floor:					Date:
Visual-constructive/executive skills					Draw a CLOCK (10 minutes past twelve - 3 points)			Points
					Circuit	Numbers	Arrows
Naming								_/3
Memory	Read the list of words and the subject must repeat them. Make 2 attempts. Ask to repeat the words after 5 minutes		face	velvet	church	violet	red	no points
		Attempt 1
		Attempt 2
Attention	Read a list of numbers (1 digit in 1s)	The subject must repeat them in direct order 2 1 8 5 4						_/2
		The subject must repeat them in reverse order 7 4 2 /2
Read a series of letters. The test taker must clap his hand for each letter A. No points if there are more than 2 errors		F B A V M N A A J K L B A F A K D E A A A F M O F A A B						_/1
Serial subtraction of 7 from 100			93 86 79 72 65					_/3
4–5 correct answers – 3 points; 2–3 correct answers – 2 points; 1 correct answer – 1 point; 0 correct answers – 0 points
Speech	Repeat: All I know is that Ivan is the one who can help today.							_/2
	The cat always hid under the sofa when the dogs were in the room.
Speech fluency. In 1 minute, name the maximum number of words starting with the letter L (N≥11 words)								_/1
Abstraction	What do words have in common, for example: banana – apple = fruit			train - bicycle		clock - ruler		_/2
Delayed playback	You need to name words without prompting	face	velvet	church	violet	red	Points only for words without prompting	_/5
Additionally upon request	Category hint
	Multiple Choice
Orientation		Date	Month	Year	Day of the week	Place	City	_/6
Norm 26/30				Number of points				_/30
				Add 1 point if education ≤12
© Z.Nasreddine MD Version 7.1 Norm 26/30

Tests to assess the general state of cognitive functions

Appendix 3 Instructions

1. Orientation in time. Ask the patient to fully state today's date, month, year, season and day of the week. The question must be asked slowly and clearly, the rate of speech is no more than one word per 1 second. The maximum score (5) is given if the patient independently and correctly gives a complete answer.

2. Orientation in place. The question is asked: “Where are we?” The patient must name the country, region (for regional centers it is necessary to name the city district), city, institution in which the examination is taking place, floor (or room number). Each error or lack of answer reduces the score by 1 point.

3. Memorization. The instruction is given: “Repeat and try to remember 3 words: pencil, house, penny.” Words should be pronounced as clearly as possible at a speed of 1 word per 1 second. Correct repetition of a word by the patient is scored 1 point for each word. Words should be presented as many times as necessary for the subject to repeat them correctly. However, only the first repetition is scored.

4. Attention and counting. They are asked to sequentially subtract 7 from 100. The instructions may be approximately as follows: “Please subtract 7 from 100, from what you get, 7 again, and so on several times.” 5 subtractions are studied. Each correct subtraction is worth 1 point.

5. Playback. The patient is asked to remember the words that were memorized in step 3. Each correctly named word is scored 1 point.

6. Speech. They show a pen and ask: “What is this?”, similarly - a watch. Each correct answer is worth 1 point. The patient is asked to repeat a complex phrase. Correct repetition is scored 1 point. A command is given orally, which requires the sequential performance of 3 actions. Each action is worth 1 point. A written command is given; the patient is asked to read it and complete it. The command must be written in fairly large block letters on a blank sheet of paper. Then the verbal command is given: “Write a sentence.” Correct execution of the command requires that the patient independently write a meaningful and grammatically complete sentence.

7. Constructive praxis. For correct execution of each command, 1 point is given. For correct execution of the drawing, 1 point is given. The patient is given a sample (2 intersecting pentagons with equal angles). If spatial distortions or unconnected lines occur during redrawing, the execution of the command is considered incorrect.

The test result is determined by summing the scores for each item. You can score a maximum of 30 points in this test, which corresponds to the highest cognitive abilities. The lower the test result, the more severe the cognitive deficit. Patients with dementia of the Alzheimer's type score less than 24 points, with subcortical dementia - less than 26 points.

