Neuropsychological Assessment Lezak Pdf Free Download

Discover the world's research

• 20+ million members
• 135+ million publications
• 700k+ research projects

Join for free

Joumnal

of

Neurology,

Neurosurgery,

and

Psychiatry

1995;58:655-664

NEUROLOGICAL

INVESTIGATIONS

Neuropsychological

assessment

Lisa

Cipolotti,

Elizabeth

K

Warrington

Patients

with

brain

damage

may

present

with

impairments

of

memory,

language,

percep-

tion,

thought,

action,

and

other

functions.

These

cognitive

deficits

can

occur

both

in

multiple

domains

or

as

highly

selective

impairments.

In

the

19th

century

and

early

20th

century,

neurologists

investigated

cogni-

tive

impairments

in

patients

with

neurological

disease

by

clinical

and

descriptive

methods.

These

methods

provided

new

insights

and

allowed

the

isolation

of

distinct

syndromes-

for

example,

aphasia,'2

alexia

and

agraphia,3

acalculia,4

visual

agnosia,5

and

amnesia.6

Indeed,

these

discoveries

formed

the

basis

for

the

development

of

a

new

discipline,

"neu-

ropsychology",

devoted

to

the

study

of

the

relation

between

the

brain

and

cognitive

functions.

The

clinical

and

descriptive

meth-

ods,

however,

provided

a

poor

standard

of

description

of

the

cognitive

impairments

in

these

syndromes.

They

were

".

.

.

little

more

than

the

bald

statement

of

the

clinical

opin-

ion

of

the

investigator.

.

.".

To

deal

with

this

lack,

neuropsychologists

developed

principled

techniques

for

the

mea-

surement

of

cognitive

functioning.

In

the

early

days,

psychometric

tests,

originally

developed

for

the

measurement

of

either

scholastic

attainment

or

occupational

guid-

ance,

were

used.

In

particular,

tests

for

the

measurement

of

intellectual

and

memory

functions

became

available

to

the

clinician.8-1

Gradually,

over

the

past

four

decades

an

increasing

number

of

measurement

tools

have

been

specifically

designed

for

investigating

the

cognitive

functions

of

patients

with

sus-

pected

or

confirmed

cerebral

disease.

Neuropsychological

assessment

involves

the

use

of

a

series

of

tests

that

are

"reliable"-in

the

same

circumstances

they

produce

the

same

result-and

"valid"-they

measure

what

they

are

designed

to

measure.

The

aim

of

this

paper

is

to

provide

an

overview

of

the

main

methods

for

the

assess-

ment

of

cognitive

function

and

an

outline

of

what

may

prompt

a

neuropsychological

assessment

(see

also

Lezak,"2

Crawford

et

al,3

and

Hodges'4).

Before

approaching

a

neu-

ropsychological

assessment

it

is

necessary

to

have

a

general

theoretical

structure

on

which

to

base

and

interpret

the

different

levels

of

disturbance

that

can

arise

as

a

result

of

cere-

bral

damage.

(for

a

similar

view

see

Hodges'4)

In

the

next

three

sections

we

discuss

our

gen-

eral

theoretical

schema;

the

methods

of

assessment

of

cognitive

function;

and

the

pur-

poses

of

a

neuropsychological

examination.

General

theoretical

schema

Our

approach

makes

the

assumption

that

impairments

in

cognitive

function

can

best

be

studied

and

understood

by

(a)

assuming

that

there

is

a

high

degree

of

functional

specialisa-

tion

in

the

cerebral

cortex;

(b)

by

undertaking

a

modularity

approach

to

the

analysis

of

com-

plex

cognitive

skills;

and

(c)

by

assuming

that

brain

damage

can

selectively

disrupt

some

components

of

a

cognitive

system.'5

The

extent

to

which

these

assumptions

have

a

direct

anatomical

substrate

is

less

established.

The

idea

that

the

human

brain

is

highly

differentiated

in

terms

of

its

functional

organ-

isation

is

not

new.

The

phrenologists

in

the

early

19th

century

were

already

speculating

that

the

convoluted

surface

of

the

brain

reflected

the

juxtaposition

of

a

large

number

of

discrete

cerebral

organs

each

subserving

a

particular

psychological

faculty.'6

Several

years

after

these

accounts,

neurologists

began

to

study

and

record

impairments

of

the

higher

cortical

functions

and

their

accompa-

nying

cerebral

lesions.

Aphasic

disorders

were

extensively

studied

and

the

specialised

lan-

guage

functions

of

the

left

hemisphere

were

recognised.'2'7

Subsequently,

after

the

pio-

neering

work

of

Jackson,'8

the

specialised

visuoperceptual

functions

of

the

right

hemi-

sphere

were

also

recognised.

These

early

workers

not

only

localised

a

number

of

spe-

cialised

functions

in

the

brain

but

they

also

discussed

their

findings

within

a

theoretical

framework.

For

example,

Lichtheim'9

pro-

duced

a

complex

diagram

of

the

various

sub-

components

of

the

language

system

by

incorporating

and

expanding

on

Wemicke's2

original

scheme.

In

his

diagram,

the

various

subcomponents

of

the

language

functions

are

represented

as

a

series

of

"centres"

(for

exam-

ple,

the

concept

centre,

the centre

of

the

motor

images

of

the

words,

the

centre

of

the

auditory

images

of

the

words),

each

of

which

was

thought

to

be

located

in

a

specific

area

of

the

brain.

These

different

functional

centres

were

thought

to

be

connected

with

each

other

through

sets

of

fibre

tracts.

This

approach-

those

adopting

it

were

termed

the

"diagram

makers"-has

some

resemblance

to

that

of

Psychology

Department,

National

Hospital

for

Neurology

and

Neurosurgery,

Queen

Square,

London

WClN

3BG,

UK

L

Cipolotti

E

K

Warrington

Correspondence

to:

Professor

E

K

Warrington.

655

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

Cipolotti,

Warrington

modem

cognitive

neuropsychology

theorists.

Despite

this,

the

idea

that

cognitive

skills

such

as

language

could

consist

of

multicom-

ponents

and

be

localised

in

different,

highly

specialised

areas

of

the

brain

came

under

attack

from

the

"global

theorists".2'

Of

par-

ticular

relevance

here

is

the

development

of

"mass

action"

theories.

These

theories

pro-

posed

that

there

was

no

differentiation

in

the

cortex

for

specific

cognitive

functions;

rather,

that

it

was

equipotential

with

respect

to

cog-

nitive

abilities.24

According

to

such

a

view,

any

form

of

neurological

damage

would

deplete

by

a

greater

or

lesser

extent

the

avail-

able

amount

of

some

general

cognitive

resource

and

not

specific

cognitive

functions.

The

amount

of

damage

to

the

general

cogni-

tive

resource,

also

termed

intellect

or

abstract

attitude,

would

depend

on

the

extent

of

the

brain

damage

and

not

on

the

site

of

the

damage.

The

notion

that

different

brain

regions

are

specialised

for

different

cognitive

functions

regained

popularity

in

the

1950s

and

the

modem

revolution

in

imaging

techniques

has

made

it

possible

to

visualise

these

structures

in

the

living

human

brain.

The

idea

that

there

are

cognitive

processing

systems

that

involve

only

specialised

brain

regions

is

now

accepted

".

. .

as

one

of

the

comerstones

of

modem

brain

science

.".

