Assessing Deficits in Cognitive Functioning

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Assessing Deficits in Cognitive Functioning

• Theodore Tsaousides, Ph.D.
• Mount Sinai School of Medicine
• New York, NY

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Neuropsychology

• The science of brain-behavior relationship
• Dysfunctional brain ? Dysfunctional behavior
• Injury to the brain leads to
• Physical changes
• Cognitive changes
• Emotional changes
• Behavioral changes

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Neuropsychology Assessment

• Evaluate degree of impact of brain damage on
  behavior
• Diagnosis
• Patient care
• Treatment planning/evaluation
• Research
• Good assessment ? good treatment

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Neuropsychology Treatment

• Restoration
• Retraining
• Repetition
• Compensation
• Skill building
• Use of tools
• Restructuring
• Environmental adaptations
• Changes in demands

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Disorders that affect the brains function

• Traumatic brain injury (TBI)
• Vascular disorders
• Degenerative disorders
• Toxic exposure
• Infections
• Brain tumors
• Oxygen deprivation
• Metabolic/endocrine disorders
• Thought disorders

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Traumatic Brain Injury

• Definition
• Causes
• Incidence in the US
• Symptoms

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Traumatic Brain Injury

• Definition
• Insult to the braincaused by external physical
  forcewhich results in impairment of cognitive
  abilities or physical functioning (BIAA)
• A traumatically induced physiologic disruption of
  the brain function as manifested by
• Loss of consciousness
• Loss of memory for events before or after the
  accident
• Alteration of mental state at the time of the
  accident
• Focal neurological deficits that may or may not
  be transient (ACRM)

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Traumatic Brain Injury

• Causes

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Traumatic Brain Injury

• Incidence annually
• 1.4 million sustain TBI (based on Hospital
  admission and ED records
• Unidentifiable
• Physician visits
• No care sought
• Military/VA
• Other settings (psychiatric/substance abuse
  settings shelters prisons)

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TBI Physical symptoms

• Fatigue
• Sleep problems
• Headaches
• Balance problems/dizziness
• Vision problems
• Chronic pain
• Sexual dysfunction

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TBI Cognitive symptoms

• Attention
• Processing speed
• Memory and learning
• Language and communication
• Executive functions

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TBI Emotional symptoms

• Apathy
• Abulia
• Disinhibition
• Hyperemotionality
• Depression
• Anxiety

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Behavioral symptoms

• Forgetting/missing appointments
• Getting lost
• Difficulty following instructions
• Not paying attention
• Inappropriate
• Argumentative
• Outbursts
• Forgetting to take medication
• Impatient
• Disorganized
• Impulsive

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What to do

• You
• Observe
• Screen
• Refer
• Me
• Review referral
• Conduct testing
• Provide feedback

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First impressions

• Conclusions based on interactions
• Non-compliant
• Difficult to engage
• Poor historian
• Oppositional
• Makes things up

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Observe

• Appearance
• Is appearance unusual?
• Orientation
• Person, place, time, (situation, object)
• Speech
• Receptive language (unable to follow
  instructions)
• Fluency (word finding problems)

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Observe

• Attention/concentration
• Distractibility (distracted by things around)
• Spacing out (need to repeat yourself often)
• Memory
• Short-term (forgets what was just said)
• Prospective memory (forgets to get things done)
• Past memories (remembers things inaccurately)
• Thought Process
• Logical coherent (responses make no sense)
• Blocking (unable to come up with answers)
• Tangentiality (cannot stay on track)

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Observe

• Cognitive functioning
• Vocabulary (vocabulary is consistent with
  education)
• General information (also consistent with
  education)
• Emotional state
• Overwhelmed and anxious
• Depressed
• Apathetic
• Hyperemotional
• Special preoccupations/experiences
• Obsessions (perseverations)
• Bodily preoccupations (physical symptoms)
• Paranoid thoughts
• Insight/judgment
• Reasoning (poor social judgment/decision making)

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Screen

• Brain Injury Screening Questionnaire (BISQ)
• Part One (lifelong)
• Blow to the head?
• In a car crash
• Being hit by a falling object
• Being assaulted or mugged
• Hospitalized or in the ER?
• Concussion
• Near drowning
• Altered mental state?

