Transcript Goals of neuropsychological assessment

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Outline
1. Neuropsychological Assessment
a. Goals of neuropsychological assessment
b. Psychometric approach – advantages
c. Psychometric approach – interpretation
2. IQ and Neuropsychological Testing
3. Malingering
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Outline
4. Neuropsychological Test Batteries
a. Halstead-Reitan
5. Functions of interest to neuropsychologists
a.
b.
c.
d.
e.
Laterality
Visual Perception
Language
Memory
Attention & Executive Control
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1. Neuropsychological Assessment
Goals
• Diagnosis
• What happened that
damaged the patient’s
brain?
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1. Neuropsychological Assessment
• Goals
• Description
• What went wrong
cognitively, emotionally,
or behaviorally as a
result?
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1. Neuropsychological Assessment
• Goals
• Tracking changes
• Observe changes in
patient’s performance
over time, to monitor
healing/worsening and
effects of treatment
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1. Neuropsychological Assessment – advantages
• Standardized:
• Repeatable instructions,
presentation, and tasks
• Norms
• Intensive:
• Multiple measures
within and among wide
range of domains
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1. Neuropsychological Assessment – advantages
• Sensitive
• Valid indicators of skills,
capable of detecting
abilities and deficits
• Scaled
• Hierarchical items
• Start/stop rules
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1. Neuropsychological Assessment – advantages
• Precise
• Allows reliable, exacting
quantification of relative
abilities
• Allows comparison
within/over time
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1. Neuropsychological Assessment
• Interpretation
• Quantitative
observations:
• Many tests give
standardized scale
scores (like Wechsler
tests) based on norms
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1. Neuropsychological Assessment
• Interpretation
• Actuarial results (e.g.,
Boston Aphasia Battery)
– profile of subtest
scores indicates nature
of disorder
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1. Neuropsychological Assessment
• Interpretation
• Cut-off scores used to
make decisions
• How are cut-offs set?
Norm-referenced?
Criterion-referenced?
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1. Neuropsychological Assessment
• Interpretation
• Neuropsychologists also
make up tests as
needed – these typically
are not standardized, so
interpretation may be
problematic.
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1. Neuropsychological Assessment
• Interpretation
• Example: line-crossing
task used to detect
“neglect” following
right-hemisphere brain
damage
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1. Neuropsychological Assessment
• What do we know
about the line-crossing
test? What cognitive
operations are involved
in test performance?
• Why do neglect patients
fail at this test?
• Is this test valid?
Reliable?
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2. IQ and neuropsychological testing
• Estimating pre-morbid
IQ may be necessary to
determine whether
there is actual loss of
function or capacity.
• Often difficult to use a
regular IQ test with
patients
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2. IQ and neuropsychological testing
• Estimating pre-morbid
IQ – Clinical approaches
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Education
Vocabulary
Occupation, farm size
Functional capacities
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2. IQ and neuropsychological testing
• Actuarial &
psychometric
approaches
• Demographic formulas
• Reading level
• Subtest pattern
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3. Malingering
• Faking a disorder or
deficit.
• Important for legal and
financial reasons –
people sometimes fake
a deficit in order to
collect insurance
payments, or to
fraudulently obtain
narcotics
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3. Malingering
• Tests to catch
malingering usually
based on fact
malingerers don’t know
what real deficits look
like – they often show
too much loss of
function.
• Munchausen Syndrome
– psychopathology
involves faking illness,
but not for money or
drugs
• Rarely treated
successfully
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4. Neuropsychological test batteries
• Test batteries – large
sets of tests
• Wide variety of tests to
tap many different skills
and abilities
• Developed before the
era of brain scanning, in
part to help locate site
of brain damage
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To use test batteries or not?
• On the plus side:
• Many batteries have known psychometric
properties (e.g., reliability, validity).
• Use of standardized procedure permits
comparison of one patient with others, even if the
others are tested by different clinicians.
• Tests cover a wide range of cognitive functions
and behaviors
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To use test batteries or not?
• On the minus side:
• Test-centered rather than patient-centered
• Time-consuming
• Patient may fail a test for many different reasons
• Batteries are developed for general purposes –
may lack flexibility to assess any given patient’s
idiosyncratic deficits.
• May reduce clinician’s potentially useful curiosity,
lead to “cookie-cutter reports.”
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4a. HRNTB
• Ward Halstead
• Ph.D. psychologist, taught in U Chicago Medical
School
• Through 1940s, devised and tried out many tests
for use with brain-damaged patients
• With his student Ralph Reitan, settled on a battery
of tests that allowed comprehensive evaluation of
BD patients
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Reitan’s four-fold approach
• Inferential decisionmaking using the
HRNTB based on:
• Level of performance
• Pattern of performance
• Specific behavioral
deficits
• Comparison of two
sides of the body (rightleft comparisons)
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Reitan’s four-fold approach
• Level of performance
• Comparison of
individual with
normative groups of
impaired and nonimpaired persons
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Reitan’s four-fold approach
• Pattern of Performance
• Examination of intratest performance and
subtest scores
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Reitan’s four-fold approach
• Specific Behavioral
Deficits
• Sensitivity to deviant or
deficient performance
which, of itself, points
to impairment
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Reitan’s four-fold approach
• Comparison of Two
Sides of the Body
• Looking for
discrepancies in test
performance which may
reveal weakness or
lateralized impairment
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4a. HRNTB
• Category test
• Tests abstraction and
reasoning
• Tactual performance
test
• Manual dexterity, spatial
memory, tactile
discrimination
• Seashore rhythm test &
Speech-sounds
perception test
• Attention,
concentration, auditory
discrimination
• Finger tapping test
• Motor speed and
manual dexterity
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4a. HRNTB
• Trail making (see below)
• Reitan-Indiana Aphasia
Screening Examination
• Reitan-Klove Sensory
Perceptual Examination
• Version of standard
neurological screening test
for sensory processes
• Strength of Grip Test
• Uses hand dynamometer
• Lateral Dominance
Examination
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Functions of interest to neuropsychologists
a.
b.
c.
d.
e.
