Assessing Deficits in Assessing Deficits in Cognitive FunctioningCognitive Functioning

Theodore Tsaousides, Ph.D.Theodore Tsaousides, Ph.D.

Mount Sinai School of Mount Sinai School of MedicineMedicine

New York, NYNew York, NY

NeuropsychologyNeuropsychology

The science of brain-behavior relationshipThe science of brain-behavior relationship

Dysfunctional brain Dysfunctional brain Dysfunctional Dysfunctional behaviorbehavior

Injury to the brain leads to:Injury to the brain leads to: Physical changesPhysical changes Cognitive changesCognitive changes Emotional changesEmotional changes Behavioral changesBehavioral changes

Neuropsychology: AssessmentNeuropsychology: Assessment

Evaluate degree of impact of brain Evaluate degree of impact of brain damage on behaviordamage on behavior DiagnosisDiagnosis Patient carePatient care Treatment planning/evaluationTreatment planning/evaluation ResearchResearch

Good assessment Good assessment good treatment good treatment

Neuropsychology: TreatmentNeuropsychology: Treatment

RestorationRestoration RetrainingRetraining RepetitionRepetition

CompensationCompensation Skill buildingSkill building Use of toolsUse of tools

RestructuringRestructuring Environmental adaptationsEnvironmental adaptations Changes in demandsChanges in demands

Disorders that affect the Disorders that affect the brain’s functionbrain’s function

Traumatic brain injury (TBI)Traumatic brain injury (TBI) Vascular disordersVascular disorders Degenerative disordersDegenerative disorders Toxic exposureToxic exposure InfectionsInfections Brain tumorsBrain tumors Oxygen deprivationOxygen deprivation Metabolic/endocrine disordersMetabolic/endocrine disorders Thought disordersThought disorders

Traumatic Brain InjuryTraumatic Brain Injury

DefinitionDefinition CausesCauses Incidence in the USIncidence in the US SymptomsSymptoms

Traumatic Brain InjuryTraumatic Brain Injury DefinitionDefinition

Insult to the brain…caused by external physical Insult to the brain…caused by external physical force…which results in impairment of cognitive force…which results in impairment of cognitive abilities or physical functioning (BIAA)abilities or physical functioning (BIAA)

A traumatically induced physiologic disruption A traumatically induced physiologic disruption of the brain function as manifested byof the brain function as manifested by

Loss of consciousnessLoss of consciousness Loss of memory for events before or after the Loss of memory for events before or after the

accidentaccident Alteration of mental state at the time of the accidentAlteration of mental state at the time of the accident Focal neurological deficits that may or may not be Focal neurological deficits that may or may not be

transient (ACRM)transient (ACRM)

Traumatic Brain InjuryTraumatic Brain Injury

CausesCauses

Traumatic Brain InjuryTraumatic Brain Injury

Incidence annuallyIncidence annually 1.4 million sustain TBI (based on 1.4 million sustain TBI (based on

Hospital admission and ED recordsHospital admission and ED records UnidentifiableUnidentifiable

Physician visitsPhysician visits No care soughtNo care sought Military/VAMilitary/VA Other settings (psychiatric/substance Other settings (psychiatric/substance

abuse settings; shelters; prisons)abuse settings; shelters; prisons)

TBI: Physical symptomsTBI: Physical symptoms

FatigueFatigue Sleep problemsSleep problems HeadachesHeadaches Balance problems/dizzinessBalance problems/dizziness Vision problemsVision problems Chronic painChronic pain Sexual dysfunctionSexual dysfunction

TBI: Cognitive symptomsTBI: Cognitive symptoms

AttentionAttention Processing speedProcessing speed Memory and learningMemory and learning Language and communicationLanguage and communication Executive functionsExecutive functions

TBI: Emotional symptomsTBI: Emotional symptoms

ApathyApathy AbuliaAbulia DisinhibitionDisinhibition HyperemotionalityHyperemotionality DepressionDepression AnxietyAnxiety

Behavioral symptomsBehavioral symptoms Forgetting/missing appointmentsForgetting/missing appointments Getting lostGetting lost Difficulty following instructionsDifficulty following instructions Not paying attentionNot paying attention InappropriateInappropriate ArgumentativeArgumentative OutburstsOutbursts Forgetting to take medicationForgetting to take medication ImpatientImpatient DisorganizedDisorganized ImpulsiveImpulsive

What to doWhat to do

YouYou ObserveObserve ScreenScreen ReferRefer

MeMe Review referralReview referral Conduct testingConduct testing Provide feedbackProvide feedback

First impressionsFirst impressions

Conclusions based on interactions:Conclusions based on interactions: Non-compliantNon-compliant Difficult to engageDifficult to engage Poor historianPoor historian OppositionalOppositional Makes things upMakes things up

ObserveObserve

AppearanceAppearance Is appearance unusual?Is appearance unusual?

