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Clinical Neuropsychology > Neuropsychological Assessment > Flashcards

Neuropsychological Assessment Flashcards

1
Q

Basic aim of neuropsych assessment

A
  • reliable and valid picture of the relationship between the brain and behaviour
  • identification of cogniitive, emotional, motor and behavioural consequences of brain dysfunctions
    central focus: assessment of cognitive dysfunctions
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2
Q

Reasons for neuropsych assessment

A
  1. is there evidence of organic brain dysfunction?
    • diagnosis of brain pathology not always possible by neuroimaging, neurophysiological assessment, lab or physical markers
    • cognitive impairment sometimes the only indicator of pathology
      eg.
      - mild cognitive impairment (MCI)
      - dementia
      - developmental disorders
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3
Q

what is nature and extent of cognitive impairment

A

eg

  • is there memory deficit
  • what aspect of memory are affected? (eg. short-term vs long-term memory, memory for verbal vs figural information, recall from memory vs recognition)
  • how severe are the disturbances?
    (eg. mild, moderate or severe)
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4
Q

what are the practical consequences of cognitive impairment?

A
  • activities of daily living (eg dressing)
  • driving capacity
  • social functioning (social skills, social role, responsibilities)
  • work/education
  • leisure
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5
Q

in what way is an individual’s mood and behaviour affected by brain dysfunction?

A
  • identification of mood disorders meaningful, since they
    • need treatment
    • may affect test performance (important for interpretation of test results)
    • may be an additional burden for relatives
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6
Q

Does cognitive performance change over time?

A
  • detection of the process of cognitive decline associated with progressive disorders (eg Parkinson’s disease, Alzheimer’s disease)
  • recording the process of recovery from brain lesions (eg. traumatic brain injury, stroke)
  • recording the effects of treatment (eg. neuro-rehabilitation, neurosurgery, pharmacological treatment)
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7
Q

Problem
Solution
Problem
Problem

A

Problem: Practice effects

Solution: Use of parallel versions of tests

Problem: no parallel versions available for most tests

Problem: and even if: Test idea known on retesting (no novelty effect (eg. in delayed recall tasks), reduced nervousness (eg. elderly on computerised tasks))

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8
Q

what are cognitive strengths and weaknesses of an individual regarding the rehabilitation process?

A

Example
Individual has intact visual memory and impaired verbal memory
rehabilitation efforts
supporting individual to develop compensatory strategies using the intact system

  • providing feedback to patient and family
  • improving patient self-awareness
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9
Q

approaches to assessment:

review of info from referrer

A
  • begin of assessment
  • great variability of available information
    • only patient’s complaints (eg. difficulties remembering names or dates)
    • Detailed clinical history, family history, brain images, neurological evaluation, data from former maps assessments
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10
Q

approaches to assessment:

Information from clinical and laboratory examinations

A

Can be related to neuropschological findings

  • lesions localisation to cognitive functions (eg. MRI)
  • cognitive decline with progressive diseases (eg. Alzheimer’s disease)
  • Fluctuations in performance to epileptic seizures (eg. EEG)
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11
Q

approaches to assessment:

Clinical Neurological examination, what to do ?

A

Taking the patient’s history

  • what are the complaints?
  • what are complaints localised?
  • when did complaints start?
  • how did complaint start? (suddenly or gradually)?
  • what course have complaints taken?
  • which situations trigger or relieve complaints?
  • what treatment has been tried?
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12
Q

approaches to assessment:

How many cranial nerves? and for what?

A

12 cranial nerves to relay motor functions, senses and reflexes of the head

  • don’t need to learn the individual cranial nerves for the exam
  • olfactory - smell
  • optic - vision
  • oculomotor nerve - eyelid and eyeball movement
  • trochlear - innervates superior oblique turns eye downward and laterally
  • trigeminal nerve- chewing face and mouth touch and pain
  • abducens nerve - turns eye laterally
  • facial nerve - controls most facial expressions secretion of tears and saliva taste
  • vestibulocochlear nerve - hearing equilibrium sensation
  • glossopharyngeal nerve - taste senses carotid blood pressure
  • vagus nerve - senses aortic blood pressure slows heart rate stimulates digestive organs Tate
  • spinal accessory nerve - controls trapezius and sternocleidomastoid - controls swallowing movement
  • hypoglossal nerve - controls tongue movements
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13
Q

approaches to assessment:

motor functions

A

muscle power
paresis/paralysis = muscle weakness

plegia = complete loss of force

hemiparesis = weakness of one side of body

paraparesis = weakness of both legs

tetraparesis/quadriparesis = weakness of all four limbs

coordination (fine and gross motor movement)

finger-nose test (move index finger and touch nose)

