HIGHER COGNITIVE

FUNCTIONS

DR. K. SPANDANA
1ST YEAR POST GRADUATE
DEPARTMENT OF
PSYCHIATRY
• COGNITIVE FUNCTIONS:

• Higher cognitive functions are important in carrying out day to-day

activities and to perform effectively in the environment.

• As a result, impairment can lead to social and vocational difficulties.

• Restoring these functions or helping the patient to find suitable

measures to overcome these deficits would therefore be important in
rehabilitative work.
• Clinical assessment includes
• Attention & concentration
• Orientation
• Memory
• Intelligence
• Judgement
• A general sense of intellectual level and how much schooling the
patient has had can help distinguish intelligence and educational issues
versus cognitive impairment that might be seen in delirium or
dementia.
ATTENTION & CONCENTRATION:

• Attention is the taking into possession of the mind, in clear and vivid form,
of one out of what seem several simultaneously possible objects or trains of
thought.

• Focalization, concentration, of consciousness are of its essence.

Aspects of Attention:
Aspect of attention Definition
Focused or selective The capacity to highlight important stimuli while
attention suppressing awareness of competing distractions
Sustained attention or The capacity to maintain attentional activity over
vigilance a prolonged period
Divided attention The ability to respond to more than one task at a
time, including taking account of the multiple
elements within a complex task
Alternating attention The ability to shift attentional focus from task to
task
Attentional capacity The extent of the processing ability inherent in
the attentional system; it is often considered to
be a form of working memory
• Tests used in clinical assessment
• Digit span test:
• Forward : 573, 5387, 16495, 341796, 7259483, 47291685
• Normal Digit span: 7 + 2
• Backwards: 417, 6158, 29763, 615839, 4715386, 92583174
• Normal Digit span: 5 + 2
• Read the digits at the rate of one per second to the patient.
• The same digit should not be presented more than once
• If the pt. cannot repeat a second trial with same number of digits, the
digit span is taken as highest number of digits repeated correctly.
• SERIAL SUBTRACTIONS : Increasingly difficult tests are presented.
• Task correct response and Time limit
• 20 – 1 15 secs
• 40 – 3 60 secs
• 100-7 120 secs
• Days or months repeated in forward & backward order
Impression:
Attention – Aroused
Concentration - sustained.
• Attention is decreased in normal people in sleep, dreams, hypnotic states,
fatigue and boredom.
• It may be pathologically decreased in organic states, usually with lowering of
consciousness.
• Eg: head injury, acute toxic confusion states such as drug- and alcohol-
induced conditions, epilepsy, raised intracranial pressure and brainstem
lesions.
• In psychogenic states, attention may be altered.
• Diminished in hysterical dissociation.
• Narrowing of attention is also prominent in depressive illness, in which
the morbid mood state results in attention being limited to a restricted
number of themes – mostly unhappy.
• A severe deficit of attention is a prominent feature in the hyperkinetic
disorders in childhood but which also occur in adult life.
• Impairment of focused attention and concentration is a feature of mania
and hypomania and also occurs in organic states. These features
combine to show the symptoms of distractibility, which is prominent in
mania and some organic states.
• Narrowing of attention entails the ability of the subject to focus on a
small part of the field of awareness and occurs in conditions in which
involuntary attention is directed elsewhere – by hallucinations, by
delusions or by strong emotion.
• In schizophrenia, there is a greater susceptibility to lures within the
environment that capture the passive attention of the patient.
• Eg: A patient with schizophrenia repeatedly ignored questions and said, ‘I
wish you would not interrupt when I am being given my instructions’.
• In mood disorders, including bipolar mood disorders, during the acute
phase as well as in the euthymic state there are impairments in sustained
attention and working memory.
• In normal people a sudden, unexpected noise captures passive attention.
• In mood disorder, what lures the individual are people and not things, in
contrast to schizophrenia where the reverse is true.
ORIENTATION :
• Orientation is the capacity of an individual to accurately gauge time, space
and person in his current setting.
• TIME :
• Approximately what time of the day is it ? Is it morning / evening /
afternoon / night ?
• Approximately how long is it since u had ur breakfast / lunch / tea
• Approximately how long I have been talking to you ? What is the date &
day is today ?
• PLACE:
• What place is this ?
• PERSON:
• Orientation of person is tested by asking identity of the pt. Inquire
about the identity of the pt s relatives and family members.