Laterality
Visual Perception
Language
Memory
Attention & Executive Control
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5a. Laterality
• Compares functions of
the L and R
hemispheres of the
cortex
• Especially important if
neurosurgery is
planned: where are
language functions?
• Language functions are
in left hemisphere in
most people, bilateral in
some
• Annett Handedness
Questionnaire
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Annett Handedness Questionnaire
Please indicate which hand you habitually use for each of the following: (R, L or E)
1. Writing
2. Throwing a ball
3. Holding a racquet
4. Striking a match
5. Cut with scissors
6. Threading a needle
7. At top of broom
8. At top of shovel
9. To deal cards
10. To hammer a nail
11. To hold a toothbrush
12. To unscrew a lid
There are several ways to score this test
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5b. Visual Perception
• Visual field deficits
• Informal assessment by
clinician
• More precise
assessment requires
special optometry
equipment.
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5b. Visual Perception
• Agnosia – inability to
recognize familiar
objects visually.
• To test – ask patient to
name various objects
• Meaning of objects has
not been lost –it’s a
deficit of visual
recognition.
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Visual agnosias
• visual object agnosia –
inability to identify
common visual objects
• prosopagnosia –
inability to recognize
familiar faces
• color agnosia – inability
to discriminate between
colors and to name
colors
• simultanagnosia –
visual perception of
simultaneously
presented objects is
impaired
Figure/ground
discrimination
– separate
figure from
background
The embedded
figures test – task
is to find all the
objects in this
figure.
The objects in the embedded figures
test stimulus
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Visual Memory
• Rey-Osterrieth figure
• complicated, abstract
figure (next slide)
• patient looks at it briefly
then asked to reproduce
the figure from memory
• scoring is quite complex
• assesses visual memory,
visual construction skill
The Rey-Osterrieth Complex Figure (Osterrieth, 1946)
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5c. Language
• A very important
function for humans,
typically mediated by
left hemisphere
• Expressive and
receptive language can
be independently lost
or spared
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5c. Language
• Batteries include
Boston Diagnostic
Aphasia Examination
and Western Aphasia
Battery (developed at
UWO School of
Medicine)
• Task-specific tests used
with patients having
comparatively isolated
dysfunctions
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Boston Diagnostic Aphasia Examination
• Oral Expression – word
repetition, body part
naming, visual
confrontation naming
• Writing
• Auditory
comprehension: Body
part identification
• Understanding written
language: Word picture
matching.
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Task-specific tests
• Graded Naming Test or
Boston Naming Test both assess ability to
name objects.
• Token Test - detects
non-obvious loss of
receptive language
• Pyramid & Palm Trees
Test - tests the
understanding of words
Graded Naming Test examples –
test has 30 of these, presented in
order of increasing difficulty
Boston Naming Test examples
Pyramid
Palm
Tree
3 Picture Version
Fir
Tree
3 Word Version
Pyramid and Palm Trees Test – which one of
the two lower items goes with the upper item?
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5d. Memory
• Amnesia is loss of
episodic (personal)
memory, which may
include knowledge of
public people/events
• Two distinct kinds of
amnesia:
• Retrograde
• Anterograde
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5d. Memory
• Retrograde
• loss of memory for
events from patient’s
past
• patient asked to retrieve
old events
• Anterograde
• loss of ability to store
new memories.
• patient exposed to new
information, then
memory for that
information tested
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Retrograde amnesia
• Boston Remote Memory
test
• 2 types of questions
• Easy vs. hard
• 2 types of material
• Famous faces (hints
given if needed)
• Events – asked to recall
information about them
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Anterograde amnesia
• Warrington’s
Recognition Memory
Test
• 50 faces and 50 words
presented separately
• 2AFC test administered
immediately after
learning phase
• Severely impaired
patients may perform at
chance.
• Then, it’s hard to tell
what’s wrong with their
memory
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Anterograde amnesia
• Wechsler Memory Scale
III
• Separate short-term and
long-term retention
scores
• Tries to differentiate
between verbal and nonverbal elements of
memory
• Includes recall and
recognition tests
• 2+ hours to administer
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5e. Attention & Executive Control
• Spatial attention: Line
bisection, cancellation
tasks
• Sustained attention /
vigilance: Continuous
performance test (CPT)
• Focused attention:
Dichotic listening /
visual search
• Divided attention: Trail
making, task
combinations
Trails B
Trails A
1
8
2
4
4
5
D
9
3
6
1
A
2
7
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C
B
10
5
3
E
Trails A and Trails B – from Halstead-Reitan test battery
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5. Attention & Executive Control
• Executive functions
• Assess higher cortical
functions such as
planning, response
inhibition, controlled
functions (e.g., new task,
or new environment).
• Wisconsin Card Sort
Task used frequently
Sort by
number
Sort by
color
Sort according to unspoken rule; examiner changes rule – can
patient adapt to new rule?