ASN 2016 UPDATE

27 May 2016

Preparation for postgraduate

examinations
 ASN 2016 UPDATE

10 EXAMINATION TOPICS
MEDICAL EXAMINATIONS
Knowledge is needed but not small print
Clinical problems the basis of study
Common conditions are common!
Patients cannot be manufactured!
Read on bedside clinical problems
Do not learn answers to MCQQ but read around
the stem of the question
Indirectly provide Questions and answers
MEDICAL EXAMINATIONS
Focused on clinical diagnosis mainly by
determining site of lesion on history and
examination
Non neurologists used to quip that you make a
brilliant diagnosis and you are stuck because there
is no treatment
Concentration on diagnosis confirmed by CT and
MRI kindled new interest
Now diagnosis is not a challenge but
MANAGEMENT is.
CONTROVERSIES OF NEUROLOGY ARE MAINLY
CENTRED AROUND MANAGEMENT
POST GRAD EXAMINATIONS
In the past, clinical diagnosis orientated
With modern advances and technology,
diagnosis is more investigation oriented
Hence both clinical and written exams are
more management oriented
Management = appropriate investigation and
correct treatment
ACP- AMERICAN COLLEGE OF
PHYSICIANS
MKSAP 17 2015
MEDICAL KNOWLEDGE SELF
ASSESSMENT PROGRAM
American College of Physicians (ACP)
Medical Knowledge Self Assessment
Program MKSAP 17
American College of Physicians (ACP)
Medical Knowledge Self Assessment
Program MKSAP 17 10 topics
Headache and facial Movement disorders
pain Multiple sclerosis
Head injury Disorders of spinal cord
Seizures and epilepsy Neuromuscular
Stroke disorders
Cognitive impairment Neuro-oncology
 #1
stroke
55 year male 1
PRESENTATION
ED - Emergency Department
20 minute episode of painless visual
loss in left eye.
Followed by 5 mt of slurred speech
No residual symptoms
Hypertension on amlopdipine, no
other medication
55 year male 1
SIGNS

BP178/92, HR 78/mt regular, RR 12/mt.

No cardiac murmurs or carotid bruits
CXR, haematology normal
ECG, Plain CT head normal
55 year male 1
PRESENTATION SIGNS
ED - Emergency
Department BP178/92, HR 78/mt
20 minute episode of regular, RR 12/mt.
painless visual loss in left No cardiac murmurs or
eye. carotid bruits
Followed by 5 mt of CXR, haematology
slurred speech normal
No residual symptoms ECG, Plain CT head
Hypertension on normal
amlopdipine,
no other medication
55 year male 1
Which of the following is the most
appropriate next investigation

(A)Carotid ultrasonography (Duplex

carotids)
(B)CT angiography of neck
(C)MRI of the brain
(D)Trans-oesophageal echo cardiography
Diagnosis
TIA
 1
Educational objective

Evaluate a T I A
ABCD SCORING SYSTEM
Critique /discussion 1
He has most probably had a TIA without
cerebral infarction in CT, with an ABCD score of 2
ABCD2 score
age
Blood pressure -01
Presentation - speech- - 01
Duration of symptoms
Diabetes mellitus
Critique /discussion 1
A) Carotid ultrasonography
TIA most likely involving both speech area and
uni-ocular vision incriminates the proximal carotid
artery, commonest been in the neck.
Given the high risk of recurrence, Duplex carotids is
most appropriate and is non interventional and
relatively cheap.

(B) CT angiography of neck

If Stenosis is more than 50% the exact extent needs
conclusive confirmation by CT or MR Angiography.
 Critique /discussion 1
(C) MRI BRAIN
MRI can differentiate a stroke from TIA and also
show ischaemia elsewhere but is the not the most
appropriate next test.
(D) TOE
useful when other investigations are negative
for source of emboli are negative but yield is small
-?1%.

