L6 - Neurobehavioural Assessment

Question 1

Explain the changing and interdisciplinary nature of clinical neuropsychology.

Answer 1

• Changes: neuroscience developments / imaging technology, new pharmaceutical treatments, awareness of cultural issues, increased use of electronic medical records, changes in structure of reimbursement
• Must work with physicians, educational psychologists, lawyers, insurers (challenge of understanding language of coworkers)

Question 2

What are the two approaches of neuropsychological assessment?

Answer 2

• Comprehensive approach: Correlates the results of a full neurologic and neuropsychological exam with patient history and differential diagnosis. Very involved, as it gives a complete picture of a patient’s status, but takes longer (a week) and is expensive (about 10, 000 dollars).
• Hypothesis-driven approach: From information provided by patient history, derive a working diagnosis and then seek information that will most specifically support or refute it. More direct and less expensive but can miss important clues.

Question 3

What are the 3 basic questions that neuropsychologists start with in their assessments?

Answer 3

1. Definition: Is there a neurological / neuropsychological syndrome?
2. Location: Where in the NS is this problem?
3. Causation: What is the etiology of this problem?

Question 4

Explain the 6 components of a neurological exam.

Answer 4

1. Beside mental status testing: Rapidly assessing cognitive status of individual. Concerned with identifying presence or absence of a disease, such as disorders of consciousness, dementia, psychiatric syndromes, and brain abnormalities.
2. Cranial nerve examination: Functions of cranial nerves affected by syndromes involving the meninges, base of the brain, brainstem, and peripheral nerves.
3. Motor examination: Observations of muscle bulk, muscle tone, motor coordination, abnormal movements, apraxia
4. Tactile sensory testing: Testing light touch, temperature, 2 point discrimination, vibration threshold, and position sense
5. Reflex examination: Testing muscle stretch reflexes to determine whether there is a generalized neuropathy, corticospinal tract disorder, lateralized CNS disorder, etc. Can also detect pathological reflexes resulting from damage to the corticospinal tract, such as the Babinski sign.
6. Gait evaluation: Observations of parkinsonism, ataxia, chorea, hemiparesis, foot drop, cogwheel rigidity (spastic paraparesis)

Question 5

Explain how motor functions are assessed in neurobehavioral exams.

Answer 5

• Tasks are presented bilaterally to assess symmetry in performance
• Strength of grip: Patient squeezes fingers of examiner as hard as they can and examiner looks for asymmetry
• Pronator drift: Patient holds arms outstretched with palms up and examiner looks for one arm dropping or the hand turning inward as a sign of unilateral weakness
• Manual facilitation and speed: Tasks involving symmetrical movements with fine motor skills (e.g. tapping the tip of each finger to the thumb). Observe symmetry and evidence of unilateral fatigue.
• Copying tests: motor sequencing, go / no-go, repetitive drawings (frontal lobe patients often do more repetitions than necessary)

Question 6

How are sensory functions assessed in neurobehavioral tests?

Answer 6

• Simple tactile discrimination: patient’s hands are placed on a table and examiner touches each hand while patient keeps eyes closed. Patient has to identify which hand was touched. Failure to do so may indicate damage to the contralateral S1.
• Discrimination of movement by touch: Examiner strokes patient’s hand while patient has eyes closed and patient has to indicate which direction they stroked. Failure may indicate damage to S2.
• Double simultaneous tactile extinction: Touching both hands at the same time. If patient only reports one hand being touched, it could signal damage to S2, the cingulate cortex, thalamus, BG, or frontal lobe.

Question 7

How are visuospatial functions assessed in neurobehavioral tests?

Answer 7

• Visual fields: Patient fixates on examiner’s nose and examiner measures sensitivity to the presence of hand-held targets present in different regions of patient’s visual fields. Examiner looks for asymmetry in patient’s field sensitivity.
• Double simultaneous visual extinction: Examiner places hands in left and right upper quadrants of patient’s visual fields. Examiner wiggles their hands separately and then simultaneously, asking the patient to indicate whether they are wiggling their right, left, or both hands. Extinction is revealed when patient says right or left but not both.
• Line bisection: Patient is given a set of horizontal lines of varying lengths and is asked to bisect each line with a pencil. If the bisecting lines are shifted to one side of each horizontal line, this suggests inattention and contralateral parieto-occipitaq lesion.
• Visual construction: Patient is asked to copy designs of varying difficulty. Inability to produce drawings may indicate attentional or organizational difficulties.

Question 8

What is finger agnosia?

Answer 8

• The loss in the ability to discriminate, name, or recognize fingers
• Tested by assigning a number to each finger and having patient close eyes while examiner touches fingers one at a time. Patient indicates what finger was touched by saying the number.
• Indicates left parieto-occipital dysfunction

Question 9

Explain how language is tested in neurobehavioral tests.

Answer 9

• Assessment of auditory comprehension: Use commands of varying difficulty, starting with the most complex
• Complex ideational
• Repetition of words or phrases (deficits may be due to lesions of accurate fasciclulus)
• Naming of objects
• Reading aloud, writing

Question 10

How is memory assessed in a neurobehavioral examination?

Answer 10

• Patient is given 3 nouns to remember and are asked to repeat the words several times
• In 5 to 10 minutes, asked to repeat the words
• If only one of the words are remembered, this shows memory deficits in patients of all ages
• Recalling only 2/3 words is indicative of memory impairment in middle aged and younger people