Testing Orientation, Concentration, Knowledge, and Constructional Ability

Ovid: Field Guide to the Neurologic Examination

Authors: Lewis, Steven L.
Title: Field Guide to the Neurologic Examination, 1st Edition
> Table of Contents > Section 2
– Neurologic Examination > Mental Status Examination > Chapter 8
– Testing Orientation, Concentration, Knowledge, and Constructional

Chapter 8
Testing Orientation, Concentration, Knowledge, and Constructional Ability
The purpose of testing parameters of cognitive function
is mainly to look for evidence of any diffuse or focal brain disorder
that can affect cognition.
You should assess your patient’s orientation,
concentration, or knowledge whenever there is any clinical suspicion
for or complaint of cognitive dysfunction. Testing constructional
ability (e.g., clock drawing) is helpful whenever a disorder of
cognition is suspected, but it is particularly useful if you suspect a
focal right hemisphere process. None of these mental status tests need
to be formally performed if there is no clinical suspicion or complaint
of an abnormality of mental status or right hemispheric function.
Orientation, concentration, and knowledge are not
clearly localizable to a specific neuroanatomic area of the brain and
should be thought of as requiring the coordinated effort of multiple
(diffuse) regions of the cerebral hemispheres. Constructional ability,
however, resides primarily in the nondominant (usually right)
Pen or pencil and paper.
  • To assess if the patient is oriented to
    place, simply ask where he or she is. If the patient is able to respond
    correctly in a general way (e.g., in a hospital or in a clinic), try to
    see how specific his or her answer can be, such as which hospital room
    number or which floor of the clinic. If he or she is unable to respond
    to the general question correctly, ask an even more general question,
    such as what city he or she is in.
  • To assess if the patient is oriented to
    time, simply ask what the date is (including the month, date, year, and
    the day of the week). If you suspect


    patient may have difficulty knowing the exact date, start the
    questioning more generally by asking what year it is before asking more
    specifically about the month, day of the week, and date.

Concentration is tested by asking the patient to perform
a task that requires juggling of information in the patient’s mind,
and, therefore, these tasks need to be performed without the patient
using pencil or paper. In practice, concentration is often tested by
asking the patient to spell a word (such as “world”) backward, after
showing that he or she can correctly spell it forward. Another test of
concentration is the test of serial sevens.
To test serial sevens, ask the patient to “subtract seven from one
hundred and then keep going down by sevens,” with the patient reciting
the answers one by one aloud. Avoid the serial seven test if the
patient’s educational status suggests that the calculation involved
(which is not trivial if the patient has only a partial grammar school
education) would be a problem.
Knowledge can be assessed in many ways, including asking
about personal information (e.g., “How many grandchildren do you
have?”) or about current events (e.g., “Who’s the President of the
United States?” or “What’s going on in the news these days?”). To save
time, it’s probably best to start with a more difficult question and
proceed to easier questions if the patient has problems with the harder
Constructional Ability
Constructional ability can be tested in several ways.
One useful test for constructional ability consists of asking the
patient to draw a clock. To do so, draw a circle on a piece of paper,
making sure that the circle is big enough (e.g., more than 2 in. in
diameter) that the patient can comfortably fill in the numbers, and
then ask the patient to “Draw the numbers of a clock in the circle.”
Once the patient has filled in the numbers, ask the patient to draw the
hands to make the clock read a particular time (e.g., “Draw the hands
of the clock to make the clock read 2:30.”).
Clinicians also often test constructional ability by
asking the patient to copy a diagram showing two pentagons intersecting
at one corner (so that a four-sided figure is created by the
intersecting sides); this is the constructional task included within
the commonly performed Mini-Mental State Examination (see Chapter 5, Approach to the Mental Status Examination).
Normally, patients should be oriented to place
(including the name of the hospital or clinic and the floor of the
building) and time (including day of the week, date, month, and year).
Normally, patients should be able to spell the word
“world” backward if they can correctly spell it forward. Assuming a
baseline ability to subtract appropriately, patients should be able to
perform serial sevens down to the 50s or 60s.
Patients should normally be able to give you correct
personal information, such as their address and the number of children
and grandchildren they


have. Patients should also have knowledge of current events compatible with their baseline level of education and interest.

