Chapter 2 Basic concepts and principles of neuropsychological assessment Jonathan J. Evans 1 Assessment objectives Neuropsychological assessment is concerned with identifying the cognitive, emotional, and behavioural consequences of brain dysfunction. This type of assessment is used to address a number of different questions. )\) \s there evidence of organic brain dysfunction? Despite considerable technological advances, it is not always possible to diagnose brain dysfunction purely on the basis of evidence from brain imaging, neurophysiological assessment, or other physical tests. In some cases, cognitive impairment is the only indi- cator of a pathological process. The most common situation of this sort involves identify- ing whether someone who complains of a memory problem is suffering from an organic brain disease such as dementia of the Alzheimer’s type or a mood disorder such as depres- sion. A question that occurs frequently in medico-legal cases is whether someone who has experienced a mild head injury or whiplash has suffered a brain injury sufficient to affect cognitive processing. 1.2 What is the nature and extent of cognitive impairment? In some cases, the existence of brain dysfunction is not in dispute, but the nature and extent of any cognitive impairment needs to be clarified through more detailed neuropsy- chological assessment. Neuropsychological assessment is used to identify both cognitive impairment and areas of relative cognitive strength. Some neurological disorders present with specific patterns of neuropsychological impairment and therefore neuropsychologi- cal assessment may also contribute to differential diagnosis. One of the duties of the Neuropsychologist is to enable the patient to understand, or make sense of, his or her cognitive strengths and deficits. 1.3 What are the practical consequences of cognitive impairment? A comprehensive neuropsychological assessment should address the practical or func- tional consequences of cognitive impairment for the individual in terms of limitations on the ability to participate in activities of daily living, work, education, leisure, and16 | BASIC CONCEPTS AND PRINCIPLES OF NEUROPSYCHOLOGICAL ASSESSMENT social relationships. In some circumstances the main question for the assessment is sim- ply whether or not a person is suffering with some form of brain dysfunction, but it is always useful to consider what practical impact particular cognitive, emotional, or behav- ioural problems might have on the individual’s life. For this purpose the use of question- naires such as symptom checklists or rating scales relating to the performance of everyday tasks are often useful. When possible, it is helpful to observe the patient in practical situ- ations. Although this inevitably produces only qualitative information, if used in combi- nation with standardized test data it is likely to produce more accurate predictions about the practical consequences of brain injury. Neuropsychological assessment is used in forming an opinion regarding a person’s capacity to manage his or her affairs, particu- larly financial affairs, or consent to treatment. 1.4 How are an individual's mood and behaviour affected by brain dysfunction? Although the central focus of neuropsychological assessment is cognition, the neuropsy- chologist should also examine the impact of brain dysfunction on mood, personality, and behaviour. There are two major reasons why an assessment of mood is essential. ¢ The presence of a mood disorder, caused directly or indirectly by brain injury, is an important area of psychological assessment in its own right. « A mood disorder may have a significant impact on performance on cognitive tests and therefore must be taken into account when interpreting test results. 1.5 Does cognitive performance change over time? A further use for neuropsychological assessment is in measuring change over time. This might involve charting the process of decline in cognitive functioning associated with progressive disorders such as Alzheimer’s disease, monitoring recovery from head injury or stroke, or measuring fluctuations in cognitive performance in conditions such as epi- lepsy. One problem with the use of neuropsychological tests for monitoring change is that many tests are vulnerable to practice effects. A practice effect occurs when the patient who is tested for a second, third, or fourth time on the same test improves simply because of increased familiarity with the test materials and test demands, rather than as a result of any real change in the underlying cognitive skill. This is particularly the case if tests are repeated within a matter of a few weeks, but practice effects may last a lot longer. One solution is to use parallel versions of tests on each occasion, though the number of neu- ropsychological tests with multiple parallel tests remains very small. 1.6 What are the implications of the pattern of cogni and weaknesses for the rehabilitation process? Information about cognitive strengths and weaknesses is used in planning rehabilitation interventions. The presence of severe impairments in some areas of cognition will have implications for the types of intervention that are possible (e.g. external aid or self- initiated mental strategy) or the way in which patients learn new information or skills. e strengthsAPPROACHES TO ASSESSMENT—BEHAVIOURAL NEUROLOGY AND NEUROPSYCHOLOGY | 17 Information about areas of retained cognitive strength can help to plan how to compen- sete for deficits. The most straightforward example of this occurs when an individual has ‘Setact visual memory and impaired verbal memory, or vice versa. Rehabilitation efforts ‘may then involve helping the individual to develop compensatory strategies using the " imitact system, Performance on cognitive tests, however, is not the best way of measuring the impact of rehabilitation, at least not in the post-acute stages. Rehabilitation at this ‘stage is primarily concerned with helping individuals to cope with or compensate for “cognitive deficits and improve practical performance in everyday life. In other words, the ‘zim is usually to reduce the activity limitations imposed by the impairment, rather than ‘seducing the impairment. Using a measure of impairment is therefore unlikely to reflect Sanctional gains made in rehabilitation. +2 How might cognitive function be affected by neurosurgery? ‘One specialist role for neuropsychological assessment is in examining the potential impact __ em cognitive functioning of surgery carried out, (e.g. for the relief of epilepsy). The Wada "assessment involves temporarily shutting down each cerebral hemisphere by an injection ‘ef sodium amobarbital. The effect on cognitive processes, particularly language and ==emory, can then be assessed and the information used to inform clinical decision- ‘making about the appropriateness of a surgical intervention. +8 How is cognitive function affected by medication? ‘Many medicines affect cognitive performance. Neuropsychological assessment may be ‘ssed to monitor the effect of starting a particular medication. Medications, such as those ‘esed in the management of epilepsy, Parkinson’s disease or psychosis may affect cogni- ‘Son negatively, or sometimes positively, and neuropsychological assessment may there- Sere contribute to clinical decision making in relation to prescribing or managing cognitive side effects. 2 Approaches to assessment—behavioural neurology and neuropsychology ‘in the behavioural neurology approach, observable signs or symptoms are used as indices ‘ef brain pathology. However, whilst some patterns of behaviour are clearly absent in the person with no neurological condition and only occur in the context of brain lesions, ‘snany forms of cognitive impairment do not fit this dichotomy. For most cognitive skills, ‘here is a continuum of performance in the non-neurological population. Nevertheless, she skilled observer can determine a large amount of information from relatively short Seteractions with the patient. By spending time talking with or observing the patient, it is possible to identify deficits in a number of cognitive domains. Short bedside tests can also ‘be usefull in highlighting the presence of some disorders. However, qualitative observa- ‘Son is usually not sufficient to judge the severity of impairment and may not detect enain forms of more subtle cognitive dysfunction at all.