Download NeurologicDisability Assessment

Assessing Neurological
Disability
Corina Azores-Macalintal, M.D., F.P.N.A
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Questions
When is the patient neurologically
disabled?
What kind of neurological disabilities
does neurological diseases brings?
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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.
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When is the patient
neurologically disabled?
Mental/ cognitive
Visual / auditory
Motor
Sensory
Balance and Coordination
Gait
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Mental Disability
Language dysfunction (Aphasia)
 Speech
 Comprehension
 Reading and writing
Executive dysfunction
Memory dysfunction
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Aphasia
 Acquired impairment of comprehension and
production of verbal language caused by brain
damage.
 Loss of ability to understand or express
speech
 Alexia - (inability to see words or to read) and
agraphia often co-exist with aphasia
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Aphasia
Four areas of language functioning
 Auditory comprehension
 Repetition
 Fluency of verbal expression
 Confrontation naming
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 Non-fluent
Broca’s
Transcortical motor
Global
Mixed Transcortical
 Fluent
Wernicke’s
Transcortical sensory
Conduction
Anomic
Aphasia
 Auditory
comprehension
 Asyntactic (no arrangement
of words to create a wellformed sentence)
 Can be asyntactic
 Severe impairment and
 Retain prosody (stress and
intonation)
 Like global
 Milder than global
 Asyntactic
 intact
Verbal
expression
Aphasia
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 Non-fluent
Broca’s
Transcortical motor
Global
Mixed Transcortical
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
Nonmeaningful logorrhea, anosognosia
Wernicke’s
Transcortical sensory
Intact repetition, echolalia
Conduction
Anomic
Conduit d’approche, poor repetition
Pauses for word retrieval, intact repetition
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 Non-fluent
Broca’s
Transcortical motor
Global
Mixed Transcortical
 Fluent
Wernicke’s
Transcortical sensory
Conduction
Anomic
Aphasia
 Typical word retrieval
errors
Semantic, verbs worse than nouns
No response, perseverations
Stereotypies, semantic
Stereotypies, semantic
Neogolisms, semantic, phonemics
Semantic, phonemic,
circumlocutions
Phonemics, semantic
Circumlocutions, no response,
semantic, nouns worse than verbs
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 Non-fluent
Broca’s
Transcortical motor
Global
Mixed Transcortical
 Fluent
Wernicke’s
Transcortical sensory
Conduction
Anomic
Aphasia
 Left Hemisphere lesion
locations
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
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Executive Dysfunction
Impairments in initiation, intention,
planning, sequencing, inhibition,
flexibility, monitoring and various
complex aspects of attention
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MCI
Dementia
Memory Dysfunction
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Dementia
 Memory impairment (learning and recall)
 One or more:




Aphasia
Apraxia - inability to perform purposeful functions
Agnosia - inability to interpret sensation and recognize things
Dysexecutive function (planning, organizing, sequencing,
abstracting)
*** deficits of sufficient severity to affect social or
occupational functioning
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Criteria for
Organic Mental Disorder
A. Loss of specific cognitive abilities and medically
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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
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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 de-compensation, each
of extended
Or
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C. medically documented history of chronic organic
mental disorder of at least 2 years
and one of the following:
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 Repeated episodes of de-compensation, 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
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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
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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
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 Type
Limb-kinetic
Ideomotor
Limb Apraxia
 Clinical features
Impaired ability to make fine
precise, independent finger
movements
Gesture production errors
Ideational
Impaired sequencing of tool use
conceptual
Content errors in tool use, errors
in tool selection
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 Type
Limb-kinetic
Ideomotor
Ideational
conceptual
Limb Apraxia
 Assessment tasks
Rotate coin between
thumb and fingers
Gesture to command,
gesture imitation
Serial acts (e.g.fold letterm
place in envelope, seal,
stamp)
Tool-object matching
(hammer and nail)
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Assessment Tools
Mini Mental State Examination
(MMSE)
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Orientation
Registration
Attention and Calculation
Recall
Language
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Neuropsychological Testing
Comprehensive examinations may be
used to establish the existence and
extent of compromise of brain function
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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
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Neuropsychological Testing
Should include evaluating pathological
features as:
 Emotional lability
 Abnormality of mood
 Impaired impulse control
 Passivity and apathy
 Inappropriate social behavior
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 Presentations:
 Visual acuity
 Visual field defects
(anopsia)
 blindness
Visual
 Assessment
Field testing
Fundoscopy
Visual acuity test
(snellen)
VEP
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auditory
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 Presentation:
Deafness
 Assessment
Weber, rinne’s
Associated s/sx
Tinnitus, ear
discharges,
BAER
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Motor, sensory, balance, coordination
and gait disabilities
= disorganization of motor function
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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
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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.
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Assessment
Motor Strength
Sensory
 Light touch, pressure, heat/cold,
proprioception
*** abnormal sensation as dyseasthesia,
allodynia, hypereasthesia
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Assessment
Balance, coordination and gait
 Finger to nose test / heal to shin test
 Tandem walking
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Category of
Neurological Impairments
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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
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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
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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)
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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
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Vascular Accidents
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(> 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
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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
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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
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Brain Tumors
 Maligant gliomas( astrocytomas grades III-IV,
glioblastoma multiforme) medulloblastoma,
epenymoblastoma, primary sarcoma) or
 Astrosarcoma (grades I-II), meningioma,
pituitary tumors, oligodendroglioma,
epndymoma, clivus chordoma and benign
tumors
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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
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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
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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
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Spinal cord or nerve root lesions
Disorganization of motor function
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Episodic conditions
Multiple sclerosis/ myasthenia gravis
 Frequency and duration of exacerbation
 Length of remissions
 Permanent residuals
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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
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Multiple Sclerosis
II. Visual impairments
 Impairment of central visual acuity
 Contraction of peripheral visual fields in the
better eye
 Loss of visual efficiency
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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
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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
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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
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Amyotrophic lateral sclerosis
Significant bulbar signs
Disorganization of motor function
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Anterior Poliomyelitis
Persistent difficulty with swallowing or
breathing
Unintelligible speech
Disorganization of motor function
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Muscular Dystrophy
Disorganization of motor function
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Tabes Dorsalis
Tabetic crisis occurring more frequently
than once monthly; or
Unsteady, broad based or ataxic gait
causing significant restriction of mobility
substantiated by appropriate posterior
column signs
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Subacute combined cord
Degeneration
Disorganization of motor function, not
significantly improved by prescribed
treatment
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Degenerative disease
(Huntington’s chorea, Frieddreich’s ataxia, and Spino-cerebellarr
degeneration)
Disorganization of motor function
Chronic brain syndrome
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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
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Traumatic Brain Injury
Evaluated according to:
 Secondary seizure
 Secondary motor or sensory aphasia
 Significant or persistent disorganization of
motor function