Constructional Ability
Patients should be able to draw all of the numbers of a
clock in the approximate correct places, should not ignore any side of
the clock, and should be able to place the clock hands in the
appropriate places. Patients should also be able to copy a figure, such
as two intersecting pentagons, keeping both figures five-sided, and
they should be able to correctly copy the intersection of the two
pentagons as a four-sided figure.
Disorientation to place or time is abnormal and
consistent with any abnormality of cognition. This is not localizable
to a specific hemispheric region and is most suggestive of diffuse or
multifocal brain dysfunction.
Abnormalities on tests for concentration include
difficulties spelling the word “world” backward or errors performing
serial sevens (assuming the patient has the baseline ability to
subtract). Difficulties with concentration are not localizable to a
particular hemispheric region and can be seen due to any cause of
diffuse or multifocal brain dysfunction.
Lack of knowledge of personal information, such as home
address or information about family members, is usually clearly
abnormal. Be careful, though, not to overinterpret gaps in knowledge of
current events or knowledge of public figures (such as the name of the
President or especially the Vice President), unless it is clear that
this information would have been known at baseline. Abnormalities of
knowledge should always be interpreted within the context of your
presumption of the patient’s baseline level of cognitive functioning
(based on the history you have obtained from the patient or family) and
should be considered indicative of a new abnormality only if worse than
baseline. Most abnormalities of knowledge are not localizable to a
particular hemispheric region and can be seen due to any cause of
diffuse or multifocal brain dysfunction. Recently acquired knowledge,
however, may be lost due to deficits in short-term memory, such as can
be due to bilateral temporal lobe dysfunction, as described in Chapter 7, Memory Testing.
Constructional Ability
  • Errors in clock drawing can include
    incorrect placement of numbers, repeating numbers, and incorrect
    placement of the clock hands. Errors in drawing the intersecting
    pentagons include any errors in drawing the correct number of sides or
    the appropriate intersection of the two figures. Although all these
    errors in constructional ability suggest the possibility of focal
    nondominant (usually right) parietal pathology, most of these errors
    are nonspecific and can also be seen as a result of any diffuse or
    multifocal hemispheric dysfunction.
  • A more specific and localizing kind of
    error can be seen when testing constructional ability. Patients who
    consistently leave out the left side of the clock (i.e., drawing all of
    the numbers on the right side) or ignore the left


    of a figure when copying it have evidence for left-sided neglect that
    is suggestive of a focal nondominant (right) parietal cortical process.

  • Assessment of other aspects of cognition,
    such as abstract thinking or judgment, can sometimes be useful. These
    tests may be helpful, for example, when a frontal lobe dementia is
    suspected, because memory and other aspects of cognition that are
    routinely tested may not be abnormal early in this condition.
    • To test abstract thinking, ask the
      patient to interpret a proverb (one you would assume the patient would
      have heard), such as “A stitch in time saves nine.” Don’t look for
      perfection; simply listen for significant abnormalities, such as
      extreme concreteness or any unusual response.
    • One way to test judgment is to ask what
      the patient would do if he or she found a stamped, sealed, addressed
      envelope on the ground. There is no single correct answer to this
      scenario, but listen for the general appropriateness of the response.
  • All the tests of cognitive function described in this chapter (as well as the tests described in Chapter 7, Memory Testing) would be significantly affected if language function is abnormal (see Chapter 6,
    Language Testing) and, therefore, are difficult to perform and
    interpret in the presence of aphasias, especially Wernicke’s aphasia.
  • As described in Chapter 7,
    Memory Testing, knowledge for self is rarely lost, even in patients
    with a severe lack of orientation to place and time, and it usually
    does not need to be specifically asked when testing orientation. The
    loss of personal identity in an awake, communicative (nonaphasic)
    patient suggests a nonneurologic cause of that dysfunction.

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