Transcript Goals of neuropsychological assessment

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Outline – Health & Neuropsychology
Neuropsychological Assessment
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Background on brain function & behavior
Goals of neuropsychological assessment
Psychometric approach – advantages
Psychometric approach – interpretation
Neuropsychological Test Batteries
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Halstead-Reitan
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Outline – Health & Neuropsychology
IQ and Neuropsychological Testing
Malingering
Functions of interest to neuropsychologists
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Laterality
Visual Perception
Language
Memory
Attention & Executive Control
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Neuropsychological testing
• Basic ideas:
 Human mind is most complex system we
know of in the universe.
 Human brain is also very complicated.
 As a result, there are many ways that things
can go wrong.
 Many combinations of behavioral and mental
impairment following an insult to the brain.
Goals of neuropsychological
assessment
Diagnosis
• What happened?
What went wrong as
a result?
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Goals of neuropsychological
assessment
• Diagnosis
• Description
• Cognitive and
behavioral deficits
that result
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Goals of neuropsychological
assessment
• Diagnosis
• Description
• Tracking changes
• in patient’s
performance over
time, to monitor
healing/worsening
and effects of
treatment
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Psychometric assessment advantages
• Standardized:
• Repeatable
instructions,
presentation, and
tasks
• Norms
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Psychometric assessment advantages
• Standardized
• Intensive:
• Multiple measures
within and among
wide range of
domains
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Psychometric assessment advantages
• Standardized
• Intensive
• Sensitive
• Valid indicators of
skills, capable of
detecting abilities and
deficits
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Psychometric assessment –
advantages
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Standardized
Intensive
Sensitive
Scaled
• Hierarchical items
start/stop rules
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Psychometric assessment –
advantages
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Standardized
Intensive
Sensitive
Scaled
Precise
• Allows reliable,
exacting
quantification of
relative abilities
• Allows comparison
within/over time
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Psychometric assessment –
Interpretation
• Quantitative
observations:
 Many tests give
standardized scale
scores (like Wechsler
tests) based on norms
• Actuarial results (e.g.,
Boston Aphasia
Battery) – profile of
subtest scores
indicates nature of
disorder
• Cut-off scores used to
make decisions
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Psychometric assessment –
Interpretation
• Neuropsychologists
also make up tests as
needed – these
typically are not
standardized, so
interpretation may be
problematic.
• Example: linecrossing task used to
detect “neglect”
following righthemisphere brain
damage
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Line-crossing task to detect neglect
• What do we know
about this 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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IQ and neuropsychological testing
• IQ is frequently of
interest to clinicians
testing a BD patient.
• Often difficult to use a
regular IQ test with
patients – e.g., they
may not understand
instructions, or may
not be able to move
their right hand
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IQ and neuropsychological testing
• We sometimes try to
estimate pre-morbid
IQ on the basis of
education, job, or
other evidence
• Individual IQ subtests
are often used to
assess broader
cognitive skills without
producing a full IQ
score
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Estimating pre-morbid IQ
• Clinical approaches
• Educational level
• Vocabulary skills
• Occupational
background, farm size
• Functional capacities:
self-care, finances,
driver’s license, food
preparation, parenthood,
daily activities
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Estimating pre-morbid IQ
• Clinical approaches
• Actuarial &
psychometric
approaches
• Demographic
Formulas
• Reading level
• Subtest pattern
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Neuropsychological test batteries
• Test batteries are large sets of tests that
tap a variety of skills and abilities
• Developed before the era of scanning, in
part to help locate site of brain damage
• Wide variety, large number of tests
thought necessary because human
behavior is so complex
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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.”
Halstead Reitan Neuropsychological
Tests
• 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
(right-left
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
• Level of performance
• Pattern of
Performance
• Examination of intratest performance and
subtest scores
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Reitan’s four-fold approach
• Level of performance
• Pattern of
Performance
• Specific Behavioral
Deficits
(Pathognomonic
Signs)
• Sensitivity to deviant
or deficient
performance which, of
itself, points to
impairment
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Reitan’s four-fold approach
• Level of performance
• Pattern of
Performance
• Specific Behavioral
Deficits
• Comparison of Two
Sides of the Body
• Looking for
discrepancies in test
performance which
may reveal weakness
or lateralized
impairment
Halstead-Reitan Neuropsychological
Tests
• 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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Halstead-Reitan Neuropsychological
Tests
• 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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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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Malingering
• In general, tests to
catch malingering are
based on the fact that
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
Functions of interest to
neuropsychologists
1. Laterality
2. Visual Perception
3. Language
4. Memory
5. Attention & Executive Control
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1. 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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2. Visual Perception
• Visual field deficits –
informal assessment:
clinician moves
fingers into patient’s
field of vision from the
side. Patient
announces when
he/she can see
fingers.
• Assessed more
precisely using
special optometry
equipment.
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2. Visual Perception
• Agnosia – inability to
recognize familiar
objects visually.
• Objects can be
recognized on basis
of sound (e.g.,
lawnmower)
• Meaning of objects
has not been lost –it’s
a deficit of visual
recognition.
• To test – ask patient
to name various
objects
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 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
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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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3. Language
 A very important function for humans, typically
mediated by left hemisphere
 Expressive and receptive language can be
independently lost or spared
 Batteries include Boston Diagnostic Aphasia
Examination and Western Aphasia Battery
(developed at UWO School of Medicine)
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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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3. Language
• Task-specific tests
used with patients
having comparatively
isolated dysfunctions
• 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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4. Memory
• Amnesia is loss of
episodic (personal)
memory, which may
include knowledge of
public people/events
• Two distinct kinds of
amnesia:
• Retrograde – loss of
memory for events
from patient’s past
 Old things in memory
cannot be retrieved
• Anterograde – loss of
ability to store new
memories.
 New things cannot be
put into memory
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Retrograde amnesia
• Boston Remote
Memory test
• 2 types of questions
 Easy
 Hard
• 2 types of material
 Name 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
• Mild impairment in
young patients not
detected
• 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
non-verbal elements of
memory
• Includes recall and
recognition tests
• 2+ hours to
administer
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5. 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
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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?