• Disorientation in time and loss of intellectual grasp (situational

disorientation) usually occur first in a progressive illness; disorientation
in place usually occurs later and, in person, last of all.
• Disorientation for one’s own identity occurs at a later stage than for
that of other people.
• Delusions that Mimic Disorientation
• Disorientation is usually associated with other organic features, such as
lowering of consciousness or disturbance of memory.
• Delusions of misorientation have the features of a delusion.
• Eg: a person on the ward may believe himself to be in prison, and a
visiting relative may be considered to be an interrogator from the
Gestapo.
 MEMORY:
• Mental process that allows the individual to store information for
last recall.
• Memory can be divided into:
• sensory memory
• short-term memory
• central executive
• visuospatial scratch pad
• phonological loop
• long-term memory
• SENSORY MEMORY
• Sensory memory is the initial and early phase of memory.
• It holds large amounts of incoming information briefly.
• It is a selecting and recording system via which perceptions enter
the memory system
Eg: Fleeting visual image, iconic memory (lasts up to 200
milliseconds)
Auditory, echoic memory (lasts up to 2,000 milliseconds)
• The information selected and recorded at this level needs to be
further processed as short-term memory or it quickly decays and is
lost.
• SHORT-TERM MEMORY
• It is a limited capacity system that operates as a set of subsystems.
• It is span of attention limited to six or seven items and lasting 15 to 30
seconds unless the items are rehearsed.
• Baddeley and Hitch (1974) hypothesized a model of working memory
comprising a central executive, a visuospatial scratch pad and a
phonological loop.
• The central executive is the attentional controller assisted by the
visuospatial scratch pad that allows for the temporary storage and
manipulation of visual and spatial information.
• The phonological loop holds memory traces of verbal information for a
couple of seconds combined with subvocal rehearsal
• LONG-TERM MEMORY
• Long-term memory can be conceptualized into two retrieval systems:
• Declarative system, or explicit memory: deals with facts and events
and is available to consciousness for declaration
• Semantic (fact memory)
• Episodic (memory for specific autobiographical incidents).
• Non-declarative or implicit system.
• Long-term memory can hold information for periods of time from a few
minutes to many decades.
• It is impaired in the dysmnestic syndromes.
Long term memory can be divided into the following five
functions:
FUNCTIONS DEFINATIONS

Registration or It is the capacity to add new information to the

encoding memory store

Retention or storage It is the ability to maintain knowledge that can

subsequently be returned to consciousness

Retrieval It is the capacity to access stored information

from memory by recognition, recall or
implicitly by demonstrating that a relevant task
is performed more efficiently as a result of prior
experience
Recall It is the effortful retrieval of stored information into
consciousness at a chosen moment. It requires an active,
complex search process
Eg: The question ‘What is the capital of France?’ requires
the recall function
Recognition It is the retrieval of stored information that depends on the
identification of items previously learned and is based on
either remembering (effortful recollection) or knowing
(familiarity-based recollection)
Eg: The question ‘Which of the following is the capital of
France: Paris, Lille or Lyon?’ tests the recognition function.