For a complete evaluation of an ischaemic event , one

needs to also exclude abnormalities of blood and cardiac
rhythm
 1
Correct answer

Appropriate first/next investigation for

search of a source of embolus in retinal
and middle cerebral thrombus is carotid
ultra sonography
 1
Educational objective

Evaluate a T I A
 KEY POINT
take home message
In a patient with suspected TIA,
Non invasive Ultrasonic sonography is the
is the most appropriate test to exclude
significant atherosclerotic disease
 #2
Epilepsy
22 year female 2
PRESENTATION

10 year history of
Recurrent episodes of fear and anxiety,
associated with dry mouth and roller coaster
sensation in stomach lasting 15-60 seconds.
22 year female 2
PRESENTATION
4 times a year but 1-2/month in last 3 months
Momentarily confused and boy friend says she
becomes fidgety.
Well between episodes.
Medical history otherwise negative and she is
not on drugs or medication
22 year female 2
SIGNS
oVital signs normal
oGeneral and CNS examination
normal
oMRI and EEG normal
22 year female 2
PRESENTATION SIGNS

10 year history of SIGNS

Recurrent episodes of fear and
anxiety, associated with dry
mouth and roller coaster o Vital signs normal
sensation in stomach lasting 15-
60 seconds.
o General and CNS
4 times a year but 1-2/month in examination normal
last 3 months o MRI and EEG normal
Momentarily confused and boy
friend says she becomes fidgety.
Well between episodes.
Medical history otherwise
negative and she is not on drugs
or medication
55 year male 2
Which of the following is the
most likely diagnosis
(A) Frontal lobe epilepsy
(B) Juvenile absence epilepsy
(C) panic disorder
(D) Pseudo seizure
(E) TLE/ CPS
Critique /discussion 2
(A) Frontal lobe epilepsy
Different types of aura and seizures but fear and
epigastric aura uncommon. Usually they cause
motor manifestations-focal jerking, cycling
movements that awaken patient from sleep
(B) Juvenile absence epilepsy
At or after puberty absent seizures with or without
convulsions.
No aura.
Lasts 3-10 seconds
Critique /discussion 2
(C) panic disorder
Somewhat similar to presentation but are longer
and not so stereotyped or repetitive
(D) Pseudo seizure
Less likely to be stereotyped and longer in duration
with a post attack phase of reaping the harvest.
(E) TLE/ CPS
Aura described is the most common in TLE. A
simple partial seizure can become complex with
automatisms, like being fidgety
 KEY POINT 2
take home message
A rising epigastric sensation is the most common
epileptic aura that originates in the temporal lobes.
EEG and MRI are often normal

Educational objective
To diagnose TLE/CPS
 #3
Gait disorder
72 year male 3
PRESENTATION
3year history of
Progressive difficulty in walking with imbalance
Slow walk, not agile and recent falls
Occasional problem recalling details, recalling
conversations and events.
Household tasks difficult and also money matters
though he was an accountant before.
Urinary urgency and frequency
Hypertensive on HCT
No history of head trauma, meningitis or ICH
72 year male 3
SIGNS
Vital signs and general examination normal
Slow gait with poor foot clearance, shuffling,
multi step turn, intermittent hesitation
Tandem gait impaired
MMSE 23/30 with points off for serial 7s and
delayed recall.
MRI shows dilated ventricles with no cortical
atrophy
84 year male 3

MRI T 1 MRI T 2
72 year male
PRESENTATION
3year history of
Progressive difficulty in
walking with imbalance
Slow walk, not agile and
recent falls
Occasional problem recalling
details, recalling conversations
and events.
Household tasks difficult and
also money matters though he
was an accountant before.
Urinary urgency and frequency
Hypertensive on HCT
No history of head trauma,
meningitis or ICH
3
SIGNS
Vital signs and general
examination normal
Slow gait with poor foot
clearance, shuffling, multi
step turn, intermittent
hesitation
Tandem gait impaired
MMSE 23/30 with points
off for serial 7s and delayed
recall.
MRI shows dilated
ventricles with no cortical
atrophy
72 year male 3
Which of the following is the
most appropriate next step in
management
(A) MR angiography
(B)Large volume lumbar puncture
(C) trial of donepezil
(D) trial of levodopa
Critique /discussion 3
(A) MRI angiography
Periventricular white matter changes seen in MRI
are similar to non specific changes of small vessel
disease. Periventricular white matter changes in
MRI of NPH may be due to trans-ependymal
absorption of CSF.
However extensive neuro-vascular investigations
are not indicated unless clinically or radiologically
indicated
Critique /discussion 3
(B) Large volume lumbar puncture
Indicated in this patient with the triad of gait
abnormality, cognitive impairment, urinary
disturbance and MRI showing ventriculomegaly
without proportionate cortical atrophy.
LP with removal of 30-50ml of CSF with
measurement of ICP is needed. Before and after LP
cognitive, balance and gait examination is needed.
How soon after LP should repeat examination be
carried out is ?.
Critique /discussion 3

