Primitive reflexes and perceptual sensory tests in the elderly—Their usefulness in dementia

002 l-968118 l/080367-1 I lO2.00/0 Copyrrght 0 1981 Pergamon Press Lld

J Chron Dis Vol. 34. pp. 367 to 371. 1981 Printed in Great Bnrarn. All right% reserved

PRIMITIVE REFLEXES AND PERCEPTUAL SENSORY TESTS IN THE ELDERLYTHEIR USEFULNESS IN DEMENTIA NERLIGE G.

BASAVARAJU,* FELIX A. SILVERSTONE,? LESLIES. LIBOW$ and KLEOMANISPARASKEVA$~ (Receioed

in wised form 20 August 1980)

Abstract-The prevalence of primitive reflexes and abnormal perceptual-sensory tests was compared in 3 elderly groups-the healthy, the demented and those with focal neurologic diseaseand in a fourth group of healthy young volunteers. Test responses differed significantly among the 3 elderly groups and between the combined ill and the healthy elderly in all tests. Discrimination between-demented and neurologically impaired patients was achieved only by the palmomental and grasp reflexes. The bilateral palmomental reflex and the extinction phenomenon in the face-hand test are age-related changes in healthy adults. For individual diagnosis the palmomental and grasp reflexes, and the large-small figure and face-hand test can be easily and usefully applied in the evaluation of dementia.

INTRODUCTION AT A RECENTconference on Alzheimer’s Disease convened by the National Institutes of Health Cl], it was emphasized that most instances of senile dementia occurring after age 65 are pathologically indistinguishable from pre-senile Alzheimer’s Disease with onset prior to age 65. However, there may be different, though as yet unknown, etiologic factors. By 1980 it is projected that 127; of the United States population will be 65 yr or older Cl]. Of these, 4.411; will have severe dementia and ll-12% mild to moderate dementia. Projections from these data yield 1 million severely demented and another 3 million moderately demented persons in this country, estimates which are indeed of impressive magnitude. Approximately 507; of the elderly demented have senile dementia of Alzheimer’s type; 127: have multi-infarct dementia attributable to cerebral infarctions. A mixed form showing pathological features of Alzheimer’s and multi-infarct dementia is found in 18% [23 with the remaining 20% of patients composed of pseudosenility and unclassified types. Among the clinical signs of dementia, the primitive reflexes and perceptual sensory tests are a comparatively neglected group. When searched for, they provide a useful guide to the presence of impairment of cerebral function, a territory of interest to the neurologist, the geriatrician, the internist and the psychiatrist. The primitive reflexes such as the palmomental [3-53, snout [6], sucking [6,7], and grasp [6,7], are physiological and universally present in the human infant. They disappear with maturation of the central nervous system and the development of inhibitory mechanisms in adults. They may reappear in advanced age, in dementia and in some neurological disorders [S-lo]. The appearance of these primitive reflexes can be viewed in terms of Hughling Jackson’s concept of ‘dissolution’ or loss of higher levels which *Jewish Institute for Geriatric Care, New Hyde Park, State University of New York at Stony Brook, NY 11040. tJewish Institute for Geriatric Care, Associate Clinical Professor of Medicine, State University of New York at Downstate Medical Center, Brooklyn. $Jewish Institute for Geriatric Care, State University of New York at Stony Brook. *Jewish Institute for Geriatric Care, New Hyde Park, New York, U.S.A. 367

NERLIGE G. BASAVARAIU et 01.

368

TABLE 1. POPULATION CHARACTERISTICS

Group

II

F

M

Senile dementia of Alzheimer’s type (SDAT) Neurologically impaired elderly (NIE) Healthy elderly (HE) Healthy young adults (HYA)

