NOTE: DUE TO A TECHNOCAL ERROR WITH THE RECORDING OF THE LECTURE, ONLY THE FIRST HALF OF THE
FIRST LECTURE IS NOT INCLUDED IN THIS SUMMARY. HOWEVER, ALL THE OTHER LECTURES ARE COMPLETE.
Part 3: Basic principles of diagnostics in CNP
- Neuropsychological assessment (NPA): As a neuropsychologist you look at the intertwining of
cognition, emotion, and behavior in relationship to dysfunction of the brain.
- The referral and development of a “research question” usually start with the general practitioner →
following the empirical cycle.
*The neuropsychologist fulfills the role of a scientist-practitioner with N=1
- Empirical cycle:
- Recognition/diagnosis: what are the
problems, what is intact and what is
impaired?
- Explanation: Why do the problems occur
and/or in what way are they maintained?
- Prediction: In what way will the problems
of the patient develop in the future?
- Indication: In what way can the problems
be treated?
- Evaluation: Are the problems sufficiently
addressed by the treatment?
The diagnosis process:
- The diagnostic process is dynamic: hypotheses can be generated, tested and updated at multiple
stages in the empirical cycle.
→ These are all the steps included in the
diagnostic process
IN THIS LETURE AN EXAMPLE CASE IS USED TO DESCRIBE AND SHOW ALL THE STEPS OF THE DIAGNOSTIC
PROCESS, THIS EXAMPLE CASE WILL BE INDICATED IN GREY AND SMALLER FONT.
- Example case: Mrs. R.. 89 years old (1930)
*Referral for “extensive neuropsychological assessment” (in 2020)
*Setting: geriatric rehabilitation, Referrer: specialist in geriatric medicine
*Clinical rehabilitation: fall with femoral fracture (near hip replacement)
*Relevant observations in the clinic and during therapy: tends to act unsafely, in bed a lot, often
refuses to do physiotherapy, has difficulties with remembering therapy instructions, sometimes “demanding
behavior” (frequently calling the nurses)
, *Main questions: What is the nature and severity of her cognitive problems? (Recognition/explanation)
& What is her current need for care? (Indication)
*Relevant (medical information:
- 2010 hypertension/high blood pressure/high cholesterol, total knee replacement (left)
- 2014 hip replacement (both sides)
- 2015 thrombosis eye
- 2018 fall/right-sided stroke/delirium (medical examination: multiple small watershed
cerebral infarcts (right side) and very high-grade stenosis ICA right side; > 70%)
*Premorbid level of functioning:
- Home care: putting on compression stockings, preparing breakfast, lunch and dinner
(microwave meal)
- Intention to start home care for showering
- Medication intake: independently
- External assistance: groceries and cleaning
*Educational level/work:
- Primary school during WWII (4 years completed)
- Butcher shop, market stall, manager of a canteen, saleswoman (until 74)
*First hypotheses?
- Mild neurocognitive disorder related to vascular disease/MCI
- Major neurocognitive disorder related to vascular disease/Vascular dementia
- Depression (note: in bed a lot, refuses therapy often (apathy?), demanding behavior)
- Delirium
- 1. Anamnesis/history taking:
*Is in the form of a semi-structured conversation
*You focus on the type, course and severity of complaints
*You focus on predictions based on the “first” hypotheses, which is based on brain-behavior
relationships
*Ask for limitations in daily life activities
*Always ask for specific examples to avoid misunderstandings
- Memory complaints
- Concept of long-term and short-term memory
*At the same time: observation!
- Symptoms vs. syndromes: symptoms are not equal to syndromes
*All the symptoms together form the syndrome. Theoretical knowledge allows you to order
the complaints/symptoms of the patients and to recognize these symptoms as part of a syndrome.
*Recognition of syndromes and patterns of impairments is thus important
*Note 1: Do not only search for confirmation. Also ask for symptoms that would not fit one or
more of your hypotheses in order to be able to reject incorrect ones.
*Note 2: Take the base-rate information (i.e. the a priori chance) into account = the
percentage of a population that demonstrates symptoms or the disease.
- 2. Heteroanamnesis:
*Includes information from someone close or otherwise health care professional (e.g. nurse)
*Ask the patient for informed consent
*It is an additional source of information, which increases reliability
*It gives insight/awareness of the disease
*Pay attention to inconsistencies and make sure you notice them
*Again: it is an opportunity to observe! (behavior and interaction)
- Follow up 1 example case: Mrs. R.
