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Assessing Deficits in Cognitive Functioning

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    Assessing Deficits in Cognitive Functioning Assessing Deficits in Cognitive Functioning Presentation Transcript

    • Assessing Deficits in Cognitive Functioning Theodore Tsaousides, Ph.D. Mount Sinai School of Medicine New York, NY
    • Neuropsychology
      • The science of brain-behavior relationship
      • Dysfunctional brain  Dysfunctional behavior
      • Injury to the brain leads to:
        • Physical changes
        • Cognitive changes
        • Emotional changes
        • Behavioral changes
    • Neuropsychology: Assessment
      • Evaluate degree of impact of brain damage on behavior
        • Diagnosis
        • Patient care
        • Treatment planning/evaluation
        • Research
      • Good assessment  good treatment
    • Neuropsychology: Treatment
      • Restoration
        • Retraining
        • Repetition
      • Compensation
        • Skill building
        • Use of tools
      • Restructuring
        • Environmental adaptations
        • Changes in demands
    • Disorders that affect the brain’s function
      • Traumatic brain injury (TBI)
      • Vascular disorders
      • Degenerative disorders
      • Toxic exposure
      • Infections
      • Brain tumors
      • Oxygen deprivation
      • Metabolic/endocrine disorders
      • Thought disorders
    • Traumatic Brain Injury
      • Definition
      • Causes
      • Incidence in the US
      • Symptoms
    • Traumatic Brain Injury
      • Definition
        • Insult to the brain…caused by external physical force…which results in impairment of cognitive abilities or physical functioning (BIAA)
        • A traumatically induced physiologic disruption of the brain function as manifested by
          • Loss of consciousness
          • Loss of memory for events before or after the accident
          • Alteration of mental state at the time of the accident
          • Focal neurological deficits that may or may not be transient (ACRM)
    • Traumatic Brain Injury
      • Causes
    • Traumatic Brain Injury
      • Incidence annually
        • 1.4 million sustain TBI (based on Hospital admission and ED records
      • Unidentifiable
        • Physician visits
        • No care sought
        • Military/VA
        • Other settings (psychiatric/substance abuse settings; shelters; prisons)
    • TBI: Physical symptoms
      • Fatigue
      • Sleep problems
      • Headaches
      • Balance problems/dizziness
      • Vision problems
      • Chronic pain
      • Sexual dysfunction
    • TBI: Cognitive symptoms
      • Attention
      • Processing speed
      • Memory and learning
      • Language and communication
      • Executive functions
    • TBI: Emotional symptoms
      • Apathy
      • Abulia
      • Disinhibition
      • Hyperemotionality
      • Depression
      • Anxiety
    • Behavioral symptoms
      • Forgetting/missing appointments
      • Getting lost
      • Difficulty following instructions
      • Not paying attention
      • Inappropriate
      • Argumentative
      • Outbursts
      • Forgetting to take medication
      • Impatient
      • Disorganized
      • Impulsive
    • What to do
      • You
        • Observe
        • Screen
        • Refer
      • Me
        • Review referral
        • Conduct testing
        • Provide feedback
    • First impressions
      • Conclusions based on interactions:
        • Non-compliant
        • Difficult to engage
        • Poor historian
        • Oppositional
        • Makes things up
    • Observe
      • Appearance
        • Is appearance unusual?
      • Orientation
        • Person, place, time, (situation, object)
      • Speech
        • Receptive language (unable to follow instructions)
        • Fluency (word finding problems)
    • Observe
      • Attention/concentration
        • Distractibility (distracted by things around)
        • Spacing out (need to repeat yourself often)
      • Memory
        • Short-term (forgets what was just said)
        • Prospective memory (forgets to get things done)
        • Past memories (remembers things inaccurately)
      • Thought Process
        • Logical & coherent (responses make no sense)
        • Blocking (unable to come up with answers)
        • Tangentiality (cannot stay on track)
    • Observe
      • Cognitive functioning
        • Vocabulary (vocabulary is consistent with education)
        • General information (also consistent with education)
      • Emotional state
        • Overwhelmed and anxious
        • Depressed
        • Apathetic
        • Hyperemotional
      • Special preoccupations/experiences
        • Obsessions (perseverations)
        • Bodily preoccupations (physical symptoms)
        • Paranoid thoughts
      • Insight/judgment
        • Reasoning (poor social judgment/decision making)
    • Screen
      • Brain Injury Screening Questionnaire (BISQ)
        • Part One (lifelong)
          • Blow to the head?
            • In a car crash
            • Being hit by a falling object
            • Being assaulted or mugged
          • Hospitalized or in the ER?
