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Lecture 10 - Neuropsychological Assessment (DN) Flashcards

1
Q

What are the two fields of Neuropsychology?

A
  1. Experimental Neuropsychology
  2. Clinical Neuropsychology
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2
Q

What is the focus of Experimental Neuropsychology?

A
  • the “normal” brain

Method: animal & human models (e.g., lesions)

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3
Q

What is the focus of Clinical Neuropsychology?

A
  • “dysfunction” - particularly CNS dysfunction &
    • its impact on behaviour & quality of life
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4
Q

What are the two main areas of clinical neuropsychology

A
  • Assessment
  • Rehabilitation
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5
Q

What is the (NAN, 2001) definition of a Clinical Neuropsychologist?

A

8:00

  • professional within the field of psychology
  • special expertise in applied science of the brain-behaviour relationships

9:50

  • they use this knowledge to assess, diagnose, treat &/or rehabilitate patients with
  • neurological, medical, neurodevelopmental & psychiatric conditions
  • as well as other cognitive & learning disorders
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6
Q

What is the difference between treatment & rehabilitation in clinical neuropsychology?

A

10:50

  • Treatment engages some technique applied to a client
  • Rehabilitation applies a dynamic interaction between patient, clinician, family & community resources to achieve maximum possible recovery

(we know that most of CNS will not fully recover) but need to work to maximum possible recovery to improve client’s daily life

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7
Q

What are the 4 areas of definition required by the American Psych Assoc for a discipline to be recognised?

A
  1. Type of Problem
  2. Populations
  3. Settings
  4. Services

15:35

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8
Q

What type of problems would a Clinical Neuropsychologist attend to?

A
  • characterisation of impairment
  • differential diagnosis e.g., between dementia & other conditions
  • measurement of change
    • preliminary baseline measurement e.g., Parkinsons disease to track change
    • applicable to every dysfunction that can be detected early (huntingtons, MS)
  • prediction of functional outcomes
    • e.g., can this person continue to work / drive safely etc)
  • planning rehabilitation
  • rehabilitation

16:05

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9
Q

What populations do Clinical Neuropsychologists work with?

A
  • Neurological
    • brain injury
  • Psychiatric
    • depression, OCD, schizophrenia
  • General medical & surgical
    • vascular conditions impacting brain
  • Professional
    • sports (brain trauma, post concussional syndrome), occupational (exposed to neurotoxic agents)
  • Children (learning disabilities, developmental disorders)

22:45

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10
Q
  • What settings do Clinical Neuropsychologists work in?
A
  • Hospitals
  • Clinics
  • Forensic
  • Private Practise

25:35

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11
Q

What services can a Clinical Neuropsychologist provide?

A
  • Neuropsychological Assessment
  • Cognitive remediation & intervention
  • Neuropsychological rehabilitation
  • Psychological therapies (for brain dysfunction)
    • e.g., personality problems resulting from brain injury may require specific therapies
  • Counselling to Public Agencies, Private Companies, Educational Centres

25:50

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12
Q

What proportion of a Clinical Neuropsychologist’s time is spent in assessment?

A
  • 40%
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13
Q

How do current views of Neuropsychological Assessment differ from old views?

A

Old Views - relevance to current views

  • locate the lesion -
    • other techniques are better equipped for this (e.g., brain imaging)
    • current priority is to characterise cognitive status
  • determine organicity -
    • do not distinguish between organic & non-organic (psychological)
    • current view is that it is always organic & always psychological
    • provide a reasoned account of cognitive strengths & weaknesses
  • neurological or psychiatric diagnosis -
    • this is for a neurologist or psychiatrist
    • role is to work out how neuropsych system works and what is not working well
    • determine functional (everyday) impact
    • provide a neuropsychological diagnosis

27:25

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14
Q

What is the first question one should ask before performing a Neuropsychological Assessment?

A
  • Why is this assessment necessary
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15
Q

What are the two approaches to Neuropsychological Assessment?

A
  1. Fixed Battery, Pattern Analysis
  2. Flexible Approach, Hypothesis Testing
  • assess only particular parts of system that you think are causing the problem
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16
Q

How does the Fixed Battery differ from the Flexible Approach to Assessment?

