The Core Areas of Cognition Assessed in the Neuropsychological Examination - Essay Example

Name: Instructor: Course: Date of submission: Introduction Alzheimer’s disease (AD), also called primary degenerative dementia, is an irreversible, progressive brain disease that accounts for more than half of all dementias. The condition results in memory loss, confusion, impaired judgment, personality changes, disorientation, and loss of language skills. Because this is a primary progressive dementia, the prognosis for a patient with the disease is poor. AD is the most common cause of dementia in people above 65. Dementia is loss of memory, reason, judgment, and language (National Institute on Aging [U.S.] 2003). On the other hand, Lewy body is a microscopic abnormality found in the brain autopsy, a condition caused by a build up in the number of Lewy bodies. The Lewy bodies are characteristically proteins that are abnormally deposited in the cells of the brain that are tasked with controlling various aspects of both memory and also motor control in humans. Lewy body represents the second most prevalent type in the area of progressive dementia. Symptoms are similar to those of AD in addition to Parkinson’s disease symptoms (Prigatano & Pliskin 2002). Because of similar symptoms the cognitive disease assessment in both cases is similar. This essay addresses two kinds of conditions under the neuropsychological methods; Alzheimer’s disease and Lewy Body Dementia. This paper will discuss in particular three main issues relating to these conditions; the core areas of cognition assessed in neuropsychological examination, how the behavioural tests are used to address these cognitive functions and how accurate and reliable the assessments are with a critical look at the potential for misdiagnosis of these disorders. The Core Areas of Cognition Assessed in a Neuropsychological Examination The Neurobehavioral Cognitive Status Examination (NCSE) and Clinical Dementia Rating (CDR) were developed to specifically evaluate cognitive domains. They are composed of shortened subtests to assess verbal reasoning (the ability to learn, recall and recognize a list of 10 noun), language (the ability to name 15 line-drawn objects), and visual-spatial construction skills, arithmetic, memory, judgment and problem-solving. The CERAD battery is well standardized and is sensitive to cognitive features of mild to moderate dementia. The evaluation takes an average of 45 minutes (Agronin & Maletta 2006) Language deficit is revealed after few minutes of the subject’s talk, particularly where poor fluency, prosody, agrammatism, and articulation are involved; these serve as evidence of mental impairment. Orientation is usually assessed to time, place, and person; it is not sensitive, and intact orientation includes memory disorder (Prigatano & Pliskin 2002). Time orientation is most important and includes time of the day, lack of knowledge of time or day indicative of the disease. Place should be confirmed, and asking what name of the building may show lack of awareness of location. Person orientation include name, age, and date of birth. Disorientation to name is usually only seen in psychogenic amnesia. In the aphasic patient, conversation reveals the true deficit, but a mistaken label of ‘confusion’ is frequently applied because such patients either fails to comprehend the question, or produce the wrong answer. Given a choice, they can usually pick out their own name. Attention is tested by serial 7s, digit span, spelling WORLD backwards and recitation of the months of the year in reverse order. Although 7s is commonly used, it is frequently performed incorrectly by the elderly, as well as patients with impaired attention. Digit span is dependent on working memory, but it is not specific, and can be impaired in delirium, focal left frontal damage, aphasia, and moderate to severe dementia. It should however be normal in the amnesic syndrome. Memory loss and learning impairment out of proportion to other cognitive disturbance is known as the amnesic syndrome. Impairment of memory is the hallmark and often among first symptoms of the majority of neurodegenerative diseases. Poor memory complaints provide a good starting point despite not being specific. The patient forgets recent personal and family events. Non-verbal memory can be assessed by asking a subject to copy and later recall geometric shapes. Alternatively, it is possible to hide several objects at random around the room and ask the patient to search for them several minutes later. This is an easy task, and inability to perform well is a convincing sign of memory impairment (Hersen 2004). The symptoms associated with both Lewy body dementia and Alzheimer’s disease can vary significantly among individuals. The symptoms also do vary during different stages in the progress of the disease (Potocny 2010). The symptoms may also vary from hour to the next or day to the next. The symptoms are evidently mild or even sometimes