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NEUROPSYCHOLOGICAL ASSESSMENT - CHAPTER 5

the neuropsychological examination:

procedures

- Two guiding rules for the neuropsychological examiner:

- Treat each patient as an individual
- Be thoughtful and deliberate in the examination process
- A flexible and creative approach is necessary due to the variety of neurological conditions,
patient capacities, and examination purposes.
- General guidelines for the examination:
- Tailor the examination to the patient's needs, abilities, and limitations
- Consider special examination requirements
- Adapt the examination to the patient in a sensitive and resourceful manner
- The neuropsychological examination can be tailored in two ways:
- Selecting appropriate examination techniques and tests based on patient
characteristics and relevant diagnostic/planning questions
- Incorporate both selection goals in each examination when possible
- Sorting through available assessment tools to choose those that provide the most
comprehensive information is important.
- Test procedures can be adapted to a patient's condition when necessary to gather complete
information.

1. purposes of the examination

• Neuropsychological examinations serve various purposes, including: •

Explaining behavior •
Aiding in diagnosis •
Assisting with management, care, and planning •
Evaluating treatment effectiveness •
Providing information for legal matters •
Conducting research •
Examinations may have multiple purposes, and the examiner must be aware of
the reasons for the patient's evaluation.
• The referral question usually defines the chief purpose, but its appropriateness should be
evaluated, as it may not address all relevant issues. •
Referral questions may be poorly formulated, leading to potential mismatches between
the stated purpose and the patient's actual needs.
• The neuropsychological assessment often addresses several important issues for the
patient's well-being, even if the referral focused on only one aspect.
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• Communicating with the referral source is the best way to clarify all the issues related to
the examination.
• If direct communication is not possible, the examiner relies on history, interviews, and
the patient's performance during the examination to determine the content and direction of the
assessment.

2. examination questions

a. diagnostic questions •
Diagnostic questions in neuropsychological evaluation arise when patients present with cognitive
or behavioral problems without a known cause.
• The diagnostic categorization involves distinguishing between different possible
conditions that best explain the patient's behavior.
• Neuropsychological evaluations rely on syndrome analysis, comparing the patient's
characteristics to well-described neurological conditions.
• Unusual presentations may be analyzed based on theoretical understanding of
brain-behavior relationships.
• The examiner needs to assess the patient's level of functioning and consider risk factors
for brain diseases, such as family history or exposure to toxins.
• The examination assesses compromised and intact brain functions and how deficits may
account for behavioral anomalies.
• The diagnostic process involves formulating hypotheses and progressively refining them
as more information is gathered.
• Neuropsychologists do not provide neurological diagnoses but contribute data and
diagnostic formulations that aid in diagnostic conclusions.
• Neuropsychological testing is unnecessary when other methods already demonstrate
clear neurological disorders.

b. descriptive questions
• Behavioral descriptions are crucial after a diagnosis is established, particularly in
vocational and educational planning. •
Questions about specific capacities are important for decisions involving adult rights and
privileges, such as driving or legal mental capacity.
• Neuropsychological examination for planning and rehabilitation focuses on relevant skills
and functions.
• Accurate behavioral descriptions are essential for effective remediation and rehabilitation
programs.
• Longitudinal studies with repeated measures are needed for monitoring disease
progression, assessing improvement, or documenting treatment effectiveness. •
Regularly repeated assessments allow comparisons to baseline data and reveal rates of
improvement or deterioration in different functions.
• Most examinations address multiple questions and should be tailored to the individual's
needs and referral questions.
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• One-size-fits-all examinations can be lengthy and costly, and may not adequately address
specific defects or problems.
3. conduct of the examination

a. examination foundation
i. the examiner’s background • The
knowledge base in medicine, psychology, and basic sciences is expanding rapidly,
leading to increasing specialization among clinicians. •
Clinicians' biases and preconceptions can influence the diagnostic process, making it crucial for
them to update their knowledge and be aware of their biases.
• Responsible and effective neuropsychological assessments require a strong background in
neurological sciences, including neuroanatomy, neurophysiology, and neuropathology.
• Familiarity with cognitive psychology and clinical psychology is necessary for
understanding cognitive functions and psychiatric syndromes. •
Clinical training and supervised experience are essential for conducting interviews, interpreting
extratest data, and integrating information in a meaningful and practical
manner.
• The Policy Statement of the Houston Conference outlines the qualifications required for a competent
neuropsychological examiner.
• Additional information about examiner qualifications can be found in various resources
cited in the text.

ii. the patient’s background • In

neuropsychological assessment, individual pieces of information must be evaluated
within a suitable context to avoid misinterpretation.
• The patient's background information is essential for proper interpretation. •
Information about the patient's social history, including educational and work experiences,
can provide insight into their cognitive potential.
• Educational and occupational background can influence attitudes about symptoms and
reactions to cognitive impairments.

• Social history: •
Information about the patient's educational and work experiences is crucial to understand
their cognitive potential.
• Military service history may also be relevant for some patients. •
Information about the patient's family history, socioeconomic status, and family
attitudes about illness can be significant.