A

Fixed Battery

  • Quantitave
    • gives you numbers - interpreted relative to norms
  • Outcome Focussed
    • scores/performance
  • Matrix Vision
  • Comprehensive

Flexible Approach

  • Mixed Quantitative/Qualitative
  • Process Focussed
    • why did the client achieve this outcome, what compensatory processes, what could he have done differently
  • Modular Vision
    • assumes certain systems of brain are specific to certain functions
    • isolated on other systems of the brain
    • so only focus on module which is dysfunctional
  • Hypothesis-driven
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17
Q

What are the advantages of the Fixed Battery approach to Neuropsychological Assessment?

A
  • Systematic
    • always done the same way
  • Comprehensive
    • addresses every possible cognitive determinant
  • Objective Interpretation
    • scores can be trasformed into deficits or strengths
  • Easy to train
  • Easy to replicate

37:15

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18
Q

What are the advantages of the flexible approach to Neuropsychological Assessment?

A
  • Patient-tailored
    • individuality of each case
  • Focus on relevant domains
    • not whole system
  • Process (WHY) emphasis rather than outcome (WHAT)
  • Time efficient

38:00

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19
Q

What are the disadvantages of the

  1. Fixed Battery
  2. Flexible Approach
A

Disadvantages of

Fixed Battery

  • time consuming
    • could take 6-10 hours just for administration of instruments
  • relies on availability of quality norms
    • this is because reliance is on the outcomes
    • provides reference framework for interpretation of scores

Flexible Approach

  • Susceptible to bias
    • hypothesis may be wrong
    • clinician may be misled by certain factors
    • could mistakenly exclude vital points
    • e.g., referall from lawyer - could bias you by adding relevance to some symptoms
  • Relies on training/experience

38:35

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20
Q

How do you determine which assessment approach is better?

A

It depends on the referral question

42:05

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21
Q

What are some of the most frequent referral questions?

A
  • 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%
  • localisation of lesion 2.7%

source Rabin et. al., (2005)

42:30

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22
Q

How did the flexible approach originally come about?

A
  • in the diagnosis of certain language disorders
  • it was established that using a relatively small number of tests language disorders
    • e.g., aphasia could be accurately diagnosed
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23
Q

Which assessment approach is better in the following scenario: Fixed or Flexible?

  • Intellectual disability determination
A

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 likely be assessing
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24
Q

Which assessment approach is better for this scenario: Fixed or Flexible?

Diagnosis of acquired language deficits

A

Flexible

  • very specific referral question
  • posterior parts of brain are more modular
  • perceptual, language, motor is probably ok to do flexible
    • wheras general cognitive ability or memory etc would need Fixed
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25
Q

Which assessment approach is better in the following scenario: Fixed or Flexible?

Forensic determination

A

Fixed

  • Replicability
  • Many professionals involved
  • Court - challenged, needs to be backed up by systematic assessment
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26
Q

Which assessment approach is better in the following scenario: Fixed or Flexible?

Characterisation of a football players deficits post concussion

A

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

51:50

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27
Q

Which assessment approach is better in the following scenario: Fixed or Flexible?

Prognostic assessment of a recently diagnosed multiple sclerosis patient

A

Flexible

  • already have a diagnosis
  • know what typically occurs in MS

53:20

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28
Q

Which approach do professionals use?

Fixed, Purely Flexible, or Flexible (combination of both)

A
  • Most people use a combination of approaches
    54: 30
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29
Q

What are the four steps of a combination flexible battery?

A
  • An intial “fixed” set of attempts to cover all relevant domains
    • (i.e., cover most of cognitive system)
    • to develop broad quantitative profile
  • Develop hypothesis
  • Select specific instruments to examine hypothesis
  • Interpretation or Reiteration

54:45

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30
Q

What are the four phases of a Neuropsychological Assessment?

A

Phase 1 - Interview

Phase 2 - Selection of Instruments

Phase 3 - Administration of Instruments

Phase 4 - Interpretation of the whole assessment

56:25

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31
Q

What happens in Phase 1 of the Neurolopsychological Assessment?

