Venue: IPS USM KL Date: 23 Sept 2018

1. NEUROPSYCHOLOGICAL ASSESSMENT Dr Zahiruddin Othman
Psychiatry Department, USM
23-09-2018

2. ORIENTATION
Orientation is awareness of self in
relation to one’s surroundings requires
consistent and reliable integration of
attention, perception, and memory.
Impaired orientation to time & place
occurs with
 Widespread cortical involvement (e.g.,
Alzheimer disease)
 Lesions in the limbic system (e.g., Korsakoff’s
psychosis)
 Damage to reticular activating system (e.g.,
delirium)
Time
 Day of week, date, month, year, season
Place
 State, county, town/city, building, floor
Person
 Name, age, date of birth, address, highest level
of education

3. Kolakowsky-Hayner, S. (2010). The PatientCompetency Rating Scale. The Centerfor Outcome Measurementin Brain Injury. http://www.tbims.org/combi/pcrs( accessedSeptember 14, 2018 ).

4. OrientationBody
orientation
Directional
(Right-Left)
orientation
Spatial
disorientation
Topographical
orientation
Topographical
localization

5. ATTENTION, PROCESSING SPEED, AND WORKING
MEMORY
Capacity
Digits forward
Corsi’s Block-Tapping
Test
Symbol span
Sentence repetition
Tracking
(Working Memory)
Digits backward
Reversing spelling
Alpha span
Letter-number
sequencing
Arithmetic
Paced Auditory Serial
Addition Test (PASAT)
Concentration/focused
attention
Vigilance test
Continuous
Performance Test II
(CPT II)
Stroop tests
Speed of processing
Reaction time
Digit Symbol-Coding
Symbol digit
modalities test (SDMT)
Divided attention
Trail making test
Color trail
Alphanumeric
sequencing

6. DIGITS FORWARD
Examiner read the numbers aloud at rate of one per
second  subject’s task is to repeat the sequence
Examiner proceed with the next longer sequence,
continuing until the subject
 Fails a pair of sequences, or
 Repeats the highest sequence correctly
DF measures efficiency of attention (freedom from
distractibility) rather than memory
Lower scores in
 Anxiety
 Diffuse brain damage (MS, post-TBI, dementia)
9 7 5 4
3 8 2 5
9 4 3 1 8
6 8 2 5 9
9 1 3 8 2 5
6 4 8 3 7 1
7 9 5 8 4 3 2
5 3 1 6 8 4 2
8 6 9 5 1 3 7 2
5 1 7 3 9 8 2 6
7 1 9 3 8 4 2 6 1
1 6 3 8 7 4 9 5 2
9 1 5 2 4 3 8 1 6 2
7 1 5 4 8 5 6 1 9 3

7. FACTORS AFFECTING MEMORY SPAN
Extrinsic factors
1. Characteristics of materials used
2. Addition of non-target elements
3. Rhythm of presentation
4. Rate of presentation
5. Modality of presentation
6. Time required to vocalize responses
7. Method of scoring responses
8. Distraction
Intrinsic factors
1. Age
2. Practice of music

8. CORSI’S BLOCK-TAPPING TEST
Assesses visuo-spatial short term working
memory
Examiner taps the blocks in a
prearranged sequence the subject
attempt to copy this pattern
The Corsi Span, and averages about 5
for normal human subjects
The ventrolateral prefrontal cortex is
highly involved
(From Milner, 1971)

9. SYMBOL SPAN
Subject is shown a series of designs of
increasing length
The subject select the correct design from
the foils and choose them in the correct
sequence
(Wechsler Memory Scale-IV)

10. SENTENCE REPETITION
Assess the auditory span
Has a naturalistic quality that can be
directly related to subject’s everyday
functioning
Neuropsychological findings: below
lower limit in
 TBI and MS
 Alzheimer disease
 Lesions in the left hemisphere
Multilingual Aphasia Examination (MAE)
Sentence Repetition: Form I
1. Take this home
2. Where is the child?
3. The car will not run
4. Why are they not living here?
5. The band played and crowd cheered
6. Where are you going to work next summer?
7. He sold his house and they moved to the farm
8. Work in the garden until you have picked all the beans
9. The artist painted many of the beautiful scenes in the valley
10. This doctor does not travel to all the town in the country

