Basic issues in neuropsychological assessment

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Basic issues in neuropsychological assessment

• Attention and goal dircted behavoiurs

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Cognition
Speech and language
Memory
Attention and goal dircted behavoiurs
Orientation in time and space
Emotions
Personality
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Types of attention

• Sustained attention
• Keeping your concentration
• Selective attention
• Not being distracted
• Divided attention
• Doing two things at once
• Auditory and visual

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Sustained attention

• Most basic level
• Maintaining your concentration on something that
  isnt necessarily attention-grabbing
  listening to talk, watching a television programme

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Selective attention

• More difficult than sustained attention
• Freedom from distractability
• Filtering out unimportant things so you can focus
  on what you want to do listening to a
  conversation in a pub, crossing the road safely

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Divided attention

• The most difficult level of attention
• Concentrating on two or more things at once
• Common example in rehab is walking and talking
  taking notes while listening, buttering bread
  while making sure soup doesnt boil over

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Visual attention

• Efficient scanning of environment
• Radar sweeping across whats in our field of
  vision
• Neglect of one side of space
• You dont reach round to the left
• Not an eyesight problem
• As if ignoring half the world eating half a
  meal, shaving half of face, not attending to
  people/objects on left

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Speed of information processing

• Common consequence of brain injury
• Takes longer to take in information, dael with it
  and then respond to it
• thinking more slowly
• Impact often more noticeable in more demanding
  situations

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Attentional problems

• Being easily distracted
• Harder to notice or find things
• Going off the topic of converstion
• Finding it hard to concentrate for long periods
  of time
• Finding it difficult sticking to task or activity
• Mind wandering more easily

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Attentional problems

• Making mistakes because of thinking about
  something else
• Missing important detailes in tasks
• Being confused when there is a lot going on
• Being unable to deal with more than one thing at
  a time

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Attention, concentration and tracking

• Reaction time
• Vigilance
• Short term storage capacity (digit span)
• Mental tracking tests of working memory (digits
  backward) Stroop Test (Stroop, 1953 A.R. Jensen
  Rohwer, 1966)
• Complex Attention Tests Digit Symbol Coding
  (Wechsler, 1997a) Trail Making Test (TMT)

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Stroop Test

• green yellow red blue
• red green blue yellow
• green blue yelow red
• yellow red green blue

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Executive functions

• As the most complex of behaviours, executive
  functions (EF) are intrinsic to the ability to
  respond in an adaptive manner to novel situations
  and are also the basis of many cognitive,
  emotional and social skills.

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• Executive functions describes skills that a
  good chief executive would have
• Making long term goals
• Organising steps towards these
• Initiating, monitoring and adjusting these steps
• Having good judgement

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Frontal lobes

• The front parts of the brain act like the manager
  of the rest of the brain
• Usually one points
• Premotor area
• Supplementary motor area
• Prefrontal area

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Frontal lobes topography

• Dorsolateral area
• Cingulate area
• Orbitofrontal area

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• Include mental functions necessary for
• Planning courses of action
• Putting them into practice effectively
• Monitoring their progress
• Processes by which we plan, organise, monitor,
  and adjust our thinking and behaviour
• Very relevant to complex and emanding settings,
  e.g. work, socialising

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Common difficulties

• Harder to identify own strengths and weaknesses
  self monitoring and insight
• Lack of foresight and anticipation
• Difficulty planning and problem solving
• Difficulty proritising and making decisions
• Difficulty generating ideas and putting plans
  into action - initiation

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• EF can be conceptualized as having four
  components
• Volition
• Planning
• Purposive action
• Effective performance

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• She seems to be lazy now, lacking any
  motivation. She needs to be made to do things

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Volition

• Patients may be fully capable of performing
  complex activities and yet not carry them out
  unless instructed to do so
• Usage of utensils
• Lack of seeking the food spontaneously
• Lack of ability of appreciation of long term
  abstract goals

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Volition examination

• Examining the capacity for self-awareness
• Awarness of ones phisical status
• Awareness of the envioronment and situational
  context
• Social awareness

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Planning

• Proteus Maze Test (Proteus 1959, 1965)
• Up to four trails given in difficult versions
• No time limit
• Qualitative errors (e.g. first-third error, cut
  corner, lift pencil etc.)
• Tower of London Drexel University (TOLDX)
  (Culberston and Zillmer, 2001)
• Everyday tasks

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Purposive action

• The translation of intention or plan into
  productive, self-serving activity requires the
  actor to initiate, maintain, switch and stop
  sequences of complex behaviour in an orderly and
  intergrated manner
• Tinkertoy Test (Lezak, 1982a)

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Self regulation

• Flexibility and capacity to shift
• Ruff Figural Fluency Test (RFFT) (R.W. Evans et
  al., 1985 Ruff Light, Evans 1987)
• The examiner asks the subject to make as many
  different figures (patterns) as possible within 5
  minutes by connecting any number of the dots with
  straight lines

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• Wisconsin Card Sorting Test (WCST) (E.A. Berg,
  1948 Grant and Berg, 1948)
• Devised to study abstract behaviour and shift
  of set
• Consits of 60 cards on which are printed one of
  four symbols in one of four colours
• The task is to put the cards according to the
  rule which remains unknown
• Most widely used scores are for categories
  achieved (at least 4) and mistakes such as (e.g.)
  perseverative responses

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• He says and does things that are quite rude, and
  very out of character for him he says or does
  things without thinking

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Disinhibition

• The front parts of the brain inhibit behaviour
  put social brakers on thinking, doing, saying
• Brain injury can make the brakers less efficient

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• Hes much more emotional now, he cries at
  silly, little things

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Emotional liability

• Harder to inhibit the physical responses to tears
  even though the emotional aspect isnt too
  upsetting
• Can be confusing, often more distressing for
  family or friends

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• Shes so repetetive shell get stuck on one
  topic of conversation when everyone else has
  moved onshe wont take advice but insists on
  trying to do things her own way, even when it
  clearly isnt working

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Cognitive inflexibility

• Front parts of the brain are resposible for
  flexible thinking and shifting our train of
  thought
• Frontal injury can lead to sticky thinking it
  might be hard to stop one train of
  thought/behaviour and move on

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• She seems to take everything very literally I
  have to spell things out and explain whats going
  on when were watching television

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Concrete thinking

• Frontal lobes are involved in abstract thinking
  thinking here and now
• Brain injury can make it harder to pick up subtle
  implications, hidden meanings, humour, and take
  other peoples perspective

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Bibliography

• Lezak, M., Howieson, D. B., Loring, D. W. (2004).
  Neuropsychological assessment. Oxford University
  Press
• Chapter 16 Executive Functions and Motor
  Performance, p. 611-646