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Clinical and Neuropsychology - 1 > NPch2 - Clinical Practice 1 > Flashcards

NPch2 - Clinical Practice 1 Flashcards

1
Q

What is Neuropsychology?

A
  • it’s a science that studies the relationship between (physical) brain functions and behavior, emotions and cognition
  • neuropsychologists are scientists-practitioners
  • neuropsychologists are clinicians with knowledge of neuropsychological symptoms and test methods to carry out the diagnosis and treatment of patients with brain disorders
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2
Q

What do neuropsychologists do beyond diagnosing the patients?

A

They conduct scientific research to increase our knowledge about the functioning of the brain in relation to behavior

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3
Q

What are the working domains of a neuropsychologist?

A
  • hospitals
  • mental health care (GGZ)
  • rehabilitation centers
  • forensic institutions
  • residential or nursing homes
  • specialized institutions (e.g. centers for epilepsy of visual impairments)
  • others (e.g. assessment centers, teaching and research, …)
    ! many times neuropsychologists work both in hospitals and mental health care because of high comorbidity
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4
Q

Hospitals - professional fields

A
  • teaching (link to research and universities) or general hospital (patient care)
  • identify cause of cognitive complaints or assess the effects of brain injury that has already been identified
  • psychoeducation
  • ascertain effectiveness of treatment or intervention
  • some patients are offered cognitive rehabilitation or neuropsuchological treatment in case of anxiety and mood complaints related to brain injury
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5
Q

Psychoeducation

A
  • explaining the various effect of a brain disorder to the patient
  • provide patient with insight on strengths and weaknesses
  • advice on how patient and people around should deal with emotional, behavioral and cognitive consequences
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6
Q

Mental Health Care - professional fields

A
  • neuropsychologists can explain a patient’s behavior using a neuropsychiatric model which has cognitive disorders at its center
  • e.g. explanation of hallucinations (internally generated) and of emotion recognition in autism-related disorders
  • psychoeducation
  • ASD, ADHD, psychotic disorders, mood disorders, addicion, …
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7
Q

Rehabilitation Centers - professional fields

A
  • patients here are treated for neurological disorders (stroke, multiple sclerosis, brain injury, …) and non-neurological disorders (amputation, cardiac problems, …)
  • focus on treatment
  • neuropsychological assessment provides insight into disorders that would hinder treatment and shows patient’s remaining abilities that could be used in treatment
  • np assessment often conducted at the end of treatment in order to assess the ability of patient to function independently
  • in R.C. neuropsychologists have important role in multidisciplinary teams
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8
Q

Forensic Institution - professional fields

A
  • (e.g.) assess cognitive condition of delinquent
  • determine possible relationship between objective cognitive disorder and offence
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9
Q

Residential homes, nursing homes and supported housing - professional fields

A
  • Somatic departments (patients need care for serious physical limitations)
  • Psychogeriatric departments (patient suffers from serious cognitive disorder; e.g. dementia)
  • neuropsychologists:
    > evaluate cognitive skills, expected course of complaints and starting points of tratments
    > evaluate questions about placement of patients, living situations and care arrangements
    > evaluate ways of influencing behavior
    > focus also on family’s support
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10
Q

When should you consult a neuropsychologist?

A
  1. from brain damage to symptoms
    - you have brain damage due to car accident and you want to know what the consequences are on your behavior, emotions or cognition
  2. from symptoms to management/help
    - you have a brain disorder and you want help in order to deal with the cognitive, emotional and/or behavioral consequences of this disorder
  3. from symptoms to brain damage
    - your grandfather has problems with his memory, concentration and planning skills and he wants to know whether this is due to a (beginning) dementia or a depression
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11
Q

what are some typical questions of a neuropsychologist?

A
  • are there cognitive, emotional or behavioral dysfunctions?
  • are these dysfunctions caused by damage or malfunction of the brain?
  • what are the consequences of the brain disorder for the patient’s daily life?
  • what support/assistance does this patient and their environment need?
  • are there any treatment options?
    ! neuropsychological assessment is only one piece of the diagnostic assessment
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12
Q

what patients will be tested?

A
  • cardiovascular accident
  • traumatic brain injury
  • brain tumors
  • epilepsy
  • dementia
  • parkinsons
  • huntington
  • multiple sclerosis
  • children with brain accident or developmental disorders (born with brain problems)
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13
Q

What domains will be tested?

