Tutorial 1: Introduction in
neuropsychological assessments: tests
Summary of Chapter 1 and 2 of Lezak and summary of practical and test scores
Neuropsychological assessment – Lezak et al. Chapter 1: The practice
of neuropsychological assessment
Examination purposes
Six different purposes may prompt a neuropsychological examination:
1. Diagnosis
2. Patient care and planning
3. Treatment-1: identifying treatment needs, individualizing treatment programs, and keeping
abreast of patients’ changing treatment requirements
4. Treatment-2: evaluating treatment efficacy
5. Research: both theoretical and applied
6. Forensic neuropsychology
1. Diagnosis
Neuropsychological assessment can be useful for:
o Discriminating between psychiatric and neurological symptoms
o Identifying a possible neurological disorder in a non-psychiatric patient
o Helping to distinguish between different neurological conditions
o Providing behavioral data for localizing the site of a lesion
Imaging alone is not enough, as specific patterns of brain function sites differ between people.
Neuropsychological assessment can identify these specific patterns and thus the nature of
residual behavioral strengths and the accompanying deficits.
In addition, cognitive assessment can document mental abilities that are inconsistent with
anatomic findings.
Neuropsychological assessment can also aid in prodromal or early detection and prediction of
dementing disorders or outcome.
2. Patient care and planning
Many patients are referred for detailed information about their cognitive status, behavioral
alterations, and personality characteristics so that they and the people responsible for their well-
being may know how the neurological condition has affected their behavior.
The neuropsychologist has a responsibility to describe the patient as fully as necessary for
intelligent understanding and care.
Descriptive evaluations may be employed in many ways in the care and treatment of brain
injured patients.
Precise descriptive information about cognitive and emotional status is essential for careful
management of many neurological disorders.
, Rational planning usually depends on an understanding of patients’ capabilities and limitations,
the kinds of psychological change they are undergoing, and the impact of these changes on their
experiences of themselves and on their behavior.
In many cases the neuropsychological examination can answer questions concerning patients’
capacity for self-care, reliability in following a therapeutic regimen, etc.
With all the data of a comprehensive neuropsychological examination taken together (history,
background, present situation, the qualitative observations and quantitative scores), the
examiner should have a realistic idea of how the patient reacts to deficits and can best
compensate for the, and whether and how retraining could be profitably undertaken.
Repeated testing can help to track changes in patients over time or show the effect of
medication om cognitive functioning.
Many brain damaged persons share the experience of perplexity, which is self-doubt about
specific abilities.
Careful reporting and explanation of psychological findings can decrease the patient’s anxieties
and confusion.
3. Treatment-1: Treatment planning and remediation
Today, much more of the work of neuropsychologists is involved in treatment or research on
treatment.
In the rehabilitation setting, sensitive, broad-gauged, and accurate neuropsychological
assessment is necessary for determining the most appropriate treatment for each rehabilitation
candidate with brain dysfunction.
These assessments will include both identification of problem areas and evaluation of the
patient’s strengths and potential for rehabilitation.
The assessments will enable different treatment specialists to maintain common goals and
understanding of the patient. They will also clarify the problems underlying patients’ failures, so
that therapists know how patients might improve their performances.
4. Treatment-2: Treatment evaluation
Was the treatment effective? Does it produce lasting behavioral changes that have psychological
or social value and are maintained long enough to warrant the costs?
Neuropsychological evaluation can often best demonstrate the neurobehavioral response, both
positive and negative, to for example surgical interventions.
Testing for drug efficacy and side effects also requires neuropsychological data.
5. Research
Neuropsychological assessment has been used to study the organization of brain activity and its
translation into behavior, and to investigate specific brain disorders and behavioral disabilities.
It also involves the development, standardization, and evaluation of these assessment
techniques.
Many of the tests used in neuropsychological evaluations were originally developed for the
examination of normal cognitive functioning and recalibrated for use in the course of research on
brain dysfunction.
Neuropsychological research has also been crucial for understanding normal behavior and brain
functions and the association of cognition with the underlying functional architecture of the
brain.
,6. Forensic neuropsychology
Neuropsychological assessment undertaken for legal proceedings has become common in
personal injury actions in which financial compensation is sought for claims of bodily injury and
loss of function.
The neuropsychologist attempts to determine whether the claimant has sustained brain
impairment which is associable to the injury in question.
When the claimant is brain impaired, an evaluation of the type and amount of behavioral
impairment sustained is intrinsically bound up with the diagnostic process. In such cases, the
examiner typically estimates the claimant’s rehabilitation potential along with the extent of any
need for future care.