            • Concussion
            • Near drowning
          • Altered mental state?
    • BISQ – Part One
    • BISQ – Part Two
        • Part Two (within past month)
          • Physical symptoms
            • Having trouble falling asleep or staying asleep
            • Having double vision or blurred vision
          • Cognitive symptoms
            • Being easily distracted
            • Difficulty following instructions, written or oral
          • Behavioral symptoms
            • Feeling impatient or irritable
            • Arguing
    • BISQ – Part Two
    • BISQ – Part Two
    • Screen
      • Positive screen ≠ diagnosis
      • Positive screen = need to evaluate further
    • Other short measures
      • Mini-Mental State Examination (MMSE)
      • Dementia Rating Scale 2 (DRS-2)
      • Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)
      • NART/WTAR
      • TONI-3
      • WASI
    • Refer
      • Physiatrist
        • Most knowledgeable specialty re: TBI
        • Assessment of physical symptoms
        • Referrals to neuro & rehab psychology, PT, OT, Speech
      • Neurologist
        • Imaging
        • Neurological impairments
      • Neuropsychologist
        • Assessment of cognitive/emotional/behavioral functioning
      • Psychiatrist
        • Assessment of extent of psychiatric comorbidity
        • Not always aware of TBI and its consequences
    • Review referral
      • Preparation
        • Review referral question
          • Diagnostic
          • Descriptive
        • Obtain medical records (incl. imaging)
        • Obtain academic records
      • Clinical observations
    • Review referral
      • Clinical interview
        • Patient’s background
        • Social history
        • Present life history
        • Medical history
        • Current medical status
        • Circumstances surrounding the examination
    • Conduct testing
      • Test selection
        • Goals of assessment
        • Validity and reliability
        • Sensitivity and specificity
        • Parallel forms
        • Time and cost
        • Non-standardized assessment
    • Conduct testing
      • Cognitive Domains
        • Processing speed
        • Attention
        • Visual/Perceptual skills
        • Verbal/Reading skills
        • Intellectual functioning
        • Memory and learning
        • Executive functioning
      • Emotional functioning/Personality
    • Provide feedback
      • Review and integrate assessment results
      • Write report
      • Follow-up interview with patient
      • Others involved in care present
      • Client-friendly language
      • Validate
      • Edit
    • Conclusion
      • Damage to the brain causes physical, cognitive, emotional, and behavioral deficits
      • Several conditions can cause damage to the brain
      • TBI is a common but often unidentifed condition
      • Cognitive deficits of TBI often manifest as “behavioral problems”
      • Proper screening and identification implies appropriate treatment
    • First impressions revisited
      • Conclusions based on clinical observation and screening:
        • Non-compliant =
        • Difficult to engage =
        • Poor historian =
        • Oppositional =
        • Makes things up =
    • References
      • Fischer, J.S., Hannay, J.H., Loring, D.W., & Lezak, M.D. (2004). Observational methods, rating scales, and inventories. In M.D. Lezak, D.B. Howieson, & D.W. Loring (Eds.), Neuropsychological Assessment, 4 th edition (pp. 698-737). New York: Oxford University Press.
      • Gordon, W.A., Haddad, L, Brown, M., Hibbard, M.R., & Silwinski, M. (2000). The sensitivity and specificity of self-reported symptoms in individuals with traumatic brain injury. Brain Injury, 14, 21-33.
      • Kay, T., Harrington, D.E., & Adams, R. (1993). Mild traumatic brain injury. American Congress of Rehabilitation Medicine, Head Injury Interdisciplinary Special Interest Group. Definition of mild traumatic brain injury. Journal of Head Trauma Rehabilitation, 8, 86-87.
      • Lezak, M.D., Howieson, D.B., & Loring, D.W. (2004). Neuropsychological assessment (4 th ed.). New York: Oxford University Press.
      • McCullagh, S., & Feinstein, A. (2005). Cognitive changes. In J.M. Silver, T.W. McAllister, & S.C. Yudofsky (Eds.), Textbook of Traumatic Brain Injury (pp.321-337). Arlington, VA: American Psychiatric Publishing.
      • Strauss, E., Sherman, E.M.S., & Spreen, O. (2006). A compendium of neuropsychological tests (3 rd ed.) . New York: Oxford University Press.
      • Zuckerman, E.L. (2000). Clinician’s Thesaurus (5 th ed.). New York: The Guilford Press.
      • Thank you for your attention
      • Theodore Tsaousides, Ph.D.
      • Instructor/Rehabilitation Neuropsychologist
      • Mount Sinai School of Medicine
      • e: [email_address]
      • p: 212-241-6547