A
  • general cognitive functioning (intelligence)
  • memory
  • attentions
  • executive functions
  • language
  • perception
  • spatial cognition
  • sensory motor skills
  • emotion and social cognition
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14
Q

What is the neuropsychological assessment based on?

A
  • hypothesis testing
  • hypothesis are made about each stage of the cycle
  • hypothesis can be readjusted or rejected
  • diagnositc cycle not always completed
    > e.g. sometimes stop after complaints analysis
    > e.g. if the patient is still consuming excessive amounts of alcohol or still confused after brain trauma
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15
Q

What are the four stages of the diagnostic cycle?

A
  1. complaints analysis (patient/informant interview and medical record)
  2. problem analysis (tests)
  3. diagnosis
  4. indication for treatment (if asked)
    - need to monitor treatment to verify success
    - maybe diagnosis should be made again if not working or if there are new things to consider (e.g. new symptoms)
    * important also to interview family or important people for the patient (partner, friends…) because they have a more objective view of patient’s behaviors (HETEROANAMNESIS)
    * awareness of the problem can be already an indication of one and not another disorder (with certains disorders, the patient does not have awareness of it)
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16
Q

Referral question

A
  • what the patient/family wants to know; what the neuropsychologist has to discover (e.g. assessment needed? accident? symptoms? …)
  • very important to have a well-defined referral question (e.g. what are the consequences of this specific brain injury on cognition?)
  • additional questions are implemented by the neuropsychologist
  • treatments are usually standard, the diagnosis is the hard part
  • most of the times when neuropsychologists make a diagnosis, the patient is referred back to doctors, …
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17
Q

who is the patient often referred to the neuropsychologist by?

A
  • medical specialist
  • fellow psychologist
  • social-insurance doctor
  • lawyer
  • paramedic
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18
Q

Interview - what to ask

A
  • interview both the patient (anamnesis) and the informants (heteroanamnesis)
    ask about:
    • origin, nature, course and severity of complaints (what)
    • impact of complaints on daily functioning (now)
    • impression of premorbid level of functioning (before)
      > = how the patient was functioning before the complaints
      > e.g. education, work, social
  • questions are often standard but additional questions are asked when prompted by referral question or previous answers
  • interviews are important also to build a working relationship which is important given the painstaking assessment that follows
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19
Q

Interview with the informant

A
  • because of specific disorders, sometimes patients are not reliable when reporting complaints (e.g. if no awareness of disorder or if big language impairments)
  • permission for informant interview is requested from the patient (rule)
  • informant can be parent, child, partner, neighbor, friend, GP, previous carer, …
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20
Q

What are the negative sides of the informant interview?

A
  • can be subjective
  • at times not possible because patient has no informant
    > patient comes to appointment unaccompanied
    > patient is hospitalized
  • takes a lot of time
  • sometimes informant is embarassed about giving the clinician information about the patient
    -> best to carry out interview in patien’s absence
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21
Q

why are the informant interviews at times still subjective?

A
  • emotional overload or underlying relationship problems can result in over-reporting of complaints and changes
  • acceptance problems can cause an informant to minimise the complaints
22
Q

Observation - what to observe

A
  • physical appearance
  • contact
  • language, memory, attention
  • awareness of illness and insight into own functioning
  • mood
  • motivation
    ! important to observe from the beginning
    ! e.g. look at how person stands up from the chair, observe mood, …
    ! e.g. how the patient performs the test (e.g. if patient starts task straight away-> inhibition problems-> sign of some disorders)
23
Q

Observation
- what is a negative factor?

A
  • sometimes subjective
    > if patient cries clinician should not report that he’s sad-> might be crying out of frustration or because of compulsive crying
    PS mostly focuses on cognition (e.g. how test is performed
24
Q

What is a test plan?

A

plan of tests you want to give the patient in order to carry out the assessment

25
Q

tests and questionnaires - what types

A
  • screening tests (for first impression of cognition)
  • standardised test batteries (IQ-tests) (series of small tests to gain a complete assessment)
  • tests on one cognitive function
  • behavioral neurological tests
    > info about processing of thinking and movements
    > movement tests to see speed and accuracy
    > e.g. slow thinking-> slow movements
  • self-assessment questionnaires
  • informant questionnaires
  • observation scales
    > can be normal or structured
    > e.g. if patient seems confused-> is it neurological or psychotic? -> structured observation
26
Q

What are the two types of test batteries?
When are they used?

