Assessing Deficits inAssessing Deficits in
Cognitive FunctioningCognitive Functioning
Theodore Tsaousides, Ph.D.Theodore T...
NeuropsychologyNeuropsychology
 The science of brain-behavior relationshipThe science of brain-behavior relationship
 Dy...
Neuropsychology: AssessmentNeuropsychology: Assessment
 Evaluate degree of impact of brain damageEvaluate degree of impac...
Neuropsychology: TreatmentNeuropsychology: Treatment
 RestorationRestoration
 RetrainingRetraining
 RepetitionRepetitio...
Disorders that affect the brain’sDisorders that affect the brain’s
functionfunction
 Traumatic brain injury (TBI)Traumati...
Traumatic Brain InjuryTraumatic Brain Injury
 DefinitionDefinition
 CausesCauses
 Incidence in the USIncidence in the U...
Traumatic Brain InjuryTraumatic Brain Injury
 DefinitionDefinition
 Insult to the brain…caused by external physicalInsul...
Traumatic Brain InjuryTraumatic Brain Injury
 CausesCauses
Traumatic Brain InjuryTraumatic Brain Injury
 Incidence annuallyIncidence annually
 1.4 million sustain TBI (based on Ho...
TBI: Physical symptomsTBI: Physical symptoms
 FatigueFatigue
 Sleep problemsSleep problems
 HeadachesHeadaches
 Balanc...
TBI: Cognitive symptomsTBI: Cognitive symptoms
 AttentionAttention
 Processing speedProcessing speed
 Memory and learni...
TBI: Emotional symptomsTBI: Emotional symptoms
 ApathyApathy
 AbuliaAbulia
 DisinhibitionDisinhibition
 Hyperemotional...
Behavioral symptomsBehavioral symptoms
 Forgetting/missing appointmentsForgetting/missing appointments
 Getting lostGett...
What to doWhat to do
 YouYou
 ObserveObserve
 ScreenScreen
 ReferRefer
 MeMe
 Review referralReview referral
 Condu...
First impressionsFirst impressions
 Conclusions based on interactions:Conclusions based on interactions:
 Non-compliantN...
ObserveObserve
 AppearanceAppearance
 Is appearance unusual?Is appearance unusual?
 OrientationOrientation
 Person, pl...
ObserveObserve
 Attention/concentrationAttention/concentration
 Distractibility (distracted by things around)Distractibi...
ObserveObserve
 Cognitive functioningCognitive functioning
 Vocabulary (vocabulary is consistent with education)Vocabula...
ScreenScreen
 Brain Injury Screening QuestionnaireBrain Injury Screening Questionnaire
(BISQ)(BISQ)
 Part One (lifelong)...
BISQ – Part OneBISQ – Part One
BISQ – Part TwoBISQ – Part Two
 Part Two (within past month)Part Two (within past month)
 Physical symptomsPhysical symp...
BISQ – Part TwoBISQ – Part Two
BISQ – Part TwoBISQ – Part Two
ScreenScreen
 Positive screen ≠ diagnosisPositive screen ≠ diagnosis
 Positive screen = need to evaluate furtherPositive...
Other short measuresOther short measures
 Mini-Mental State Examination (MMSE)Mini-Mental State Examination (MMSE)
 Deme...
ReferRefer
 PhysiatristPhysiatrist
 Most knowledgeable specialty re: TBIMost knowledgeable specialty re: TBI
 Assessmen...
Review referralReview referral
 PreparationPreparation
 Review referral questionReview referral question
 DiagnosticDia...
Review referralReview referral
 Clinical interviewClinical interview
 Patient’s backgroundPatient’s background
 Social ...
Conduct testingConduct testing
 Test selectionTest selection
 Goals of assessmentGoals of assessment
 Validity and reli...
Conduct testingConduct testing
 Cognitive DomainsCognitive Domains
 Processing speedProcessing speed
 AttentionAttentio...
Provide feedbackProvide feedback
 Review and integrate assessment resultsReview and integrate assessment results
 Write ...
ConclusionConclusion
 Damage to the brain causes physical, cognitive,Damage to the brain causes physical, cognitive,
emot...
First impressions revisitedFirst impressions revisited
 Conclusions based on clinical observationConclusions based on cli...
ReferencesReferences
 Fischer, J.S., Hannay, J.H., Loring, D.W., & Lezak, M.D. (2004).Fischer, J.S., Hannay, J.H., Loring...
Thank you for your attentionThank you for your attention
Theodore Tsaousides, Ph.D.Theodore Tsaousides, Ph.D.
Instructor/R...