Appendix 3. Brief Mental Status Rating Scale

Try	Score (points)
Time orientation:
Give the date (day, month, year, season, day of the week)	0-5
Orientation to the place:
Where are we located (country, region, city, clinic, floor)?	0-5
Memorization:
Repeat three words: pencil, house, penny	0-3
Attention and account:
Serial count (“subtract 7 from 100”) 5 times	0-5
Playback
Remember 3 words (see paragraph “Perception”)	0-3
Speech
Naming (show the pen and watch and ask what it is called)	0-2
Ask to repeat the sentence “One today is better than two tomorrow”	0-1
Running a 3-step command:	0-3
“Take a piece of paper with your right hand, fold it in half and place it on the next chair.” Read and follow:
Close your eyes	0-1
Write a proposal	0-1
Constructive praxis Copy the drawing	0-1
Total score	0-30

Appendix 4. Comparative characteristics of mild cognitive impairment and dementia

Criteria	Mild cognitive impairment	Dementia
Daily Activities	Not impaired (only the most complex actions are limited)	Patients “cannot cope with life” due to an intellectual defect and require outside help
Flow	Variable: along with progression, long-term stabilization and spontaneous regression of the defect are possible	In most cases it is progressive, but sometimes it is stationary or reversible
Cognitive defect	Partial, may involve only one cognitive function	Multiple or diffuse
Mini-Mental Status Scale score	Can range from 24 to 30 points	Often below 24 points
Behavior Changes	Cognitive defect is not accompanied by pronounced changes in behavior	Behavioral changes often determine the severity of a patient's condition
Criticism	Safe, disturbances are more of a concern to the patient himself	Sometimes reduced, violations worry relatives more

Appendix 5. Mini-Cog technique

1. Instructions: “Repeat 3 words: lemon, key, ball.” Words must be pronounced as clearly and legibly as possible, at a speed of 1 word per second. After the patient has repeated all 3 words, we ask: “Now remember these words. Repeat them 1 more time." We ensure that the patient independently remembers all 3 words. If necessary, repeat the words up to 5 times.
2. Instructions: “Please draw a round clock with numbers on the dial and hands.” All numbers must be in place, and the arrows must point to 13 hours 45 minutes. The patient must independently draw a circle, arrange numbers and draw arrows. Hints are not allowed. The patient should not look at a real clock on his hand or wall. Instead of 13 hours 45 minutes, you can ask to set the hands at any other time.
3. Instructions: “Now let’s remember the 3 words that we learned at the beginning.” If the patient cannot independently remember the words, then you can offer a hint, for example: “Did you remember some other fruit, instrument, geometric figure.”
The inability to remember at least 1 word after a hint or errors when drawing a clock indicate the presence of clinically significant CIs.

Appendix 6. Memory self-assessment questionnaire

1. I forget the phone numbers I call regularly.

2. I don’t remember what I put where

3. When I stop reading, I can’t find the place I was reading.

4. When I shop, I write down on paper what I need to buy so I don’t forget anything.

5. Forgetfulness causes me to miss important meetings, dates, and activities.

6. I forget things I plan on the way home from work.

7. I forget the first and last names of people I know.

8. I find it difficult to concentrate on the work I am doing.

9. It’s difficult for me to remember the content of a TV show I just watched.

10. I don't recognize people I know

11. I lose the thread of conversation when communicating with people.

12. I forget the first and last names of people I meet.

13. When people say something to me, it’s hard for me to concentrate.

14. I forget what day of the week it is

15. I have to check and double-check that I closed the door and turned off the stove.

16. I make mistakes when writing, typing, or using a calculator.

17. I often get distracted

18. I need to listen to instructions several times to remember them.

19.ohm what am I reading

20. I forget what I was told

21. I have trouble counting change in the store.

22. I do everything very slowly

23. My head feels empty

24. I forget what date it is

How to interpret test results The McNair and Kahn questionnaire must be completed by the patient. This will allow you to assess his CI in everyday life. Each question must be scored from 0 to 4 points (0 - never, 1 - rarely, 2 - sometimes, 3 - often, 4 - very often). A total score >43 suggests the presence of CI.

Appendix 7. Tests for assessing regulatory functions

Battery of "frontal" tests

1. Similarity (conceptualization)

“Banana and orange. What do these objects have in common? If there is a complete or partial inability to name the common thing (“there is nothing in common” or “both are covered with peel”), you can provide the hint “both a banana and an orange are...”; but the test is scored 0 points; do not help the patient answer the following 2 questions: “Table and chair”, “Tulip, rose and daisy”.

Evaluation: only the category names (fruits, furniture, flowers) are evaluated as correct:

• 3 correct answers - 3 points;
• 2 correct answers - 2 points;
• 1 correct answer - 1 point;
• no correct answer - 0 points.

2. Speech activity

“Name as many words as possible that begin with the letter L, excluding names or proper names.”