.".25

For

about

95%

of

right

handers

and

70%

of

left

handers

major

lan-

guage,

literacy

(reading,

writing,

and

calcula-

tion),

verbal

short

term

memory,

verbal

long

term

memory,

semantic

memory,

and

praxis

are

represented

in

the

left

hemisphere.

The

right

hemisphere

is

involved

in

non-verbal

processing

such

as

the

analysis

of

perceptual

and

spatial

stimuli,

spatial

short

term

mem-

ory,

visual

long

term

memory,

spatially

directed

attention,

face

recognition,

topo-

graphical

knowledge,

and

in

some

prosodic

components

of

language.

For

those

few

peo-

ple

who

do

not

have

normal

lateralisation

this

pattern

seems

to

be

reversed,

although

a

very

small

proportion

of

subjects

may

have

bilat-

eral

organisation

of

some

cognitive

skills.

The

anterior

parts

of

both

hemispheres

have

been

accepted

as

being

implicated

in

problem

solv-

ing

processes

that

are

required

in

a

wide

range

of

situations

including

practical

rou-

tines

and

social

interactions

as

well

as

abstract

reasoning

tasks.7

The

most

posterior

parts

of

both

hemispheres

are

involved

in

early

visual

processing.

Subcortical,

as

well

as

cortical,

brain

regions,

are

involved

in

atten-

tion

and

alertness.

Subcortical

brain

regions

are

also

involved

in

episodic

memory,

in

some

aspects

of

long

term

memory,

and

in

the

motor

control

of

language.12

A

modularity

approach

to

the

analysis

of

cognitive

skills

implies

that

each

complex

cognitive

process

can

be

thought

of

as

con-

sisting

of

a

series

of

functionally

independent

specialised

subprocesses.72$29

The

interaction

of

these

subprocesses

results

in

the

complex

cognitive

skills.

The

way

in

which

the

cogni-

tive

processes

are

organised

is

often

charac-

terised,

similarly

to

the

"diagram

maker"

approach,

in

terms

of

flow

diagrams

that

attempt

to

detail

the

way

that

the

different

subprocesses

are

brought

together

to

perform

a

specific

task.

Empirical

support

for

the

modularity

approach

can

be

obtained

at

vari-

ous

levels

including

the

neurophysiological,

neuroanatomical,

and

neuropsychological.'031

For

example,

numeracy

has

been

fractionated

into

several

independent

components:

cogni-

tive

mechanisms

for

number

comprehension,

number

production,

arithmetical

fact

retrieval,

and

arithmetical

procedures.'2

The

idea

that

complex

cognitive

skills

are

carried

out

by

distinct

subprocesses

com-

bined

with

the

idea

that

there

are

highly

spe-

cialised

areas

in

the

brain,

has

led

many

cognitive

neuropsychologists

to

assume

that

a

cerebral

lesion

can

damage

only

some

sub-

processes

within

complex

cognitive

skills.

Indeed,

cognitive

neuropsychologists

have

succeeded

in

showing

many

dissociations

between

the

subcomponents

of

cognitive

skills

that

allow

valid

conclusions

about

the

nature

and

functions

of

the

impaired

process-

ing

components

to

be

drawn.

Methods

of

assessment

of

cognitive

functions

One

of

the

fundamental

principles

underlying

neuropsychological

assessment

is

to

establish

whether

the

subject

is

still

functioning

at

their

premorbid

optimal

level

or

whether

there

has

been

a

deterioration.

Therefore,

the

methods

used

for

assessing

cognitive

functioning

in

neuropsychology

need

to

be

able

to

provide:

(a)

an

indirect

measure

of

the

premorbid

skills

of

a

person

and

(b)

a

measure

of

the

present

cognitive

state

of

that

person.

Once

the

two

types

of

measures

are

obtained

they

can

be

compared.

This

should

indicate:

firstly,

whether

the

functioning

has

changed

from

the

premorbid

state;

and

secondly

whether

this

reflects

organic

or

functional

impairment.

If

the

results

indicate

organic

impairment

then

an

attempt

will

be

made

to

establish

the

extent

of

the

change.

It

is

not

only

useful

to

know

that

a

change

in

cognitive

functioning

has

occurred;

it

is

also

useful

to

know

whether

the

change

can

be

charac-

terised

as

global

or

focal.

If

the

cognitive

impairment

is

focal,

neuropsychological

mea-

sures

can

be

used

to

specify

more

precisely

the

cognitive

impairments:

whether

the

impairment

is

indicative

of

lateralised

dys-

function

or

confined

to

the

anterior

or

poste-

rior

regions

of

the

brain.

In

exceptional

cases,

it

is

possible

to

document

highly

selective

cognitive

impairments

with

a

known

and

rela-

tively

precise

anatomical

localisation.

A

comprehensive

neuropsychological

examination

would

include

the

assessment

of:

(a)

premorbid

ability;

(b)

general

intellec-

tual

level;

(c)

memory;

(d)

language;

(e)

calculation;

(f)

problem

solving;

(g)

alertness

and

attention;

(h)

visual

and

space

percep-

tion.

Ideally

a

cognitive

profile

would

be

constructed

from

performance

on

tests

of

proved

validity

and

comparable

difficulty.

A

long

term

aim

for

the

neuropsychologist

is

to

achieve

a

level

of

measurement

for

all

656

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

Neuropsychological

assessment

Verbl

IQ

Speed

..,..

Pe

rforma

nce

IQ

.I

\Verba

memory,/

Naming

Pe

Reading

_

Spelling

Spatial

skills

Arithmetic

Percentiles

<1

a1<5

a5<25

E

>25<50-

¢50O

cognitive

skills

that

permit

comparison

across

tasks

and

is

sensitive

to

change.

The

method

described

by

Newman

et

al

in

their

study

that

monitored

subjects

at

risk

for

Alzheimer's

dis-

ease

exploited

this

methodology

(figure)."

In

the

next

section

we

do

not

attempt

to

describe

all

the

tests

and

techniques

available

to

the

neuropsychologists

for

investigation

of

all

these

different

areas

of

cognition.

Rather

we

focus

on

three

main

areas

of

cognitive

function:

intelligence,

memory,

and

language

functions.

These

serve

to

illustrate

the

range

of

techniques

and

procedures

available

for

the

investigation

of

cognitive

impairments."

ASSESSMENT

OF

PREMORBID

ABILITY

Various

procedures

are

adopted

for

obtaining

an

indirect

measure

of

a

subject's

premorbid

skills,

which

can

then

be

compared

with

his

current

level

of

performance.

These

proce-

dures

can

be

divided

into

two

main

types:

methods

that

use

demographic

data

such

as

age,

sex,

race,

education,

and

occupation;

and

methods

that

use

tests

considered

to

be

relatively

resistant

to

neurological

and

psychi-

atric

disorders.

The

first

type

of

method

is

based

on

the

known

relation

between

a

num-

ber

of

demographic

variables

and

measured

IQ*.34

Not

only

may

educational

and

occupa-

tional

records

be used

as

a

rough

estimate

of

a

subject's

optimal

or

premorbid

level

of

functioning;

they

may

also,

through

the

use

of

various

types

of

regression

equations,

provide

a

more

precise

and

objective

estimate.'5

One

of

the

principle

limitations

of

this

type

of

technique,

however,

is

that

educational

and

occupational

histories

may

not

always

be

readily

available

and

they

may

be

incomplete,

uninformative,

or

anomalous.