*History taking: she fell in the restaurant of her apartment building. She states that she broke both of
,her hips. She experiences no cognitive difficulties or changes. She feels somewhat gloomy.
*Heteroanamnesis: She provided approval for a heteroanamnesis with one of her daughters. Cognitive
changes apparent since 2018, when she fell on her knee (wound) and went through a delirium. She improved
after she recovered from the delirium. She functioned largely independently, except for the groceries and
cooking. Between 2018 and now: six falls. She again went through a delirium after the last fall. Now “98%”
herself again. Somewhat sad but not gloomy (probably due to visiting restrictions covid).
*Observation: Friendly, well-groomed, contact growth present/open, answers often with stories from
the past when asked about recent events, clear difficulties with the details in her story and ordering events in
time, verbose, and sometimes repeats herself. Later appointments: more often talks about recent events,
provides accurate details about recent events and knows some names of fellow patients.
*Updating the hypotheses?
- Mild cognitive disorder related to vascular disease/MCI
- Major neurocognitive disorder related to vascular disease/Vascular dementia
- Depression
- (Delirium)
- 3. Determine the set of hypotheses you are going to test. Operationalization: how to test the
premises of the hypotheses? Choosing instruments to measure
cognitive functions:
- Preferably at least 2 tests per
cognitive domain
- Relationships between attention,
memory and executive function
- Impossibilities of the patient (e.g.
visual impairment, hearing problems,
paralysis of the dominant hand)
- Quality of the instruments
*Quality of instruments: COTAN reviews the quality of common (neuro)psychological tests
- Validity
- Reliability: through repeated testing, which measures the cognitive functions over
time (can it point out disease progression, recovery…, confidence interval: significant change or not?,
but: practice effects (especially on memory tests) & test wiseness)
- Norms: availability of an appropriate norm group based on age, gender and
education
*COTAN evaluations: “The ‘mission’ of the COTAN is to enhance the quality of tests and the
use of tests in the Netherlands by informing test users, developers and publishers about the
availability, the content and quality of various instruments. First, this is done by reviewing the quality
of a wide range of tests and questionnaires, and second, by drawing up standards on the use of
(psychological) instruments, such as the Algemene Standaard Testgebruik (General Standard Test
Use).”
- The COTAN reviews amongst other things the quality of the test construction, the
manual, and the norms of tests. They also examine the psychometric qualities of tests, such as the
validity (does the test measure what it aims to measure) and the reliability (e.g., how stable are the
scores over time).
- There are high demands placed on the size and composition of the norm groups
(has to be > 400 participants for a “sufficient” rating). However, this is not always feasible due to the
relatively small number of Dutch speakers.
- The COTAN needs time to conduct reviews. As a result, recently developed tests or
recently released new norms have often not yet been reviewed.
- Bottom line: be aware about the limitations of instruments and, if available, choose
instruments with the highest quality.
, - Follow up 2 example case: Mrs. R.: What type of instruments should be included in the NPA?
*Cognition (MCI, Vascular Dementia, Depression), Emotion, Behavior
- 4. Test administration:
*Order → generally no significant effects of order on test results, however:
- Interference effects, for example with the 15WT test:
- Effects of fatigue due to long testing
- Tests addressing the same function
- Motivation and anxiety (high anxiety → start with easy test)
*Preferably use standardization of test instructions
*Testing the limits: if a patient cannot keep up with the standardized test instruction, than be
flexible
*Quitting a test early
*When to test? → Wait at least 6 weeks before starting NPA, because of acute, expected
recovery. For example in cases of:
- Substance abuse
- Delirium
- Stroke/TBI
- Premorbid functioning: is a made estimation based on demographics (e.g. age, gender, education).
The following estimates are used in this course = the Bouma Qualifications
The specific terms and
number of terms to be
used is internationally
under heavy
discussion
- Either 7 or 9 terms →
the field tends to shift
toward using 7 terms.
- Purpose: uniformity
and reduce the use of
stigmatizing terms
*Note: The term only provides a qualitative description for the standardized score. The
relative position of the patient’s performance in the normal distribution remains exactly the same!
*For example: John obtains a raw score of 8 animals on a verbal fluency test. Based on the
norm group, his performance turns out to be in the 4th percentile.
- Bouma et al.: “low” - Guilmette et al. 2020: “below average”
!But the standardized score remains the same!
