Download Assessing Neurological Disability

Assessing Neurological
Disability
Corina Azores-Macalintal, M.D., F.P.N.A
Questions
When is the patient neurologically
disabled?
 What kind of neurological disabilities does
neurological diseases brings?

Disability

Definition:

Inability to engage in any substantial gainful
activity by reason of any medically determined
physical or mental impairment(s) which can
be expected to result to death or which has
lasted or can be expected to last for a
continuous period of time.
When is the patient neurologically
disabled?
Mental/ cognitive
 Visual / auditory
 Motor
 Sensory
 Balance and Coordination
 Gait

Mental Disability
Language dysfunction (Aphasia)
 Executive dysfunction
 Memory dysfunction

Aphasia

Acquired impairment of comprehension
and production of verbal language caused
by brain damage.

Alexia and agraphia often co-exist with
aphasia
Aphasia

Four areas of language functioning
Auditory comprehension
 Repetition
 Fluency of verbal expression
 Confrontation naming

Aphasia

Non-fluent





Broca’s
Transcortical motor
Global
Mixed Transcortical

Auditory comprehension

Asyntactic
Can be asyntactic
Severe impairment and
Retain prosody



Fluent




Wernicke’s
Transcortical sensory
Conduction
Anomic




Like global
Milder than global
Asyntactic
intact
Aphasia

Non-fluent





Broca’s
Transcortical motor
Global
Mixed Transcortical

Verbal expression




Agrammatism, aprosodia, apraxia of
speech, poor repetition
Poor initiation, elaboration, intact
repetition,echolalia
Limited to automatisms, stereotypies,
poor repetition
Limited spontaneous, intact repetition,
echolalia
Fluent




Wernicke’s
Transcortical sensory
Conduction
Anomic

Nonmeaningful logorrhea, anosognosia

Intact repetition, echolalia

Conduit d’approche, poor repetition

Pauses for word retrieval, intact
repetition
Aphasia

Non-fluent





Broca’s
Transcortical motor
Global
Mixed Transcortical

Typical word retrieval
errors




Semantic, verbs worse than
nouns
No response, perseverations
Stereotypies, semantic
Stereotypies, semantic
Fluent


Wernicke’s
Transcortical sensory





Conduction
Anomic

Neogolisms, semantic, phonemics
Semantic, phonemic,
circumlocutions
Phonemics, semantic
Circumlocutions, no response,
semantic, nouns worse than verbs
Aphasia

Non-fluent





Broca’s
Transcortical motor
Global
Mixed Transcortical

Left Hemisphere lesion
locations




Fluent




Wernicke’s
Transcortical sensory

Conduction
Anomic



Inf. Frontal, operculum
Dosolateral frontal, or thalamus
Large pre-rolandic + post
rolandic
Watershed/ extrasylvian cortex
Superior temporal
Temoral-parietal or
degenerative
Parietal, insula
Inferior temporal or thalamus or
degenerative
Executive Dysfunction

Impairments in initiation, intention,
planning, sequencing, inhibition, flexibility,
monitoring and various complex aspects of
attention
Memory Dysfunction
MCI
 Dementia

Dementia
Memory impairment (learning and recall)
 One or more:

Aphasia
 Apraxia
 Agnosia
 Dysexecutive function (planning, organizing,
sequencing, abstracting)
*** deficits of sufficient severity to affect social
or occupational functioning

Limb Apraxia

Impaired ability to perform skilled,
purposeful limb movements as a result of
neurologic dysfunction
***excluding weakness, akinesia,
abnormalities of tone or posture and
movement disorders
Limb Apraxia

Type

Clinical features

Impaired ability to make finem
precise, independent finger
movements
Gesture production errors

Limb-kinetic

Ideomotor

Ideational

Impaired sequencing of tool
use

conceptual

Content errors in tool use,
errors in tool selection

Limb Apraxia

Type

Limb-kinetic

Ideomotor

Ideational

conceptual

Assessment tasks




Rotate coin between
thumb and fingers
Gesture to command,
gesture imitation
Serial acts (e.g. fold
letter place in
envelope, seal, stamp)
Tool-object matching
(hammer and nail)
Assessment Tools
Mini Mental State Examination
(MMSE)
Orientation
 Registration
 Attention and Calculation
 Recall
 Language

