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NEUROPSYCHOLOGICAL ASSESSMENT TESTS AND PROCEDURES
Most neuropsychologists obtain standard intellectual measures including Full Scale IQ, Verbal IQ, and Performance IQ. In adults, the most commonly employed intelligence test is the Wechsler Adult Intelligence Scale-Revised (WAIS-R). The three summary IQ measures are derived from averaging individual subtest scores. Thus, unless diffuse decline in cognitive abilities exists (e.g., dementia or head injury), the usefulness of the summary measures is limited (Lezak, 1988). Nevertheless, by tradition if nothing else, these scores are dutifully reported in the neuropsychological report. Of more interest is specific IQ subtest performance, and most neuropsychologists interpret tests scores with non-IQ subtests measures of similar neuropsychological constructs (e.g., WAIS-R Block Design compared with the Rey-Osterrieth Complex Figure). Full Scale IQ measures are helpful in selected cases such as in head injury because, in addition to reflecting diffuse cognitive decline, they are familiar and many believe (erroneously) that they know what IQ scores mean. One major advantage of IQ tests is their large-scale formal standardization with excellent normative information.
Academic Achievement. Achievement testing usually consists of reading single words, spelling, and arithmetic. Achievement tests such as the Wide Range Achievement Tests (WRAT) are well standardized and provide good measures of scholastic attainment or accomplishment. However, the reading subtest requiring pronunciation of single words is often used to estimate premorbid level of function. As the test gets harder, words are presented than cannot be pronounced correctly based upon phonics (e.g., paradigm). Thus, correct pronunciation is taken as evidence of prior familiarity, and unless the patient is aphasic, provides one measure to estimate level of function prior to an accident or disease.
Other measures of academic achievement are more specialized and are commonly employed in school-aged children when learning disability or attention deficit disorders are being evaluated. These tests may include measures of reading comprehension for paragraphs, receptive vocabulary (e.g., point to the picture of an owl), or reading recognition.
Language. Language is commonly assessed with the Aphasia Screening Test of the Halstead-Reitan Battery. However, this test yields primarily qualitative information. It is frequently supplemented by examining generative verbal fluency (how many words can be generated beginning with either a particular letter of the alphabet or from a specific semantic category such as fruits and vegetables), confrontation naming (e.g., Boston Naming Test or Multilingual Aphasia Examination Visual Naming Test), or comprehension (e.g., Token Test). Comprehensive aphasia batteries such as the Boston Diagnostic Aphasia Examination, Multilingual Aphasia Examination, or Western Aphasia Battery are typically not administered unless there are specific questions regarding aphasia subtyping or the need to fully delineate language functioning exists.
Visual Spatial. Visual spatial ability is assessed with a variety of tests, the most familiar of which are the WAIS-R Block Design test and the Rey-Osterrieth Complex Figure. Although the Bender Gestalt test has been frequently used to assess visual motor function, it has been used less over the last decade, perhaps due to poor standardization and scoring criteria and the presence of newer tests of visual spatial function. Other commonly used tests include the Visual Retention Test, Judgement of Line Orientation and Facial Recognition Tests of Benton, and the Hooper Visual Organization Test.
Attention/Concentration. Attention and concentration can be measured with a variety of neuropsychological tests. From the Halstead-Reitan Battery, the Seashore Rhythm Test and Speech Sounds Perception Test are sensitive to attentional deficits. Many neuropsychologists continue to use these tests as measures of right and left temporal lobe function, but recent research from Reitan's laboratory shows that although both are good measures of attentional processes, they are poor measures of lateralized temporal lobe impairment (Reitan & Wolfson, 1989; Reitan & Wolfson, 1990). Trail Making A and B require the patient to connect either numbers, or alternate between numbers and letters (i.e., 1-A-2-B, etc.), distributed in a spatial array. Although Trail Making can be affected by visual spatial impairment due to a significant scanning component, the time to completion makes it also sensitive to attentional impairments. The task alternation aspect of Trail Making B makes it sensitive to certain aspects of executive/frontal lobe function.