Shin-heel-test (moving the heel too the opposite knee and along the shin)

posture and gait
(eg. patient stands straight or bent, secure or insecure)

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14
Q

approaches to assessment:

Romberg Test

A

Patient is asked to stand still with heels together
Patient is asked to remain still and close eyes
Some patients lose their balance

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15
Q

approaches to assessment:

Reflexes

A

biceps and triceps reflexes in arms, knee jerk, ankle jerk iiim legs

pathological reflexes indicate lesion in CNS

eg. Babinski reflex
occurs when great toe flex toward top of foot and other toes fan out when the sole of the foot has been firmly stroked

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16
Q

approaches to assessment:

cognition

A

brief mental state examination

full nosy examination provides significantly more detailed analysis of cognitive deficits

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17
Q

laboratory examinations

computerised tomography (CT)

A

transmission of X-rays through the head from different sides

strength measures by detectors on opposite side

weakening (absorption) during passage through head depends on density of tissue

spatial solution 2 mm

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18
Q

laboratory examinations

examples of computerised tomography

A

Hypodense areas are darker
indicates stroke, oedema, inflammation or certain brain tumours

hyper dense areas are lighter
indicates fresh bleeding, calcification or other brain tumours

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19
Q

laboratory examinations

size of ventricles

A

increase in size indicates hydrocephalus or brain atrophy

decrease in size indicates brain oedema (swelling of brain)

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20
Q

laboratory examinations

Magnetic resonance imaging (MRI)

A

Hydrogen protons (H+) in brain tissue constantly rotate (spin)

powerful magnetic field forces all protons into a single direction

direction briefly diverted by short electromagnetic impulses

emission of high-frequency radiation (echo), when returning to previous state

echo can be measured by MRI

characteristic of each proton’s echo is influenced by surrounding brain tissue

consequently generation of high-resolution pictures of the brain

spatial solution 1mm

functional MRI (fMRI) not used in routine clinical practice

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21
Q

laboratory examinations

single-photon emission computer tomography (SPECT) and positron emission tomography (PET)

A

use of radioactive substances (tracers) in both (injected or inhaled)

uptake preferentially in most active brain areas
therefore images of blood flow and activity of different brain areas

no detailed anatomical pictures (in contrast to CT, MRI)

spatial resolution 1-2 cm in SPECT and 0.5-1 cm in PET

both rarely used in clinical practice

both (SPECT, PET) allow study of receptor binding

eg.
dopamine receptors of patients with Parkinson’s disease

decrease in dopamine as the disease progresses (in putamen)

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22
Q

laboratory examinations

angiography (or arteriography)

A

conventional x-ray examination after injection of iodine-containing contrast substance

leads to visualisation of arteries and veins

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23
Q

laboratory examinations

showing

A

stenosis (narrowing) of an artery

blockade of an artery

aneurysms (bulging of artery by a weakness of artery wall)

Arteriovenous malformation or angioma (AVM, a tangle of pathological vessels)

pathological vessels in a brain tumour

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24
Q

laboratory examinations

electroencephalography (EEG)

A

Hans Berger recorded the first human EEG in 1924

he noted rhythms in the electric activity - brain waves

the first one he noticed he called alpha waves

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25
Q

laboratory examinations

electroencephalography (EEG) how it works

A

neurons generate action potentials that bread across axons and dendrite

multitude of action potentials of cortisol neutrons adds up to electrical field potentials
measurement of electric activity of cerebral cortex

most important use
searching for signs of epileptic activity

EEG abnormality also in other diseases, such as

eg.
degenerative diseases such as Alzheimer’s disease
general slowing (indication of)

brain tumours
focal changes of rhythm or shape of EEG waves

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26
Q

laboratory examinations

evoked potentials

A

electric responses recorded from scalp surface as a response to an external stimulus

recording of reaction of primary cortisol areas to external stimulation

provide information about the functioning of sensory or motor pathways

visual evoked responses (VER)
flickering checkerboard

brainstem auditory evoked responses (BAER)

somatosensory evoked responses (SSER)

motor-evoked responses (MEP)
transcranial magnetic stimulation

measurement of evoked response requires application of hundreds of consecutive stimuli

latencies, amplitudes and shapes of waves are altered when items are dysfunctional

