Neuropsychological assessment
Questions and answers
Neuropsychological Assessment
What are the two fields of Neuropsychology?
Experimental Neuropsychology and Clinical Neuropsychology
What is the focus of Experimental Neuropsychology?
The "normal" brain Method: animal and human models (e.g., lesions)
What is the focus of Clinical Neuropsychology?
Assessment of central nervous system deficits, and their impact on behavior and quality of life
What are the two principal areas of clinical neuropsychology?
Assessment and Rehabilitation
What is the definition of a Clinical Neuropsychologist?
A professional within the field of psychology special expertise in the applied science of the brain-behavior relationships 9:50 they use this knowledge to assess, diagnose, treat &/or rehabilitate patients with neurological, medical, neurodevelopmental, and psychiatric conditions and other cognitive and learning disorders
What is the difference between treatment and rehabilitation in clinical neuropsychology?
Treatment engages some technique applied to a client Rehabilitation applies a dynamic interaction between patient, clinician, family, and community resources to achieve maximum recovery (we know that most of CNS will not fully recover) but need to work to maximize recovery, improve client's daily life
What are the four areas of definition required by the American Psych Assoc for a discipline to be recognized?
Type of Problem Populations Settings Services
What type of problems would a Clinical Neuropsychologist deal with?
Characterization of impairment differential diagnosis e.g., between dementia and other conditions measurement of change preliminary baseline measurement e.g., Parkinson’s disease to track change applicable to every dysfunction that can be detected early (Huntington's, MS) prediction of functional outcomes e.g., can this person continue to work/drive safely, etc) planning rehabilitation.
What populations do Clinical Neuropsychologists work with?
Neurological brain injury Psychiatric depression, OCD, schizophrenia General medical and surgical vascular conditions affecting brain Professional sports (brain trauma, post-concussional syndrome), occupational (exposed to neurotoxic agents) Children (learning disabilities, developmental disorders)
What settings do Clinical Neuropsychologists work in?
Hospitals Clinics Forensic Private Practice
What services can a Clinical Neuropsychologist provide?
Neuropsychological Assessment Cognitive remediation and intervention Neuropsychological rehabilitation Psychological therapies (for brain dysfunction) e.g., personality problems resulting from a brain injury may require specific therapies Counselling to Public Agencies, Private Companies, Educational Centers
What proportion of a Clinical Neuropsychologist's time is spent in the assessment?
40%
How do current views of Neuropsychological Assessment differ from old views?
Old Views - relevance to current views locate the lesion - other techniques are better equipped for this (e.g., brain imaging) current priority is to characterize cognitive status determine organicity - do not distinguish between organic and non-organic (psychological) current view is that it is always organic and always psychological provide a reasoned account of cognitive strengths and weaknesses neurological or psychiatric diagnosis - this is for a neurologist or psychiatrist role is to work out how neuropsychic system works and what is not working well determine functional (every day) impact provide a neuropsychological diagnosis.
What is the question to ask yourself before a performing neuropsychological assessment?
Why is this assessment necessary?
What are the two approaches to Neuropsychological Assessment?
Fixed Battery, Pattern Analysis Flexible Approach, Hypothesis Testing, assess only particular parts of a system that you think is causing the problem
How does the Fixed Battery differ from the Flexible Approach to Assessment?
A Fixed Battery Quantities gives you a number-interpreted relative to norms Outcome Focused scores/performance Matrix Vision Comprehensive Flexible Approach Mixed Quantitative/Qualitative Process Focused why did the client achieve this outcome, what compensatory processes, what could he have done differently Modular Vision assumes certain systems of the brain are specific to certain functions isolated on other systems of the brain so only focus on the module which is dysfunctional Hypothesis-driven
What are the advantages of the Fixed Battery approach to Neuropsychological Assessment?
Systematic always done the same way Comprehensive addresses every possible cognitive determinant Objective Interpretation scores can be transformed into deficits or strengths Easy to train Easy to replicate.
What are the advantages of the flexible approach to Neuropsychological Assessment?
Patient-tailored individuality of each case Focus on relevant domains not entire system Process (WHY) emphasis rather than outcome (WHAT) Time efficient 38:00
What are the disadvantages of the Fixed Battery Flexible Approach?
Disadvantages of Fixed Battery time consuming could take 6-10 hours just for the administration of instruments relies on the availability of quality norms this is because reliance is on the outcomes provides a reference framework for the interpretation of scores Flexible Approach Susceptible to bias hypothesis may be the wrong clinician may be misled by certain factors could mistakenly exclude vital points e.g., a referral from a lawyer - could bias you by adding relevance to some symptoms Relies on training/experience
How do you determine which assessment approach is better?
It depends on the referral question
What are the most frequent referral questions for a neuropsychological assessment?
