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Clinical Neuropsychology 5/4/2018 Overview The Role of Neuropsychology What is clinical neuropsychology? -- Goals of practice in Dementia Care Common settings – Specific focus on relationship with nursing Typical referral questions Erica Schmidt, Ph.D. – Specific focus on normal aging versus dementia Clinical Neuropsychology Fellow Intro to neuropsychological assessment – Test examples – Test interpretation Common recommendations What is Clinical Neuropsychology? Common Work A sub-specialty in clinical psychology that involves the study of Settings brain-behavior relationships. Individual consultation practice A psychologist who applies principles of assessment and intervention based upon the scientific study of human behavior as it relates to Medical school normal and abnormal functioning of the central nervous system. Hospital or group medical practice Clinical neuropsychologists… Rehabilitation hospital Psychiatric hospital – Provide “assessment, diagnosis, treatment, and/or rehabilitation of patients across the lifespan with neurological, medical, neurodevelopmental and psychiatric conditions” (NAN, 2001) – Have doctoral degrees in psychology/neuropsychology; two years of supervised, specialized training in neuropsychology Common Referral Sources Reasons for Referral Assist with diagnosis Family / Internal Medicine – Cognitive deficit(s): Present or absent? Hospitalist – Severity of deficits Neurology – Pattern of deficits – Suspected etiology Neurosurgery Establish baseline PM&R Assist with treatment planning Psychiatry Provide psycho-education and compensatory strategies – Importance of specifying the referral question! Cardiology Skilled Nursing Facilities (PA, RN, APRN) 1 5/4/2018 Case Example: Typical Referral Questions Normal Aging vs. 1. My 45 year-old patient is depressed and complains of Dementia forgetfulness. Does she have memory impairment, and if so, is it due to brain dysfunction or depression? My 70 year-old mother is becoming forgetful. Does she have dementia? Is she able to live alone and drive her car safely? 2. My 75 year-old father had a stroke 3 months ago. What is his expected recovery, and how can we help his communication In other words, skills? – Is she more forgetful than most people her age? 3. My 70 year-old mother is becoming forgetful. Does she have dementia? Is she able to live alone and drive her car safely? – What could be causing her forgetfulness? – Has the forgetfulness affected her functioning? 4. My patient seems confused at times and is refusing treatment. Is he competent to make this decision on his own? – Will this continue to worsen? – Are there any treatments that may help her memory functioning? Biomarkers and Stages of AD Dementia – Major Neurocognitive Disorder (DSM-5) (e.g., Alzheimer’s disease): • Memory (or other cognitive) impairment • Other cognitive disturbance(s): » Aphasia » Apraxia » Executive dysfunction • Cognitive deficits cause significant functional impairment and represent a decline from previous functioning • Not due to delirium or another Axis I disorder – Incidence of dementia increases with age but is not inevitable • 8% of population >65 has dementia – Dementia is not the only syndrome that may explain memory difficulty… Jack et al., 2010 Neuropsychological Evaluation Domains to Assess: Review of medical records (if available) Clinical interview – Presenting complaints • Orientation • Motor abilities – Current functional abilities (perceived vs collateral report) • Intellectual functioning • Executive functioning – Current and past medical and psychiatric problems • Attention/concentration (planning, organizing, • Speed of thinking problem-solving, – Psychosocial history (educational, work, family, etc.) abstract reasoning) • Memory Behavioral Observations • Mood and personality Neuropsychological testing • Language Interpretation and integration • Visuospatial skills Report writing Feedback to patient and referring provider 2 5/4/2018 Estimate of Premorbid Orientation Intellectual Functioning Demographic predictors Person – Education – Autobiographical information – Occupation Place – City, state, county, type/name of place Cognitive measures Time – Test of Premorbid Functioning (TOPF) – Year, season, month, date, day of the – WASI week, time of the day Situation – Reason for evaluation, nature of deficits Attention/Concentration Processing Speed How long it takes your computer to load all the information Simple attention Rapid “connect the dots” – Repeating digits Rapid symbol substitution Word and color naming – Spatial span Complex attention (e.g., working memory) – Repeating digits backwards – Spatial span backwards – Mental math • Serial 7s Distractibility Vigilance/sustained attention Verbal and Nonverbal Language Memory Object naming Verbal Fluency List Learning – Semantic vs Phonemic – Learning trials – Immediate and delayed recall (free/cued) Language comprehension – Recognition – E.g., “Put the pencil on the Story Memory other side of the watch and – Learning trials turn over the card.” – Immediate and delayed recall – E.g., “Will a cork sink in – Recognition water?” Visual memory – E.g., “Point to the yellow – Complex figures circle.” – Geometric figures Repetition – Faces – Etc. 3 5/4/2018 Visuospatial Skills Visuospatial Visuo-construction Block Design Line Discrimination – Figure copies – Blocks – Clocks Visuo-perceptual – Visual scanning – Neglect tests – Visual discrimination – Line orientation – Visual integration A few clocks 4 5/4/2018 Executive functions Executive Functions Brain CEO, Orchestra conductor Problem solving and planning – Divided Attention / Set shifting Cognitive flexibility and inhibition – Selective Attention / Inhibition – Planning, organization – Deductive reasoning – Abstract / Conceptual reasoning – Self monitoring Divided attention and set shifting – Judgment / Problem solving – Insight Executive Functions Motor Judgment test Fine motor dexterity Motor speed You are vacationing far from home and realize you don’t have enough blood pressure pills for the entire trip. What would you do? Motor strength Rapid alternating movements You receive a phone call indicating that you’ve just won a new car Luria Maneuver in a contest you entered several months before. The caller asks you to provide your address, social security number, and credit card account. What would you do? Challenge of Interpretation Challenge of Interpretation What is “normal?” What is “normal?” Considering….. the determinants of behavior Neuropsychology looks at individual variables of • Age performance in comparison to available normal distributions • Education Establish cutoffs • Gender • Ethnicity Consider base rates • Language Look for patterns • Culture • Other abilities / variables / premorbid • Different etiology = different patterns (e.g. Alzheimer’s functioning vs vascular) 5 5/4/2018 Challenge of Interpretation Challenge of Interpretation What is “normal?” Outside of a clinical context, numbers are meaningless Role of functional status in results interpretation – MCI by test results vs dementia by functional status Recommendations and Recommendations and Feedback Feedback Diagnosis and prognosis Rehabilitation (e.g., stroke) Memory-enhancing medications Functional activities Imaging study – Driving issues Psychoeducation – Medication management – Compensatory strategies, memory mnemonics – Finance management – Behavior management – Supervision needs – Communication strategies – Environmental modification – Caregiver burnout Psychological/psychiatric treatment Help with residential planning (e.g. IL, AL, memory support) Long term care planning (living will, POA, estate planning) Determine capacity (e.g. medical, financial, testamentary, etc.) Cognitive re-testing to compare to baseline Questions? References: Barth, J. T., Pliskin, N., Axelrod, B., Faust, D., Fisher, J., Harley, J. P. …Silver, C. (2003). Introduction to the NAN 2001 Definition of a Clinical Neuropsychologist. NAN Policy and Planning Committee. Archives of Clinical Neuropsychology, 18, 551-555. Jack, C. R., Knopman, D. S., Jagust, W. J., Shaw, L. M., Aisen, P. S., Weiner, M. W. …& Trojanowski, J. Q. (2010). Hypothetical model of dynamic biomarkers of the Alzheimer’s pathological cascade. Lancet Neurology, 9(1), 119. 6 .
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