(p. 95) Adult Neuropsychological Assessment
Fundamental Assumptions of Clinical Neuropsychological Assessment
1. It is possible to make valid inferences regarding the integrity of the brain through the observation of behavior. Such inferences require a firm grasp of brain–behavior relationships and characteristic neurobehavioral syndromes.
2. Observable behavior is frequently the most sensitive manifestation of brain pathology.
3. A neuropsychological test is simply one means of eliciting a sample of behavior, under standardized conditions, which is then to be observed and analyzed.
4. Test performance and “real-life” behavior are imperfectly correlated. Proceed with caution in using test data to predict behavior.
5. Most behaviors are multifactorial and depend on a complex interplay of cognitive, perceptual, emotional, and environmental factors.
6. Most neuropsychological tests are multifactorial and depend on a confluence of cognitive and perceptual functions for their performance.
7. As with any psychological intervention, the neuropsychological evaluation should proceed in a sensitive manner and with explicit communications regarding the use of clinical information.
8. A dynamic developmental life span perspective is critical in the evaluation of each patient.
9. All behavior should be viewed within a sociocultural context.
Uses of Neuropsychological Assessment
1. Neuropsychological assessment is indicated for questions of differential diagnosis and prognosis.
2. Neuropsychological assessment should be considered in the setting of a deterioration in neuropsychological status or when there is a history of neurological disease, injury, or developmental abnormality affecting cerebral functions.
3. Neuropsychological assessment is used to clarify the significance of known or suspected pathology for “real-life” functioning in everyday activity, relationships, education, and work.
4. Neuropsychological assessment provides information relevant to management, rehabilitation, and treatment planning for identified cognitive problems.
5. Baseline (pretreatment) status and measurement of treatment response (e.g., medication, neurosurgery, behavioral intervention, electroconvulsive therapy) can be monitored with serial neuropsychological testing. (p. 96)
6. Neuropsychological consultation is frequently critical in determination of legal/forensic issues, including need for guardianship, neuropsychological damages, criminal responsibility, and competence to stand trial.
7. Neuropsychological research investigations enhance the understanding of brain–behavior relationships and neurobehavioral syndromes. These studies are of tremendous value to the understanding of neurological disease and normal brain function.
8. Specialized applications include determination of viability for functional neurosurgery (Parkinson’s disease), presurgical functional lateralization in patients who are to undergo epilepsy surgery (i.e., Wada testing), and intraoperative cortical mapping.
9. Neuropsychological testing has become central to evaluation of sports concussion and return-to-play decisions.
Approach to Neuropsychological Evaluation
1. Evaluation should be individually tailored to each patient.
2. Test data are viewed from both qualitative and quantitative perspectives.
3. Assessment proceeds in a hypothesis-testing manner. Tests are selected to answer specific questions, some of which emerge during the evaluation process.
4. Standardized tests can be modified to test limits and produce richer qualitative data.
5. Task performance is analyzed to determine component processes, with the goal of identification of dissociations between such processes.
6. The most pertinent normative data are used to analyze test scores with regard to salient demographic variables, including age, gender, ethnicity, and educational level.
7. Because typical neuropsychological assessments include a large number of individual tests, a small percentage of abnormal (i.e., impaired) scores may be obtained on the basis of chance alone; these may be spurious findings.
The chief complaint and presenting problems are reviewed to produce a clear description of their onset and course, as well as information regarding the medical and social context in which the problem(s) emerged. The patient’s overall understanding of his or her current circumstances and the reason for the consultation are sought.
Information is obtained from a variety of sources, including the patient’s self-report, observations of family members or close friends, medical records, and prior evaluations from academic or work situations. Information is obtained regarding the following:
1. Developmental background, including circumstances of gestation, birth/delivery acquisition of developmental milestones, and early socialization skills
2. Social development, including major autobiographical events and relationships (a three-generational genogram is highly useful in gaining relevant family information)
3. Past medical history, including illnesses, injuries, surgeries, medications, hospitalizations, substance abuse, and relevant familial medical history
4. Psychiatric history, including hospitalizations, medications, and outpatient treatment
5. Educational background, including early school experiences and academic performance during high school, college, postgraduate study, and other educational and technical training
6. Vocational history, including work performance, work satisfaction, and relationships with supervisors and coworkers
7. Current functional level with regard to basic and instrumental activities of daily living, recreational interests, and hobbies
8. Review of systems, including quality of sleep, appetite, libido, physical activity, and pain (p. 97)
9. Assessment of effort has become a key component for all cases. Reduced effort can be observed in severe depression, pain, apathy, frank malingering, and failure to attain an appropriate “test-taking attitude.” Individuals from divergent cultural backgrounds may have a different “set” or attitude toward the overall assessment enterprise. Effort can be assessed through the use of dedicated freestanding tests, embedded measures, and consideration of performance in the context of known functional status.