27
Q

laboratory examinations

Event-related potentials (ERPs)

A

recording of reaction of secondary cortisol areas to external stimulation

ERPs considered to represent cognitive processes (eg. focussing of attention)

most commonly used ERP’s
P300 (positive potential approx 300 ms after stimulus)
N400 (negative potential approx 400 ms after stimulus)

28
Q

laboratory examinations

Doppler ultrasound

A

detection of stenosis (narrowing) of an artery leading blood to the brain (internal carotid or vertebral artery)
blood supply to a part of the brain compromised

probe is pressed on skin above one of these arteries

probe emits ultrasound

ultrasound bounces back from blood cells

same probe records returning signal

character of returning signal gives information about blood flow

increase in bloodstream as an indication of a stenosis

29
Q 
laboratory examinations 
cerebrospinal fluid (CSF)
A

collection by lumbar puncture

supports in diagnosing

hydrocephalus
increased CSF pressure

subarachnoid haemorrhage
CSF gained with blood

Inflammation
increased amount of protein and leukocytes in CSF

Brain tumours
Pathological tumour cells in CSF

30
Q

Clinical Interview

A

interview of patient and relative (if necessary separately)

tactful and systematic questions to determine patient’s perspective on problems, history, disturbances and impact of daily living

discrepancies between patient and relative are worth noting
inaccurate reports of patients because of memory disturbances
unawareness of or indifference to the existence of disturbances (ansognosia, anosodiaphoria)

overestimation of disturbances (less frequent)

31
Q

Clinical Interview

brief informal assessment of

A

temporal spatial orientation

understanding verbal instructions

language functions
formulation of adequate sentences

storing and retrieval of new information

autobiographical information

main biographical steps and milestones in personal and familial life
eg recent holidays, school periods, academic/professional training, wedding, children’s birth, jobs, retirement)

32
Q

Clinical Interview

Questionnaires and symptom checklists

A

prompting patients and relatives to report problems that may otherwise be forgotten or unstated

eg assessment of

behavioural disturbance

impact of cognitive deficits on daily activities

increase of burden for relatives

33
Q

standardised tests

A

main tool in neuropsychological assessment

designed to assess specific cognitive functions

accepted as a euro-diagnostic tool (independent from EEG, neuroimaging, etc)

crucial difference to other methods (eg. observation, interview)

no other profession trained to apply tests (eg. physicians, physiologists, physiotherapist)

neuropsychological testing expertise –> unique service –> differentiating –> neuropsychologist from other psychologists and non-psychologists

ability to design, apply and interpret neuropsychological tests –> defining characteristic of clinical neuropsychology

administration of tests in standardised fashion (as outlined in a test manual)

normative data
like a control group, stratified for factors such as age, gender, etc

allows comparison between individual test score and average score of population also considering variability in normal population

allows quantification of deficit (eg percentiles)

certain groups are often not well represented in normative samples of tests (eg. elderly people, people with learning disorder)

34
Q

standardised tests

Graph and classification off ability levels

A

refer to powerpoint

classification of ability levels
classification

very superior 
z score is 2 and above 
percent included 
2.2
lower limit of percentile range 
98 
superior 
1.3 to 2
percent included 
6.7
lower limit of percentile range 
91 
high average 0.6 to 1.3 
percent included 
16.1
lower limit of percentile range 
75 
borderline 
z score 
-1.3 to -2 
percent included 6.7 
lower limit of percentile range 
2 
retarded 
z score 
-2.0  and below 
percent included 
2.2 
lower limit of percentile range 
_
35
Q

standardised tests

1. comprehensive or big battery approach

A

no universally agreed set of tests
2 approaches
comprehensive or big battery approach
battery of tasks designed to assess most cognitive functions

premise:
when there is a deficit, it will be detected by the battery

eg. Halstead-reitan neuropsychological test battery
disadvantages: very time consuming and some functions are not assessed in sufficient detail (eg. attention)

36
Q

standardised tests

2. individualised, hypothesis-testing approach

A

based on particular question posed in assessment

information prior and during assessment is sued to select tests for assessing certain functions in detail

disadvantage: failing to assess particular functions because deficit is not readily apparent

usually combination of both approaches are used in clinical practice

37
Q

functions assessed in npsy assessment

A

premorbid functioning

intellectual functioning

memory

attention

language functions

visuospatial and visa-constructional skills

executive functioning

mood, personality and behaviour

motor functioning

38
Q

functions assessed in npsy assessment

premorbid functioning

A

cognitive functions always represent spectrums with people scoring high or low (variability)

in npsy assessment
comparison of individual test score with normative data

2 outcomes when a deficit is present
–> individual test score shows an impairment or not

39
Q

functions assessed in npsy assessment

test score results if below average in impaired individuals

A

tests scores of individual results are below average

therefore, individual is impaired

individual requires treatment, support, pension or compensation

40
Q

functions assessed in npsy assessment

test score results if above average in impaired individuals

A

severity of impairment of individual results if above average or the normal range

conclusion
individual is NOT impaired

no entitlement to treatment, support, pension or compensation

41
Q

functions assessed in npsy assessment

relative impairment of performance

A

therefore
premorbid level of functioning has to be considered

problem
usually patient did not participate on any form of cognitive assessment premorbidly

consequently
premorbid functioning has to be estimated

3 most common ways

42
Q

functions assessed in npsy assessment

3 most common ways to estimate premorbid functioning in relative impairment of performance testing

A

General demographic information
–> age, years of education, social class

individual’s best performance on any of the cognitive tests applied

tests that are relatively resistant to the general effects of brain injury

–> eg. national adult reading test

43
Q

National adult reading test NART

A

50 phonetically irregular words

correct pronunciation of these words implies prior knowledge of them

44
Q

National adult reading test NART

a study by Crawford et al 2001

A

high correlation between IQ scores

comparing older adults with their own IQ scores at 11 years of age

data offer reassurance regarding continued use of NART as valid estimate of premorbid intelligence in number of conditions

45
Q

National adult reading test NART

Be aware

A

according to neuropsychological panel of American academy of neurology 1996

no neuropsych tests have shown to have consistent diagnostic validity. some tests accurately distinguish between two or three diseases when samples of patients with these diseases are assessed, but no study shown neuropsychology tests have predictive value when patients with wide variety of disorders are tested

46
Q

prerequisites of assessment

selection of appropriate measures

A

requires
consideration of patients’ characteristics

age (eg normative data)
education (eg. education-specific normative data)
reading level
primary language (caveat: direct translations of English tests are not always adequate)
Ethnicity/cultural factors (cultural traditions, test-taking experience and attitudes towards testing) may cause variance

47
Q

prerequisites of assessment

Cultural factors

A

immigrants come to america via Ellis Island, greeted by immigration officials

leads to

evaluation of physical, mental and other variables

leads to

failing of physical, mental or other tests

leads to

return to home country

leads to

at expense of the shipping company that had brought them

48
Q

prerequisites of assessment

assumptions

A

assumption
- some of immigrants who failed mental tests were sent away because they did not understand English enough to execute instructions

Furthermore
- criterion against which immigrants were being evaluated can be questioned
eg
who served as the standardisation sample
how appropriate was that sample for this application

49
Q

prerequisites of assessment

Diana Bossie v. State Board of Education (1970)

A

Children with Spanish surnames:

  • 18% of student body
  • 33% in classes for educable mentally retarded

however,
all testing in English

use of intelligence tests developed primarily on white children

retesting of nine Spanish-speaking children in Spanish, eight scored in the non-retarded range

50
Q

prerequisites of assessment increasing cultural sensitivity

A

cultural sensitivity
consideration of various aspects of culture, including

verbal communication

nonverbal communication

culture-fair tests

standards of evaluation

51
Q

prerequisites of assessment

verbal communication

A

eg. problems with use of interpreters
- one language may lack words to fully correspond to meaning of word in another language

interpreter may unintentionally change, embellish or distort information

interpreter’s own cultural norms and values may interfere

the interpreter may lack an understanding of what is important from psychological perspective

confidentiality issues may cause client to provide more limited info when interpreter is family member or friend

52
Q

prerequisites of assessment

nonverbal communication

A

eg. eye contact

western cultures
a person failing to look at another person in the eye when speaking may be viewed as deceitful or having something to hide

other cultures
failure to make eye contact when speaking may be a sign of respect