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BISQ Part One
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BISQ Part Two

• Part Two (within past month)
• Physical symptoms
• Having trouble falling asleep or staying asleep
• Having double vision or blurred vision
• Cognitive symptoms
• Being easily distracted
• Difficulty following instructions, written or
  oral
• Behavioral symptoms
• Feeling impatient or irritable
• Arguing

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BISQ Part Two
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BISQ Part Two
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Screen

• Positive screen ? diagnosis
• Positive screen need to evaluate further

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Other short measures

• Mini-Mental State Examination (MMSE)
• Dementia Rating Scale 2 (DRS-2)
• Repeatable Battery for the Assessment of
  Neuropsychological Status (RBANS)
• NART/WTAR
• TONI-3
• WASI

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Refer

• Physiatrist
• Most knowledgeable specialty re TBI
• Assessment of physical symptoms
• Referrals to neuro rehab psychology, PT, OT,
  Speech
• Neurologist
• Imaging
• Neurological impairments
• Neuropsychologist
• Assessment of cognitive/emotional/behavioral
  functioning
• Psychiatrist
• Assessment of extent of psychiatric comorbidity
• Not always aware of TBI and its consequences

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Review referral

• Preparation
• Review referral question
• Diagnostic
• Descriptive
• Obtain medical records (incl. imaging)
• Obtain academic records
• Clinical observations

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Review referral

• Clinical interview
• Patients background
• Social history
• Present life history
• Medical history
• Current medical status
• Circumstances surrounding the examination

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Conduct testing

• Test selection
• Goals of assessment
• Validity and reliability
• Sensitivity and specificity
• Parallel forms
• Time and cost
• Non-standardized assessment

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Conduct testing

• Cognitive Domains
• Processing speed
• Attention
• Visual/Perceptual skills
• Verbal/Reading skills
• Intellectual functioning
• Memory and learning
• Executive functioning
• Emotional functioning/Personality

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Provide feedback

• Review and integrate assessment results
• Write report
• Follow-up interview with patient
• Others involved in care present
• Client-friendly language
• Validate
• Edit

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Conclusion

• Damage to the brain causes physical, cognitive,
  emotional, and behavioral deficits
• Several conditions can cause damage to the brain
• TBI is a common but often unidentifed condition
• Cognitive deficits of TBI often manifest as
  behavioral problems
• Proper screening and identification implies
  appropriate treatment

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First impressions revisited

• Conclusions based on clinical observation and
  screening
• Non-compliant
• Difficult to engage
• Poor historian
• Oppositional
• Makes things up

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References

• Fischer, J.S., Hannay, J.H., Loring, D.W.,
  Lezak, M.D. (2004). Observational methods, rating
  scales, and inventories. In M.D. Lezak, D.B.
  Howieson, D.W. Loring (Eds.),
  Neuropsychological Assessment, 4th edition (pp.
  698-737). New York Oxford University Press.
• Gordon, W.A., Haddad, L, Brown, M., Hibbard,
  M.R., Silwinski, M. (2000). The sensitivity and
  specificity of self-reported symptoms in
  individuals with traumatic brain injury. Brain
  Injury, 14, 21-33.
• Kay, T., Harrington, D.E., Adams, R. (1993).
  Mild traumatic brain injury. American Congress of
  Rehabilitation Medicine, Head Injury
  Interdisciplinary Special Interest Group.
  Definition of mild traumatic brain injury.
  Journal of Head Trauma Rehabilitation, 8, 86-87.
• Lezak, M.D., Howieson, D.B., Loring, D.W.
  (2004). Neuropsychological assessment (4th ed.).
  New York Oxford University Press.
• McCullagh, S., Feinstein, A. (2005). Cognitive
  changes. In J.M. Silver, T.W. McAllister, S.C.
  Yudofsky (Eds.), Textbook of Traumatic Brain
  Injury (pp.321-337). Arlington, VA American
  Psychiatric Publishing.
• Strauss, E., Sherman, E.M.S., Spreen, O.
  (2006). A compendium of neuropsychological tests
  (3rd ed.). New York Oxford University Press.
• Zuckerman, E.L. (2000). Clinicians Thesaurus
  (5th ed.). New York The Guilford Press.

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• Thank you for your attention
• Theodore Tsaousides, Ph.D.
• Instructor/Rehabilitation Neuropsychologist
• Mount Sinai School of Medicine
• e theodore.tsaousides_at_mssm.edu
• p 212-241-6547