The

second

method

involves

the

measure-

ment

of

a

cognitive

skill

that

is

known

to

be

highly

correlated

with

intellectual

factors

and

resistant

to

brain

damage.

This

method

is

obviously

not

reliant

on

preexisting

data.

Some

of

the

first

methods

of

this

type

involved

the

use

of

vocabulary.'6

These

meth-

ods

were

based

on

the

finding

that

patients

with

brain

disease

retained

old,

well

estab-

lished

verbal

skills,

such

as

those

implicated

in

the

verbal

definition

of

words,

long

after

other

cognitive

skills

were

impaired.

The

application

of

the

same

principle

led

to

the

development

of

various

Wechsler

deteriora-

tion

indices.'2

More

recently,

a

measure

of

premorbid

optimal

level

of

functioning

has

been

based

on

the

overlearned

skill

of

reading.

Nelson

and

McKenna"7

first

established

that

word

reading

skill,

as

measured

by

the

Schonell

graded

word

reading

test38

was

highly

corre-

lated

with

general

intelligence

in

a

normal

population.

Nelson

and

O'Connel139

then

established

that

the

reading

of

irregular

words,

such

as

"heir"

or

"chord",

which

can-

not

be

pronounced

correctly

by

applying

the

usual

rules

that

map

spelling

on

to

phonol-

ogy,

were

better

indicators

of

premorbid

intelligence

(IQ)

in

demented

subjects

than

estimates

based

on

reading

regular

words.

Nelson

subsequently

developed

the

National

adult

reading

test

(NART),

which

consists

of

50

irregular

words.

Indeed,

the

NART

has

become

one

of

the

most

commonly

used

measures

of

premorbid

intelligence.4'

An

American

version

of

this

test

is

also

avail-

able.42

One

of

the

major

limitations

of

the

NART

test

is

that

it

cannot

be

used

with

those

who

have

poor

literacy

skills

or

in

patients

with

obvious

impairments

of

speech

production

or

problems

associated

with

dyslexia.

In

addition,

there

have

been

claims

that

patients

with

dementing

disorders

may

not

present

with

preserved

irregular

word

reading.43

Consequently

these

patients

pre-

sent

with

difficulties

in

reading

the

NART

words,

and

this

would

result

in

erroneous

low

estimates

of

their

premorbid

IQ.

In

the

cases

of

early

dementia

when

language

skills

are

rel-

atively

unimpaired,

however,

it

has

been

shown

that

the

NART

remains

stable

over

time

and

can

be

used

as

a

predictor

of

the

premorbid

optimal

level

(Paque

and

Warrington,

unpublished

data).

ASSESSMENT

OF

GENERAL

INTELLECTUAL

LEVEL

Historically,

intelligence

has

been

defined

in

many

different

ways.

For

example,

Spearman,44

although

he

himself

avoided

the

term

intelligence,

proposed

the

existence

of

a

central

intellectual

ability,

which

he

referred

to

as

"g".

Although

he

never

actually

defined

what

g

was

he

thought

that

it

involved

"the

eduction

of

relations

and

correlates".4"

In

his

formulation

g

referred

to

the

determinant

of

shared

variance

among

various

tests

of

intel-

lectual

ability.

An

alternative

view,

associated

with

Thurstone45

and

Guilford,46

involved

the

application

of

the

term

intelligence

to

a

large

set

of

diverse

mental

abilities

(or

fac-

tors).

These

included

not

only

reasoning

and

problem

solving

on

new

data

but

also

*The

term

IQ

was

first

introduced

by

Stern40

to

describe

a

method

of

comparing

one

child's

score

on

the

Binet

intelligence

scale

with

the

performance

of

average

children

of

the

same

age.

It

is

nowadays

used

to

indicate

intellectual

level

by

comparing

a

subject's

performance

with

the

average

scores

attained

by

mem-

bers

of

the

same

age

group.

Example

of

a

circle

diagram

of

cognitive

skills.

Sectors

of

the

circle

have

been

apportioned

to

each

of

the

cognitive

skills

examined.

The

concentric

circles

represent

the

level

of

functioning

in

terms

of

percentile

score.

The

levels

of

the

subject's

test

performance

are

indicated

by

the

degree

of

eccentricity

within

a

sector.

In

this

patient

the

most

prominent

feature

was

a

global

memory

impairment

more

pronounced

for

verbal

than

visual

material.

(Diagram

courtesy

of

Newman

et

al.

33)

657

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

Cipolotti,

Wanington

specialised

knowledge

derived

from

prior

schooling

or

experience.

In

line

with

this,

Cattell47

distinguished

between

fluid

intelli-

gence,

the

ability

to

deal

with

novelty

and

to

adapt

one's

thinking

to

a

new

cognitive

prob-

lem,

and

crystallised

intelligence,

which

reflects

a

knowledge

base

and

skills

that

have

been

previously

acquired

through

learning

and

experience.

The

available

measures

of

intelligence

reflect

these

different

formulations

of

the

abil-

ities

underlying

intelligence.

For

example,

Raven's

test,

including

the

coloured

progres-

sive

matrices,"1

the

standard

progressive

matrices,'0

and

the

advanced

progressive

matrices

(sets

I

and

II)48,

are

widely

used

for

the

clinical

assessment

of

general

intelligence.

The

various

versions

of

this

test

are

believed

to

weigh

heavily

on

g

and

measure

processes

that

are

central

to

the

definition

of

fluid

intel-

ligence

(more

recently

also

termed

analytic

intelligence49).

Indeed,

they

require

abstract

reasoning,

induction

of

relations,

and

educ-

tion49

The

test

was

developed

as

a

"culture

fair"

measure

of

general

intellectual

ability

and

because

of

its

non-verbal

format,

its

ease

of

use,

and

its

speed

(especially

the

coloured

progressive

matrices),

it

has

gained

wide

use

in

both

clinical

and

research

settings.

This

may

be

overoptimistic

as

educational

level

has

subsequently

been

shown

to

have

a

major

effect

on

the

normal

subject's

performance.50

The

Wechsler

adult

intelligence

scale

(WAIS)5'

52

iS

considered

to

be

one

of

the

core

measures

for

evaluating

general

intellectual

ability.

It

involves

six

verbal

and

five

non-

verbal

subtests

that

sample

various

skills.

These

subtests

are

thought

to

measure

vari-

ous

mental

abilities

as

would

follow

from

Thurstone's45

and

Guilford's46

views,

includ-

ing

both

the

explicit

knowledge

base

derived

from

educational

and

previous

experience

and

the

ability

to

deal

with

and

solve

new

cognitive

problems.

Verbal

and

performance

IQs

are

determined

from

the

use

of

the

Wechsler

scales.

Much

research

has

focused

on

discrepancies

between

verbal

and

perfor-

mance

IQ

as

a

means

of

differentiating

between

left

and

right

hemisphere

impair-

ment53

although

this

has

not

resulted

in

a

general

consensus.'2

Indeed,

Warrington

et

al54

suggested

that

such

scales

have

little

value

as

regards

the

localisation

of

a

lesion

or,

for

that

matter,

the

identification

of

specific

cognitive

deficits.

Nevertheless,

the

Wechsler

adult

intelligence

scale-revised

(WAIS-R),

the

successor

of

the

WAIS

is

the

most

often

used

psychological

test

of

intellectual

functioning

and

is

a

cornerstone

for

most

neuropsycho-

logical

test

batteries.

It

is

also

widely

used

with

geriatric

patients,

and

recently,

norma-

tive

data

for

people

who

are

75

or

older

have

become

available.55

Numerous

studies

are

based

on

the

WAIS-R.

