Adam Brickler, Psy.D. March 1, 2019 The Benefits of Neuropsychological Assessment in the Diagnosis and Treatment of Brain Injury Adam Brickler, Psy.D. March 1, 2019

Goals Define neuropsychological assessment Identify advantages of neuropsych testing vs. neuroimaging Discuss value of neuropsych assessment in differentiating and/or establishing severity of injury Review various neuropsychological evaluation processes

Definition of Neuropsychological Assessment A branch of clinical psychology that studies how the brain and nervous system affect how we function on a daily basis Uses various assessment methods to ascertain function and dysfunction and applies this knowledge to evaluate, treat and rehabilitate individuals with suspected or demonstrated neurological or psychological problems. In essence, goal is to identify cognitive strengths and weaknesses Unlike the use of neuroimaging techniques such as MRI, CT scans and EEG where the focus is on nervous system structures, neuropsychology seeks to understand how various components of the brain are able to do their jobs (FUNCTIONING) Entails a detailed knowledge of brain anatomy, the role that different brain areas serve and how these functions are likely to be impacted by various disorders  AB include point about assessing across biopsychosocial domains

Purposes of Neuropsych Testing Lesion Location Diagnosis Level of Functioning Strengths Weaknesses Conditions Rehab Recommendations Prognosis

Brief History Largely rooted in the need for screening and diagnosing brain injured and behaviorally disturbed servicemen during World War I Continued to be driven by rehabilitation needs of veterans after combat Evolution of field equally impacted by movement to measure the concept of intelligence and “educational evaluation” Led to recognition of statistics-dependent testing, normative data

Normative-based Testing

Neuropsych Evaluation vs. Neuroimaging MRI/CT Examiner bases clinical opinion on visual representation of brain anatomy/metabolic processes Neuropsych assess. based on functional status of patient and norm- based, providing more accurate depiction of patient’s abilities While imaging typically more clearly observable for acute ABI, as brain heals, images change, but deficits remain Neurologist's expertise is diagnosing and treating the structural and physiological consequences of brain injuries and neurological illnesses. Neuropsychologists assess the effects of brain injuries and illnesses on cognition and behavior; they are experts in assessing functional capacities

Electroencephalogram (EEG)

Computed Tomography (CT)

CT Normal vs. Abnormal Atrophy Normal CT Severe bifrontotemporal atrophy

CT (Small Vessel Ischemia)

Magnetic Resonance Imaging (MRI)

Diffusion Tensor Imaging (DTI)

Positron Emission Tomography (PET)

Neuropsych vs. neuroimaging Case Example 1 Paula, 77 Family reported sig. STM problems, confusion when completing tasks, irritability, geographic confusion, and sig. problems completing functional activities MRI reflected “age-appropriate” cortical atrophy Neuropsych results suggested statistically sig. verbal and visual STM, executive, and visuospatial deficits Pt was diagnosed with an Alzheimer’s Dementia

Neuropsych vs. Neuroimaging Case Example 2 Ruth, 81 Family reported sig. STM impairment and functional problems CT scan reflected “minimal” small vessel ischemic changes Neuropsych testing revealed moderate to severe verbal and visual STM deficits Pt diagnosed with a Vascular Dementia

Value of Neuropsychological Testing Specific profiles obtained on testing reveal more detailed data on location and severity of injury Injury can cause inflammatory response affecting whole brain Pressure-related affects on other areas Coup-Contrecoup Frontal- “everything” connection (i.e., frontal-cerebellar) Helps differentiate co-morbid conditions

Types of Neuropsychological Assessments Low-level evaluation Glasgow Coma Scale Brief Cognitive Examinations Montreal Cognitive Assessment (MOCA) Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Neurobehavioral Cognitive Status Examination (Cognistat)

Comprehensive Neuropsychological Battery Extensive battery involving assessment of multiple cognitive and biopsychosocial domains Cognitive domains Verbal/language abilities Visuospatial skills Executive functioning Attention, planning/sequencing, working memory, mental flexibility Verbal and Visual Memory Processing Speed Motor/sensory

Neuropsych subtest examples Rey-O Complex Figure Copy Alzheimer’s patient copy

Trailmaking B subtest

Stroop subtest

Picture Naming subtest

List Learning subtest

Processing Speed Measure

Comprehensive Neuropsychological Battery Emotional Factors Depression Anxiety Adjustment to medical condition Lability PTSD

Medical History Review Medical Co-morbidities i.e. cardiovascular disease, diabetes Medications Substance Abuse Neuroimaging findings

Social/Environmental Factors Family/Social Relationships Financial Status Academic History Vocational History Living Situation

Stroke Case Example 1 Include walk-through of interview, chart review, battery, and interpretation

Questions?

References Neuropsychological Assessment, Fifth Edition; Lezak, Howieson, Bigler, & Tranel Advanced Psychological Assessment, P.C. (www.advancedpsy.com) Signs of cerebral small vessel disease. From Inzitari et al, BMJ. 2009 Jul 6;339:b2477. doi: 10.1136/bmj.b2477 Inflammatory Response in Acute Traumatic Brain Injury. Current Opinion in Critical Care: Apr 2002