(D) Trial of donepezil

The cholinesterase inhibitor donepezil is

sometimes effective in improving cognitive
symptoms and function in patients with
Alzheimer but is of no benefit in gait and
cognitive symptoms of NPH
Critique /discussion 3

(D) Trial of Levodopa

Though patient has evidence of lower body

Parkinsons, he lacks other symptoms of tremor,
asymmetry of symptoms, and typical non motor
symptoms. Therefore, levodopa may not produce
an improvement.
Triad of gait abnormality, dementia 3
and incontinence
B) PARKINSONS DISEASE
Only Parkinsonian symptom is gait
abnormality.
Other 3 facets of TRAP not present
TREMOR absent
RIGIDITY normal tone
AKINESIS present in gait only
POSTURAL DISTURBANCE - absent

42
 Comparison of gaits
3

Normal wide apart short, short,

close wide apart
 Comparison of gaits
3

Normal wide apart short, short,

close wide apart
cerebellar Parki NPH
Triad of gait abnormality, dementia 3
and incontinence
D) VASCULAR DEMENTIA
No history of previous stroke or
vascular disease
Onset not acute or repeated
ischaemic episodes
No predisposing factors for
vascular disease 45
 3

MULTI INFARCT
DEMENTIA
MRI SMALL VESSEL DISEASE 3
Triad of gait abnormality, dementia 3
and incontinence
E) LEWY BODY DEMENTIA
Overlap with Parkisons disease and
dementia
Fluctuations in cognition
visual hallucinations
No response or worsened by L Dopa
48
Lewy body 3

Found in

1. Parkinsons

2. Lewy body
dementia
NPH 3
 3

NPH after VP shunt

Answer to Question 3
#3
Best response
is
(C)
Normal Pressure
Hydrocephalus (NPH)
 NORMAL PRESSURE HYDROCEPHALUS
(NPH)
Take home message
Dementia, incontinence, difficulty in walking,
falls, incontinence are common in the elderly
but are not necessarily due to ageing!
Treatable causes must be detected early and
treated early for good results.
The triad of gait apraxia, dementia and urinary
incontinence, especially when accompanied by
large ventricle without cortical atrophy requires
early exclusion of NPH easy by MRI (or CT)
 The Gait 3

Normal Patient (NPH) 54

Educational objective
to diagnose NPH

KEY POINT
Large volume LP should be done
before VP shunt for NPH
tremor

#4
52 year female 4
SYMPTOMS
tremor of upper limbs
for 20 years
recently more
prominent, with
difficulty in writing and
using fork and knife
No other Parkinson
features of (T)RAP
52 year female 4
Signs
normal vital signs
outstretched arms show a
Show a large amplitude tremor
and on finger nose testing
B/L and absent at rest
mildly abnormal tandem
gait
 52 year female 4
SYMPTOMS Signs
normal vital signs
tremor of upper outstretched arms
limbs for 20 years show a
tremor
recently of upper
more
Show a large amplitude
tremor
limbs forwith
prominent, 20 and on finger nose
years in writing
difficulty testing
B/L and absent at
using
and fork
recently and
more rest
knife
prominent, with mildly abnormal
No Parki features tandem gait
of (x)RAP
52 year female 4
Which of the following is the most
appropriate next step in treating this patient?
A) Botulinum toxin
B) DBS
C) Levodopa
D) Primidone
E) Topiramate
critique 4
A) Botulinum toxin
Can be effective for essential tremor of voice
and head, but for limbs benefit is limited
because of weakness and side effects.
B) DBS
Useful only for those refractory to medication
and severe disabling tremor. Too early for
patient who has not had the full range of
effective drugs
critique 4
C) Levodopa
Does not have features of Parki like tremor at rest
and unlikely to show a response
D) Primidone
Features are of a familial benign tremor which is
usually non progressive. Primidone and
propranolol are the FDA approved first line
treatment. Primidone was removed from BNF as
an AED but was reintroduced for BET on
recommendation by UK neurologists.
critique 4
E) Topiramate
Topiramate is a second line drug for BET but
is contraindicated in a patient with kidney
stones and glaucoma
Stroke due to atrial
fibrillation

#5
 57 year woman in ED
o Symptoms

o L Hemiparesis with L hemi-neglect of

24 hours
o Hypertension and non ischaemic heart
failure
o Rx frusemide, enalapril and Metoprolol
52 year female
5
SIGNS
BP 166/78, RR pulse 68/mt irregular
Irregularly irregular heart rhythm
L arm and leg weakness 4+,
Dysarthria
L tactile and visual inattention
Dysphagia for liquids
INR 1.1, LDL 54mg/dl
52 year female
5
INVESTIGATIONS
CT recent infarction of R frontal and
parietal hemisphere involving half the
hemisphere
ECG Atrial fib (normal one year ago)
2DE EF 50%, no valvular or wall motion
abnormalities
CXR, Duplex carotids normal
 52 year female 5
SYMPTOMS SIGNS
BP 166/78, RR pulse 68/mt
o L Hemiparesis with L irregular
hemi-neglect of Irregularly irregular heart
rhythm
24 hours L arm and leg weakness 4+,
o Hypertension and non Dysarthria
ischaemic heart failure L. tactile and visual
o Rx frusemide, inattention
enalapril and Dysphagia for liquids
Metoprolol INR 1.1, LDL 54mg/dl

CT recent infarction of R frontal and parietal hemisphere involving half hemisphere

ECG Atrial fib (normal one year ago)
2DE EF 50%, no valvular or wall motion abnormalities
CXR, Duplex carotids normal
52 year female 5
Which of the following is the most
appropriate next step in the treatment

A) Aspirin
B) Dabigatran
C) I V heparin
D) Warfarin
CRITIQUE 5
She has A Fib and an acute L hemisphere infarct.
She is beyond window period for rtPA therapy
Anticoagulation with warfarin or newer
anticoagulants like dagibataran is required for long
term Mx to prevent thrombo-embolism.
If infarct was small and patient stable, warfarin may
have been considered
Withholding anticoagulants for 4 days to 2 weeks is
recommended for moderate or large strokes
Until that time patients are managed with aspirin
Critique 5
She has had an acute ischaemic stroke and has
atrial fibrillation
No other obvious cause is present and she is
beyond window period for rtPA
Aspirin no later than end of 2nd day is standard
practice in stroke units and reduces risk of
recurrence in next two weeks without risk of a
bleed.
aspirin should be added to patients medical
regimen
 #6

MYASTHENIA
 Treat myasthenic crisis 6
60 year male in ED
Symptoms
Progressive SOB for 10 days,
3 month h/o difficulty in swallowing
5 month h/o blurry vision and fatigue
UTI treated with ciprofloxacin after which
fatigue and other symptoms worsened
markedly
 Treat myasthenic crisis 6
Signs
Temp, BP, pulse rate normal
RR 21/mt
B/L ptosis, diplopia with sustained horizontal
gaze, nasal speech snarling smile,
Weakness of neck flexion and all limb muscles
with demonstrable fatigability
No atrophy or fasciculation
Normal reflexes and sensation
 Treat myasthenic crisis 6
Investigations
FBC and metabolic screen normal
CXR normal
Serum Mg 1.2 mg/dl ( 0.62Mmol/L)
Admitted to ICU
Diminishing VC
 Treat myasthenic crisis 6
Question
Which of the following is the most
appropriate emergency treatment
A) High dose i.v steroids
B) I V Magnesium
C) I V Pyridostigmine
D) plasmapharesis
Critique 6
Patient is in myasthenic crisis plasmapharesis
should be started without delay
Diagnosis conclusive on history
Immediate Rx with PE or IVIG
Mg deficiency presents as muscular hyper excitability
not weakness. Mg can worsen MG by NM blockade.
Other contraindicated drugs aminoglycosides, beta
blockers and Ca channel blockers
Pyridostigmine can make condition worse by
increasing secretions
 6

Key point
Patients in Myasthenic crisis should
be treated emergently with
Plamapheresis or IVIG
 Cholinergic side effects 6
Cholinergic symptoms (effects of excess acetyl
choline)
Effect on cholinergic nerve endings and
parasympathetic cranial nerves
NMJ fasciculation
Cholinergic sympathetic sweating
Parasympathetic cranial nerves
III, VII, IX, X
 Parasympathetic cranial nerves6
III small pupil
VII, IX salivation
X vomiting
bronchial secretions and bronchospasm
bradycardia, cardiac arrest
abdominal cramps and colics
Similar side effects with cholinergic drugs
neostigmine, pyridostigmine
 6
MYASTHENIC vs CHOLINERGIC CRISIS

Symptoms similar
increased weakness of affected muscles
Weakness of additional muscles
Respiratory distress
Pre-crisis features may help differentiate dose of
medication, infections, other drugs.
Test dose of tensilon worsens cholinergic but may
improve myasthenic crisis
 MYASTHENIC CRISIS - Mx 6