ASSESSMENT

OF

MEMORY

Memory

is

not

a

unitary

function

but

rather

a

collection

of

distinct

and

independent

com-

ponents,

each

of

which

is

associated

with

dif-

ferent

brain

structures.

A

broad

distinction

is

generally

made

between

short

and

long

term

memory.

Short

term

memory

is

considered

to

be

responsible

for

the

immediate

retention

of

a

limited

amount

of

information;

this

infor-

mation

will

decay

in

a

matter

of

seconds

if

it

is

not

refreshed.

Long

term

memory

retains

larger

amounts

of

information

for

longer

peri-

ods-depending

on

the

salience-which

may

be

for

minutes,

days,

and

years.

Short

and

long

term

memory

functions

can

be

further

divided

into

verbal

and

visual

memory

according

to

whether

they

retain

verbal

or

non-verbal

information.56

Long

term

memory

is

also

subdivided

into

implicit

(or

proce-

dural)

and

explicit

(or

declarative)

memory.57

Implicit

memory

retains

information

that

affects

behaviour

but

it

is

not

available

for

conscious

recollection

(for

example,

motor

skills,

conditioned

reflexes,

priming).

A

fur-

ther

example

is

the

three

letter

word

stem

completion

task,

which

can

be

performed

by

guessing

rather

than

by

conscious

recall.58

In

this

task

patients

are

presented

with

a

list

of

words

and

their

retention

is

tested

either

by

standard

recall

and

recognition

techniques

or

by

presenting

the

first

three

letters

of

the

target

item

in

a

word

completion

task

(for

example,

"cha"-chair).

Explicit

memory

retains

information

that

can

be

consciously

accessed.

It

is

subdivided

into

episodic

and

semantic

memory.59

Episodic

memory

con-

tains

information

about

temporally

dated

episodes

or

events

and

temporospatial

rela-

tions

among

them

(for

instance,

this

can

be

for

both

autobiographical

memories

and

memories

of

an

artificial

event

such

as

a

word

list

or

short

stories).

Semantic

memory

con-

tains

our

organised

knowledge

of

concepts

and

facts

as

well

as

words

and

their

meanings

(for

example,

encyclopaedic

memories).

Most

clinical

assessments

focus

on

three

main

types

of

memory

functions:

short

term

memory,

episodic

memory,

and

semantic

memory.

Assessment

of

short

term

memory

The

assessment

of

verbal

short

term

memory

usually

requires

the

repetition

of

a

progres-

sively

lengthening

string

of

digits

(digit

span),

letters,

and

words.

The

normal

range

of

digits

is

five

to

nine.

Spatial

short

term

memory

can

be

assessed

with

the

Corsi

block

tapping

test.60

This

requires

the

subject

to

tap

a

pro-

gressively

lengthening

sequence

of

blocks.

Assessment

of

episodic

memory

Many

tests

and

batteries

are

available

for

the

assessment

of

episodic

memory.61

These

use

either

a

recall

or

recognition

paradigm

and

typically

assess

the

anterograde

(the

ability

to

acquire

new

information)

rather

than

the

ret-

rograde

component

(the

ability

to

recall

pre-

viously

learnt

material).

One

of

the

oldest

batteries

used

is

the

Wechsler

memory

scale

(and

the

Wechsler

memory

scale-revised),

which

requires

the

recall

of

both

complex

ver-

bal

material

(for

example,

short

stories)

and

visual

material

(for

example,

reproduction

of

geometrical

designs).

Some

of

its

subtests

are

not

dependent

on

memory

itself

but

rather

on

attentional

processes

(for

example,

mental

658

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

659

Neuropsychological

assessment

control

and

orientation).

Unfortunately

all

the

subtests

contribute

to

the

final

memory

quotient.

A

more

recently

developed

test

for

the

assessment

of

long

term

verbal

memory

is

the

adult

memory

and

information

processing

battery,62

which

has

many

similarities

to

the

Wechsler

memory

scale.

The

Rivermead

behavioural

memory

tests

consist

of

a

series

of

tests

held

to

have

ecological

validity.6'

A

task

that

is

also

very

often

used

for

assessing

verbal

anterograde

recall

is

word

list

learning

(for

example,

the

auditory-verbal

learning

test64).

For

the

assessment

of

non-verbal

anterograde

recall,

the

two

most

commonly

used

tests

are

the

Rey-Osterreith

complex

figure

test65

and

the

Benton

revised

visual

retention

test.66

Both

require

the

recall

of

geometric

figures.

Warrington67

developed

a

test

that

used

a

recognition

rather

than

a

recall

paradigm

(the

recognition

memory

test).

The

recognition

paradigm

was

chosen

because

it

is

possible

to

have

comparable

tests

of

verbal

and

visual

memory.

This

test

incorporates

the

verbal

and

non-verbal

dichotomy

by

having

separate

subtests

with

word

and

face

stimuli.

Age

cor-

rected

percentile

scores

of

a

large

standardisa-

tion

sample

are

available.

Validation

of

this

test

has

shown

that

patients

with

right

hemi-

spheric

lesions

are

impaired

on

the

visual

ver-

sion

and

patients

with

left

hemispheric

lesions

are

impaired

on

the

verbal

version.

It

has

also

been

shown

that

this

test

can

detect

minor

degrees

of

memory

deficit."

Clegg

and

Warrington68

have

also

recently

standardised

and

validated

four

"easy"

memory

tests

(three

recognition

memory

tests

and

a

word

paired

associate

learning

test)

for

older

adults

(64

and

older)

that

are

recommended

for

patients

in

whom

memory

impairment

is

suspected

but

whose

mental

state

(for

example,

poor

attention,

anxiety,

or

agitation)

precludes

longer

or

more

demanding

tests.

Most

tests

of

retrograde

verbal

and

visual

recall

have

been

devised

for

research

rather

than

clinical

purposes.

They

normally

test

recall

and

recognition

of

famous

names

and

famous

faces.

Perhaps

because

they

so

quickly

become

dated

their

standardisation

and

validation

are

problematic.

A

relatively

new

test

assessing

autobiographical

memory

is

an

exception

to

this

rule

(autobiographical

memory

interview69).

This

test

requires

the

recall

of

personal

remote

facts

and

incidents

from

three

epochs:

childhood,

early

adult

life,

and

recent

experience.

Assessment

of

semantic

memory

Patients

with

a

semantic

memory

disorder

present

a

general

loss

of

knowledge,

including

object

and

word

meaning.

This

deficit

can

manifest

itself

as

an

inability

to

comprehend

words

and

identify

pictures

and

objects.

The

classic

syndromes

of

transcortical

sensory

aphasia

and

visual

associative

agnosia

have

been

identified

with

the

impairment

of

semantic

memory.70

There

are

no

standard-

ised

batteries

for

the

assessment

of

semantic

memory

because,

unlike

episodic

memory,

it

has

only

been

studied

in

the

past

20

years,

after

the

seminal

paper

of

Tulving.59

Semantic

memory

can,

however,

be

assessed

through

tests

devised

for

other

domains

(mainly

tests

also

used

for

the

assessment

of

language

dis-

orders).

To

evaluate

the

difficulties

in

word

definition

some

verbal

subtests

of

the

Wechsler

scales,

such

as

vocabulary

and

information,

can

be

used.

Naming

tests

can

be

used

as

indirect

evidence

of

semantic

memory

impairment

(see

language

section

later).