If the patient does not respond within the first 5 s, you should say: “For example, a tray.” If the patient is silent for 10 seconds, you should stimulate him by repeating: “Any word starting with the letter L.” The test execution time is 60 s.

Rating [repeated words or their variations (love, lover), titles or names are not taken into account):

• more than 9 words - 3 points;
• from 6 to 9 words - 2 points;
• from 3 to 5 words - 1 point;
• less than 3 words - 0 points.

3. Serial movements

“Watch carefully what I do.” The examiner, sitting in front of the patient, performs the Luriev series of fist-rib-palm movements with his left hand 3 times. “Now with your right hand, repeat the same series of movements, first with me, then on your own.” The examiner performs the series 3 times with the patient, then tells him: “Now do it yourself.”

• the patient independently performs 6 consecutive series of movements - 3 points;
• the patient performs at least 3 correct consecutive series of movements - 2 points;
• the patient is not able to perform series of movements independently, but performs 3 consecutive series together with the researcher - 1 point;
• the patient is not able to perform 3 correct consecutive series even with the researcher - 0 points.

Registration and payment

Total:

ADDITIONAL MATERIALS

Cognitive scales

Tests for Cognitive Disorders

Six questions

1. Ask the patient: “What year is it now?”(for an incorrect answer 4 points)
2. Ask the patient: “What time is it?” month?"
3. Offer to the patient remember address consisting of 5 components(for example, Ivan Kovalenko, st. Geroev, 25, Poltava)
4. Ask the patient: “What time is it?” hourapproximately - to within hours?"(for an incorrect answer 3 points)
5. Ask the patient to count backwards from 20 to 1 (for one mistake 2 points, for several mistakes 4 points)
6. Ask the patient to recite the months of the year in reverse order. (for one mistake 2 points, for several mistakes 4 points)

REPETITION

1. Ask the patient to repeat the address that was given to him earlier

(for each mistake - first name/last name/street/house/city - 2 points each)

Interpretation of the result:

Total score of 8 or more clinically significant cognitive impairment.

MINI-MENTAL STATE EXAMINATION (MMSE)

(M. F. FOLSTEIN, S. E. FOLSTEIN, P. R. HUGH, 1975)

Brief Mental State Examination

The most widely used technique for screening and assessing the severity of dementia

Evaluation of results

1. Time orientation: 0 – 5
Enter the date (day, month, year, day of the week)

2. Orientation in place: 0 – 5
Where are we? (country, region, city, clinic, room)

3. Perception: 0 – 3
Repeat three words: pencil, house, penny

4. Concentration of attention: 0 – 5
Serial count (“subtract 7 from 100”) - five times
Or: Say the word “earth” backwards

5. Memory 0 – 3
Remember three words (see point 3)

6. Speech
* Naming (pen and clock) 0-2
* Repeat the sentence: “No ifs, ands or buts” 0 -1
* 3-step command:
* “Take a sheet of paper with your right hand, fold it in half and place it on the table” 0 – 3
* Reading: “Read and complete” (text – “close your eyes”) 0 – 1
* Write a sentence 0-1

9. Draw drawing 0 – 1

TOTAL SCORE 0 – 30

Instructions

1. Orientation in time. Ask the patient to fully state today's date, month, year and day of the week. The maximum score (5) is given if the patient independently and correctly names the date, month and year. If you have to ask additional questions, 4 points are given. Additional questions may be the following: if the patient names only the date, ask “What month?”, “What year?”, “What day of the week?”. Each error or lack of answer reduces the score by one point.

2. Orientation in place. The question is asked: “Where are we?” If the patient does not answer completely, additional questions are asked. The patient must name the country, region, city, institution in which the examination is taking place, and room number (or floor). Each error or lack of answer reduces the score by one point.

3. Perception. The instruction is given: “Repeat and try to remember three words: pencil, house, penny.” Words should be pronounced as clearly as possible at a speed of one word per second. Correct repetition of a word by the patient is scored one point for each word. Words should be presented as many times as necessary for the subject to repeat them correctly. However, only the first repetition is scored.

4. Concentration. They are asked to subtract 7 from 100 in sequence. Five subtractions are enough (up to the result “65”). Each mistake reduces the score by one point.

Another option: they ask you to pronounce the word “earth” backwards. Each mistake reduces the score by one point. For example, if “yamlez” is pronounced instead of “yalmez”, 4 points are given; if “yamlze” – 3 points, etc.

5. Memory. The patient is asked to remember the words that were memorized in step 3. Each correctly named word is scored one point.

