PSY3010S - Neuropsychological Assessment.pdf
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WEEK TWO:Neuropsychological Assessment How are we different? Neuropsychology...
WEEK TWO:Neuropsychological Assessment How are we different? Neuropsychology - Studies the relationship between brain function and behavior. europsychological Assessment One N - Assesses and treats cognitive, behavioral, and emotional disorders resulting What do neuropsychologists do from brain injury or disease Concerned with behaviour associated with brain damage Neurology - Identification - Deals with disorders of the nervous system. - Description - Diagnoses and treats diseases of the brain, spinal cord, nerves, and muscles - Quantification of changes - Emphasis on higher-order function Psychiatry Investigate relationships between: - Focuses on the diagnosis, treatment, and prevention of mental illnesses. - Human behaviours - Addresses mood disorders, anxiety disorders, psychotic disorders, and other - Brain function psychiatric conditions. - Brain dysfunction - Emphasis on higher-order functions Clinical psychology We are interested in brain-behaviour relationships - Studies and treats mental, emotional, and behavioral disorders. - Provides psychotherapy for a wide range of psychological issues, including What are neuropsychologists' purpose anxiety, depression, and personality disorders. Differential Diagnosis - Observe brain behaviour relationships Rehabilitation Measure baseline cognitive performance Who are our patients Litigation / compensation We generally see - People with known brain damage Pros of Neuropsychological Assessment - People with risk factors for brain damage Differential neurologic diagnosis - People with suspected brain damage Differentiate between acute vs static conditions We also see other patients, including: - Acute: symptoms pass - Rehabilitation - Static: symptoms remain the same - Psychiatric - Chronic: symptoms are degenerative (it gets worse) - Developmental disorders Differentiate between focal vs diffuse damage - General medical conditions - Focal: specific area - Diffuse: damage all over the brain Assessment Procedure Establish baseline performance Evaluate work readiness post-injury Medico-legal assessment Differentiate between organic vs psychiatric aetiology - Organic: symptoms that arise from a physical or biological cause. - Psychiatric: symptoms that originate from mental health conditions without a direct physical cause Neuropsychological contribution Provide knowledge linking anatomy with behavioural functions - Study people with damage to particular brain structures Knowledge enables assessment - Precise characterisation of level of functioning Accurate assessment is very valuable - Important for patient and family - Important for other health professionals (rehabilitation) Referral Neuropsychological Assessment Two Get a letter from the clinician based on observed issues or concerns which states the reasons the patient was referred, specific problems or symptoms Assessment Approaches Typical questions include: Historically: - What deficits has the [stroke/MVA/etc] caused? 1. Standard (fixed) battery approach - Describe the pattern of [memory/language/etc] impairments 2. Process approach (hypothesis/hypothetico-deductive) - Does this fit a diagnosis of [insert diagnosis]? Third middle-ground approach – flexible approach - Is this normal age-related change or a dementing process? - Can the patient return to work? Fixed Battery Approach Aims to evaluate ALL major skills XAMPLE: E Please assess this 36 year old male with known focal onset seizures with secondary ALL tests are given to ALL patients generalisation. Aetiology is suspected to be medial-temporal sclerosis. Waiting on MRI. Pros The patient is now complaining of memory loss which has worsened over the past 3 All abilities tested and scored months (mainly short-term memory difficulty). Seizures are also not controlled. Good for ‘beginners’ Objective interpretation based on normative data Please do a formal assessment of this patient to see if it fits the medial temporal pattern. Cons Hours of testing History Expensive Gathers comprehensive background information from their medical folder, patient Tests are only as good as their standardisation and collateral to understand the context and contributing factors Scores may not reflect a single cognitive process Once history is gathered a hypothesis is formulated Critique - Update and refine it during assessment Battery is only as good as the tests it contains Plan well Knowing WHY a patient failed a test is as NB as knowing THAT they failed it - Flexibility important, though - Start off with more open-ended questions Process Approach Questions: Each assessment tailored to patient - Do you know why you are here? - Knowledge of person’s pathology - What are your main concerns? - Patient’s history Be personable - Referral question - Patients are people Assessment varies Other sources of information: Tests are altered/adapted to answer questions about the nature of deficits - Medical history from medical professionals (folder or reports) Conclusions based on qualitative interpretation of test results and person’s behaviour - Collateral (Family and friends) Heavily reliant on clinician’s: - Brain scans - Theoretical knowledge - School reports (where applicable) - Familiarity with clinical literature Testing/Assessment - Experience of what is normal - Conducts specific tests and assessments to evaluate cognitive, emotional, Pros and behavioural functioning. Acknowledges individuality of patient - Knows what's wrong and test for it Focusses on most NB deficits Report Writing Emphasises HOW a person fails a test - Summarizes findings, provides a diagnosis if applicable, and offers Possibility of non-standardised administration recommendations for treatment or further action. Cons - Answer referral question Assessment procedure may be biased by clinician Difficult method to teach Not always useful in large-scale research europsychological Assessment Three N TestsLanguage: Tests: Tests for: Standardisation - Reading Reliability and validity - Writing Sensitivity - Repetition Specificity - Production - Naming TestOrientation: - Comprehension NB to establish upfront Check of someone is orientated to PPT - Person - Place - Time TestsAttention: Complex construct - Basic level - Higher levels ‘Gate-keeper’ TestsMemory: Tests range from simple to complex Different types Tests have an element of TestsROCF: - Immediate and delayed recall and recognition Rey-Osterrieth Complex Figure Test - Free recall and cued recall Assesses: - Visuospatial memory TestsExecutive Function - Visuospatial constructional problems Umbrella term - Executive problems - Planning - Neglect - Abstract thinking - Complex problem solving - Inhibition / set-shifting - Perseveration - Error monitoring - Attention and working memory Report Writing Written report - Objective - Specific and meaningful recommendations Feedback and follow-up Cross-Cultural Considerations Moderator Variables Setting the context:South Africa Multilingual Age ≠ level of education Economic disparity Quality of education disparity Various levels of acculturation to Western society Problematic Test Example: BNT BNT cross-cultural suitability - Non-European performance is poor, even in English speaking countries Psychometric Properties - Poor performance by ethnic minorities in the US Trust our tools we have modified / developed Familiarity with North American culture influences perf Modified / developed tests must still be reliable and valid The Critical Problem Lezak et al.’s (2004) rationale of deficit measurement: - “One distinguishing characteristic of neuropsychological assessment is its emphasis on the identification and measurement of psychological – cognitive and behaviour – deficits.”(p. 86) Normative comparison standards are needed In SA, we lack normative data Four Possible Solutions 1. Create, standardize, and norm SA-specific tests 2. Develop normative datasets for unmodified existing tests 3. Modify existing tests to satisfy local concerns and develop norms for those modified Normative Data tests Given enough time and money, we can stratify norms by: 4. Use individual comparison standards - Age - Sex Language Modification - Language Simple translation is not enough - SES - Forward and back translation - HLOE (also quality of education) Pay attention to - Level of acculturation - Idiom / expressions of language Regional norms are preferable - Regional variations in the use of language - Relative difficulty of items across languages Conclusion What counts as a first language? Population norms are ideal What are ‘individual comparison standards’? How do we gain access to those standards? - Estimate patients premorbid ability - This estimation is very difficult in SA context
