The Benefits of Neuropsychological Assessment in the Diagnosis and Treatment of Brain Injury

1. The Benefits of Neuropsychological Assessment in the Diagnosis and Treatment of Brain Injury Adam Brickler, Psy.D. March 1, 2019

2. Goals • Define neuropsychological assessment • Identify advantages of neuropsych testing vs. neuroimaging • Discuss value of neuropsych assessment in differentiating and/or establishing severity of injury • Review various neuropsychological evaluation processes

3. Definition of Neuropsychological Assessment • A branch of clinical psychology that studies how the brain and nervous system affect how we function on a daily basis • Uses various assessment methods to ascertain function and dysfunction and applies this knowledge to evaluate, treat and rehabilitate individuals with suspected or demonstrated neurological or psychological problems. • In essence, goal is to identify cognitive strengths and weaknesses • Unlike the use of neuroimaging techniques such as MRI, CT scans and EEG where the focus is on nervous system structures, neuropsychology seeks to understand how various components of the brain are able to do their jobs (FUNCTIONING) • Entails a detailed knowledge of brain anatomy, the role that different brain areas serve and how these functions are likely to be impacted by various disorders  • AB include point about assessing across biopsychosocial domains

4. Purposes of Neuropsych Testing • Lesion Location • Diagnosis • Level of Functioning • Strengths • Weaknesses • Conditions • Rehab Recommendations • Prognosis

5. Brief History • Largely rooted in the need for screening and diagnosing brain injured and behaviorally disturbed servicemen during World War I • Continued to be driven by rehabilitation needs of veterans after combat • Evolution of field equally impacted by movement to measure the concept of intelligence and “educational evaluation” • Led to recognition of statistics-dependent testing, normative data

6. Normative-based Testing

7. Neuropsych Evaluation vs. Neuroimaging • MRI/CT • Examiner bases clinical opinion on visual representation of brain anatomy/metabolic processes • Neuropsych assess. based on functional status of patient and norm-based, providing more accurate depiction of patient’s abilities • While imaging typically more clearly observable for acute ABI, as brain heals, images change, but deficits remain • Neurologist's expertise is diagnosing and treating the structural and physiological consequences of brain injuries and neurological illnesses. • Neuropsychologists assess the effects of brain injuries and illnesses on cognition and behavior; they are experts in assessing functional capacities

8. Electroencephalogram (EEG)

9. Computed Tomography (CT)

10. CT Normal vs. Abnormal Atrophy Normal CT Severe bifrontotemporal atrophy

11. CT (Small Vessel Ischemia)

12. Magnetic Resonance Imaging (MRI)

13. Diffusion Tensor Imaging (DTI)

14. Positron Emission Tomography (PET)

15. Neuropsych vs. neuroimaging Case Example 1 • Paula, 77 • Family reported sig. STM problems, confusion when completing tasks, irritability, geographic confusion, and sig. problems completing functional activities • MRI reflected “age-appropriate” cortical atrophy • Neuropsych results suggested statistically sig. verbal and visual STM, executive, and visuospatial deficits • Pt was diagnosed with an Alzheimer’s Dementia

16. Neuropsych vs. Neuroimaging Case Example 2 • Ruth, 81 • Family reported sig. STM impairment and functional problems • CT scan reflected “minimal” small vessel ischemic changes • Neuropsych testing revealed moderate to severe verbal and visual STM deficits • Pt diagnosed with a Vascular Dementia

17. Value of Neuropsychological Testing • Specific profiles obtained on testing reveal more detailed data on location and severity of injury • Injury can cause inflammatory response affecting whole brain • Pressure-related affects on other areas • Coup-Contrecoup • Frontal- “everything” connection (i.e., frontal-cerebellar) • Helps differentiate co-morbid conditions

18. Types of Neuropsychological Assessments • Low-level evaluation • Glasgow Coma Scale • Brief Cognitive Examinations • Montreal Cognitive Assessment (MOCA) • Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) • Neurobehavioral Cognitive Status Examination (Cognistat)

19. Comprehensive Neuropsychological Battery • Extensive battery involving assessment of multiple cognitive and biopsychosocial domains • Cognitive domains • Verbal/language abilities • Visuospatial skills • Executive functioning • Attention, planning/sequencing, working memory, mental flexibility • Verbal and Visual Memory • Processing Speed • Motor/sensory

20. Neuropsych subtest examples Rey-O Complex Figure Copy Alzheimer’s patient copy

21. Trailmaking B subtest

22. Stroop subtest

23. Picture Naming subtest

24. List Learning subtest

25. Processing Speed Measure

26. Comprehensive Neuropsychological Battery • Emotional Factors • Depression • Anxiety • Adjustment to medical condition • Lability • PTSD

27. Medical History Review • Medical Co-morbidities • i.e. cardiovascular disease, diabetes • Medications • Substance Abuse • Neuroimaging findings

28. Social/Environmental Factors • Family/Social Relationships • Financial Status • Academic History • Vocational History • Living Situation

29. Stroke Case Example 1 • Include walk-through of interview, chart review, battery, and interpretation

30. Questions?

31. References • Neuropsychological Assessment, Fifth Edition; Lezak, Howieson, Bigler, & Tranel • Advanced Psychological Assessment, P.C. (www.advancedpsy.com) • Signs of cerebral small vessel disease. From Inzitari et al, BMJ. 2009 Jul 6;339:b2477. doi: 10.1136/bmj.b2477 • Inflammatory Response in Acute Traumatic Brain Injury. Current Opinion in Critical Care: Apr 2002