• Present life circumstances: •

Inquiring about the patient's current life situation and feelings provides valuable
information.
• Knowledge of the patient's family life, sexual problems, and family concerns can
impact symptoms and test performance.
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• Medical history and current medical status:

• Medical history, including medication records, can help understand the nature of
the patient's condition and related problems.
• Overlooked health aspects like visual and auditory defects, motor disabilities, and
sleeping/eating habits may be important for assessment.
•

• Circumstances surrounding the examination: • Test

performance must be evaluated considering the reasons for referral and the patient's
expectations and needs. •
Understanding what the patient stands to gain or lose as a result of the evaluation
helps perceive how the patient views the examination.

4. examination procedures

• Referral:
• How patients learn about the referral for neuropsychological assessment can
affect their attitudes and responses during the examination.
• Referring persons should explain the purpose of the referral, the nature of the
examination, and the patient's choices in the matter.
• Providing informational letters to new patients can help prepare them for the
examination.

• Patient's Questions:
• Understanding what the patient hopes to learn from the examination helps guide
the assessment procedures.
• Patient's questions may differ from the referral source's questions, but they
should be incorporated into the examination planning.

• When to Examine:
• For sudden onset conditions (e.g., trauma, stroke), a brief examination may be necessary
early on to assess the patient's abilities and determine if retraining is possible.

• Full assessments during the acute or post-acute stages (up to 6-12 weeks) may not be ideal
due to rapid changes in the patient's status and potential fatigue.
• An initial comprehensive examination can be conducted when the patient's
sensorium has cleared and stamina has been regained, usually within the third to sixth
month after the event.
• Long-term planning examinations can be done within one to two years after the
event.

• Initial Planning:
• The examiner plans an overall approach to the problem, tests hypotheses, and
considers the information about the patient before proceeding to the assessment.
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• The preparatory interview with the patient covers essential topics, including the
purpose of the examination, the nature of the examination, confidentiality,
feedback to the patient, and more. •
The examiner aims to obtain informed consent before the examination begins,
particularly when patients have limited capacity or are under legal duress.

• Preparatory interview •
Establishing Rapport: •
Build a positive and trusting relationship with the patient. •
Create a supportive and non-judgmental atmosphere.

• Gathering Background Information: •

Ask about medical and psychological history. •
Understand the reason for referral and current concerns. •
Inquire about family history, education, employment, and living conditions.

• Ensuring Informed Consent: •

Explain the purpose of the evaluation. •
Describe the specific tests to be conducted. •
Discuss the confidentiality of information gathered. •
Clarify potential benefits and risks of the assessment.

• Addressing Patient's Questions and Concerns: •

Encourage the patient to ask questions. •
Address fears and misconceptions about the process.

• Setting Expectations: •
Discuss the duration of the examination and potential breaks. • Inform
the patient about follow-up sessions and feedback.

• Adjusting for Patient's Needs: •

Modify the interview approach for patients with impaired mental functioning. • Involve
family members or caregivers if necessary.

• Establishing Communication Channels: •

Determine the best mode of communication for the patient. •
Consider face-to-face or telehealth communication options.
• Observations:
• Observation is the foundation of all psychological and neuropsychological
assessment.
• Psychological assessment involves the evaluation and interpretation of
behavioral data obtained through observations of the patient. •
Indirect observations include statements or examples of patient behavior
provided by others or recorded in records.
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• Direct observations consist of informal observations made from the moment the
patient appears and formal observations during test-based examinations. •
Nontest observations can be recorded using checklists or questionnaires to aid in
organizing important areas needing questioning.

• Test Selection:
• Test selection depends on the goal(s) of the examination, aspects of the tests,
and practical considerations.
• The goals of the examination influence the choice of tests, ranging from brief
mental status rating scales for competency evaluation to extensive assessments for
rehabilitation candidates.
• Validity and reliability are essential considerations for test selection, with
published score data from normal control groups improving the usefulness of
cognitive tests.
• Face validity and ecological validity are important factors, with tasks that appear relevant
to patients' needs facilitating learning and real-world behavior prediction.
• Parallel forms of tests suitable for repeated measurements are crucial for
monitoring changes over time.
• Administration time and cost of materials are practical factors to consider when
selecting tests.
• Computer tests offer advantages such as uniform administration, automatic scoring,
and potential for adaptive testing, but considerations include the absence of
qualitative aspects of test performance and technical challenges.

• Nonstandardized Assessment Techniques:

• In certain cases, no well-standardized test may be suitable for a patient, requiring
the use of nonstandardized or experimental techniques. •
Clinical examiners can improvise appropriate testing techniques or use
experimental methods found in literature.
• Unproven tests may still be useful and serve as a source of ideas for further
innovations.
• Clinical standards for evaluating unfamiliar tests need not be as strict as research
standards.

