Neuropsychological Assessment chapter 28

R. L. was a 32-year-old nurse and mother of four. Driving home from work one afternoon, she stopped at a red light and was rear-ended by another vehicle. R. L.’s head snapped back and struck the head rest and then the side window as she bounced forward. She blacked out for a few minutes, but, when the emergency vehicles arrived, she was con- scious, although disoriented and dysphasic, in addition to having severe pain in her back and neck from the whiplash. R. L. spent about a week in the hospital, where neither CT nor MRI scans identified any cerebral injury, although several vertebrae were damaged. An accomplished musician, she could still play the piano well from memory, but she could no longer read music. In addi- tion, her oral language skills remained impaired and she was completely unable to read. R. L.’s difficulties did not abate, and she had spells of apraxia. For example, she often found herself unable to figure out how to put on her makeup; she would stare at her lip- stick and have no idea how to use it. When R. L. came to us, she was depressed because, although the neurologists could find no reason for her impairments, she continued to have significant difficulties. Our neuropsychological evaluation revealed a woman of above- average intelligence who had a significant loss of verbal fluency and verbal memory, as well as severe dyslexia even a year after the accident. Now nearly 10 years later, she is still unable to read music and reads text only with great difficulty.

. L.’s case illustrates one of the remaining problems in clinical neurology. R People with closed-head injuries often have no sign of cerebral injury vis- ible on neuroimaging but still have significant cognitive deficits, often so se- vere that they cannot resume their preinjury life styles. For many, the only evidence of neurological disorder comes from neuropsychological tests. The 1980s were the heyday of neuropsychological assessment. Clinically trained neuropsychologists were in demand and neuropsychological evaluation was regarded as an essential tool in neurological assessment. The role of neu- ropsychological assessment has changed radically, however, and it has begun to develop a new face that is likely to continue changing for some time. In this chapter, we describe this changing role for neuropsychological assessment, consider the rationale behind assessment, and present summaries of six actual case assessments. 751

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The Changing Face of Neuropsychological Assessment The roots of neuropsychological assessment lie in neurology and psychiatry. Clinician Kurt Goldstein, for example, was expert in neurology, psychology, and psychiatry. The psychological basis of assessment began to diverge from medicine in the 1940s. The first neuropsychological tests were designed to identify people suffering from cerebral dysfunction attributable to some type of organic disease process (brain pathology), rather than to “functional disor- ders” linked to behavior. Although test designers originally believed that it would be possible to con- struct a single test for brain damage and to establish a cutoff point that sepa- rated the brain-damaged from the non-brain-damaged patient, the task proved to be impossible. Gradually, more-sophisticated testing procedures were de- veloped, largely in a few locations in Europe and North America, including Cambridge (Oliver Zangwill), Oxford (Freda Newcombe), Moscow (Alexander Luria), Montreal (Brenda Milner and Laughlin Taylor), Boston (Edith Kaplan and Hans-Leukas Teuber), and Iowa City (Arthur Benton). By the early 1980s, neuropsychology was no longer confined to a few elite laboratories, and the new field of clinical neuropsychology blossomed in clin- ics and hospitals. Since that time, three factors have enhanced the rate of change in neuropsychological assessment: functional imaging, cognitive neu- roscience, and managed health care. We consider each briefly.

Functional Imaging Perhaps the biggest change in both neurology and neuropsychology in the past 25 years has been the development of functional imaging. Indeed, we have em- phasized the importance of functional imaging in the Snapshots in Chapters 6 through 27. Thus, whereas in earlier eras the effects of cerebral injury or dis- ease often had to be inferred from behavioral symptoms, neuroimaging has al- lowed investigators to identify changes in cerebral functioning in a wide variety of disorders, including most of the neurological and behavioral disorders dis- cussed in Chapters 26 and 27. The main role of the clinical neuropsychologist therefore has changed from one of diagnosis to one of participating in rehabilitation, especially in cases of chronic disease such as stroke and head injury. An important point to bear in mind, however, is that even the most sophisticated functional imaging tech- niques often do not predict the extent of behavioral disturbance observed in people with certain types of brain injury, especially in head trauma, as R. L.’s case illustrates. For people with closed-head injury, the only way to document the nature and extent of their disabilities is by a thorough neuropsychological assessment (see Christensen and Uzzell).

