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Methods ofassessment
2021
jody starmans
[BEDRIJFSNAAM]
, Task 1 – What’s all that testing about
Abbate C & Trimarchi PD (2013). Clinical neuropsychologists
need a standard preliminary observational examination of
cognitive functions.
Introduction
Clinical neuropsychologist is the specialist who makes diagnosis of cognitive function impairments and
determines the relationship between cognitive impairments and the underlying brain damage.
2 instruments available to neuropsychologist:
1. Clinical interview
2. Psychometric test core method
o however, many clinicians underline the importance of carrying out a preliminary clinical
interview during a neuropsychological assessment, talking with the patient and observing
her/his behaviour in order to identify signs and symptoms of cognitive impairments -> this
clinical interview is usually described under vague terms
o There is not a standard procedure utilized to observe, register, quantify, interpret, and
report cognitive data detected at the stage of the preliminary interview
This paper: proposal for a standard version of preliminary observational evaluation of cognitive functions for
neuropsychologists = preliminary neuropsychological examination (NPE) in parallel to the standard clinical
neurological examination (NE)
Theoretical framework
Clinical practice neurologist: concerns the observation of spontaneous signs and symptoms of a neurological
dysfunction (E.g. tremors) NE
→ During preliminary NE: patients motor responses will be stimulated through some simple standard
actions (E.g. grasping reflex)
Clinical practice neuropsychologist: observation of spontaneous signs and symptoms of a
neuropsychological dysfunction (E.g. confabulations) NPE
→ During preliminary NPE: patients behavioural responses will be provoked by some simple questions
(E.g. questions about temporal orientation)
→ Mind examination
Clinical method in steps – cognitive assessments are further elucidated:
1. Elicitation (= uitlokken) of clinical facts: collecting symptoms of cognitive dysfunction referred by
caregiver and reported complaints of patient
a. Also attempts to register the signs of cognitive dysfunction from preliminary NPEs and
neuropsychological tests
2. Interpretation of signs and symptoms in term of anatomy and physiology: interpreting signs and
symptoms of the cognitive dysfunction in terms of functional anatomy of cognitive system and in
terms of processes inside of the cognitive system (physiology)
models of normal cognitive processing (E.g. EF model) are the reference for this step
3. Disclose the clinical diagnosis when the characteristic cluster of symptoms and signs of cognitive
dysfunction are recognized -> An accurate diagnosis offers a contribution to the next steps
4. Anatomical diagnosis
5. Pathological and etiological diagnosis
Definition, purpose and characteristics
1
, The preliminary NPE = a systematic collection of cognitive data based on the observation of a patient
behaviour during the interaction with the clinician in the context of a preliminary interview.
→ Aims: to obtain a description of the patient’s current cognitive state
→ The NPE can be structured, flexible or mixed
The Mental status examination is usually used in medical practice, however, this is not an appropriate tool
for neuropsychologists, because:
→ MSE includes many aspects of the mental functioning which do not directly concern the cognitive
domain
→ Cognitive domains are not investigated enough -> too superficial for clinical NP
o However, the MSE is a useful tool to detect psychological and/or psychiatric symptoms that
are common in patients with neuropsychological syndromes
You can use both NPE and MSE
Use of preliminary NPE:
→ Preliminary NPE mainly depends on the knowledge of the clinician about the neuropsychological
signs and symptoms is important (knowledge of the behavioural expression of cognitive
dysfunctions) instead of the available normative data based on performance of healthy controls
→ Preliminary NPE offers to the clinician a set of empirical observations and objective descriptions of
behaviours which are related to neuropsychological dysfunctions
o These tools do not provide reliable and detailed info on the impairment of different cognitive
domains
→ It concerns the mind and not the brain the outcome of the preliminary NPE are descriptions of the
mind dysfunctions
o The underlying brain damage doesn’t directly concern the preliminary NPE
→ It only includes the cognitive domains for which an observation is sufficient enough to draw a
conclusion from it (E.g. language, memory, attention etc.)