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Assessing Deficits in Cognitive Functioning

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Assessing Deficits in Cognitive Functioning

  1. 1. Assessing Deficits inAssessing Deficits in Cognitive FunctioningCognitive Functioning Theodore Tsaousides, Ph.D.Theodore Tsaousides, Ph.D. Mount Sinai School of MedicineMount Sinai School of Medicine New York, NYNew York, NY
  2. 2. NeuropsychologyNeuropsychology  The science of brain-behavior relationshipThe science of brain-behavior relationship  Dysfunctional brainDysfunctional brain  Dysfunctional behaviorDysfunctional behavior  Injury to the brain leads to:Injury to the brain leads to:  Physical changesPhysical changes  Cognitive changesCognitive changes  Emotional changesEmotional changes  Behavioral changesBehavioral changes
  3. 3. Neuropsychology: AssessmentNeuropsychology: Assessment  Evaluate degree of impact of brain damageEvaluate degree of impact of brain damage on behavioron behavior  DiagnosisDiagnosis  Patient carePatient care  Treatment planning/evaluationTreatment planning/evaluation  ResearchResearch  Good assessmentGood assessment  good treatmentgood treatment
  4. 4. Neuropsychology: TreatmentNeuropsychology: Treatment  RestorationRestoration  RetrainingRetraining  RepetitionRepetition  CompensationCompensation  Skill buildingSkill building  Use of toolsUse of tools  RestructuringRestructuring  Environmental adaptationsEnvironmental adaptations  Changes in demandsChanges in demands
  5. 5. Disorders that affect the brain’sDisorders that affect the brain’s functionfunction  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
  6. 6. Traumatic Brain InjuryTraumatic Brain Injury  DefinitionDefinition  CausesCauses  Incidence in the USIncidence in the US  SymptomsSymptoms
  7. 7. Traumatic Brain InjuryTraumatic Brain Injury  DefinitionDefinition  Insult to the brain…caused by external physicalInsult to the brain…caused by external physical force…which results in impairment of cognitiveforce…which results in impairment of cognitive abilities or physical functioning (BIAA)abilities or physical functioning (BIAA)  A traumatically induced physiologic disruption of theA traumatically induced physiologic disruption of the brain function as manifested bybrain function as manifested by  Loss of consciousnessLoss of consciousness  Loss of memory for events before or after the accidentLoss of memory for events before or after the accident  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 transientFocal neurological deficits that may or may not be transient (ACRM)(ACRM)
  8. 8. Traumatic Brain InjuryTraumatic Brain Injury  CausesCauses
  9. 9. Traumatic Brain InjuryTraumatic Brain Injury  Incidence annuallyIncidence annually  1.4 million sustain TBI (based on Hospital1.4 million sustain TBI (based on Hospital admission and ED recordsadmission and ED records  UnidentifiableUnidentifiable  Physician visitsPhysician visits  No care soughtNo care sought  Military/VAMilitary/VA  Other settings (psychiatric/substance abuseOther settings (psychiatric/substance abuse settings; shelters; prisons)settings; shelters; prisons)
  10. 10. TBI: Physical symptomsTBI: Physical symptoms  FatigueFatigue  Sleep problemsSleep problems  HeadachesHeadaches  Balance problems/dizzinessBalance problems/dizziness  Vision problemsVision problems  Chronic painChronic pain  Sexual dysfunctionSexual dysfunction
  11. 11. TBI: Cognitive symptomsTBI: Cognitive symptoms  AttentionAttention  Processing speedProcessing speed  Memory and learningMemory and learning  Language and communicationLanguage and communication  Executive functionsExecutive functions
  12. 12. TBI: Emotional symptomsTBI: Emotional symptoms  ApathyApathy  AbuliaAbulia  DisinhibitionDisinhibition  HyperemotionalityHyperemotionality  DepressionDepression  AnxietyAnxiety
  13. 13. 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
  14. 14. What to doWhat to do  YouYou  ObserveObserve  ScreenScreen  ReferRefer  MeMe  Review referralReview referral  Conduct testingConduct testing  Provide feedbackProvide feedback
  15. 15. 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
  16. 16. ObserveObserve  AppearanceAppearance  Is appearance unusual?Is appearance unusual?  OrientationOrientation  Person, place, time, (situation, object)Person, place, time, (situation, object)  SpeechSpeech  Receptive language (unable to followReceptive language (unable to follow instructions)instructions)  Fluency (word finding problems)Fluency (word finding problems)
  17. 17. 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)
  18. 18. 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)
  19. 19. ScreenScreen  Brain Injury Screening QuestionnaireBrain 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?
