Neuropsychological Assessment of Cognitive Functions …downloads.pearsonclinical.com/videos/... ·...

Assessment of Cognitive Functions – TBIDr. Dean Delis

9/7/2016

Copyright 2016. Pearson Education and its affiliates. All rights reserved. 1

Neuropsychological Assessment of Cognitive Functions in Individuals with TBI: Part 2

Dean C. Delis, Ph.D.

Professor Emeritus

University of California, San Diego, School of Medicine

• California Verbal Learning Test – II• California Verbal Learning Test – Children’s Version• Delis-Kaplan Executive Function System• Delis Rating of Executive Function• Wechsler Intelligence Test for Children – IV Integrated• Wechsler Intelligence Test for Children – V Integrated

Disclosure: I am an author of the following tests and receive royalties from them:


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TBI

• TBI accounts for more than 50,000 deaths per year

• TBI comprises 50% of deaths due to physical injury

Combat TBI - Prevalence

• Over 20,000 soldiers overseas have suffered from blast-related concussions caused by improvised explosive devices

• 28% of all military evacuated to Walter Reed Medical Center have TBIs


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Leading Causes of TBI

Motor VehicleAccident

50%

Falls21%

Assault12%

Sports10%Other

7%

*

Concussion/TBI

Mild Moderate Severe

Altered or LOC < 30 min

&

Normal CT &/or MRI

LOC < 24 hours

&

Abnormal CT &/or MRI

LOC > 24 hours

&

Abnormal CT &/or MRI

GCS = 13-15 GCS = 9-12 GCS = < 9

PTA < 24 hours PTA < 7 days PTA > 7 days


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Physiology of InjuryTwo Main Mechanisms of Brain Injuries:1. Focal: Contusion (bruise) or Hematoma (blood

mass with possible pressure effects)2. Diffuse: Diffuse axonal injury in which there is

stretching and tearing of neurons• TBI may involve both• Focal damage = More likely to be seen on CT or MRI

brain scans• Diffuse = Often difficult to be detected on CT or MRI

brain scans3. Implications for cognitive deficits:

Focal/lateralized versus more generalized cognitive impairments.

Diffuse Axonal Injury (DAI)

• Results from acceleration-deceleration forces

www.brainlaw.com


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Common Areas of Assessment in the Neuropsychological Evaluation

• Verbal Attention: Simple/Complex (Working Memory)

• Visual Attention: Visual Scanning/Multi-variable

• Language Skills: Vocabulary, Reading, Spelling

• Written Math

• Visual-Spatial Perception and Construction Skills

• Verbal Learning and Memory (Stories v. Word Lists)

• Design Learning and Memory

• Verbal Abstract Thinking

• Nonverbal Reasoning

• Novel Problem Solving/Concept Formation

• Fluency of creative thinking (verbal v. nonverbal)

• Cognitive Flexibility/Multi-tasking (verbal v. nonverbal tasks)

• Processing Speed

• Motor Speed and Dexterity

Importance of Estimating Premorbid Verbal Functioning

• Definition of Acquired Deficit: A decline from a premorbid level.

– Acquired deficits in adults v. acquired deficits in children (deficit versus delay).

• Methods for estimating premorbid level of cognition should be used in a flexible manner.

• Method 1: Scores on “Hold Tests” (e.g., Reading; Vocabulary). Example of when not to use: Left temporal-parietal lesion.

• Method 2: Education-Corrected Norms. Example of when not to use: brain insult occurred prior to or while attending school.

• Method 3: Past School Records (e.g., group achievement test results). Example of when not to use: Unstable home environment.


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Cognitive Domains Particularly Vulnerable to TBI

• New Learning and Memory

• Higher-Level Executive Functions

• Visual-Motor and Verbal Processing Speed

• Have in common: Complex, multi-factorial cognitive functions


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CVLT II List A Trial 1 v. Digit Span Forwards

• Correlate around .90

• Digit Span Forward > Trial 1 Emotional Factor?

• Trial 1 > Digit Span Forward Rapid Auditory Processing Deficit?