→ Moreover, preliminary NPE may not be sufficient enough to detect a cognitive impairment a
person who might seem to have no impairment in the preliminary exam but might show a deficit in a
neuropsychological test assessment
Preliminary NPE is one of the tools involved in the neuropsychological assessment + it should be integrated
with an accurate anamnesis of the cognitive impairments taken from relatives, a complete survey of the
patients cognitive complaints and both quantitative and qualitative data from psychometric tasks
Rationale: why do we need a standard preliminary-observational NPE?
Psychometric tests are the core tool of a NP assessment, however there are some limitations –
Limitations of psychometric tests:
→ Heterogeneity by the testing procedures (use of different tests for same cognitive domain), the major
consequence is that cognitive data become not very comparable and communication among
clinicians is difficult
→ Neuropsychological evaluation takes a lot of time (> 3 hours)
→ There are many occasions in which a neuropsychological evaluation cannot be performed (patient
with brain damage) or may be difficult to administer (patient with sensory impairment)
→ Repeatability is limited due to learning effect
Preliminary NPE is a standard inventory, fixed and unvarying therefore it is easy to compare results between
patients, conditions or follow up evaluations in a same patient. It is brief and cheap and always
administrable. Also easy to communicate to other neuropsychologists.
→ Moreover, the preliminary NPE allows a neuropsychologist to decide and manage the referral to a
subsequent test evaluation.
2
, → Thus: the preliminary NPE is a useful tool for clinical neuropsychology
However: it shouldn’t replace neuropsychological testing (it’s more of an addition)
Blokland A (2020). He compiled a PDF highlight the most
important aspects of Luria’s brain model.
Luria states that human mental processes represent complex functional systems that involve groups of brain
areas working together, with each area making an
unique contribution to the organization of a functional
system
There are 3 functional units (See picture) in the brain
which are necessary for human mental processing. Each
of these 3 units have a hierarchical structure comprising
3 cortical zones based one upon the other:
1. The primary (projection area): receives impulses
from or sends impulses to the periphery
2. Secondary (projection-association) area:
incoming info is processed and programs are
prepared
3. Tertiary (zones of overlapping) areas: most
complex forms of mental activity require the
involvement of many cortical areas
Unit 1 – the unit for regulating tone or waking and mental states
Mental activity cannot be obtained without the waking state.
Structures maintaining and regulating cortical tone are located in the subcortex and brain stem have a
double relationship with the cortex
→ Ascending reticular system (BS -> Cortex): activates cortex and regulates state of activity
→ Descending reticular system (Cortex -> BS): subordinates the lower structures to the control of the
cortex (maakt de lagere structuren (=BS) ondergeschikt aan de controle van de cortex)
This thus suggests a vertical organization to all structures of the brain
The reticular formation has both activating and inhibiting portions
→ Reticular formation = a diffuse network of nerve pathways in the brainstem connecting the spinal cord, cerebrum, and cerebellum, and mediating the overall level of consciousness.
Sources of activation of the reticular formation:
1. Metabolic processes: leads to the maintenance of homeostasis ‘vital’ form of activation
2. Orienting reflex: increased alertness to the changing environment related to the arrival of stimuli
from the outside world
o Tonic + generalized form of activation = allocated to lower regions of reticular formation
o Phasic + local forms of activation = allocated to the higher structures (thalamus, limbic)
3. Intention and plans by forecasts and programmes: That were social in their motivation and formed
consciously with the help of speech highest forms of organizational activity. Played a role in
regulation of the general state, modification of the tone and control over the inclinations
(=neigingen) and emotions
Impairments in this unit show a relation between disturbances of memory and disturbances of consciousness
Unit 2 – the unit for receiving, analysing and storing info
The unit is in the neocortex on the convex (=bol) surface of the hemispheres: the posterior regions including
the visual (occipital), auditory (temporal) and general sensory (parietal) regions. This unit consists of isolated
3
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