• Abnormality of memory may occur in any of these areas. There can be

impairment of encoding, impairment of storage or impairment of retrieval.
• Assessment includes immediate, recent and remote memory
• Immediate memory: tested by
• digit span test.
• Recent memory – tested by
• i. address test: An address consisting of about 4-5 facts not known
to the pt. is slowly read to the pt. after instructing him to attend to
the examiner to engage in the conversation (to avoid rehearsal) and
the response is noted verbatim.
• ii. Asking the pt. to recall events in the last 24 hrs. Responses given
by the pt. is crosschecked from the reliable source
• Remote memory – Information on life events
• Date of birth or age, No. of children, Name and no. of family
members, Time since marriage or death of any family members,
Year of completing education
• Facts may be asked that are relevant to pt. background
• Memory disturbances can be divided into:
• Psychogenic, sometimes occurring in healthy people
• Organic (true amnesias), associated with disease of the brain.
• IMPAIRMENT OF REGISTRATION
• Anterograde amnesia (failure of retrieval of information encountered
after the onset of a clinical disorder)- Korsakov’s syndrome
• IMPAIRMENT OF RETENTION
• Retrograde amnesia (loss of memory for events preceding the onset of
brain injury). Newer memories are more vulnerable to loss than older
ones.
• IMPAIRMENT OF RETRIEVAL OR RECALL
• Retrieval is the capacity to access information from memory stores.
• Direct retrieval, in which a cue elicits a memory automatically
• Eg: The question ‘Have you ever been to Lagos?’
• Direct retrieval is dependent on medial temporal lobes and related structures
• Strategic (indirect) retrieval, in which a cue provokes a strategic search
process that produces a result.
• Eg: The question ‘Who won the World Cup before the current
champions?’
• Strategic retrieval is dependent on the ventromedial prefrontal cortex.
• Confabulation is an example of a condition that is a result of impairment of
• IMPAIRMENT OF RECOGNITION
• Recognition is the retrieval of stored information that depends on the
identification of items previously learned.
• Conscious recollection (remembering)
• Knowing based simply on a sense of familiarity.
• A ‘remember’ response indicates that recognizing the stimulus
brings back to mind some conscious recollection of its prior
occurrence, whereas a ‘know’ response indicates that recognizing
the stimulus is not accompanied by any conscious recollection of
its prior occurrence.
• Impairment of recognition has been described in Alzheimer’s disease and
in schizophrenia.
INTELLIGENCE:
• The only precise measurement for this category can be obtained by
administering specialized intelligence tests such as Wechsler's Intelligence
Scale for Adults and Children respectively.
• However, a preliminary assessment of intelligence can be made at the
bedside which includes areas of general information, comprehension,
arithmetic, abstraction.
• GENERAL INFORMATION – Information relevant to the pt's literacy, age,
occupation may be asked.
• For literates – Names of prime minister, chief minister, Capitals of
countries, Current events (major)
• For illiterates – Seasons, crops, and fruits grown in particular seasons,
Prizes of food grains or food items, Prizes of land
• SCORING:
• The average patient with an adequate educational background should
answer a minimum of six questions appropriately.
• The fund of information is quite stable over a wide age range.
• Only in the 80s does one find a small yet statistically significant drop
off in this function.
• By contrast, patients with Alzheimer's disease, even those with mild
disease, score only an average of 3.5 of a possible 10 on this. 3
• Table 2:
• COMPREHENSION:
• The ability to understand questions asked during an interview is one
index.
• Questions of increasing difficulty may be asked :
• 1.What will you do when you feel cold ?
• 2. What will you do if it rains, when you start for work ?
• 3. What will you do if you miss the bus when you are on journey ?
• 4. Why should be away from bad company ?
• ARITHMETIC :
• Calculation ability has two major aspects:
• Firstly, the basic arithmetic concepts of rote tables, addition, sub traction,
multiplication, and division;
• Secondly, the recognition of mathematical signs and symbols and the spatial
alignment of written calculations.
• The patient is first asked to do sums by verbal instructions
starting with simple examples involving addition (e.g., what is 4 plus 6)
subtraction (e.g., what do you get when you take away 4 from 9)
multiplication (e.g., what is the product of 3 times 7)
division (e.g., what do you get when you divide 49 by 7)
• Then proceeding to complex ones (e.g., what is 18 plus 3: 43-18; 21 x 5;
and 1179).
• The patient is expected to respond to each question within 20 seconds and
even if the patient gives a correct response after this time period, it is
considered as a failure.
• This is then repeated using written examples. Failure to respond within 30
seconds is considered a failure.
• If the patient is inattentive and distractible, it is useful to provide each
example on individual cards or to write each new example after the
patient completes the previous example.
• Calculation ability is stable across all age groups, although variable
performance is seen within each group. Performance in early dementia is
not significantly impaired, particularly in older patients. Performance
deteriorates dramatically in the second and third stages of the disease

• Dyscalculia (impaired calculation ability) usually results from dominant

hemisphere lesions. While some patients with other cortical lesions as in
dementia or subcortical lesions involving left caudate nucleus may also
exhibit dyscalculia

• Errors in alignment in right parietal lesions.