Neuropsychological Testing

Comprehensive examinations may be
used to establish the existence and extent
of compromise of brain function
Neuropsychological Testing






Cerebral dominance
basic sensation and
perception
motor speed and
coordination,
attention and
concentration,
visual-motor function
memory across verbal
and visual modalities





Receptive and expressive
speech
Higher-order linguistic
operations
Problem-solving
Abstraction ability
General intelligence
Neuropsychological Testing

Should include evaluating pathological
features as:
Emotional lability
 Abnormality of mood
 Impaired impulse control
 Passivity and apathy
 Inappropriate social behavior

Criteria for
Organic Mental Disorder
A. Loss of specific cognitive abilities and medically
documented persistence of at least one of the FF:







Disorientation to time and place, or
Memory impairment (short-term, intermediate, or longterm), or
Perceptual or thinking disturbances (e.g. hallucinations,
delusions, or
Change in personality, or
Disturbance in mood, or
Emotional lability (e.g. explosive temper outbursts,
sudden crying…) and impairment of impulse control
Loss of measured intellectual ability of at least 15 I.Q
points from premorbid levels or severely impaired range
on neuropsychological testing
And
B. Resulting in at least two
of the following
Marked restriction of activities of daily
living; or
 Marked difficulties in maintaining social
functioning; or
 Marked difficulties in maintaining
concentration, persistence, or pace; or
 Repeated episodes of decompensation,
each of extended duration

Or
C. Medically documented history of chronic
organic mental disorder of at least 2 years
and one of the following:
Repeated episodes of decompensation,
each of extended duration
 A residual disease process that has
resulted in such marginal adjustment that
even a minimal increase in mental
demands or change in the environment
would be predicted to cause the individual
to decompensate


Current history of 1 or more years’ inability
to function outside a highly supportive
living arrangement, with an indication of
continued need for such an arrangement
Visual

Presentations:


Visual loss/blurring
Visual field defects
(anopsia)

Assessment




Field testing
Fundoscopy
Visual acuity test
(Snellen)
VEP
auditory

Presentation:



Deafness
Tinnitus
Dizziness

Assessment



Weber, Rinne’s
Audiogram
BAER

Motor, sensory, balance, coordination and
gait disabilities
= disorganization of motor function
Disorganization of Motor function

In the form of paresis or paralysis, tremor
or other involuntary movements, ataxia,
sensory disturbances which may occur
singly or in various combinations
Disorganization of Motor function

Assessment of impairment depends on the
degree of interference with locomotion
and/or interference with the use of fingers,
hands and arms.
Assessment
Motor Strength
 Sensory

Light touch, pressure, heat / cold,
proprioception
*** abnormal sensation as dysaesthesia,
allodynia, hyperaesthesia

Assessment

Balance, coordination and gait
Finger to nose test / heal to shin test
 Tandem walking

Category of
Neurological Impairments
Convulsive Seizure

Degree of impairment
Determined according to type, frequency,
duration and sequelae
 At least 1 detailed description of a typical
seizure
 Presence of associated signs/ symptoms
 Documentation with at least 1 EEG

Convulsive seizure

Only if impairment persists despite
treatment

Blood levels of anticonvulsant medications
 Compliance
to anticonvulsant medication
 Idiosyncrasy in absorption or metabolism

Use of alcohol or drug interactions
Convulsive Seizure

Category of impairments:

Major motor seizures: (grand mal or
psychomotor)
 Occuring
> 1 / month, in spite of at least 3 months
of prescribed treatment with:


Daytime episodes
Nocturnal episodes with residuals ( significantly
interfering with activity during the day)
Convulsive Seizure

Minor motor seizures: (petit mal, psychomotor
or focal)
>
1x / week in spite of at least 3 months of
prescribed treatment
 With alteration of consciousness and transient
postictal manifestations of conventional behavior
or significant interference with activity during the
day
Vascular Accidents
(> 3 most post=vascular accident)
Sensory or motor aphasia resulting in
ineffective speech or communication; or
 Significant or persistent disorganization of
motor function in two extremities, resulting
in sustained disturbances of gross and
dexterous movements, or gait and station.