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Span/Slope Scenarios

20

40

60

80

100

Color Naming Word Reading Inhibition Switching

aver

age

tim

e to

com

ple

tion

(se

conds)

FLE

TLE

Control

Color-Word Interference Test

Group x condition; F[6,186] = 4.3, p< .001*Cohen’s d reported as ES estimate between FLE group and controls

*

*

d = .73*d = .71

d = .89

d = 1.15

McDonald, C. R. Delis, D. C., Norman, M. A., Wetter, S. R., Tecoma, E. S., & Iragui, V. J. (in press). Epilepsy & Behavior.


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0

20

40

60

80

100

120

140

Verbal IQ PerformanceIQ

Full Scale IQ

C.D.’s IQ Scores

0

2

4

6

8

10

12

14

Sca

led

Sco

re

Color Name Word Read Inhibition Inhib/Switch Inhib/SwitchErrors (11)

C.D.’s Scores on the DKEFS Color-Word Interference Test

Three EF profiles: Deficit only in time to completion, deficit only in errors, deficit in both


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0

3

6

9

12

15

Filled Dots Empty Dots Only Switching

aver

age

num

ber

of

des

igns

ated

FLE

TLE

Controls

Design Fluency Test

F(4,126) = 2.5, p< .05; η2 = .07

*

McDonald, C. R. Delis, D. C., Norman, M. A., Tecoma, E. S., & Iragui, V. J. (in press). Discriminating patients with frontal lobe epilepsy and temporal lobe epilepsy: Utility of a new measure of design fluency. Neuropsychology.

Correct Raw Score = 8Errors = 0

Aged Scale Score = 10

Design Fluency: Condition 1Filled Dots


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Design Fluency: Condition 2 Empty Dots Only

Correct Raw Score = 9Errors = 1


Design Fluency: Condition 3 Switching

Correct Raw Score = 0Set Loss Errors = 6



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0

2

4

6

8

10

12

14

Sca

led S

core

s

FilledDots

EmptyDots

Switching Set LossDesigns

RepeatedDesigns

C.D.’s Scores on the DKEFS Design Fluency Test

10

30

50

70

90

110

130

Visual Scanning NumberSequencing

LetterSequencing

Number-LetterSwitching

Motor Speed

Tim

e t

o c

om

ple

tio

n (

se

co

nd

s)

FLETLEcontrols

Trail Making Test

Group x condition; F[8,248] = 9.0, p < .01, η2 = .23

*

McDonald, C. R., Delis, D. C., Norman, M. A., Tecoma, E. S., & Iragui, V. J. (in press). Is impairment in set-shifting specific to frontal-lobe dysfunction? Evidence from patients with frontal-lobe or temporal-lobe epilepsy. Journal of the International Neuropsychological Society.


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C.D.’s Scores on the DKEFS Trail Making Test


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Case Example: NA

• 15- year-old male

• Native American/White

• Right Handed

• Possible Fetal Alcohol Syndrome

• h/o ADHD

• WISC-IIIFSIQ = 87

VIQ = 73

PIQ = 106

VC = 75

PO = 105

FD = 75

PS = 101

D-KEFS Trail Making Test: NA’s Results

0

2

4

6

8

10

12

Scal

ed S

core

VisualScanning

NumberSquencing

LetterSequencing

Number-Letter

Sequencing

Motor Speed

Condition

Contrast Scores

NLS vs. Visual Scan = 5

NLS vs. Number Seq = 5

NLS vs. Letter Seq = 7

NLS vs. Combined = 1

NLS vs. Motor Speed = 2


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PF

Age at injury: 7

Front seat collapsed, depressed bifrontal skull fracture. GCS = 8-9

Bilateral prefrontal damage, left > right

Post-Injury: Normal on most neuro-psychological tests

MRI Brain Scans of PF and His Twin Sister


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PF’s Speed/Accuracy Scores on D-KEFS Tests

PF’s Scores on IQ Versus Executive Function Tests


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Processing Speed Measures

• Coding• Symbol Search• Trails Visual Scanning• Trails Number Sequencing• Trails Letter Sequencing• Trails Switching• [Trails Motor Speed]

Visual-Motor Verbal

• CWIT Naming• CWIT Reading• CWIT Inhibition• CWIT Inhibition/Switching• Verbal Fluency Letter • Verbal Fluency Category• Verbal Fluency Switching