• One sided neglect such as left neglect in right hemisphere lesion (indicated
by ignoring the numbers on the left side in written tasks)
• Deficits in arithmetic concepts as in Alzheimer's dementia.
• Alexia (inability to read) and agraphia
(inability to write) relating to
numbers is termed aphasic acalculia and this is commonly seen in patients
with aphasia.

• Alexia for numbers and signs but not for words is a common finding in
lesion of the dominant parietal lobe (Gerstmann syndrome).

• Acalculia due to parietal lobe dysfunction may also lead to errors in

alignment of numbers due to visuospatial deficits.

• Inability to understand and carry out manipulation of numbers

(anarithmetria) is a feature of bilateral or left hemisphere lesions.
Examples of calculation errors:
(1)Patient with a large right hemisphere lesion and left
neglect.
(2)Patient with head trauma and a right parietal
hematoma. Note poor alignment, as well as other
calculation errors
(3)Patient with 2 years of college education, now
showing signs of early dementia.
(4)Patient with Alzheimer’s disease. Note that route
multiplication is good, but basic arithmetic
processes have gross problems.
• ABSTRACTION :
• Abstract reasoning is the ability to shift back and forth between general
concepts and specific examples.1
• Verbal tests
• Nonverbal tests
• Verbal abstraction is tested by similarities, differences and Proverbs
• A commonly used test is the Wechsler Similarities Subtest, where the
task is to identify how two objects are similar or different
• Differences being easy task is always presented before similarities.
• SIMILARITIES:
• The following test items are presented in ascending order of difficulty.
• 1. Turnip-Cauliflower
• 2. Car-Airplane
• 3. Desk-Bookcase
• 4. Poem-Novel
• 5. Horse-Apple
• SCORING: The response for each item pair is scored for adequacy.
• 2 points should be given for any abstract similarity or general classification
that is highly pertinent for both items in the pair.
• 1 point should be given for responses that indicate specific properties of
both items in the pair and that constitute a relevant similarity.
• 0 is given when the response reflects properties of only one member of the
pair, differences or generalizations that are not pertinent to the item pair,
and failures to respond.
• Total for this section is 10 points.
• Eg: 1. Turnip-Cauliflower:
2 points: Vegetables
1 point: Food; grow in the ground; edible
0 points: Buy in the store; one is a root, the other grows above
ground
3. Desk-Bookcase
• 2 points: Articles of furniture; office furniture
• 1 point: Household objects; put books on them; made of the
same material
• 0 points: Sit at a desk and put books in the bookcase; for
studying
5. Horse-Apple
• 2 points: Living things; God's living objects, organic things
• 1 point: Both grow; both have skins; both need food
• 0 points: Horses eat apples; one is big and one is small; we
use them
• The non retarded patient with a normal educational background should
obtain a score of 5 or 6 on this test.
• Two concrete (0-point) responses or a total score of less than 4 suggests
reduced general intelligence or impaired abstract thinking ability.
• In general, performance on this test should be compatible with performance
on the fund of information and proverb interpretation tests.
• PROVERBS:
• The patient is asked the following questions:
Whether he knows what a proverb is?
An example of proverb and what it means?
PROVERBS:
• SCORING: Is done by the degree of abstraction demonstrated by the
patient in explaining the proverb; Abstract (2 points); semiabstract (1
point); and concrete (0 points). The possible total for this section is 10
points.
• Concrete responses are pathologic in all but the retarded or illiterate
patient.
• The average patient should provide abstract interpretations to at least the
first three proverbs and minimally semiabstract responses to the
remaining proverbs.
• Often, uneducated patients will initially give a concrete response but
can give abstract interpretations when specifically asked if there is
another way of explaining the proverb. Such cued responses should be
scored as semiabstract responses.
• A total score of less than 5 on proverb interpretation is suspicious.
• Performance on proverb interpretation is stable across all ages
• The average score of patients with early Alzheimer's disease is only
