Indications PDF
Indications PDF
Indications PDF
tion of batteries of tests aimed at identifying only through formal neuropsychological test-
and evaluating the severity of behavioral ing. The tests provide useful information
deficits in patients with brain damage and aid- about the patient’s competency and decision-
ing in diagnosis. One goal of these assessments making capacity and have implications for the
was to pinpoint the location of brain lesions, choice of treatment.
as sophisticated neuroimaging had not yet Structural changes are not always visi-
been developed. ble. Many neurologic disorders result from
The most commonly used test battery was structural changes that are invisible to even
devised by Halstead and Reitan,1,3,12 who cor- the highest-resolution scanners. Examples
related test results with findings on autopsy include Alzheimer disease, transient ischemic
after the patients died. Their goal was to attacks, many epilepsies, and many infections
determine the site of lesions by noninvasive of the brain and spinal cord.
means as an aid in diagnosis. Neuropsychological assessment is also
The Halstead-Reitan battery was found useful in many disorders of children in which
useful in assessing not only severe deficits but no markers can be visualized, such as atten-
also moderate and mild dysfunction. It also tion deficit/hyperactivity disorder, specific
proved helpful in describing the functional verbal and nonverbal learning disabilities,
deficits that arise from brain dysfunction. neurotoxic exposure, and some concussions
Furthermore, it allowed physicians to make and infectious processes.13 In some instances,
reasoned judgments about whether the neuropsychological examinations provide
deficits observed were “organic” (ie, due to objective data that help specify the diagnosis.
neurologic factors) or “psychiatric” (ie, due to Even when a diagnosis can be made with
psychological factors). specific physical markers, neuropsychology
Ways of assessing cognitive function have can play an important role. For example,
since been expanded and refined. However, although Down syndrome is readily identified
central to all approaches is the notion that the by its physical manifestations and specific
pattern of data obtained from the tests pro- genetic abnormality (trisomy 21), neuropsy-
Patients who vides information about the location and chological assessment can provide invaluable
perform well effect of brain lesions and the functional prognostic information to families concerning
deficits that accompany them. their children’s abilities.13 Once again, the
on the MMSE functional capabilities mean as much as the
are not ■ NEUROPSYCHOLOGY VS NEUROIMAGING structural abnormalities, if not more.
Symptoms often precede visible struc-
necessarily Now that we have the technology to image tural changes.1,2,6 If some diseases are detect-
previously hidden areas of the brain, today’s ed early by their behavioral symptoms, physi-
healthy neuropsychologists are less often asked to cians can often provide better care and man-
deduce the location of brain lesions. age symptoms better. For example, if a pro-
Nevertheless, they still have an important role gressive incurable disorder such as Alzheimer
in characterizing the behavioral sequelae of disease is diagnosed early, the patient and fam-
brain injuries and illnesses, for several reasons: ily members have more time to plan for the
Structure does not equal function. inevitable deterioration in function.
Neuroimaging can locate structural lesions Neuropsychological evaluation is useful
accurately, but we cannot accurately predict for serial assessment, providing objective
the functional sequelae (the cognitive and measures of progressive deterioration or
behavioral changes that follow a neurologic recovery following traumatic brain injuries or
insult) using structural data alone: substantial strokes.1–3,6
variability exists among patients with regard Serial assessments are, however, con-
to their structural and functional integrity. founded by repeated exposure to the test, a
Indeed, one could argue that, for the patient, phenomenon called “practice effect” or “test-
function is more important than structure. retest effect.” To counteract this effect,
The nature and extent of behavioral researchers have estimated the amount of
deficits and retained abilities can be defined improvement that might be expected on vari-
as to a patient’s competency. The evaluation whether her neurocognitive deficits were con-
can provide evidence of a patient’s ability to sistent with a neurodegenerative process or
act purposefully, think rationally, and deal were more likely the result of psychological
effectively with the environment.2,3 disruption.
The evaluation showed that Ms. Smith
Specify what you want from the referral had significant psychomotor slowing,
When referring a patient for a neuropsycho- impaired attention and concentration,
logical evaluation, the physician should spec- mild memory impairments, and significant
ify the diagnostic and functional questions depressive symptoms, including fatigue,
that he or she is trying to answer. Referrals loss of appetite, and poor self-concept. The
should address the areas of concern and the pattern of her performance was not indica-
type of conclusions requested (eg, treatment tive of a progressive neurodegenerative
planning, competency, functional limitations, process.
diagnostic accuracy). Ms. Smith was referred for psychiatric
consultation for medication management and
■ CASE CONTINUED for individual psychotherapy. She was encour-
aged to use memory aids during the interim,
Ms. Smith was referred for a neuropsychologi- including notebooks to record important
cal evaluation. The referring physician asked information.
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Cohn and Weigart, 1874. ADDRESS: Joseph Kulas, PhD, The Child Development Center, Connecticut
9. Brodmann K. Vergleichende Lokalisationslehre der Grosshirnrinde in Children’s Medical Center, 282 Washington Street, Hartford, CT 06106;
ihren Prinzipien dargestellt auf Grund des Zellenbaues. Leipzig, e-mail jfkulas@ccmckids.org.