Outline – Health

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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

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Outline – Health & Neuropsychology

IQ and Neuropsychological Testing

Malingering

Functions of interest to neuropsychologists• Laterality• Visual Perception• Language• Memory• Attention & Executive Control

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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.

4Goals of neuropsychological assessment

Diagnosis • What happened? What went wrong as a result?

5Goals of neuropsychological assessment

• Diagnosis• Description

• Cognitive and behavioral deficits that result

6Goals of neuropsychological assessment

• Diagnosis• Description• Tracking changes

• in patient’s performance over time, to monitor healing/worsening and effects of treatment

7Psychometric assessment - advantages

• Standardized: • Repeatable instructions, presentation, and tasks

• Norms

8Psychometric assessment - advantages

• Standardized• Intensive:

• Multiple measures within and among wide range of domains

9Psychometric assessment - advantages

• Standardized• Intensive• Sensitive

• Valid indicators of skills, capable of detecting abilities and deficits

10Psychometric assessment – advantages

• Standardized• Intensive• Sensitive• Scaled

• Hierarchical items start/stop rules

11Psychometric assessment – advantages

• Standardized• Intensive• Sensitive• Scaled• Precise

• Allows reliable, exacting quantification of relative abilities

• Allows comparison within/over time

12Psychometric 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

13Psychometric assessment – Interpretation

• Neuropsychologists also make up tests as needed – these typically are not standardized, so interpretation may be problematic.

• Example: line-crossing task used to detect “neglect” following right-hemisphere brain damage

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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?

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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

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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

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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

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Estimating pre-morbid IQ

• Clinical approaches• Actuarial &

psychometric approaches

• Demographic Formulas

• Reading level• Subtest pattern

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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

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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

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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.”

23Halstead Reitan Neuropsychological Tests

• Ward Halstead Ph.D. psychologist, taught in U Chicago

Medical School Through 1940s, 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

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Reitan’s four-fold approach

• Inferential decision-making using the HRNTB based on:

• Level of performance• Pattern of

performance• Specific behavioral

deficits• Comparison of two

sides of the body (right-left comparisons)

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Reitan’s four-fold approach

• Level of performance • Comparison of individual with normative groups of impaired and non-impaired persons

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Reitan’s four-fold approach

• Level of performance• Pattern of

Performance

• Examination of intra-test performance and subtest scores

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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

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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

29Halstead-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

30Halstead-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

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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

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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

33Functions of interest to neuropsychologists

1. Laterality

2. Visual Perception

3. Language

4. Memory

5. Attention & Executive Control

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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

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Annett Handedness Questionnaire

Please indicate which hand you habitually use for each of the following: (R, L or E)

1. Writing2. Throwing a ball3. Holding a racquet 4. Striking a match5. Cut with scissors6. Threading a needle7. At top of broom8. At top of shovel9. To deal cards10. To hammer a nail11. To hold a toothbrush12. To unscrew a lid

There are several ways to score this test

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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.

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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

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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

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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)

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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)

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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.

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3. Language

• Task-specific tests used with patients having comparatively isolated dysfunctions

• Graded Naming Test or Boston Naming Test - both assess ability to name objects.

• Token Test - detects non-obvious loss of receptive language

• Pyramid & Palm Trees Test - tests the understanding of words

Graded Naming Test examples – test has 30 of these, presented in order of increasing difficulty Boston Naming Test examples

Pyramid

Palm Tree

Fir Tree

3 Picture Version 3 Word Version

Pyramid and Palm Trees Test – which one of the two lower items goes with the upper item?

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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

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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

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Anterograde amnesia

• Warrington’s Recognition Memory Test 50 faces and 50 words

presented separately 2AFC 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

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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

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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

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Trails A

8

24

3

1

95

6

107

Trails B

A

24

B

1

CD

E

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Trails A and Trails B – from Halstead-Reitan test battery

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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 according to unspoken rule; examiner changes rule – can patient adapt to new rule?

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