A

Interview

  • Clarify the Referral Question (this should be done before the interview)
  • Medical History
    • via patient, relatives
  • Developmental Milestones
  • School/Occupational History
  • Psychosocial History
  • Symptoms: evolution & coping

56:35

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32
Q

What happens in Phase 2 of the Neuropsychological Assessment?

A

Selection of Instruments

based on the:

  • referral question
  • selected approach
  • information collected at the interview (phase 1)
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33
Q

What happens in Phase 3 of the Neuropsychological Assessment?

A

Administration of Instruments

  • Neuropsychological Tests
  • Personality/Mood Scales
  • Behavioural Trials
  • Life-log
34
Q

What happens in Phase 4 of the Neuropsychological Assessment?

A

Interpretation of the whole assessment

  • History analysis
  • Observations
  • Test scores
  • Qualitative observations
  • Estimated impact

Feedback is ongoing, not just at the end

35
Q

What type of information do neuropsychologists use in assessments?

A
  • Medical/psychiatric history
  • Neuropsychological test data
  • Referral source
  • Psychsocial history
  • Mood & affect measures
  • Developmental history
  • Current social supports
  • Objective personality tests
  • Mental status exam
  • Significant other interview
  • Environmental demand charcteristics
  • Behavioural assessments
  • School records
  • Functional Assessments
  • Work records
  • Projective personality tests

source: Rabin et al., (2005)
58: 50

36
Q

Why would it be important to include school & work records in a neuropsychological examination?

A
  • Important to understand how the patient was before the dysfunction
    • e.g., in order to differentiate lesion related injury from pre-morbid condition
37
Q

Which three interviews are important in a Neuropsychological assessment?

A
  1. Patient
  2. Relative (significant other)
  3. Both together

1:01:05

38
Q

What should be covererd in the interview with patient?

A
  • create rapport - trust, empathy
    • will get more accurate information from them
  • comprehensive history
    • developmental
    • medical
    • vocational
    • social
    • helps to understand how the brain works in different situations
  • Allow patient directed (idiosyncratic) description of symptoms
    • current, evolution, coping
  • Attention to Potential Gains
    • e.g., financial, legal, emotional (attention)

1:01:50

39
Q

What should be covered in the interview with a significant other/relative?

A
  • 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

1:04:02

40
Q

What should be covered in the patient/relative joint interview?

A
  • 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

41
Q

What should be considered when selecting instruments

A

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. Verisimiltude

Forensic Cases:

  • Attention to base rates, predictive value
  • Select replicable tests
  • Include malingering tests

1:07:05

42
Q

Which aspects of assessment tests should be prioritised in the following case:

  • Neurology Service referral for differential diagnosis between Mild Cognitive Impairment vs. Dementia
A
  • Need test that will distinguish between the two
  • Weigh up sensitivity & specificity

1:11:35

43
Q

Which aspects of assessment tests should be prioritised in the following case:

  • Hospital HR referral: Can an employee (surgeon) go back to a previous position after a stroke?
A
  • 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

44
Q

Which aspects of assessment tests should be prioritised in the following case:

  • Self-referral: Strong memory complaints, but no neuroimaging/biomarker evidence
A
45
Q

Which aspects of assessment tests should be prioritised in the following case:

  • Self-referral: Recently diagnosed MS client, requesting working hours reduction from the employer
A
46
Q

What instruments are available for Neuropsychological Assessments?

A
  • General batteries
  • Domain-specific batteries
  • Disorder-specific batteries
  • Setting-specific batteries

1:13:05

47
Q

What are some general batteries

A
  • WAIS
    • can be interpreted from a Neuropsych perspective
  • Halstead-Reitan
    • been used extensively as fixed battery
  • CANTAB
  • Luria-Nebraska
48
Q

What are the subtests of the Halstead-Reitan Battery?

(fixed battery)

A
  • 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

p.560 Text - Table 15-7

49
Q

What is the Luria-Nebraska Neuropsychological Battery?

A
  • a fixed battery
  • LNNB takes about 1/3 of the time of Halstead-Reitan
  • contains clinical scales which assess cognitive process & functions
  • Analysis of scores leads to judgement on whether impairment exists
    • if so which part of the brain is affected

p.559

50
Q

What is the CANTAB?

