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Higher Mental Function (HMF) — Step-by-Step Practical Examination

Used in Neurology & Physiotherapy Neuro Practicals as part of the bedside/clinical neurological examination.

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Preparation Before Testing

• Ensure the patient is alert and cooperative
• Account for language, educational level, cultural background, and sensory/motor deficits before interpreting results
• Perform in a quiet, well-lit room
• Introduce yourself and explain the purpose

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Components of Higher Mental Function (Systematic Order)

1. 🔵 Level of Consciousness

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2. 🟢 Orientation (Person, Place, Time)

• Person: "What is your name?"
• Place: "Where are you right now? Which hospital/city?"
• Time: "What is today's date? Day of the week? Month? Year?"

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3. 🟡 Attention & Concentration

• Digit Span Forward: Say digits at 1/second — "2, 7, 4" — ask the patient to repeat. Normal: 7 ± 2 digits forward.
• Digit Span Backward: Same but repeat in reverse. Normal: 5 ± 2 digits.
• Serial 7s: Ask the patient to subtract 7 from 100 repeatedly: 93, 86, 79, 72, 65…
• Serial 3s (simpler, for less educated): Subtract 3 from 20.
• Months in reverse: "Tell me the months of the year backwards."
• Spelling "WORLD" backwards: W-D-L-R-O

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4. 🔴 Memory

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5. 🟣 Speech & Language

• Dysarthria = motor speech problem (slurred, but language intact)
• Dysphonia = voice quality problem

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6. 🟠 Fund of Information

• "Who is the current Prime Minister / President?"
• "Name the last 5 Prime Ministers"
• "What is the capital of [country]?"
• "What was a major recent news event?"

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7. 🔵 Insight and Judgment

• "Why have you come to the hospital today?"
• "Do you think there is anything wrong with you?"

• "What would you do if you found a wallet on the street?"
• "What would you do if you smelled smoke inside a crowded theater?"
• "What would you do if you found a stamped, addressed envelope on the ground?"

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8. 🟤 Abstract Thinking

• "How are an apple and an orange alike?" (both fruits)
• "How are a desk and a chair alike?" (both furniture)
• "How are poetry and sculpture alike?" (both art forms)
• Score: Abstract (best) → Concrete → Unrelated (abnormal)

• "What is the difference between a child and a dwarf?" (age vs. growth disorder)

• "What does 'A rolling stone gathers no moss' mean?"
• "Don't cry over spilled milk"
• Concrete interpretation = frontal/diffuse dysfunction

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9. 🟢 Calculations

• Serial subtraction: 100 − 7 = 93, − 7 = 86… (Serial 7s)
• Serial 3s from 20 for less educated
• Word problems: "If you have ₹50 and spend ₹17, how much is left?"
• "If oranges cost ₹5 each, how many can you buy for ₹30?"

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10. 🔴 Visuospatial & Constructional Ability

• Clock Drawing Test: "Draw a clock face, put all the numbers in, and set the hands to 10 past 11." Assess number placement, hand placement, overall shape.
• Copying figures: Ask to copy intersecting pentagons (part of MMSE), cube.
• Neglect testing: Draw a line bisection — does the patient bisect to one side?

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11. 🟡 Praxis (Purposeful Movement)

• Ideomotor apraxia: "Show me how you would brush your teeth / wave goodbye / salute / comb your hair" (without the object)
• Ideational apraxia: Give a 3-step task involving an object — "Take this paper, fold it, and put it in the envelope"
• Constructional apraxia: Draw/copy tasks as above

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12. 🟣 Executive Function (Frontal Lobe)

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Standardized Screening Tools

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Practical Scoring Summary (MMSE — 30 Points)

• 24–30: Normal
• 18–23: Mild cognitive impairment
• 10–17: Moderate dementia
• <10: Severe dementia

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Physiotherapy-Specific Notes (Neuro Practical)

1. Rehabilitation planning — cognitive deficits affect ability to follow instructions, learn exercises, or use assistive devices
2. Apraxia — directly affects motor learning and ADL retraining
3. Neglect — affects balance, gait training, and safety
4. Insight/judgment — determines fall risk and compliance with home program
5. Executive function — impacts carryover of therapy between sessions
6. Attention — essential for dual-task training (gait + cognitive task)

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Higher Mental Function (HMF) — Complete Practical Demonstration

As Performed in a Neuro Physiotherapy Practical/Clinical Setting

"Bedside evaluations of cognition and memory are an integral part of the neurological examination and a tool by which the clinician localizes lesions affecting higher cortical functions — just as the motor or cerebellar examination localizes neurological deficits." — Bradley and Daroff's Neurology in Clinical Practice

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SETUP — Before You Begin

• Patient's mother tongue / language of examination
• Education level (illiterate / primary / secondary / graduate)
• Hearing or vision impairment — correct before testing
• Emotional/psychiatric state — anxious or drowsy patient will score poorly

"I am going to ask you some questions and simple tasks. There are no right or wrong answers — just do your best."