absent during the usual early stages of the condition of Lewy body dementia. But as the effects of this disease progresses, so does the symptoms that become more pronounced. With time lapse, the disease becomes more severe (Whitworth, Whitworth, & Whitworth 2010). Visual-spatial ability: the common features include, topographical disorientation, dressing apraxia, inability to reach for objects, or failure to identify familiar faces; these are markers of brain degenerative disease. Copying 3-D shapes such as wire cube, interlocking pentagons or constructing a clock-face with numbers are good tests of constructional ability. The Lewy bodies and other many of symptoms associated with Lewy body dementia are more often associated with the Parkinson's disease and Alzheimer's disease too. Consequently, researchers in the field of psychological ailments are not yet decided on whether Lewy body dementia is in its own a condition or whether perhaps it is a variant of the Alzheimer's or the other Parkinson's disease. The disease of Lewy body dementia will usually occur just sporadically among people with no known history of the Lewy body dementia in their family line. However, it is worth noting that familial cases occasionally have been observed. The other names for the condition of Lewy body type of dementia include: Parkinson's disease with dementia, Dementia with Lewy bodies, Diffuse Lewy body disease, Lewy body disease, Lewy body variant of Alzheimer's and Cortical Lewy body disease (Shankle & Amen 2005). Behavioural Tests used to Address the above Cognitive Functions In both conditions of Lewy body dementia and Alzheimer’s, the conditions are slowly progressive and that ultimately results in a gradual intellectual and also functional deterioration. Here, there is no known medicinal cure, nor are there any reported known treatments either to stop or even slow the progression of the conditions. Patients with these two ailments will live an average of approximately seven years after the onset of the symptoms. Alzheimer’s disease and Lewy body dementia are associated with a range of symptoms evident in cognition and other behaviours, which include, most notably, psychosis, depression, agitation, wandering, insomnia, incontinence, catastrophic verbal. Others include emotional or physical outbursts, sexual disorders and weight loss. Behavioural symptoms however are not required for diagnosis. While behavioural symptoms have received little attention than cognitive, there is serious ramification such as patients and caregiver distress, premature institutionalization, and significant compromise of the quality of life of patients and their families. Therapy consists of attempts to slow disease progression, manage behavioural problems, modify the home environment and elicit family support (Shankle & Amen 2005). Behavioural changes are the first symptoms determination of which enables administration of drugs, which helps slow down the progression of the illness. Behavioural tests assist in addressing cognitive function in a patient in several ways: It helps establish an effective communication system with patient and his/her family to help them adjust to patient’s altered cognitive abilities, and offer emotional support to the patient and his family members. Changes in an already established repetitive practice and excess stimulation can worsen behavioural problems; and occasions motivating anxiety may motivate instances of excessive fear and agitation on the patient. Intervention is by helping the patient focus on another activity. Patients are provided with a safe environment and encouraged to exercise as ordered, which helps maintain mobility (Williams & Wilkins 2008). Behavioural test help determine the type of AD depending on the cognitive disturbance. Clinicians identify codes for the diseases: 294.10 without behavioural disturbance, if the cognitive disturbance is not accompanied by any clinically significant behavioural disturbance; and 294.11 with behavioural disturbance, if the cognitive disturbance is accompanied by a clinically significant behavioural disturbance, 293.83 Mood Disorder due to AD, with depressive features, and 310.1 personality change due to AD, aggressive type (Goldenberg & Miller 2008). Depending on the behavioural alterations that may seem to endanger the client and caregiver, the doctor is able to give psychotropic medication. Drug usage is tailored to the client’s disorder and his/her response to these medications (Bédard 2003). When behavioural analysis is done a thorough description of deficit and abilities leads to recommendations for rehabilitation and treatment. In using such tests, clinical neuropsychologists are interested principally in indentifying, quantifying, and describing changes in behaviour that relate to the cognitive integrity of the brain. Serial assessment can demonstrate gradual improvement or deterioration in mental status over time, allow better differentiation of cognitive deficits, and assist in