Adult cognitive disorders Neuropsych assessment post brain injury
Recall falls to 60-75% after
10 second delay with interference. Decrement is much worse after interference for brain injured population
100% recall after
30 second delay
Advantage of RBANS
4 versions of test. Tracks recovery during rehab and progression of neuro disorders. Downward extension to 12 yrs old. Available in spanish
MOCA normative score
> or = 26/30
Auditory perception
Acuity, auditory discrimination, inattention, yes/no questions, nonverbal aud perception
Neuropsych assessment rationale
Admin by neuropsychologist but SLP makes recommendations or conducts therapy
Extinction example
Am I touching your R hand or L hand or both?
Which type of memory loss is most detrimental to rehab?
Anterograde
Pts post TBI have more difficulty with
Anterograde memory
Nonverbal tasks-controversy
Are they really nonverbal? For most have to use expressive language to answer
When someone you're going to assess produced unintelligible speech you should
Ask if they wear dentures
CLQT personal facts
Asks 4 questions about pt. Assesses episodic memory and language
CLQT mazes
Assesses executive functions, attention, visual perceptual skills
What is the advantage of the SCATBI?
Assesses high level of functioning
What is advantage of BTHI?
Assesses low level of functioning
CLQT cognitive domains
Attention, memory, executive function, language, visuospatial skills
CLQT yields severity ratings for
Attention, memory, executive function, language, visuospatial skills
Orientation
Awareness of self in relation to surroundings. Person, place, time, event
CLQT severity ratings
Based on norms for 2 age ranges. WNL, mild, moderate, severe
Orientation deficits are most frequent symptom of
Brain disease
BTHI
Brief test of head injury. Useful for pts with severe TBI.
Selective attention tasks
Cancellation tasks. Cross out all the letter "k"'s
RIPA-2 scoring system
Combination of numeric scores and diacritical descriptors for quantitative and qualitative information
Psychological functioning of pt
Compare mental health before injury to now. Any change as a result of injury?
Intact attention is necessary for both
Concentration and mental tracking activities
CLQT symbol trails
Connect starting with smallest shape to next biggest.. then move up to alternating between different shapes
Requirements for orientation
Consistent and reliable integration of attention, perception, and memory.
Flexible assessment provides
Consistent baseline measures as well as ongoing pt specific reassessment
CLQT
Criterion referenced instrument. Can be administered at bedside. Generally takes 30-40 min.
CLQT symbol cancellation
Cross out symbols that match target. Assesses visual attention, scanning, inhibition, response shifting
Spatial orientation
Distance estimations, mental transformations in space, topographical organization/localization, extra personal orientation
1 of the questions you should ask before beginning a cognitive linguistic assessment is
Do you wear glasses?
Assessment of alertness
During initial interview, caregiver reports, EMR
Dysphonias post TBI may be due to
Extubation
In neuro typical adults, recall is 100% after a 10 second delay with interference
False
Most common deficits in orientation
For time and place. Require continuity of awareness
Recovery of communicative function
General marked resolution of linguistic deficits (30-60 days), spontaneous recovery (1 yr), pragmatic comm deficits (convo turns)
Overall cognitive assessment
Generative cognitive/intellectual abilities. Broad measures of intellectual ability (WAIS-R)
CLQT target population
H/o neurological dysfunction, English and spanish speaking, ages 18-89, pt must be able to manipulate pen, verbal responses required for 4 tasks
RBANS assesses
Immediate memory, visuospatial, language, attention, delayed memory
Retention span
Immediate or short term (delayed)
Language assessment
Impairments depend on site, extent, severity of damage
Visual scanning
Important for reading/writing and telling time. Can do visual search or counting dots
Visual agnosia
Inability to recognize familiar objects. Unable to connect sensory info and past experience. Unable to understand object fx
Tactile perception
Inattention to touch, extinction, recognition/discrimination
Pts with TBI as communicators
Ineffective even though speech and language skills per se are relatively unimpaired
Sustained attention tests
Involve presentation of stimuli over period of time with instructions to indicate when given target stimulus is perceived. Ex. Tap hand every time you hear letter "a"
Why is orientation to time most challenging?