Digit span from the WAIS-R (both forward and backward) is a good measure of gross attention, although vigilance tests (i.e., Continuous Performance Test in which the patient responds only when the letter "X" is flashed among a series in individually presented letters, or to respond only to the letter "X" if immediately preceded by the letter "A") and reaction time measures may be obtained when a more fine grained analysis is necessary. The Paced Auditory Serial Addition Tests (PASAT) is a measure of sustained attention, and requires the patient to add pairs of serially presented randomized number so that each number is added to the number immediately preceding it.
Memory and Learning. Memory is most often assessed using the Wechsler Memory Scale (WMS) or its revision (WMS-R). However, the WMS has been criticized on both methodological and theoretical grounds (Erickson and Scott, 1977; Loring and Papanicolaou, 1987). The WMS, published in 1945, yields a memory quotient, or MQ, that may be informally contrasted with a patient's IQ to suggest if a relative impairment exists in memory functioning. However, the individual subtests contributing to the MQ were not standardized, and several subtests contained constructs that, although necessary for successful memory performance, are not genuine measures of memory (e.g., Orientation and Mental Control). In addition, the WMS does not examine retention of information over time.
The most commonly employed WMS subtests that are individually administered include Logical Memory, Visual Reproduction, and Paired Associate Learning. Logical Memory is a test of paragraph or prose passage recall. Visual Reproduction examines immediate reproduction of simple geometric designs. Paired Associate Learning tests the ability to form associations between word pairs, some of which are easy (e.g., penny/quarter), and some of which are difficult (yield/page). When selected subtests are administered, a 30 minute delay component is often obtained (e.g., Russell, 1975). Significant limitations of the WMS include lack of adequate scoring criteria for memory units of the paragraph, and lack of adequate normative information.
The WMS was revised in 1987, and in addition to retaining the commonly employed subtests described above, added several new subtests although many problems associated with the test remain (Loring, 1989). Five summary measures are derived from performance on this test: General Memory, Verbal Memory, Visual Memory, Delayed Recall, and Attention Concentration. The WMS is now undergoing revision and restandardisation and will most likely be called the WMS-III.
The other major self contained standardized collection of memory subtests in the Memory Assessment Scales (Williams, 1990). The specific content of the items differs from the WMS-R, but it also yields summary measures for General Memory, Verbal Memory, and Visual Memory. It is less popular than the WMS-R, but in our experience at the Medical College of Georgia, it frequently provides lateralizing information in candidates for anterior temporal lobectomy.
Many neuropsychologists give word list learning tasks as additional measures of verbal memory. The most common word list learning tests are the Rey Auditory Verbal Learning Test, California Verbal Learning Test, and Buschke Selective Reminding Test. Visual memory is frequently assessed using the Rey-Osterrieth Complex Figure. However, the specificity of visual memory impairment to right temporal lobe dysfunction is much less than that associated with verbal memory deficits and left temporal lobe impairment. Although the Benton Visual Retention is sometimes employed as a visual memory test, it does not examine retention of material over long delays, and is generally considered as a test of visual construction or visual attention. The Memory Assessment Scale is a battery of tests similar in construction to the WMS, and yields a general memory measure in addition to verbal and visual memory summary scores.
Executive Function/"Frontal" Lobe Tests. Tests of executive function, informally called frontal lobe tests, most commonly include the Wisconsin Card Sorting Test (WCST) and Halstead Category Test. In the WCST, the subject is given a deck of cards that can be sorted into different categories based upon color, shape, and number. It is the subject's task to figure out how to sort the cards based solely on feedback from the examiner whether each response is "correct" or "incorrect." The Category Test is similar, although each stimulus represents a number from 1-4 and it is the patient's task to figure out what aspect of the stimulus is used for number representation. The only information given to the patient concerns the correctness of the response. Consequently, the patient must engage a series of hypotheses to learn the underlying principle. Tests of maze performance may also be used to assess planning and impulse control. Trail Making B is sensitive to task alternation difficulty (1-A-2-B).
Sensory and Motor Function. Tests of sensory and motor function are tested to varying degrees depending both upon the patient population and the biases of the examiner. Common tests of motor and fine motor function include the finger tapping and grooved pegboard tests. Grip strength is assessed with a hand dynamometer. Sensory testing may consist of measures of stereognosis from the Halstead-Reitan Battery, although this test is sensitive to inter-examiner variability. The Halstead-Reitan Battery tactual performance test requires the blindfolded patient to feel different shapes and to fit them into a formboard. However, many factors contribute to the tactual performance test (visual spatial ability, memory, motor function), making this test sensitive to brain impairment independent of its location.
