lecture 8 : clinical neuropsyc assesment part 2 Flashcards
JD case study
-what happened to him
-why was he referred
-treatment
-aged 54
-18 years of education
- Severe closed-head injury from car accident
- Frontal and temporal lobe damage
Reported issues (referred to neuropsycholgist)
-Mild speech and motor problems
-Unable to return to work
-Difficulties with multitasking, time management, memory, social interactions.
Neuropsychological testing revealed :
-Problems attention & executive function (control functions of cognitions (ability to switch task to task, inhibit irrelevent info)
Intensive rehabilitation resulted in improvements in executive function, time management and functional ability
assessing current cognitive functioning (what are the 3 important aspects in psyc)
a) intelligence
b) memory
c) language
classes of cognitive assessment
sensory reception and perception
-memory
-thinking and decision making
-motor functions
-language
-numerical processing
-executive function and attention
intelligence tests
-why is this test helpful
eg
wechsler adult intelligence scale (WAIS)
-within the wais it will pick up many classes of cognitive assessment
-
WAIS
Ten core subtests with mean of 10 and a SD of 3
The subtests are arranged into four indexes (mean 100, SD = 15)
There is also an overall IQ (Full Scale IQ) that is obtained by summing scores on all the subtests
clinical assesment with the WAIS
-why use it initially
-weaknesses
Use intelligence test as initial screening assessment (trying to identify is there a problem around this area)
-To help decide which areas to explore in more detail
-Standardised tests with observation
-May use shortened version involving fewer subtests
-Gives overall FSIQ and index scores
-Extensive standardization, excellent norms, good reliability and construct validity
Weaknesses of WAIS
-Does not assess executive functions
since they dont assess the specific skills that are needed in every day life :
-Predictive validity (the WAIS does not predict your ability to function in every day life )and treatment validity poorer than other tests
memory classes and problems
-short term memory (could asses digit span)
-working memory (storing and processing information)
-long term memory ;
(anterograde(post brain injury) retrograde (before the brain injury)) (crucial aspect of brain illness is separating these)
(verbal v non verbal)
(semantic v episodic) can get amnesia in these
procedural or implicit memory (memory without conscious recall)
prospective memory: remembering to carry out intentions etc taking meds
Wechsler memory scales (WMS)
-mean
-subtests
-evaluation
Mean = 100, SD = 15: co-normed with WAIS
Multiple subtests assess:
-Auditory-verbal immediate & delayed memory
-Visual-spatial immediate & delayed memory
-Working memory
Evaluation (see e.g. Kent, 2013)
-Good reliability
-WMS more sensitive to head injury than WAIS
-Does not assess procedural or prospective memory (can be important in every day function and helping design rehabilitation)
-WMS IV no assessment of verbal working memory
-Not linked to neuroanatomical theory of memory (how brain relates to memory, no theory to underscore the test design)
-Factor structure not as proposed in manual
assessing language
-aphasia
-what clinical examinations can be used
aphasia
-the set of different language impairments that you can get if you have brain illness
clinical examinations
-Spontaneous speech and observation
-To diagnose presence of aphasia
assesing language
after clinical exams : then diagnostic tests (understand nature of problem)
-E.g. Boston Diagnostic Aphasia Exam (BDAE III)
-To pinpoint nature of language problems (aphasia)
-To provide guidance for rehabilitation
-8 subscales: fluency, auditory comprehension, naming, oral reading repetition, automatic speech, reading comprehension, writing.
-
Very wide range of tasks (34 subtests!)