50

45

50 50 50

Age range, yr

Mean age

5

70-96

82.6

39

11

52-91

77.1

28 41

22 9

65-81 20-55

73.6 38.3

leads to a release phenomenon that had been repressed since the earliest developmental phases [ 111. Similarly, perceptual sensory functions develop in infancy and early childhood and become a part of the permanent intellectual and behavioral characteristics of the youth and adult. These discriminative functions tend to decline in late life in both cutaneous and visual perceptual modalities. They can be demonstrated by double simultaneous stimulation tests such as the face-hand and hand-hand tests (cutaneous), and the largesmall figure test (visual) [S]. We have studied the relationships of these primitive reflexes and perceptual sensory tests to ‘normal’ aging as well as to dementia and to focal neurological diseases in the elderly. A recent paper by L. R. Jenkyn et al. [12] points to the usefulness of a number of physical signs in combination with mental status examination in the evaluation of cerebral dysfunction. Their patients were between the ages of 16-80, with a mean age of 43.8 yr. Our focus is on a more concise battery of simple clinical signs in the evaluation of dementia specifically in the elderly, aged 70-96 (mean age of 82.6) and in distinguishing this entity from specific neurologic disease and the healthy aged. PATIENTS

AND

METHODS

Four groups of 50 subjects each were examined as shown in Table 1. The first group consisted of elderly patients residing at the Jewish Institute for Geriatric Care, New Hyde Park. New York, with advanced senile dementia of Azheimer’s type (SDAT), 70-96 yr of age. The mean age was 82.6. The second group consisted of neurologically impaired elderly (NIE) who needed longterm institutionalization. This group was demarcated by distinct focal neurologic disease, in almost all instances hemiplegia or hemiparesis due to cerebrovascular accident. Their ages were 52-91, with a mean age of 77.1 yr. The third group consisted of healthy elderly (HE). functioning independently in the community and not receiving psychotropic medications. Their ages were 65-81. with a mean age of 73.6 yr. The fourth group consisted of healthy young adults (HYA) between 20 and 55 yr of age, with a mean age of 38.3. These adults were community residing volunteers and employees in the Institute. Mental status evaluation as judged by Function, Reasoning, Orientation, Memory, Arithmetic, Judgement, Emotional State (FROMAJE) [13] was performed in all subjects and delineated the SDAT group as advanced dementia. A routine neurological examination in addition to primitive reflexes and perceptual sensory tests were carried out on all subjects. Statistical assessments were performed using the chi-square method for differences in test responses among subject groups, and probability estimates with confidence limits for classifying individuals within groups, i.e. for diagnostic evaluation. All the subjects were examined by one examiner (K.P.). THE Palmomentnl

PRIMITIVE rejex.

