Common Intellectual Functions – Problem Solving, Abstract Thinking, Insight, and Judgment
The ability to think abstractly is assessed by asking the person how two objects are either similar or different (“How are a bus and train alike?”) or to interpret the meaning of a proverb or saying. For example, when presented with the proverb “People who live in glass houses shouldn’t throw stones,” a person who previously taught college English but now has Dementia may give a very concrete and literal interpretation rather than considering the metaphorical implications of the statement. “It means that you have to be careful because the stone may fall out of your hand and smash the window.”
Judgment and insight are two higher-order intellectual functions that reflect a person’s self-awareness and awareness of social conventions and expectations. Standard questions used to assess judgment include: “What should you do if you are in a theater and you see a fire?” or “Why are laws necessary?” It is probably more relevant to tailor questions about judgment to the person’s actual living situation.
For example, asking a retired businessman how to deal with a phone solicitation asking for money; or asking a grandmother who baby-sits with two young children what she would do if she had to leave them to go to the doctor; or asking an elderly woman why it is not a good idea to go out alone at night. Assessment of insight usually focuses on whether the person knows he is ill: “Why do you think you have been brought in to see a doctor?” A person with little insight might respond, “Because my wife needs help; I’m perfectly okay.”
Be cautious when considering the significance of a cognitive problem: Anyone can have an unrepresentative bad day in mental performance based on fatigue, physical discomfort, performance anxiety, lack of motivation, or inattentiveness. Moreover, many other psychiatric disturbances, such as depression, mania, Attention-Deficit/Hyperactivity Disorder, or Schizophrenia may exert a negative impact on cognitive functioning that translates into poor performance on cognitive tests. The person may be on medications that impair memory or attention. Finally, it can be difficult to know how to interpret a cognitive assessment without having the results of a prior baseline evaluation for comparison. For example, two calculation errors in subtracting sevens would be much more indicative of a problem when it occurs with a mathematics professor than it would for a person with a sixth-grade education. People who started with superior intelligence may continue to do well on fairly simple testing but have difficulties performing complex tasks that previously were a snap for them.
Delirium is the most fluid of the three, with cognitive symptoms that start abruptly, fluctuate over time, and cause gross confusion and interference with a panoply of intellectual functions. Delirium is a medical emergency that is caused by an acute medical illness or by an intoxication or withdrawal from a medication, street drug, or alcohol. Dementia and Amnestic Disorder usually come on more gradually, are more stable (or steadily progressive), and are caused by ongoing and long-standing medical conditions (like Alzheimer’s disease, strokes, chronic HIV infection, or vitamin deficiencies) or long-term exposure to toxic substances (chronic alcohol abuse, occupational exposure to toxins). They are usually, but not always, irreversible. Dementia differs from Amnestic Disorder in that many more cognitive difficulties are involved beyond the loss of memory.