1 Outline Health Neuropsychology Neuropsychological Assessment

1 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

2 Outline – Health & Neuropsychology IQ and Neuropsychological Testing Malingering Functions of interest to neuropsychologists • • • Laterality Visual Perception Language Memory Attention & Executive Control

3 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? 4

Goals of neuropsychological assessment • Diagnosis • Description • Cognitive and behavioral deficits that result 5

Goals of neuropsychological assessment • Diagnosis • Description • Tracking changes • in patient’s performance over time, to monitor healing/worsening and effects of treatment 6

7 Psychometric assessment - advantages • Standardized: • Repeatable instructions, presentation, and tasks • Norms

8 Psychometric assessment - advantages • Standardized • Intensive: • Multiple measures within and among wide range of domains

9 Psychometric assessment - advantages • Standardized • Intensive • Sensitive • Valid indicators of skills, capable of detecting abilities and deficits

Psychometric assessment – advantages • • Standardized Intensive Sensitive Scaled • Hierarchical items start/stop rules 10

Psychometric assessment – advantages • • • Standardized Intensive Sensitive Scaled Precise • Allows reliable, exacting quantification of relative abilities • Allows comparison within/over time 11

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 12

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 13

15 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?

16 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

17 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

18 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

19 Estimating pre-morbid IQ • Clinical approaches • Actuarial & psychometric approaches • Demographic Formulas • Reading level • Subtest pattern

20 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

21 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

22 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 1940 s, 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 23

24 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)

25 Reitan’s four-fold approach • Level of performance • Comparison of individual with normative groups of impaired and nonimpaired persons

26 Reitan’s four-fold approach • Level of performance • Pattern of Performance • Examination of intratest performance and subtest scores

27 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

28 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 29

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 30

31 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

32 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 33

34 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

35 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

36 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.

37 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

41 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

42 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)

44 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)

45 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.

46 3. Language • Task-specific tests • Token Test - detects used with patients non-obvious loss of having comparatively receptive language isolated dysfunctions • Pyramid & Palm • Graded Naming Test Trees Test - tests the or Boston Naming understanding of Test - both assess words ability to name objects.

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?

49 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

50 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

51 Anterograde amnesia • Warrington’s Recognition Memory Test § 50 faces and 50 words presented separately § 2 AFC 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

52 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

53 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 1 8 2 4 4 5 D 9 3 6 1 A 2 7 54 C B 10 5 3 E Trails A and Trails B – from Halstead-Reitan test battery

55 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?