The Neurological and Cognitive Examination

A neurological and cognitive examination, also described as a neurological exam or a neuro exam, is an important method for evaluating neurological conditions like delirium, Parkinson’s disease, multiple sclerosis (MS), and spinal muscular atrophy.

There are many components to a neurological exam, including cognitive testing, motor strength and control, sensory function, gait (walking), cranial nerve testing, and balance.

Anyone at any age can have a neurological and cognitive examination, although some parts of the exam differ slightly based on factors like a person’s age, ability to participate, and level of consciousness.

Doctor performs neurological and cognitive exam with senior patient
​LWA/Dann Tardif / Stone / Getty Images 

Purpose

You might have a neurological and cognitive examination if you have memory or concentration problems, muscle weakness, altered sensation, diminished coordination, communication deficits, or visual changes. Sometimes this test is done to assess brain death or brain damage associated with trauma.

This is a detailed, non-invasive, and painless physical examination. Some parts of the exam involve your cooperation. These parts are adapted for young children or for people who have a diminished level of consciousness.

A neurological and cognitive examination assesses skills such as coordination, language comprehension, fluency of speech, eye control, and many other skills.

Your doctor will let you know what to expect with each step, and you’ll have clear instructions about the parts you need to participate in. You can also ask questions about what’s going on before, during, or after any part of your neuro exam. 

You can rest assured that if you know what to expect ahead of time, it will not alter the results of your neurological and cognitive testing.

Cognitive Examination 

Generally, the cognitive portion of your examination includes an assessment of your level of alertness, awareness, concentration, and memory. A big part of the cognitive portion of your neurological exam is based on your natural interaction during your medical visit, but you will also have to answer some focused questions that test specific cognitive abilities.

People who are unable to respond due to a severe medical issue like a coma, would not be able to have most of the cognitive portion of a neurological exam.

During a standard neurological and cognitive exam, your doctor will assess whether know your name, if you can identify the date, and if you understand why you are having a medical visit. In addition, you may be asked to draw a clock, recall the names of a few items, or explain a simple phrase. 

Cognitive Tests Used for Dementia Screening

Your doctor might do a mini mental status exam, which includes 30 questions that involve tasks like naming common objects.

You may have another more detailed cognitive examination at another appointment, such as the Montreal Cognitive Assessment Test (MoCA), which can be used to help in the diagnosis of dementia caused by diseases like Alzheimer’s disease

These examinations are usually done if you’ve had issues or complaints about your memory, concentration, or behavior. Additionally, since dementia is associated with advanced age—you might have one of these tests even if you don't have memory problems if you are over age 60.

Mood Assessment

Keep in mind that the cognitive portion of your neurological examination doesn’t screen for issues like depression or anxiety. There are specific tests that evaluate emotional and psychiatric conditions, and you might have one or more of these at a later appointment if your symptoms or preliminary medical assessment are suggestive of a psychiatric diagnosis.

For instance, the two-item and nine-item Patient Health Questionnaires, PHQ-2 and PHQ-9, are used to screen for depression. And the Positive and Negative Syndrome Scale (PANSS) is used to help identify schizophrenia. 

Motor Examination 

Your neurological examination includes motor testing, which is an evaluation of your movements, strength, and muscle tone. Most aspects of your motor exam involve your active participation, and some parts of your motor examination are passive and don’t involve your participation.

Your doctor will begin by looking at you to see if you have any involuntary movements that could signal neurological disease, like tics or tremors. Your doctor will also look to see if you have any changes in the size or appearance of your muscles, such as atrophy (shrinking), or contractions (muscles appear to be frozen in place). 

Your doctor will check your muscle tone by asking you to relax, and then moving your arms and legs gently. Some neurological conditions affect muscle tone.

For example, a recent stroke can cause diminished muscle tone, but after a few months, a stroke can cause some of your muscles to be spastic. And if you have Parkinson’s disease, your muscles can be rigid and choppy when your doctor moves them. 

And the last part of your motor examination is a measure of your strength. You need to cooperate for this part of the exam by exerting your full strength for each of the movements your doctor asks you to do. Each muscle group, such as the biceps and triceps of your arms and the muscles of your feet, will be rated on a scale of zero to five. 

The scoring of muscle strength is as follows:

  • The highest score of five means that you have full strength. with ability to push against the doctor’s hand
  • A score of four means that you can push against pressure, but not with normal strength 
  • A score of three means you can lift against gravity, but you can’t push not against pressure 
  • A score of two means you can move side to side, but not against gravity
  • A score of one means you can barely move 
  • And a score of zero indicates that you can’t move

Each muscle group and action is scored separately. Your doctor might write out your strength scores or may draw your results by placing numbers on a stick figure drawing of a body. If your strength is generally normal, your doctor might indicate that your strength was 5/5 in all of your muscles and list the weaker muscle groups by name, along with the numerical designation. 

This test would be modified for young babies or people who can’t participate due to a diminished level of alertness. For a modified a motor exam, involuntary movements, tone, and appearance will be the main focus. 

Sensory Examination 

The sensory part of your neurological examination can help your doctors identify certain conditions, and it is especially helpful in distinguishing the difference between spine disease and peripheral neuropathy.