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SEQUENCE OF EXAMINATION

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STEP 1 — LEVEL OF CONSCIOUSNESS

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STEP 2 — ORIENTATION

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STEP 3 — ATTENTION AND CONCENTRATION

"I will say some numbers. Repeat them back to me in the same order."

• Start: 3 digits → "3 – 7 – 2"
• Increase by 1 digit each time if correct
• Normal forward span: 7 ± 2 digits

"Now I will say numbers. Repeat them in REVERSE order."

• Normal backward span: 5 ± 2 digits

"Start at 100 and keep subtracting 7. Tell me each answer."

• 100 → 93 → 86 → 79 → 72 → 65
• Score 1 point per correct subtraction (max 5)

"Start at 20 and subtract 3 each time."

• 20 → 17 → 14 → 11 → 8 → 5

"Spell the word WORLD" → then: "Now spell it backwards."

• D-L-R-O-W (score 1 per correct letter in sequence)

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STEP 4 — MEMORY

A. Immediate (Registration) Memory

"I am going to say 3 words. Listen carefully and repeat them back to me immediately."

• Patient repeats immediately → ensures registration
• If patient cannot repeat all 3, say them again (max 3 trials) — document number of trials needed
• Score: 0–3

B. Short-Term (Recent) Memory

After 5 minutes (distract with other tests in between): "Do you remember those 3 words I asked you to remember?"

"One was a fruit…" / "One was a piece of furniture…"

"Was it apple, mango, or banana?"

• Repeat at 15 minutes if suspicion is high
• Score: 0–3

C. Long-Term (Remote) Memory

"Tell me your date of birth." "Where did you go to school? What did you study?" "Who was the Prime Minister 10 years ago?" "Name your children / siblings and their ages."

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STEP 5 — SPEECH AND LANGUAGE

A. Spontaneous Speech — observe during history taking:

B. Comprehension (Wernicke's area):

Give a 3-step command: "Take this paper with your right hand, fold it in half, and place it on the table."

C. Naming (Temporal lobe):

Pen → Watch → Knuckle → Fingernail → Collar → Lapel

D. Repetition (Arcuate fasciculus):

"Repeat after me: No ifs, ands, or buts." "Repeat: The cat sat on the mat."

E. Reading (Visual association + language):

F. Writing:

"Please write a complete sentence — anything you like." Check: Spontaneous sentence, grammatically complete, meaningful.

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STEP 6 — FUND OF INFORMATION (General Knowledge)

"Who is the current Prime Minister of India?" "What is the capital of India?" "Name 2 recent major events in the news." "Name 3 freedom fighters."

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STEP 7 — INSIGHT AND JUDGMENT

"Why have you come to the hospital?" "Do you think there is something wrong with you?" "Do you need help with daily activities?"

• Full insight: Acknowledges illness and its limitations
• Partial insight: Recognizes illness but minimizes disability
• No insight: Denies illness (anosognosia — common in right parietal strokes)

"What would you do if you found a wallet on the street?" "What would you do if you smelled smoke in a crowded room?" "What would you do if you found a stamped, addressed envelope on the ground?"

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STEP 8 — ABSTRACT THINKING

A. Similarities (Concept Formation):

"How are an apple and an orange alike?" "How are a chair and a table alike?" "How are poetry and sculpture alike?"

B. Differences:

"What is the difference between a child and a dwarf?" "What is the difference between a mistake and a lie?"

C. Proverb Interpretation:

"What does this saying mean: 'Don't cry over spilled milk'?" "A rolling stone gathers no moss."

• Abstract interpretation = normal frontal function
• Concrete or bizarre interpretation = frontal/diffuse dysfunction

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STEP 9 — CALCULATIONS

"If you have ₹100 and spend ₹37, how much is left?" "If oranges cost ₹5 each, how many can you buy for ₹30?" "If you have 3 dozen eggs and use 10, how many remain?"

"If you buy something for ₹8 and give ₹10, what change do you get?"