Cognitive Neuroscience One effect of the growth of clinical neuropsychology is the diversification of methods used by individual neuropsychologists, the choice of tests varying with the disorder being investigated. Indeed, there are now two texts that

CHAPTER 28 NEUROPSYCHOLOGICAL ASSESSMENT 753 summarize the various tests available (one by Lezak and the other by Spreen and Strauss). From the early 1950s through the early 1980s, batteries of tests were devel- oped, each with a different focus (Table 28.1). Many of these test batteries, such as the Halstead-Reitan Battery, retained the concept of cutoff scores, although this assumption presents difficulties because performance below a particular level cannot always be taken as being indicative of brain damage. For one thing, cerebral organization varies with such factors as sex, handedness, age, educa- tion, and experience. Furthermore, test problems can be solved by using differ- ent strategies and can thus entail different cortical regions. Symptoms of cortical injury can be highly specific (recall the color-blind painter’s case de- scribed in Chapter 13). Finally, because many tests require problem solving of various kinds, we might expect task performance to vary with intelligence. All these factors make the use of cutoff scores difficult to justify. A serious handicap in the development of test batteries was the absence of theory in test construction or use. Knowledge of brain function was based largely on clinical observation, and few clinicians other than Alexander Luria had tried to formulate a general theory of how the brain functions to produce cognition. The emergence of cognitive neuroscience in the 1990s produced a dramatic change in the theoretical understanding of brain and cognition. Case studies once again became popular, each directed by sophisticated cognitive theory and assisted by structural and functional imaging technologies (see Shallice). These more-cognitive approaches also use multivariate statistical methods such as structural equation modeling to attempt to understand the way in which neural networks are disrupted in both individual cases and in groups. Test design has begun to incorporate this knowledge, but the emerging field of cognitive neuroscience will certainly change the way in which neuropsycho- logical assessment is conducted in the future. Perhaps the area most influenced to date is in understanding the functions of the right frontal lobe (see a review by Stuss and Levine). Historically, the right frontal lobe proved remarkably unresponsive to neuropsychological assessment. The combination of functional imaging and neuropsychological test develop- ment has now led to an understanding of the role of the right frontal lobe in previously inaccessible functions such as social cognition (see Chapter 22).

Table 28.1 Overview of neuropsychological test batteries

Test battery Type Basic reference Benton’s neuropsychological investigation Composite Benton et al., 1983 Boston Process Approach Composite Kaplan, 1988 Oxford neuropsychological procedures Composite Newcombe, 1969 Montreal Neurological Institute approach Composite Taylor, 1979 Frontal lobe assessment Composite Stuss and Levine, 2002 Western Ontario procedures Composite Kimura and McGlone, 1983 Halstead-Reitan Battery Standardized Reitan and Davison, 1974 Luria’s neuropsychological investigation Standardized Christensen, 1975 Luria-Nebraska Standardized Golden, 1981 CanTab Computerized Robbins et al., 1998

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Managed Care Perhaps economics is the greatest challenge faced by practicing psychologists in the past decade. In the era of managed health care, clinicians are pressured to reduce the time and money spent on neuropsychological services. In particular, there is sometimes unreasonable pressure to reduce the number of tests given to individual patients, especially in view of the perception that medical imaging can provide faster and more accurate assessments of cerebral dysfunction. As already noted, imaging has changed the way in which neuropsychologi- cal assessment will be used, but, in cases of head trauma, as R. L.’s case demon- strates, neuropsychological assessment is often the only way to document cognitive disturbances. Groth-Marnat suggests that psychologists must de- velop and promote assessment procedures that • focus on diagnostic matters that are most clearly linked to treatment choice and outcomes; • identify conditions that are likely to result in cost savings; • are time efficient; and • integrate treatment planning, progress monitoring, and outcome evaluation. It is clear that clinical assessment will have to change if it is to survive the challenge of managed health care.