A
  • Fixed test battery
    > predetermined set of tests that is the same for every patient, regardless of complaint or reason of referral
    > popular for evaluation of treatmets or scientific research
  • Flexible test battery
    > larger degree of customisation
    > based on referral question, complaints, disease
    > freedom to adapt test batteries on previous findings
27
Q

Standardization of tests vs Expectation of what’s being asked

A
  • all patients should have the same understanding of what’s expected of them
  • patient should know what the purpose of the test is and what he’s expected to do (e.g. they have to be accurate or fast?)
  • the clinician should strive to achieve a standardised condition for administering the test (e.g. test set same way each time with same observer each time)
    -> however, sometimes test instructions have to be adapted so that the patient can understand what it’s being asked of them
28
Q

what are some additional standardized questionnaires?

A
  • personality traits (e.g. fear of failure and neuroticism)
  • styles of coping (e.g. avoidance)
  • mental complaints (e.g. depression and anxiety)
    ! these additional questionnaires show whether these factors affect performance and determine neuropsychological problems in daily functioning
29
Q

are computerized tests or in person tests better?

A
  • observation is half of the results
  • tests can be computerized or paper and pencil tasks
  • tests cannot be done home because there observation would not be possible
  • ## however, sometimes the patient’s problems start and home, so it’s hard for the neuropsychologist to observe in his office natural behavior of the patient
30
Q

What are some disadvantages of computerized testing?

A
  • lack of qualitative observations and flexibility
    -> test might lose significance
  • not everyone is able to use a computer (e.g. older patients)
31
Q

What are the advantages of computerized testing?

A
  • high level of standardization
  • accurate recording of responses
  • time saving
  • examiner doesn’t have to be present for the whole time
  • best for measurements of attention and reaction time
32
Q

interpretation of the data - questions to ask

A
  • are the test results reliable and valid? (test situation)
    > e.g. are the poor memory scores really indicative of poor memory or are they more a reflection of fatigue, nervousness or lack of effort?
    > for this it’s important to consider normative data (age group, gender, education)
  • is the test reliable and valid? (psychometric properties of the test)
  • additional observational test information
    > how the test is performed, strategies used, occupation, level of education, consistency with complaints, type of impairments to be expected in case of certain disorder
33
Q

Reporting the diagnosis
- how to make a report
- what must be taken into consideration

A
  • professional code (be respectful when writing the report; no personal things)
  • verbal
  • written
  • monodisciplinary and multidisciplinary (test results are combined with other disciplines - e.g. medical, …)
  • important client permission and consent for privacy/sharing the report with his doctor
  • sometimes client does not want the report
  • responsability to tell client what consequences of (no) report are
  • patients are never the problem, they have a problem
34
Q

What is important for a neuropsychologist to have when indicating treatment?

A
  • knowledge about all kinds of treatments
  • do not have to be specialised in all treatments, but they have to know about them
35
Q

what are some common errors when interpreting the results?

A
  • sometimes complaints are equated with disorders (e.g. poor concentration= attention disorder)
  • confirmation bias (considering only findings that confirm the initial hypothesis and ignoring findings that contradict it)
36
Q

What is a Differential Diagnosis?
Why is it important?

A
  • Check of diagnosis to verify whether the complaints and problems might not also have another explanation
  • important to fight erros in diagnosis and biases of neuropsychologist
37
Q

Informing the patient of neuropsychological assessment - positives and negatives

A
  • ethical to inform the patient before sharing the diagnosis with a multidisciplinary team or referrer
  • not always a good idea to inform the patient of neuropsychological examination if diagnosis is still not clear and neuropsychological assessment is part of multidisciplinary process
    = it’s better if patient is informed of the final conclusion by the person who combines data from all examinations
    ! oftentimes the patient has the right of perusal, correction, blocking, copy of report
38
Q

what are important factors to consider regarding the psychometric properties of tests?

A
  • reliability
  • validity
  • normative data
  • discriminative power (sensitivity and specificity)
  • availability of parallel versions
39
Q

What are some types of Reliability?

