What components should be included in a full neuro assessment for a general adult population?

Full Neurological Assessment Components

A comprehensive neurological assessment should systematically evaluate six core domains: mental status/cognition, cranial nerves, motor function, sensory function, cerebellar function, and reflexes, with standardized documentation using validated scoring systems when applicable. 1

Mental Status and Cognitive Assessment

Level of Consciousness and Orientation

• Assess level of consciousness using the Glasgow Coma Scale (alert, drowsy, obtunded, coma/unresponsive) 1
• Test orientation to person, place, and time by asking two orientation questions and documenting correct responses 1
• Evaluate command following with two simple commands 1

Cognitive Domains

• Screen for memory deficits, focusing on short-term and long-term memory function 2
• Assess attention and executive functioning, including problem-solving, speed of decision making, and judgment 3
• Evaluate language function, documenting as normal, mild aphasia, severe aphasia, or mute/global aphasia 1
• Test perception abilities 2

Behavioral and Mood Assessment

• Assess current mood state and level of anxiety 2
• Screen for hopelessness and suicidal ideation, including active or passive thoughts of suicide or death 2
• Evaluate for aggressive or psychotic ideas 2
• Screen for depression using validated scales (Center for Epidemiological Studies-Depression or Geriatric Depression Scale) 1

General Appearance

• Document general appearance, nutritional status, and coordination 2
• Assess for involuntary movements or abnormalities of motor tone 2
• Examine skin for signs of trauma, self-injury, or substance use 2

Cranial Nerve Examination

Systematically assess all 12 cranial nerves with specific attention to functional deficits: 1

• CN II-III: Test visual fields, pupillary reactivity, and red reflexes (should be detectable and symmetric) 1
• CN III, IV, VI: Evaluate gaze and extraocular movements, documenting normal horizontal movements versus partial or complete gaze palsy 1
• CN V, VII: Assess facial movement and expression including smile, cry, and eye opening/closure, grading as normal, minor weakness, partial weakness, or complete unilateral palsy 1
• CN IX, X: Test oromotor movement, palate and tongue movement, and swallowing ability 1
• CN XI: Evaluate shoulder shrug quality 1
• CN XII: Observe tongue movement and check for fasciculations 1

Motor System Evaluation

Strength and Movement

• Assess strength through functional observation of antigravity movement, posture, and quality of movement 1
• Perform arm drift testing, documenting as no drift, drift before 5 seconds, falls before 10 seconds, no effort against gravity, or no movement for each side 1
• Conduct leg drift testing using the same grading scale 1
• Observe Gower maneuver (inability to rise from floor without pushing up with arms suggests proximal weakness) 1
• Focus motor assessment on strength, coordination, and reaction time 3

Additional Motor Findings

• Assess muscle bulk and texture 1
• Test coordination including limb ataxia, documenting as no ataxia, ataxia in 1 limb, or ataxia in 2 limbs 1
• Evaluate for abnormal movements including involuntary movements, tremor, rigidity, and bradykinesia 1
• Screen for parkinsonian signs when relevant: bradykinesia, rigidity, gait abnormalities, and tremor 1

Sensory System Assessment

Comprehensive sensory testing should focus on multiple modalities: 3

• Test for sensory deficits, grading as no sensory loss, mild sensory loss, or severe sensory loss 1
• Assess vision, visual fields, and visual attention 3, 1
• Evaluate reading comprehension 3
• Test for extinction or inattention, grading as absent, mild loss in 1 sensory modality, or severe loss in 2 modalities 1
• Screen hearing function 1

Cerebellar Function

Evaluate coordination and balance through specific testing maneuvers to detect cerebellar dysfunction 4

Reflexes

Document deep tendon reflexes systematically as part of the comprehensive assessment 4

Speech and Language

• Assess fluency and articulation, documenting as normal, mild dysarthria, or severe dysarthria 2, 1
• Evaluate speech quality as part of the overall neurological examination 2

Vital Signs and Physical Parameters

• Record vital signs: blood pressure, heart rate, oxygen saturation, and temperature 1
• Document growth parameters in children: head circumference, weight, length/height with percentile interpretation 1

Standardized Scoring Systems

When applicable, use validated assessment tools for standardized documentation: 1

• Apply the NIH Stroke Scale (0-42 points across 11 domains) in acute stroke settings at defined intervals: immediately post-intervention, 24 hours, 72 hours, 7-10 days, 30 days, and 90 days 1
• Obtain additional NIHSS when neurological deterioration occurs (defined as 4-point increase) 1
• Use the Modified Rankin Scale for disability outcomes 1
• Apply the Barthel Index or Pfeffer Functional Assessment Questionnaire for activities of daily living 1

When to Escalate to Specialized Testing

Neuropsychological evaluation is recommended when office-based cognitive assessment is insufficient, particularly when patients or caregivers report concerning symptoms but the patient performs within normal limits on cognitive examination 3, 1

Indications for Neuropsychological Testing

• Atypical cognitive abnormalities (aphasia, apraxia, agnosia) 3
• Sensorimotor dysfunction (cortical visual abnormalities, movement or gait disorders) 3
• Severe mood/behavioral disturbance (profound anxiety, depression, apathy, psychosis, or personality changes) 3
• Rapid progression or fluctuating course 3
• Discordant presentation between reported symptoms and examination findings 5

Comprehensive Neuropsychological Battery Components

At minimum, neuropsychological evaluation should include normed testing of: 3

• Learning and memory (delayed free and cued recall/recognition) 3
• Attention and processing speed 3
• Executive function 3
• Visuospatial function 3
• Language 3

Critical Documentation Elements

Document the following contextual information: 1

• Symptom onset and progression: timing, quality, and evolution of neurological symptoms 1
• Risk factors: hypertension, hyperlipidemia, diabetes, smoking, alcohol use 1
• Past medical history: prior stroke, TIA, myocardial infarction, atrial fibrillation, peripheral artery disease 1
• Medications: all medications including over-the-counter preparations within 48 hours 1
• Family history: stroke, vascular disease, or dementia in first-degree relatives 1

Common Pitfalls to Avoid

• Do not rely solely on global cognitive screening test scores to distinguish between different neurological conditions 1
• Recognize that executive dysfunction may not be present on formal testing in early stages, so consider qualitative evidence when examining task performance 1
• Avoid failing to consider education level, language barriers, or cultural factors when interpreting results 2
• Do not overlook subtle signs of cognitive impairment in high-functioning individuals 2
• Always obtain collateral information when available, especially when evaluating patients with potential cognitive impairment 2
• Note that NIHSS may underestimate posterior circulation strokes as it lacks assessment of vertigo and dysphagia 1