12 - 3. Attention and orientation

3. Attention and orientation

© SPMM Course 3. Attention and orientation  Attention can be clinically tested using serial 7s, digit span, spelling ‘‘world’’ backwards, or asking to recite the months of the year or days of the week in reverse order.  Although serial 7s is commonly used, it is frequently performed incorrectly by the elderly, as well as by patients with impaired attention.  A reverse-order month of the year is a highly over-learned sequence and is a preferred measure of sustained attention.  Digit span is a relatively pure test of attention that depends on working memory. Digit span is impaired in delirium, focal left frontal damage, aphasia, and moderate to severe dementia, but preserved in the amnesic syndrome (for example, Korsakoff’s syndrome or medial temporal lobe damage). Normal digit span of 7 +/- 2 varies with age and general intellectual ability. In the elderly, or intellectually impaired, 5 can be considered normal. Reverse digit span is usually one less than forward span.  Orientation is usually assessed in time, place and person; it is worth noting that an intact orientation does not exclude a memory disorder.  Time orientation is the most helpful test and should include the time of day. Many apparently healthy people do not know the exact date, and being inaccurate by two days or less is considered normal.  Time intervals are often poorly monitored by patients with delirium, moderate to severe dementia, and in the amnesic syndrome, and are easily tested by asking about the length of time spent in hospital.  Person orientation includes name, age, and date of birth. Disorientation to one’s own name is usually only seen in psychogenic amnesia.  Orientation to place is affected in reduplicative paramnesia, seen in delirium.