The sensory portion of a neurological examination should not hurt. If you have any wounds or if you have severe pain, your doctor may skip certain parts of your sensory examination to avoid exacerbating your discomfort. 

You need to participate and communicate with your doctor during the sensory portion of your neurological examination. Your doctor may ask you to look away or close your eyes for some of your sensory testing so your ability to detect sensations without seeing them can be accurately assessed. 

You may need to move a little bit for this portion of your exam, just so your doctor can reach the areas on your skin that need to be tested. You need to take off your shoes and socks for your sensory exam. 

Your doctor will check your sensation to sharp and light touch, temperature, position, and vibration in all four of your limbs and possibly on other areas of your body as well.

  • Your light touch may be tested with a cotton head of a QTip on your arms, hands, legs, and feet. 
  • You may have a semi sharp (but not painful) device used to assess your ability to detect sharp sensation. 
  • Your temperature sensation will be tested with something moderately cold, like a medical tuning fork. 
  • Your ability to sense vibration will be examined with a vibrating tuning fork. 
  • Your proprioception (position sense) will be tested as your doctor gently moves your fingers and toes to see how well you can detect changes in position—usually without looking. 

You will be asked to indicate when and where you feel these different sensations, and sometimes you might be asked to compare the sensation on the right and left sides of your body. You might also experience a sudden change of sensation, for example, as the QTip or sharp device is moved up on your legs or arms. 

The location of sensory changes helps determine exactly which nerves or which area of the spine might be affected by a neurological disease.

Reflexes 

Your reflexes are involuntary automatic muscle movements that your body makes without any effort. You don’t need to do anything for the reflex portion of your neurological exam. This part of the neurological exam is done for all levels of consciousness and ages, including babies.

There are several reflexes that your doctor will check, including a corneal reflex of your eye and deep tendon reflexes throughout your body. Your corneal reflex, also described as a blink reflex, is a measure of whether you blink if an object is brought close to your eye. 

Your deep tendon reflexes are generally tested with a reflex hammer as your doctor taps on your tendon to cause your muscle to jerk. This test does not hurt at all. Common deep tendon reflexes include the patellar, biceps, triceps, brachioradialis, ankle, and jaw jerk reflexes.

Reflexes are described on a scale between zero to five, with normal reflexes described as 2+. 

The reflex scale is as follows:

  • 0: No reflex in the muscle that’s being tested 
  • 1+: Diminished reflex 
  • 2+: Normal reflex 
  • 3+: Brisk reflex 
  • 4+: Clonus (repeated jerking of the muscle)
  • 5+: Sustained clonus (prolonged jerking of the muscle)

Reflexes correspond to specific spinal nerves, and reflex changes can help your doctor find out whether you have a disease in certain areas of your brain, spinal cord, or nerves.

In general:

  • New problems affecting the brain and spinal cord may cause diminished reflexes.
  • After several months, brain or spine disease causes reflexes to become brisk.
  • Severe spine or brain disease may result in clonus or sustained clonus.
  • Conditions that cause impairment of the nerves may cause diminished reflexes.

Walking and Coordination 

Your doctor will also check your coordination and your gait (walking). Your gait involves many components, including coordination, balance, vision, muscle strength, and sensation. 

Your doctor may have already watched you walk into the room. Besides walking as you normally do, your gait exam includes specific tasks, such as walking one foot in front of the other.

And your doctor may do a Romberg test by asking you to stand with your feet together and your eyes closed. If it is difficult for you to balance this way, it could mean that you have trouble with proprioception or with the balance center of your brain. 

If it’s already clear that you have a problem with balance, some steps of your gait exam will be skipped as a safety precaution.

Coordination

In addition to the effect that your coordination has on your gait, your coordination will also be tested separately. Your doctor will ask you to do a few tasks that can identify coordination issues.

  • Your rapid alternating movements test is when your doctor asks you to put your hands in your lap and quickly flip your hands from palm up to palms down.
  • You will also be asked to accurately and quickly touch your finger to your nose and then to the doctor’s hand.
  • Another test of coordination is quickly pinching and separating your thumb and forefinger, possibly with both hands at the same time. 
  • Your doctor may also ask you to move your heel up and down the opposite shin, one at a time. 

Coordination relies on many skills, and a defect in coordination can help identify the cause of a neurological disease. 

Language 

Your language examination has some features that overlap with your cognitive exam, but there are specific aspects of language that your doctor will be testing. If there is a language barrier because you don’t speak the same language as your doctor, you may need a translator.

Your language includes fluency and comprehension.

  • Fluency is your ability to speak with a normal rhythm.
  • Comprehension is your ability to understand the meaning of words and phrases, as well as your ability to use words correctly.

A problem with language is described as aphasia. There are several types of aphasia. For example. fluent speech with impaired comprehension is described as Wernicke’s aphasia. A deficit in language fluency is described as Broca’s aphasia.

These language deficits, which are the most commonly identified, are often associated with strokes. A stroke is a type of brain damage caused by an interruption of blood flow. Blood vessels in the brain are arranged to supply blood to specific language regions that are dedicated to either fluency or comprehension.