11. DIGITS BACKWARD
The normal score difference between DF
and DB  1.0
 4 to 5 is within normal limit
 3 is borderline to impaired (depending on
educational background)
 2 is impaired for everyone
The task involves mental double-tracking
 memory and the reversing operation
Impairment seen in
 Left hemisphere damage
 Diffuse brain damage
 Solvent abuse, chronic progressive MS, Dementia

12. REVERSING SPELLING AND COMMON SEQUENCE
Reversing spelling of WORLD
 An item in MMSE (Folstein, 1975)
Counting days of the week backward

13. ALPHA SPAN (CRAIK, 1990)
Subjects listen to increasingly longer list
of common unrelated words and recall
them in alphabetical order
Correlations
 Strongest with DF, DB & category fluency
 Very weak with letter fluency
 Unrelated to TMT
Impairment seen in mild cognitive
impairment (MCI)

14. LETTER-NUMBER SEQUENCING
Longer and more complex span than DF
 Greater sensitivity to attentional deficits
Subjects hear lists of randomized
numbers and letters (in alternating
order) of increasing lengths (2 to 8)
Subjects are asked to repeat the
numbers and letters
 From the lowest in each series, starting with
numbers
 E.g., “6-F-2-B”  “2-6-B-F”

15. ARITHMETIC
Requires subject to solve basic arithmetic
problem mentally, respond orally, and
within a time limit
Examples
 Sam had three pieces of candy and Joe gave
him four more. How many pieces of candy did
Sam have altogether?
 Three women divided 18 golf balls equally
among themselves. How many golf balls
did each person receive?
 If two buttons cost 15 cents, what will be the
cost of a dozen buttons?

16. PACED AUDITORY SERIAL ADDITION TEST (PASAT)
Complex racking test
Requires subject to add 60 pairs of
randomized digit to the digit
immediately preceding it.
Example:
 Examiner “2-8-6-1-9”
 Subject: “10-14-7-10”
This task is difficult & stressful
Performance decline with age
Middle age adult: 72% correct
responses

17. CONCENTRATION/FOCUSED ATTENTION
Vigilance tests examine the ability to
focus and sustain attention for detecting
target stimuli
Usually involves sequential presentation
of stimuli over a period of time with
instruction for the subject to indicate in
some way
Example
 subjects were asked to respond to every X that
appear randomly on a screen Rosvold (1956)

18. CONTINUOUS PERFORMANCE TEST II (CONNOR, 2000)
A computerized test
Requires subject to indicate every time a
letter other than X appear
Measures reaction time & accuracy
14 minutes to complete
Put high demand on inhibition to withhold
responding to infrequent X

19. STROOP TEST
Based on findings that it takes longer to
call out the colour names of the coloured
patches than to read word.
Selective processing of “only one visual
feature while continuously blocking out
the processing of others” (Shum et al,
1990)
Name the color | Read the text

20. STROOP TEST
Test characteristics
 Satisfactory reliability
 Practice effect vary from study to study
 No male-female difference
 Anxiety lowers the score
 Longer formats may be the most sensitive
 Subjects slow down as they proceed
Important role of anterior cingulate
cortex (Ravnkilde, 2002)

21. DIGIT SYMBOL TEST
Highly speed dependant, also important are
 Visual scanning, motor persistence, sustained attention, response speed, and visuo-motor coordination

22. SYMBOL DIGIT MODALITIES TEST (SDMT)
Reverses the presentation
 Enable subject to respond in more familiar act of number writing
 Allows a spoken response trial

23. TRAIL MAKING TEST (TMT)
Consists of two parts, A and B
The subject must first draw lines to
connect consecutive numbered circles on
one work sheet (Part A), and
 “as fast as you can”
 Without lifting the pencil from the paper
Scoring
 Original: 10 for correct, stop after 3 errors
 Armitage (1946): allow to finish regardless of
erros
 Reitan (1958): based on time alone

24. TRAIL MAKING TEST (TMT)
then connect consecutively numbered and
lettered circles on another sheet (Part B)
Often used to assess executive
functioning

25. COLOR TRAIL TEST
A page containing yellow/pink coloured
numbered circles
1y-1p-2y-2p-…
This is a non-alphabetical parallel form
of TMT

26. ALPHANUMERIC SEQUENCING
Subjects are instructed to alternate between counting and reciting the alphabet aloud
beginning with “1-A-2-B-3-C…”
Scores are obtained for time and errors
Able to differentiate
 Chronic progressive MS (poor on both measures)
 Relapsing-remitting MS (poor on time to completion only)