Physical appearance is inspected, including symmetry of gross anatomic features, facial expression, manner of dress, and attention to personal hygiene. The patient is asked specific questions regarding unusual sensory or motor symptoms. Affect and mood are assessed with respect to range and modulation of felt/expressed emotions and their congruence with concurrent ideation and the contemporaneous situation. Interpersonal comportment is assessed in the context of the interview. Does the patient’s behavior reflect a normal awareness of self and other in interaction? The patient’s motivation and compliance with examination requests, instructions, and test procedures are observed with respect to the validity of test findings.
Domains of Neuropsychological Function
A sufficiently broad range of neuropsychological functions is evaluated using tests and other assessment techniques.
1. General intellectual ability. Intelligence encompasses a broad array of capacities, many of which are not directly assessed in the traditional clinical setting. The estimate of general intellectual ability is based on both formal assessment methods and a survey of demographic factors and life accomplishments. Particular care must be exercised in the evaluation of patients from varying educational and sociocultural backgrounds. In cases of known or suspected impairment, premorbid ability is surmised from performance on measures presumed less sensitive to cerebral dysfunction (i.e., vocabulary), so-called best performance methods, educational/professional accomplishment, avocational interests and pursuits, and demographic variables. The level of general ability provides a reference point from which to view performance on other measures.
2. Sensation and perception. It is important to establish to what degree primary sensation and perception are intact prior to initiation of testing. Significant impairment of sensory function (auditory, visual, kinesthetic) is usually obvious and points to a need for specialized assessment procedures. Unusual or abnormal gustatory and olfactory experiences should be sought through direct questioning. Simple auditory function can be assessed by finger-rub stimuli to each ear. Vision is examined with tests of acuity, tracking, scanning, depth perception, color perception, and attention/neglect for visual field quadrants. Kinesthetic perception is assessed with tests of graphesthesia and stereognosis. Double simultaneous stimulation can be used in auditory, visual, and kinesthetic modalities to determine whether hemiextinction occurs.
3. Motor functions. Naturalistic observations of the patient’s gait and upper- and lower-extremity coordination are an important part of the motor examination. Hand preference should be assessed through either direct inquiry or a formal handedness questionnaire. Motor speed, dexterity, and programming are tested with timed tasks, some of which involve repetition of a specific motor act (e.g., finger tapping, peg placement) and others of which involve more complex movements (e.g., finger sequencing, sequential hand positions). Manual grasp strength can be assessed with a hand dynamometer. Various forms of verbally guided movement or praxis are examined.
4. Attention/concentration. The capacity to selectively maintain and shift attentional (p. 98) focus forms the basis of all cognitive activity. Evaluation of attention includes observations of a broad array of interrelated behaviors. General level of arousal or alertness is determined through clinical observation. An appraisal is made of the extent to which environmental or diurnal factors modify arousal. Attentional functions are assessed in both auditory/acoustic and visual modalities. Attention span is measured by determining the number of unrelated “bits” of information that can be held on line at a given moment in time. Sustained attention is assessed with tests that require the patient to maintain focused attention over longer periods. Selective attention is measured with tasks requiring the patient to shift focus from one event to another. Resistance to interference is assessed with tasks requiring the patient to inhibit overlearned responses or other distractions that could undermine a desired response.
5. Executive functions. Executive functions comprise the capacity of the patient to produce cognitive behavior in a planned, organized, and situationally responsive manner. The assessment of executive functions is accomplished in an ongoing fashion through observation of the patient’s approach to all types of tests and via his or her comportment within the consultation. Although few tests assess these functions directly or specifically, the clinician looks for evidence of flexibility versus perseveration, initiation versus abulia, self-awareness versus obliviousness, planfulness versus impulsivity, and capacity to assume an abstract attitude versus concreteness.
6. Learning and memory. The assessment of memory function is perhaps the most complex endeavor of the neuropsychological examination. Memory is assessed with respect to time of initial exposure (anterograde vs. retrograde), modality of presentation (acoustic vs. visual), material (linguistic vs. figural), and locus of reference (personal vs. nonpersonal). The evaluation of memory should include measures that allow the neuropsychologist to parse out the component processes (encoding, consolidation, retrieval) entailed in the acquisition and later recall of information. To this end, measures are used to assess performance with respect to length of interval between exposure and demand for recall (none vs. short vs. long delay) and extent of facilitation required to demonstrate retention (free recall vs. recognition). The assessment of retrograde memory function poses a special problem insofar as it is difficult to know with certainty what information was contained at one time in the remote memory of a particular patient. Although a number of formal tests can be used for this purpose, we also assess this aspect through asking for personal information that presumably is or had been well known at one time by the patient (e.g., names of family members, places of prior employment).