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STEP 10 — VISUOSPATIAL AND CONSTRUCTIONAL ABILITY

Give a blank circle drawn on paper: "Draw a clock face. Put in all the numbers, and set the hands to 10 past 11."

Show pre-drawn intersecting pentagons "Copy this figure exactly."

• 1 point if both pentagons have 5 sides AND the intersection forms a 4-sided figure

Draw a 20 cm horizontal line "Mark the exact middle of this line with a pen."

• Marking > 1 cm to the right of center = left hemispatial neglect (right parietal lesion)

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STEP 11 — PRAXIS (Purposeful Learned Movement)

Ideomotor Apraxia — test with gestures (WITHOUT object):

"Show me how you would brush your teeth." "Show me how you would wave goodbye." "Show me how you would use a hammer." "Show me how you would comb your hair." "Show me the military salute."

Ideational Apraxia — test with sequence of actions:

Give paper, envelope, stamp: "Fold the letter, put it in the envelope, and seal it."

Bucco-facial Apraxia:

"Show me how you would blow out a candle." "Lick your lips / whistle / cough."

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STEP 12 — EXECUTIVE FUNCTION (Frontal Lobe)

"Name as many animals as you can in 1 minute."

• Normal: > 12 animals in 60 seconds
• < 10 = frontal or subcortical dysfunction

"Name as many words as you can beginning with the letter F — not proper names — in 1 minute."

• Normal: > 10 words

"Watch carefully, then copy what I do." Repeat 5–6 cycles; then ask patient to continue independently.

• Normal: Learns and continues sequence smoothly
• Perseveration = stuck on one movement = frontal dysfunction

"Continue this pattern to the end of the line."

• Perseveration (repeating same shape) = frontal lobe impairment

"When I tap once, you tap once. When I tap twice, you do NOT tap at all." Practice then test with random single/double taps.

• Inability to inhibit = frontal disinhibition

"How tall is the average Indian man?" "How fast does a car travel on a highway?" Tests reasoning and real-world judgment under uncertainty.

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STANDARDIZED SCALES USED IN NEURO PHYSIOTHERAPY

Note: Education-adjusted norms — illiterate normal cutoff is 19; college graduate cutoff is 29. — Bradley and Daroff's Neurology in Clinical Practice

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LOCALIZATION SUMMARY

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DOCUMENTATION FORMAT (Write in Practical File)

DATE:
PATIENT: Age / Sex / Diagnosis / Side of lesion

HIGHER MENTAL FUNCTIONS:

1. Consciousness:    Alert / Drowsy / Stuporous / Comatose
                     GCS: E__V__M__ = Total __/15

2. Orientation:      Person: Intact / Impaired
                     Place:  Intact / Impaired
                     Time:   Intact / Impaired

3. Attention:        Digit Span F: __  B: __
                     Serial 7s: __/5
                     Spell WORLD backwards: __/5

4. Memory:           Immediate:  __/3
                     Short-term (5 min): __/3 (free / cued / recognition)
                     Long-term:  Intact / Impaired

5. Speech/Language:  Fluency: Fluent / Non-fluent
                     Comprehension: __/3 (3-step command)
                     Naming: __/6
                     Repetition: Intact / Impaired
                     Reading: Intact / Impaired
                     Writing: Intact / Impaired
                     Type of aphasia: ___________

6. Fund of information: Adequate / Reduced (for education level)

7. Insight:          Full / Partial / None (anosognosia)
   Judgment:         Intact / Impaired

8. Abstract thinking: Similarities: Abstract / Concrete
                      Proverbs:    Abstract / Concrete

9. Calculations:     Intact / Impaired

10. Visuospatial:    Clock Drawing: __/5
                     Pentagon copy: Intact / Impaired
                     Line bisection: Normal / Left neglect / Right neglect

11. Praxis:          Ideomotor: Intact / Impaired (L / R hand)
                     Ideational: Intact / Impaired
                     Bucco-facial: Intact / Impaired

12. Executive:       Verbal fluency (animals/min): __
                     Luria sequence: Intact / Perseveration
                     Go/No-Go: Intact / Disinhibition

MMSE Score: __ / 30
MoCA Score: __ / 30 (if administered)

SUMMARY:
HMF examination reveals [normal cognition / mild / moderate / severe impairment]
with specific deficits in [domains], consistent with [e.g., left MCA territory stroke / 
right parietal lesion / frontal lobe dysfunction / global dementia].

PHYSIOTHERAPY IMPLICATIONS:
- [List implications for treatment planning]

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PHYSIOTHERAPY IMPLICATIONS TABLE

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