treatment and disposition planning (Zillmer, Spiers & Culbertson 2008). The test is used to document the extent of cognitive strength or weakness to outline effective treatment. Because many patients with neurological disorders vary widely in rate at which the illness progresses or improves, the most meaningful way to equate patients for severity of illness is to assess their behaviour objectively. Behaviour evaluation has several advantages; it is non-invasive and provides descriptive information about the patient. The tests have been used as an empirical basis in various medical and psychiatric settings, are sensitive to the organic integrity of the brain and often pinpoint specific deficits. The tests have become useful in clinical service delivery and from research regarding the cognitive aspects of medical disorders (O'Donohue 2009). Accuracy and Reliability of the Assessments and the Potential for Misdiagnosis of Neuropsychological Disorders There are several neuropsychological assessments for both cognitive and behavioural functions. Each of the method has its advantages and disadvantages in terms of determining the reliability and accuracy of the method. The one with more strength than weakness is the most reliable. Neuropsychological evaluation is an objective, comprehensive assessment of a wide range of cognitive and behavioural areas of functioning, which the neuropsychologist integrates with intellectual and personality assessments and evaluates within context of CT and MRI scans. When based on a thorough description of abilities and deficits, testing leads to recommendations for rehabilitation and treatment. Serial assessments can demonstrate gradual improvement or deterioration in mental status over time, allow better differentiation of cognitive deficits, and assist in treatment and disposition planning (Klonoff & Landrine 2000). Neuropsychological assessments have a number of advantages that include its non-invasiveness, and provide descriptive information about the patient. Neuropsychological assessments have been used as an empirical basis in various medical and psychiatric settings, are sensitive to the organic integrity of the cerebral hemispheres, and can often pinpoint specific neurologic deficits. Neuropsychological assessment is reliable and credible in determining the following: development of remedial methods for rehabilitation, patient management, assessment of environmental needs after discharge (disposition planning), location of damage, and establishment of a baseline for neuropsychological performance from which future evaluations can assess improvement or deterioration ( Zillmer, Spiers & Culbertson 2008) For psychological test to be useful, it must be both reliable and valid/credible. Reliability is the dependability of a test score as reflected in its consistency on repeated tests on the same individual. Validity is the meaningfulness of specific inference made from the test scores. Validity of the assessment is evident, and the construct validity focuses on test score as a measure of the abstract, psychological characteristic or construct of interest (such as memory, intelligence, and impulsiveness). This validity is important in demonstrating cognitive or functional abilities (visual-spatial problem solving or perceptual-motor functioning). There is Content validity which pertains to the degree to which a sample of items or tasks makes conceptual sense or represents some defined psychological domain. The test is designed to assess conditions such as how fast someone can tap a finger, and to assess upper extremity motor speed. There is criterion validity demonstrating that the score relates systematically to one or more outcome criteria, either now (concurrent validity) or in the future (prospective validity). This is of prime concern in assessment and classification of diagnostic groups including brain-impaired, psychiatric, and normal individuals (Vasterling 2005). There is potential of misdiagnosis in the absence of appropriate tests or adequate normative data. Misdiagnosis arising from a failure to assess personality leads to improper treatment. Observation can be misinterpreted. For example, the lack of initiation and apathy that sometimes characterize individuals who have frontal-lobe impairment are easily misinterpreted as signs of depression. Transient ischemic attacks may be misinterpreted as symptoms of panic disorder or epic seizures, which can be mistaken for dissociative episodes (Vanderploeg 2000). Ferraro (2002) noted that if there is any language comprehension and/or expression difficulty, there is high risk of misdiagnosis. It is critical that there be consonance among the language of the test, the language of the test taker, and the language of the test administrator. Patients have been misclassified as brain damaged if they had low levels of education, were African-American, or older. Behaviours and beliefs that are acceptable in one culture maybe considered symptoms of illness in another. For