7. Language. Language is the medium through which much of the neuropsychological examination is accomplished. Language function is assessed both opportunistically, as during the interview, and via formal test instruments. Conversational speech is observed with respect to fluency, articulation, and prosody. The patient’s capacity to respond to interview questions and test instructions provides an informal index of receptive language ability or comprehension. Visual confrontation naming is carefully assessed so that word-finding problems and paraphasic errors may be elicited. Repetition is measured with phrases of varying length and phonemic complexity. Auditory comprehension is evaluated by asking the patient questions that vary in length and grammatical complexity. Reading measures include identification of individual letters, common words, irregularly spelled words, and nonwords, as well as measures of reading speed and comprehension. Spelling can be assessed in both visual and auditory modalities. A narrative handwriting sample can be obtained by instructing the patient to describe a standard stimulus scene.
8. Visuospatial functions. After basic visuoperceptual status is established, the assessment of visuospatial function commences with the evaluation of the spatial distribution of (p. 99) visual attention. Visual neglect is examined by way of tasks entailing scanning across all quadrants of visual space. Left/right orientation can be assessed by having the patient point to specific body parts on himself or herself or the examiner. Topographic orientation can be tested in most patients by instructing them to indicate well-known locales on a blank map. Graphic reproduction of designs and assembly of patterns using sticks, blocks, or other media are used to assess visual organization and constructional abilities.
9. Psychological factors and emotion. Standardized measures of mood, personality, and psychopathology can be used to explore the role of these issues in the patient’s presentation and diagnosis. It is important to note, however, that neurological and other medical conditions can skew performance on certain personality tests; hence, interpretation must take this into account through the use of “correction” methods where available and in exercising caution in drawing diagnostic conclusions.
Data from the history, observation, and testing of the patient are analyzed collectively to produce a concise understanding of the patient’s symptoms and neuropsychological diagnosis. A configuration of abilities and limitations is developed and used both diagnostically and as a framework for the elucidation of goals for treatment. When possible, the diagnostic formulation should identify the neuropathological factors giving rise to the patient’s clinical presentation, including underlying anatomy and disease process.
Recommendations and Feedback
Consultation concludes with feedback, in which findings and recommendations are reviewed with relevant individuals (e.g., referring physician, patient, family, treatment team members). A variety of treatment plans may be advised, including pharmacological intervention, psychiatric consultation, psychotherapy, vocational guidance, and cognitive-behavioral remediation. Recommendations should be pragmatic and individually tailored to each patient’s specific needs. Strategies for optimizing performance in personal, educational, and occupational spheres are identified and discussed in lay language that the patient and family member can comprehend. Where possible, specific behaviorally based suggestions are made for remediation of identified problems. Further clinical evaluations and other neurodiagnostic procedures are suggested when appropriate in order to provide more information relevant to differential diagnosis, response to treatment, and functional status over time. Appropriate neuropsychological follow-up is also arranged.
References and Readings
American Academy of Clinical Neuropsychology. (2011). Position papers. Retrieved January 2013, from theaacn.org/position_papers
Heilman, K., & Valenstein, E. (Eds.) (2011). Clinical neuropsychology (5th ed.). New York: Oxford University Press.Find this resource:
Kaplan, E. (1988). A process approach to neuropsychological assessment. In T. Boll & B. Bryant (Eds.), Clinical neuropsychology and brain function: Research, measurement, and practice (pp. 129–167). Washington, DC: American Psychological Association.Find this resource:
Lezak, M., Howieson, D., Bigler, E., & Tranel, D.Neuropsychological assessment (5th ed.). New York: Oxford University Press.Find this resource:
Manly, J. J. (2008). Cultural issues in cultural neuropsychology: Profit from diversity. Neuropsychological Review, 18, 179–183.Find this resource:
Mesulam, M. M. (Ed.). (2000). Principles of behavioral neurology (2nd ed.). Philadelphia, PA: F. A. Davis.Find this resource:
Morgan, J. E., & Ricker, J. H. (2008). Textbook of clinical neuropsychology. London: Taylor and Francis.Find this resource:
National Association of Neuropsychology. (2011). Position papers. Retrieved March 19, 2013 from: www.nanonline.org/nan/Research___Publications/Position_Papers/NAN/_Research_Publications/Position_Papers.aspx?hkey=71602191-716a-4375-8eb8-4b4e6a071e3a (p. 100)
Schretlen, D. J., Munro, C. A., Anthony, J. C., & Pearlson, G. D. (2003). Examining the range of normal intra-individual variability in neuropsychological test performance. Journal of the International Neuropsychological Society, 9, 864–870.Find this resource:
Snyder, P. J., Nussbaum, P. D., & Robins, D. L. (2006). Clinical neuropsychology: A pocket handbook for assessment (2nd ed.). Washington, DC: American Psychological Association.Find this resource: