INTRODUCTION

Neuropsychology

Submitted to

Department of Applied Psychology

Shyama Prasad Mukherji College for Women

University of Delhi

Submitted by

Aditi Bhatia

19/0292

19075505003

2021
Introduction
 INTRODUCTION TO NEUROPSYCHOLOGY

INTRODUCTION

The brain has evolved to play a particularly significant role in the human body, not only in
sustaining life, but also in all thought, behavior, and reasoning. It is the only organ completely
enclosed by protective bony tissue, the skull, and it is the only organ that cannot be transplanted
and still maintain the person’s self. Neuropsychology as a scientific discipline is a young field,
although the earliest attempts to relate mental functions to the brain may be traced back to
classical Greece, and Roman Empire (Pagel, 1958; Finger, 1994). Neuropsychology became
an independent discipline only in the second half of the 19th century, as an amalgam of several
fields: neurology, psychology, neuroanatomy, neurophysiology, neuropharmacology,
neurochemistry (Benton, 1988). Neuropsychology seeks to understand the relationship
between the brain and behavior, i.e., it attempts to explain the way in which the activity of the
brain is expressed in observable behavior. Some refer to this field as biopsychology,
psychobiology, behavioral biology, or behavioral neuroscience.

Neuroscience is the scientific study of nervous system concerning biological basis of

consciousness, perception, memory and learning. Neuroscience links our observations about
cognitive behavior with the actual physical processes that support such behavior. It is an
umbrella term and consists of several subdisciplines. One of them is neuropsychology or
biopsychology which is derived from two separate fields, biology and psychology. Psychology
is the study of behavior; specifically, it seeks to describe, explain, modify, and predict human
and animal behavior. Neuropsychology or biopsychology, a subspecialty of psychology, is
basically the scientific study of biology of behavior. Here, psychology is at the center of this
discipline. Hence, neuropsychology is the study of how complex properties of the brain allow
behavior to occur. It is not only a field of study. It is also a point of view. It holds that the
proper way to understand the behavior is in terms of how it evolved and how the functioning
of the brain and other organs controls behavior. We think and act as we do because we have
certain brain mechanisms, and we evolved those brain mechanisms because ancient animals
with these mechanisms survived and reproduced better than animals with other mechanisms.
Biopsychology also has a tendency to frame its understanding of cognition and behavior within
the principles derived from cognitive psychology. In other words, it tries to provide a
biological/neuroscientific explanation for our psychological explanation of the human mind,
rather than a more ‘bottom-up’ process starting with brain mechanisms to determine their
function and then try to relate to psychology.

RELATION OF BIOPSYCHOLOGY TO OTHER DISCIPLINES OF NEUROSCIENCE

Fig 1: Biopsychology and a few of the disciplines of neuroscience that are particularly
relevant to it

The knowledge base of biopsychology is also dependent upon other allied scientific
endeavours, including the study of cognitive psychology and other areas that may be loosely
described as neurobiological. Biopsychology can be defined by its relation to other
neuroscientific disciplines. This includes neuroanatomy, neurochemistry, neuropharmacology,
neurochemistry, neuropathology, and neuroendocrinology.

● Neuroanatomy: Neuroanatomy is the study of the structures and relationships among

the various parts of the nervous system. It is the description of the parts of the nervous
system encompassing the brain, spinal cord, peripheral nervous system and nerves.
Hence, by understanding the structure of the entire nervous system, we can get to know
about how the entire system and its parts influence our activities and behavior.
 ● Neurophysiology: Neurophysiology is the study of the functions and activities of the
nervous system. Whereas neuropsychology deals with the relationship between the
brain and mental functions such as language, memory and perception. Hence, all the
behavioral and psychological features depend on the functions of the nervous system
and so these two subdisciplines are interrelated to each other.
● Neuropharmacology: Neuropharmacology is the study of the effects of drugs on
neural activity. This includes the effects of therapeutic drugs as well as recreational
drugs and toxins. This is really important to understand the range of behaviors, activities
and emotions that human beings exhibit.
● Neuropathology: Neuropathology is the study of nervous system disorders. It is the
study of the diseases of the brain, spinal cord, and nerves. The brain and spinal cord
can develop a whole host of disorders including disorders which are unique to the
nervous system such as neurodegenerative disorders like Alzheimer’s disease and
Huntington’s disease. By getting to know about such disorders, we can definitely
understand the relationship between brain functions and behavior.
● Neurochemistry: Neurochemistry is the study of the chemical bases of neural activity.
It is the branch of neuroscience that deals with the roles of atoms, molecules, and ions
in the functioning of nervous systems. With the help of this, the activities of
neurotransmitters, drugs and other molecules in the nervous system and how they
influence the psychological processes can be understood.
● Neuroendocrinology: Neuroendocrinology is the study of the interactions between the
nervous system and endocrine system. Some cells within the nervous system release
hormones which are called neuroendocrine cells. The interrelationship of
neuropsychology and neuroendocrinology explains how hormones affect the brain
activities and behavior, in turn, allowing the human to act and react in a certain way.

DIVISIONS OF BIOPSYCHOLOGY

There are basically six divisions of biopsychology that have gained wide recognition as
separate divisions of biopsychological research. These divisions study human behavior and
experience using different but complementary levels of analyses and methodologies. Several
also vary in the type of participants they examine. Following are those six divisions:
 Fig 2: The six major divisions of biopsychology

● Physiological Psychology: Physiological psychology is the division of biopsychology

that studies the neural mechanisms of behavior through the direct manipulation and
recording of the brain in controlled experiments- surgical and electrical methods are the
common ones. As such there is a tendency for this approach to rely on laboratory
animals rather than human subjects due to the explorative and invasive nature of this
research. For example, Anand & Brobeck (1951) performed bilateral electrolytic
lesions to the lateral hypothalamus of rats and cats and observed that the animals
stopped eating.
● Psychopharmacology: Psychopharmacology investigates the effects of drugs on
physiological activity, behavior and experience (Coull, 1998; Meyer & Quenzer, 2004;
Vitiello, 2007). The purpose of many psychopharmacological experiments is to develop
therapeutic drugs or to reduce drug abuse.
● Psychophysiology: Psychophysiology investigates the correspondence between
physiological activity, behavior and experience in human subjects. The procedures tend
to be significantly less invasive than those used in physiological psychology such as
EEG, ECG, EMG, EOG, etc. The research focuses on understanding the physiology of
psychological processes such as attention, emotions, information processing, etc.
● Cognitive neuroscience: It focuses on studying the neural bases of cognition, i.e.,
higher intellectual processes such as memory, attention, etc. Research involves human
subjects and the methods tend to be non-invasive such as functional magnetic resonance
imaging (fMRI), etc.
● Comparative psychology: Comparative psychology is concerned with the general
biology of behavior and performs comparisons across different species in order to
understand the evolution, genetics, and adaptiveness of behavior (Dewsbury, 1990).
Some of the research is ethological in nature, i.e., the study of animal behavior in its
natural environment.
 ● NEUROPSYCHOLOGY: Neuropsychology is the study of the psychological effects
of brain damage in human patients. Researchers in neuropsychology attempt to identify
how cerebral structures contribute towards cognitive processing by studying what
happens when the cerebral region has been damaged. In other words, it attempts to
identify how cerebral structures influence both normal and impaired functioning.
Neuropsychology deals almost exclusively with case studies and quasiexperimental
studies of patients with brain damage resulting from disease, accident, or neurosurgery.

The term neuropsychology refers broadly to the study of behavior, the mind, and their
relationship with the central nervous system, particularly the two cerebral hemispheres
and related subcortical structures. Neuropsychology was defined as concerning the
relationships between “cerebral structures” and “higher mental functions” (Hécaen,
1972), the “neural mechanisms underlying human behavior” (Hécaen & Albert, 1978),
“the interrelations of the brain with behavior” (Benton, 1988), “the relationships
between mind, brain, and behavior” (Berlucchi, 2009). It was defined by Meier (1974)
as “the scientific study of brain-behavior relationships”. Neuropsychology is then
placed at the intersection between the neurosciences (neurology, neuroanatomy,
neurophysiology, neurochemistry, neuroimaging), and the behavioral sciences
(psychology, linguistics), including cognitive and emotional-motivational processes
(Hécaen & Albert, 1978).

HISTORY OF NEUROPSYCHOLOGY

Neuropsychology is a relatively new field of study with a history dating back to the beginning
of the 20th century. The term neuropsychology was first used by Sir William Osler on April 16,
1913, in an address entitled “Specialism in the General Hospital” given at the opening
ceremony for the Phipps Psychiatric Clinic at Johns Hopkins Hospital (Osler, 1913). Donald
Hebb (1949) used the term as the subtitle of his 1949 book The Organization of Behavior: A
Neuropsychological Theory. During that time period neuropsychology represented the
combined interests of many disciplines including psychologists, neurologists, psychiatrists,
speech pathologists, and others interested in the relationship between brain and behavior. As
time passed the term became widely used and appeared in the title of Lashley’s writings, The
Neuropsychology of Lashley published in 1960 after his death in 1958 (Beach, 1961). The
official birth of neuropsychology as an independent scientific discipline can be dated to 1963,
when an international specialty journal titled Neuropsychologia started its publication on the
initiative of a small group of neurologists, psychologists, and psychiatrists partaking in an
informal discussion forum called the International Neuropsychology Symposium. The major
use of the term neuropsychology was ultimately related to the study of the relationship between
the brain and behavior. Most of the subjects for the early studies were animals.

ANCIENT HYPOTHESES

Neolithic Period or Stone Age

The earliest neuropsychological investigations recognized how diseases and blows to the brain
affect behavior. Trephination was an early procedure that involved boring, cutting, scraping,
or chiselling a piece of bone from the afflicted individual’s skull. The procedure is believed to
have developed as a way to relieve the pressure caused by brain swelling. Trephining is
estimated to have first occurred approximately 7,000 years ago during the Neolithic Period or
Stone Age. Many accounts of trephining relate the procedure to the release of evil spirits which
were thought to reside within the individual’s head (brain). Modern surgeons use two
procedures, viz. drilling a hole in the skull area, and draining internal bleeding after a blow to
the head.

The Egyptians

The next indication of how early people conceptualized the brain came from the Egyptians as
early as the Third Dynasty (2650-2575 BC). The Egyptians’ lack of brain knowledge is shown
through examining early Egyptian burial practices. The process of mummification used to take
almost 70 days to complete. In this, the brain was discarded and the heart was never removed
because it was considered the seat of the mind and soul (Leca, 1981). One of the earliest
documents describing the effects of brain damage on function dates from the 17th century BC.
This ancient manuscript, called the Edwin Smith Surgical Papyrus describes 48 observations
of brain and spinal injury and its treatment. It is an extraordinary document in that it contains
the first description of various brain parts and is the first scientific document to use the word
‘brain’. The Eber Papyrus (1555 BC), contains many early prescriptions. It is often thought
to contain more magical or superstitious forms of healing than the Edwin Smith Papyrus
(Sarton, 1927). Herophilus (335-280 BC) and Erasistratus (304-250 BC) were the first to
propose the brain as the center of reason. During the same period there arose a theory of brain
functioning, called the ventricular localization hypothesis, which continued into the middle
Ages. The theory stated that the fluid-filled compartments of the brain (ventricles) were
responsible for higher mental as well as spiritual processes. Later the theory was termed the
cell doctrine.

Ancient Greeks

The classical Greeks were interested in accounts of brain-behavior relationships. Heraclitus

(540-480 BC), a philosopher of the 6th century BC, called the mind an enormous space whose
boundaries we could never reach (Kirk, Raven, & Schofield, 1995). Pythagoras (582-507 BC),
a mathematician, was the first to suggest that the brain was the organ responsible for human
thought. With the assistance of other writers these ideas are described in what is now called the
brain hypothesis, the idea that the brain is the source of all behavior (Edelstein, 1967).

● Hippocrates (460-377 BC), considered to be the founder of modern medicine, further

expanded the understanding of the brain. He believed, as a central tenet, that the brain
controlled all sensing and movements. He was the first to indicate that damage to one
side of the brain affected the other side of the body. The modern way of expressing this
principle is contralateral control. He suggested that pleasure, laughter as well as grief,
pain, all arise from the brain (Haeger, 1988). He argued that epilepsy is no more divine
or sacred but has specific characteristics and has a medical cause. According to him,
the patient was to be treated as a whole, not an assemblage of parts. Borrowing
somewhat from the Pythagoreans came the idea of balance between the humors: blood,
yellow bile, phlegm, and black bile.
● Plato (420-347 BC) thought that the soul was divided into three functions: appetite,
reason, and temper, which resided within the brain. He chose the brain because the brain
was closest to the heavens. He also discussed the mind-body question which discusses
the essence of the mind. He took this concept further by describing physical health as
the harmony between the mind and body. In addition, historians credit Plato with some
of the earliest references to mental health (Finger, 2000). The concept introduced by
him suggested that a balance between all parts of life would lead to good mental health.
● Aristotle (384-322 BC), a student of Plato, believed the heart rather than the brain to
be the main organ of rational thought. The heart was the organ that was warm, active,
and the center of the soul. The brain was bloodless, according to him, and functioned
to cool hot blood as it came from the heart. He was the designer of the cardiac
hypothesis, which stated that the heart was the originator of numerous emotions
 (Karenberg & Hort, 1998). An equally important idea emphasized by Aristotle was that
direct observation of the subject was critical.

The Romans

Galen (131-201 AD) had an influence for approximately 1,300 years after his death (Finger,
2000). He is considered the first experimental physiologist and physician. In his writing, he
accurately described many organs of the body. He also took the bold step to challenge
Aristotle’s belief and stated that the frontal lobes are the location of the soul. He supported the
ventricular localization hypothesis based on his studies of the pig and the ox. He believed that
all physical function depends on the balance of bodily fluids or humors, specifically blood,
mucus, yellow bile, and black bile, which he related to the four basic elements- air, water, fire,
and earth respectively. Doctors often bled patients as a curative procedure because of the belief
that the agent that causes sickness resides in blood. He believed that stroke resulted either from
an accumulation of a thick cold humor in the ventricles or from obstructions of the flow of
animal spirits.

The Middle Ages (500-1400)

During the Middle Ages, there was a return to superstitious beliefs regarding the causes of
many of the difficulties people exhibited. During the latter part of the Middle Ages, the works
of Aristotle were rediscovered and translated (between 1200 and 1225), and made available to
an expanded audience. The initial move away from the ventricular localization theory started
in the 13th century. Albertus Magnus (1206-1280) theorized that behavior resulted from a
combination of brain structures including the cortex, the midbrain, and the cerebellum.

Renaissance Europe (1400-1600)

In the late 15th century, Leonardo da Vinci (1452-1519) conducted several hundred human
dissections on cadavers in secret due to religious prohibition against autopsies. In 1543,
Andreas Vesalius (1514-156) published the first accurate book on human anatomy entitled On
the Workings of the Human Body. During the 17th century, scientists were looking for a single
site for the functioning of the mind. The philosopher Rene Descartes (1596-1630) believed in
dualism, i.e., the mind and body are completely separate. He speculated that the mental
processes resided within the pineal gland because it lies in the center of the brain; it is the only
structure not composed of two symmetric halves, and it is also close to the ventricular system.
18th century: Localization theory

Franz Joseph Gall (1758-1828) began to write about localization of function in 1810. He
stated that the brain consists of a number of separate organs, each responsible for a basic
psychological trait. He hypothesized that the size of a given brain area is related to the amount
of skill a person has in a certain field. By assigning specific functions to particular places in
the cerebral cortex, Gall formulated the basis of the localization theory of brain function. From
his basic theory of localization, the “science” of phrenology was born. This theory holds that
abilities were so localized that they would appear as protuberances on the skull. If a given brain
area is enlarged, then the corresponding area of the skull will also be enlarged. This theory led
to cross-cultural and gender-specific studies. For example, men have larger brain areas in the
social region, compared with women, whose brains reflect “inhabitiveness” and a lack of self-
esteem. They suggested that the skulls of white people were superior and the skulls from “less
advanced races” did not fare as well.

Paul Broca (1824-1880) is often given credit for the discovery of localization of language
within the left hemisphere. In 1861, he discovered that motor speech was located in the
posterior, inferior region of the left frontal lobe. Broca is also credited with articulating the
concept of aphasia, which means the inability to use or comprehend language. This region has
become known as Broca’s area and the deficit in language production as Broca’s aphasia.
Several years after Broca wrote, another researcher, Carl Wernicke (1848-1904) described a
second language area of the brain. This area was located in the superior, posterior region of the
temporal lobe which is related to understanding of speech. Damage here led to the inability to
make sense with language, a condition called Wernicke’s aphasia. In An Understanding of
Aphasia (1891), Sigmund Freud (1856-1938) criticized Broca’s and Wernicke’s work. He
believed that aphasia comes in different layers and that one aphasia could be related to many
different areas. He pointed out that Broca’s and Wernicke’s areas were nodal points and that
there was no need to figure out one area for one particular psychological function. Pierre
Flourens (1794-1867) supported his opinion through studying bird brains. He proclaimed there
was no specific localization of ability, but rather the amount or extent of tissue damage is what
mattered. In other words, the greater the mass of impaired tissue, the more dysfunctional the
individual will appear. He stated that all cerebral material is equipotential. Hughlings
Jackson (1835-1911) claimed that behavior exists on different levels in the nervous system
and gave his alternative model. Alexander Luria (1902-1977) gave his functional model
influenced by Jackson’s model and stated that each area in the central nervous system is
involved in three functions, labelled as units. Those three units are the brain stem and associated
areas; posterior area of the cortex; and the frontal and prefrontal lobes. The multifunctional role
of the brain is called pluripotentiality.

Marc Dax (1771-1837) was a French neurologist who discovered through clinical practice the
link between the damage to the left cerebral hemisphere and the loss of the ability to produce
speech. The discovery that language and motor abilities are lateralized to the left hemisphere
triggered a search for other lateralized functions. In effect, the discovery of language and motor
lateralization established lateralization of function as a major area of scientific research. In
1953, Sperry & Myers conducted a ground-breaking experiment on cats which was a spilt-
brain experiment. In their experiment, both the researchers trained cats to perform a simple
visual discrimination task. On each trial, each cat was confronted by two panels, one with a
circle on it and one with a square on it. In their key experimental group, Myers & Sperry
transected both the optic chiasm and the corpus callosum of each cat and put a patch on one
eye. In the first phase of the study, all cats learned the task with a patch on one eye. When the
patch was transferred to the other eye in the second phase, the performance of the experimental
cats dropped immediately to baseline. Myers & Sperry concluded that the cat brain has the
capacity to act as two separate brains. The current perspective says that besides corpus
callosum, there are other indirect pathways connecting both hemispheres.

The first neuropsychology laboratory in the United States was founded in 1935 by Ward
Halstead at the University of Chicago. Together with Ralph Reitan, Halstead later developed
the popular Halstead- Reitan Neuropsychological battery, an empirical approach to
assessing brain damage (Halstead, 1947; Reitan & Wolfson, 1993). Henry Hécaen (1912)
founded the journal Neuropsychologia. One of his discoveries was his demonstration of the
functional properties of the right hemisphere. Hécaen and his co-workers generated an
irrefutable mass of evidence that the right hemisphere played a crucial role in mediating
visuoperceptual and visuoconstructional processes. Much of Hécaen’s work was not translated
into English from French until the 1970s.

Oliver Zangwill (1913) founded Neuropsychology in Great Britain. Zangwill was also among
the first investigators to show that hemispheric specialization for speech in left-handers did not
conform to the then-accepted rule of right hemisphere dominance (Zangwill, 1960). He also
contributed significantly to understanding of the nature of neuropsychological deficits
associated with unilateral brain disease or injury. Norman Geschwind (1926-1984) is another
important neuropsychologist who helped to shape his profession’s focus and development.
Among his contributions was his proposal that behavioral disturbances are based on the
destruction of specific brain pathways that he called disconnections. He presented his idea in
his now classic article “Disconnexion Syndromes in Animals and Man” (1965), which was
largely responsible for reemphasizing the important role of neuroanatomy in neuropsychology.

Non-Western attitudes

Although Western ideologies predominantly shaped the behavioral sciences, non-Western

cultures also developed theories to explain behavior. In India, one of the earliest and most
important medical documents, the Atharva-Veda (700 B.C.), proposed that the soul is
nonmaterial and immortal. The ahamkara represents an aspect of the mind, which personalises
every experience and ascribes everything to oneself, thus, constituting cognitions and feelings
of ‘me’ and ‘mine’ (Jakubczak, 2013). Four sub-concepts of ahamkara based on Indian
tradition have been described: individuality (sense of uniqueness), agency (sense of doer-ship),
identification (relationship with worldly objects, involving associations and companionship,
attractions and attachment, and ownership), and separation (feeling of being different from
others).

Common to eastern Mediterranean and African culture was the belief that a god or gods sent
diseases. Egyptians viewed life as a balance between internal and external forces. They
conceptualized the brain as different from the mind. Arab countries demonstrated a humanist
attitude toward the mentally ill, partly because of the Muslim belief that God loves the insane
person. The treatment of mental patients was humanist and emphasized diets, baths, and even
musical concerts especially designed to soothe the patient. Chinese medical practitioners
endorsed a mechanistic view of mental processes.

BRAIN-BEHAVIOR RELATIONSHIP

The central topic in neuropsychology is how brain and behavior are related. In two closely
related aspects, the link between biology (brain) and psychology (behavior) is a ‘two-way
street’.
 Fig 3: Links between levels of (a) the phenomena of behavior and brain and (b) the
disciplines studying them

The brain controls behavior. In turn, behavior (e.g., social contact) influences events within the
brain. Also, there is the relationship between biologists of the brain (e.g., neuroscientists) and
psychologists. Psychologists need to look at the biological level to seek brain mechanisms that
explain mind and behaviour. However, researchers concerned with the brain can get insight
into its working by looking to psychology. Knowing what the brain is doing at a psychological
level can give vital insight into how it does it and the kind of brain structures involved. Thus,
there is a regular exchange of information between biology and psychology.

Two doctrines have emerged which shaped the field of neuropsychology. The first doctrine,
vitalism, suggests that many behaviors, such as thinking, are only partially controlled by
mechanical or logical forces- they are also partially self-determined and are separate from
chemical and physical determinants. Extreme proponents of vitalism argue that spirits or
psychic phenomena account for much observable behavior. The second doctrine, materialism,
suggests that logical forces determine brain-behavior function. Materialism favours a
mechanistic view of the brain. The idea is that rational behavior can be fully explained by the
workings of the nervous system. No need to refer to a nonmaterial mind.

Biological explanations of behavior fall into four categories: physiological, ontogenetic,

evolutionary, and functional (Tinbergen, 1951). A physiological explanation relates a
behavior to the activity of the brain and other organs. It deals with the machinery of the body-
for example, the chemical reactions that enable hormones to influence brain activity and the
routes by which brain activity controls muscle contractions. An ontogenetic explanation
describes how a structure or behavior develops, including the influences of genes, nutrition,
experiences, and their interactions. For example, the ability to inhibit impulses develops
gradually from infancy through the teenage years, reflecting gradual maturation of the frontal
parts of the brain. An evolutionary explanation reconstructs the evolutionary history of a
structure or behavior. An evolutionary explanation of human goose bumps is that the behavior
evolved in our remote ancestors and we inherited the mechanism. A functional explanation
describes why a structure or behavior evolved as it did. For example, many species have an
appearance that matches their background. A functional explanation is that camouflaged
appearance makes the animal inconspicuous to predators.

Talking about brain-behavior relationship, mentalism and dualism were the two classic
theories which debated upon the brain-behavior relationship. The Greek philosopher Aristotle
(384-322 BC) was the first person to develop a formal theory of behavior. He proposed that a
nonmaterial psyche is responsible for human thoughts, perceptions, and emotions and for such
processes as imagination, opinion, desire, pleasure, pain, memory and reason. The psyche is
independent of the body but in Aristotle’s view, works through the heart to produce action. The
philosophical position that a person’s mind is responsible for behavior is called mentalism,
meaning “of the mind”. Rene Descartes (1596-1650) proposed that the body is like the
machines. It is material and thus clearly has spatial extent, and it responds mechanically and
reflexively to events that impinge on it. Described as nonmaterial and without spatial extent,
the mind, as Descartes saw it, was different from the body. The body operated on principles
similar to those of a machine, but the mind decided what movements the machine should make.
He located the site of action of the mind in the pineal body. His choice was based on the logic
that the pineal body is the only structure in the nervous system not composed of two bilaterally
symmetrical halves and moreover that it is located close to the ventricles. Descartes’s position
that mind and body are separate but can interact is called dualism, to indicate that behavior is
caused by two things.

Different theories were proposed to describe brain-behavior relationship such as localization,

lateralization, and equipotentiality. Around 1800, Franz Gall (1757-1828) proposed that the
human mind was organized in different innate faculties, which were localized in different
organs or centers of the brain, making the cerebral localization of mental functions a central
issue in the relationships between brain and mind (Lesky, 1970). He developed his hypothesis,
called localization of function, that a different, specific brain area controls each kind of
behavior. Paul Broca discovered the location of motor speech (localization of language) in the
posterior, inferior region of the left frontal lobe which came to be known as Broca’s area and
the syndrome that results from its damage is called Broca’s aphasia. Carl Wernicke
discovered the location of understanding of speech in the superior, posterior region of temporal
lobe, called Wernicke’s area and its damage resulted in Wernicke’s aphasia. Pierre
Flourens proposed that the cerebral cortex, cerebellum, and brainstem functioned globally as
a whole, equipotential and in conjunction with every other part.

According to lateralization, the two halves of the human brain are not exactly alike. Each
hemisphere has functional specializations. The left and right sides of the brain are specialised
to attend to different information, to process sensory inputs in different ways and to control
different types of motor behavior. This is referred to as hemispheric specialization or brain
lateralization. Marc Dax (1771-1837) discovered through clinical practice that the left
hemisphere is responsible for language and hence it is dominant. In the 1950s, Roger Sperry &
Ronald Myers did a spilt-brain experiment on cats by damaging the corpus callosum and found
that if the corpus is damaged, the two hemispheres act differently and that the function of the
corpus is to transfer learned information from one hemisphere to the other. According to the
current perspective, a lot of factors determine how much the two hemispheres communicate.

UNDERSTANDING NERVOUS SYSTEM

Cells are the building blocks of all living organisms. Moving up the evolutionary ladder,
increased complexity of behavior corresponds with a more specialized nervous system, which
is essential for speeded communication. The nervous system is an organized group of cells,
called neurons, specialized for the conduction of electrochemical stimuli from sensory
receptors through a network to the site at which a response occurs. It is the network of nerve
cells and fibres which transmits nerve impulses between parts of the body.

Structure of the nervous system: Traditionally, the vertebrate nervous system is divided into
two major parts: the central nervous system (CNS) and the peripheral nervous system (PNS).
The central nervous system is located within the skull and spine and consists of the brain and
spinal cord. The peripheral nervous system is located outside the skull and spine and consists
of the nerves outside the brain and spinal cord.
 Fig 4: The human central nervous system and peripheral nervous system

CENTRAL NERVOUS SYSTEM

The central nervous system consists of brain and spinal cord. It is responsible for all forms of
cognition including perception, attention and memory in addition to reflexes, compilation of
somatosensory information and prompting motor movement. It is protected by three layers of
tissue, called meninges which consists of dura mater, arachnoid layer, and pia mater.

● BRAIN:

Fig 5: The human brain

The brain is the most important organ in the human body and the most complex
structure. It plays a role in regulating other organs and determines our ability to think,
move, use language, perceive the world, etc. The brain is protected by the skull,
cerebrospinal fluid (CSF) and the blood-brain barrier in addition to the meninges. It
 also contains ventricles which are filled with CSF. The brain consists of three distinct
parts: the brainstem, cerebrum, and cerebellum. The brain could be split along the
corpus callosum and divided into two cerebral hemispheres. The brain’s outer layer
is the cerebral cortex. The folds, or bumps, in the cortex are called gyri and the creases
between them are called sulci.
The brain can be divided into three main divisions which are the forebrain, the
midbrain, and the hindbrain. The forebrain includes the cortex, the basal ganglia,
and the limbic system. The midbrain is important for both sensory and motor functions.
The hindbrain includes the medulla, pons, and cerebellum. The medulla is responsible
for heartbeat, breathing, swallowing, etc. The pons plays a part in sleep, dreaming,
arousal, and left-right body coordination. The reticular formation is an area of neurons
responsible for general attention, alertness, and arousal. The cerebellum controls and
coordinates involuntary, rapid, fine motor movements. The limbic system is a group of
several brain structures located under the cortex and involved in learning, emotion,
memory, and motivation. It includes the thalamus, which relays sensory information;
hypothalamus, which regulates body temperature, thirst, hunger, sexual activity, etc;
hippocampus, responsible for the formation of long-term declarative memories;
amygdala, responsible for fear responses and memory of fear; and the cingulate
cortex, responsible for both emotional and cognitive processing.
The cortex of each hemisphere forms four lobes, each named after the skull bones
beneath which they lie. The frontal lobe is at the front of the brain responsible for
higher mental processes and functions. The temporal lobe, located along the side of
the brain, is responsible for the sense of hearing and meaningful speech. The occipital
lobe, located at the rear and bottom of each cerebral hemisphere, contains the primary
visual centers of the brain. The parietal lobe, located at the top and back of each
hemisphere, contains the centers for touch, temperature, and body position.

● SPINAL CORD
 Fig 6: The vertebrate spinal cord
The spinal cord is a tubular structure composed of nervous tissue that extends from the
brainstem and continuing distally before tapering at the lower thoracic/upper lumbar
region as the conus medullaris. The spinal cord is anchored distally by the filum
terminale, a fibrous extension of the pia mater anchoring the spinal cord to the coccyx.
Protecting the spinal cord is the surrounding cerebrospinal fluid, supportive soft tissue
membranes and meninges, and the osseous vertebral column. The length is about 45
cm in men and 43 cm in women. The spinal cord comprises 5 segments, viz. cervical,
thoracic, lumbar, sacral and coccygeal. There are in total 31 nerve root segments: 8
cervical segments, 12 thoracic segments, 5 lumbar segments, 5 sacral segments,
and 1 coccygeal segment. Cross-sectional view of the spinal cord shows its
organization into gray and white matter. The H-shaped gray matter in the center of the
cord is densely packed with cell bodies and dendrites. There are three categories of
nerve cells: afferent (sensory) neurons that carry messages from the senses to the
spinal cord, efferent (motor) neurons that carry messages from the spinal cord to the
muscles and glands, and interneurons that connect the afferent neurons to the efferent
neurons. This part of the spinal cord is also responsible for certain reflexes (an
involuntary response) and reflex arc. Many neurons of the spinal cord send axons from
the gray matter to the brain or other parts of the spinal cord through the white matter,
which consists mostly of myelinated neurons.

PERIPHERAL NERVOUS SYSTEM

The peripheral nervous system includes all of the cranial, spinal, motor, and sensory neurons,
organs and neurotransmitters located beyond the central nervous system. The PNS is
responsible for transmitting signals to the CNS from the body through the afferent neurons and
also receives feedback from the CNS via the efferent neurons. The PNS consists of autonomic
nervous system and somatic nervous system.

Autonomic nervous system: It is responsible for governing responses which are largely
beyond conscious control. It controls everything else in the body-organs, glands, and
involuntary muscles. It is divided into two systems, the sympathetic nervous system and the
parasympathetic nervous system.

Fig 7: Autonomic nervous system

● The sympathetic nervous system: It is primarily located on the middle of the spinal
column. It is usually called the “fight-or-flight system” because it allows people and
animals to deal with all kinds of stressful events. Emotions during these events might
be anger or fear or even extreme joy or excitement. The sympathetic division’s job is
to get the body ready to deal with stress. The pupils seem to get bigger; the heart starts
pumping faster and harder. The adrenal glands will be stimulated to release certain
stress-related chemicals into the bloodstream. Digestive functions decrease and it
inhibits bladder contraction. Saliva dries right up. It is also going to demand that the
body burn a tremendous amount of fuel, or blood sugar.
● The parasympathetic nervous system: It might be called the “eat-drink-and-rest”
system. The neurons of this division are located at the top and bottom of the spinal
column, on either side of the sympathetic division neurons. This system’s job is to
return the body to normal functioning after a stressful situation ends. It slows the heart
and breathing, constricts the pupils, and reactivates digestion and excretion. Signals to
the adrenal glands stop. In a sense, the parasympathetic system allows the body to
restore all the energy it burned. It is the parasympathetic division that is responsible for
 most of the ordinary, day-to-day bodily functioning such as regular heartbeat and
normal breathing and digestion. This system is typically active.

Somatic nervous system: It is also known as the voluntary nervous system. It is a division of
the peripheral nervous system which is responsible for monitoring and interacting with the
external world. It coordinates bodily movement and receives information concerning external
stimuli via the somatosensory system. It is made up of the sensory pathway, which comprises
all the nerves carrying the messages from the senses to the CNS, and the motor pathway,
which is all of the nerves carrying messages from the CNS to the voluntary, or skeletal, muscles
of the body. It consists of sensory system having afferent nerve fibres and motor system
having efferent nerve fibres. The somatic nervous system has two parts: spinal nerves and
cranial nerves. It controls the process of voluntary reflex arcs.

Cells of the nervous system: The nervous system consists of two kinds of cells: neurons and
glia. Of the two, neurons alone account for about 100 billion cells, and estimates suggest that
glial cells outnumber neurons by 10 to 1. The neuron is specialized for information processing.
To some degree all functions that sustain life, as well as those that make us human, are
coordinated and depend on the communication of neurons.

Fig 8: The components of a vertebrate neuron

● Structure of a neuron: Neurons contain the DNA of the individual, enveloped in a

nucleus. The region of neurons where the nucleus is found is known as the cell body
or the soma. Dendrites are the projections that conduct the electrochemical stimulation
received from other neural cells to the cell body of a neuron. Axons are the projections
that extend from the soma of the neuron to the terminal endings and transmit the neural
 signals. Many axons are covered with an insulating material called myelin sheath with
interruptions known as nodes of Ranvier. An axon has many branches, each of which
swells at its tip, forming a presynaptic terminal, also known as an end bulb or button.

● Glia: Glial cells are often described as “servants” to neurons. They help support
neurons by physically and chemically buffering them from each other, and they supply
nutrients and oxygen to neurons to support their very high metabolic rate. There are
several kinds of glial cells. Oligodendrocytes are the glial cells with extensions that
wrap around the axons of some neurons of the central nervous system. They are rich in
myelin and form myelin sheaths which increase the speed and efficiency of axonal
conduction. A similar function is performed in the peripheral nervous system by
Schwann cells, a second class of glia. Microglia respond to injury or disease by
multiplying, engulfing cellular debris and triggering inflammatory responses.
Astrocytes are the largest glial cells and allow the passage of some chemicals from the
blood into CNS neurons.

THE ENDOCRINE SYSTEM

Fig 9: Hormones: (a) location of some of the glands that secrete them and (b) kidney
showing adrenal gland and its divisions.
Source: adapted from Toates (1997a, Figure 3.1, p. 142).

The term ‘endocrine system’ describes the hormones, the cells and glands that secrete them
and the effects that hormones exert (Becker et al. 1992). Hormones are naturally occurring
chemicals which influence bodily functions, physical development, and emotions. There are
two types of glands: exocrine and endocrine glands. Exocrine glands (e.g., sweat glands)
release their chemicals into ducts, which carry them to their targets, mostly on the surface of
the body. Endocrine glands (ductless glands) release their chemicals, which are called
hormones, directly into the circulatory system. Once released by an endocrine gland, a hormone
travels via the circulatory system until it reaches the targets on which it normally exerts its
effect.

● Pituitary gland: It is located under the brain, just below the hypothalamus. It is
frequently referred to as the master gland because most of its hormones are tropic
hormones. Their function is to influence the release of hormones from other glands.
One of the hormones secreted by the pituitary gland is the growth hormone that
controls and regulates the increase in size as children grow from infancy to adulthood.
Gonadotropin is a pituitary tropic hormone that travels through the circulatory system
to the gonads, where it stimulates the release of gonadal hormones. The hormone that
controls aspects of pregnancy is called oxytocin and is responsible for contractions of
the uterus in childbirth. The hormone that controls the levels of water in our body is
called vasopressin.
● Pineal gland: It is located in the brain, near the neck, directly above the brain stem. It
secretes a hormone called melatonin, which helps track day length and regulates the
sleep-wake cycle.
● The thyroid gland: It is located inside the neck and secretes hormones that regulate
growth and metabolism. One of these, a hormone called thyroxin, regulates
metabolism.
● Pancreas: It controls the level of blood sugar in the body by secreting insulin and
glucagon. If the pancreas secretes too little insulin, it results in diabetes. If it secretes
too much insulin, it results in hypoglycaemia, or low blood sugar.
● The gonads: They are the sex glands, including the ovaries in the females and the testes
in the males. They release androgens, oestrogens, and progestins. All these regulate
sexual behavior and reproduction.
● The adrenal glands: They are on top of each kidney. Each adrenal gland is divided
into two sections, the adrenal medulla and the adrenal cortex. It is the adrenal medulla
that releases epinephrine and norepinephrine when people are in stress and aids in
sympathetic arousal. The adrenal cortex produces more than 30 different hormones
 called corticoids that regulate salt intake, help initiate and control stress reactions, and
also provide a source of sex hormones. One of the most important of these adrenal
hormones is cortisol, released when the body experiences stress, both physical and
psychological.

LOCALIZATION, EQUIPOTENTIALITY, AND LATERALIZATION

Localization: The first general theory to propose that different parts of the brain have different
functions was developed in the early 1800s by German anatomist Franz Joseph Gall (1758-
1828). He postulated the most seriously proposed, although ultimately ridiculed and
disregarded, theory of localization in the nineteenth century which stated that the brain
comprised a number of separate organs, each of which controlled a separate inner faculty and
each of which created indentations in the skull. He hypothesized that the size of a given brain
area is related to the amount of skill a person has in a certain field. From Gall’s basic theory of
localization, the “science” of phrenology was born. This theory holds that if a given brain area
is enlarged, then the corresponding area of the skull will also be enlarged. Development of
these organs led to prominences or ‘bumps’ in the individual’s skull. A bump on the skull
indicated a well-developed underlying cortical gyrus and therefore a greater faculty for a
particular behavior. Conversely, a skull depression was a sign of an undeveloped gyrus and,
therefore, a lack of function.

Gall’s work, however, was severely limited by faculty psychology which held that such
abilities as reading, writing, or intelligence were independent, invisible faculties. He also
lacked statistical or methodologic theory that would have let him reliably measure the basic
skills of interest to him. His critics accused him of having made the most absurd theories about
the faculties of human understanding. Men, he suggested, have larger brain areas in the social
region, with a predominance of pride, energy, and self-reliance, compared with women, whose
brains reflect “inhabitiveness” and a lack of firmness and self-esteem. There were cross-
cultural studies too which suggested that the skulls of races and nations differ widely in form.
Erroneously, phrenologists suggested that the skulls of white people were superior, indicating
great intellectual power and strong moral sentiment. The skulls from “less advanced races” did
not fare as well, because those virtues were thought to be almost invariably small in “savage”
and “barbarous tribes” (Wells, 1869).

The French surgeon Pierre- Paul Broca, in 1861, reported a patient, named Leborgne, who
suffered from a right-sided motor deficit, and who could articulate only a single syllable that
he typically repeated twice, “tan, tan”, to any question that was asked to him. Based on this, he
discovered that motor speech was specifically located in the posterior, inferior region of the
left frontal lobe. He argued that language ability was not a property of the entire brain but rather
was localized in a restricted brain region. Because speech is thought central to human
consciousness, the left hemisphere is frequently referred to as the dominant hemisphere to
recognize its special role in language (Joynt, 1964). Broca’s landmark contribution was in
understanding the origins of aphasia. In recognition of Broca’s contribution, this speech region
of the brain is called Broca’s area, and the syndrome that results from its damage is called
Broca’s aphasia. The other singularly important discovery of the period was made by the
German neurologist Carl Wernicke (1848-1904). He had also reported an aphasic deficit, but
this time patients were unable to comprehend speech. This type of aphasia was associated with
left hemisphere damage in a location below that of Broca’s area (specifically, superior,
posterior region of temporal lobe). This condition came to be known as Wernicke’s aphasia
in the Wernicke’s area.

Sigmund Freud (1856-1938) made significant discoveries in the area of brain-behavior

relationships. In one of his influential works, An Understanding of Aphasia (1891), he
criticized the works of Broca and Wernicke. At the time of Freud’s publication, many
neurologists confronted the task of explaining the many partial and mixed varieties of aphasias.
Freud suggested that various aphasias could be explained by subcortical lesions in less
localized association pathways. He pointed out that the Broca and Wernicke centers are nodal
points and that multiple areas are responsible for such functions.

Equipotentiality: One of phrenology’s fiercest critics was Marie-Jean-Pierre Flourens, a

French neurologist who argued that no functional localization occurred in the cerebrum. In a
series of experiments to determine the effects of removal of certain parts of the bird brain on
function, he found that it was not the site of the removal that was important but the quantity of
tissue removed. Sensory input at an elementary level is localized, but the process of perception
involves the whole brain. In other words, he argued that cerebral matter was equipotential: any
part of the brain could perform another’s function. Thus, the size of the injury, rather than its
location, determines the effects of brain injury. This was also known as the aggregate field
view of the brain. He noted this in birds and animals where recovery was possible following
ablation (removal of parts of the brain). This notion of equipotentiality was a strong and
popular one at that time.
Flourens, however, was criticized on a number of points. He used animals with brains so small
that any ablation would invade more than one functional area. He observed only motor
behavior, i.e., behaviors such as eating or wing flapping, whereas the localizationists were
mostly interested in more complex faculties such as intellect or friendship. He also erroneously
suggested that humans use only 10% of the brain, an idea that laypeople still commonly hold
today.

Different versions of equipotentiality were proposed by various researchers. Karl Lashley

(1890-1958) believed in a combination of localization and equipotentiality, or the belief that
higher cortical functions are too complex to be confined to any single area of the brain. He also
proposed the principle of mass action, which states that the extent of brain impairment is
directly proportional to the amount of tissue damage. He talked about the multipotentiality of
brain which means that each part of the brain was responsible for more than the one function.
Lashley felt more allegiance to the equipotentialists than the localizationalists. Hughlings
Jackson (1835-1911) wrote in the 1800s but was not published until the 1950s. He disagreed
with Broca, Wernicke, and others and believed in holistic brain functioning. He observed that
higher mental functions are not unitary abilities, but consist of simpler and more basic skills.
These skills are relatively localized, but because of the potential variety of complex ways in
which the skills are linked to form intelligent functions, the higher-level behavior does not
appear to be localized. He saw the brain as functioning in a hierarchical manner. Each level
higher would control more complex functioning. The three levels he often described were the
spinal cord, the brain stem, and the forebrain. The loss of a specific area of the brain causes the
loss or impairment of all higher skills dependent on that one area. Alexander Luria (1902-
1977) described each area of the central nervous system as being involved in one or more brain
functions. The first unit, defined as brainstem and associated areas, regulated the arousal level
of the brain and proper muscle tone. The second unit, defined as posterior areas of the cortex,
played a role in the reception, integration, and analysis of sensory information. The third unit,
frontal and prefrontal lobes, was involved with planning, executing, and verifying behavior
(Luria, 1966). All behavior reflects the brain operating as a whole. As with the equipotentiality
theory, Luria regards behavior as the result of interaction among many areas of the brain. As
with the localization theory, he assigns a specific role to each area of the brain. The
multifunctional role of the brain is called pluripotentiality; any given area of the brain can be
involved in relatively few or many behaviors.
Lateralization: In general terms lateralization refers to placing to one side any structure or
function in a living organism. The term is usually applied to brain functions mediated
asymmetrically by either the left or right cerebral hemisphere, and is closely aligned to the
terms cerebral dominance and hemispheric specialization. Early in the 19th century, a number
of papers were published that began to link complex psychological functions to specific areas
of the brain. Marc Dax (1771-1837) was a French neurologist who discovered through clinical
practice the link between the damage to the left cerebral hemisphere and the loss of the ability
to produce speech. Dax wrote two papers in 1836 and died the following year without
publishing his findings. The discovery that language and motor abilities are lateralized to the
left hemisphere triggered a search for other lateralized functions. In effect, the discovery of
language and motor lateralization established lateralization of function as a major area of
scientific research.

In 1953, Sperry & Myers conducted a split-brain experiment on cats. In their experiment, both
the researchers trained cats to perform a simple visual discrimination task. On each trial, each
cat was confronted by two panels, one with a circle on it and one with a square on it. In the first
phase of the study, all cats learned the task with a patch on one eye. When the patch was
transferred, the performance of the experimental cats dropped immediately to baseline; and
then the cats relearned the task with no savings whatsoever, as if they had never seen it before.
Myers & Sperry concluded that the cat brain has the capacity to act as two separate brains and
that the function of the corpus callosum is to transmit information between them.

The corpus callosum is not the only medium for that. There can be indirect pathways which
connect both the hemispheres. For example, feelings of emotion appear to be readily passed
between the hemispheres of most split-brain patients. Another factor that has been shown to
contribute substantially to the hemispheric independence of split-brain patients is task
difficulty (Weissman & Banich, 2000). As tasks become more difficult, they are more likely
to involve both hemispheres of split-brain patients. The two hemispheres can also communicate
with each other by an external route, by a process called cross-cuing. Currently, the left
cerebral hemisphere, assuming right-handedness, is specialized for language and symbolic
processing. The right hemisphere is specialized for the perception and organization of visual-
spatial stimuli, certain perceptual-motor skills, and emotional functioning.

BRAIN PLASTICITY
Neural plasticity, also known as neuroplasticity or brain plasticity, can be defined as the ability
of the nervous system to change its activity in response to intrinsic or extrinsic stimuli by
reorganizing its structure, functions, or connections. A fundamental property of neurons is their
ability to modify the strength and efficacy of synaptic transmission through a diverse number
of activity-dependent mechanisms, typically referred to as synaptic plasticity. The development
of the brain and behavior is guided not only by a basic genetic blueprint but also by a wide
range of experiences that shape the emerging brain. Brains exposed to different environmental
events such as sensory stimuli, stress, injury, diet, drugs, and social relationships show a unique
developmental trajectory. Although the brain was once seen as a rather static organ, it is now
clear that the organization of brain circuitry is constantly changing as a function of experience.
These changes are referred to as brain plasticity, and they are associated with functional
changes that include phenomena such as memory, addiction, and recovery of function.

The term “neuroplasticity” was first used by Polish neuroscientist Jerzy Konorski in 1948 to
describe observed changes in neuronal structure, although it was not widely used until the
1970s. However, the idea goes back even farther (Demarin, Morović, & Béne, 2014) - the
“father of neuroscience”, Santiago Ramόn y Cajal, talked about “neuronal plasticity” in the
early 1900s (Fuchs & Flügge, 2014). In the 1960s, it was discovered that neurons could
“reorganize” after a traumatic event. Further research found that stress can change not only the
functions but also the structure of the brain itself (Fuchs & Flügge, 2014).

Broadly speaking, there are two main types of neuroplasticity. Functional plasticity involves
changes in some physiological aspect of nerve cell function, such as the frequency of nervous
impulses or the probability of release of a chemical signal- both of which act to make synaptic
connections stronger or weaker- or changes to the degree of synchronicity among populations
of cells. Structural plasticity includes volumetric changes in discrete brain regions and the
formation of new neural pathways, brought about either by the formation of new nerve fiber
branches and synapses or by the growth and addition of new cells.

Changes in the brain can occur due to a variety of stimuli. Kolb et al. (2003) state that there are
three main types of plasticity that shape the developing brain:

● Experience-independent plasticity: It is pretty much everything that happens with the

brain during the prenatal developmental phase. Neuronal connections and brain
formation are processes driven by complex genetic instructions. There is so much going
on at this stage of brain development: neurons that fire together make some structures
 stronger and parts of the brain more prominent than others, whereas those that do not
sync very well together die out.
● Experience-expectant plasticity: It is independent of external factors and helps the
neurons connect to each other independent of other processes. An example is the
formation of the retinal ganglion.
● Experience-dependent plasticity: It can be seen throughout the lives. Brain changes
when different situations occur: moving to new territory, learning problems or suffering
from injury.

Factors affecting brain plasticity: Factors that are now known to affect neuronal structure
and behavior include the following: experience (both leading pre- and post-natal); psychoactive
drugs (e.g., amphetamine, morphine); gonadal hormones (e.g., estrogen, testosterone); anti-
inflammatory agents; growth factors; dietary factors (e.g. vitamin and mineral supplements);
genetic factors; disease (e.g. Parkinson’s disease, schizophrenia, epilepsy, stroke); stress; brain
injury and leading disease.

There are two main perspectives on neuroplasticity:

1. Neuroplasticity is one fundamental process that describes any change in final neural
activity or behavioral response, or;
2. Neuroplasticity is an umbrella term for a vast collection of different brain change and
adaptation phenomena.

Research and studies on neuroplasticity:

1. Enriched environments (saturated with novelty, focused attention, and challenge) are
critical for promoting neuroplasticity, and can provoke growth and positive adaptation
long after the “critical learning period” of early childhood and young adulthood is over
(Kempermann et al. 2002; Vemuri et al. 2014).
2. “Newborn” neurons at 8 weeks old and older neurons are generally at the same level of
maturation (Deshpande et al. 2013).
3. As few as ten 1-hour sessions of cognitive training over 5 or 6 weeks have the potential
to reverse the same amount of age-related decline that has been observed in the same
time period (Ball et al. 2002).
4. Physical activity and good physical fitness can prevent or slow the normal age-related
neuronal death and damage to the hippocampus, and even increase the volume of the
hippocampus (Niemann et al.2014).
 5. Intermittent fasting can promote adaptive responses in synapses (Vasconcelos et al.
2014).
6. Chronic insomnia is associated with atrophy (neuronal death and damage) in the
hippocampus, while adequate sleep may enhance neurogenesis (Joo et al. 2014).

RESEARCH METHODS USED IN NEUROPSYCHOLOGY

There are variety of research methods which are widely used in the field of neuropsychology.
Some require human subjects and some other methods have non-human participants. Research
conducted on human participants is easy and the results are applicable to the population. These
participants are good in following instructions, and they report their experiences in a subjective
manner which is helpful in conducting research and finding results. As far as non-human
participants are concerned, there are less restrictions for using them as subject and it is easy to
get permission for doing any research on animals. Their brain structure is simpler than those
of humans which makes it easier to understand phenomenon.

Neuropsychological research can be either pure or applied. Pure research is motivated primarily
by the curiosity of the researcher- it is done solely for the purpose of acquiring knowledge. In
contrast, applied research is intended to bring about some direct benefit to humankind.

Biopsychological research involves both experiments and non-experimental studies. Two

common types of non-experimental studies are quasiexperimental studies and case studies. The
experiment is the method used by scientists to study causation. The experimenter assigns the
subjects to conditions, administers the treatments, and measures the outcome in such a way that
there is only one relevant difference between the conditions being compared. It is not possible
for neuropsychologists to bring the experimental method to bear on all problems of interest to
them. In such prohibitive situations, neuropsychologists sometimes conduct quasiexperimental
studies- studies of groups of subjects who have been exposed to the conditions of interest in
the real world. Studies that focus on a single case are called case studies. They often provide a
more in-depth picture than that provided by an experiment or a quasiexperimental study.
However, their generalizability is a major problem.

There are other methods used by neuropsychologists. These are:

● Computed Tomography: Computed tomography (CT) is a computer-assisted x-ray

procedure that can be used to visualize the brain and other internal structures of the
living body.
 ● Positron emission tomography: Positron emission tomography (PET) was the first
brain-imaging technique to provide images of brain activity (functional brain images)
rather than images of brain structure (structural brain images). In one common version,
radioactive fluorodeoxyglucose (FDG) is injected into the patient’s carotid artery.
● Magnetic resonance imaging: Magnetic resonance imaging (MRI) is a structural
brain-imaging procedure in which high-resolution images are constructed from the
measurement of radio-frequency waves that hydrogen atoms emit as they align with a
powerful magnetic field. It provides clearer images of the brain than does CT. It can
produce images in three dimensions.
● Functional MRI (fMRI): It produces images representing the increase in oxygen flow
in the blood to active areas of the brain. Nothing is injected into the volunteer; it
provides both structural and functional information in the same image; its spatial
resolution is better; and it can be used to produce three-dimensional images of activity
over the entire brain.
● Psychophysiological measures: They include electroencephalography (electrical
activity of the brain), electromyography (measures muscle tension), electrooculography
(records eye movements), electrocardiogram (records heartbeats), to name a few.
● Neuropsychological tests: For intelligence, Wechsler Adult Intelligence Scale (WAIS)
is common. For language lateralization, two tests are common: sodium amytal test
(Wada, 1949), and dichotic listening test (Kimura, 1973). For memory, repetition
priming tests are common. Lastly, for frontal lobe function, Wisconsin card sorting test
is commonly used.

CONCLUSION

Neuropsychology is a vast field of study and is of great importance in today’s times. It is one
of the most significant branches of neuroscience and has a rich history. It explores the
fundamental relationship between brain function and behavior. Understanding the overall
nervous system is crucial to understanding the field of neuropsychology. The three theories of
localization, equipotentiality, and lateralization have gained immense importance.
Neuropsychology has a huge role to play in explaining and understanding brain plasticity.
Neuropsychologists use various research methods to study various phenomena in the field.

REFERENCES
Ackerman, C.E. (February 05, 2021). What is neuroplasticity? Retrieved from
https://positivepsychology.com/neuroplasticity/

Beaumont, J.G. (2008). Introduction to neuropsychology. (2nd ed). Guilford Press.

Freberg, L.A. (2019). Discovering behavioral neuroscience: an introduction to biological

psychology. (4th ed). Wadsworth.

Kalat, J.W. (2009). Biological psychology. (10th ed). Wadsworth.

Kolb, B. & Whishaw, I.Q. (2015). Fundamentals of human neuropsychology. (7th ed). Worth
Publishers.

Pinel, J.P. & Barnes, S.J. (2018). Biopsychology. (10th ed). Pearson.

Toates, F. (2011). Biological psychology. (3rd ed). Pearson.

Zillmer, E.A., Spiers, M.V. & Culbertson, W.C. (2008). Principles of neuropsychology. (2nd
ed). Wadsworth.
 PRACTICAL-I

Neuropsychology

Submitted to

Department of Applied Psychology

Shyama Prasad Mukherji College for Women

University of Delhi

Submitted by

Aditi Bhatia

19/0292

19075505003

2021
Clinical Case Study
 CLINICAL CASE STUDY

Aim: To diagnose and formulate the treatment plan for the given clinical case through case
analysis

Basic Concepts:

INTRODUCTION TO BRAIN

Fig: The anatomy of the human brain

The brain is the most important organ in the human body and the most complex structure. It
plays a role in regulating other organs and determines our ability to think, move, use language,
perceive the world, etc. The brain is protected by the skull, cerebrospinal fluid (CSF) and the
blood-brain barrier in addition to the meninges. It also contains ventricles which are filled with
CSF. The brain consists of three distinct parts: the brainstem, cerebrum, and cerebellum. The
brain could be split along the corpus callosum and divided into two cerebral hemispheres.
The brain’s outer layer is the cerebral cortex. The folds, or bumps, in the cortex are called gyri
and the creases between them are called sulci.

The brain can be divided into three main divisions which are the forebrain, the midbrain, and
the hindbrain. The forebrain includes the cortex, the basal ganglia, and the limbic system.
The midbrain is important for both sensory and motor functions. The hindbrain includes the
medulla, pons, and cerebellum. The medulla is responsible for heartbeat, breathing,
swallowing, etc. The pons plays a part in sleep, dreaming, arousal, and left-right body
coordination. The reticular formation is an area of neurons responsible for general attention,
alertness, and arousal. The cerebellum controls and coordinates involuntary, rapid, fine motor
movements. The limbic system is a group of several brain structures located under the cortex
and involved in learning, emotion, memory, and motivation. It includes the thalamus, which
relays sensory information; hypothalamus, which regulates body temperature, thirst, hunger,
sexual activity, etc.; hippocampus, responsible for the formation of long-term declarative
memories; amygdala, responsible for fear responses and memory of fear; and the cingulate
cortex, responsible for both emotional and cognitive processing.

The cortex of each hemisphere forms four lobes, each named after the skull bones beneath
which they lie. The frontal lobe is at the front of the brain responsible for higher mental
processes and functions. The temporal lobe, located along the side of the brain, is responsible
for the sense of hearing and meaningful speech. The occipital lobe, located at the rear and
bottom of each cerebral hemisphere, contains the primary visual centres of the brain. The
parietal lobe, located at the top and back of each hemisphere, contains the centres for touch,
temperature, and body position.

The brain is the most complex part of the human body and it sets humans apart from all other
species. It has led people to great achievements, such as travelling in space and being able to
create and use highly technical electronic devices such as smartphones and computers. The
brain assists us in composing music, achieving athletic feats, and developing medications for
deadly diseases, among other accomplishments. The brain even allows us to have insight into
understanding our own brain and dysfunctions that occur. It is the seat of intelligence,
interpreter of the senses, initiator of body movement, and controller of behaviour. It controls
thought, memory, emotion, touch, motor skills, vision, breathing, temperature, hunger, and
every process that regulates our body. In other words, the brain controls all bodily activity,
including heart rate, learning, motor functioning, and sexual behaviours. It plays a role in
influencing the immune system, controlling our sleep, and developing our personality.
Essentially, the brain is what makes us human.

Although the brain was once seen as a rather static organ, it is now clear that the organization
of brain circuitry is constantly changing as a function of experience. These changes are referred
to as brain plasticity, and they are associated with functional changes that include phenomena
such as memory, addiction, and recovery of function. Recent research has shown that brain
plasticity and behaviour can be influenced by a myriad of factors, including both pre- and
postnatal experience, drugs, hormones, maturation, aging, diet, disease, and stress. Throughout
life, humans encounter and act on changing environmental stimuli that require them to learn
and adapt. The term ‘neuroplasticity’ describes the capacity of the brain to change in response
to these environmental experiences. Neuroplasticity allows humans to adapt to changing
circumstances by reconfiguring brain structure and function to accomplish new patterns of
thought and behaviour. Understanding how these factors influence brain organization and
function is important not only for understanding both normal and abnormal behaviour, but also
for designing treatments for behavioural and psychological disorders ranging from addiction
to stroke. During childhood, the brain undergoes three types of plasticity: experience-
independent, experience-expectant, and experience-dependent (Kolb & Gibb, 2014).
Experience-independent plasticity involves brain changes that take place regardless of the
environment and unfold over time through a tightly regulated series of molecular events.
Experience-expectant changes, by contrast, do not unfold until they are triggered by specific
environmental cues that the brain expects to encounter. Experience-dependent brain plasticity
refers to ways neural pathways are strengthened through repeated engagement, via multiple
cellular mechanisms, so that they become more efficient over time.

CAUSES OF BRAIN DAMAGE

There are basically six main causes of brain damage. These include brain tumours, strokes,
closed-head injuries, brain infections, neurotoxins, and genetic factors.

● Brain tumors: The term tumor refers to a morbid enlargement or new growth of tissue
in which cell multiplication is uncontrolled and progressive. It is also called neoplasm
which means “new tissue”. Brain tumors make up approximately 5% of all cancers and
appear in approximately 2% of all autopsies. They can occur at any age, but are most
common in early and middle adulthood (Golden, Zillmer, & Spiers, 1992). Brain
tumors are atypical and involve uncontrolled growth of cells. Tumors grow at the
expense of healthy cells. About 20% of tumors found in the brain are meningiomas-
tumors that grow between the meninges. Brain tumors can be conceptualized according
to two principal forms: infiltrative tumors (they take over neighbouring areas of the
brain and destroy its tissue), and non-infiltrative tumors (they are encapsulated and
differentiated but cause dysfunction by compressing surrounding brain tissue).
 Tumors can also be classified according to two additional descriptors: malignant
(indicates that the properties of the tumor cells invade other tissue and are likely to
regrow or spread), and benign (describes cell growth that is usually surrounded by a
fibrous capsule, is typically non-invasive, and will not spread). Malignant tumors may
also travel to other organs in the body through the bloodstream. This form of spreading
is called metastasis. Metastatic brain tumors typically originate from primary sites
other than the brain, most frequently the lung or the breast.
● Strokes: Strokes are sudden-onset cardiovascular disorders that cause brain damage.
The brain’s blood vessels are damaged, which can decrease blood flow within and to
the brain. In simple terms, stroke “suffocates” brain tissue and often produces an area
of dead or dying brain tissue. This area is called infarct. Surrounding the infarct is a
dysfunctional area called the penumbra. The tissue in the penumbra may recover or die
in the ensuing days, depending on a variety of factors. The primary goal of treatment
following stroke is to save the penumbra. There are two major types of strokes:

○ Cerebral haemorrhage: Cerebral haemorrhage (bleeding in the brain) occurs

when a cerebral blood vessel ruptures and blood seeps into the surrounding
neural tissue and damages it. Bursting aneurysms are a common cause of
intracerebral haemorrhage. An aneurysm is a pathological balloon like dilation
that forms in the wall of an artery at a point where the elasticity of the artery
wall is defective. They can be congenital or can result from exposure to vascular
poisons or infection.

○ Cerebral Ischemia: Cerebral ischemia is a disruption of the blood supply to an

area of the brain. The three main causes of cerebral ischemia are thrombosis,
embolism, and arteriosclerosis. Thrombosis is the formation of a blood clot or
thrombus within the blood vessel. It blocks blood flow at the site of its
formation. Embolism refers to a blood clot that has travelled from one part of
the body to another. In arteriosclerosis, the walls of blood vessels thicken and
the channels narrow, usually as the result of fat deposits; this narrowing can
eventually lead to complete blockage of the blood vessels.

● Closed-head injuries: Brain injuries produced by blows that do not penetrate the skull
are called closed-head injuries. Contusions are closed-head injuries that involve
damage to the cerebral circulatory system. Such damage produces internal bleeding.
 Contusions occur when the brain slams against the inside of the skull. When there is a
disturbance of consciousness following a blow to the head and there is no evidence of
a contusion or other structural damage, the diagnosis is concussion. The effects of
concussion can last many years and that the effects of repeated concussions can
accumulate. Chronic traumatic encephalopathy (CTE) is the dementia and cerebral
scarring observed in boxers, rugby players, and other individuals who have experienced
repeated concussive, or even sub concussive, blows to the head. For example, one study
found that 34 of 35 former American football players met the diagnostic criteria for
chronic traumatic encephalopathy (Riley et al, 2015).
● Infections of the brain: An invasion of the brain by microorganisms is a brain
infection, and the resulting inflammation is called encephalitis. There are two common
types of brain infections: bacterial infections and viral infections.
o Bacterial infections: When bacteria infect the brain, they lead to the formation
of pockets of pus in the brain. Bacteria are also the major cause of meningitis
(Castelblanco, Lee, & Hasbun, 2014). Syphilis is one bacterial infection (Berger
& Dean, 2014). Syphilis bacteria are passed from infected to uninfected people
through contact with genital sores. The syndrome of mental illness and dementia
that results from a syphilitic infection is called general paresis.
o Viral infections: There are two types of viral infections of the nervous system:
those that have a particular affinity for neural tissue and those that attack neural
tissue but have no greater affinity for it than for other tissues. Rabies is an
example of a virus that has a particular affinity for the nervous system. The
mumps and herpes viruses are common examples of viruses that can attack the
nervous system but have no special affinity for it. Although these viruses
sometimes spread into the brain, they typically attack other tissues of the body.
● Neurotoxins: Neurotoxins include any substances that are poisonous to the brain
(Lezak, 1995). These may include drugs, solvents, alcohol, fuels, pesticides, and metals
such as lead or mercury. Many substances can be toxic to the brain in high doses,
whereas they may not be toxic in low doses. Many heavy metals, such as lead or
mercury, can be extremely damaging to the body and the CNS, even in low dosages
(Zillmer, Lucci, Barth, Peake, & Spyker, 1986). The general population may be
exposed to some toxins routinely or by accident. For example, more than half a million
accidental poisonings from pesticides are reported each year worldwide. Most common
effects are cognitive deficits ranging from mild to severe on tasks that require speeded
 processing, problem solving, and delayed memory. Somatization, hysterical features,
and depression often dominate the clinical picture. Thus, chemicals can have significant
neuropsychological effects (Hartman, 1995).
● Genetic factors: Some neuropsychological diseases of genetic origin are caused by
abnormal recessive genes that are passed from parent to offspring. Inherited
neuropsychological disorders are rarely associated with dominant genes because
dominant genes that disturb neuropsychological function tend to be eliminated from the
gene pool. Genetic accident is another major cause of neuropsychological disorders of
genetic origin. Down syndrome is such a disorder. The genetic accident associated with
Down syndrome occurs in the mother during ovulation, when an extra chromosome 21
is created in the egg. The consequences tend to be characteristic disfigurement,
intellectual impairment, and troublesome medical complications.

NEUROLOGICAL DISORDERS

Neurological disorders affect the entire nervous system. These include dyslexia, cerebral palsy,
Alzheimer’s disease, and Parkinson’s disease.

Problems in children

● Dyslexia: Dyslexia is typically characterized by ‘an unusual balance of skills’. It is a

syndrome: a collection of associated characteristics that vary in degree and from person
to person. The syndrome of dyslexia is now widely recognized as being a specific
learning disability of neurological origin that does not imply low intelligence or poor
educational potential, and which is independent of race and social background.
Dyslexia refers to a cluster of symptoms which result in people having difficulties with
specific language skills, particularly reading. Students with dyslexia usually experience
difficulties with other language skills, such as spelling, writing, and pronouncing
words. The exact causes of dyslexia are still not completely clear, but anatomical and
brain imagery studies show differences in the way the brain of a person with dyslexia
develops and functions. General problems experienced by people with dyslexia include
difficulty in learning to speak, learning letters and their sounds, organizing written and
spoken language, memorizing number facts, learning a foreign language, correctly
doing math operations, etc. A comprehensive evaluation typically includes intellectual
and academic achievement testing, as well as an assessment of the critical underlying
language skills that are closely linked to dyslexia. These include receptive and
 expressive language skills, phonological skills, and also a student’s ability to rapidly
name letters and names. An individualized intervention plan should be developed which
should include appropriate accommodations, such as extended time.
● Cerebral palsy: Cerebral palsy describes a group of permanent disorders of the
development of movement and posture; causing activity limitation, that are attributed
to non-progressive disturbances that occurred in the developing foetal or infant brain.
The motor disorders of cerebral palsy are often accompanied by disturbances of
sensation, perception, cognition, communication and behaviour, by epilepsy and by
secondary musculoskeletal problems (Rosenbaum, 2007; Brooks, 2014). It is the most
common motor disability of childhood. In approximately 90% of cases, cerebral palsy
results from destructive processes that injure healthy brain tissue rather than
abnormalities in brain development. Encephalitis, meningitis, and traumatic brain
injury may also cause cerebral palsy in early childhood. Maternal and infant infections
are also associated with increased risk for CP. Neurocognitive deficits seem to progress
as high-risk children mature. Many children with CP have concomitant learning
disabilities, cognitive retardation, and attention-deficit disorders (Blondis et al. 1993).
Localization of brain damage also has an impact on the type of learning difficulties
experienced by children with CP. Many children with CP receive comprehensive
services in educational settings, including physical and occupational therapy, language
and communication therapy, and academic instruction (Thorogood & Alexander,
2007). Synthesized and augmented speech devices, specially designed computers and
other electronic devices are commonly used.

Problems in adults

● Alzheimer’s disease: Alzheimer’s disease is one of a number of degenerative

conditions associated with aging that results in dementia. Patients with this disease
account for 60 to 90 percent of all patients with dementia (APA, 2013). It is the most
devastating and prevalent of the dementias, representing the eighth leading cause of
death overall for people older than 65 (Hoyert & Rosenberg, 1997). AD is linked to
increased age, which has led some to speculate that it is a disease of “accelerated aging”.
AD does not have a clearly identified genetic component in most cases. A definitive
diagnosis of AD requires the behavioural presence of dementia and the identification
of neuropathologic markers of AD. No single medical test, imaging procedure, or
behavioural test can positively identify AD. AD is difficult to diagnose because there
 are other dementias that may have similar symptoms, especially in the later stages of
the disease. AD tends to be overdiagnosed, meaning that other progressive dementias
may be misdiagnosed as AD (Lopez et al. 1999). The clinical presentation of patients
with AD can vary, but many share characteristic patterns. The most consistent deficits
across patients are memory and fluent anomic aphasia. Visuospatial difficulties are also
characteristic. Some frontal areas of the brain appear relatively spared. The impairments
progress over time, gradually affecting all higher mental functions of the brain. Memory
dysfunction is the hallmark of AD. Many patients appear to lose metacognitive
awareness, or the inability to self-monitor their own behaviour and performance. There
are treatments for cognitive enhancement and cognitive, behavioural, and psychiatric
symptom control.
● Parkinson’s disease: Parkinson’s disease is a slowly progressive disease that, like
Alzheimer’s disease, largely affects older adults. PD is marked by a degeneration of
dopaminergic cells and pigmentation in the substantia nigra. It is also characterized by
Lewy bodies, which are small, tightly packed granular structures with
neurodegeneration. The motor symptoms of PD generally fall into groups of positive
and negative symptoms. Positive symptoms indicate a diminution or loss of motor
functioning. Negative symptoms include slowness of movement, reduced motor
initiation, gait disturbance, slowed speech, decreased voice amplitude, etc. Patients
with PD perform poorly on spatial tasks that have a motor component. Many patients
have executive functioning difficulties. The treatment for PD appears to be traveling
full circle from surgery to drugs to surgery. In addition, gene therapies, tissue implants,
and various approaches to prevention are on the horizon.

SPONTANEOUS RECOVERY

Spontaneous recovery refers to the natural redevelopment or improvement in function

following an injury to the nervous system. It generally occurs following acute, non-progressive,
neurological damages such as strokes, closed head trauma, tumor resection, and anoxia. The
mechanisms underlying behavioural or functional improvements depend, in large part, on the
nature of the original pathology.

The many theories about how the brain recovers from such insults may be thought of as falling
into one of two broad categories, for example, those that attempt to explain either acute or long-
range recovery. Some common mechanisms associated with acute recovery likely involve
edema and other forms of increased pressure causing temporary suppression of function.
Edema can result from a breakdown of intracellular processes or cytotoxic edema (as is
common in infarcts), a disruption of the blood- brain barrier or vasogenic edema (as often
occurs in brain tumors and traumatic brain injuries), or as a result of disruption of CSF
circulation (interstitial edema). Pressure can also be exerted on brain structures by the
accumulation of blood, either directly inside brain tissue or simply within the cranial cavity as
a result of haemorrhagic lesions. Such lesions may be primary, as might result from
hypertension, or secondary, as seen in closed head injury. Whether as a result of edema,
haemorrhage or brain tumor, the resulting pressure on brain tissue, either local or generalized,
can disrupt normal neuronal function. Immediately following an injury to the brain, acute
changes in metabolic functions and a disruption of neurochemical processes can contribute to
behavioural disturbances. An excess release of glutamate can lead to increases in intracellular
calcium and production of oxygen free radicals, all of which can contribute to excitotoxicity
and subsequent cell death. The eventual stabilization of these processes can also provide a basis
for recovery.

Another example of short-term spontaneous recovery is that provided by transient ischemic

attacks where return of function is thought to result from spontaneous resolution of circulation
to the affected brain area.

Functional recovery can continue for days or weeks, possibly for years. The mechanisms
behind these long-term changes are less well studied. In the case of strokes, anoxia, or other
types of brain injury, it is suspected that different levels of damage may occur. Another theory
behind long-term recovery is that over time some revascularization occurs that enables
damaged neurons to function more efficiently.

It is believed that, following a damage to a portion of the brain, at least two things might
happen. The first is that other areas of the brain may assume the function of the damaged cortex
or that new neuronal pathways are recruited to carry out a particular function. The
consequences of early loss of language or sight appear to support this idea. When language is
lost as a result of childhood brain injury, the recovery or re-emergence of language skills is
usually much better than when such loss occurs later in life. Similarly, individuals who lose
their sight appear to develop enhanced acuity of other sensory modalities, allowing them, for
example, to become proficient in Braille. Such recoveries or enhanced proficiencies are
attributed to a phenomenon known as neuroplasticity. A second premise is that the patient
learns new techniques, strategies, or other compensatory mechanisms to carry out functions
impaired by the brain lesion. While these two mechanisms of recovery occur spontaneously,
repeated, facilitated, or guided practice may be useful.

TREATMENT AND REHABILITATION

One approach to treating behavioral neurological issues goes by the name of cognitive
behavioral therapy. CBT focuses on reorienting a patient’s thoughts and behaviors related to
their issue. Clearly, CBT is not called for in the case of patients recovering from a stroke,
traumatic injury or degenerative brain diseases. In cases such as these, other therapeutic
methods are preferred. These may range from medications such as the neuroleptics used to treat
organic disorders of the brain, to comparatively simple analgesics. Therapies of neurological
disorders may often consist of lifestyle changes to either prevent or minimize the impact of
such conditions; physiotherapy to manage the symptoms and restore some function; pain
management, as many impairments can be associated with considerable discomfort; and
medication to either restore function or prevent the worsening of the patient’s condition.

Rehabilitation is a process of education of the disabled person in making plans and setting goals
that are important and relevant to their own personal circumstances. In other words, it is a
process that is not done to the disabled person but a process that is done by the disabled person
themselves, but with the guidance, support, and help of a wide range of professionals. A key
factor that differentiates rehabilitation from much of neurology is that it is not a process that
can be carried out by neurologists alone, but necessarily requires an active partnership with a
whole range of health and social service professionals. Neurological rehabilitation is an active
participatory process involving a dynamic interaction between the person with neurological
deficits and the health professional members of the team. Appreciating the amount of effort
required to achieve agreed upon functional goals and establishing a framework for the
interaction among everyone participating is necessary to obtain an ideal balance concerning
perceived effort, maintenance of attention and motivation, and expectations of the rewards and
benefits of and satisfaction with rehabilitation. The basic approaches in neurological
rehabilitation include approaches that reduce disability, approaches designed to acquire new
skills and strategies which will maximise activity, and approaches that help to alter the
environment, both physical and social, so that a given disability carries with it minimal
consequent handicap.
The process includes working in partnership with the disabled person and their family; giving
accurate information and advice about the nature of the disability, natural history, prognosis,
etc.; listening to the needs and perception of the disabled person and their family; working with
other professional colleagues in an interdisciplinary fashion; liaising as necessary with key
carers and advocates; and assisting with the establishment of realistic rehabilitation goals,
which are both appropriate to that person’s disability and their family, social, and employment
needs.

Definition and uses of clinical case study

Clinical case studies have been the earliest form of medical communication. A clinical case
study is a means of disseminating new knowledge gained from clinical practice. Clinical case
studies are a type of academic publication where medical practitioners share patient cases.
Acquiring patient consent and maintaining patient anonymity are essential aspects of writing a
clinical case study. These case studies follow a standard structure and format different from
that of original or normal case studies. Medical practitioners often come across patient cases
that are different or unusual such as previously unknown conditions, a complication of a known
disease, an unusual side effect or adverse response to a mode of treatment, or a new approach
to a common medical condition. Thus, a clinical case study is expected to discuss the signs,
symptoms, diagnosis, and treatment of a disease.

Clinical case studies are the first-line evidence in medical literature as they present original
observations and can be an excellent way for medical students and practitioners to get started
with academic writing. The case study provides the details of the case in the following order:
patient description, case history, physical examination results, results of pathological tests and
other investigations, treatment plan, expected outcome of the treatment plan, and actual
outcome.

Clinical case studies detail a particular case, describing the background of the patient and any
clues the physician picked up. They discuss investigations undertaken in order to determine a
diagnosis or differentiate between possible diagnoses, and indicate the course of treatment the
patient underwent as a result. As a whole, case studies are an informative and useful part of
every physician’s medical education, both during training and on a continuing basis. It is
different from the normal case study in the sense that in the former, there is the in-depth study
of an individual or event or subject for a longer period of time. It emphasizes observing,
analysing, and interpreting the case. In a clinical case study, the study is restricted to diagnosis
and treatment.

CASE DESCRIPTION

Demographic details

● Name: Alice
● Age: 66
● Gender: Female

Reason for referral

The patient was referred by her primary care provider for complaints of mood swings and
memory problems.

Complaint

The chief complaints include experiencing mood swings and memory problems.

Family history

The patient’s mother is 85 years old and has Type II DM which is controlled with oral
medications. Her father died from liver failure, dementia, at age 76. The patient does not have
any siblings. The patient’s maternal grandmother was diagnosed with dementia in her final
years of life. She died at age 82, following a fall at home.

Medical history

The patient was diagnosed with the following diseases:

● Tonsillectomy, age 10 years.

● Appendectomy, age 17 years
● Post-menopausal, age 50 years
● Hyperlipidaemia, diagnosed in 2014
● Type II DM diagnosed in 2017
● Hypertension diagnosed in 2017
● The patient denies head injury, stroke, or seizure history

Tests used: The physical exam and neurological exam were conducted on the patient.
According to the physical exam, the following results appeared:
 ● Height 5’6”, Weight 185 lbs.
● Temperature: 98.7 degrees Fahrenheit, temporal
● HR: 85, regular
● BP: 142/76
● Respiratory rate: 17 unlaboured
● The patient appears as per the stated age and is well-groomed, well-nourished.
● Head and neck exam- unremarkable
● Eye exam- The patient wears glasses; saw an optometrist last month.
● Respiratory exam- Lung sounds equal and clear bilaterally
● Cardiac exam- No murmur
● Abdominal exam- soft supple, non-tender

Neuropsychological exams revealed impairments on multiple cognitive tests. Many of these

performances were associated with a high level of emotional distress and the patient frequently
complains that she simply “couldn’t think straight”. Her behavior during the evaluation was
initially well-composed. She was conversant and effectively stable during the interview.
During formal testing, however, she decompensated markedly and became very anxious. Her
ability to tolerate frustration was minimal, and she immediately decompensated into tears with
minimal cognitive challenge.

Three tests were conducted under neuropsychological assessment. These were Mini-Mental
State Examination (MMSE), Clock Drawing Test, and Geriatric Depression Scale.

Mini-Mental State Exam: The patient’s score was 24/30.

Clock drawing test: The patient’s scores were- CLOX1: 10/15; CLOX 2: 12/15.

Geriatric depression scale: The patient’s score was 5.

CT scan: The results revealed mild diffuse cortical atrophy.

Cerebrospinal fluid (CSF) analysis: It revealed decreased levels of amyloid B1-42 peptide
and increased level of protein TAU.

Summary of strengths and weaknesses

The patient was able to maintain composure during the interview. She was affectively stable.
In formal testing, she was not able to tolerate her frustration and got anxious. The cognitive
tests revealed some impairments. The performances were associated with high levels of
emotional distress.

CASE ANALYSIS

Diagnosis

The patient displays most of the symptoms of Alzheimer’s disease that are the basis of
diagnosis.

● Memory loss: Alzheimer’s disease globally and profoundly impairs memory. New
declarative learning problems at all levels (encoding, storage, and retrieval) and
retention over time are usually noticed first. In addition, structures of the brain that hold
previously well-learned semantic knowledge information in organized associational
frameworks begin to deteriorate. Finally, short-term memory span, names of family
members, and familiar stories fragment. Memory loss shows up in forgetting events,
repeating oneself or frequently relying on more aids to help one remember. The patient
experiences memory loss as reported by her, “I’ve been forgetting things. Yesterday, I
couldn’t remember my dog’s name. I was trying to call her to come in and I just stood
there staring at her for a good long time. It was very scary.” The patient’s major reason
for referral was her experiencing memory problems. The patient’s husband reports that
he has noticed her to repeat herself and forget more prominent details, and that it seems
to be getting worse.
● Problems with words in speaking or writing (Language/Speech problems): Patients
with AD do show language problems. Early in the disease process, AD patients show
an anomic aphasia, characterized chiefly by word-finding and naming difficulties
(Cummings, Benson, Hill, & Read, 1985). As the disease progresses, language
problems become more profound. Comprehension problems begin to appear, followed
by problems in repeating information, and last, declines in fluent conversational output
may appear that resemble a global aphasia (Zec, 1993; Cummings et al. 1985). This
symptom appears as in having trouble following or joining a conversation or struggling
to find a word the person is looking for (e.g., saying “that thing on your wrist that tells
time” instead of “watch”). The patient displays this symptom often. She reports that she
sometimes has difficulty thinking of the words she needs to express herself.
 ● Misplacing things: This could include, for example, placing car keys in the washer or
dryer or not being able to retrace steps to find something. The patient reports that she
is forgetful, frequently misplacing objects or forgetting what she was doing.
● Changes in mood and personality: A person in the earlier stages of Alzheimer’s will
often have changes in their mood. They may become anxious, irritable, agitated, or
depressed. Many people become withdrawn and lose interest in activities and hobbies,
and experience major mood swings. They get easily upset in common situations or may
become fearful and suspicious. The major reason for referral is the patient experiencing
mood swings. The patient and her husband report mood swings starting in the last two
months. The patient said, “I just seem to get frustrated or irritated easily.” Many of the
performances in neuropsychological assessment and other cognitive tests are associated
with a high level of emotional distress. During formal testing, the patient became very
anxious and was not able to tolerate her frustration. She immediately decompensated
into tears.

Proposed treatments

GENERAL INTERVENTIONS

● Medications: According to Han (2020), no disease-modifying drugs are available for

AD, but some options may reduce the symptoms and help improve quality of life. Drug
called cholinesterase inhibitors can ease cognitive symptoms, including memory loss,
confusion, altered thought processes, and judgment problems. They improve neural
communication across the brain and slow down the progress of these symptoms. Three
common drugs with Food and Drug Administration (FDA) approval to treat these
symptoms of AD are donepezil, galantamine, and rivastigmine. For emotional and
behavioral changes occurring within the patient, antidepressants for low mood,
antianxiety drugs, and antipsychotic drugs for hallucinations, delusions, and aggression
are recommended.
● Psychological therapies: Psychological therapies can take many different forms. They
can be used in a formal or informal way. Behavioral approaches can be effective in
lessening or abolishing problem behaviors. They are especially useful for treatment of
depression in moderate stages of AD. The steps involve careful description of the
problem behavior, assessment of specific antecedents and consequences, and
implementing specific strategies (Rabins et al. 2002). Emotion-oriented approaches
 include but are not limited to supportive psychotherapy (early stages of AD),
reminiscence therapy (mild to moderate stages of AD), validation therapy (mild to
moderate stages of AD), sensory integration, and simulated presence therapy (moderate
to severe stages) (Rabins et al. 2002; Robichaud et al. 1994; Woods & Ashley, 1995;
Baines et al. 1987). These interventions have been shown to improve mood and
behavior. Cognition-oriented approaches include cognitive therapy effective for
treating depression in early stages of AD (Powell-Proctor & Miller, 1982; Tappen,
1994). Stimulation-oriented approaches include activities (structured and
unstructured) or recreational therapies (e.g., crafts, games, pets) and art therapies
(music, dance, art, etc.). There is some evidence that, while they are in use, these
interventions decrease behavioral problems and improve mood (Gerber et al. 1991;
Karlsson et al. 1988; Rovner et al. 1996).

SPECIFIC INTERVENTIONS

● To aid in improving memory: The patient can use a diary and Dictaphone to help her
remember events, names, conversations, and other things. The patient should try and
concentrate on doing things she is good at, rather than pursuing tasks she cannot manage
(Grossberg & Desai, 2003). The patient can engage in doing mental challenges which
has been proved to protect patients with AD against cognitive decline (Fratiglioni,
2004). To help in remembering information, the patient can take help of cognitive
interventions such as solving arithmetic problems, doing exercises in which series of
numbers are to be completed, or in which images have to be remembered and
recognized (Woods et al. 2012). Other exercises involving words and puzzles are also
helpful (Woods et al. 2012). The patient can practice chunking, and make musical
mnemonics to improve verbal working memory (Huntley et al. 2011).
● To aid in decreasing irritability, agitation and in improving mood: Use of
therapeutic touch, including massage, may decrease agitation/irritability (Snyder, Egan,
& Bruns, 1995). Doing some meaningful activities may decrease depressive symptoms
and diminish agitation (Grossberg & Desai, 2003). The patient can engage in
socialization which has been proved to reduce depressive symptoms and improve mood
(Mushtaq et al. 2014). Reducing bright lights, avoiding loud and noisy environments,
and avoiding large groups of people, can also be useful for the patient (Mushtaq et al.
2018).
 ● Having a healthy diet and engaging in regular physical exercise as a part of lifestyle
strategies can help lighten mood, and improve cognitive performance. Vitamin D
supplementation improves cognitive performance (Gangwar et al. 2015). Combining
different types of exercises to improve strength, agility, and balance might help the
patient perform everyday activities on her own for longer period of time (Litterbrand et
al. 2011).
● The patient can take help of speech impairment therapy to improve language
functioning (Ben-Aharon, 2021).

Conclusion

The aim of the practical was to diagnose and formulate the treatment plan for the given clinical
case through case analysis. The case selected has Alzheimer’s disease. The patient was referred
by her primary caregiver for complaints of memory problems and mood swings. The patient
shows symptoms of frequent memory loss, changes in mood and personality, misplacing
things, and problems in speaking. The possible interventions suggested for the patient include
general treatments such as medications, and psychological therapies. Specific treatments
include practicing mental exercises, having a healthy diet, engaging in physical exercise, doing
meaningful activities, engaging in socialization, to name a few.

References

10 warning signs of Alzheimer’s. (n.d.). Retrieved from

https://www.cdc.gov/aging/healthybrain/pdf/10-Warning-Signs-HBI-Road-Map-508.pdf

Alpi, K.M. (2019). Distinguishing case study as a research method from case reports as a
publication type. Journal of the medical library association, 107(1), 1-5. DOI:
https://dx.doi.org/10.5195%2Fjmla.2019.615

Alzheimer’s disease: a case study. (n.d.). https://u.osu.edu/morrison.792/patient-case-

presentation/

Barnes, M.P. (2003). Principles of neurological rehabilitation. Journal of neurology,

neurosurgery, and psychiatry, 74. DOI: http://dx.doi.org/10.1136/jnnp.74.suppl_4.iv3

Basics of Alzheimer’s disease. (n.d.). Retrieved from

https://www.alz.org/national/documents/brochure_basicsofalz_low.pdf
Ben-Aharon, A. (March 1, 2021). How Alzheimer’s affects your speech. Retrieved from
https://greatspeech.com/how-alzheimers-affects-your-speech/

Depression and dementia. (n.d.). Retrieved from https://www.alzheimers.org.uk/about-

dementia/symptoms-and-diagnosis/depression-dementia

Evidence briefing: psychological therapies for people with dementia. (n.d.). Retrieved from
https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-
%20Files/Evidence%20Briefing%20-
%20Psychological%20Therapies%20for%20People%20With%20Dementia.pdf

Grossberg, G.T. & Desai, A.K. (2003). Management of Alzheimer’s disease. Journal of
gerontology, 58(4), 331-353. Retrieved from https://doi.org/10.1093/gerona/58.4.M331

Han, S. (September 22, 2020). What to know about Alzheimer’s disease? Retrieved from
https://www.medicalnewstoday.com/articles/159442

Kleiner, J.S. (2018). Spontaneous recovery. DOI: https://doi.org/10.1007/978-3-319-57111-

9_692

Majumder, K. (June 8, 2015). A young researcher’s guide to writing a clinical case report.
Retrieved from https://www.editage.com/insights/a-young-researchers-guide-to-writing-a-
clinical-case-report

Mendiola-Precoma, J. et al. (2016). Therapies for prevention and treatment of Alzheimer’s

disease. BioMed research international, 3, 1-17. DOI:
https://dx.doi.org/10.1155/2016/2589276

Non-drug interventions for Alzheimer’s disease. (July 3, 2013). Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK279355/

Pinel, J.P. & Barnes, S.J. (2018). Biopsychology. (10th ed.). Pearson.

What is Alzheimer’s disease? (n.d.). Retrieved from

https://www.alz.org/national/documents/brochure_basicsofalz_low.pdf

Zillmer, E.A., Spiers, M.V. & Culbertston, W.C. (2008). Principles of neuropsychology. (2nd
ed.). Wadsworth.
 PRACTICAL-II

Neuropsychology

Submitted to

Department of Applied Psychology

Shyama Prasad Mukherji College for Women

University of Delhi

Submitted by

Aditi Bhatia

19/0292

19075505003

2021
Neuropsychological Screening
 NEUROPSYCHOLOGICAL SCREENING

Aim: To screen and compare the prevalence of cognitive impairments between young and
middle-aged adults by administering Addenbrooke’s Cognitive Examination (ACE) test.

Basic concepts

NEUROPSYCHOLOGY

Neuropsychology as a scientific discipline is a young field, although the earliest attempts to

relate mental functions to the brain may be traced back to classical Greece, and Roman Empire
(Pagel, 1958; Finger, 1994). Neuropsychology became an independent discipline only in the
second half of the 19th century, as an amalgam of several fields: neurology, psychology,
neuroanatomy, neurophysiology, neuropharmacology, neurochemistry (Benton, 1988).
Neuropsychology seeks to understand the relationship between the brain and behavior, i.e., it
attempts to explain the way in which the activity of the brain is expressed in observable
behavior. Some refer to this field as biopsychology, psychobiology, behavioural biology, or
behavioural neuroscience.

Neuroscience is the scientific study of nervous system concerning biological basis of

consciousness, perception, memory and learning. Neuroscience links our observations about
cognitive behavior with the actual physical processes that support such behavior. It is an
umbrella term and consists of several subdisciplines. One of them is neuropsychology or
biopsychology which is derived from two separate fields, biology and psychology. Psychology
is the study of behavior; specifically, it seeks to describe, explain, modify, and predict human
and animal behavior. Neuropsychology or biopsychology, a subspecialty of psychology, is
basically the scientific study of biology of behavior. Here, psychology is at the centre of this
discipline. Hence, neuropsychology is the study of how complex properties of the brain allow
behavior to occur. It is not only a field of study. It is also a point of view. It holds that the
proper way to understand the behavior is in terms of how it evolved and how the functioning
of the brain and other organs controls behavior. We think and act as we do because we have
certain brain mechanisms, and we evolved those brain mechanisms because ancient animals
with these mechanisms survived and reproduced better than animals with other mechanisms.
Biopsychology also has a tendency to frame its understanding of cognition and behavior within
the principles derived from cognitive psychology. In other words, it tries to provide a
biological/neuroscientific explanation for our psychological explanation of the human mind,
rather than a more ‘bottom-up’ process starting with brain mechanisms to determine their
function and then try to relate to psychology.

Neuropsychology is the study of the psychological effects of brain damage in human patients.
Researchers in neuropsychology attempt to identify how cerebral structures contribute towards
cognitive processing by studying what happens when the cerebral region has been damaged. In
other words, it attempts to identify how cerebral structures influence both normal and impaired
functioning. Neuropsychology deals almost exclusively with case studies and
quasiexperimental studies of patients with brain damage resulting from disease, accident, or
neurosurgery.

The term neuropsychology refers broadly to the study of behavior, the mind, and their
relationship with the central nervous system, particularly the two cerebral hemispheres and
related subcortical structures. Neuropsychology was defined as concerning the relationships
between “cerebral structures” and “higher mental functions” (Hécaen, 1972), the “neural
mechanisms underlying human behavior” (Hécaen & Albert, 1978), “the interrelations of the
brain with behavior” (Benton, 1988), “the relationships between mind, brain, and behavior”
(Berlucchi, 2009). It was defined by Meier (1974) as “the scientific study of brain-behavior
relationships”. Neuropsychology is then placed at the intersection between the neurosciences
(neurology, neuroanatomy, neurophysiology, neurochemistry, neuroimaging), and the
behavioural sciences (psychology, linguistics), including cognitive and emotional-motivational
processes (Hécaen & Albert, 1978).

Role in the present time: Neuropsychology is now a recognized profession with most
practitioners working with patients in hospitals and rehabilitation centres, or in private practice.
The death of behaviourism, the birth of transformational grammar, and the inspiration of
information theory and computer science renewed interest in the ‘mind’ as programmed
software that ‘ran’ on the computer hardware of the brain. Many research areas of
neuropsychology in which neuropsychologists and neuropsychology students can participate
are emerging. Three such areas are at the forefront of applied neuropsychological science:
forensic neuropsychology; sports neuropsychology; and the neuropsychology of terrorism, law
enforcement, and the military (Zillmer, 2004). We are already seeing a significant revival of
interest in the neurobiology of emotions (LeDoux, 1992) and greater concern with how mood
and affect interact with problem-solving and decision-making (Damasio, 1999). It is perhaps
in the domain of psychiatric and affective disorders that functional neuroimaging techniques
and analysis procedures will have one of their most important clinical applications. The
neurological examination is becoming a better guide to the anatomical localization of deficit.

BRAIN: LOBES AND ITS FUNCTIONS

The brain is the most important organ in the human body and the most complex structure. It
plays a role in regulating other organs and determines our ability to think, move, use language,
perceive the world, etc. The brain is protected by the skull, cerebrospinal fluid (CSF) and the
blood-brain barrier in addition to the meninges. It also contains ventricles which are filled with
CSF. The brain consists of three distinct parts: the brainstem, cerebrum, and cerebellum. The
brain could be split along the corpus callosum and divided into two cerebral hemispheres. The
brain’s outer layer is the cerebral cortex. The folds, or bumps, in the cortex are called gyri and
the creases between them are called sulci.

The cortex of each hemisphere forms four lobes, each named after the skull bones beneath
which they lie. These lobes are:

• Frontal lobe: Planning, execution, and evaluation of motor and cognitive behaviors are
performed by the frontal lobes, working with other brain areas. The frontal lobes direct
behavior toward goals, make judgments with respect to time allocation and passage,
and also play a role in terms of decisions with respect to material to be remembered. In
addition, there is a relationship between the frontal lobes and emotional response as
many decisions with respect to emotional expression require input to the frontal lobes.
Broca’s area resides in the left frontal lobe and is connected with motor speech or
expressive language. The right frontal lobe is particularly involved with visual-spatial
integration and maze learning (Corkin, 1965; Teuber, 1963). The visuo-spatial
 problems, however, may be more related to integration of motor aspects than visuo-
perceptual components.
• Temporal lobe: The perception, analysis, and evaluation of auditory stimuli are the
special ability of the temporal lobes (Luria, 1966). In addition, the temporal lobes
subserve memory function involving both verbal and nonverbal stimuli. As would be
expected, verbal stimuli such as the sounds of letters, words, and numbers are perceived
by the left temporal lobe. Impairment of the left temporal lobe can make it difficult for
an individual to appreciate language (Luria, 1966). As the left hemisphere is associated
with language and verbal short-term memory, the right hemisphere is associated with
perception of nonverbal stimuli, particularly auditory perception of stimuli such as
rhythm and pitch (Horton & Wedding, 1984). Impairment of the right temporal lobe
can cause a person to be unable to appreciate music.
• Parietal lobe: Tactile and kinesthetic perception is based in the parietal lobes. Lesion
studies involving the parietal lobes usually show deficits in appreciating tactile stimuli,
such as an inability to recognize objects perceived through touch and problems
integrating tactile and kinesthetic information (Horton & Wedding, 1984). Other
deficits include the inability to consider multiple aspects of objects and problems with
complex voluntary perceptual-motor skill movements (i.e., apraxia). The left parietal
lobe is situated in a central location between the temporal and occipital lobes, and as a
result, it plays a special role in terms of verbal information processing. It contains
numerous connections between the temporal and occipital lobes, which are responsible
for facilitating communication and integrating information from visual, auditory, and
tactile sensory and modalities. The right parietal lobe is important in the processing of
nonverbal information. The parietal lobe region of the right parietal lobe is particularly
important in terms of combining visual, auditory, and tactile stimuli into integrated
nonverbal wholes. The perception of faces and the drawing of complex spatial figures
is dependent on the intact right parietal lobe functioning. In addition, arithmetic
operations in which place values are important and dressing difficulties and left-sided
visual neglect are related to the right parietal lobe functioning.
• Occipital lobe: The occipital lobes mediate visual functions. The occipital lobes in
different cerebral hemispheres perceive the contralateral visual field. Visual
discrimination and analysis of language-related visual forms such as symbolic stimuli
are mediated by the left occipital lobe. This includes symbols such as letters, numbers,
 and words. Visual perception of nonverbal forms is subserved by the right occipital
lobe.

Broca’s area: It is an area of the posterior frontal cortex named after the French neurologist
Paul Broca who, in 1861, described a patient who had a lesion in this area, on the left side of
the brain. As a result of his studies, Broca located speech in the third convolution (gyrus) of
the frontal lobe on the left side of the brain. By demonstrating that speech is located only in
one hemisphere, Broca discovered the brain property of functional lateralization. Because
speech is thought central to human consciousness, the left hemisphere is frequently referred to
as the dominant hemisphere to recognize its special role in language (Joynt, 1964). In
recognition of Broca’s contribution, the anterior speech region of the brain is called Broca’s
area, and the syndrome that results from its damage is called Broca’s aphasia.

Wernicke’s area: German anatomist Carl Wernicke (1848-1904) created the first model of
how the brain produces language in 1874. Wernicke was aware that the part of the cortex into
which the sensory pathway from the ear projects- the auditory cortex- is located in the temporal
lobe behind Broca’s area. He therefore suspected a relation between hearing and speech
functioning, and he described cases in which aphasic patients had lesions in this auditory area
of the temporal lobe. These patients displayed no opposite-side paralysis. They could speak
fluently, but what they said was confused and made little sense. Although Wernicke’s patients
could hear, they could neither understand nor repeat what was said to them. Wernicke’s
syndrome is sometimes called temporal-lobe aphasia or fluent aphasia, to emphasize that the
person can say words, but is more frequently called Wernicke’s aphasia. The associated region
of the temporal lobe is called Wernicke’s area.

COGNITIVE FUNCTIONS AND IMPAIRMENTS

Cognitive functioning refers to multiple mental abilities, including learning, thinking,

reasoning, remembering, problem solving, decision making, and attention, memory, language,
visuo-construction, perception, and executive functions (Lezak et al. 2004). In addition, mental
speed is an essential feature of cognitive functioning. These cognitive domains can be impacted
selectively or can be affected by other non-cognitive factors that contribute to task
performance, such as motivation or mood.

• Attention: The term attention can refer to a general level of alertness or vigilance; a
general state of arousal; orientation versus habituation to stimuli; the ability to focus,
divide, or sustain mental effort; the ability to target processing within a specific sensory
 arena; or a measure of capacity. In many types of brain dysfunction, efficiency of the
brain to process information diminishes. Sometimes people cannot sustain attention to
one particular stimulus for longer periods or cannot select information from competing
sources. This impairment may be minimally present and detected only through formal
neuropsychological testing, or may be profound and easily noticeable by any observer.
The disorders that show prominent attentional dysfunction are attention-
deficit/hyperactivity disorder, neurologic diseases (multiple sclerosis, Alzheimer’s
disease, Parkinson’s disease), head trauma, seizure disorders, metabolic disorder
(hypoglycemic encephalopathy, hyperthyroidism). Psychiatric disorders (depression,
mania, schizophrenia), and right hemisphere stroke: unilateral neglect.
• Memory: Memory is an umbrella concept, and it is impossible to say categorically that
someone has an overall good or bad memory. It is simply not a single system. It is
parceled into subsystems based on ideas of storage and processing. Memory has three
main divisions. Sensory memory is fleeting, lasting only milliseconds, but its capacity
is essentially unlimited in what may be taken in. Short-term memory (STM) is of
limited capacity and degrades quickly over a matter of seconds if information is not
held via a means such as rehearsal, or transferred to LTM. Long-term memory (LTM)
is of unlimited capacity and is relatively permanent. Memory loss (amnesia) is unusual
forgetfulness and is of two types. Anterograde amnesia is the loss of the ability to
encode and learn new information after a defined event. Retrograde amnesia is the loss
of old memories from before an event or illness.
• Executive functioning: It denotes a class of behavioral manifestations that may be
directly or indirectly related to frontal lobe functioning. Functions attributed to the
executive system include planning, flexible problem solving, working memory,
attentional allocation, inhibition, and at the highest levels, the self-monitoring and self-
assessment of behavior. Clearly, executive functioning refers to sets of higher order
behavior, rather than a single type of behavior. Executive functioning impairments
become more evident in the most complex aspects of human conscious activity, or those
activities of higher problem solving, reasoning, abstraction, critical self-awareness, and
social interaction that make us human.
• Visual-spatial abilities: Visual spatial processing is an individual’s ability to process
visual stimuli to comprehend spatial relationships between objects and to visualize
different scenarios or images. Visual spatial skills help people find their orientation in
 space through taking in information from the world around them and organizing that
visual information to create an understanding of meaningful patterns. Challenges in the
cognitive area of visual-spatial processing may be a lifelong weakness as it not only
affects an individual’s ability to learn but also their ability to participate in ordinary
activities.
• Language: Language involves much more than being able to understand and articulate
words in a spoken fashion. It also requires putting meaning to word fragments, words,
and groups of words. Another major requirement of language is knowledge of its syntax
or grammatical rules. This requires learning information regarding subject-verb
agreement, how to use articles and propositions, and how to put strings of words
together to make meaningful sentences. Aphasia is a disturbance of language usage or
comprehension. It may impair the power to speak, write, read, gesture, or to
comprehend spoken, written, or gestured language.
• Orientation: It describes a person’s basic awareness of himself or herself to the world
around them. Specifically, in neuropsychology, orientation refers to an individual’s
knowledge of who he or she is (orientation to person), what the date is (orientation to
time), and where he or she is (orientation to place). Difficulties in orientation result in
disorientation, which can be due to various conditions, from delirium to intoxication.
• Word fluency: It is the ability to list words rapidly in certain designated categories,
such as words that begin with a particular letter of the alphabet. The ability is associated
with a part of the brain anterior to Broca’s area in the dominant frontal lobe. Individuals
with lesions in that part of the brain are likely to experience word-fluency deficits in
verbal tests and tasks.

NEUROPSYCHOLOGICAL ASSESSMENTS

The neuropsychological assessment is an objective, comprehensive assessment of a wide range

of cognitive and behavioural areas of functioning, which the neuropsychologist typically
integrates with intellectual and personality assessments and evaluates within the context of CT
and MRI scans. When based on a thorough description of abilities and deficits,
neuropsychological testing leads to recommendations for rehabilitation and treatment. In using
such tests, neuropsychologists are interested principally in identifying, quantifying, and
describing changes in behavior that relate to the cognitive integrity of the brain.
Neuropsychological evaluations can provide useful information about the impact of a patient’s
limitation on his or her educational, social, or vocational adjustment. The neuropsychological
evaluation has a number of advantages that many standard neurodiagnostic techniques do not
share; for example, it is non-invasive and provides descriptive information about the patient.
Specific tests used in neuropsychological assessment batteries may vary, although most
assessments include objective measures of intelligence, academic achievement, language
functioning, memory, new problem solving, abstract reasoning, constructional ability, motor
speed, strength and coordination, and personality functioning (Zillmer & Greene, 2006).
Neuropsychological evaluations involve the intensive study of behavior by means of
standardized tests that provide relatively sensitive indices of brain-behavior relationships.

Neuropsychological tests traditionally have been defined as those measures that are sensitive
indicators of brain damage. Today, scientists consider a measure to be a neuropsychological
test if a change in brain function is systematically related to a change in test behavior.

• Orientation: To measure orientation, neuropsychologists frequently use the Galveston

Orientation and Amnesia Test (GOAT). This short mental status examination assesses
the extent and duration of confusion and amnesia after traumatic brain injury.
• Sensation and Perception: Part of the well-known and often used Halstead- Reitan
Neuropsychological Battery includes a sensory-perceptual examination that tests for
finger agnosia, skin writing recognition, and sensory extinction in the tactile, auditory,
and visual modalities (Reitan & Wolfson, 1993).
• Attention/concentration: Standardized tests of attention include the Symbol Digit
Modalities Test (SDMT) (Smith, 1982), which requires the respondent to fill in blank
spaces with the number that is paired to the symbol above the blank space as quickly
as possible for 90 seconds. It primarily assesses complex scanning, visual tracking, and
sustained attention. An interesting test of selective attention is the d2 Test of Attention
(Brickenkamp & Zillmer, 1998).
• Motor skills: Examples of standardized motor tests include a measure of grip strength
and finger-tapping speed, both from the Halstead- Reitan Neuropsychological Battery.
• Verbal functions/language: A simple but effective test of auditory comprehension
(receptive language) is the Token Test. The Controlled Oral Word Association
(COWA) test (Benton & Hamsher, 1989) assesses the subject’s ability to use expressive
speech.
• Visuospatial Organization: The Bender Gestalt test consists of nine geometric
designs, which the patient must reproduce exactly (Bender, 1938; Hunt, 1985). The
“Bender”, as it is often called, is a popular measure of visuospatial construction. The
 Rey-Osterrieth Complex Figure Test is another drawing test to investigate perceptual
organization.
• Memory: One of the memory assessment instruments most frequently used by
neuropsychologists is the Wechsler Memory Scale (WMS; first introduced by Wechsler
in 1945). It consists of seven subtests, which include personal and current information,
orientation, mental control, logical memory, digit span, visual reproduction, and
associate learning.
• Judgment/ problem solving: The Trail Making Test B, part of the Halstead- Reitan
Neuropsychological Battery, requires the participant to draw lines to connect
consecutively numbered and lettered circles by alternating the two sequences. The
Wisconsin Card Sorting Test (WCST) (Berg, 1948) is widely used to study “abstract
behavior” and “shifting sets”. The Tower of London- Drexel University (TOLdx),
designed by Culbertson & Zillmer (2005), measures executive planning that involves
the ability to conceptualize change, respond objectively, generate and select
alternatives, and sustain attention (Lezak et al. 2004).

NORMAL AGING AND RELATED NEUROPSYCHOLOGICAL DISORDERS

Aging is an inevitable process that starts at birth and that intensifies with age. The most visible
consequences are observed on the face and body. Among the changes observed, there is strong
interest in physiological and cognitive decline. Normal aging is logically opposed to
pathological aging, which is accelerated by diseases that may become increasingly common
with age. Various biological, psychological, and social factors influence the speed with which
normal and pathological aging progress, as well as the effects associated with these processes.
Normal aging is the result of a complex process that is progressive in nature, in the absence of
disease. It is important to note that the speed of aging varies by individual. In the same way,
major morphological and functional differences can be observed between individuals of the
same age. In other words, biological age and chronological age may not coincide. Commonly
described as healthy lifestyle habits, the following actions- physical exercise, a healthy diet,
restorative sleep, abstaining from tobacco and alcohol use- contribute positively to normal
aging. That said, some people experience normal aging without following these habits. Other
factors, such as genetics, heredity or gender, also come into play.

Main perceptible effects of normal ageing: The effects listed in the following table are only
a portion of the changes that may be observed in the course of normal aging. Other effects
occur at the metabolic level and in the nervous, cardiovascular, respiratory, digestive and
urinary systems, but their diagnosis often requires medical examinations in addition to the
simple observations that friends or family can make.

Mobility Loss of strength and endurance/ slower movements/ loss of

reflexes, balance and coordination
Sense organs Sight and hearing changes
Cognitive functions Reduction in concentration and learning abilities
Memory Not remembering the details of events dating back several months/
not remembering the name of an acquaintance/ occasional
forgetfulness/ occasional difficulties finding their words
Immune system Slower immune response
Sleep Lighter sleep/ different sleep schedule (taking naps)
Nutrition Loss of appetite, taste for food and thirst

The findings from various researchers in aging and cognition suggest that both crystallized and
fluid intelligence are important for successful functioning in advanced age. Ability, level of
education, and knowledge gained early in life appear to provide some buffer against later brain
disorders. Not everyone ages cognitively at the same rate, and many people retain high abilities
into advanced age. Some individuals may suffer devastating effects, both physical and
cognitive, whereas others suffer relatively few effects. Therefore, among groups of older
people, age is not the only, or best, predictor of cognitive decline or mortality. The process of
aging increases the probability of cognitive problems. Aging also results in brain and neuronal
changes, but physical changes do not by themselves always differentiate between normal aging
and dementia because of a wide range of individual differences and differences in functional
cognitive reserve. Different measures of functional capacity may well be the key to identifying
those at greatest risk for cognitive impairment.

Neurological disorders affect the entire nervous system. These include Alzheimer’s disease and
Parkinson’s disease.

• Alzheimer’s disease: Alzheimer’s disease is one of a number of degenerative

conditions associated with aging that results in dementia. AD is linked to increased age,
which has led some to speculate that it is a disease of “accelerated aging”. A definitive
diagnosis of AD requires the behavioural presence of dementia and the identification
 of neuropathologic markers of AD. AD is difficult to diagnose because there are other
dementias that may have similar symptoms, especially in the later stages of the disease.
AD tends to be overdiagnosed, meaning that other progressive dementias may be
misdiagnosed as AD (Lopez et al. 1999). The clinical presentation of patients with AD
can vary, but many share characteristic patterns. The most consistent deficits across
patients are memory and fluent anomic aphasia. Visuospatial difficulties are also
characteristic. Some frontal areas of the brain appear relatively spared. The impairments
progress over time, gradually affecting all higher mental functions of the brain. Memory
dysfunction is the hallmark of AD. Many patients appear to lose metacognitive
awareness, or the inability to self-monitor their own behaviour and performance. There
are treatments for cognitive enhancement and cognitive, behavioural, and psychiatric
symptom control.

• Parkinson’s disease: Parkinson’s disease is a slowly progressive disease that, like

Alzheimer’s disease, largely affects older adults. PD is marked by a degeneration of
dopaminergic cells and pigmentation in the substantia nigra. It is also characterized by
Lewy bodies, which are small, tightly packed granular structures with
neurodegeneration. The motor symptoms of PD generally fall into groups of positive
and negative symptoms. Positive symptoms indicate a diminution or loss of motor
functioning. Negative symptoms include slowness of movement, reduced motor
initiation, gait disturbance, slowed speech, decreased voice amplitude, etc. Patients
with PD perform poorly on spatial tasks that have a motor component. Many patients
have executive functioning difficulties. The treatment for PD appears to be traveling
full circle from surgery to drugs to surgery. In addition, gene therapies, tissue implants,
and various approaches to prevention are on the horizon.

TREATMENT AND REHABILITATION

One approach to treating behavioural neurological issues goes by the name of cognitive
behavioural therapy. CBT focuses on reorienting a patient’s thoughts and behaviours related to
their issue. Clearly, CBT is not called for in the case of patients recovering from a stroke,
traumatic injury or degenerative brain diseases. In cases such as these, other therapeutic
methods are preferred. These may range from medications such as the neuroleptics used to treat
organic disorders of the brain, to comparatively simple analgesics. Therapies of neurological
disorders may often consist of lifestyle changes to either prevent or minimize the impact of
such conditions; physiotherapy to manage the symptoms and restore some function; pain
management, as many impairments can be associated with considerable discomfort; and
medication to either restore function or prevent the worsening of the patient’s condition.

Successful treatment rests on appropriate evaluation. Assessments need to answer questions

related to the possibilities of success in treatment and in returning to the “real world”. What is
the pattern of strengths and weaknesses according to the functional areas of verbal processing,
visuospatial processing, and so forth? Will the person be able to absorb the purpose of therapy
and remember instructions? Does the patient appreciate the need for therapy? When deficits
appear, what exactly is the nature of the problem? How severe is the problem? What is the
likelihood that this person will be able to return home, return to work, return to independent
functioning? These questions, in addition to describing patterns of neuropsychological
functioning, definitely require predictions. This forces the neuropsychologist to consider not
only current level of functioning but also the accumulated research and clinical knowledge
regarding the probability and time course of recovery for the particular problem.

Rehabilitation is a process of education of the disabled person in making plans and setting goals
that are important and relevant to their own personal circumstances. In other words, it is a
process that is not done to the disabled person but a process that is done by the disabled person
themselves, but with the guidance, support, and help of a wide range of professionals. A key
factor that differentiates rehabilitation from much of neurology is that it is not a process that
can be carried out by neurologists alone, but necessarily requires an active partnership with a
whole range of health and social service professionals. For the psychologist working with brain
disorders, neuropsychological rehabilitation- or brain injury rehabilitation, as it is more
commonly known- represents the intersection of neuropsychology and rehabilitation. As such,
the focus is on the process of recovery, adjustment, and rehabilitation of people with brain
disorders. The conditions most often seen on brain injury units of rehabilitation hospitals
include TBI caused by head injuries from accidents and falls and cerebrovascular accidents
(CVAs).

Neurological rehabilitation is an active participatory process involving a dynamic interaction

between the person with neurological deficits and the health professional members of the team.
Appreciating the amount of effort required to achieve agreed upon functional goals and
establishing a framework for the interaction among everyone participating is necessary to
obtain an ideal balance concerning perceived effort, maintenance of attention and motivation,
and expectations of the rewards and benefits of and satisfaction with rehabilitation. The basic
approaches in neurological rehabilitation include approaches that reduce disability, approaches
designed to acquire new skills and strategies which will maximise activity, and approaches that
help to alter the environment, both physical and social, so that a given disability carries with it
minimal consequent handicap.

The process includes working in partnership with the disabled person and their family; giving
accurate information and advice about the nature of the disability, natural history, prognosis,
etc.; listening to the needs and perception of the disabled person and their family; working with
other professional colleagues in an interdisciplinary fashion; liaising as necessary with key
carers and advocates; and assisting with the establishment of realistic rehabilitation goals,
which are both appropriate to that person’s disability and their family, social, and employment
needs. In rehabilitation, assessment is an ongoing process, monitoring the progress of treatment
and aiding decision making regarding the effectiveness of interventions and the prognosis for
long-term outcome. With specialized knowledge of the brain and behavior, as well as technical
advances, neuropsychologists are uniquely positioned to guide individuals and their families
to their highest potential for recovery and functioning.

Review of literature

Several studies have investigated the use of Addenbrooke’s Cognitive Examination Test (ACE)
in young, middle, and older adults and in people with neuropsychological disorders.

Amaral and Caramelli (2012) conducted a study to provide normative data for healthy middle-
aged and elderly Brazilians' performance on the Addenbrooke Cognitive Examination-Revised
(ACE-R) and to investigate the effects of age, sex, and schooling on test performance. For the
same, 144 cognitively healthy volunteers (50% men, 50% women) aged 50 to 93 years, with 4
to 24 years of schooling were evaluated by being divided into 4 age groups, each of which was
then stratified into 3 groups according to years of education. All the participants were then
assessed with the ACE-R, the Mattis Dementia Rating Scale, and the Cornell Scale for
Depression in Dementia. Results revealed that years of education affects all ACE-R subscores.
Age influences the Verbal Fluency subscore (P<0.001) and the ACE-R total score (P<0.05).
Sex affects the Attention and Orientation (P=0.037) and Mini-Mental State Examination
subscores (P=0.048), but not the ACE-R total score (P>0.05). Based on the results it was
concluded that the performance of healthy middle-aged and elderly individuals on the ACE-R
battery is strongly influenced by education and, to a lesser extent, by age. These findings are
of special relevance in countries with populations that have marked heterogeneity in
educational levels.

In a study conducted by Cherkil, Panikar, and Soman (2017), the aim was to profile cognitive
deficits using Addenbrooke's Cognitive Examination-Malayalam (ACE-M) as a screen and to
determine the sensitivity and specificity of the same. The participants of the study were
seventy-four drug naïve patients diagnosed to have brain tumors were assessed for cognitive
functioning using ACE-M before surgery. The results indicated that the patients with high-
grade intra-axial tumors showed a significant association on the cognitive domains of
registration (0.04), recall (0.01), and visuospatial functioning (0.02). Gender showed an
association between registration (0.02) and verbal fluency (0.02) with females performing
better while education was significantly associated with retrograde or remote memory (0.00)
with college-educated samples performing better. Significance was assumed at P < 0.05. In
extra-axial tumors, laterality had a single association with recall (0.02). Males showed a
significant cognitive decline on the cognitive domains of attention (0.02), recall (0.05), naming
(0.02), and language functions (0.01). College educated group performed better on registration
(0.01), recall (0.09), naming (0.00), and visuospatial functioning (0.00). It was lastly deduced
that the ACE-M is capable of bringing out cognitive deficits along with a number of cognitive
domains in patients with intra- and extra-axial tumors in the capacity of a screen, with fairly
good levels of sensitivity and specificity.

Bajpai et al. (2020) conducted a study to validate the Hindi version of Addenbrooke’s
Cognitive Examination III (ACE-III) in Indian older adults and compare its validity with the
Hindi Mini-Mental State Examination (HMSE). The sample of 412 consenting older adults
visiting a memory clinic was recruited into the study. They were categorized into three groups:
healthy controls (n=222), MCI (n=70), and MNCD (n=120). The complete clinical protocol
was followed. Hindi ACE-III and HMSE were administered and were statistically analyzed.
The results of the study reported that the optimal cut-off values to detect MCI and MNCD with
ACE-III were 71 and 62 (AUC: 0.849 and 0.884), respectively, which were slightly higher than
with HMSE (AUC: 0.822, 0.861). Education- and age-stratified cut-offs were also computed.
Hence, it was brought to an agreement that Hindi ACE-III has good discriminating power at
lower cut-offs than the standard scores in differentiating between MCI and MNCD.

In another study conducted by Kahali et al. (2020), the aim was to investigate the influence of
age, gender, and education in the Indian population. For the same, 444 and 1344 volunteers
were enrolled in TLSA and SANSCOG respectively. ACE-III was administered on them by
trained psychologists. They were classified in four age groups (45– 55, 56–65, 66-75, and >75
years of age) and six levels for years of education (0-4, 5-8, 9-12, 13-15, 16-18, >18).
Univariate analysis was performed to study the effect of age, gender, or education, on the ACE-
III total scores. Multivariate analysis was done to study the effects of age, gender, and education
on the different cognitive domains of ACE-III. The results showed that age, gender and
education of participants can have important effects on performance of ACE-III and its
cognitive sub-domains.

Qassem et al. (2015) conducted a study to provide normative data for healthy adult performance
on Egyptian–Arabic ACE-III for which the aforesaid ACE-III (2012) was adapted to the
Egyptian population. This version was then evaluated on 139 cognitively healthy volunteers
aged 20 years or older (54.7% male and 45.3% female) who were subsequently stratified both
by age (<60 years and >60 years) and by degree of education (basic, secondary or university
education). None of the participants had any complaints of cognitive decline. The normative
data for healthy Egyptian adults was established below 60 years and above 60 years on each of
the subdomains of the ACE-III. The data generated from the performance was assigned
according to percentiles. The result of the study found a significant difference (P<0.001)
between the performance of older and younger adults on the category task of the verbal fluency
test and concluded that by adapting the ACE-III to the Egyptian–Arabic population, we were
able to establish normative data for healthy Egyptian adults.

Rationale

As our population ages, there is a growing important role for cognitive screening tools to detect
cognitive impairment that would otherwise go unnoticed. Screening tests are generally brief
and narrow in scope, and they can be helpful for identifying individuals in need of more
comprehensive assessment. Comprehensive neuropsychological assessments are
multidimensional in nature and used for purposes such as identifying primary and secondary
diagnoses, determining the nature and severity of a person’s cognitive difficulties, determining
functional limitations, and planning treatment and rehabilitation. Cognitive screening tests are
expected to play an increasingly important role in identifying people with cognitive impairment
and in determining which individual should be referred for further neuropsychological
assessment. Globally, in 2016, neuropsychological disorders were the leading cause of
disability and the second leading cause of deaths (9 million) in the world (GBD 2016
Neurology collaborators, 2016). Neuropsychological disorders are so frequent in the general
population, particularly in elderly individuals, that they pose a massive global health problem.
It is tempting to view neuropsychological disorders as expressions of accelerated ageing.
Ageing is fundamental to neurodegeneration and dementia. Hence, with an increase in the
screening process, the disorder could be prevented from getting out of control. This would lead
to timely diagnosis. The current practical aims to explore and compare young and middle-aged
adults in terms of cognitive abilities; and to compare the prevalence of cognitive impairments
in both the age groups.

Objectives

1. To screen young and middle-aged adults on different cognitive abilities.

2. To compare young and middle-aged adults in terms of cognitive deficits.

Hypothesis

1. There will be a difference between the cognitive abilities of young and middle-aged
adults.

Method

SAMPLE CHARACTERISTICS: The sample consisted of 42 young adults (20-40 years)

and 42 middle-aged adults (40-60 years).

