College aantekeningen Neuropsychological Assessment

Neuropsychological assessment college 2 14 september
Interview & observation Anselm Fuermaier
Introduction
- Cognitive functions (cognition)  functioning in daily life (behavior)
- Cognitive impairment  impairment in daily life
o Pijl ertussen  assessment
 Psychometric npsy tests – performance tests
 Clinical interviews (unstructured, semistructured, structured) – usually first
step
 Questionnaires (self-report, other reports) – score them and quantify
behavior
 Observations (during clinical assessment) – all aspects of clinical evaluation
 Questionnaires and tests on memory  not the same  problems in quest.
And test but almost had no association to eachother (both sensitive)
 Believe a test is optimal performance  quest. More typical
performance

The clinical interview
- Before the interview  record viewing (optimal situation)
o Injury and post-injury records
 Head injuries
 Cardiovascular accidents
 Tumors/surgeries
 Epilepsy
 Infections
 Neurodegenerative disorders
 Alcohol abuse etc.
o Neuroimaging data – location brain damage
o Psychiatric history
 Developmental disorders (‘premorbid’ reference point lacking)
 Very important  what can you expect to be normal, premorbid level
of functioning, baseline level, affects self-report of patient (learn to
compensate, what is really the impairment)
 Psychotic disorders (decreased insight?)
 Self-report may be biased
 Affective disorders (often associated with marked cognitive impairments)
 Lijken op elkaar
 Anxiety disorders
 Personality disorders (treatment motivation?)
 Suicide attempts
o Previous (npsy) assessments – parallel tests, learning effect etc.
o Previous treatments  behavioral and pharmacological interventions
 Pharmacological  very useful to know what helped before, hoe het nu gaat
tegenover voor medicatie
 Mood stable but cognitive problem unaffected etc.
o School records
 Grades
 Standardized test scores
 Transcripts
 Reports
o Vocational situation – what can you expect as baseline functioning

,  Training
 Type of job
 Working hours
 Reports
o Physical problems
o Where does the information stem from? – is information confirmed by multiple
(independent) sources?
 Do not rely on one source, talk to family
- Before the interview  are you prepared?
o What is the purpose of assessment?
o What is the aim, which question will be addressed?
o Are you confident your assessment will help to answer this question?
o Are you confident your level of expertise is sufficient to answer this question?
o Are you confident your equipment is sophisticated enough to answer this question?
- Performing the interview
o Informing the patient about purpose and content
 The patient’s reports and behavior can only be interpreted in a valid fashion
if the patient has been informed about purpose, content, and duration of the
interview!
 What is the goal of the interview  explain etc.
o Biographical information
 Family situation – parents, siblings
 School situation
 Vocational situation
 Socio-economic status
 Private situation – partnerships, stability of friendships, children
 Living situation
 Interests, hobbies and goals
 Stressors – partnership crises, children, parents, job, money
o Premorbid level of functioning
 Previous assessments
 School education
 Vocational situation
 Income
 Hobbies and interests
 Family background
 Acquired brain damage vs. developmental disorder
 Involve a spouse/parent! (if patient agrees)
 Not necessarily more valid or reliable  give a different view, but
very important
 Discrepancy between self- and informant report
 Evaluation of insight of patient
 Many standardized scales offer self- and other report forms –
quantify between self-report and other reports
o Type and nature of complaints
 Start with spontaneous self-reported complaints – don’t direct, stay on
general level
 Rather on behavioral level, than on a level of cognitive functions
 Ask to specify complaints and to give examples
 Check the patient’s interpretation!
 Example

, o Different meaning of attention (cognition vs. self-
presentation)
o Many causes for loss of interest in reading (motivational,
cognitive, visual, …)
 Continue with more specific questions
 When did they start? How?
 How often do they occur?
 In which intensity?
 Information and further elaboration on medical history helps and
guides your interview on complaints!
o Did medication help? In which way?
o Did other form of treatment help?
o Discrepancy between medical records and self-reports
informative! – what you took and how it helped
 Eventually determine complaints on cognitive/modular level
 Attention and concentration
 Memory and orientation
 Planning, flexibility and reasoning
 Impulse control
 Language and arhythmics
 Perception
 Motor behavior and praxis
 Personality characteristics
 Physical complaints
o Course of complaints – very important, are problems because of stroke, depression or
first symptom of MCI, remission?
 Are complaints getting worse? Since then? How?
 Period of remission?
 What became worse, what became better?
o Consequence of complaints
 Do complaints affect daily functioning? How? – no problems in life,
psychiatric disorder not necessary. In environment where his symptoms do
not affect him

Observations
- Think beforehand about the behavior you like to observe
- In which situations
o During administrative contact prior and after assessment - how they make
appointments
o Waiting room – punctual, inpatient, problem in questionnaires, how they wait
o On the way to the testing room
o During the interview
o During testing
- What can we learn?
o Level of arousal and alertness – concentration
o Retrieval of recent and remote events – memory
 How coherent their past is
o Thought content and processes – executive functions
o Emotionality – e.g. affect, mood, and appropriateness)
o Level of cooperation – effort and motivation

, o Appearance – manner of dress, gait, posture
o Sensorimotor functions – e.g. muscle strength, eyesight, hearing
o Discourse abilities – conversational speech
o Appropriateness of social skills
- What kind of behavior?
o Appearance
 Noticeable, physical characteristics (overweight, health, etc.)
 Personal care (proper, untidy)
 More/less youthful than indicated by age
o Motor skills
 Overall
 E.g. speed of movements, hyperactivity, restlessness, fidgeting,
clumsiness, sudden or careless movements, neglecting one side of
body, (partial) paresis, involuntary muscle spasms, tremor, difficulty
controlling movements
 Walking
 E.g. speed, flexibility, rigidity, tripping, bumping into things (on the
left or right), requiring assistance, losing balance, struggling with
climbing stairs, etc.
o Facial expression
 General impression – e.g. vivid, expressive, cheerful, dramatic, rigid,
motionless
 Reaction to emotional content of conversation
 Eye contact
o Overall attitude
 E.g. confident and cheeky vs. shy, hesitant and quiet
 Active and alert vs. passive and not accessible
 Positive and optimistic vs. tensed and not at ease
o Attitude towards (test) supervisor and (test) instructions
 Friendly, sincere, and aiming to meet other’s expectations
 Over-polite, business-like, aiming to impress
 Clingy, dependent, insecure
 Sloppy, superficial, careless – how they react to explanation of test,
overreporting/overestimating
 Suspicious, criticizing, shows aggression or annoyance
 Disinhibited, comments on all actions, responds to contact straightforwardly
- At specific actions
o Behavioral observations at
 Writing/reading
 Planning meetings and making agreements (e.g. questionnaires, medication)
 Instruction phase and practice trials of npsy tests
 Reactions to feedback in npsy tests
 Describing complex drawing
 Drawing complex figures (copying, or clock drawing)
 Strategy of planning tasks

Interview and observation
- Validity (accuracy of conclusions) and reliability (consistency between clinicians)
o Validity and reliability vary greatly, but usually never above 0.8
o Reliability demands consistency – often not given due to large differences across
raters. Interaction between clinician and patient very specific