REFLEXES

AND

PERCEPTUAL

SENSORY

TESTS

First described by Marinesco and Radovici in 1920 [14], this reflex

Primitive Reflexes

369

consists of contraction of the ipsilateral mentalis muscle in response to stroking the thenar eminence of the hand. The prevalence of the reflex in the normal adult population has varied from zero to 587: [15]. The superficial reflex is a clinical curiosity, because it is exaggerated in pyramidal lesions, in contrast to diminution or loss of other superficial reflexes, such as abdominal or cremasteric reflexes in similar situations, and also because of the long distance between the sensory stimulus and motor response. Its exact pathway has not been delineated. Experimental evidence suggests that afferent conduction is by way of fast pain fibers [16]. The facial nerve obviously forms the efferent arc. The association of palm and chin in this reflex has been explained by the close proximity of thumb and mouth areas in the sensory and motor cortex and also in the thalamus. Snout rej7ex. This consists of a brief puckering movement of lips due to contraction of orbicularis oris, evoked by a sharp tap on the closed lips. The snout reflex is mediated through the trigeminal (sensory) and facial nerve (motor). It is positive in pyramidal lesions above the nuclei of the VII cranial nerve, diseases of the extrapyramidal system and diffuse cerebral degeneration. Sucking reflex. On stroking the oral region some patients turn towards the stimulus and exhibit sucking movement of lips, tongue and jaw like an infant. Grasp reflex. This is a flexor response of the fingers and thumb elicited by a moving stimulus, such as the examiner’s fingers passing across the palmar surface of the hand and fingers, especially the region between thumb and index finger. The grasp refIex of the hand is a release phenomenon. It is believed that pyramidal tracts at their origin in the precentral convolution are normally inhibited by impulses originating in the first frontal convolution and gyrus fornicatus of both frontal lobes, the inhibitory fibers of the opposite frontal lobe crossing in the corpus callosum to join those from the ipsilateral hemisphere. For the appearance of a grasp reflex, fibers from both frontal lobes should be interrupted and the lesion should be so located as to involve the first frontal convolution and the adjacent part of the corpus callosum, thereby interrupting fibers from the opposite side [17]. Tumors affecting this part of the brain and cerebral infarction due to occlusion of the anterior cerebral artery can cause a contralateral grasp reflex; whereas increased intracranial pressure due to any cause, amyotrophic lateral sclerosis and diffuse cerebral degeneration can cause bilateral grasp reflexes. Face-hand test. The face-hand test, also known as double simultaneous stimulation on face and hand, was first described by Bender er al., in 1951 [18] and has been used as a test for cerebral dysfunction. Kahn et al. in 1960 concluded that the face-hand test combined with mental status questionnaire are valid measures for determination of mental status in the aged [19]. We have modified this test so that all patients were examined with the eyes open and looking at the examiner’s face. Stimulus on the face was more easily perceived than that on the hand; in this sense the face was dominant. The test was performed as follows. With the subject looking at the examiner’s face, a side of the subject’s face and the dorsum of the opposite hand were simultaneously touched (e.g. patient’s right face and left hand). The subject was instructed that there were two stimuli and was asked to localize these stimuli. If only one stimulus was reported by the patient, the test was repeated two more times for confirmation. Similarly the test was repeated by double simultaneous stimulation of the other side of the face and contralateral hand (i.e. patient’s left face and right hand). Then the test was modified so that the examiner touched his own face (e.g. patient’s left hand and examiner’s left face) and the patient was asked to localize the stimuli. A normal response consisted of appropriate localization of both stimuli. Errors in response consisted of failure to perceive one of the two stimuli (extinction) or mislocalization of one of the stimuli (displacement). An uncooperative response was recorded if the patient could not respond to questions because of wordspeech problems, agitation and failure to comprehend. Hand-hand test. With the subject looking at the examiner’s face, the dorsa of both hands of the subject were touched simultaneously by the examiner. The subjects were instructed regarding two stimuli and were asked to localize them. If the subject reported

NERLIGE G. BASAVARAJU er (11.

370

2 22 2 2

2

2

2 2 2

2

2

2 2

2

222222

22 2 2

Fig. I. Example of figure used to identify numbers in large-small figure test.

only one stimulus, the test was repeated two more times. The test was considered positive if the subject consistently omitted one stimulus. Large-smull,fiyure test. The subject was shown a large figure such as 4 or 6, about 7 cm high and made up of many small figures such as 9’s or 2’s, each about 5 mm high. He was asked to identify the number shown. A normal individual would identify both large and small figures. Figure 1 illustrates a Large-Small Figure as used in this test. RESULTS

Palmomenral

rejex.

Table 2 illustrates that about a third of the healthy elderly and half of the ill elderly with senile dementia of the Alzheimer Type (SDAT) or focal neurological impairment (NIE), had positive bilateral palmomental reflexes. Patients with focal neurological deficits had a positive unilateral palmomental reflex four times more frequently compared to the SDAT group. Interestingly when a positive response occurred in the healthy elderly, bilateral palmomental reflexes rather than unilateral were the rule. This reflex was absent in the younger age group (HYA). Comparisons of the relative frequencies of the findings among the elderly groups, Table 2, revealed significant differences in response patterns among the 3 elderly groups, the ill compared to the healthy elderly and between SDAT and NIE groups. There was a striking age effect noted in comparing the HE, aged 65-81 with a mean of 73.6 yr, and the HYA groups, aged 20-55 with a mean of 38.3 yr. The difference in ratios of observed positive responses in the palmomental reflkx, 17,/50 in the HE group and O/50 in the HYA’s was enormously significant by Fisher’s exact test (p I 3 x lo-“). These findings preclude merely a sampling effect and indicate an age related biological alteration. For differential classification or diagnosis of SDAT and NIE patients a bilaterally positive palmomental response was not useful. In contrast a unilateral response was diagnostically selective. occurring in only 6”; of SDAT patients compared to 289, in

TABLE 2. PALMOMENTAL REFLEXIN SUBJECTSWITHSENILEDEMENTIA OF ALZHEIMER’S TYPE (SDAT). NEUROLDGICALLY IMPAIREDELDERLY(NIE). HEALTHYELDERLY(HE) AND HEALTHY YOUNG ADULTS (HYA)

Number of subjects Positive unilateral Positive bilateral Negative

SDAT

NIE

HE

HYA

50

50 I4 26 IO

50 1 I6 33

50 0 0 50

2: 20

Comparison of all three groups of elderly individuals: Comparison of healthy elderly vs diseased: Comparison of SDAT vs NIE:

x: = 32.2*** x; = 19.7*** x: = 10.5**

*Significant at 5”, level; **significant at I”,, level: ***significant at O.l”, level.

Primitive Reflexes TABLE

3.

SNOUT REFLEXIN SUBJECTSWITH

Number of subjects Positive Negative

371

SDAT, NIE, HE

AND

HYA

SDAT

NIE

HE

HYA

50 35 15

50 37 13

50 18 32

50 17 38

Comparison of all three groups of elderly individuals: Comparison of healthy vs diseased elderly: Comparison of SDAT vs NIE:

x: = 18.2*** x; = 18.0*** x: = 0.20

*Si gnificant at 59’0 level.. ** stgnificant at 1% level; ***significant at 0.1% level.

NIE. A negative response favored the diagnosis of SDAT as opposed to NIE, Table 8. Assuming random samples from populations of SDAT and NIE, 95% confidence limits for the frequency of a unilateral response are 1.25 to 16.6% for SDAT and 16.2 and 42.5 for NIE. Snout reflex. Table 3 demonstrates that about a quarter of the healthy young adults, over a third of the healthy elderly and about three-quarters of the ill elderly patients with advanced chronic organic brain syndrome (SDAT) and neurological impairment (NIE) had positive snout reflexes. Significant differences in the occurrence of this reflex were noted in the three elderly groups and in the diseased compared with the healthy elderly. The test did not distinguish between the two disease groups and was not diagnostically selective for the individual patient. Sucking reflex. Only one patient with severe chronic organic brain syndrome showed this reflex. Grasp refiex. As shown in Table 4, neither of the healthy groups had a positive grasp reflex. Patients with senile dementia of Alzheimer’s type had bilaterally positive grasp reflexes four times more often than the neurologically impaired elderly. Significant differences in the frequency of a positive grasp reflex were apparent among the elderly, in comparing the ill with the HE and the SDAT with NIE. In differentiating between SDAT and NIE, the occurrence of 26% positive bilateral grasp responses in the SDAT group as against 6% in NIE provided justification for evaluating the diagnostic application of this test, Table 8. The test sharply distinguishes between the healthy and ill elderly (SDAT + NIE), but its modest frequency among the ill, 26/100, limits its usefulness. Face-hand rest. Most subjects in our series who showed extinction phenomenon failed to recognize the stimulus on the hand, the face being dominant. The patients showing displacement phenomena mislocalized the stimulus on the examiner’s face to the mirror image side of their own face and curiously also frequently showed extinction of the hand. One patient showed ‘reverse’ displacement; the stimulus on the patient’s face was displaced to the examiner’s face. Another patient displaced into extrapersonal spaceexosomesthesia. Rarely displacement crossed the midline-allesthesia.

TABLE 4. GRASP REFLEX SDAT

Number of subjects Unilateral Bilateral Negative

50 4 13 33

NIE

HE

HYA

50 6 3 41

50 0 0 50

50 0 0 50

Comparison of all three groups of elderly individuals: Comparison of healthy vs diseased elderly: Comparison of SDAT vs NIE:

x; = 27.7*** x: = 25.5*** x: = 7.14*

*Significant at 54; level; **significant at I’,:, level; ***significant at 0.1”; level

NERLIGEG. BASAVARAIU er ul.

312

TABLE 5. FACE-HANDTEST

SDAT

NIE

HE

HYA

Number of subjects Extinction Displacement

50 8 16

50 9 12

50 9 0

50 1 0

Extinction Uncooperative Negative

20 6

18 11

0 41

0 49

Comparisons, including uncooperative as positive: x; = 71.2*** SDAT vs NIE vs HE: x; = 694*** SDAT f NIE vs HE: x: = 2.21 SDAT vs NIE: After exclusion of uncooperatives: x: = 41.8*** SDAT vs NIE vs HE: x: = 39.5*** SDAT + NIE vs HE: x: = 2.00 SDAT vs NIE: *Significant at 5”,, level: **significant at l”,, level: ***significant at O.l”,, level.

Contrary to the report by Bender [S], our study showed that displacement was more common than pure extinction in patients with senile dementia of Alzheimer’s type and the neurologically impaired elderly, Table 5. Almost a third of the SDAT group and a quarter of neurologically impaired elderly showed displacement, mislocalizing the stimulus on the examiner’s face to the mirror image side of their own face. The healthy elderly showed only extinction of the hand in 187; of the subjects. There were no uncooperative responses among the healthy subjects. Forty percent of patients with SDAT and 36q/, of NIE were considered uncooperative in that they were unable to respond to questions because of dysphasia or aphasia, agitation and failure to comprehend. Group comparisons yielded significant differences in patterns of response among the 3 elderly groups and between the combined ill as compared to the HE, taking both displacement and uncooperative as positive test responses. No uncooperative responses occurred among healthy subjects and in this sense such responses were equivalent to an abnormal test result. These intergroup differences persisted even after exclusion of the uncooperative responses. Except for its rarity in young adults, the extinction only response was evenly distributed, occurring in l&lS~,;, of all the elderly. Neither displacement nor uncooperativeness occurred in the healthy elderly. In contrast these responses were recorded in 66”,; of the sick elderly, or in 28:/k if the ‘uncooperative’ responses were excluded, Table 8. These findings are of diagnostic value in differentiating sick from well elderly. Assuming that our subject groups were equivalent to random samples of their populations as defined. the 95?‘, confidence limits for the occurrence of the displacement response are 55.8-75.19; for the ill and not above 5.81:/i for the healthy elderly. Exclusion of the uncooperative patients reduced these limits for the ill to 19.5-37.95;. The response of extinction only revealed a definite age effect in the healthy subjects. The frequencies 9/50 in the HE and l/50 in HYA differed significantly (p I 0.02 by the Fisher exact test). Hand-hand rest. Neither the young nor healthy old had a positive hand-hand test, Table 6. Patients with SDAT had a positive hand-hand test in 120/6as contrasted to 2”/:, in the NIE group and none in the healthy subjects. Uncooperative responses were defined as in the face-hand test. The intergroup statistical differences in Table 6 include uncooperative responses as positive. Diagnostically this test was not sufficiently selective among patients and if uncooperative responses were excluded, the frequency of positive responses was too low to be useful in distinguishing the ill from the healthy elderly. Large-small$gure rest. All of the healthy young adults and all of the healthy elderly except one (29;) recognized both large and small figures, Table 7. About a quarter of the

373

Primitive Reflexes TABLE 6. HANLFHAND TEST

Number of subjects Positive (Extinction) Negative Uncooperative

SDAT

NIE

HE

HYA

50 6 23 21

50 1 30 19

50 0 50 0

50 0 50 0

Comparisons, including uncooperative as positive: All three groups of elderly individuals: xi = 38.6*** x: = 34.2*** Healthy vs diseased elderly: x: = 3.16 SDAT vs NIE: *Significant at 5;; level; **significant at 17; level: ***significant at 0.13:, level.

SDAT group and almost half of NIE read only the large figure and failed to recognize the small figure. Six percent of patients with SDAT read only small figures and failed to recognize the large figure and interestingly, this disorder of perception was limited to the SDAT group. Uncooperative status was the same as described in the face-hand test. Excluding inconsistent but including uncooperative responses as abnormal, intergroup differences were observed as shown in Table 7. This test is diagnostically selective between the healthy elderly and the ill, Table 8. Including uncooperative and inconsistent responses as positive, the probability of obtaining a positive response in the HE lies (with 95% confidence) below 12.1%. In the ill this probability lies between 69.7 and 86.5%. Exclusion of the uncooperative and inconsistent responses lowered these probability estimates to less than 9.2% for HE and 30.3-50.3x for the ill elderly. The tests with best potential for diagnostic application are summarized in Table 8, showing their interpretations and probability estimates for diagnosis. DISCUSSION

All the tests were performed by one examiner to provide uniformity and a standard, trained technique. This avoided the problem of reconciling differences among examiners. Some bias may exist since the diagnoses and group categories were not unknown to the examiner. Selection of the healthy subjects was straightforward in terms of the screening procedures, normal mental status evaluation-FROMAJE [13] and negative neurologic examination. Similarly the neurologically impaired elderly (NIE) clearly had focal deficits. However, they were institutionalized patients whose mental status scores were somewhat impaired in contrast to their healthy counterparts. Their focal disease was almost entirely hemiplegia associated with cerebral vascular accident. Although we had no evidence of multiple infarcts, some mental impairment on this basis may have existed.

TABLE 7. LARGE-SMALLFIGURETEST SDAT

Number of subjects Read small figure only Read large figure only Inconsistent Uncooperative Read large and small figures

50 3 14 2 17 14

NIE

HE

HYA

50 0 23 4 16 7

50 0 1 0 1 48

50 0 0 0 0 50

Comparisons including ‘uncooperative’ as abnormal response, excluding ‘inconsistent’: x: = 81.3** Three groups of elderly individuals: x; = 73.1*** Healthy vs diseased: x: = 6.47 SDAT vs NIE: *Significance at 54; level; **significant at 19; level: ***significant at 0.1% level.

figure

Interpretations**

-NIE --SDAT -No interpretation -SDAT --No interpretation -No interpretation

Displace or Uncooperative Negative Extinct Displace Negative Extinct or uncooperative Posit. either figure Uncooperative or inconsistent Negative both figures Positive Negative Uncooperative or inconsistent 40 96

HE

96

79

ILL

HE

ILL -HE ~ ILL HE ~ No interpretation

ILL

82

82 28

HE ILL

HE

66

2

21

4

2

39

18

0

21

I8 55

17

0 I7

17

52 14

20 0

28 26

NIE SDAT

ILL

54

6

40

Probability estimates in percent Correct diagnosis Misdiagnosis No diagnosis

SDAT

m--ILL

~-No interpretation

-ILL -HE ---No interpretation ILL P-HE

B. Distinguishing HE from ILL (SDAT + NIE)

Unilateral Negative Bilateral Bilateral Unilateral Negative

Clinical State**

PROBABILITIES OF THE MORE USEFUL TESTS FOR CORRECT AND INCORRECT DIAGNOSIS*

A. Distinguishing SDAT from NIE

8.

*See text for Confidence Limits (9Y{,) of true probability. **HE = healthy elderly; NIE = neurologically impaired elderly; SDAT = senile dementia and Alzheimer’s type; ILL = SDAT + NIE.

(exclude uncooperative or inconsistent)

test

Large-Smdll

(exclude uncooperative)