slightly lower than the average for normal individuals.
• As dementia progresses, performance drops rapidly.
• In general, a score of 2 or 3 on proverb interpretation in educated
individuals indicates organic impairment.
• Nonverbal tests of abstraction:
• Wisconsin Card Sorting Test (WCST)
• Category Test (under Halstead-Reitan Battery)
• Stroop Test for cognitive flexibility.
• Wisconsin Card Sorting Test (WCST)
• In WCST, the patient is asked to sort a series of stimulus cards that
vary in colour, form, and number by matching to a sample array
containing a red triangle, two green stars, three yellow crosses, and
four blue circles.
• A correct matching sequence is given such as "colour-form-number-
colour-form number". Impaired conceptualization, failure to sustain
the correct set, perseveration etc., are noted.
• Difficulty in thinking abstractly is a relatively common consequence of
brain injury.
• Equal impairment on this and the fund of information test suggests
mental retardation or educational deprivation rather than a specific
deficit in abstract thinking.
• Verbal reasoning and abstraction are usually affected in dominant
hemisphere lesions and in extensive cortical involvement as in
Alzheimer's dementia.
• Organic brain syndrome may result in deficits in organizing, planning,
and reasoning ability.
• Thus the patient may be unable to suppress one type of information while
focusing on another
• Eg: when asked to read the colour of ink while pointing to the word
"red", the patient reads the word "red" rather than the colour of the ink
which is "yellow", or may have difficulty in handling two sets of
information simultaneously such as when asked to "sort by colour and
shape".
• In schizophrenia, the patient may exhibit concrete thinking but this can
be distinguished by the fact that this is not associated with any other
cognitive deficits.
 JUDGMENT :
• Judgment refers to the person’s capacity to make good decisions and act on
them.1
• The level of judgment may or may not correlate to the level of insight. A
patient may have no insight into his or her illness but have good judgment.
• Is accused in three areas – personal, social, test
• Personal judgment - by inquiries about the patients future plans.
• Social judgment - Subtle manifestations of behavior that are harmful to the
patient and contrary to acceptable behavior in the culture; whether the
patient understands the likely outcome of personal behavior and is
influenced by that understanding;2
• Can be tested by observing behavior in social situations.
• Test judgment – two problems are presented in a manner in which he can
comprehend. It has been traditional to use hypothetical examples to test
judgment.1
• For example, “What would you do if you found a stamped envelope on the
sidewalk?” It is better to use real situations from the patient’s own
experience to test judgment.
• The important issues in assessing judgment include whether a patient is
doing things that are dangerous or going to get him or her into trouble
and whether the patient can effectively participate in his or her own
care.
• Significantly impaired judgment can be cause for considering a higher
level of care or more restrictive setting such as inpatient
hospitalization.1
• Impairment in social judgment in mania may take the form of
overfamiliarity and inappropriate sexual advances, while patients with
frontal lobe syndrome may exhibit disinhibited behavior such as
urinating in public
 INSIGHT:
• Insight refers to the patient’s understanding of how he or she is feeling,
presenting, and functioning as well as the potential causes of his or her
psychiatric presentation.1
• Insight can be assessed by asking patients whether they are aware of their
problem.
• The patient may have no insight, partial insight, or full insight.
• A component of insight often is reality testing.
• An example of intact reality testing in a patient with psychosis would
be, “I know that there are not really little men talking to me when I am
alone, but I feel like I can see them and hear their voices.”
 • As indicated by this example, the amount of insight is not an indicator of the
severity of the illness.
• A person with psychosis may have good insight, while a person with a mild
anxiety disorder may have little or no insight.
• 1- Complete denial of illness
• 2- Slight awareness of being sick and needing help, but denying it at the same time