Diagnosis - 70% rehabilitation/treatment planning - 48.3% forensic - 31.8% educational planning - 29.6% capacity to work assessment - 27.9% establish baseline function for future testing - 24.3% assess capacity for independent living - 19.7% pre- and post-medical intervention - 9.6% localization of lesion 2.7% source Rabin et al., (2005)
How did the flexible approach of neuropsychological assessment originally come about?
in the diagnosis of certain language disorders, they established that using a few tests language disorders e.g., aphasia could be accurately diagnosed
Which neuropsychological assessment approach—Fixed or Flexible—is better for Intellectual disability determination?
Fixed as don't want to miss anything also has other implications need to measure against population norms findings also need to be replicable as other professionals will be assessing
Which assessment approach is better for this scenario: Fixed Or Flexible? Diagnosis of acquired language deficits
Flexible extremely specific referral question posterior parts of the brain are more modular perceptual, language, the motor is ok to do flexible whereas general cognitive ability or memory etc would need Fixed
Which assessment approach is better in the following scenario: fixed or flexible? Forensic determination
Fixed Replicability Many professionals involved Court - challenges, needs to be backed up by a systematic assessment
Which assessment approach is better in the following scenario: Fixed or Flexible? Characterization of a football players deficits post-concussion
Fixed in sports concussion brain moves a lot - damage may be away from injury site best to go broad, so as not to miss anything
Which assessment approach is better in the following scenario: Fixed or Flexible? Prognostic assessment of a recently diagnosed multiple sclerosis patient
Flexible already have a diagnosis know what typically occurs in MS 53:20
Which approach do professionals use? Fixed, Purely Flexible, or Flexible (a combination of both)
Most people use a combination of approaches 54:30
What are the four steps of a combination flexible battery?
An initial "fixed" set of attempts to cover all relevant domains (i.e., cover most of the cognitive system) to develop a broad quantitative profile Develop hypothesis Select specific instruments to examine hypothesis Interpretation or Reiteration 54:45
What are the four phases of a Neuropsychological Assessment?
Phase 1 - Interview Phase 2 - Selection of Instruments Phase 3 - Administration of Instruments Phase 4 - Interpretation of the whole assessment 56:25
What happens in Phase 1 of the Neuropsychological Assessment?
Interview Clarify the Referral Question (we should do this before the interview) Medical History via patient, relatives Developmental Milestones School/Occupational History Psychosocial History Symptoms: evolution and coping 56:35
What happens in Phase 2 of the Neuropsychological Assessment?
Selection of Instruments based on the: referral question selected approach information collected at the interview (Phase 1)
What happens in Phase 3 of the Neuropsychological Assessment?
Administration of Instruments Neuropsychological Tests Personality/Mood Scales Behavioral Trials Life-log
What happens in Phase 4 of the Neuropsychological Assessment?
Interpretation of the whole assessment History analysis Observations Test scores Qualitative observations Estimated impact Feedback is ongoing, not just at the end
What type of information do neuropsychologists use in assessments?
Medical/psychiatric history Neuropsychological test data Referral source Psychosocial history Mood and affect measures Developmental history Current social supports Objective personality tests Mental status exam Significant other interview Environmental demand characteristics Behavioral assessments School records Functional Assessments Work records Projective personality tests "text-align: right source: Rabin et al., (2005) 58:50
Why would it be important to include school and work records in a neuropsychological examination?
Important to understand how the patient was before the dysfunction e.g., to differentiate lesion related injury from the pre-morbid condition
Which three interviews are important in a Neuropsychological assessment?
Patient Relative (significant other) Both together
What we should cover in the interview with the patient?
create rapport - trust, empathy will get more accurate information from the comprehensive history developmental, medical vocational social helps to understand how the brain works in different situations Allow patient-directed (idiosyncratic) description of symptoms currently, evolution, coping Attention to Potential Gains e.g., financial, legal, emotional (attention) 1:01:50
What we should cover in the interview with a significant other/relative?
Double-check history, symptoms Enquire about more interpersonal aspects e.g., husband, wife, child - how is the patient engaging socially affect, empathy, communication etc. Enquire about blind spots
What we should cover in the patient/relative joint interview?
Observe interactions how the relative treats patient (e.g., like a child, or harshly) Gently confront inconsistencies Request additional information Outline the assessment plan 1:04:50
What should be considered when selecting instruments
Always: Adapt instrument to referral question (relevant, comprehensive) patient status (floor, ceiling) expected prognosis (repeated testing requires test that allow for this) Norms (e.g., Cultural - American vs. Russian norms - fast vs. slow accurate completion) Reliability Construct Validity Be aware of the test limitations - there is no pure Neuropsychological test Depending on the referral question: Sensitivity vs. Specificity ecological validity: Veridicality vs. Verisimilitude Forensic Cases: Attention to base rates, predictive value Select replicable tests Include malingering tests 1:07:05
Which aspects of assessment tests would you prioritize for differential diagnosis between mild cognitive impairment and dementia?