Rationale Behind Neuropsychological Assessment

By the 1990s, neuropsychologists had an impressive array of tests from which to choose, as summarized in Table 28.1. At one end of the spectrum are stan- dardized test batteries with fixed criteria for organicity. These tests have in common the advantage of straightforward administration, scoring, and inter- pretation. There is little need to understand the theoretical bases of the tests or the nuances of cerebral organization to administer the tests, although such understanding is necessary for interpretation. Examples include the Halstead- Reitan Battery and the Luria-Nebraska Battery. More recently, Robbins and his colleagues at Cambridge University devised a computerized version of a standardized battery (CanTab) that has the advantage of being administered in a highly structured manner. At the other end of the spectrum are individualized test batteries that re- quire particular theoretical knowledge to administer and interpret. These as- sessments are more qualitative than quantitative. The testing of each patient is tailored to that person’s etiology and by the qualitative nature of the perfor- mance on each test. An example is Luria’s neurological approach, which is not really so much a test battery as a strategy for examining patients. (The Luria- Nebraska Battery was an attempt to make Luria’s procedure more structured and quantitative but, in doing so, the Luria-Nebraska Battery became a com- pletely different analysis.) There is a middle ground, too, represented by composite batteries in which each test is given in a formalized way and may have comparison norms, but the

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qualitative performance on tests and the pattern of test results are considered. An example is the Boston Process Approach (Table 28.2). Other examples are described by Benton and colleagues, by Lezak, by McKenna and Warrington, by Milberg and colleagues, by Newcombe, by Smith, and by Taylor. Across this spectrum, each battery is constantly changing in re- sponse to test revisions and developments, as well as to the clinical population being evaluated. One constraint on the choice of any test, however, is the training of clinical neuropsychologists. The use of tests that are based on theory requires an understanding of the theory of cerebral organization. It is not possible to take weekend workshops and emerge qualified to administer, evaluate or interpret such tests.

Factors Affecting Test Choice Throughout this book, we have seen that circumscribed lesions in dif- ferent cortical regions can produce discrete behavioral changes. Thus, working backward from this knowledge to localize unknown brain damage would seem reasonable. That is, given a particular be- havioral change, one should be able to predict the site or sites of the disturbance most likely to be causing the change. There are problems in working backward in such a manner, how- ever. Research patients are often chosen for specific reasons. For ex- ample, whereas patients with rapidly expanding tumors would not be chosen for research, because their results are so difficult to interpret, neurosurgical patients are ideal research subjects, because the extent of their damage is known. Therefore, differences in the etiology of the neurological disorder might be expected to make assessment dif- Academic Skills ficult. Indeed, people with diffuse dysfunction, as in head trauma, would seem likely to perform very differently from people with sur- gical removals. Even after the practitioner has chosen tests that are appropriate for the etiology in question, significant questions must be resolved. First, how sensitive are the tests? If a large region of the brain is dysfunc- tioning, the assessment test need not be particularly sensitive to dem- onstrate the dysfunction. If the lesion is small, on the other hand, the behavioral effect may be rather specific. As we have seen, for example, a lesion in the right somatosensory representation of the face may produce very subtle sensory changes, and, unless specific tests of nonverbal fluency are used (see Chapter 16), the cognitive changes may go unnoticed, even with dozens of tests. A related problem is that various factors may interact with brain pathology to make interpretation of test results difficult. Tests are seldom developed for subjects older than 60 or from ethnic or cultural backgrounds that differ from those subjects on whom the tests were developed. Therefore, as noted earlier, test scores cannot be interpreted with strict cutoff criteria. Furthermore, intelligence alters an investigator’s expectations of perfor- mance on tests: someone with an IQ score of 130 may be relatively impaired on a test of verbal memory but may appear normal compared with someone with a score of 90. Thus, unlike standard, quantitative psychometric assessment,

CHAPTER 28 NEUROPSYCHOLOGICAL ASSESSMENT 756 neuropsychological assessment must be flexible. This flexibility makes interpre- tation difficult and requires extensive training in fundamental neuropsychology and neurology as well as in neuropsychological assessment. Finally, we have seen in several earlier discussions that significant differ- ences in test performance are related to factors such as sex and handedness. In addition, test performance is often biased by demographics. For example, in one three-city study of the effects of head trauma, investigators found that normal subjects in one city performed as poorly as brain-damaged subjects in another. Significant demographic differences influenced the test performance and thus had to be considered in the interpretation of the results.