• 3- Awareness of being sick, but it is attributed to external or physical factors
• 4- Awareness of being sick, but it is attributed to something unknown in self
• 5- Intellectual Insight: Awareness of being ill and that the symptoms/failures in
social adjustment are due to own particular irrational feelings/thoughts; yet does
not apply this knowledge to the current/future experience.
• 6- True Emotional Insight: It is different from intellectual insight in that the
awareness leads to significant basic changes in the future behavior
• Lack of insight, or denial, is also seen in patients with large right hemisphere lesions,
dementia
• Two bedside tests commonly used to screen for cognitive function are:
• Mini Mental State Examination (MMSE)
• Montreal Cognitive Assessment (MOCA).
• Each requires about 5 to 10 minutes to administer and both are scored on a 30-
point scale providing cutoffs between normal range and levels of impairment.
• The MOCA is supplanting the better known MMSE in many settings because
it tests a wider range of functional problems, performs better in identifying
mild cognitive impairment and provides administration instructions in many
languages.
• ANATOMY:
• The higher cognitive functions rely primarily on an intact cerebral cortex,
although subcortical lesions can also affect performance.
• Abstract thinking, the ability to manipulate old knowledge, and similar
functions are probably widely represented in the cortex, and subcortical
structures.
• Impairment is particularly prominent in widespread bilateral disease (e.g.,
dementia).
• Many of these higher cognitive functions are probably localized in the
posterior rather than in the frontal areas of the brain except Social judgment.
• Patients who have frontal lesions often show very poor social judgment
despite normal cognitive functioning.
• Frontal lobe damage have a loss of abstraction, defects of attention,
memory, and perseveration that may well account for the observed deficits
in higher cognition.
• Verbal reasoning and abstraction are primarily dominant-hemisphere
functions having very close relationships with language.
• Left hemisphere lesions in the right-handed patient typically result in more
severe impairment of calculations than the corresponding lesions of the
non dominant hemisphere.
• Alexia and agraphia for numbers, so-called aphasic acalculia, is a common
finding in mild aphasia.
• Some patients, however, are alexic for numbers and signs (i.e., +, -, x, -;-)
but not for words. This type of dyscalculia is a significant component of
Gerstmann's syndrome, which is secondary to a dominant parietal lobe
lesion.
• Anarithmetria (inability to understand and carry out the complex
manipulations of numbers) is usually seen in left hemisphere lesions or in
bilateral disease (e.g., dementia).
• Impaired calculating ability is most commonly caused by focal lesions in
the parietal lobes.
• In addition to the cases with cortical involvement, some patients with
purely subcortical lesions (e.g., involving the left caudate nucleus) have
shown dyscalculia.
• Parietal lobe acalculia is characterized by a loss of the ability to understand
the meaning of numbers and numeric concepts (e.g., larger or smaller) and
by the inability to align numbers correctly on the page, owing to visual-
spatial deficits.
• The malalignment in complex computations can often be the most striking
feature in the dyscalculia seen in patients with right parietal lobe lesions.
• CLINICAL IMPLICATIONS:
• Deficits in higher cognitive functions are most frequently seen in
patients with widespread brain disease of any etiology.
• These deficits may often be the first sign of deterioration in progressive
brain diseases such as Alzheimer's disease.
• Focal dominant parietal lobe lesions may produce defects in verbally
mediated functions and must be considered in the differential diagnosis
in any patient presenting with a loss of abstract ability or impaired
calculations.
• Lesions of the frontal lobe typically do not interfere with the fund of
knowledge, abstract thinking, and problem solving unless other, more
basic deficits are also present (e.g., perseveration or aphasia).
• Conversely, social awareness and judgment in social situations are
often impaired in patients with large frontal lesions.
• Significant functional disease, particularly schizophrenia, may also
cause impaired abstracting ability.