INCLUSION AND EXCLUSION CRITERIA

Age was the major inclusion criterion; the developmental period of young and middle
adulthood was examined as the sample of the study. People with chronic illnesses, physical,
and visual disabilities were excluded.

TOOL DESCRIPTION

The Addenbrooke’s Cognitive Examination (ACE) is a neuropsychological test which was

developed to provide a brief test sensitive to the early stages of dementia, and capable of
differentiating subtypes of dementia including Alzheimer’s disease, frontotemporal dementia,
Parkinson’s disease and others. The original Addenbrooke’s Cognitive Examination (ACE)
was developed in the Medical Research Council Cognition and Brain Sciences Unit in
Cambridge in the late 1990s as a simple bedside test battery designed to detect mild dementia.
The original ACE includes the mini-mental state examination (MMSE), along with fronto-
executive and extra visuospatial items. However, weaknesses were identified in the ACE,
which prompted the development of the Addenbrooke’s Cognitive Examination-Revised
(ACE-R) to facilitate cross-cultural usage and improve sensitivity. The original 26 components
were combined to produce five subscores, each representing a specific cognitive domain:
attention/orientation (18 points), memory (26 points), fluency (14 points), language (26 points),
and visuospatial function (16 points)- 100 in total. It gives a cut-off score for the five
subdomains against controls and takes between 12 and 20 minutes (average 16). The ACE-R
also incorporated the MMSE, such that this score (out of 30) might also be generated. The
results of each activity are scored to give a total score out of 100. The score needs to be
interpreted in the context of the patient’s overall history and examination, but a score of 88 and
above is considered normal; below 83 is abnormal; and between 83 and 87 is inconclusive. The
cut-off for dementia is 82-88/100. The alpha coefficient of the ACE-R was 0.80, which is
considered very good (McDowell & Newell, 1996; Streiner, 2003a). It has high construct
validity (Mathuranath et al. 2000).

Procedure

ADMINISTRATION: The assessment focuses on five cognitive domains:

• Attention and Orientation

• Memory
• Fluency
• Language
• Visuospatial abilities

Attention and orientation: These cognitive domains are tested by asking the participant for
the date including the season and the current location; repeating back three simple words; and
serial subtraction.

Memory: Memory is tested by asking the participant to recall the three words previously
repeated; memorizing and recalling a fictional name and address; and recalling widely known
historical facts.

Fluency: Fluency is tested by asking the participant to say as many words as they can think of
starting with a specified letter within one minute; and naming as many animals as they can
think of in one minute.

Language: Language is tested by asking the participant to complete a set of sequenced physical
commands using a piece of paper; to write a grammatically-complete sentence; to repeat
several polysyllabic words and two short proverbs; to name the objects shown in 12 line
drawings, and answer contextual questions about some of the objects; and to read aloud five
commonly mispronounced words.

Visuospatial abilities: Visuospatial abilities are tested by asking the participant to copy two
diagrams; to draw a clock face with the hands set at a specified time; to count sets of dots; and
to recognize four letters which are partially obscured.

After arranging all the required materials on the table, the participants were called inside an
illuminated and fanned room, concurrently they were made comfortable by carrying out a
genuine conversation in order to relax their nerves about taking the test. Then, the material
required for the conduction of the test was provided to them and subsequently the instructions
were read about to them. Following the understanding of the instructions by the participants,
the test was carefully conducted with them. Upon the completion of the test, the subject’s scores
were totalled, and they were asked to share their thoughts on Addenbrooke’s Cognitive
Examination-Revised (ACE-R). At the end, both the respondents were thanked for their time
and cooperation, and they were assured that their responses would be kept confidential in their
best interests.

INSTRUCTIONS

“The test covers five cognitive domains. Each cognitive domain measures specific cognitive
ability through different subtests. Specific instructions will be given for the conduction of every
subtest. If there is any sort of query, you can ask. Thank you for participating!”

Results

The scores were compiled to calculate mean, standard deviation, and t-values. Table 1
represents mean scores of young and middle-aged adults on the measure of Mini-Mental Status
Examination (MMSE), Addenbrooke’s Cognitive Examination (ACE) and its components. It
can be observed from the table that there is a significant difference in all the domains except
fluency domain.

TABLE 1: Mean scores and SD of Young Adults and Middle Adults on MMSE, ACE and its
components
 Scale Young Adults (N=42) Middle Adults(N=42) df t-value

Mean S.D. Mean S.D.

MMSE 28.93 1.45 28.14 2.08 82 2.01*

ACE 93.38 4.66 87.36 5.63 82 5.37***

AO 17.59 .94 17.09 1.22 82 2.10*

Memory 24.95 2.35 23.02 2.96 82 3.30**

Fluency 10.90 2.70 9.88 3.19 82 1.58

Language 24.5 1.29 23.64 2.05 82 2.29**

Visuo-spatial 15.26 1.27 14.48 1.85 82 2.27**

*P<.05, **P<.01, ***P<.001

Discussion

The aim of the practical was to screen and compare the prevalence of cognitive impairments
between young and middle-aged adults by administering Addenbrooke’s Cognitive
Examination (ACE) test. The objectives were to screen young and middle-aged adults on
different cognitive abilities; and to compare young and middle-aged adults in terms of cognitive
deficits. One hypothesis was formulated which states that there will be a difference between
the cognitive abilities of young and middle-aged adults.

Cognitive functions are the mental processes that allow us to receive, select, store, transform,
develop, and recover information that we have received from external stimuli. This process
allows us to understand and to relate to the world more effectively. Cognitive function is a
broad term that refers to mental processes involved in the acquisition of knowledge,
manipulation of information, and reasoning. Cognitive functions include the domains of
perception, memory, learning, attention, decision making, and language abilities. Cognitive
functioning refers to multiple mental abilities, including learning, thinking, reasoning,
remembering, problem solving, decision making, and attention, memory, language, visuo-
construction, perception, and executive functions (Lezak et al. 2004). In addition, mental speed
is an essential feature of cognitive functioning. These cognitive domains can be impacted
selectively or can be affected by other non-cognitive factors that contribute to task
performance, such as motivation or mood.

Cognitive impairment occurs when problems with thought processes occur. It can include loss
of higher reasoning, forgetfulness, learning disabilities, concentration difficulties, decreased
intelligence, and other reductions in mental functions. Cognitive impairment- which is also
called “cognitive decline”- can come on suddenly or gradually, and can be temporary or more
permanent. It may or may not keep getting slowly worse; it all depends on the underlying cause
or causes. Cognitive impairment is when a person has trouble remembering, learning new
things, concentrating, or making decisions that affect their everyday life. It ranges from mild
to severe. With mild impairment, people may begin to notice changes in cognitive functions,
but still be able to do their everyday activities. Severe levels of impairment can lead to losing
the ability to understand the meaning or importance of something and the ability to talk or
write, resulting in the inability to live independently.

The Addenbrooke’s Cognitive Examination (ACE) is a neuropsychological test which was

developed to provide a brief test sensitive to the early stages of dementia, and capable of
differentiating subtypes of dementia including Alzheimer’s disease, frontotemporal dementia,
Parkinson’s disease and others. The original Addenbrooke’s Cognitive Examination (ACE)
was developed in the Medical Research Council Cognition and Brain Sciences Unit in
Cambridge in the late 1990s as a simple bedside test battery designed to detect mild dementia.
The original ACE includes the mini-mental state examination (MMSE), along with fronto-
executive and extra visuospatial items. However, weaknesses were identified in the ACE,
which prompted the development of the Addenbrooke’s Cognitive Examination-Revised
(ACE-R) to facilitate cross-cultural usage and improve sensitivity. The original 26 components
were combined to produce five subscores, each representing a specific cognitive domain:
attention/orientation (18 points), memory (26 points), fluency (14 points), language (26 points),
and visuospatial function (16 points)- 100 in total. It gives a cut-off score for the five
subdomains against controls and takes between 12 and 20 minutes (average 16). The ACE-R
also incorporated the MMSE, such that this score (out of 30) might also be generated. The
results of each activity are scored to give a total score out of 100. The score needs to be
interpreted in the context of the patient’s overall history and examination, but a score of 88 and
above is considered normal; below 83 is abnormal; and between 83 and 87 is inconclusive. The
cut-off for dementia is 82-88/100. The alpha coefficient of the ACE-R was 0.80, which is
considered very good (McDowell & Newell, 1996; Streiner, 2003a). It has high construct
validity (Mathuranath et al. 2000).

The sample consisted of 42 young adults (20-40 years) and 42 middle-aged adults (40-60
years). After administering the test with the participants, the test scores were totaled to obtain
MMSE and ACE-R scores. Mean, Standard deviation, and t-values were calculated to analyze
the obtained data.

The mean scores and t-values of young and middle-aged adults on MMSE, ACE-R, and its
components are given in Table 1. As can be seen from the table, there is a significant difference
in all the domains except fluency. It shows that age has an impact on cognitive abilities. As age
declines, people show decline in their cognitive abilities. The formulated hypothesis, which
states that there will be a difference between the cognitive abilities of young and middle-aged
adults, was accepted. There is a significant difference in all the scales except for fluency.

The Mini-Mental Status Examination (MMSE) was initially developed to screen dementia;
however, it has been widely used as a measure of general cognitive functioning. The MMSE is
the most widely used screening tool to assess mental or cognitive status in the elderly. On a
descriptive level, the mean score of young adults (M= 28.93; S.D.= 1.45) was higher than the
mean score of middle-aged adults (M= 28.14; S.D.= 2.08). Similar results have been reported
by Kochhann et al. (2009) in their study. There is a decline in MMSE performance among
healthy individuals with age, reinforcing the notion that mental and cognitive status changes
with aging. A variety of factors can cause cumulative damage to the brain with age and lead to
cognitive decline, such as toxins, head damage, degenerative dementia, etc. On an inferential
level, there is a significant difference in the MMSE scores of young and middle-aged adults.

The Addenbrooke’s Cognitive Examination (ACE) is a neuropsychological test which was

developed to provide a brief test sensitive to the early stages of dementia, and capable of
differentiating subtypes of dementia including Alzheimer’s disease, frontotemporal dementia,
Parkinson’s disease and others. On a descriptive level, the mean score of young adults (M=
93.38; S.D.= 4.66) was higher than that of middle-aged adults (M= 87.36; S.D.= 5.63). This
reinforces the notion that chances of cognitive impairments and neural deficits increase as age
progresses. Age has an influence on the performance in such neuropsychological screening
tests. On an inferential level, there is a significant difference in the ACE scores of young and
middle-aged adults.
The term attention can refer to a general level of alertness or vigilance; a general state of
arousal; orientation versus habituation to stimuli; the ability to focus, divide, or sustain mental
effort; the ability to target processing within a specific sensory arena; or a measure of capacity.
Attention is the cognitive or brain function that we use to select between stimuli that reach our
brain simultaneously, both external (smells, sounds, images) and internal (thoughts, emotions),
that are useful for carrying-out a mental or motor activity. In reality, it is a whole set of
processes that vary in complexity and allow us to carry-out the rest of our cognitive functions
well. Orientation describes a person’s basic awareness of himself or herself to the world around
them. Specifically, in neuropsychology, orientation refers to an individual’s knowledge of who
he or she is (orientation to person), what the date is (orientation to time), and where he or she
is (orientation to place). On a descriptive level, the mean score of young adults (M= 17.59;
S.D.= 0.94) was higher than that of middle-aged adults (M= 17.09; S.D.= 1.22). Similar results
were reported by Parasuraman and Giambara (1991). Age-related cognitive differences are due
to a generalized slowing that results in less computational processing being completed in a set
amount of time, which leads to less available information for higher-level functions (Salthouse,
1996; Salthouse & Madden, 2007). Deficits in attention can be largely attributed to a general
slowing of information processing in middle-aged and older adults. Issues in orientation could
be because of drugs, dementia, head injuries, etc. On an inferential level, there is a significant
difference in the attention and orientation of young and middle-aged adults.

Memory is a complex process that allows us to code, store, and recover information. It has
three main divisions: sensory memory, short-term memory, and long-term memory. On a
descriptive level, the mean score obtained by young adults (M= 24.95; S.D.= 2.35) was higher
than that of middle-aged adults (M= 23.02; S.D.= 2.96). Similar results were reported by Davis
et al. (2003). Studies of aging suggest that middle-aged and older people are more likely to
have more difficulties in many aspects of memory. Poorer performance occurs with free recall,
compared with recognition, with less contextualized information, and when more effort is
involved. On an inferential level, there is a significant difference in the memory of young and
middle-aged adults.

Fluency is the ability to list words rapidly in certain designated categories, such as words that
begin with a particular letter of the alphabet. The ability is associated with a part of the brain
anterior to Broca’s area in the dominant frontal lobe. On a descriptive level, the mean score of
young adults (M= 10.90; S.D.= 2.70) was higher than that of middle-aged adults (M= 9.88;
S.D.= 3.19). Similar results were reported by Mathuranath et al. (2003). It has been shown that
in normal individuals, the effect of age on fluency results from impaired naming abilities as
age advances (Au et al. 1995; Nicholas et al. 1985). On an inferential level, there is no
significant difference in the fluency of young and middle-aged adults.

Language involves much more than being able to understand and articulate words in a spoken
fashion. It also requires putting meaning to word fragments, words, and groups of words.
Another major requirement of language is knowledge of its syntax or grammatical rules. This
requires learning information regarding subject-verb agreement, how to use articles and
propositions, and how to put strings of words together to make meaningful sentences. On a
descriptive level, the obtained mean score of young adults (M= 24.5; S.D.= 1.29) was higher
than that of middle-aged adults (M= 23.64; S.D.= 2.05). Similar results were reported by Goral
(2004). Salthouse (1988) proposed that with aging, there is a general reduction in resources for
cognitive processing. Hasher and Zacks (1988) proposed that the cause of middle-aged and
older adults’ poorer performance is an inefficient inhibition mechanism that increases
vulnerability to distractions and may lead to difficulties concentrating on the task and/or the
material at hand. On an inferential level, there is a significant difference in the language domain
of young and middle-aged adults.

Visual spatial processing is an individual’s ability to process visual stimuli to comprehend

spatial relationships between objects and to visualize different scenarios or images. Visual
spatial skills help people find their orientation in space through taking in information from the
world around them and organizing that visual information to create an understanding of
meaningful patterns. On a descriptive level, the mean scores obtained by young adults (M=
15.26; S.D.= 1.27) was higher than that of middle-aged adults (M= 14.48; S.D.= 1.85). Similar
results were reported by de Bruin et al. (2016). This could be due to age-related decline in
perceptual and motor speed. On an inferential level, there is a significant difference in the
visuo-spatial abilities of young and middle-aged adults.

As our population ages, there is a growing important role for cognitive screening tools to detect
cognitive impairment that would otherwise go unnoticed. Screening tests are generally brief
and narrow in scope, and they can be helpful for identifying individuals in need of more
comprehensive assessment. Comprehensive neuropsychological assessments are
multidimensional in nature and used for purposes such as identifying primary and secondary
diagnoses, determining the nature and severity of a person’s cognitive difficulties, determining
functional limitations, and planning treatment and rehabilitation. Cognitive screening tests are
expected to play an increasingly important role in identifying people with cognitive impairment
and in determining which individual should be referred for further neuropsychological
assessment. Ageing is fundamental to neurodegeneration and dementia. Hence, with an
increase in the screening process, the disorder could be prevented from getting out of control.
This would lead to timely diagnosis.

A growing body of scientific research suggests that the following steps are linked to cognitive
health. Research shows that a combination of these healthy lifestyle behaviors may also reduce
the risk for neuropsychological disorders such as Alzheimer’s disease (National Institute on
Aging, 2020). Taking care of physical health can help improve cognitive health. One can get
recommended health screenings; manage chronic health problems; consult with health care
provider about the medicines and possible side effects on memory, sleep, and brain function;
limit use of alcohol and quit smoking; and get enough sleep.

Decades of observational studies have shown that having high blood pressure in midlife- the
40s to early 60s- increases the risk of cognitive decline later in life. Preventing or controlling
high blood pressure, not only helps one’s heart, but may help one’s brain too. A healthy diet
can keep brain healthy. There is some evidence that people who eat a Mediterranean diet have
a lower risk of developing dementia (Dugdale, 2020). In one study, exercise stimulated the
human brain’s ability to maintain old network connections and make new ones that are vital to
cognitive health. Other studies have shown that exercise increases the size of a brain structure
important to memory and learning, resulting in better spatial memory (Erickson et al. 2011).
One study found that older adults who learned quilting or digital photography had more
memory improvement than those who only socialized or did less cognitively demanding
activities (Park et al. 2014). People who engage in personally meaningful and productive
activities with others tend to live longer, boost their mood, and have a sense of purpose. Studies
show that these activities seem to help maintain their well-being and may improve their
cognitive function. Writing in a journal, trying relaxation techniques, staying positive,
exercising regularly, etc. can help manage stress.

Conclusion

Overall, the formulated hypothesis, which states that there will be a difference in the cognitive
abilities of young and middle-aged adults was accepted. There is a significant difference in the
MMSE, ACE and its components except fluency domain.
Limitations

The sample size of the study was too small. Hence, it cannot be generalized. There was a lack
of responses from older adults, which limits the study to only two age groups. Also, other
variables such as stress, medical causes, etc. were not considered.

Future outcomes

In future, a large number of participants can be included to make it more comprehensive and
results more generalized. Older adults can also be taken into account in future. Other variables
which could have an effect on brain, such as stress and medical causes, can be taken into
consideration.

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