Goals of Neuropsychological Assessment The goal of assessment in general clinical psychology is the diagnosis of the disorder for the purpose of changing behavior. For example, intelligence and achievement tests may be given to schoolchildren to try to identify particular problem areas (poor short-term memory, for example, or slow reading) as an aid in teaching. Similarly, personality tests are used with an eye toward defin- ing and curing a behavioral disorder, such as an anxiety disorder. The goals of clinical neuropsychology are different in some respects: • Assessment aims to diagnose the presence of cortical damage or dysfunction and to localize it where possible. In doing so, there is an attempt to provide an accurate and unbiased estimate of a person’s cognitive capacity. • Assessment is used to facilitate patient care and rehabilitation. Serial assessments can provide information about the rate of recovery and the potential for resuming a previous lifestyle. • Neuropsychological assessment can identify the presence of mild disturbances in cases in which other diagnostic studies have produced equivocal results. Examples are the effects of head trauma or the early symptoms of a degenerative disease. • A related goal is to identify unusual brain organization that may exist in lefthanders or in people who have suffered childhood brain injury. This information is particularly valuable to surgeons, who would not want, for example, to inadvertently remove primary speech zones while performing surgery. Such information is likely to be obtained only from behavioral measures. • In disorders such as focal epilepsy, the primary evidence corroborating an abnormal EEG may emerge from behavioral assessment, because radiological procedures often fail to specifically identify the abnormal brain tissue giving rise to the seizures. • Because some recovery of function may be expected after brain injury, this recovery must be documented not only with rehabilitation in mind but also to determine the effectiveness of any medical treatment, particularly for neoplasms (tumors) or vascular abnormalities. • Assessment assists a patient and the patient’s family in understanding the patient’s possible residual deficits so that realistic life goals and rehabilitation programs can be planned.

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Intelligence Testing in Neuropsychological Assessment Most neuropsychological assessments begin with a measure of general in- telligence, most often one of the Wechsler scales, the most recent version being the Wechsler Adult Intelligence Scale-Third Edition (WAIS-III). The Wechsler scales have proved invaluable in determining a base level of cognitive functioning. These scales provide the distinct advantage of producing separate scores for verbal and performance subtests, as well as an overall IQ score. The WAIS-III has seven subtests for evaluating verbal and performance scales. The verbal score is a measure of acquired knowledge, verbal reasoning, and comprehension of verbal information. The performance score provides an indication of a person’s nonverbal reasoning, spatial processing skills, atten- tiveness to detail, and visuomotor integration. Although the verbal and performance subtests were not designed to measure left- and right-hemisphere functions, respectively, the subtests have proved use- ful as a rough measure of left- and right-hemisphere function, respectively. The IQ scores obtained on both the verbal and the performance sections have a mean of 100 and a standard deviation of 15. A difference of more than 10 points between the verbal and the performance scores is usually taken as a clinically significant difference, although statistically this interpretation is liberal. The results of a number of studies have demonstrated that well-defined left- hemisphere lesions produce a relatively low verbal IQ score compared with performance score, whereas well-defined right-hemisphere lesions produce a relatively low performance score. Diffuse damage, on the other hand, tends to produce a low performance score, leading to the erroneous belief that the verbal–performance IQ difference is not diagnostically useful. Although a reduced performance score is not definitive, it is rare to obtain a relatively low verbal IQ, and its appearance should not be ignored. An evaluation of the WAIS subscales and IQ values was performed by Warrington and her colleagues, who did a retrospective study of 656 unselected patients with unilateral brain damage. Overall, their results showed that lesions of the left hemisphere depressed verbal IQs, whereas lesions of the right hemi- sphere depressed performance IQs, the exception in both cases being that of oc- cipital lesions. However, the verbal–performance discrepancy score was less than 10 points in 53% of left-hemisphere cases and in 43% of right-hemisphere cases. A small number of cases had discrepancy scores greater than 10 points in the op- posite direction: 6% with left-hemisphere lesions and 3% with right-hemisphere lesions. (It is curious that the patients with left parietal or temporoparietal lesions did not show a large drop in IQ, considering that one would expect them to be dysphasic. Because language skills were not mentioned in the Warrington study, her analysis could have excluded aphasic subjects. In our experience, dysphasic patients have very depressed verbal IQs, as would be expected.) Warrington also analyzed a subset of WAIS subtests, including four verbal instruments (arithmetic, similarities, digit span, and vocabulary) and three nonverbal (picture completion, block design, and picture arrangement). Overall, left-hemisphere frontal, temporal, and parietal patients performed significantly more poorly on the four verbal tests. There were no differences between these left-hemisphere groups on the tests, however. The performance tests were less predictive of lesion side, because only the right parietal patients were significantly poorer on block design and picture arrangement.