A
  • 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

Warning: this slide is taken from WIKI (couldn’t find in text)

51
Q
  • What are some domain specific batteries?
A
  • McQuarrie (Motor) Boston Diagnostic Aphasia Examination
  • Wechsler Memory Scale
  • Delis-Kaplan Executive Function Systems
52
Q

What are some other test batteries?

I think these are ‘domain specific’??? check

A
  • the Neurosensory Centre Comprehensive Examination of Aphasia (NCCEA)
    • focus: communication deficit
  • the Montreal Neurological Institute Battery
    • helps locate specific kinds of lesions
  • the Southern California Sensory Integration Tests
    • assess sensory-integrative & motor functioning in children 4-9yrs
  • the Severe Impairment Battery (SIB)
    • used with severley impaired who may perform near the floor of other tests
  • the Cognitive Behavioural Driver’s Inventory
    • determines whether brain damaged individuals are capable of driving a car

p.561 - text

53
Q

What are some disorder-specific batteries?

A
  • MATRICS Consensus Cognitive Battery
    • Schizophrenia
  • CAPSIT Protocol
    • Parkinsons Disease
54
Q

What are some setting-specific batteries?

A
  • Sports Concussion Battery
  • Military
55
Q

What are some of the behaviours/functions you may need to test in a Neuropsychological assessment?

A
  • 0-3 yrs milestones
  • IQ or Academic Achievement Test
    • what are abilites required for different courses etc
  • Information input & output (Perceptual/Motor)
  • Language
  • Attention
  • Memory
  • Executive Functions
  • Social Cognition
    • empathy, understnading humour etc.
  • Personality
  • Everyfay functioning
  • Effort/Malingering

1:17:25

56
Q

How is Perceptual/Motor ability assessed & what are the relevant tests?

A
  • Visual Perception
    • Visual Discrimination Test
    • Judgement of Line Orientation Test
  • Visual Integration
    • Hooper Visual Organisation 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

57
Q

How is Language ability assessed & what are the relevant tests?

A
  • Perception
    • distinguish between sound, phonemic. lexical levels
  • Comprehension
    • rule following test
  • Production
    • free speech analysis
  • Repetition
  • Reading/Writing
  • Syntax
    • verbs, planning/sequencing
    • some times related to executive function
  • Semantics
    • access, concepts
    • also relatd to executive function

1:19:50

58
Q

How is Memory assessed & what are the relevant tests?

A

Episodic Memory

  • Verbal learning & memory: Word lists (15-16 words)
    • Learning Slope/Encoding (5 trials)
    • hort-term after interference memory (3 mins)
    • Long-term memory (20-30 mins)
    • Recognition (Recollection/Familiarity)
  • Verbal forgetting: Selective Reminding Test
    • 5-trial word list
    • subsequent presentations (2,3,4,5) dont repeat previously learned words
  • Visual Memory:
    • Rey Complex (but watch perceptual/motor)
    • Continuous Visual Memory Test

Semantic memory

  • Verbal Fluency by Category

Logical memory

  • Gist from passages, stories

Procedural memory (HM case study)

  • Repeated drawing accuracy

Meta-memory

120:55

59
Q

Which kind of memory do Neuropsychologists often refer to as ‘mental time travel’?

A

Episodic Memory

(which is a form of declarative memory)

1:23:20

60
Q

……………. memory decline is s goof predictor of trouble with daily function?

A

Episodic

1:23:35

61
Q

What are the different phases of a memory test?

A

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)

1:23:45

62
Q

What are the different kinds of memory problems?

A
  • Learning
  • Encoding
  • Recovering
  • Forgetting (Degradation of information)

125:45

63
Q

Which two kinds of memory can be declared?

A

Episodic & Semantic

64
Q

What is a visual memory test?

A
  • Rey Complex Test
  • Abstract picture - cannot use things that can be associated with words or semantics, so they are actually remembering what they see
  1. asked to copy it
  2. after 3 mins > free recall
  3. after 30mins > delayed free recall
    4.
65
Q

What are the average number of elements recalled in the Rey Complex visual Memory test for

  • immediate recall
  • delayed recall
A

12-14 elements in immediate recall

10-12 elements in delayed recall

1:28:20

66
Q

How can the type of memory problem be examined?