53
Q

prerequisites of assessment

culture-fair tests

A

cultural loading
magnitude with which cultural influence is reflected in the measured psychological variable (eg. IQ)

eg. name three words for snow
high cultural load
(items drawn from eskimo culture when many words exist for snow)

by contrast, people from Groningen would be hard put to come up with more than one word for snow

eg. culture fair test of intelligence

54
Q

prerequisites of assessment

ways of reducing the cultural loading of tests

A

culturally loaded

  • reading required
  • specific factual knowledge
  • scholastic skills
  • recall of past-learned information

cultural loading reduced

  • purely pictorial
  • abstract reasoning
  • nonscholastic skills
  • solving novel problems
55
Q

prerequisites of assessment

standards of evaluation

A

eg.
judgments related to certain psychological variables can be culturally relative
- schizophrenia versus voodoo

56
Q

prerequisites of assessment selection of appropriate measures

good theoretical and practical knowledge of the measures used

A

requires
good theoretical and practical knowledge of the measures used

availability of tests
diagnostic validity 
reliability 
sensitivity 
specificity 
normative data
57
Q

prerequisites of assessment selection of appropriate measures

good knowledge of type and severity of disease and deficits

A

level of global impairment
(test selection should avoid ceiling and floor effects)

cognitive deficits 
(eg. attention deficit) 
Physical disabilities 
(eg. motor deficits)
58
Q

prerequisites of assessment selection of appropriate measures

consideration of referral question

A

diagnosis (eg. Alzheimer disease)

patient care and planning

treatment planning and remediation

treatment evaluation

research

forensic neuropsychology

59
Q

prerequisites of assessment selection of appropriate measures
examples of rehabilitation procedure

A

evaluation of rehabilitation procedure

has 3 aims to
1. is there a change in cognitive status over time? (improvement or deterioration?)

  1. Is the rehabilitation programme effective?
  2. have rehabilitation effects generalised to non-trained items within the rehabilitated domain or to non-rehabilitated domains?
    - -> leads to eg. computer training of selective attention
60
Q

prerequisites of assessment selection of appropriate measures
evaluation example of rehabilitation procedure

A

eg. evaluation of rehabilitation procedure

eg. computer training of selective attention
- improvement on computer test
- improvement on reading task
- improvement on driving a vehicle

61
Q

prerequisites of assessment selection of appropriate measures
evaluation of rehabilitation procedure pitfalls

A

3 pitfalls

  • acute
  • assessment prior to rehabilitation (10 weeks post injury)
  • assessment following rehabilitation (eg. 20 weeks post injury)
  1. test-retest effects
  2. test specificity to the rehabilitated cognitive function

selection of tests that are specific to cognitive function trained in rehabilitation programme
AND
selection of tests that are independent from cognitive function trained in rehabilitation programme
(application already at baseline before any treatment)

  1. spontaneous variability and natural history of the cognitive deficit
    - the severity of a deficit might improve because of a spontaneous recovery (even when no therapy is applied)
62
Q

prerequisites of assessment

concentration

A

patient must be able to concentrate for time of assessment

neuropsychological assessment usually takes several hours

ensure that adequate breaks are taken (assessment should not take longer than 90 to 120 min)

impairments of attention/concentration in up to 85% of patient with brain pathology

63
Q

prerequisites of assessment

comprehension

A

impaired comprehension makes test results invalid

ensure yourself that patients comprehend the task instructions
(no verbal comprehension difficulties, no impairment of perception)

ask patients whether they wear glasses (often patients forget to bring their glasses to assessment)

caveat: not all patients complain about their difficulties (eg. anosognosia, neglect)

64
Q

prerequisites of assessment

motivation

A

very important and complex issue

  • NPSY tests require motivation, cooperation and effort of examinees
  • 5 mechanisms
  1. brain areas responsible for drive and initiation of action directly damaged

in some patients
inability to initiate action unless each stage of action is prompted

  1. motivation problems resulting from mood disorder
    eg. depression in a patient
    –> cannot make effort during testing
    therefore overestimation of level of impairment

affects almost all cognitive test, however certain tests more sensitive

rule of thumb: the more tedious and difficult a task, the more likely is effect

Clinical Neuropsychology (2 decks)

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