Other specific language deficits include conduction aphasia, stuttering, and anomic aphasia. Each of these is characterized by a specific speech pattern and can develop due to a stroke, a brain tumor, head trauma, or without a known reason. 

Cranial Nerves 

Your cranial nerve examination is a crucial part of your neurological evaluation. This part of your exam is an assessment of the function of the 12 pairs of cranial nerves that emerge from your brainstem.

There are many aspects to the cranial nerve exam, and some of them test cranial nerve function while also assessing other functions of your brain at the same time. 

A cranial nerve exam is especially important in the assessment of severe brain damage or a coma, because many aspects of this exam are not voluntary. However, if a person can’t participate, then it’s impossible to do some of the parts of the cranial nerve exam. 

Cranial Nerve One 

Your doctor may ask you to identify a smell to examine your olfactory nerve, which is cranial nerve one. This nerve can become damaged due to head trauma.

Cranial Nerve Two 

Your doctor may look directly at your optic nerve, which is cranial nerve two. This is done using a non-invasive, painless examination with an ophthalmoscope that can visualize the area inside your eye.

You may need to have your pupils dilated for this portion of the test. Your optic nerve can become swollen or inflamed as a result of certain conditions, such as MS or hydrocephalus (fluid pressure in the brain).

Your doctor will check your vision to determine whether you can see in all of your visual fields. This portion of your cranial nerve exam isn’t the same as a visual acuity test, which can identify problems like nearsightedness and farsightedness. These issues are assessed by a vision and eye exam, which is a more detailed test of your near and far vision.

Cranial Nerves Three, Four, and Six 

Your doctor will assess the oculomotor nerve (three), trochlear nerve (four), and abducens nerve (six) by asking you to move your eyes up and down and side to side. These nerves control eye movement.

Usually, defects don’t cause obvious eye movement problems but can cause double vision. Sometimes, nystagmus (jerky eye movements) can be a sign of disease, like cerebellar involvement in MS.

Cranial Nerve Five 

Your face sensation will be tested with a light touch to assess your trigeminal nerve, which is cranial nerve five. Decreased sensation or an unpleasant sensation can indicate problems with this nerve.

Cranial Nerve Seven 

Your face movements are assessed in the evaluation of your facial nerve, which is cranial nerve seven. Damage to your facial nerve causes weakness of a whole side of your face, including your forehead.

But if the lower part of your face is weak on one side with normal forehead strength, then the problem is caused by damage to the brain rather than the facial nerve. 

Cranial Nerve Eight 

Your vestibucochlear nerve, which is cranial nerve eight, controls your hearing and balance. Your doctor may ask you if you can hear soft sounds and sense the vibrations of a tuning fork.

If you have a hearing problem, a dedicated hearing test with special equipment can help identify specific conditions and distinguish between nerve problems and problems in the ear's conduction system. A defect of this nerve can also cause severe dizziness and balance problems.

Cranial Nerves Nine and 12

Your glossopharyngeal nerve (nine) and hypoglossal nerve (12) control your tongue movements, tongue sensation, taste, and production of saliva. Your doctor will test these functions by asking you to open your mouth and move your tongue side to side.

Additionally, one of the only uncomfortable parts of the neurological examination is when your doctor tests your gag reflex. You will be asked to open your mouth so your doctor can place a stick near the back of your throat.

The gag reflex is an important part of the neurological examination when a person is not conscious, but your doctor might skip it if you don’t have any signs or symptoms that point to a problem with this function.

Cranial Nerve 10

Your vagus nerve is cranial nerve 10, and it affects functions like your heart rate and respiration, so it’s not likely that you will have a focused examination of this nerve. 

Cranial Nerve 11

Your doctor will test your accessory nerve, which is cranial nerve 11, by asking you to rotate your head side to side and shrug your shoulders. This nerve controls your sternocleidomastoid and trapezius muscles.

Your cranial nerve examination has several components, and any abnormalities will be followed up with more focused testing.

Similar Neurological Tests 

There are several diagnostic tests that have similarities to a neurological examination. These other tests, however, have purposes and features that aren’t exactly the same as a neurological examination. 

For example, the National Institute of Neurological Disorders and Stroke (NINDS) Scale evaluates some aspects of neurological function and overall health as a way to compare a person’s improvement or worsening after a stroke. 

And different conditions, including Parkinson’s disease, dementia, and MS, have their own scales that are focused on the specific disease. These scales don’t include components of the neurological examination that aren’t affected by the disease. Disease-specific tests are used to evaluate changes in a person’s condition over time or to assess a person’s response to treatment. 

Physical examination ratings that are used to evaluate disability are not the same as a neurological examination, although some components may overlap. 

A Word From Verywell

Your neurological and cognitive examination is an important part of your medical evaluation. In some situations, your doctor will repeat certain parts of the exam if the changes are subtle. Or your doctor may focus on specific details to identify the exact nerve, spinal level, or brain region that might be impaired. It can take a long time for you to have a full neurological and cognitive exam, but the diagnostic clues this test provides are highly informative when it comes to understanding the cause of your symptoms.

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