• Beginning with a basic test battery:

• The examiner starts with a basic battery that covers major dimensions of cognitive
behavior. • Tests
may be dropped or added based on the patient's strengths, limitations, and specific
handicaps.

• Test selection for research:

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• In research, the selection of examination techniques depends on whether they

effectively test the hypotheses or demonstrate the phenomenon under
investigation.
• Research batteries need to be carefully selected, and flexibility is important to
allow for adjustments.

• Hypothesis testing:
• The examination involves multiple steps, beginning with initial questions and
continuously formulating and testing hypotheses.
• Hypotheses can be tested through appropriate tests, testing the limits, seeking
more information, or changing examination procedures.

• Selection of additional tests: •

Specialized tests are added based on the continuing formulation and
reformulation of hypotheses as new data is obtained.
• Specific tests are chosen to explore different hypotheses and functions, and
testing can be tailored accordingly.

• Concluding the examination: •

The final stage involves concluding the examination based on supported or
rejected hypotheses.
• Recommendations for improving the patient's condition and follow-up contacts
may be provided.

• Interpretive interview: •
An important part of the neuropsychological examination is the follow-up
interpretive interview, which provides patients with an understanding of their
problems and how they relate to their future.
• Counseling and recommendations are often given during this interview.

• A note on ready-made batteries: •

Ready-made batteries can be helpful for standardized research programs but
may not suit individual patients with specific handicaps.
• The use of ready-made batteries does not replace the expertise and knowledge of
the examiner.
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• An aid to test selection: a compendium of tests and assessment techniques:

• The last chapters of the book provide reviews of tests of cognitive functions and
personality commonly used in neuropsychological examination. •
Tests are suited for clinical assessment purposes in various settings, but caution
is needed when applying normative data to individual patients.

• The report •
1. Tailoring the Written Report:
• The importance of tailoring the written report to the circumstances cannot be overstated.
Depending on the complexity of the case and the intended audience, the level of detail and
technicality should be adjusted accordingly. A brief bedside examination may only require
a concise chart note, while a complex diagnostic problem with significant implications
may demand a comprehensive and explanatory report. It's crucial to consider the
needs and expectations of the readers to effectively communicate the findings and
conclusions.

• 2. Clear and Direct Communication Style:

• Given the critical nature of the examination report as a formal communication and a
potential sole record of a patient's neuropsychological status, clarity is paramount.
Decisions affecting the patient's life, health, and financial well-being may rely on the
report. As such, it must be written in a manner that is readily comprehensible to
individuals with varying levels of knowledge. The "grandmother rule" advises avoiding
clinical jargon and using language that a layperson, like one's grandmother, would
understand. Additionally, following the "Shakespeare rule" allows for the use of
commonly understood words to aptly describe behaviors, emotions, and conditions.

• 3. Inclusion of Relevant Data:

• The report must include essential identifying data such as the patient's name, age, sex, and
relevant information like Social Security number or patient record number.
Additionally, the examination date, examiner's name, and details about the tests and
procedures used in the examination should be provided. These details help ensure
accuracy and make it easier to reference the report in the future.

• 4. Structuring the Report: •

Typically, examination reports have a specific structure to ensure comprehensive
coverage of relevant information. These sections may include:

• - Review of Patient History: Providing a background of the patient's medical and

psychological history relevant to the examination. •
- Summary of Patient's Complaints: Describing the issues and concerns raised
by the patient.
• - Description of Patient's Behavior: Observations made by the examiner during the
examination.
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• - Test Performances: Reporting the results and performances on specific

neuropsychological tests administered.
• - Integrated Summary and Conclusions: Analyzing and synthesizing all
examination data to arrive at diagnostic, prognostic, and evaluative conclusions.
• - Recommendations: Suggesting specific actions or interventions based on the
examination results.

• 5. Scope and Length of the Report:

• The length and depth of the report should be determined by the purpose of the
examination and the relevant issues at hand. Reports can range from short answers to
focused questions to comprehensive documents in complex cases or legal contexts. For
litigation cases, extensive reports may be necessary, covering all relevant historical and
medical information. In contrast, brief reports for research or screening examinations
may omit some sections, focusing on specific data like test scores.

• 6. Tailoring the Report for the Audience:

• Knowing the intended readership is essential for crafting an effective report. The
audience can vary from professionals with knowledge of neuropsychology to laypersons,
including patients and their families. Reports should strike a balance between
technicality and readability, using appropriate terminology depending on the readers'
understanding. It is essential to consider the potential impact of the report on different
readers, as it might affect the patient's care, legal proceedings, or other significant
decisions.

• 7. Reporting Test Performances: •

The report should include descriptions of how the patient performed on various tests,
highlighting relevant behaviors and reactions during the examination. The inclusion of
test data, such as scores, is a subject of debate among neuropsychologists. While
scores can be meaningful to knowledgeable professionals, they might be confusing or
misinterpreted by others. Therefore, some recommend reporting test performances in
terms of commonly accepted ability levels or percentiles, making the information more
accessible to a broader audience.