The

pyramids

and

palm

tree

test7'

was

developed

specifically

to

evaluate

impair-

ments

in

the

understanding

of

concepts.

There

is

a

verbal

and

a

pictorial

version

of

this

task

devised

for

assessing

conceptual

relations.

Limited

normative

data

are

avail-

able.

A

further

test,

the

British

picture

vocab-

ulary

test,72

which

uses

a

word

picture

matching

technique,

was

first

developed

for

the

assessment

of

language

developments

between

the

ages

2

and

18.

More

recently

it

has

been

standardised

in

a

normal

healthy

elderly

population

(Clegg

and

Warrington,

unpublished

data).

ASSESSMENT

OF

LANGUAGE

Language

is

not

a

unitary

fimction.

The

most

useful

dichotomy

is

to

consider

spoken

and

written

language

separately.

Spoken

language

can

be

characterised

as

a

collection

of

independent

components,

each

of

which

is

associated

with

different

brain

structures.

The

three

main

central

linguistic

components

are

phonology,

syntax,

and

semantics.7'

Phonological

processing

analyses

the constituent

sounds

of

words.

Syntactic

processing

analyses

the

grammatical

aspects

of

language-for

example,

the

ordering

of

the

individual

words

in

the

sentence.

Semantic

processing

analyses

the

referential

meaning

of

words.

In

addition

to

these

three

components

there

are

more

specialised

peripheral

systems

subserving

articulation

and

prosody.

Furthermore,

at

least

for

phonology

and

syn-

tax,

receptive

and

expressive

deficits

can

occur

as

selective

impairments.7'76

Disruptions

in

phonological

or

semantic

pro-

cessing

are

found

at

the

level

of

single

words

whereas

disruptions

in

syntactic

processing

are

found

at

the

level

of

sentences.

Assessment

of

spoken

language

There

are

several

traditional

clinical

tax-

onomies

of

the

acquired

aphasias

principally

inherited

from

the

earliest

scientific

papers

on

language

disorder.'-3

19

These

taxonomies,

based

on

mixed

functional,

anatomical,

and

pathological

terms,

have

inspired

the

develop-

ment

of

classic

aphasia

batteries.

The

most

widely

used

are

the

Boston

diagnostic

aphasia

examination,76

the

western

aphasia

battery,77

the

Porch

index

of

communicative

ability,78

and

the

Aachen

aphasia

test.79

The

traditional

taxonomies

that

form

their

basis

have

been

questioned

in

so

far

as

they

failed

to

capture

the

multidimensional

pattern

of

language

breakdown,

they

are

not

useful

for

guiding

therapy

or

for

the

detailed

analysis

and

understanding

of

language

disorders.80

In

this

section

we

provide

a

brief

account

of

the

core

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

Cipoloti,

Wamngton

tests

that

could

provide

a

framework

for

the

more

detailed

assessment

of

a

patient's

lan-

guage

impairment.

We

discuss

only

two

areas

of

language

dysfunction:

word

and

sentence

comprehension

and

word

and

sentence

retrieval.

Word

and

sentence

comprehension-Word

comprehension

deficits

can

occur

as

a

result

of

an

impairment

in

auditory

perception

or

as

a

result

of

an

impairment

in

word

meaning.

An

auditory

word

perception

deficit

can

be

identified

in

patients

that

have

a

deficit

in

word

repetition

that

cannot

be

attributed

to

a

more

general

articulatory

deficit.8'

It

can

be

assessed

through

phonological

discrimination

tasks

that

are

usually

included

in

most

of

the

traditional

aphasia

batteries.

Impairment

of

word

meaning

is

one

component

of

the

semantic

memory

disorders

(see

earlier)

and,

as

the

word

retrieval

deficit

(see

later),

can

be

category

specific.

For

example,

selective

deficits

for

abstract

and

concrete

concepts

and

within

the

concrete

domain

animate

or

inanimate

reference

and

even

specific

word

class

effects

have

all

been

reported.82

One

of

the

most

direct

tests

of

word

meaning

are

synonyms

tests

(for

example,

"timid"

means

"afraid"

or

"quiet").

Coughlan

and

Warrington83

have

offered

a

modest

standard-

isation

of

one

such

test.

Word

meaning

com-

prehension

can

also

be

tested

by

using

word-picture

matching

tests

such

as

the

pyra-

mids

and

palm

tree

test7l

and

the

British

picture

vocabulary

test,72

described

in

the

semantic

memory

section.

In

addition,

the

recent

psycholinguistic

assessment

of

lan-

guage

processing

in

aphasia84

is

a

useful

research

tool

for

assessing

comprehension

in

the

domains

of

verbal

and

visual

knowledge.

One

of

the

earliest

and

most

commonly

used

test

of

sentence

comprehension

is

the

token

test

devised

by

De

Renzi

and

Vignolo.85

This

test

uses

tokens

of

different

shapes,

sizes,

and

colours

and

the

patient

is

given

an

oral

instruction

in

progressively

more

com-

plex

non-redundant

sentences

(for

example,

"put

the

red

circle

between

the

yellow

square

and

the

green

square").

There

have

been

var-

ious

modifications

of

the

test

including

a

shortened

version

by

De

Renzi

and

Faglioni

and

a

very

abbreviated

version

by

Coughlan

and

Warrington.8'

Educationally

standardised

normative

data

are

available.

Parisi

and

Pizzamiglio86

devised

a

test

specifically

for

testing

syntactic

comprehension

(for

an

English

version

see

Lesser87).

Another

test

for

grammatical

comprehension

is

the

test for

reception

of

grammar.88

This

test

was

devel-

oped

for

the

assessment

of

language

develop-

ments

and

has

been

used

also

in

the

context

of

acquired

aphasia

investigations.

It

should

be

acknowledged

that

some

normative

data

are

available

for

the

sentence

comprehension

test

reviewed

here

and

are

undoubtedly

very

useful

for

in

depth

assessment

of

a

patient's

aphasic

deficit.

Word

and

sentence

retrieval-Word

retrieval

difficulties

are

exemplified

by

the

syndrome

of

amnestic

or

nominal

dysphasia

and

are

often

present

in

other

aphasic

syndromes

and

in

cortical

degenerative

conditions.

They

can

be

specific

for

particular

categories

such

as

letters,

colours,

body

parts,

proper

names,

and

fruits

and

vegetables.3'

To

evaluate

word

retrieval

difficulties

naming

from

verbal

description

(for

example,

"what

is

the

name

of

the

large

grey

animal

with

a

trunk")

and

picture

naming

tests

can

be

used.

The

graded

naming

test89

was

developed

to

identify

very

mild

degrees

of

anomia.

It

comprises

items

of

low

frequency

and

it

has

been

standardised

in

a

normal

population

and

validated

in

patients

with

unilateral

lesions.

The

Boston

naming

test90

comprises

line

drawings

of

objects

and

has

been

widely

used

in

aphasia

studies.

Only

a

limited

standardisation

is

available.

Spontaneous

language

is

often

elicited

by

complex

picture

description.

The

cookie

jar

theft

picture

from

the

Boston

diagnostic

aphasia

examination

is

widely

used

for

this

purpose.

De

Renzi

and

Ferrari9'

devised

the

reporter

test

requiring

the

patient

to

act

as

a

reporter

of

the

performance

carried

out

by

the

examiner

who

acts

in

accordance

with

the

commands

of

the

token

test

described

earlier.