Completion Times v. Errors

Differential error rate will tell you if this Trails profile likely reflects only a visual-motor processing speed deficit or also an executive function impairment

5%

16%

9%5%


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• Test of Memory Malingering• CVLT-II Forced Choice Trial• Medical Symptom Validity Test• Word Memory Test• Word Choice Test• Victoria Symptom Validity Test• Rey 15 Item Test• b Test• Dot Counting Test• Validity Indicator Profile• Hiscock Digit Memory Test• Portland Digit Recognition Test

Cognitive/Performance Validity Test

Future Embedded Performance Validity Measures


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CVLT-II Scores Across Exams

Dr. Y’s Testing 7/10

93% 93%

Dr. Delis’ Testing 7/11 Dr. X’s Testing 1/09

Scores on Trail Making Tests Across Exams

69%

35%

63%

Dr. X’s Exams in 2/2012 and 10/2012 Dr. Delis’ Exam in 2/2014

5%


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16%

1%

25%

63%

Ms. J’s Scores on the Color‐Word Interference Test

Criteria for Concluding that a Low Score Represents an Acquired Cognitive Impairment

1. The score represents a significant decline from an estimated premorbid level of functioning. This criterion applies better to some cognitive domains relative to others (e.g., phonemic fluency versus cognitive flexibility).


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1. The score represents a significant decline from an estimated premorbid level of functioning. This criterion is better applied to some cognitive domains relative to others (e.g., phonemic fluency versus cognitive flexibility).

2. The score is significantly lower not only from a statistical perspective, but also from a base rate perspective.


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3. The score represents an internally consistent cognitive deficit according to known brain-behavior relationships.

16%

1%

25%

63%

Ms. J’s Scores on the Color‐Word Interference Test


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3. The score represents an internally consistent cognitive deficit according to known brain-behavior relationships.

4. The score is a relatively consistent finding across repeat neuropsychological exams.

CVLT-II Scores Across Exams

Dr. Y’s Testing 7/10

93% 93%



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R.S.’s Scores on Various Cognitive Tests

90%

Dr. Delis’ Testing 8/13

Tests Often Not Affected by Brain Damage

Tests Vulnerable to Brain Damage

75%

87%

16%

8%

R.S.’s Scores on Various Cognitive Tests

90%


Tests Often Not Affected by Brain Damage

91%

84%

75%

87% 86%

16%

5%8%

Tests Vulnerable to Brain Damage


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My Recommendations for Report Writing

Include a table describing normative data for each test

The normative data for the neuropsychological tests were taken from the following studies:

Test Number of normal subjects

Demographic Correction

Reference

WAIS-IV 2,200 Age Wechsler, 2008

WMS-IV 1,400 Age Wechsler, 2009

ACS 1,400 to 2,200 Age Wechsler, 2009

WRAT-4 3,000 Age Wilkinson & Robertson, 2006

BNT 531 Age, Gender, Education

Heaton et al., 1999

WCST 899 Age, Gender, Education

Heaton et al., 1993

CVLT-2 1,087 Age and Gender Delis et al., 2000

D-KEFS 1,750 Age Delis et al., 2001

Motor Tests 1,212 Age, Gender, Education

Heaton et al., 2004

MMPI-2 RF 2,600 Gender Ben-Poraf & Tellegen, 2008


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• Mildly Impaired• Moderately Impaired• Severely Impaired

Results Section of Report

• Mildly below average• Moderately below average• Severely below average






Include a large table with all main standardized scores and percentile ranks



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Cognitive Validity Measures Raw