It requires continuity of awareness. Have to be present in the moment
Advantage of SCATBI
Items progress in difficulty to levels that some neuro typical adults do not typically master
Anterograde memory
Learning new information
BTHI scoring system
Linguistic and gestural communicativeness
Flexible assessment
Measures selected based on presenting problem. Can be mixed model (combo of standard battery and additional measures)
Most common deficit post TBI
Memory deficits
CLQT generative naming
Name as many animals as you can in 1 minute, as many words with letter "f"
Controlled Oral Word Association
Name as many words as you can in 60 seconds that start with letters F,A,S
Is there a gold standard for neuropsych tests?
No
Areas of cognitive function assessed
Orientation (most basic), language, attention, memory, visuospatial, visuomotor, executive function (most specific). Psychological functioning
BTHI areas of assessment
Orientation, attention, follow commands, organization, naming, reading, memory, visual spatial
Verbal learning and memory assessment
Paragraph recall and word list learning
SCATBI assesses
Perception and discrimination, orientation, organization, recall, reasoning
CLQT subtests
Personal facts, symbol cancellation, confrontation naming, clock drawing, story retell, symbol trails, word fluency, design memory, mazes, design generation
Standard (fixed battery)
Pre determined set of tests to assess variety of abilities. Need wide range of tests for comprehensive eval
What is missing from CLQT
Problem solving
Post TBI language impairments
Problem with pragmatics and word retrieval
What type of memory is critical for accomplishing tasks throughout the day?
Prospective
Benton Word Fluency Test
Pt asked to say aloud as many words beginning with certain letter and tester records
CLQT design generation
Pt produces up to 13 unique designs following specific rules. Assesses executive functions and memory
CLQT story retelling
Pt required to repeat story and respond with yes/no questions about story. 18 key elements, 6 follow up questions
How do TBI language and pragmatics compare to aphasia?
Pt with aphasia will have language impairment but pragmatics intact. Use compensatory strategies and residual skills to comm effectively in social contexts
Thurstone Word Fluency Test
Pts asked to write as many words beginning with "s" in 5 minutes
Attention TBI
Pure attention deficits appear as distractibility or impaired ability for focused behavior.
Visual memory
Recall (show designs then pt draws from memory) and recognition (view designs then select target from large array)
Retrograde memory
Recalling old information
RBANS
Repeatable battery for assessment of neuropsych status.
Nonverbal learning and memory
Reproduce figure from memory after delay, recognize figure from array
CLQT clock drawing
Requires integrated cognitive functioning. Memory, executive function, language, visuospatial skills
Impact of delay and interference
Retention span testing (delay may not make a difference). Interference will affect ability to recall
CLQT +
Revised version of CLQT. Added semantic comprehension component
RIPA-2
Ross Info Processing Assessment. Assesses memory, orientation, problem solving, word fluency, auditory comprehension
MOCA
Screening tool. Exec function, naming, memory, attention, language, abstraction, delayed recall, orientation.
CLQT design memory
Show design then identify it from larger array. Have to have pt look at design for full 20 seconds
Speech deficits after TBI
Spastic dysarthria most common, followed by ataxic and flaccid. Dysphonias and dysfluencies are rare
Tactile recognition
Sterognosis-inability to recognize object by touch alone (Ex. Reach into bag with object unknown cannot guess the object)
Divided attention tasks
Subject must retain info in memory while performing mental operations on the information. 2 types of tasks
Selective attention-stroop test
Subject perceives conflicting colors and color names. Can be asked to state color of ink, alternate between ink and actual color, etc
A cancellation task is assessing
Sustained attention
Alternating attention tasks
Sustained attention tests in which response requirements periodically change. Ex. Take 100 subtract by 7 then add 3. Ex. trail making
Post assessment of pt with TBI
Team meeting, reality orientation, goal setting
Retrospective memory
Test for personal information
Word Fluency Tasks
Thurstone word fluency and benton word fluency test
Prospective memory
Use of object (hide object then later ask where it is) and use of instruction (when timer goes off do this)
Halstead-Reitan Battery
Used to be most popular and the gold standard but not used anymore
Neuropsych screening
Used when pt can't tolerate full battery. SLP can administer. May over rely on certain faculties (verbal processing)
CLQT confrontation naming
Verbally name 10 simple drawings of common items. Assesses for presence of anomia
Assessing perception
Visual inattention (neglect, extinction) and cancellation tasks
Variety of assessment measures-Most common
Woodcock-Johnson test of cognitive abilities, Raven's coloured matrices, Wisconsin card sort
Can pts with brain injury still recover after spontaneous recovery?
Yes