This

test

is

particularly

useful

for

the

identifi-

cation

of

impairments

in

grammatical

sen-

tence

construction,

although

there

are

only

limited

normative

data

at

present.

WRItEN

LANGUAGE

In

the

past

30

years

cognitive

neuropsycholo-

gists

have

investigated

reading

and

writing

disorders

in

detail

and

depth.

This

has

resulted

in

the

identification

of

new

syn-

dromes

that

take

the

description

of

reading

and

writing

difficulties

well

beyond

the

classic

syndrome

described

by

Dejerine3:

dyslexia

with

dysgraphia

and

dyslexia

without

dys-

graphia.

Each

of

these

different

dyslexic

and

dysgraphic

syndromes

corresponds

to

an

identifiable

impairment

in

a

subcomponent

or

subcomponents

of

the

reading

and

writing

process.

Shallice

and

Warrington92

have

pro-

posed

a

distinction

between

peripheral

and

central

dyslexic

syndromes

and

this

dichotomy

applies

equally

well

to

the

dys-

graphia

syndromes.

Peripheral

dyslexias

and

dysgraphias

result

from

damage

to

processes

responsible

for

the

categorisation

of

a

string

of

letters

or

phonemes

as

orthographic

or

phonological

entities.

Central

dyslexias

and

dysgraphias

are

due

to

impairment

in

the

comprehension

and

production

of

a

target

stimulus.

The

study

of

central

dyslexias

and

dysgraphias

has

provided

evidence

that

there

are

at

least

two

parallel

forms

of

processing

for

reading

and

writing:

one

phonologically

based

and

one

semantic

based.

Phonological

processing

utilises

a

set

of

rules

for

translating

print

to

sound

or

sound

to

print.

It

is

used

for

reading

or

writ-

ing

unfamiliar

words

or

non-words.

Semantic

processing

accesses

meaningful

representa-

tions

of

the

words

that

are

in

the

subject's

vocabulary.

These

two

types

of

processing

can

break

down

independently

to

produce

different

types

of

reading

and

writing

impairments.

660

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

Neuropsychological

assessment

Assessment

of

written

language

Following

the

seminal

work

of

Marshall

and

Newcombe93

a

psycholinguistic

method

of

assessment

of

written

language

disorders

has

gained

wide

popularity.

This

method

involves

the

presentation

of

lists

of

words

that

sample

contrasting

psycholinguistic

properties.

It

is

thought

that

the

data

on

the

effect

of

the

psy-

cholinguistic

and

visual

(length,

script,

and

displays)

variables

coupled

with

an

errors

analysis

allow

conclusions

to

be

drawn

about

the

likely

origin

of

dysfunction

within

the

reading

system.

In

this

section

we

provide

a

description

of

some

of

the

standardised

and

validated

formal

tests

for

the

assessment

of

reading

and

spelling

disorders.

Reading-Any

assessment

of

reading

skills

should

include

an

evaluation

of

a

patient's

ability

to

read

both

single

words

and

text.

In

some

peripheral

dyslexias

the

ability

to

read

text

can

be

impaired

whereas

the

ability

to

read

single

words

can

be

spared.

(for

exam-

ple,

attentional

dyslexia94)

The

Neale

test95

for

assessment

of

prose

reading

in

children

is

useful

in

this

context.

In

addition,

most

of

the

standard

aphasia

batteries

include

a

subtest

for

text

reading

(for

example,

Boston

diag-

nostic

aphasia

examination).

For

the

formal

assessment

of

single

words,

the

two

most

widely

used

tests

are

the

NART

and

the

Schonell

graded

word

reading

test.

Both

tests

are

graded

in

difficulty

and

are

measures

of

reading

skills;

an

estimate

of

premorbid

opti-

mal

level

of

functioning

can

also

be

obtained

(see

earlier).

When

assessing

reading

skills

it

is

important

to

evaluate

the

patient's

ability

to

read

aloud

non-words.

This

ability

can

be

selectively

impaired

despite

good

word

read-

ing

as

in

the

case

of

phonological

dyslexia.96

No

formal

standardised

tests

for

non-word

reading

are

available;

however,

several

lists

have

been

devised

for

research

purposes.

Oral

and

written

spelling-Written

and

oral

spelling

are

known

to

dissociate

and

therefore

are

assessed

independently.

For

the

assess-

ment

of

written

spelling

the

Schonell

graded

spelling

test

can

be

used.

For

the

assessment

of

oral

and

written

spelling,

Baxter

and

Warrington97

have

recently

standardised

and

validated

a

test

that

is

sensitive

to

minor

degrees

of

deficit

in

the

general

neurological

population.

This

is

a

graded

difficulty

test;

thus

the

raw

scores

can

be

converted

into

per-

centile

scores.

For

patients

whose

poor

eye

sight

precludes

reading,

spelling

can

provide

a

useful

measure

of

premorbid

abilities.

The

assessment

of

non-word

spelling

is

also

important

because

patients

with

phonological

dysgraphia

might

present

with

some

pre-

served

word

spelling

despite

impaired

non-

word

spelling.98

Several

non-word

spelling

lists

have

been

developed

for

research

pur-

poses.

The

use

of

the

standard

word

reading

and

spelling

tests

described

combined

with

assess-

ment

of

the

patient's

ability

to

read

and

write

non-words

and

an

analysis

of

the

errors

made

by

the

patient

identifies

more

than

the

pres-

ence

of

a

reading

or

spelling

disorder.

It

can

also

provide

some

preliminary

indication

of

the

status

of

the

peripheral

and

central

pro-

cessing

involved

in

word

reading

and

spelling.

This,

rather

than

the

description

of

the

presence

or

absence

of

a

reading

or

spelling

disorder,

has

a

clear

clinical

and

theoretical

significance.

Purposes

of

a

neuropsychological

assessment

There

are

at

least

three

main

reasons

for

con-

ducting

a

neuropsychological

assessment:

diagnosis,

treatment

and

management,

and

research.

DIAGNOSIS

A

neuropsychological

assessment

allows

the

description

and

evaluation

of

the

major

cog-

nitive

deficits

incurred

in

neurological

patients

with

possible

brain

disease.

Furthermore,

it

can

indicate

possible

neuroanatomical

corre-

lates

of

the

cognitive

impairments.

A

neu-

ropsychological

assessment

can,

at

the

very

least,

provide

pointers

as

to

whether

there

is

unilateral,

bilateral,

or

subcortical

damage.

This

information

can

be

useful

in

diagnosis.

Neuropsychological

assessment

has

a

key

role

in

differentiating

between

organic

and

func-

tional

disorders.'4

99-101

There

are

other

neuro-

logical

conditions-for

example,

cortical

atrophy,

frontal

and

temporal

lobe

tumours,

and

undetected

temporal

lobe

seizures-that

may

manifest

themselves

with

symptoms

that

can

be

misinterpreted

as

functional.'02

For

example,

patients

with

visual

disorientation

disorders

due

to

bilateral

occipital

disease

are

often

misdiagnosed

on

the

grounds

that

their

visual

handicap

seems

to

be

disproportionate

in

the

context

of

normal

or

near

normal

acuity.

103

On

the

other

hand,

patients

with

symp-

toms

of

pseudodementia,

such

as

hysteria,

malingering,

Ganser

syndrome,

bipolar

disor-

der,

and

other

ill

defined

psychiatric

disorders

often

present

with

an

abrupt

intellectual

and

memory

failure

that

mimics

true

cognitive

deficits.

