Outline – Health & Neuropsychology

1. 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

2. Outline – Health & Neuropsychology IQ and Neuropsychological Testing Malingering Functions of interest to neuropsychologists • Laterality • Visual Perception • Language • Memory • Attention & Executive Control

3. 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.

4. Diagnosis What happened? What went wrong as a result? Goals of neuropsychological assessment

5. Diagnosis Description Cognitive and behavioral deficits that result Goals of neuropsychological assessment

6. Diagnosis Description Tracking changes in patient’s performance over time, to monitor healing/worsening and effects of treatment Goals of neuropsychological assessment

7. Standardized: Repeatable instructions, presentation, and tasks Norms Psychometric assessment - advantages

8. Standardized Intensive: Multiple measures within and among wide range of domains Psychometric assessment - advantages

9. Standardized Intensive Sensitive Valid indicators of skills, capable of detecting abilities and deficits Psychometric assessment - advantages

10. Standardized Intensive Sensitive Scaled Hierarchical items start/stop rules Psychometric assessment – advantages

11. Standardized Intensive Sensitive Scaled Precise Allows reliable, exacting quantification of relative abilities Allows comparison within/over time Psychometric assessment – advantages

12. 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 Psychometric assessment – Interpretation

13. 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 Psychometric assessment – Interpretation

15. 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? Line-crossing task to detect neglect

16. 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 IQ and neuropsychological testing

17. 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 IQ and neuropsychological testing

18. Clinical approaches Educational level Vocabulary skills Occupational background, farm size Functional capacities: self-care, finances, driver’s license, food preparation, parenthood, daily activities Estimating pre-morbid IQ

19. Clinical approaches Actuarial & psychometric approaches Demographic Formulas Reading level Subtest pattern Estimating pre-morbid IQ

20. 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

21. 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

22. 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.”

23. Halstead 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

24. 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) Reitan’s four-fold approach

25. Level of performance Comparison of individual with normative groups of impaired and non-impaired persons Reitan’s four-fold approach

26. Level of performance Pattern of Performance Examination of intra-test performance and subtest scores Reitan’s four-fold approach

27. Level of performance Pattern of Performance Specific Behavioral Deficits (Pathognomonic Signs) Sensitivity to deviant or deficient performance which, of itself, points to impairment Reitan’s four-fold approach

28. 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 Reitan’s four-fold approach

29. 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 Halstead-Reitan Neuropsychological Tests

30. 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 Halstead-Reitan Neuropsychological Tests

31. 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 Malingering

32. 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 Malingering

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

34. 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 1. Laterality

35. Annett Handedness Questionnaire Please indicate which hand you habitually use for each of the following: (R, L or E) 1. Writing 2. Throwing a ball 3. Holding a racquet 4. Striking a match 5. Cut with scissors 6. Threading a needle 7. At top of broom 8. At top of shovel 9. To deal cards 10. To hammer a nail 11. To hold a toothbrush 12. To unscrew a lid There are several ways to score this test

36. 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. 2. Visual Perception

37. 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 2. Visual Perception

38. Figure/ground discrimination – separate figure from background

39. The embedded figures test – task is to find all the objects in this figure.

40. The objects in the embedded figures test stimulus

41. 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 Visual agnosias

42. 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 Visual Memory

43. The Rey-Osterrieth Complex Figure (Osterrieth, 1946)

44. 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)

45. Oral Expression – word repetition, body part naming, visual confrontation naming Writing Auditory comprehension: Body part identification Understanding written language: Word picture matching. Boston Diagnostic Aphasia Examination

46. 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 3. Language

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

48. Pyramid Palm Tree Fir Tree 3 Word Version 3 Picture Version Pyramid and Palm Trees Test – which one of the two lower items goes with the upper item?

49. 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 4. Memory

50. 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 Retrograde amnesia