A
  • test-retest reliability: whether the test yields teh same results when taken at different times by the same patient
  • inter-rater reliability: different researchers obtain comparable results under same conditions
40
Q

What are the five types of Validity?

A
  • Face validity
  • Content validity
  • Construct validity
  • Criterion validity
    > consists of predictive validity and concurrent validity
  • Ecological validity
41
Q

Reliability and Validity - what are they

A

Reliability: accuracy of the instrument (repeated the same results?)
Validity: validity of the test (does the test measure what it should be measuring?)
- confoundings (e.g. behavior of patient during test, outside noise, …)
- underperformance (compared to normal standard or standard of the patient before the complaints)

42
Q

Face Validity

A
  • extent to which test initially seems to measure what it’s supposed to measure
  • e.g. memory test in which a patient has to remember photographs of faces along with the first and last name of the person in the photograph has a higher face validity than a memory test in which a set of random words have to be remembered
43
Q

Content Validity

A
  • extent to which test is representative of topic that is to be measured
  • e.g. IQ test consisting of sets of numbers has less content validity compared to IQ test with many subtests
44
Q

Construct Validity

A
  • extent to which the result of a test actually reflects the cognitive function that is being assessed
  • e.g. extent to which percentage of remembered elements of a newspaper report reflects memory capacity
45
Q

Criterion Validity

A
  • extent to which test can predict the performance of a patient with regard to external criterion
46
Q

What are Predictive and Concurrent validity?

A
  • Predictive validity: how accurately a test predicts actual behavior
  • Concurrent validity: difference between a neuropsychological test and another tool that aims to measure the same criterion
47
Q

Ecological Validity

A
  • how accurately a test predicts how a patient functions in their own environment
  • similar to predictive validity
  • debate on whether test should always have ecological validity
48
Q

Confounding factors

A
  • element that affects performance on a test but does not fall within the measurement objective of a test
  • e.g. sensory impairments, limited mental capacity, cultural background, limited education, fatigue, pain complaints, emotional preoccupations, lack of effort
  • must be included in interpretation of results
49
Q

Underperformance

A
  • patient’s performance is impaired compared with what they would be able to achieve if they were able to make a normal effort
  • commonly encountered in personal injury examinations and forensic-psychological assessments (patient thinks that they will serve less time in jail if score less in cognitive abilities)
  • intentional underperformance can be minimized with multiple choice questions (if below random score-> intentionally scoring lower)
  • can lead to incorrect diagnosis
  • e.g. patient that is extremely tired or nervous will perform below their actual ability in neuropsychological tests
  • e.g. if patient is exaggerating existing cognitive complaints (intentional underperformance)
50
Q

When should the neuropsychologist look out for underperformance?

A
  • inconsistencies with test profile (e.g. better performance on more difficult tasks than easy ones)
  • striking discepancy between behavioral observations and test performance (e.g. patient comes exactly on time to appointment but then scores low on orientation in time)
  • if most of patient’s complaints are not in relation to the severity of the disorder.
51
Q

Montreal Cognitive Assessment (MoCA)

A
  • test used to detect mild cognitive decline and early signs of dementia
  • it can help identify people at risk of Alzheimer’s disease and screen for conditions like Parkinson’s disease, brain tumors, substance abuse, and head trauma
  • it assesses orientation, short-term memory, attention, abstraction, animal naming, …
52
Q

what were the questions in the MoCA

A
  • trace on paper in ascending order from 1 to A to 2 to B to…
  • copy a drawing of a square
  • draw a clock
  • draw on the clock 10 past 11
  • say what three animals are called
  • repeat back in any order five words he was given (face, red, velvet, church. daisy)
  • say numbers back to clinician
  • say numbers backwards
  • tap hand when hears letter A
  • count backward from 100 by 7
  • say back sentences exactly how they are told by clinician
  • in one minute say as many words starting with same letter (no numbers or words that are capitalized or repeat similar words)
  • how a banana and an orange are alike
  • how train and bicycle are alike
  • how are a watch and a ruler alike
  • repeat words that he had to remember from before
  • date of today, day of the week, name of the place they are in, city they are in

Clinical and Neuropsychology - 1 (21 decks)

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