A
  • by comparing Immediate, Delayed & Recognition Phase scores
    • e.g., low scores on immediate & delayed, but high score on recognition may suggest the problem is with memory retrieval, not encoding or storage
      • executive processes
    • e.g., gradual decline from immediate, to delayed, to recognition (information is vanishing with time, forgetting)
      • could suggest degradation of temporal lobe

130:25

67
Q

How is Attention assessed & what are the relevant tests?

A
  • complex to assess
  • Energising, 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
    • Continous Performance Test (CPT)
    • Cancellation tests
  • Selective Attention
    • Stroop
  • Divided Attention - alternate
    • PASAT

1:31:30

68
Q

What aspect of brain function is always affected by brain injury?

A

Attention

1:34:15

69
Q

How is Executive Function assessed & what are the relevant tests?

A
  • Inferring
    • Similarities
    • Proverbs
    • 20 questions
  • 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

70
Q

What do the following tests assess?

  • Similarities
  • Proverbs
  • 20 questions
A
  • Executive function
    • specifically ‘Inferring’
71
Q

What do the following tests assess?

  • Letter Number Sequencing
  • N-back
  • Self-Ordered Pointing
A
  • Executive function
    • specifically ‘Working Memory’
72
Q

What do the following tests assess?

  • Stroop
  • Hayling Sentence Completion
  • Stop-Signal
A
  • Executive function
    • specifically ‘Response Inhibition’
73
Q

What do the following tests assess?

  • Tower of Hanoi
  • Mazes, Picture Arrangement
A
  • Executive function
    • specifically ‘Planning’
74
Q

What do the following tests assess?

  • Wisconsin Card Sorting Test
  • Trail Making Test
  • Category Test
A
  • Executive Function
    • specifically ‘Shifting’
75
Q

What do the following tests assess?

  • Iowa Gambling Task
  • Cambridge Gamble Task
A
  • Executive Function
    • specifically Decision Making
76
Q

What is the “no pure test” problem

A

no single executive function test is a pure measure of any single function

i.e., is measuring a tiny portion od 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., Nback is measuring ‘working memory’ or updating
    • but will involve ‘shifting’
  • e.g., Tower of Hanoi is measuring ‘planning’
    • but engages ‘working memory’ (to project number of movements), ‘inhibition’ (tendency to just move), ‘flexibility’

1:37:40

77
Q

How is Social Cognition relevant to Neuropsychological Assessment

A

Most info comes from triangle of face (eyes, nose, mouth)

  • Emotion recognition
  • Eyes test
  • Empathy
  • Theory of mind
  • Faux Pas
  • Moral Dilemmas
    • low conflict vs. high conflict (analyse what the style of people)
    • some people have a deontological approach
    • some have a utilitarian, concrete thinking approach (stole motor bike coz keys were there)
  • Affective Prosody Perception
  • Humour Processing
78
Q

Which Personality test are used in Neurological Assessment?

A
  • General personality tests
    • MMPI, MCMI
  • Projective tests
    • TAT
    • helps access inner experience of brain injured patients
  • Specific personality change scales for brain dysfunction
    • Iowa Scales of Personality Change
    • BRIEF
    • FrSBe: Frontal Systems Behaviour Scale (1:45:00)
      • Apathy
      • Disinhibition
      • Executive Dysfunction
79
Q

What types of tests of everyday behaviour (i.e.the Ecological Approach) may be used in a Neuropsychological Assessment?

A
  • Rivermead Behavioural Memory Test
  • Test of Everyday Attention
  • Behavioural Assessment of the Dysexecutive System
    • Poker cards N-back
    • Key Search (box - draw 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 hotel)
    • Outside clinic - Multiple Errands Test
80
Q

Why is the Ecological approach so valuable to Neuropsychological Assessment?

A
  • Neuropsychology so often tries to predict daily life using tests that are very structured and artificial
  • Ecological approach addresses this issue by utilising real life situations
81
Q

What are some important aspects of test administration?

A
  • optimise patient/client performance
  • minimise 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
82
Q

What are some important aspects of Interpretation?

A
  • If 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)

Psychometric testing (35 decks)

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