Depends on the degree of interference with
locomotion and/or interference with the use of
fingers, hands and arms
Brain Tumors

Definitive diagnosis
Histologically malignant tumor – pathological
diagnosis alone will be the decisive criterion
for severity and expected duration
 Other tumors – severity and duration of the
impairment will be determined on the basis of
symptoms, signs and pertinent laboratory
findings


Persistence of the tumor
Brain tumors
The site of primary, recurrent and
metastatic lesion must be specified- in
malignant neoplastic diseases
 Operative procedure or hospitalization with
findings of surgery and results of
pathologist’s gross and microscopic
examination of tissues

Brain Tumors
Maligant gliomas( astrocytomas grades IIIIV, glioblastoma multiforme)
medulloblastoma, epenymoblastoma,
primary sarcoma) or
 Astrosarcoma (grades I-II), meningioma,
pituitary tumors, oligodendroglioma,
epndymoma, clivus chordoma and benign
tumors

Brain Tumors

Assessment based on:
Secondary Epilepsy, major or minor
 > 3 months of

 Sensory
or motor aphasia
 Significant or persistent disorganization of motor
function

Secondary mental disorders
Parkinsonian syndrome

Significant rigidity, bradykinesia or tremor
in two extremities which singly or in
combination, result in sustained
disturbance of gross and dexterous
movements, or gait and station
Cerebral Palsy
IQ of 70 or less; or
 Abnormal behavior patterns, as
destructive or emotional instability
 Significant interference in communication
due to speech, hearing or visual defect; or
 Disorganization of motor functions

Spinal cord or nerve root lesions

Disorganization of motor function
Other Episodic conditions

Multiple sclerosis/ myasthenia gravis
Frequency and duration of exacerbation
 Length of remissions
 Permanent residuals

Multiple Sclerosis
I. Disorganization of motor function

Significant and persistent disorganization of
motor function in two extremities, resulting in
sustained disturbance of gross and dexterous
movements, or gait and station
Multiple Sclerosis
II. Visual impairments
Impairment of central visual acuity
 Contraction of peripheral visual fields in the
better eye
 Loss of visual efficiency

Multiple Sclerosis
III. Mental impairments

History and PE or laboratory tests
demonstrate the presence of a specific
organic factor judged to be etiologically
related to the abnormal mental state and loss
of previously acquired functional abilities
Multiple Sclerosis
IV. Significant reproducible fatigue of motor
function with substantial muscle weakness
on repetitive activity, demonstrated of PE
with CNS correlation
- use of assessment scale
- evoke response tests during exercise
Myasthenia Gravis
Significant difficulty with speaking,
swallowing or breathing while on
prescribed therapy; or
 Significant motor weakness of muscles of
extremities on repetitive activity against
resistance while on prescribed therapy

Amyotrophic lateral sclerosis
Significant bulbar signs
 Disorganization of motor function

Anterior Poliomyelitis
Persistent difficulty with swallowing or
breathing
 Unintelligible speech
 Disorganization of motor function

Muscular Dystrophy

Disorganization of motor function
Tabes Dorsalis
Tabetic crisis occuring more frequently
than once monthly; or
 Unsteady, broad based or ataxic gait
causing significant restriction of mobility
substantiated by appropriate posterior
column signs

Subacute combined cord
Degeneration

Disorganization of motor function, not
significantly improved by prescribed
treatment
Degenerative disease
(Huntington’s chorea, Friedreich’s ataxia, and Spinocerebellar degeneration, Alzhiemer’s dementia…)
Disorganization of motor function
 Chronic brain syndrome

Traumatic Brain Injury
May result in neurological and mental
impairments with a wide variety of
posttraumatic s/sx
 May need to defer adjudication of the
claim at least 6 months post-injury

Traumatic Brain Injury

Evaluated according to:
Secondary seizure
 Secondary motor or sensory aphasia
 Significant or persistent disorganization of
motor function
 Cognitive dysfunction