OrientationOrientation Person, place, time, (situation, object)Person, place, time, (situation, object)

SpeechSpeech Receptive language (unable to follow Receptive language (unable to follow

instructions)instructions) Fluency (word finding problems)Fluency (word finding problems)

ObserveObserve Attention/concentrationAttention/concentration

Distractibility (distracted by things around)Distractibility (distracted by things around) Spacing out (need to repeat yourself often)Spacing out (need to repeat yourself often)

MemoryMemory Short-term (forgets what was just said)Short-term (forgets what was just said) Prospective memory (forgets to get things done)Prospective memory (forgets to get things done) Past memories (remembers things inaccurately)Past memories (remembers things inaccurately)

Thought ProcessThought Process Logical & coherent (responses make no sense)Logical & coherent (responses make no sense) Blocking (unable to come up with answers)Blocking (unable to come up with answers) Tangentiality (cannot stay on track)Tangentiality (cannot stay on track)

ObserveObserve Cognitive functioningCognitive functioning

Vocabulary (vocabulary is consistent with education)Vocabulary (vocabulary is consistent with education) General information (also consistent with education)General information (also consistent with education)

Emotional stateEmotional state Overwhelmed and anxiousOverwhelmed and anxious DepressedDepressed ApatheticApathetic HyperemotionalHyperemotional

Special preoccupations/experiencesSpecial preoccupations/experiences Obsessions (perseverations)Obsessions (perseverations) Bodily preoccupations (physical symptoms)Bodily preoccupations (physical symptoms) Paranoid thoughtsParanoid thoughts

Insight/judgmentInsight/judgment Reasoning (poor social judgment/decision making)Reasoning (poor social judgment/decision making)

ScreenScreen

Brain Injury Screening Questionnaire Brain Injury Screening Questionnaire (BISQ)(BISQ) Part One (lifelong)Part One (lifelong)

Blow to the head?Blow to the head? In a car crashIn a car crash Being hit by a falling objectBeing hit by a falling object Being assaulted or muggedBeing assaulted or mugged

Hospitalized or in the ER?Hospitalized or in the ER? ConcussionConcussion Near drowningNear drowning

Altered mental state?Altered mental state?

BISQ – Part OneBISQ – Part One

BISQ – Part TwoBISQ – Part Two

Part Two (within past month)Part Two (within past month) Physical symptomsPhysical symptoms

Having trouble falling asleep or staying asleepHaving trouble falling asleep or staying asleep Having double vision or blurred visionHaving double vision or blurred vision

Cognitive symptomsCognitive symptoms Being easily distractedBeing easily distracted Difficulty following instructions, written or oralDifficulty following instructions, written or oral

Behavioral symptomsBehavioral symptoms Feeling impatient or irritableFeeling impatient or irritable ArguingArguing

BISQ – Part TwoBISQ – Part Two

BISQ – Part TwoBISQ – Part Two

ScreenScreen

Positive screen ≠ diagnosisPositive screen ≠ diagnosis

Positive screen = need to evaluate Positive screen = need to evaluate furtherfurther

Other short measuresOther short measures

Mini-Mental State Examination (MMSE)Mini-Mental State Examination (MMSE) Dementia Rating Scale 2 (DRS-2)Dementia Rating Scale 2 (DRS-2) Repeatable Battery for the Assessment Repeatable Battery for the Assessment

of Neuropsychological Status (RBANS)of Neuropsychological Status (RBANS) NART/WTARNART/WTAR TONI-3TONI-3 WASIWASI

ReferRefer PhysiatristPhysiatrist

Most knowledgeable specialty re: TBIMost knowledgeable specialty re: TBI Assessment of physical symptomsAssessment of physical symptoms Referrals to neuro & rehab psychology, PT, OT, SpeechReferrals to neuro & rehab psychology, PT, OT, Speech

NeurologistNeurologist ImagingImaging Neurological impairmentsNeurological impairments

NeuropsychologistNeuropsychologist Assessment of cognitive/emotional/behavioral functioningAssessment of cognitive/emotional/behavioral functioning

PsychiatristPsychiatrist Assessment of extent of psychiatric comorbidityAssessment of extent of psychiatric comorbidity Not always aware of TBI and its consequencesNot always aware of TBI and its consequences

Review referralReview referral

PreparationPreparation Review referral questionReview referral question

DiagnosticDiagnostic DescriptiveDescriptive

Obtain medical records (incl. imaging)Obtain medical records (incl. imaging) Obtain academic recordsObtain academic records