6. Speech. They show a pen and ask: “What is this?”, similarly - a watch. Each correct answer is worth one point.

The patient is asked to repeat the above grammatically complex phrase. Correct repetition is worth one point.

7. A command is given orally, which requires the sequential performance of three actions. Each action is worth one point.

8-9. Three written commands are given; the patient is asked to read them and complete them. Commands must be written in fairly large block letters on a blank sheet of paper. Correct execution of the second command requires that the patient independently write a meaningful and grammatically complete sentence. When performing the third command, the patient is given a sample (two intersecting pentagons with equal angles), which he must redraw on unlined paper. If spatial distortions or unconnected lines occur during redrawing, the execution of the command is considered incorrect. For correct execution of each command, one point is given.

Evaluation of results

The test result is obtained by summing the results for each item. You can score a maximum of 30 points in this test, which corresponds to the highest cognitive abilities. The lower the test result, the more severe the cognitive deficit. According to various researchers, the test results may have the following meaning.

28 – 30 points – no impairment of cognitive functions
24 – 27 points – pre-dementia cognitive impairment
20 – 23 points – mild dementia
11–19 points – moderate dementia
0 – 10 points – severe dementia

It should be noted that the sensitivity of the above technique is not absolute: in mild dementia, the total MMSE score may remain within the normal range. The sensitivity of this test is especially low in dementias with predominant damage to subcortical structures or in dementias with predominant damage to the frontal lobes of the brain.

FRONTAL ASSESSMENT BATTERY (FAB)

(B.DUBOIS ET AL., 1999)

Frontal Dysfunction Battery

The technique has been proposed for screening dementia with predominant involvement of the frontal lobes or subcortical cerebral structures, that is, where the sensitivity of the MMSE may be insufficient

1. Conceptualization. The patient is asked: “What do an apple and a pear have in common?” An answer that contains a categorical generalization (“These are fruits”) is considered correct. If the patient finds it difficult or gives a different answer, he is told the correct answer. Then they ask: “What do a coat and a jacket have in common?”... “What do a table and a chair have in common?” Each categorical generalization is worth 1 point. The maximum score in this subtest is 3, the minimum is 0.

2. Speech fluency. They ask you to close your eyes and say words starting with the letter “s” for a minute. In this case, proper names are not counted. Result: more than 9 words per minute - 3 points, from 7 to 9 - 2 points, from 4 to 6 - 1 point, less than 4 - 0 points.

3. Dynamic praxis. The patient is asked to repeat after the doctor with one hand a series of three movements: fist (placed horizontally, parallel to the surface of the table) - rib (the hand is placed vertically on the medial edge) - palm (the hand is placed horizontally, palm down). At the first presentation of the series, the patient only follows the doctor, at the second presentation he repeats the doctor’s movements, and finally, he does the next two series independently. When performing independently, prompting the patient is unacceptable. Result: correct execution of three series of movements – 3 points, two series – 2 points, one series (together with the doctor) – 1 point.

4. Simple choice reaction. The instruction is given: “Now I will check your attention. We will tap out the rhythm. If I hit it once. You must hit twice in a row. If I hit twice in a row, you only have to hit once." The following rhythm is tapped: 1-1-2-1-2-2-2-1-1-2. Result assessment: correct execution - 3 points, no more than 2 errors - 2 points, many errors - 1 point, complete copying of the doctor's rhythm - 0 points.

5. Complicated choice reaction. The instruction is given: “Now if I hit you once, then you don’t have to do anything. If I hit twice in a row, you only have to hit once." The rhythm is tapped: 1-1-2-1-2-2-2-1-1-2. Evaluation of the result is similar to step 4.

6. Study of grasping reflexes. The patient is seated, he is asked to place his hands on his knees, palms up, and the grasping reflex is checked. The absence of a grasping reflex is assessed as 3 points. If the patient asks whether he should grab, a score of 2 is given. If the patient grabs, he is instructed not to do so and the grasp reflex is retested. If the reflex is absent during repeated examination, 1 is given, otherwise – 0 points.

Thus, the test result can vary from 0 to 18; while 18 points correspond to the highest cognitive abilities.

In the diagnosis of dementia with predominant damage to the frontal lobes, a comparison of the FAB and MMSE results is important: frontal dementia is indicated by an extremely low FAB result (less than 11 points) with a relatively high MMSE result (24 or more points). In mild Alzheimer's type dementia, on the contrary, the MMSE score decreases first of all (20-24 points), and the FAB score remains maximum or decreases slightly (more than 11 points).

