Lecture 10 - Neuropsychological Assessment (DN) Flashcards
1
Q
What are the two fields of Neuropsychology?
A
- Experimental Neuropsychology
- Clinical Neuropsychology
2
Q
What is the focus of Experimental Neuropsychology?
A
- the “normal” brain
Method: animal & human models (e.g., lesions)
3
Q
What is the focus of Clinical Neuropsychology?
A
- “dysfunction” - particularly CNS dysfunction &
- its impact on behaviour & quality of life
4
Q
What are the two main areas of clinical neuropsychology
A
- Assessment
- Rehabilitation
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
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
7
Q
What are the 4 areas of definition required by the American Psych Assoc for a discipline to be recognised?
A
- Type of Problem
- Populations
- Settings
- Services
15:35
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
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
10
Q
- What settings do Clinical Neuropsychologists work in?
A
- Hospitals
- Clinics
- Forensic
- Private Practise
25:35
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
12
Q
What proportion of a Clinical Neuropsychologist’s time is spent in assessment?
A
- 40%
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
14
Q
What is the first question one should ask before performing a Neuropsychological Assessment?
A
- Why is this assessment necessary
15
Q
What are the two approaches to Neuropsychological Assessment?
A
- Fixed Battery, Pattern Analysis
- Flexible Approach, Hypothesis Testing
- assess only particular parts of system that you think are causing the problem
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
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
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
19
Q
What are the disadvantages of the
- Fixed Battery
- 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
20
Q
How do you determine which assessment approach is better?
A
It depends on the referral question
42:05
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
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
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
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
25
Which assessment approach is better in the following scenario: **Fixed or Flexible?**
Forensic determination
**Fixed**
* Replicability
* Many professionals involved
* Court - challenged, needs to be backed up by systematic assessment
26
Which assessment approach is better in the following scenario: Fixed or Flexible?
**Characterisation 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
51:50
27
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
28
Which approach do professionals use?
Fixed, Purely Flexible, or Flexible (combination of both)
* Most people use a combination of approaches
54: 30
29
What are the four steps of a combination flexible battery?
* 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
30
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
31
What happens in **Phase 1** of the Neurolopsychological Assessment?
**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
32
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)
33
What happens in **Phase 3** of the Neuropsychological Assessment?
**Administration of Instruments**
* Neuropsychological Tests
* Personality/Mood Scales
* Behavioural Trials
* Life-log
34
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
35
What type of information do neuropsychologists use in assessments?
* 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
Why would it be important to include school & work records in a neuropsychological examination?
* Important to understand how the patient was before the dysfunction
* e.g., in order to differentiate lesion related injury from pre-morbid condition
37
Which three interviews are important in a Neuropsychological assessment?
1. Patient
2. Relative (significant other)
3. Both together
1:01:05
38
What should be covererd in the interview with patient?
* 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
What should be covered 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
1:04:02
40
What should be covered 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
41
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. Verisimiltude
**Forensic Cases:**
* Attention to base rates, predictive value
* Select replicable tests
* Include malingering tests
1:07:05
42
Which aspects of assessment tests should be prioritised in the following case:
* **Neurology Service referral for differential diagnosis between Mild Cognitive Impairment vs. Dementia**
* Need test that will distinguish between the two
* Weigh up sensitivity & specificity
1:11:35
43
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?**
* 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
Which aspects of assessment tests should be prioritised in the following case:
* **Self-referral: Strong memory complaints, but no neuroimaging/biomarker evidence**
45
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**
46
What instruments are available for Neuropsychological Assessments?
* General batteries
* Domain-specific batteries
* Disorder-specific batteries
* Setting-specific batteries
1:13:05
47
What are some general batteries
* WAIS
* can be interpreted from a Neuropsych perspective
* Halstead-Reitan
* been used extensively as fixed battery
* CANTAB
* Luria-Nebraska
48
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
p.560 Text - Table 15-7
49
What is the Luria-Nebraska Neuropsychological Battery?
* 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
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
Warning: this slide is taken from WIKI (couldn't find in text)
51
* What are some domain specific batteries?
* McQuarrie (Motor) Boston Diagnostic Aphasia Examination
* Wechsler Memory Scale
* Delis-Kaplan Executive Function Systems
52
What are some other test batteries?
I think these are 'domain specific'??? check
* 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
What are some disorder-specific batteries?
* MATRICS Consensus Cognitive Battery
* Schizophrenia
* CAPSIT Protocol
* Parkinsons Disease
54
What are some **setting-specific batteries?**
* Sports Concussion Battery
* Military
55
What are some of the behaviours/functions you may need to test in a Neuropsychological assessment?
* 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
How is **Perceptual/Motor ability** assessed & what are the relevant tests?
* **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
How is **Language ability** assessed & what are the relevant tests?
* **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
How is **Memory** assessed & what are the relevant tests?
**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
Which kind of memory do Neuropsychologists often refer to as 'mental time travel'?
Episodic Memory
(which is a form of declarative memory)
1:23:20
60
................ memory decline is s goof predictor of trouble with daily function?
Episodic
1:23:35
61
What are the different 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)
1:23:45
62
What are the different kinds of memory problems?
* Learning
* Encoding
* Recovering
* Forgetting (Degradation of information)
125:45
63
Which two kinds of memory can be declared?
Episodic & Semantic
64
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 actually remembering what they see
1. asked to copy it
2. after 3 mins \> free recall
3. after 30mins \> delayed free recall
4.
65
What are 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
1:28:20
66
How can the type of memory problem be examined?
* 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
How is **Attention** assessed & what are the relevant tests?
* 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
What aspect of brain function is always affected by brain injury?
Attention
1:34:15
69
How is **Executive Function** assessed & what are the relevant tests?
* **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
What do the following tests assess?
* Similarities
* Proverbs
* 20 questions
* Executive function
* specifically **'Inferring'**
71
What do the following tests assess?
* Letter Number Sequencing
* N-back
* Self-Ordered Pointing
* Executive function
* specifically **'Working Memory'**
72
What do the following tests assess?
* Stroop
* Hayling Sentence Completion
* Stop-Signal
* Executive function
* specifically **'Response Inhibition'**
73
What do the following tests assess?
* Tower of Hanoi
* Mazes, Picture Arrangement
* Executive function
* specifically **'Planning'**
74
What do the following tests assess?
* Wisconsin Card Sorting Test
* Trail Making Test
* Category Test
* Executive Function
* specifically '**Shifting'**
75
What do the following tests assess?
* Iowa Gambling Task
* Cambridge Gamble Task
* Executive Function
* specifically **Decision Making**
76
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 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
How is Social Cognition relevant to Neuropsychological Assessment
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
Which Personality test are used in Neurological Assessment?
* 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
What types of tests of everyday behaviour (i.e.the Ecological Approach) may be used in a Neuropsychological Assessment?
* 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
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 utilising real life situations
81
What are some important aspects of test administration?
* 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
What are some important aspects of **Interpretation**?
* 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)