Face-hand test

Grasp reflex

Palmomental reflex

Test

TABLE

Primitive Reflexes

375

Co-existing mild Alzheimer’s Type disease also remains a possibility in the NIE group. Nevertheless it should be emphasized that there was a major difference between the level of mental functioning in this group compared with the advanced demented state characterizing the group labelled Senile Dementia of Alzheimer’s Type (SDAT). Although there was a past history suggestive of cerebrovascular accident in 9 of the SDAT patients, objective verification was not present at the time of this study. Nevertheless it is possible that silent infarcts had occurred and that previous neurologic deficits had cleared. As an institutional policy all patients are rigorously screened for reversible or pseudo-dementia secondary to systemic disorders by examination, blood studies, and cardiovascular-renal-metabolic surveys, as well as by drug profiles and psychiatric evaluation. Yet, prior to brain tissue examination, it is often difficult if not impossible to differentiate Alzheimer’s Type from multi-infarct dementia, even with the use of CAT Scans [20]. Prevalence data favor the diagnosis of SDAT, with SOo/, of dementias estimated to be of this type [2]. Analysis of the frequency patterns of test responses demonstrated significant differences among the 3 elderly groups and between the combined ill (SDAT + NIE) and the healthy elderly (HE) in every test. Differences between the SDAT and NIE patient groups were detected only by the palmomental and grasp reflexes, less so by the latter. Thus the battery of tests responded to and expressed differences in functional-anatomic states corresponding to the clinical grouping used in this study. The combination of tests best able to discriminate between our samples of healthy elderly and ill were two perception tests, the large-small figure and the face-hand tests. Statistical evaluation of the striking difference in the prevalence among the healthy adult groups of the palmomental reflex (almost always bilateral) and the extinction phenomenon in the face-hand perception test provided a clear demonstration of an age change in the central nervous system of healthy adults. Although derived from these cross-sectional data, these biologic alterations appeared within a 36 yr interval, from age 38-the mean of the healthy young adults, to age 74-the mean of the healthy elderly. The displacement phenomenon observed frequently in the ill elderly merits additional comment. As described under Methods, the patient’s face was touched two or more times before the examiner touched his own face. The patient who showed displacement phenomenon, reported that the mirror image side of his own face, not the examiner’s, had been touched. This response may represent perseveration of sensory perception. Correct classification or diagnosis of the individual subject is much more demanding of this battery of tests than the detection of differences among the subject groups. An analysis by probability estimates with confidence limits resulted in a selection of the 4 most useful tests, Table 8. There are, however, some limiting qualifications to be considered in regard to this assessment. The subjects in our sample were selected on the basis of availability. On the other hand the validity of statistical procedures is based on the premise that samples were obtained in a true random fashion from their underlying populations-in our case, from clearly delineated populations of demented, of neurologitally impaired, etc. subjects. In a clinical sense, we regard them as representative of their defined categories. This situation, although not always considered, is a common predicament in clinical studies and frequently for the same reasons given here. Our population samples of elderly subjects were predominantly comprised of women in accord with the naturally occurring sex distribution in the institutionalized elderly. Consequently our data regarding males was too small if taken separately to provide estimates of sex differences in response. Uncooperative responses were recorded in the sensory-perception tests with a few inconsistent responses in the large-small figure test. They were fairly equally distributed among the SDAT and NIE patients. Uncooperativeness in the SDAT patient was attributable to a deficit in mentation; in NIE patients it was attributable to aphasia. No subject was uncooperative because of blindness or deafness. With only one uncooperative response among the health9 elderly, the rarity of this finding in the healthy justifies its inclusion as an abnormal test response indicative of illness, but without further selec-

NERLIGEG. BASAVARAJU ef ul.

316

tivity. On the other hand an uncooperative response also may be viewed as data extraneous to the test, the equivalent of a non-interpretable, no diagnosis situation. The results are presented both ways, including and excluding uncooperatives (and inconsistencies), Tables 5 and 8. Several NIE patients with hemiplegia had considerable spasticity with contractures. This may have prevented the expression of a grasp reflex and resulted in an underestimate of both the frequency and diagnostic potential of this test in our patient sample. For the distinction between SDAT and NIE patients the most useful test was the palmomental reflex, a unilateral response indicating NIE and a negative response favoring SDAT. The preponderance of unilateral palmomental reflex in the NIE group may be explained by the fact that patients in this group were composed mainly of hemiplegics. However, it is not known to what extent this finding would be present in patients with other unilateral cerebral disorders. Bilateral responses were not diagnostic and as noted earlier, can be regarded as a normal aging phenomenon. The infrequency of a unilateral response in SDAT patients is useful, although the frequency of this diagnostic index of neurologic impairment was only 28% in the NIE group. The bilateral and diffuse nature of SDAT may explain the lack of a unilateral palmomental reflex in such patients. The grasp reflex, if bilaterally positive, is also of value. Conversely to the palmomental, the grasp reflex is infrequent in NIE and achieves a 26% prevalence in SDAT. The use of both tests can improve the diagnostic yield. For the distinction between ill elderly and healthy elderly subjects, two tests were useful: the face-hand test with ‘displacement’ or ‘uncooperative’ interpreted as ill and ‘negative’ as healthy; and the large-small figure test with ‘positive’ or ‘uncooperative’ equivalent to ill and ‘negative’ as healthy. The face-hand test was more specific with fewer false positives, but less sensitive because of more false negatives than the largesmall figure test. It is not feasible to attempt comparison with Jenkyn’s report 11123.He dealt with younger patients with mild, less defined disease and presented group data on patients and tests. He evaluated the usefulness of his procedures based on group false positive and false negative responses correlated with his other tests applied to define clinical states. We have dealt with an older population with long standing and clinically obvious disease. Group data are utilized to provide predictive indices for evaluation of the individual patient. There are no clinical tests that approach the ideals of nearly 1OOq;frequency of correct diagnosis with near zero misdiagnosis; certainly not for the evaluation of dementia. From a practical view this battery of 4 simple neurologic tests (palmomental reflex, grasp reflex, face-hand test and large-small figure test) which can be performed at the bedside or in an ambulatory setting merits wider recognition and application. Together with information gained from the history and neurologic examination, these tests can considerably reinforce the diagnosis of dementia or usefully shed doubt on this diagnosis and indicate the need for further observation and evaluation. REFERENCES 1. Tower DB: Alzheimer’s disease-senile dementia and related disorders: neurobiological status. In Aging, Vol. 7. Katzman R. Terrv RD. Bick LL (Eds.). New York: Raven Press. 1978. DV. l-4. 2. Tomlinson BE, Blessed 6, Roth M : Obsdrvations on the brains of demented aid people. J Neural Sci 11: 205-242, 1970 3. MagnussonJH, WernstedtW: The infantile palmo-mentalis reflex. Acta Paediat (Suppl 1) 17: 241-245, 1935 4. Schachter NM: Le re’flexe palmo-mentonnier (Marinesco-Radovici). Chez l’enfant Rev Franc de Pediat 13: 180-186, 1937 5. 6. I. 8.

