Outline Health

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Outline Health Neuropsychology

• Neuropsychological Assessment
• Background on brain function behavior
• Goals of neuropsychological assessment
• Psychometric approach advantages
• Psychometric approach interpretation
• Neuropsychological Test Batteries
• Halstead-Reitan

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Outline Health Neuropsychology

• IQ and Neuropsychological Testing
• Malingering
• Functions of interest to neuropsychologists
• 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.

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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 patients 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

• Standardized
• Intensive
• Sensitive
• Scaled

• Hierarchical items start/stop rules

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Psychometric assessment advantages

• 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 line-crossing task used to detect
  neglect following right-hemisphere 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,
  drivers 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
  patients idiosyncratic deficits.
• May reduce clinicians potentially useful
  curiosity, lead to cookie-cutter reports.

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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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Reitans four-fold approach

• Inferential decision-making 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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Reitans four-fold approach

• Level of performance

• Comparison of individual with normative groups of
  impaired and non-impaired persons

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Reitans four-fold approach

• Level of performance
• Pattern of Performance

• Examination of intra-test performance and subtest
  scores

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Reitans 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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Reitans 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

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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 dont 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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Functions of interest to neuropsychologists

• Laterality
• Visual Perception
• Language
• Memory
• 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 patients 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 its a
  deficit of visual recognition.
• To test ask patient to name various objects

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Figure/ground discrimination separate figure
from background
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The embedded figures test task is to find all
the objects in this figure.
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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

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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

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Graded Naming Test examples test has 30 of
these, presented in order of increasing difficulty
Boston Naming Test examples
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Pyramid
Palm Tree
Fir Tree
3 Word Version
3 Picture 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
  patients 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

• Warringtons 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, its hard to tell whats 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

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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

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Sort by color
Sort by number
Sort according to unspoken rule examiner changes
rule can patient adapt to new rule?