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One difficulty with postinjury intelligence testing is that a premorbid esti- mate of intellectual level must exist. A relatively low IQ score cannot be as- cribed to a brain injury unless there is some idea of what the IQ was before the injury. This estimate is usually informal and based on a patient’s education, oc- cupation, and socioeconomic background. Wilson and colleagues describe a statistical procedure for estimating premorbid IQ scores.

Case Histories

Having surveyed the basic principles of neuropsychological theory and assess- ment, we now apply the tests and theory to a sample of clinical problems. In this section, we consider the test results and case histories of six patients. These case histories illustrate the use of neuropsychological tests in neuropsycholog- ical assessment. Because of our affiliation with the Montreal Neurological Institute, our com- posite assessment battery is based on the tests derived from the study of neuro- surgical patients by Brenda Milner, Laughlin Taylor, and their colleagues. Most of the tests have been discussed elsewhere in the text, especially in Chapters 14 through 16 in relation to neuropsychological assessment of parietal, temporal and frontal lobe function. Cases 1 and 2 are borrowed from Laughlin Taylor.

Case 1 This 33-year-old man had a history of seizures beginning 4 years before his ad- mission to the hospital. His neurological examination on admission was nega- tive, but he was having increasingly frequent seizures, characterized by his head and eyes turning to the right, a pattern that suggests supplementary mo- tor cortex involvement. Figure 28.1 Psychological test The results of radiological and EEG studies suggested a left-frontal-lobe le- results before and after surgery in sion (Figure 28.1), which was confirmed at surgery when a poorly differenti- two cases. Case 1 Left frontal Case 2 lobe lesion Right face area lesion

Preop Postop 97 97 100 106 a 94 88 94 92 Verbal recall 13.5 14.0 3.5a 7.0 a a Card sorting 0 cat. 1 cat. Finger-position sense Left Right Left Right 55/60a 59/60 28/36a 26.5/36a 4/36a 9.5/36a

117 99 118 108 Verbal recall 20 14 10.5 10 Card sorting 1 cat.a 1 cat.a Finger-position sense Left Right Left Right CHAPTER 28 NEUROPSYCHOLOGICAL ASSESSMENT 759 60/60 60/60

a Significantly low score. a Significantly low score.

CHAPTER 28 NEUROPSYCHOLOGICAL ASSESSMENT 760 ated astrocytoma was removed. The only difficulty that the patient experi- enced before surgery was in doing the Wisconsin Card-Sorting Test, where he made numerous perseverative errors and sorted only one category correctly. Two weeks after surgery, all the intelligence ratings, memory quotients, and delayed verbal-recall scores decreased, but these scores remained in essentially the same ratio to one another. Other tests were unchanged, the only signifi- cantly low score again being on the sorting test. If this patient were like other patients with similar lesions, on follow-up a year after surgery, his intelligence ratings and memory scores would likely have returned to the preoperative level, although his card sorting would be unlikely to show any improvement.