instance, response to hexing, evil eye, and Zar or Gin are considered normal behaviour in some cultures, but would be misdiagnosed as psychosomatic, paranoia and dissociation by U.S. health professionals (Ferraro 2002). Normal expressions of spiritual beliefs in some culture are misperceived as symptoms of religiosity. Previous works in the study of these neuropsychological diseases suggests that the issue of misdiagnoses may actually be prevalent. Obviously, misdiagnoses can result to errors in treatment. In estimating how often neuropsychological disorders are misdiagnosed as another form of a neuropsychological disorder, and also to identify factors that increase the chances of misdiagnosing, an experiment was taken. Seventy-one patients underwent the evaluation at Neurological Institute of New York, between January 2000 and December of 2005. These patients previously had pre-evaluation diagnosis. The results were interesting in that 37 percent of the patients were misdiagnosed to having a false condition. Their true condition was Parkinson disease. Fifteen percent were diagnosed with dystonia, and eight percent with Parkinson disease were diagnosed with false essential tremor. The factors that were associated with misdiagnosis included the unilateral arm tremor, the spooning of the hands of the patient and other corresponding dystonic postures and other observed unusual features. Therefore in conclusion, about one in three people suffering from tremor was misdiagnosed in the process as having essential tremor. The most common frequent false diagnoses were observed as being that of either Parkinson disease or dystonia (Searight 2002). Conclusion The recent research is focusing on the ecological or environmental validity of the various neuropsychological tests, primarily on predicting on its functional impairment. The aforementioned functional impairment is especially of critical importance to the studies and researches on the neuropsychological diseases because of the prevalent burdens that are placed on both the informal and the formal caregivers, mainly out of the usual limitations placed upon the independence of the elderly patients of the diseases. There are other several promising trends that are currently being carried on in modern research. For example, in the current increasing integration of the neuropsychological and the neuro-imaging information in both dementia and depression; such studies are consequently enhancing the accuracy in differential diagnosis, the exciting early detection of diseases and effective determination of these disorders. Another important feature in this trend is an increased recognition of relation to the cultural diversity in these neuropsychological studies. Tests are also being adapted for the various populations that had so far been difficult to address and assess in the past. References Agronin ME., & Maletta, GJ 2006, Principles and practice of geriatric psychiatry, Lippincott Williams & Wilkins, Walnut St, PA. Amber, PA. Bédard, MA 2003, Mental and behavioral dysfunction in movement disorders, Humana Press, New York, NY. Ferraro FR 2002, Minority and cross-cultural aspects of neuropsychological assessment, Taylor & Francis, Meppel, Netherlands. Goldenberg, G., & Miller, BL 2008, Neuropsychology and behavioral neurology. Elsevier Health Sciences, Amsterdamn Netherlands. Hersen, M 2004, Comprehensive handbook of psychological assessment: intellectual and neuropsychological assessment, John Wiley and Sons, Hoboken, NJ. Klonoff, EA., & Landrine, H 2000, Preventing misdiagnosis of women: a guide to physical disorders that have psychiatric symptoms. : SAGE, Thousand Oaks, CA. National Institute on Aging (U.S.) 2003, Alzheimer's disease: unravelling the mystery, Government Printing Office, Washington, DC. O'Donohue, WT 2009, Behavioral approaches to chronic disease in adolescence: a guide to integrative care, Springer, New York, NY. Potocny, J 2010, Living with alzhiemers,' Xlibris Corporation, Bloomington, IN. Prigatano, GP., & Pliskin, NH 2002, Clinical neuropsychology and cost outcome research: a beginning, Psychology Press, Philadelphia, PA. Searight, RH 2002, Behavioral medicine: a primary care approach, Psychology Press, Philadelphia PA. Shankle, WR., & Amen, DG 2005, Preventing alzheimer's: ways to help prevent, detect, diagnose, treat, and even halt Alzheimer's disease and other causes of memory loss, : Penguin, London, UK. Vanderploeg, RD 2000, Clinician's guide to neuropsychological assessment, Taylor & Francis, Mahwah, NJ. Vasterling, JJ 2005, Neuropsychology of PTSD: biological, cognitive, and clinical perspectives, Guilford Press, New York, NY. Whitworth, HB., Whitworth, J., & Whitworth, J 2010, A caregiver's guide to Lewy Body Dementia. Demos Medical Publishing, New York, NY. Williams L., & Wilkins 2008, Professional guide to diseases, Lippincott Williams & Wilkins Zillmer E., Spiers M., & Culbertson WC 2008, Principles of neuropsychology, Cengage Learning, Belmont CA. Read More