Need test that will distinguish between the two <li style Weigh up sensitivity and specificity
Which aspects of assessment tests should be prioritized in the following case: Hospital HR referral: Can an employee (surgeon) go back to a previous position after a stroke?
need to consider ecological value of test need to predict how the surgeon will perform the type of tasks normally involved in this position 1:12:25
Which aspects of assessment tests should be prioritized in the following case: Self-referral: Strong memory complaints, but no neuroimaging/biomarker evidence?
Which aspects of assessment tests should be prioritized in the following case: Self-referral: Recently diagnosed MS client, requesting working hours reduction from the employer
What instruments are available for Neuropsychological Assessments?
General batteries Domain-specific batteries Disorder-specific batteries Setting-specific batteries
What are some general batteries?
WAIS can be interpreted from a Neuropsychic perspective Halstead-Reitan been used extensively as fixed battery CANTAB Luria-Nebraska
What are the subtests of the Halstead-Reitan Battery? (fixed battery)
Category Tactual Performance Rhythm Speech sounds perception Finger-tapping Time sense Other tests included are - Trail Making Test, Strength of Grip Test, Miles ABC Test of Ocular Dominance, WAIS, MMPI, Aphasia screening.
What is the Luria-Nebraska Neuropsychological Battery?
A fixed battery that takes about 1/3 of the time of Halstead-Reitan, with sub-scales to assess cognitive process and functions. the Analysis of scores leads to judgement on whether impairment exists if so which part of the brain has injury.
What is the CANTAB?
Cambridge Neuropsychological Test Automated Battery computer-based Cognitive Assessment Battery administered using a touch screen computer consists of 22 tests examines various areas of cognitive function general memory and learning, working memory and executive function visual memory attention and reaction time (RT) semantic/verbal memory decision making and response control.
What are some examples of domain specific batteries?
McQuarrie (Motor) Boston Diagnostic Aphasia Examination Wechsler Memory Scale Delis-Kaplan Executive Function Systems
Please enlist two examples of disorder-specific batteries?
MATRICS Consensus Cognitive Battery for Schizophrenia, CAPSIT Protocol for Parkinson’s Disease.
Name a setting-specific battery.
Sports Concussion Battery Military
What are some behaviors/functions you may need to test in a Neuropsychological assessment?
0-3 years milestones IQ or Academic Achievement Test
What are the abilities required for different courses?
Information input and output (Perceptual/Motor) Language Attention Memory Executive Functions Social Cognition empathy, understanding humor etc. Personality Everyday functioning Effort/Malingering
How is Perceptual/Motor ability assessed and what are the relevant tests?
Visual Perception Visual Discrimination Test Judgement of Line Orientation Test Visual Integration Hooper Visual Organization Test Visual Construction Rey Complex Figure-Copy Clock Drawing Bender Visual-Motor Gestalt Test Motor Speed Finger Tapping Motor Dexterity Grooved Pegboard Tactual Performance Test 1:19:25
How is language ability assessed and what are the relevant tests?
Perception distinguishes between sound, phonemic. lexical levels Comprehension rule-following test Production free speech analysis Repetition Reading/Writing Syntax verbs, planning/sequencing sometimes related to executive function Semantics access, concepts also related to executive function.
How is Memory assessed and what are the relevant tests?
- Episodic Memory, Verbal learning, and memory: Word lists (15-16 words)
- Learning Slope/Encoding (5 trials) short-term after interference memory (3 mins)
- Long-term memory (20-30 mins)
- Recognition: Recollection/Familiarity: MCQs
- Verbal forgetting: Selective Reminding Test 5-trial word list subsequent presentations (2,3,4,5) don’t repeat previously learned words
- Visual Memory: Rey Complex (but watch perceptual/motor)
- Continuous Visual Memory Test
- Semantic memory: Verbal Fluency by Category Logical memory guessed from passages, stories
- Procedural memory (HM case study) Repeated drawing accuracy Meta-memory
Which kind of memory do Neuropsychologists often refer to as 'mental time-travel'?
Episodic Memory (which is a form of declarative memory).
What memory decline is a good predictor of trouble with daily function?
Episodic
What are the distinct phases of a memory test?
Using word lists Learning Phase:
- Learning Slope/Encoding (5 trials)
- Short-term after interference memory (3 mins)
- Long-term memory (20-30 mins)
- Recognition (Recollection/Familiarity)
What are the various kinds of memory problems?
- Learning
- Encoding
- Recovering
- Forgetting (Degradation of information).
We can declare which two kinds of memory?
Episodic and Semantic
What is a visual memory test?