ACS Word Choice Test 50/50 >25 Cum %ile Clin Samp

CVLT-2 Forced Choice 15/16 5 Cum %ile Norm Samp

Reliable Digit Span 14 >25 Cum %ile Clin Samp

WMS-IV VR Recog 6/7 51-75 Cum %ile Norm Samp

Attention Standardized Score Percentile Rank

WAIS-IV Digit Span Total ASS = 15 95

Forward ASS = 16 98

Backward ASS = 14 91

Sequencing ASS = 12 75

D-KEFS Trails Visual Scanning ASS = 11 63

WAIS-4 Symbol Search ASS = 10 50

Language

WASI-II Vocabulary T = 59 82

NAB Naming Spontaneous (31/31) T = 53 62

WRAT-4 Reading (Grade = 12.9) SS = 100 50

WRAT-4 Spelling (Grade = >12.9) SS = 112 79

D-KEFS CWIT Color Naming ASS = 13 84

D-KEFS CWIT Word Reading ASS = 13 84

WASI-II VCI SS = 105 63

Arithmetic

WRAT-4 Math Comp (Grade = >12.9) SS = 104 61

Spatial Cognition

WMS-4 VR Copies (43/43) >75 cum %ile Norm Samp

WASI-II Block Design T = 53 62

WASI-II PRI SS = 105 63

Visual-Motor Processing Speed

WAIS-IV Coding ASS = 12 75

WAIS-4 Symbol Search ASS = 10 50

WAIS-IV PSI SS = 105 63

Memory

WMS-IV LM1 (35/50) ASS = 14 91

WMS-IV LM2 (29/50) ASS = 13 84

WMS-IV LM Recog (T=25/30; Hits=14/15; FP=4/15)

51-75 cum %ile Norm Samp

WMS-IV VR1 (35/43) ASS = 10 50

WMS-IV VR2 (27/43) ASS = 10 50

WMS-IV VR Recog (6/7) 51-75 cum %ile Norm Samp


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CVLT-2

List A 1-5 Total (49) T = 49 46

Raw Z-score

List A Trial 1 4 -1.5

List A Trial 2 8 -0.5

List A Trial 3 11 0

List A Trial 4 13 0.5

List A Trial 5 13 0

List B 6 0

Short Delay Free 9 -0.5

Short Delay Cued 10 -1

Long Delay Free 8 -1.5

Long Delay Cued 8 -1.5

Semantic Cluster -0.4 -1

Serial Cluster (bidirection) 1.1 0.5

% Primacy 31% 0.5

% Middle 47% 0

% Recency 22% -1

Slope (1-5) 2.3 1.5

Slope (1-2) 4 0.5

Consistency 92% 1

Repetitions Total 7 0.5

Intrusions Total 1 -0.5

Recognition Hits 12 -2

False Positive Total 1 -0.5

Recog Discrim Total 2.5 -0.5

Response Bias Total 0.6 1.5

Forced Choice Accuracy 15/16 5 Cum %ile Norm Samp

Executive Functions Standardized Score Percentile Rank

D-KEFS Verbal Fluency

Letter Fluency (62) ASS = 18 99

Category Fluency (59) ASS = 18 99

Switching Total Resp. (21) ASS = 19 99

Switching Accuracy (20) ASS = 18 99

Total Set Loss Errors (0) ASS = 13 84

Total Repetition Errors (3) ASS = 10 50

WASI-II Similarities T = 48 42

WASI-II Matrix Reasoning T = 54 66

WCST-128

Perseverative Responses (3) T = 54 66

Categories (6) > 16 Cum %ile Norm Samp

Failure to Maintain Set (0) > 16 Cum %ile Norm Samp

Total Errors (9) T = 54 66

Total Other Responses (0)

D-KEFS CWIT

Color Naming ASS = 13 84

Word Reading ASS = 13 84

Inhibition ASS = 14 91

Inhibition /Switching ASS = 14 91

Color Naming Errors (0) 100 cum %ile Norm Samp

Word Reading Errors (1) 10 cum %ile Norm Samp

Inhibition Errors (1) ASS = 11 63

Inhibition/Switching Errors (0) ASS = 12 75

D-KEFS Trails

Visual Scanning ASS = 11 63

Number Sequencing ASS = 12 75

Letter Sequencing ASS = 14 91

Number-Letter Switching ASS = 13 84

Visual Scanning Omission Errors (1) 15 cum %ile Norm Samp

NL Switch Sequencing Errors (0) 100 cum %ile Norm Samp

NL Switch Set-Loss Errors (1) 24 cum %ile Norm Samp

NL Switch Total Errors (1) ASS = 10 50

Motor Speed ASS = 13 84

MOTOR

Finger Tapping DH (raw ave = 40.4) T = 41 18

Finger Tapping NDH (raw ave = 40.2) T = 48 42

D-KEFS Trails Motor Speed ASS = 13 84


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Please: Include a large table with all main standardized scores and percentile ranks

Discussion Section of Report



Thank You


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