The evaluation takes an average of 45 minutes (Agronin & Maletta 2006) Language deficit is revealed after few minutes of the subject’s talk, particularly where poor fluency, prosody, agrammatism, and articulation are involved; these serve as evidence of mental impairment. Orientation is usually assessed to time, place, and person; it is not sensitive, and intact orientation includes memory disorder (Prigatano & Pliskin 2002). Time orientation is most important and includes time of the day, lack of knowledge of time or day indicative of the disease.

Place should be confirmed, and asking what name of the building may show lack of awareness of location. Person orientation include name, age, and date of birth. Disorientation to name is usually only seen in psychogenic amnesia. In the aphasic patient, conversation reveals the true deficit, but a mistaken label of ‘confusion’ is frequently applied because such patients either fails to comprehend the question, or produce the wrong answer. Given a choice, they can usually pick out their own name.

Attention is tested by serial 7s, digit span, spelling WORLD backwards and recitation of the months of the year in reverse order. Although 7s is commonly used, it is frequently performed incorrectly by the elderly, as well as patients with impaired attention. Digit span is dependent on working memory, but it is not specific, and can be impaired in delirium, focal left frontal damage, aphasia, and moderate to severe dementia. It should however be normal in the amnesic syndrome. Memory loss and learning impairment out of proportion to other cognitive disturbance is known as the amnesic syndrome.

Impairment of memory is the hallmark and often among first symptoms of the majority of neurodegenerative diseases. Poor memory complaints provide a good starting point despite not being specific. The patient forgets recent personal and family events. Non-verbal memory can be assessed by asking a subject to copy and later recall geometric shapes. Alternatively, it is possible to hide several objects at random around the room and ask the patient to search for them several minutes later. This is an easy task, and inability to perform well is a convincing sign of memory impairment (Hersen 2004).

The symptoms associated with both Lewy body dementia and Alzheimer’s disease can vary significantly among individuals. The symptoms also do vary during different stages in the progress of the disease (Potocny 2010). The symptoms may also vary from hour to the next or day to the next. The symptoms are evidently mild or even sometimes absent during the usual early stages of the condition of Lewy body dementia. But as the effects of this disease progresses, so does the symptoms that become more pronounced.

With time lapse, the disease becomes more severe (Whitworth, Whitworth, & Whitworth 2010). Visual-spatial ability: the common features include, topographical disorientation, dressing apraxia, inability to reach for objects, or failure to identify familiar faces; these are markers of brain degenerative disease. Copying 3-D shapes such as wire cube, interlocking pentagons or constructing a clock-face with numbers are good tests of constructional ability. The Lewy bodies and other many of symptoms associated with Lewy body dementia are more often associated with the Parkinson's disease and Alzheimer's disease too.

Consequently, researchers in the field of psychological ailments are not yet decided on whether Lewy body dementia is in its own a condition or whether perhaps it is a variant of the Alzheimer's or the other Parkinson's disease. The disease of Lewy body dementia will usually occur just sporadically among people with no known history of the Lewy body dementia in their family line. However, it is worth noting that familial cases occasionally have been observed. The other names for the condition of Lewy body type of dementia include: Parkinson's disease with dementia, Dementia with Lewy bodies, Diffuse Lewy body disease, Lewy body disease, Lewy body variant of Alzheimer's and Cortical Lewy body disease (Shankle & Amen 2005).

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