A

neuropsychological

assessment

can

distinguish

between

organic

and

functional

disorders.

It

does

this

by

highlighting

discrep-

ancies

between

subjective

complaints

and

objective

performance,

usually

detecting

a

number

of

inconsistencies

in

the

patients'

performance

and

a

too

obvious

mismatch

between

objective

performance

and

daily

life

activities.

Also,

the

body

of

neuropsychologi-

cal

knowledge

on

the

organisation

and

frac-

tionation

of

cognitive

skills

is

nowadays

highly

developed.

Crucially,

the

way

in

which

the

cognitive

functions

can

fractionate

often

diverges

from

the

common

sense

opinion

of

how

a

cognitive

function

can

break

down.

Thus

the

patient's

pattern

of

performance

can

be

interpreted

as

neuropsychologically

convncmig

or

unconvincing.

To

consider

one

example,

a

neuropsychological

assessment

is

useful

in

differentiating

organic

and

func-

tional

memory

loss.

Studies

of

patients

with

dense

organic

amnesia

have

shown

that

they

can

still

learn

new

associative

information

provided

that

they

are

tested

using

implicit

661

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

Cipolotti,

Warnngton

learning

tasks.

104

For

example,

they

show

savings

with

repeated

presentations

of

frag-

mented

or

degraded

stimuli

(pictures

or

words)

in

increasing

degrees

of

completeness.

Even

quite

severely

demented

patients

would

show

some

learning

with

these

tasks.

Clearly

a

patient

showing

additional

impairments

on

these

implicit

learning

tasks

makes

no

neuro-

psychological

sense.

It

makes good

common

sense,

however,

to

also

be

impaired

on

these

tasks

(I

have

poor

memory,

I

can't

remember

things).

Indeed,

a

poor

performance

on

these

tests

may

be

considered

indicative

of

func-

tional

memory

loss.

On

the

contrary,

a

rela-

tively

preserved

performance

on

these

tasks

conforms

to

an

organic

pattern.

Another

common

differential

diagnosis

where

neuropsychological

assessment

has

a

key

role

is

between

early

dementia,

anxiety

or

depressive

disorders,

or

the

normal

aging

process.

The

diagnosis

of

probable

dementia

is

usually

made

by

establishing

whether

there

is

an

acquired

deficit

of

cognition

without

hystopathological

evidence

obtained

from

a

biopsy

or

necropsy.

Often

in

the

early

stages

of

a

dementing

illness,

the

clinical

diagnosis

cannot

be

supported

by

neuroimaging

such

as

CT,

MRI,

or

functional

imaging.

Patients

with

depression

or

anxiety

may

complain

of

intellectual

or,

more

often,

memory

failure

similar

to

the

so

called

"worried

well"

patients.

Usually

depressive

or

anxiety

pseudodementia

should

be

suspected

when

the

patient

com-

plains

of

the

memory

problem

more

than

the

carer.'05

In

these

cases

recognition

memory

tests

should

be

used

to

determine

whether

the

failure

is

due

to

an

organic

condition

or

to

anx-

iety

or

depression.

It

has

been

shown

that

recall

tests

of

memory

are

vulnerable

to

the

effect

of

anxiety

and

depression,

whereas

recognition

memory

tests

are

not.'06

The

aging

process

itself

is

associated

with

cognitive

and

memory

changes.

Hence,

it

is

often

necessary

to

differentiate

memory

fail-

ure

due

to

cognitive

deterioration

rather

than

benign

senescent

forgetfulness.

In

these

cases

performance

in

recall

memory

tests

requiring

the

subjects

to

engage

in

elaborative

encod-

ing,

as

opposed

to

allowing

them

to

devise

their

own

encoding

strategy,

may

discrimi-

nate

those

with

brain

damage

from

normal

elderly

subjects.

For

example,

in

word

list

learning

the

strategy

of

performing

associa-

tions

between

successive

words

improves

the

overall

level

of

recall

in

normal

subjects.

Neuropsychological

assessment

can

also

have

a

central

role

in

diagnosing

presympto-

matic

cognitive

impairments

in

familial

neu-

rodegenerative

conditions.

From

the

nature

of

the

inheritance

and

the

relatively

constant

ages

of

disease

onset

within

a

family,

asymp-

tomatic

at

risk

subjects

below

the

mean

age

of

onset

can

be

examined.

Such

studies

have

shown

cognitive

abnormalities

in

apparently

asymptomatic

subjects

with

Huntington's

and

Alzheimer's

disease.33

107

TREATMENT

AND

MANAGEMENT

The

baselines

of

cognitive

functioning

pro-

vided

by

the

neuropsychological

examination

allow

the

monitoring

of

certain

conditions.

For

example,

successive

neuropsychological

examinations

provide

reliable

indications

of

whether

a

pattern

of

cognitive

deficit

associ-

ated

with

head

injury

or

stroke

is

changing

and

if

so,

how

rapidly

and

in

what

way.

This

information

is

useful

in

planning

the

future

medical

and

social

care

of

the

patient.

Similarly,

repeated-neuropsychological

testing

of

patients

with

degenerative

disorders

can

provide

information

about

their

different

rates

of

cognitive

decline

and

thus

help

them

and

their

family

plan

for

their

care.

The

results

of

a

neuropsychological

assessment

can

also

be

used

in

the

evaluation

of

medical

and

surgical

treatments

such

as

those

associ-

ated

with

subcortical

pathology

that

is

associ-

ated

with

cognitive

slowing

(for

example,

Parkinson's

disease

and

hydrocephalus).

For

instance,

obtaining

repeated

measures

of

a

hydrocephalic

patient's

performance

in

a

series

of

psychomotor

tests

can

provide

a

reli-

able

indication

of

whether

the

underlying

neurological

condition

is

improving

or

deteri-

orating.

Psychomotor

tests

are

simple

verbal

and

non-verbal

tests

that

involve

verbal

and

visuomotor

responses

and

the

measurement

of

the

patients'

speed

of

responding.

108

Practice

effects

are

minimal

in

these

tests,

which

are

at

the

same

time

sensitive

to

subtle

changes

in

cognitive

efficiency.

Therefore

they

can

be

used

at

regular

and

short

intervals

for

monitoring

the

patient's

neurological

state.

Neuropsychological

assessment

is

also

particularly

important

in

monitoring

the

vari-

ous

treatments

for

epilepsy.'09

110

The

baselines

of

cognitive

functioning

pro-

vided

by

the

neuropsychological

examination

can

be

important

for

planning

and

monitoring

rehabilitation

programmes.

In

particular,

when

planning

such

programmes,

neuro-

psychological

evaluation

can

provide

answers

to

key

questions

such

as

".

.

.

what

are

realis-

tic

treatment

goals

and

...

what

is

the

patient's

capacity

to

benefit

from

available

treatment

..

.".12

Moreover,

repeated

neu-

ropsychological

testing

can

be

used

to

monitor

the

effects

of

the

rehabilitation

programme.

Furthermore,

the

baselines

of

cognitive

func-

tioning

provided

by

neuropsychological

exam-

ination

can

be

used

to

explain

to

patients

and

their

families

their

relative

cognitive

problems

so

that

they

can

both

prepare

and

understand

the

type

of

difficulties

the

patient

may

face

when

he

leaves

the

hospital.

Neuropsychological

assessment

has

a

central

role

in

the

medicolegal

context.