Finally, in moderate to severe dementia of the Alzheimer's type, both MMSE and FAB scores are reduced.

Clock drawing test

The simplicity and unusually high information content of this test, including for mild dementia, makes it one of the most commonly used tools for diagnosing this clinical syndrome.

The test is carried out as follows. The patient is given a blank sheet of unlined paper and a pencil. The doctor says: “Please draw a round clock with numbers on the dial, and so that the clock hands show fifteen minutes to two.” The patient must independently draw a circle, put all 12 numbers in the correct places and draw arrows pointing to the correct positions. Normally, this task never causes difficulties. If errors occur, they are quantified on a 10-point scale:

10 points is the norm, a circle is drawn, the numbers are in the right places, the arrows show the specified time.
9 points – minor inaccuracies in the location of the arrows.
8 points – more noticeable errors in the placement of arrows
7 points – the hands show completely wrong time
6 points – the arrows do not perform their function (for example, the required time is circled)
5 points – incorrect arrangement of numbers on the dial: they are in the reverse order (counterclockwise) or the distance between the numbers is unequal.
4 points – the integrity of the clock is lost, some of the numbers are missing or located outside the circle
3 points – numbers and dial are no longer related to each other
2 points – the patient’s activity shows that he is trying to follow the instructions, but unsuccessfully
1 point – the patient makes no attempt to follow the instructions

The performance of this test is impaired both in frontal-type dementia and in Alzheimer's dementia and dementia with predominant damage to subcortical structures. ,For a differential diagnosis of these conditions, if the independent drawing is incorrect, the patient is asked to complete the arrows on a dial with numbers already drawn (by the doctor). In frontal-type dementia and dementia with a predominant lesion of subcortical structures of mild and moderate severity, only independent drawing suffers, while the ability to place hands on an already drawn dial is preserved. In dementia of the Alzheimer's type, both independent drawing and the ability to place hands on a ready-made dial are impaired.

1 – there are no subjective or objective symptoms of memory impairment or other cognitive functions.

2 – very mild disorders: complaints of memory loss, most often of two types (a) – does not remember what he put where; (b) forgets the names of close friends. In a conversation with the patient, memory impairments are not revealed. The patient is fully able to cope with work and is independent in everyday life. Adequately alarmed by the existing symptoms.

3 – mild disorders: mild but clinically defined symptoms. At least one of the following: (a) inability to find the way when traveling to an unfamiliar place; (b) the patient's coworkers are aware of his cognitive problems; (c) difficulties in finding words and forgetting names are obvious to the family; (d) the patient does not remember what he just read; (e) does not remember the names of people he meets; (e) put it somewhere and could not find an important item; (g) Serial counting may be impaired on neuropsychological testing.

It is possible to objectify cognitive disorders at this degree of severity only through a thorough study of higher brain functions.

Violations can affect work and home life. The patient begins to deny his existing disorders. Often mild to moderate anxiety.

4 – moderate impairment: obvious symptoms. Main manifestations: (a) the patient is not sufficiently aware of the events occurring around him; (b) memory of certain life events is impaired; (c) serial counting is broken; (d) the ability to find one’s way, carry out financial transactions, etc. is impaired.

Usually there are no violations of (a) orientation in time and in one’s own personality; (b) recognition of close acquaintances; (c) the ability to find a well-known road.

Inability to perform complex tasks. Denial of the defect becomes the main mechanism of psychological defense. There is a flattening of affect and avoidance of problematic situations.

5 – moderately severe impairment: loss of independence. Inability to remember important life circumstances, for example, home address or telephone number, names of family members (for example, grandchildren), the name of the educational institution from which you graduated.

Usually disorientation in time or place. Difficulties in serial counting (from 40 to 4 or from 20 to 2).

At the same time, basic information about yourself and others is preserved. Patients never forget their own name, the name of their spouse and children. No assistance is required with eating or bowel movements, although there may be difficulties in dressing.

6 – severe impairment: it is not always possible to remember the name of a spouse or other person on whom one is completely dependent in everyday life. Amnesia for most life events. Disorientation in time. Difficulty counting from 10 to 1, sometimes also from 1 to 10. Most of the time he needs outside help, although sometimes he retains the ability to find a well-known road. The sleep-wake cycle is often disrupted. The recall of one's own name is almost always preserved. Recognition of familiar people is usually intact.