Parmelee AH: The palmomental reflex in premature infants. Devl Med Child Neural 5: 381-387, 1963 Walton JN: Brain’s Disease of the Nervous System. New York: Oxford Univ. Press, 1977, pp. 53-58 Bieber I: Grasping and sucking. J Nerv Ment Dis 91: 31-36, 1940 Bender MB: The incidence and type of perceptual deficiencies in the aged. In Neurological and Sensory Disorders,in the Elderly. Fields WS (Ed.). Stratton Intercontinental Book Corporation, 1975, pp. 15-31 9. Paulson GW: The neurological examination in dementia. In Dementia, Contemporary Neurology Series. Wells CE (Ed.).. Philadelphia: F.A. Davis Company, 1971, pp. 18-33

Primitive Reflexes IO. Paulson G, Gottlieb G: Development 1 I.

12. 13.

14. 15.

16. 17. 18. 19. 20.

377

reflexes: the reappearance of foetal and neonatal reflexes in aged patients. Brain 91: 37-52. 1968 Taylor J, Holmes G, Walshe FMR: Selected Writings of John Hughlings Jackson, Vol. II. London: Hodder and Slaughton, 1932, pp. 3-118 Jenkyn LR, Walsh DB er al.: Clinical signs in diffuse cerebral dysfunction. J Neurol Neurosurg Psychiat 40: 95&966, 1977 Libow LS: FROMAJE: a new mental status evaluation technique. In Cognitive and Emotional Disturb antes in the Elderly. Eisdorfer C, Friedel RO (Eds.). Chicago: Year Book Medical Publishers. 1977. pp. 77-8 1 Marinesco G. Radovici A: Sur un reflexe cutane nouveau reflexe Palmomentonnier. Rev. Neurol 27: 237-240. 1920 Blake JR, Kunkle EC: The palmomental reflex. Archs Neurol Psychiat 65: 337-345. 1951 Reis DJ: The palmomental reflex. Archs Neurol4: 486-498, 1961 Brain WR, Curran RD: The grasp reflex of the Foot. Brain 55: 347-356, 1932 Bender MB, Fink M, Green M: Patterns in perception on simultaneous tests of face and hand. Archs Neurol Psychiat 66: 355-362. 1951 Kahn RL, Goldfarb AI et al.: Brief objective measures for the determination of mental status in the aged. Am J Psychiat 117: 326-328, 1960 Fox JH, Kaszniak AW, Huckman M: Computerized tomography scanning not very helpful in dementianor in craniopharyngioma. N Engl J Med 300: 437, 1979