Clinical observationsClinical observations

Review referralReview referral

Clinical interviewClinical interview Patient’s backgroundPatient’s background Social historySocial history Present life historyPresent life history Medical historyMedical history Current medical statusCurrent medical status Circumstances surrounding the Circumstances surrounding the

examinationexamination

Conduct testingConduct testing Test selectionTest selection

Goals of assessmentGoals of assessment Validity and reliabilityValidity and reliability Sensitivity and specificitySensitivity and specificity Parallel formsParallel forms Time and costTime and cost Non-standardized assessmentNon-standardized assessment

Conduct testingConduct testing Cognitive DomainsCognitive Domains

Processing speed Processing speed AttentionAttention Visual/Perceptual skillsVisual/Perceptual skills Verbal/Reading skillsVerbal/Reading skills Intellectual functioningIntellectual functioning Memory and learningMemory and learning Executive functioningExecutive functioning

Emotional functioning/PersonalityEmotional functioning/Personality

Provide feedbackProvide feedback Review and integrate assessment Review and integrate assessment

resultsresults Write reportWrite report Follow-up interview with patientFollow-up interview with patient Others involved in care presentOthers involved in care present Client-friendly languageClient-friendly language ValidateValidate EditEdit

ConclusionConclusion Damage to the brain causes physical, Damage to the brain causes physical,

cognitive, emotional, and behavioral deficitscognitive, emotional, and behavioral deficits Several conditions can cause damage to the Several conditions can cause damage to the

brainbrain TBI is a TBI is a commoncommon but often but often unidentifedunidentifed

conditioncondition Cognitive deficits of TBI often manifest as Cognitive deficits of TBI often manifest as

“behavioral problems”“behavioral problems” Proper screening and identification implies Proper screening and identification implies

appropriate treatmentappropriate treatment

First impressions revisitedFirst impressions revisited Conclusions based on clinical Conclusions based on clinical

observation and screening:observation and screening: Non-compliant = Non-compliant = Difficult to engage = Difficult to engage = Poor historian =Poor historian = Oppositional =Oppositional = Makes things up = Makes things up =

ReferencesReferences Fischer, J.S., Hannay, J.H., Loring, D.W., & Lezak, M.D. (2004). Fischer, J.S., Hannay, J.H., Loring, D.W., & Lezak, M.D. (2004).

Observational methods, rating scales, and inventories. In M.D. Lezak, Observational methods, rating scales, and inventories. In M.D. Lezak, D.B. Howieson, & D.W. Loring (Eds.), D.B. Howieson, & D.W. Loring (Eds.), Neuropsychological Assessment, Neuropsychological Assessment, 44thth edition edition (pp. 698-737). New York: Oxford University Press. (pp. 698-737). New York: Oxford University Press.

Gordon, W.A., Haddad, L, Brown, M., Hibbard, M.R., & Silwinski, M. Gordon, W.A., Haddad, L, Brown, M., Hibbard, M.R., & Silwinski, M. (2000). The sensitivity and specificity of self-reported symptoms in (2000). The sensitivity and specificity of self-reported symptoms in individuals with traumatic brain injury. individuals with traumatic brain injury. Brain Injury, 14,Brain Injury, 14, 21-33. 21-33.

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Lezak, M.D., Howieson, D.B., & Loring, D.W. (2004). Lezak, M.D., Howieson, D.B., & Loring, D.W. (2004). Neuropsychological assessment Neuropsychological assessment (4(4thth ed.). New York: Oxford University ed.). New York: Oxford University Press.Press.

McCullagh, S., & Feinstein, A. (2005). Cognitive changes. In J.M. McCullagh, S., & Feinstein, A. (2005). Cognitive changes. In J.M. Silver, T.W. McAllister, & S.C. Yudofsky (Eds.), Silver, T.W. McAllister, & S.C. Yudofsky (Eds.), Textbook of Traumatic Textbook of Traumatic Brain InjuryBrain Injury (pp.321-337). Arlington, VA: American Psychiatric (pp.321-337). Arlington, VA: American Psychiatric Publishing.Publishing.

Strauss, E., Sherman, E.M.S., & Spreen, O. (2006). Strauss, E., Sherman, E.M.S., & Spreen, O. (2006). A compendium of A compendium of neuropsychological tests neuropsychological tests (3(3rdrd ed.) ed.).. New York: Oxford University Press. New York: Oxford University Press.

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Thank you for your attentionThank you for your attention

Theodore Tsaousides, Ph.D.Theodore Tsaousides, Ph.D.

Instructor/Rehabilitation Instructor/Rehabilitation NeuropsychologistNeuropsychologist

Mount Sinai School of MedicineMount Sinai School of Medicine

e: e: theodore.tsaousides@mssm.edutheodore.tsaousides@mssm.edu

p: 212-241-6547p: 212-241-6547