IV neostigmine 8-12mg/24 hrs

S.c atropine 0.5 mg tds
Prednisolone 100 mg daily
Consider plasmapharesis or IVIG
Change I.v to oral anticholinesterase
when able to swallow.
 CHOLINERGIC CRISIS - Mx 6

Withdraw all anti-cholinesterases

Ventilate if necessary
Monitor respiratory function VC
Wean from ventilation when appropriate
Reintroduce oral anticholinesterase in low
dose and increase as required.
 #7
HEADACHE
 headache 7
44 year male
Symptoms
1 week h/o severe, recurrent, left peri-orbital
headaches.
p/h of 10-12 week period of similar headaches
every spring for past 3 years .
1-2/day, lasts 2-3 hours untreated and
accompanied by nausea, photophobia,
ipsilateral tearing but no aura or vomiting.
 headache 7
44 year male
Symptoms
No relief with resting, but paces the floor
Simple analgesics and prednisolone has had no effect.
Subcutaneous sumatriptan relieved symptoms in 5-10
minutes
Frequency and dosing limiting prevents regular use.
Smoker.
No others medication
 headache 7
44 year male
Signs
Bp 134/82, pulse 78/mt.
All other examination including CNS no
abnormality
 headache 7
Which of the following is the most
appropriate next step?
A) amitriptyline
B) Indomethacin
C0 propranolol
D) topiramate
E) verapramil
critique 7
Has 1-2 daily attacks of severe unilateral peri-orbital
pain lasting 2-3 hours accompanied by at least one
ipsilateral, cranial autonomic feature ptosis, tearing
or rhinorrhoea.
Also has motor restlessness during headache
episodes.
Meets IHS criteria for cluster headache.
Cycles of cluster headaches can last weeks months
with attack frequency varying from 1 E.O.D to 8/day
Cluster headaches typically affect young and middle
aged adults.
critique 7
Male sex and tobacco use are risk factors.
Oxygen and subcutaneous sumatriptan are most effective
for acute cluster headache.
Steroids can reduce attack frequency and are effective as
a bridge therapy for long term therapeutic agents.
Verapramil is drug of choice for cluster headache
prevention but relatively high dose may be required.
Regular ECG to exclude heart block or prolonged PR is
recommended.

Should be treated with verapramil for episodic cluster

headache
critique 7
Both amitryptilene and propranolol are effective
prophylactics for migraine but not cluster
Duration of headaches of this patient is too
short to meet criteria for migraine.
Indomethacin is effective for chronic paroxysmal
hemicrania but not clusters.
CPH is also characterised by unilateral episodes
of pain with ipsilateral autonomic features but
occurs at least 5/day with atypical duration
between 3-20 mts.
critique 7
Anticonvulsant Rx such as topiramate are
have limited effectiveness in cluster
headache.

Prevention with AED should be considered

only after verapramil is ineffective or poorly
tolerated .
 7

Key point
O2 therapy and subcutaneous sumatriptan
are the most effective cluster headache
treatments and verapramil is drug of choice
for cluster headache prevention
 #8
Facial palsy
 Facial palsy 8
53 year man with persistent R sided facial
weakness of 3 months
Difficulty in closing R eye and wrinkling
forehead,
increased sensitivity to loud noises and
occasional slurred speech
Bells palsy was diagnosed and 10 day course
of Prednisolone given
 Facial palsy 8

Only limited improvement, with continued

facial drooping and mild dysarthria
Uses eye patch over R eye at noght
No medication now
 Facial palsy 8
SIGNS
Normal
R facial weakness involving forehead, orb.oculi, lower
facial muscles.
Taste recognition impaired anterior part of R side of
tongue.
Facial sensation and muscles of mastication intact.
Corneal reflex present bilaterally and JJ normal.
Hearing intact.
Reflexes normal
 headache 8
Which of the following is the most
appropriate next step?
A) acyclovir
B) clinical follow up
C) MRI brain
D) physical therapy
critique
In a patient with incomplete recovery after 3 months with
appropriate, MRI is indicated to rule out an underlying
structural lesion.
The weakness of upper and lower facial muscles favours a
peripheral rather than a central lesion.
Initial presence of hyperacusis and impaired taste is
consistent of facial nerve involvement.
Immediate brain imaging is unnecessary in patients with
isolated typical facial palsy.
Most idiopathic Bells palsy and 70-90% recover
completely in 3 months.
Evidence for use of acyclovir and even physiothrapy in
Bells is not conclusive
critique
Severe Residual weakness occurs in a minority
but persistence of significant deficits at 3
months should prompt further investigation.
Alternative causes of facial palsy include
-Diabetes
Lyme disease
Vasculitis
HIV
Sarcoidosis, paraprotinaemia and Sjogrens
 8