Case 2 This 26-year-old man had an 8-year history of seizures dating to an episode of meningitis in which he was thought to have an intracerebral abscess. Sub- sequently, he developed seizures beginning in the left side of his face and left hand, and he was referred as a candidate for surgery because his seizures were uncontrolled by medication. Before surgery, the patient scored within normal limits on tests of intelli- gence and general memory, although he did have difficulty with delayed recall of verbal material. He had slight defects of finger-position sense on the left hand, which together with some weakness in the left arm and leg pointed to damage in the right central area of the cortex. In addition, he had difficulty copying and recalling the Rey Complex Figure and was unable to perform the Wisconsin Card-Sorting Test, which suggested that his lesion might extend into the frontal and temporal areas as well. The right facial area and a region extending into the right frontal lobe were removed at surgery (see Figure 28.1). After this removal, some residual epilep- tiform abnormality in both the frontal lobe and the superior temporal gyrus re- mained. Postoperative testing showed improvement in both verbal IQ and long-term verbal memory, but the patient had persistent difficulties on the card-sorting test, with finger-position sense on the left hand, and on the copy and recall of the Rey Complex Figure. His performance IQ score also declined. The difficulty with finger position would be expected in such a case, but the continuing difficulties with card sorting and the Rey Complex Figure imply that areas in his right hemisphere are still dysfunctioning. This dysfunction is seen in residual abnormalities in the EEG recordings from the frontal and temporal regions.

Case 3 This right-handed woman, age 28, underwent emergency surgery subsequent to the bursting of an aneurysm in the right temporal lobe. Surgical reports in- dicated that parts of the right temporal and parietal cortex were damaged, and she had a left quadrantic hemianopia, indicating that the lesion extended pos- teriorly into the visual cortex. She was referred to us 2 years after the incident, at which time she was in good health and attending a university, but she was having social problems as well as difficulty with mathematics. The results of her neuropsychological assessment are summarized in Table 28.3, where she can be seen to have several deficits consistent with right

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Table 28.3 Examples of neuropsychological assessments of neurological patients

Case 3: Case 4: Case 5: Case 6: Normal Right temporal Left temporal Left-hemisphere Traffic Test control aneurysm epilepsy stroke accident Speech Lateralization, Dichotic Words Left ear 25 18 2* F 16 Right ear 46 50 15 F 25 Handedness R R R R R General Intelligence Full-scale IQ 107 113 104 F 115 Verbal IQ 109 117 95* F 127 Performance IQ 105 107* 111 108 96* Visual Perceptual Mooney faces (abbreviated) 18/19 12/19* 16/19 16/19 17/19 Rey Complex Figure—copy 32/36 24/36* 31/36 30/36 34/36 Memory Wechsler Memory quotient 107 115 87* F 100* Rey Complex Figure—recall 22/36 11/36* 18/36* 17/36* 13/36* Delayed recall of stories and paired associates 13 17 7* — 23 Delayed recall of drawings 12 6* 10 9 2* Spatial Right–left differentiation 52/60 48/60 43/60 51/60 35/60* Semmes Body Placing 32/35 30/35 30/35 — 35/35 Language Reading 12 12 7* F 20 Object naming 23/36 20/26 14/26* F — Frontal Lobe Wisconsin Card Sorting 6.0 cat. 5.8 cat. 4.0 cat. 3.0 cat. 2.4 cat.* Chicago Word Fluency 62 50 38 F 52 Motor Function Complex arm 92% 94% 89% 72%* 82%* Face 88% 90% 89% 20%* 30%*

Abbreviations: F, could not be assessed because of dysphasia; R, right-handed; cat., categories. *Abnormally poor score.

posterior damage. Her performance IQ score was 10 points lower than her verbal score, she had difficulty with the Mooney Closure Test, and her recall of visual material was well below the level expected for a woman of her age and intelligence. In contrast, she performed within expected limits on tests of left- hemisphere and frontal lobe function.

Case 4 A 22-year-old woman was referred to us by a clinical psychologist to assess the possibility of organic dysfunction. On several occasions, she had engaged in bizarre behaviors such as undressing in public and urinating on other people;

CHAPTER 28 NEUROPSYCHOLOGICAL ASSESSMENT 762 on one occasion, she attacked her roommate. After these episodes, she was confused and amnesic about her behavior, as well as about the periods just pre- ceding the outbursts. Her neuropsychological test results indicated that her left temporal lobe was abnormal, because her verbal memory, reading, and object naming were im- paired, and she had a very low recall of dichotic words (see Table 28.3). Our di- agnosis of temporal lobe epilepsy with a left-side focus was partly confirmed by a neurologist when EEG results showed left-hemisphere abnormality. As is of- ten the case with epilepsy, a CT scan failed to reveal any unusual features, and nothing in the woman’s history accounts for the epilepsy. The seizures are com- pletely controlled with Dilantin, but her neuropsychological deficits remain.

