Neuropsychological Assessment: Uitwerkingen Hoorcolleges

Lecture 1 ‘Introduction’
What is Clinical Neuropsychology?

 The APA defines Clinical Neuropsychology as “a specialty that applies principles of
assessment and intervention based upon the scientific study of human behaviour as it relates to
normal and abnormal functioning of the Central Nervous System (CNS)”.
 The Study of brain/behaviour relationships & impact of injury/disease on cognitive, emotional
and general adaptive capacities of the individual.
Clinical Neuropsychologists need to have an understanding of functional neuroanatomy, neurological
disorders, psychopathology and theoretical background and psychometric properties of the used tests.
Psychology has an influence on what a (neuropsychological) patient does in his daily life, whether or
not he follows his treatment well, takes his medicines, if he shows up at treatment, how he feels etc.
That is why psychopathology is so important in neuropsychological assessment.
Neuropsychological assessment is “another method of examining the brain by studying its
behavioural product” (Lezak et al.). The behavioural effects of brain damage vary with:

 Nature, extent, location and duration of the lesion(s) and/or malfunctioning of the neural
networks.
 Age, sex, physical condition, psychosocial background and status of the patient.
 With individual neuroanatomical and physiological differences.
Because a scan can only show what the brain looks like, we examine the behavioural problems. This
so that we can see how the brain seems to work and/or how the person feels.
The goal of neuropsychological assessment isn’t just about gathering test data but in understanding the
behaviour of the patient in the context of the environment in which he functions. Major purposes of
neuropsychological assessment are:
1. Differential diagnosis: trying to figure out why it is this form (of dementia for example) and
not another form.
2. Planning treatment
3. Following the course of rehabilitation
4. Legal proceedings
Anatomy of the brain:

,A very simplified overview of the structures and functions of the brain:

Function Brain structures implied
Attention All areas (but especially frontal)
Perception Visual cortex (occipital lobe)
Memory Hippocampus, thalamus, M.Bs, fornix,
prefrontal
Language Left hemisphere, Broca’s, Wernicke’s
Executive Functions Frontal cortex and feedback loops
Movement Basal ganglia (pons/medulla), cerebellum,
cortex
Emotion Amygdala, cortex, right hemisphere
(Plasticity is important to keep in mind here!)
Attentional deficits are the most common problems in neuropsychological patients, this is because all
the areas of the brain are involved in attention.
The younger you are, the more likely it is that the brain can recover after a brain trauma. Recovery
however is not a natural given; not everybody recovers (or only a little bit).
Global issues in neuropsychological assessment:

 Populations – all ages.
 Comorbidity is more common in the elderly as is polypharmacy.
 Maximizing the patient’s performance (strengths and weaknesses).
 Individual differences often seem to be more ‘marked’ in brain-damaged individuals (may see
extremes of behaviour. They don’t respond the way you expect).
 Determining premorbid level of functioning is crucial (what has changed in the person? You
need to know the baseline).
Comorbidity means ‘two diseases or more, that come together in one person’. Polypharmacy means
taking multiple medicines.
Psychometrics includes consideration of:

 Reliability
 Validity and validation (most fundamental property of psychometric tests!).
 Norms and skewing.
 Standardizing scores and why important.
 Correlations that exist between tests (avoid redundant testing).
The test is good if it:

 Has ecological validity (measures what is purports to measure).
 Covers all relevant behavioural domains of interest.
 Avoids ‘floor’ and ‘ceiling’ effects.
 Patient can understand what they have to do.
 Easy to administer and score.
 Comparable with other investigators’ work.
 Has more than one version/form (reduces redundancy).
You need to know what the tests are and what they measure, and so on. Most important from this list
is the ecological validity: you want to know how that person functions in daily life and your test has to
measure that in order to be efficient.

, Procedures in neuropsychological assessment:

 Patient typically undergoes a neurology examination.
 Referral
 Deciding which approach to take: fixed battery of flexible approach? You have to ask yourself
questions before seeing the patient.
 The clinical interview.
 Gathering a case history.
 Neuropsychological testing.
 Deriving a level of premorbid functioning.
 Scoring and comparison with age-appropriate norms.
 Making a diagnosis and recommendation for treatment, and report writing (ask who your
reader will be in order to know how and what to write).
 Client feedback and possible follow-up.
Neurology exam and laboratory exams:

 Neurology: motor functions, sensations, reflexes, Brief Mental Status examination.
 Laboratory exams: CT, MRI, fMRI, SPECT, PET, EEG, ERP – not always useful. Even when
lesion site is known you still need assessment to determine the strengths and weaknesses of
the patient. Other laboratory exams are angiography, CSF (lumbar punctures) etc.
The clinical interview:

 Importance of client-tester empathy.
 Start with open-ended questions.
 Get progressively more specific.
 Can use checklists to help you.
 Partner/spouse (proxy – in interview or separate interview?)
 The art of observation – qualitative functioning?
An interview with the partner is best to conduct both together as separate from the neuropsychological
patient. Separate interviews can show you whether or not the answers become more honest, whether or
not the patient feels less pressure, and if the answers from the patient and the partner are similar. It
also prevents that the partner answers for the patient and so on. After separate interviews you can
interview them together to see how they respond at each other.
Observation: Test results say little without integrating them into an overall picture of the patient.
There is indirect vs. direct observation possible. A checklist of possible observations relevant during
testing:

 Physical condition.
 Communication between patient and tester.
 Orientation, understanding of the situation, sociable?
 Emotional reactions.
 How the person tackles the testing (motivated etc.?)
 Functioning of the senses.
 Movement.
 Speech and language.
 Attention and concentration.
 Anything unusual?