Task Motivation/Test Validity. In patients with mild head injuries, neuropsychological test performance may be the only evidence of cerebral involvement. However, the neuropsychological evaluation is dependent on patient motivation and compliance, and consequently, not all performances in the "impaired" range reflect brain pathology. Although inclusion of explicit measures of task motivation and tests validity should be included in all neuropsychological assessments, it is particularly true when a strong financial incentive to perform poorly on neuropsychological tasks exists.
As with the neurologic evaluation, inconsistent performance may suggest malingering or, at least, failure to put forth one's best effort. However, other factors such as anxiety and fatigue may produce neuropsychological test inconsistencies. Measures of task motivation and test validity include clinical judgement based upon standard neuropsychological tests, validity measures from the MMPI, performance patterns present in existing neuropsychological testing, and formal measures designed explicitly to detect performance distortion (e.g., forced-choice symptom validity checking).
Clinical judgement may be used to infer less than maximum task performance (e.g., an IQ of 60 following a minor head injury with no loss of consciousness), although often clinical experience alone is not a good indicator of motivation (e.g., Heaton et al., 1978). The MMPI contains explicit validity measures, and evidence on the MMPI suggesting that the patients are purposely presenting themselves poorly may be generalized to other test results.
Symptom Validity Memory Testing typically employs a forced choice recognition format for numbers (e.g., Hiscock & Hiscock, 1989). A series of digits is presented, typically on a computer screen. Following a delay ranging from a few seconds to as long as 30 seconds or more, two number sequences are presented from which the subject makes a selection. Feedback regarding correctness of response is given, and getting the correct answer at least half the time may make some patients get the impression that they are doing "too well" and begin purposely choosing the incorrect answer. Thus, performance of actively malingering patients may be below chance. As noted by Lezak (1995), the malingering patient may find it difficult to score within chance over many repeated trials.
Symptom validity testing results are unequivocal when the specific statistical probabilities of less than chance responding is obtained. Thus, the strongest evidence of malingering occurs when a patient scores significantly below chance, indicating that there has been a deliberate attempt to answer incorrectly. To score below chance, the patient must identify the correct answer and then choose the opposite and incorrect answer. That is, a patient must recognize the correct answer significantly above chance to score significantly below chance. Unfortunately, not all suspected malingerers perform worse than chance.
Simple "memory" tests are also frequently used. The most widely employed test in this approach is the 15 item (or 3x5) memory task described by Rey (in Lezak, 1995). The patient is presented with 15 items to "memorize," but in fact, due to immediate recall and the multiple redundancies in the stimuli, this is an extremely simple task. This technique relies on the examiner repeatedly informing the patient how hard the task is.
Personality. Most patients are administered some measure of personality function in addition to the tests of cognitive abilities. The most common approach is to use the MMPI/MMPI2, although some neuropsychologists may choose different inventories such as the MCMI/MCMI2. The need for measures of personality function is clear when performing an evaluation of possible dementia vs. depressive pseudodementia. However, personality testing is not used to determine the likelihood of cerebral compromise. Further, these inventories are unable to determine, for example, the amount of depression that is the primary result of cerebral injury vs. the amount that may be a psychological reaction to cerebral injury. Projective tests of personality are generally not employed in a neuropsychological context unless they are administered as part of a larger series of tests that includes objective measures such as the MMPI.
Personality assessment using the MMPI is frequently helpful in the evaluation of low back pain and in the prediction of outcome following back surgery. In addition, the MMPI may provide information regarding the personality contributions to medical disease including neurologic disease. Frequently, the neurologist may request personality assessment to help in the evaluation of back pain patients or to evaluation if a person's personality characteristics are significant clinical factors. When personality assessment is performed, it may be performed by clinical psychologists without specialized training and expertise in cognitive aspects of clinical neuropsychology. However, in certain cases of personality contributions to clinical complaints in patients with cerebral disease, background in neuropsychology is helpful in overall patient evaluation.