Neuropsychological Assessment Flashcards
Brain dysfunction can be due to…
▪️Structural lesions
▪️Metabolic problems
▪️Neurochemical/neurotransmitter abnormalities
What model was neuropsychological assessments originally based on?
Localisation of function
What model is neuropsychological assessment now based on and what does this mean?
Functional systems - whilst areas of the brain are still localised to particular functions, there are many systems of linked regions contributing to function, and damage to any of these areas in the system may impair it
What is a neuropsychological assessment?
A systematic, standardised measure of neuropsychological functioning that looks at a range of cognitive domains
How are neuropsychological assessments typically carried out?
Office-based pen and paper tasks
BUT could also be in real-life settings (multiple errands), medical settings (Wada test), or observations
How long does a neuropsychological assessment typically take?
2-3 hours
For which individuals should you be cautious when interpreting assessment results?
Anyone who potentially differs from the standardisation sample (e.g. English is not their first language, different culture, people with particularly low or high premorbid ability)
How are results of assessment typically represented?
▪️Percentiles
▪️Scores (e.g. IQ)
▪️Qualitative aspects may also be informative (e.g. awareness of failure, types of errors made)
What are the two main conceptual approaches to neuropsychological assessment?
▪️Psychometric
▪️Localisation
What is the psychometric approach to assessment?
It is based on statistical analysis and relies on the normal distribution of performance of most cognitive functions - how does the patient compare to this?
This is the most used approach in clinical practice
What is the localisation approach to neuropsychological assessment?
Using assessment to determine the localisation of pathology.
This is used much less due to advances in neuroimaging.
When might neuropsychological assessments still be involved in diagnostics?
As a screening tool in places were scanners are not available such as primary care.
It also may provide an overview if scans are not particularly sensitive to the damage.
What are the two main practical approaches to neuropsychological assessment?
▪️Fixed/diagnostic
▪️Flexible/functional
What is the fixed approach to neuropsychological assessment?
Assessment uses a formal composite battery that consists of a large range of fixed tests with the idea that if a deficit is present, they will likely detect it.
Results are described diagnostically
What are the limitations of a fixed, diagnostic approach?
▪️Very time consuming
▪️Doesn’t consider the impact of deficits on function
What is the flexible approach to neuropsychological assessment?
Hypothesis testing - assessment is based on a question posed by referral, background, condition, everyday functioning etc
Results are described functionally
What is the main limitation of the flexible, functional approach?
Deficits that are not readily apparent may not be assessed
What practical approach is typically take in clinical assessment?
A combination of approaches:
▪️Informal composite battery
▪️Further testing as indicated
Why do we test general intellectual functioning?
To provide context to other skills an abilities
Allows us to compare with premorbid estimates
What assessment is most commonly used to assess general intellectual functioning?
The Weschler Adult Intelligence Scale (WAIS-IV)
What are the four indices of the WAIS-IV?
▪️Verbal comprehension
▪️Working memory
▪️Perceptual reasoning
▪️Processing speed
68% of people score within ___ points above or below ____ in the Weschler intelligence score.
▪️15 points
▪️100
How do we estimate premorbid IQ?
▪️Reading vocabulary (e.g. NART, WTAR)
▪️Tests co-normed against the WAIS-IV (e.g. ToPF)
▪️Reading and demographics (combination - WTAR and ToPF)
How is reading vocabulary used to assess premorbid IQ and why?
Usually test low frequency, irregular words.
Typically correlates well with general/verbal intellectual functioning and is relatively resistent to neurological injury or illness
What are the main issues associated with using reading vocab and IQ for premorbid estimates of functioning?
▪️Use in populations who violate assumptions (e.g. acquired reading/language difficulties, English as a second language)
▪️Focus of neuropsychological assessment is often on cognition, not IQ
▪️Large margins of error
What types of memory are most commonly assessed?
▪️Verbal and non-verbal working memory
▪️Episodic memory - recall and recognition
Also anterograde and retrograde but tests of the latter are rare
What might evidence of material-specific difficulties in working memory suggest?
Lateralisation of damage
What are recall and recognition tasks useful for?
Identifying encoding vs retrieval difficulties
Which types of memory are less commonly assessed during neuropsychological assessment?
▪️Prospective memory - overlaps with EF and planning
▪️Procedural
What tests can be used to assess verbal memory?
▪️Story recall (immediate & delayed)
▪️List learning
▪️Paired associates
▪️Word recognition
What does the Rey-Osterreith figure drawing task assess?
Non-verbal (visual) memory
What is the WMS-III?
Weschler Memory Scale III
Used to measure verbal and visual recall and recognition
What does the doors and people test assess?
Visual recognition
What tests can be used to assess everyday memory?
▪️Prospective tasks from the Rivermead Behavioural Memory Test
▪️Cambridge Prospective Memory Test
What does the Pyramids and Palms test assess?
Semantic memory/associations
What are the two main clinical categories of language impairment?