  20. 20. BISQ – Part OneBISQ – Part One
  21. 21. 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
  22. 22. BISQ – Part TwoBISQ – Part Two
  23. 23. BISQ – Part TwoBISQ – Part Two
  24. 24. ScreenScreen  Positive screen ≠ diagnosisPositive screen ≠ diagnosis  Positive screen = need to evaluate furtherPositive screen = need to evaluate further
  25. 25. 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 ofRepeatable Battery for the Assessment of Neuropsychological Status (RBANS)Neuropsychological Status (RBANS)  NART/WTARNART/WTAR  TONI-3TONI-3  WASIWASI
  26. 26. 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
  27. 27. 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
  28. 28. 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 examinationCircumstances surrounding the examination
  29. 29. 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
  30. 30. Conduct testingConduct testing  Cognitive DomainsCognitive Domains  Processing speedProcessing 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
  31. 31. Provide feedbackProvide feedback  Review and integrate assessment resultsReview and integrate assessment results  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
  32. 32. ConclusionConclusion  Damage to the brain causes physical, cognitive,Damage to the brain causes physical, cognitive, emotional, and behavioral deficitsemotional, and behavioral deficits  Several conditions can cause damage to theSeveral conditions can cause damage to the brainbrain  TBI is aTBI is a commoncommon but oftenbut often unidentifedunidentifed conditioncondition  Cognitive deficits of TBI often manifest asCognitive deficits of TBI often manifest as “behavioral problems”“behavioral problems”  Proper screening and identification impliesProper screening and identification implies appropriate treatmentappropriate treatment
  33. 33. First impressions revisitedFirst impressions revisited  Conclusions based on clinical observationConclusions based on clinical observation and screening:and screening:  Non-compliant =Non-compliant =  Difficult to engage =Difficult to engage =  Poor historian =Poor historian =  Oppositional =Oppositional =  Makes things up =Makes things up =
  34. 34. 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, D.B.Observational methods, rating scales, and inventories. In M.D. Lezak, D.B. Howieson, & D.W. Loring (Eds.),Howieson, & D.W. Loring (Eds.), Neuropsychological Assessment, 4Neuropsychological Assessment, 4thth editionedition (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. (2000).Gordon, W.A., Haddad, L, Brown, M., Hibbard, M.R., & Silwinski, M. (2000). The sensitivity and specificity of self-reported symptoms in individuals withThe sensitivity and specificity of self-reported symptoms in individuals with traumatic brain injury.traumatic brain injury. Brain Injury, 14,Brain Injury, 14, 21-33.21-33.  Kay, T., Harrington, D.E., & Adams, R. (1993). Mild traumatic brain injury.Kay, T., Harrington, D.E., & Adams, R. (1993). Mild traumatic brain injury. American Congress of Rehabilitation Medicine, Head Injury InterdisciplinaryAmerican Congress of Rehabilitation Medicine, Head Injury Interdisciplinary Special Interest Group. Definition of mild traumatic brain injury.Special Interest Group. Definition of mild traumatic brain injury. Journal ofJournal of Head Trauma Rehabilitation, 8,Head Trauma Rehabilitation, 8, 86-87.86-87.  Lezak, M.D., Howieson, D.B., & Loring, D.W. (2004).Lezak, M.D., Howieson, D.B., & Loring, D.W. (2004). NeuropsychologicalNeuropsychological assessmentassessment (4(4thth ed.). New York: Oxford University Press.ed.). New York: Oxford University Press.  McCullagh, S., & Feinstein, A. (2005). Cognitive changes. In J.M. Silver,McCullagh, S., & Feinstein, A. (2005). Cognitive changes. In J.M. Silver, T.W. McAllister, & S.C. Yudofsky (Eds.),T.W. McAllister, & S.C. Yudofsky (Eds.), Textbook of Traumatic Brain InjuryTextbook of Traumatic Brain Injury (pp.321-337). Arlington, VA: American Psychiatric Publishing.(pp.321-337). Arlington, VA: American Psychiatric Publishing.  Strauss, E., Sherman, E.M.S., & Spreen, O. (2006).Strauss, E., Sherman, E.M.S., & Spreen, O. (2006). A compendium ofA compendium of neuropsychological testsneuropsychological tests (3(3rdrd ed.)ed.).. New York: Oxford University Press.New York: Oxford University Press.  Zuckerman, E.L. (2000).Zuckerman, E.L. (2000). Clinician’s ThesaurusClinician’s Thesaurus (5(5thth ed.). New York: Theed.). New York: The Guilford Press.Guilford Press.
  35. 35. Thank you for your attentionThank you for your attention Theodore Tsaousides, Ph.D.Theodore Tsaousides, Ph.D. Instructor/Rehabilitation NeuropsychologistInstructor/Rehabilitation Neuropsychologist 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
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