Case 5 This 60-year-old woman suffered a stroke that, according to her CT scan, ap- peared to be localized in the cortical facial area and in Broca’s area on the left. She was referred to us a year after the stroke because of her poor progress in regaining her speech through speech therapy. In view of her marked dyspha- sia, we first administered a token test. Although this woman appeared to understand much of what was said to her, she was severely dysphasic and therefore obtained a very poor score on the to- ken test. In view of this result, we gave her only a modified battery, designed to answer the referral question of what could be expected if she were to con- tinue speech therapy. Her test results, which are summarized in Table 28.3, showed that she was of average intelligence when measured with a nonverbal test, and she per- formed normally on all nonverbal tests of memory and perception that we ad- ministered. In contrast, she had a great deal of difficulty in copying movements, even though she had no hemiparesis. Indeed, she was totally un- able to copy sequences of facial movements, although she could manage indi- vidual facial movements with some difficulty. These results led us to conclude that this woman was aphasic and had a fa- cial apraxia. We were pessimistic about her chances for further recovery of speech functions.

Case 6 This 37-year-old man had been in a traffic accident some 15 years earlier. He was in a coma for 6 weeks and suffered secondary injury from brain infection. At the time of his accident, he was a student in a graduate program in jour- nalism, having previously obtained a bachelor’s degree with honors in English literature. When we first met him, he had severe motor problems, used canes to walk, and was both apraxic and ataxic. He had great difficulty in pronouncing words, especially when hurried or stressed, but careful language testing on the token test revealed no aphasic symptoms; his language problems were entirely due to a difficulty in coordinating the muscles of the mouth (that is, anarthria). Since the time of his accident, this man lived at home with his parents and had not learned the social skills necessary to cope with his handicap. In short, CHAPTER 28 NEUROPSYCHOLOGICAL ASSESSMENT 763

he was being treated as though he were retarded and was being completely looked after by his family. Indeed, the patient himself believed he was retarded and was very reluctant to attempt rehabilitation. At the urging of his family, we gave him a thorough assessment to evaluate his potential. His results were surprising, even to us. As summarized in Table 28.3, his intellect was superior (WAIS verbal IQ score of 127) and, although he had deficits on some tests, especially those requiring motor skills, his perfor- mance on most tests was average or above average. Despite his obvious motor handicaps, this man was clearly not retarded. One significant cognitive loss, however, was his nonverbal memory, which was very poor. Armed with our test results, we were able to show him—and his family—that he could look after himself and should seek occupational therapy.

Summary

Neurology and clinical neuropsychology have changed radically in the past 25 years. Significant developments in functional and structural imaging have had a significant effect on the field of clinical neuropsychology. Whereas neu- ropsychological assessment had promised a way to localize focal cerebral in- jury, it has now been largely replaced in this function by medical imaging techniques. Not all neurological disease can be detected by imaging. The most sensitive measure of cerebral integrity is behavior, and behavioral analysis con- sistently finds dysfunction that is not seen in MRI, especially in cases of closed- head injury and epilepsy. The tests used in neuropsychological assessment have changed in recent decades, owing in part to the dramatic development of cognitive neuroscience. And the use of test results has changed. Rather than being largely diagnostic, test results are becoming an integral part of rehabilitation. This changing role has economic implications as managed health care challenges the use of exten- sive neuropsychological evaluations, especially when adequate imaging data are available, regardless of its effectiveness. A wide range of clinical neuropsy- chological assessment tools are now available, the choice varying with the par- ticular clinical question being asked. Analysis of the test results must consider a range of variables including age, sex, cultural background, and IQ score. Case histories demonstrate that, despite technological advances, neuropsy- chological assessment is still an important tool for demonstrating functional localization after discrete functional injury and for assisting in planning for re- habilitation.