Testing Orientation, Concentration, Knowledge, and Constructional Ability

PURPOSE

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.

WHEN TO TEST ORIENTATION, CONCENTRATION, KNOWLEDGE, AND CONSTRUCTIONAL ABILITY

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.

NEUROANATOMY OF ORIENTATION, CONCENTRATION, KNOWLEDGE, AND CONSTRUCTIONAL ABILITY

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) hemisphere.

EQUIPMENT NEEDED TO TEST ORIENTATION, CONCENTRATION, KNOWLEDGE, AND CONSTRUCTIONAL ABILITY

Pen or pencil and paper.

HOW TO EXAMINE ORIENTATION, CONCENTRATION, KNOWLEDGE, AND CONSTRUCTIONAL ABILITY

Orientation

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
the 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

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

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 ones.

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.”).

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