Key point
MRI brain is appropriate in a patient with
poor recovery in 3months after appropriate
therapy.
 #9
MS and pregnancy
 29 year female 9
Evaluated at a routine follow up of MS
diagnosed 3 years ago
She wishes to discontinue oral contraceptive
and become pregnant.
She has no other personal or family history of
note
Medications are Fingoimod, Vit.D and oral
contraceptive
 Female MS 9
Signs

Temp 98.5F, BP 100/50, pulse 66/mt, RR 14

/mt, BMI 27.
R afferent pupillary defect is noted.
 Female MS 9
Besides discontinuing oral contraceptive,
Which of the following is the approprate next
step?
A) advise against pregnancy
B) discontinue fingolimod
C) substitute mitozantrone for fingolimod
D) substitute Teriflunomide for fingolimod
critique 9
Fingolimod is classified as a category C ( safety in
human pregnancy not established)
Not recommended in pregnancy or planning
pregnancy.
Fingolimod significantly reduces relapse rate.
Fingolimod has many side effects including HT,
Lymphopenia, bradycardia, macular Oedema,
liver function abnormlities.
As hormonal state of pregnancy is itself
protective against MS, withdrawal of DMD in
pregnancy is considered safe
 Pregnancy in MS 9
Advising patient against pregnancy is clearly
inappropriate
The adverse effect of pregnancy in MS is a
commonly held misconception
Mitozantrone reduces relapse rate in MS,
despite this its cardiac toxicity and secondary
leukamia has restricted its use. It is
contraindicated in pregnancy.
Teriflunomide is classified as a category X drug
for pregnancy
 9

Key point
Discontinue fingolimod. Pregnancy should
give adequate protection against relapse of
MS
 #10
Cognitive
impairment
52 year female 10
SYMPTOMS
1 year h/o increasing forgetfulness.
Names, appointments, conversations
lives alone and copes reasonably with ADL
including working as orderly in school and
enjoys life.
52 year female 10
SIGNS
No abnormality in CVS, RS, abdomen.
CNS examination normal except for
MMSE 24/30
Loses points on
Orientation
Delayed recall
52 year female 10
SYMPTOMS SIGNS
1 year h/o increasing No abnormality in
forgetfulness. CVS, RS, abdomen.
Names, appointments, CNS examination
conversations normal except for
lives alone and copes
reasonably with ADL MMSE 24/30
including working as Loses points on
orderly in school and Orientation
enjoys life.
Delayed recall
 10
Q10. Which of the following is the most
likely diagnosis

A) Dementia
B) Depression
C) MCI
D) normal aging
Critique 10
A) dementia - patients cognitive deficit must interfere
with daily functioning and result in some dependence.

In addition to ADL like eating, washing, dressing, toiletry also

ask for ability to

Pay bills
Shopping
Financial management
Taking medication
Driving
Family events
Recall of holidays
Critique 10
B) Depression
On patient history and exclusion of
others.
Depressed mood and anhedonia
Inability to experience pleasure
Dysthymia
No diagnostic tests
Critique 10
C) MCI minimal cognitive impairment
Between dementia and normal aging
No significant functional disability
Montreal cognitive assessment scale
better with more memory recall and
executive function
10-20% become demented each year it
is 1-2% in normal population
Critique 10
D) Normal aging

No features of depression,
disproportionate dependence for ADL
that cannot be accounted on neural
or physical, cardiac, respiratory or
musculo -skeletal disabilities.
Montreal Cognitive assessment
MOCA vs MMSE
MMSE
FOLSTEIN 1976
High language component
30 point scale
7-8 minutes
orientation to time, date, and
place.
tests for recall, but
remember three items.
examining orientation, word
recall, language abilities,
attention and calculation, and
visuo-spatial ability.
MOCA
1996
Better for MCI
30 point scale
10-12 minutes
orientation to time, date, and
place.
tests for recall, but
remember five items.
little more in depth and
includes tasks such as a clock-
drawing test and a trail test
(connecting the dots
Good Day