- Includes structured interview, observation and tests
Boston Diagnostic Aphasia Exam (BDAE )
evaluation
- Time-consuming, requires specialist training
-Norms for aphasic patients, and small normal sample
-Reliability acceptable, lower for ‘qualitative’ scales
-Construct validity, diagnostic validity and treatment validity good
-e.g. Fong, Van Patten & Fucetola (2019): Factor analysis in 355 people with aphasia confirmed factor structure of the BDAE III
- But only valid for those with relevant education and language exposure
Assessing executive function
-what is it
self regulation processes
- control/regulation of behaviour, cognition, planning, ability to switch
executive function preditcs….
struchen 2008
-Predict functional outcomes better than other cognitive variables
-Ecological validity important
Struchen et al. (2008)
121 people with brain injury
EFs predicted:
Return to work, social integration, marital success, and caregiver burden
Better than other measures of cognitive or physical functioning
Executive function measures predict return to work in a bipolar sample Drakopoulos et al. (2020)
Bipolar disorder associated with high levels of unemployment
120 patients with bipolar disorder
Looked at predictors of occupational status
demographic factors, clinical characteristics, IQ and executive function
Executive functioning was a more powerful predictor of occupational status than IQ, demographics and clinical factors, including illness severity.
types of executive function
-planning
-initiation , monitoring and control
-socioemotional control
planning
-decide goals, execute and adapt plans
-eg shopping, cooking,many work tasks
initiation, monitoring and control
-inhibition and switching, apathy
eg driving, self care, working
socioemotional control
-regulating mood and social behaviour
-eg social interactions, maintaining relationships, working
how can we measure executive function
neuropsychological tests
-eg fluency, Wisconsin card sort test, tower of London , Stroop
structured interviews
-dysexecutive function questionnaire
rating scales
-dysexecutive questionnaire
behavioural assessments
-multiple errands test
what are the issues in assesing executive functions
traditional psychometrics may not apply
-EF tasks must be novel: test-retest reliability ?
-EF tasks must be unstructured : reliability lower?
-so if reliability is lower must be careful when interpreting scores
-ecological validity important
-naturalistic/complex settings : norms don’t apply
-instructions less directive
executive function tasks dissociated
-poor convergent validity (executive function tests dont correlate well with each other - or there are many aspects of executive function)
EF test : tower tests (eg tower of london)
Instructions: Mentally plan sequence of moves to solve puzzle in fewest moves possible, then execute the plan
evaluation of tower tests
Not well standardised
-No commercial version with good norms
Test-retest & split-half reliability adequate
-(> 0.7)
Good evidence of validity:
-Sensitive to brain damage
-Masson et al. (2010): correlates with measures of functioning and real world planning
Suitable for use in children and adults
-Participants find task enjoyable
Test 2: Dysexecutive questionnaire (DEX)
Self-ratings and informant-ratings
evaluation
can be done as interview or self rating q
quite often patient rates themself then an informant will give a rating
20 item questionnaire
-Control of emotion, behaviour and cognition
-E.g. “I act without thinking, doing the first thing that comes to mind”
Evaluation (Shaw et al., 2015)
-Useful to have informant- and self- ratings, though poor inter-rater reliability (but then people with brain illnes tend to be unaware of their issues)
-Internal consistency >.8
-Concurrent validity with EF tests usually poor
-DEX self-ratings correlate with mood and quality of life assessments (someone who is depressed may have worse executive function)
Ratings limited: need objective tests too
Test 3: Multiple Errands Test (MET)
Test with behavioural observation
real life test
Shopping/work errands task, and asked to carry them out
-Requires planning, self-initiation, monitoring
Can have standard structure
-But adapt to situation & surroundings
-Naturalistic form of functional assessment
-Observation of behaviour including social interactions, problem-solving, planning (someone actually also looks at how you carry it out)
example of multiple errands test in
-control patient
-patient with frontal lobe damage
-the patient with dysexecutive syndrome with frontal lobe damage,you can see they take more routes, less efficient
-visited shops twice
-went backwards/forwards
-broke rules and went to area they weren’t meant to during task
-the control participant has a more efficient route
evaluation of MET
-strengths
-weaknesses
Strengths:
-Observe behaviours and social interactions
-Assess behaviour in naturalistic setting
-Help design rehabilitation
-Cuberos-Urbano et al. (2013) :
Evidence of adequate inter-rater reliability
Predicts functional outcome: adaptive behaviour
Weaknesses:
Lack of control and standardisation: no norms -unexpected things happen when you do things in every day life , they wont always preditc every day outcomes as well
Not assessing specific functions in detail
Unexpected events