In criminal cases, a neuropsychologist may assess a defendant when there is a reason to suspect
that brain dysfunction contributed to misbehavior or when there is a question about mental
capacity to stand trial.
People may exaggerate which makes them seem cognitively impaired based on test results, while
the actual impairment may be mild. Multiple techniques have been devised to this end.
The multipurpose examination
Usually a neuropsychological examination serves more than one purpose. The initial goal could
be answering a diagnostic issue, but the neuropsychologist may uncover vocational or family
problems, or patient care needs that have been overlooked, or the patient may prove to be a
suitable candidate for research.
Integral to all neuropsychological assessment procedures is an evaluation of the patient’s needs
and circumstances from a psychological perspective that considers quality of life, emotional
status, and potential for social integration.
The validity of neuropsychological assessment
Ecological validity typically refers to how well the neuropsychological assessment data reflect
everyday functioning or predict future behavior or behavioral outcomes.
Specific test results have shown to correlate well with for example employability after for
example injury.
Several components of the very practical prediction of ability to perform activities of daily living
(ADL) have been explored with neuropsychological assessments.
Neuropsychological assessment – Lezak et al. Chapter 2: Basic
concepts
Examining the brain
The clinical approach to the study of brain functions involves the neurological examination,
which includes the study of the behavior.
The neurologist examines the strength, efficiency, reactivity, and appropriateness of the patient’s
responses to commands, questions, discrete stimulation of particular neural subsystems, and
challenges to specific muscle groups and motor patterns. In addition, body structures are
examined to look for evidence of brain dysfunction such as swelling of the retina or atrophied
muscles.
, In the neurological examination of behavior, the clinician reviews behavior patterns generated by
neuroanatomical subsystems, measuring patients’ responses in relatively coarse gradations, and
taking note of important responses that might be missing.
The mental status portion of the neurological exam focuses specifically on higher behavioral
functions such as language, memory, attention, and praxis.
Neuropsychological assessment is another method of examining the brain by studying behavior,
but in far more detail than what is covered in the mental status portion of a neurological exam.
It involves the intensive study of behavior by means of interviews and standardized tests and
questionnaires that provide precise and sensitive indices of neuropsychological functioning.
Neuropsychological assessment is a means of measuring in a quantitative fashion the most
complex aspects of human behavior: attention, perception, memory, speech and language,
building and drawing, reasoning, problem solving, judgement, planning, and emotional
processing.
Laboratory techniques for assessing brain function
Some of the earliest instruments for studying brain function that remain in use are
electrophysiological: include electroencephalography (EEG), evoked and event-related potentials
(EP, ERP), and electrodermal activity.
EEG frequency and patterns are not only affected by many brain diseases but have also been
used to study aspects of normal cognition: frequency rates have been associated with attentional
activity.
o EEG: diagnosing seizure disorders and sleep disturbances and monitoring depth of anesthesia
o EP and ERP: identifying hemispheric specialization and assessing processing speed and efficiency
o Magnetoencephalography (MEG) records magnetic rather than electrical fields. It can have a
higher resolution than EEG and can thus more precisely identify the source of epileptic
discharges in patients with a seizure disorder.
EEG and NEG both provide very good measurements of the temporal aspects of neural activity,
but both techniques do not have a very good spatial resolution.
Electrodermal activity is measured as skin conductance response (SCR). It reflects autonomic
nervous system functioning and provides a sensitive measure of emotional responses and
feelings. This activity and other autonomic measures such as heart rate have also been used to
demonstrate nonconscious forms of brain processing.
Other methods that enable visualization of ongoing brain activity are collectively known as
functional brain imaging useful for exploring both normal brain functioning and specific brain
disorders.
o Regional cerebral blood flow (rCBF) reflects the brain’s metabolic activity indirectly as it
changes the magnitude of blood flow in different brain regions.
o Computerized tomography (CT) and magnetic resonance imaging (MRI) reconstruct different
densities and constituents of internal brain structures into clinically useful 3D pictures of
intracranial anatomy. A CT might be best suited for acute head injury when skull fracture and/or
bleeding are suspected, whereas MRI, with diffusion tensor imaging (DTI) might be chosen in the
chronic stages of head injury, when the clinician is especially concerned about white matter
integrity.
o Positron emission tomography (PET) visualizes brain metabolism directly as glucose radioisotopes
emit decay signals their quantity indicates level of brain activity in a given area.
o Single photon emission computed tomography (SPECT) is less expensive than PET. It involves a
contrast agent that is readily available.