Rey Complex Test Abstract picture - cannot use things that can be associated with words or semantics, so they are remembering what they see asked to copy it after 3 mins > free recall after 30mins > delayed free recall
What is the average number of elements recalled in the Rey Complex visual Memory test for immediate recall delayed recall?
12-14 elements in immediate recall 10-12 elements in delayed recall.
How can the type of memory problem be examined?
by comparing Immediate, Delayed and Recognition Phase scores e.g., low scores on immediate and delayed, but a high score on recognition may suggest the problem is with memory retrieval, not encoding or storage executive processes e.g., a gradual decline from immediate, to delayed, to recognition (information is vanishing with time, forgetting) could suggest a deterioration of the temporal lobe.
How is Attention assessed and what are the relevant tests?
It is complex to assess. Energizing, focus, orientation reaction time-based tasks, visual/auditory discrimination, matching familiar figures, seashore rhythm test, attentional span, digits then more complex, which also involve executive function/control. sustained attention continuous performance test, cancellation tests selective attention, STROOP divided attention—alternate Paced Auditory Serial Addition Test
What aspect of brain function will brain-injury always impair?
Attention
How is Executive Function assessed and what are the relevant tests?
- Abstract thinking: Inferring Similarities, for example in pen versus the pencil, Proverb interpretation,
- Working Memory: Letter Number Sequencing, N-back Self-Ordered Pointing
- Response Inhibition Stroop Hayling Sentence Completion Stop-Signal
- Planning Tower of Hanoi Mazes, Picture Arrangement
- Shifting Wisconsin Card Sorting Test, Trail Making Test Category Test Decision-making Iowa Gambling Task Cambridge Gamble Task 1:34:40
What do the following tests assess? Similarities Proverbs 20 questions
Executive function specifically 'Inferring'
What do the following tests assess? Letter Number Sequencing N-back Self-Ordered Pointing
Executive function specifically 'Working Memory'
What do the following tests assess? Stroop Hayling Sentence Completion Stop-Signal
Executive function specifically 'Response Inhibition'
What do the following tests assess? Tower of Hanoi Mazes, Picture Arrangement
Executive function specifically 'Planning'
What do the following tests assess? Wisconsin Card Sorting Test Trail Making Test Category Test
Executive Function specifically ' Shifting'
What do the following tests assess? Iowa Gambling Task Cambridge Gamble Task
Executive Function specifically Decision Making
What is the "no pure test" problem
no single executive function test is a pure measure of any single function i.e., is measuring a tiny portion of each of the executive domains at the same time e.g., TMT is measuring ' shifting' or flexibility but in order to do this you must first 'inhibit' immediate tendency to go from 1 to 2 or A to B e.g., N-back is measuring 'working memory' or updating but will involve 'shifting' e.g., Tower of Hanoi is measuring 'planning' but engages 'working memory' (to project the number of movements), 'inhibition' (tendency to just move), 'flexibility'
How is Social Cognition relevant to Neuropsychological Assessment?
Most info comes from triangle of the face (eyes, nose, mouth) Emotion recognition Eyes test Empathy Theory of mind, Faux Pas Moral Dilemmas low conflict vs. high conflict (analyze what the style of people) some people have a deontological approach some have a utilitarian, concrete thinking approach (stole motorbike coz keys were there) Affective Prosody Perception Humor Processing
Which Personality tests are used in Neurological Assessment?
General personality tests MMPI, MCMI Projective tests TAT helps access the inner experience of brain-injured patient’s Specific personality change scales for brain dysfunction Iowa Scales of Personality Change BRIEF FrSBe: Frontal Systems Behavior Scale (1:45:00) Apathy Disinhibition Executive Dysfunction
What types of tests of everyday behaviors (i.e. The Ecological Approach) may be used in a Neuropsychological Assessment?
Riverhead Behavioral Memory Test, Test of Everyday Attention Behavioral Assessment of the Dysexecutive System Poker cards N-back Key Search (box - draw the best strategy to find the keys) Zoo Map (plan a visit to the zoo, following social rules) Multitasking Clinic-based - Hotel Task (like a real-life job, concierge in a hotel) Outside clinic - Multiple Errands Test
Why is the Ecological approach so valuable to Neuropsychological Assessment?
Neuropsychology so often tries to predict daily life using tests that are very structured and artificial Ecological approach addresses this issue by utilizing real-life situations
What are some important aspects of test administration?
optimize patient/client performance minimize performance anxiety hide tools e.g., timer maintain rapport, alertness provide clear guidelines order is important (balance difficult items, with timing, etc) stick to manual instructions
What are some important aspects of Interpretation?
Quantitative - must have good norms Best way is to Integrate all sources of information Articulate response to the referral question Communicate results of the assessment clearly to the patient (verbal, report)
References