▪️Expressive dysphasia
▪️Receptive dysphasia
What is receptive dysphasia?
Difficulties understanding language. This could include written language, spoken language, single words, two step commands etc
What does the graded naming test assess?
Naming abilities, suggestive of expressive dysphasia
(anomia)
What is the cookie theft picture test?
Individual is asked to describe what is going on in the picture, assessing expressive dysphasia
What is the Test for the Reception of Grammar (TROG-2)?
A multiple choice test that measures understanding of grammatical contrasts, typically standardised on children.
It can be used to assess acquired language disorders
What are the main tests of perception?
▪️Basic visual acuity
▪️Object perception
▪️Space perception
What is the main battery used for assessing visuospatial abilities and what tests does it include?
The Visual Object and Spece Perception Battery (VOSP)
Includes incomplete letters task, object decision etc
What are the main domains of attention that are tested during neuropsychological assessment?
▪️Sustained
▪️Selective
▪️Divided
▪️Visual scanning
▪️Unilateral neglect
What cognitive domains overlap heavily with attention?
▪️Working memory
▪️Executive function
What does the Map Search from the Test or Everyday Attention assess?
Visual attention
What is the Behavioural Inattention Test and what does it assess?
Individual has to strike a line through all the lines or stars on a page.
It is used to assess for neglect
What tests can be included in the neuropsychological assessment to measure mood and behaviour?
▪️HADS (anxiety and depression)
▪️PHQ-9 (depression)
▪️GAD-7 (anxiety)
▪️DEX (everyday dysexecutive symptoms)
▪️FrSBe (frontal behaviour)
What factors might interfere with the interpretation of results?
▪️Developmental issues
▪️Early envrionmental factors (e.g. sporadic schooling)
▪️Language/culture
▪️ABI, particularly TBI (often if history or severity is unclear)
▪️Drug or alcohol effects
▪️Medication effects
▪️Psychiatric disorder
▪️Other medical conditions
▪️Practice effects
▪️Motivational issues
What are the main reasons to conduct a neuropsychological assessment?
▪️Inform diagnosis
▪️Help distinguish function and organic problems
▪️Help plan intervention
▪️Structured approach to difficulties
▪️Identify strengths and weaknesses
What are the main executive functions that are measured during neuropsychological assessment?
▪️Initiation and perseverstion (cognitive flexibility)
▪️Disinhibition
▪️Planning, sequencing and problem solving
▪️Concrete thinking
▪️Insight and awareness
What type of fluency is indicative of frontal lobe function?
Phonemic
What type of fluency is indicative of temporal lobe function?
Semantic
What type of tasks can be used to test initiation and perseveration?
▪️Fluency tasks
▪️Cognitive flexibility tests involving rule shifts (e.g. Wisconsin Card Sorting)
What does the Wisconsin Card Sorting Test assess?
Cognitive flexibility
How do you test disinhibition?
With response suppression tests that involve inhibitiom of a prepotent response
E.g. Stroop test, the Hayling test with nonsense completion
What do the Hayling and Brixton tests assess?
▪️Initiation
▪️Inhibition
▪️Sequencing and set shifting
▪️Flexibility
What is the Brixton Spatial Anticipation Test and what does it assess?
A visuospatial sequencing task with rule changes, whereby the individual has to detect the rules of the dots on the screen.
It assess cognitive flexibility
What are the two parts of the Hayling test and what does it assess?
Sensible and nonsense completion
It assess initiation and inhibition of response
What does the trail making test assess?
Sequencing, cognitive flexibility, and divided attention
What is part A of the trail making task?
Connect the dots in numerical order
What is part B of the trail making test and what does it do?
1 –> A –> 2 –> B etc
It isolates the executive component by controlling for perceptual and motor demands
What does the Stroop tests assess?
Response inhibition and focused attention
What is the BADS?
A comprehensive battery for the assessment of executive function
What do the Zoo Map and Modified Six Elements tasks on the BADS assess?
Planning and problem solving
What is the Tower of Hanoi an assessment for?
Planning and problem solving
What can you use to measure concrete thinking?
▪️Similarities (from the WAIS-IV)
▪️Cognitive estimates
▪️Proverb interpretation
What is the main issue with “frontal lobe” tests?
There is a high degree of connectivity between the FL and other brain areas. Subsequently, subcortical and cerebellar lesions may also affect executive functioning
What are the main limitation of executive tests?
▪️Don’t always correlate with eachother
▪️Poor test-retest reliability
▪️Overlap with WM, attention, & IQ
▪️Frontal paradox - may perform well on paper tests but struggle with real-world tasks
What are the main limitations of psychometric testing?
▪️Measurement error - single numbers give false sense of precision
▪️Statistical vs clinical significance
▪️How do we quantify change? Is it relative?
What are the main issues with the sensitivity and specificity of neuropsychological tests?
Tests may be sensitive to a range of factors. Few tests have been developed to measure a single, specific cognitive domain therefore tests may be failed for other reasons/deficits