Neuropsychological

data

concerning

the

type

and

severity

of

a

cognitive

deficit,

its

prognostic

value,

and

the

implications

for

future

care

are

central

issues

in

the

litigation

over

compensation

awards."'

In

this

context

neuropsychological

investigation

is

crucial

in

assessing

the

possibility

of

simulated

disability

that

can

sometimes

occur

before

financial

settlement.

"12

RESEARCH

There

are

two

main

neuropsychological

research

methodologies:

the

single

case

study

662

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

Neuropsychological

assessment

and

the

group

study.7

For

both,

neuropsycho-

logical

assessment

procedures

are

a

crucial

element.

The

strength

of

novel

findings

and

unexpected

dissociations

can

only

be

evalu-

ated

by

reference

to

performance

of

estab-

lished

tests

of

cognitive

skills.

In

group

studies

that

explore

new

hypotheses

neu-

ropsychological

measures

are

necessary

to

obtain

baseline

data.

Neuropsychological

research

may

consider

applied

clinical

problems

or

be

theoretically

driven.

In

applied

research,

batteries

of

neu-

ropsychological

tests

are

commonly

given

to

describe

the

cognitive

profiles

associated

with

particular

neurological

diseases.

For

example,

specific

cognitive

profiles

have

been

obtained

for

diseases

such

as

Parkinson's

disease

and

multiple

sclerosis.113

114

Neuropsychological

assessments

are

also

used

to

identify

specific

patterns

of

cognitive

deficits

associated

with

Alzheimer's

disease

and

other

degenerative

dementias.'

15-1

18

In

particular,

attempts

have

been

made

to

differentiate

various

subgroups

existing

within

a

category

of

dementing

disorders.

The

long

term

aim

is

to

further

the

understanding

of

the

disease,

in

particular

with

regard

to

early

diagnosis

and

the

possi-

bility

of

pharmacological

intervention."

19

120

Theoretically

driven

neuropsychological

research

has

proved

to

be

of

fundamental

importance

in

the

study

of

the

organisation

of

cerebral

functions

in

the

brain

and

especially

in

the

understanding

of

normal

cognitive

functioning.

Cognitive

neuropsychological

single

case

studies

have

been

used

as

a

legiti-

mate

type

of

evidence

to

support

or

criticise

information

processing

models

of

normal

cognition.

Furthermore

they

can

provide

valuable

findings

that

constrain

the

develop-

ment

of

new

theories.

Over

the

years

the

medical

literature

has

grown

immensely.

New

cognitive

deficits

have

been

identified

and

important

advances

have

been

made

in

the

understanding

of

the

relations

between

com-

ponents

of

complex

cognitive

skills

and

the

loci

of

brain

lesions.

The

neuropsychologist's

strategy

is

to

harness

and

incorporate

the

findings

of

research

investigations

to

a

clinical

problem

in

the

form

of

more

specific

and

more

sensitive

tests

of

cognitive

function.

These

improved

quantitative

techniques

for

clinical

assessment

can

bring

to

light

new

phenomena

that

in

turn

promote

funrther

the-

oretical

advances.

1

Broca

P.

Remarques

sur

le

siege

de

la

faculte

du

langage

articule

suivie

d'une

observation

d'aphemie.

Bulletin

de

la

Societe

d'Anatomie

Paris

1861;6:330.

(Translated

in

Herrnstein

R,

Boring

EG.

A

source

book

in

the

history

of

psychology.

Cambridge,

MA:

Harvard

University

Press,

1965.)

2

Wemicke

K.

Der

aphasische

Symptomenkomplex.

Breslau.

(Translated

in:

Boston

studies in

philosophy

of

science

1874;4:34-97.)

3

Dejerine

J.

Contribution

a

l'etude

anatomoclinique

et

clinique

des

differentes

varsetes

de

cecite

verbal.

CR

Hebdomadaire

des

Sceances

et

Memories

de

la

Societe

de

Biologie

1892;4:61-90.

4

Henschen

SE.

Klinische

und

anatomische

Betrag

zur

Pathologie

des

Gehirns.

Stockholm:

Nordiske

Bokhandein,

1920.

5

Lissauer

H.

Ein

Fall

von

Seelenblindheit

nebst

einem

Beitrag

zur

Theorie

derselben.

Archiv

fur

Psychiatrie

1890;21:222-270.

(Edited

and

reprinted

in

translation

by

M

Jackson

Lissauer

on

agnosia.

Cognitive

Neuropsychology

1988;5:155-192.)

6

Korsakoff

SS.

Uber

eine

besondere

Form

psychischer

Storung

combiniert

mit

multipler

Neuritis.

Archiv

fur

Psychiatrie

und

nervenkrankheiten

1889;21:669-704.

7

Shallice

T.

From

neuropsychology

to

mental

structure.

New

York:

Cambridge

University

Press,

1988.

8

Wechsler

DA.

Weschsler-Bellevue

intelligence

scales.

New

York:

Psychological

Corporation,

1939.

9

Wechsler

DA.

A

standardized

memory

scale

for

clinical

use.

JPsychol

1945;19:87-95.

10

Raven

JC.

Standard

progressive

matrices.

London:

H K

Lewis,

1938.

11

Raven

JC.

Coloured

progressive

matrices.

London:

H

K

Lewis,

1956.

12

Lezak

MD.

Neuropsychological

assessment.

2nd

ed.

New

York:

Oxford

University

Press,

1983.

13

Crawford

JR,

Parker

DM,

McKinlay

WW.

A

handbook

of

neuropsychological

assessment.

Hove,

UK:

Erlbaum,

1992.

14

Hodges

JR.

Cognitive

assessment

for

clinicians.

Oxford:

Oxford

University

Press,

1994.

15

McKenna

P,

Warrington

EK.

The

analytical

approach

to

neuropsychological

assessment.

In:

Grant

I,

Adams

KM,

eds.

Neuropsychological

assessment

of

neuropsychi-

atric

disorders.

New

York:

Oxford

University

Press,

1986:31-47.

16

Gall

F,

Spurzheim

G.

Research

on

the

nervous

system

in

general

and

on

that

of

the

brain

in

particular.

1809.

(Reprinted

in:

Pribram

K,

ed.

Brain

and

behaviour:

Vol

1.

Mood

states

and

mind.

Harmondsworth:

Penguin

Books,

1969.)

17

Bastian

HC.

Aphasia

and

other

speech

defects.

London:

Lewis,

1898.

18

Jackson

JH.

Case

of

large

cerebral

tumor

without

optic

neuritis

and

with

left

hemiplegia

and

imperception.

Royal

Opthalmological

Hospital

Reports

1876;8:434-44.

19

Lichtheim

L.

On

aphasia.

Brain

1885;7:433-84.

20

Freud

S.

Zur

Auffassung

der

Aphasien.

Vienna:

Deuticke,

1891.

21

Marie

P.

Revision

de

la

question

de

l'aphasie:

la

troisieme

convolution

frontale

gauche

ne

joue

aucun

role

speciale

dans

la

fonction

du

langage.

Semaine

Medicale

1906;21:241-7.

(Reprinted

in

Cole

MF,

Cole

M,

eds.

Pierre

Marie's

papers

on

speech

disorders.

New

York:

Hafner,

1971.)

22

Head

H.

Aphasia

and

kindred

disorders

of

speech.

Cambridge:

Cambridge

University

Press,

1926.

23

Goldstein

K.

Language

and

language

disturbances.

New

York:

Grune

and

Stratton,

1948.

24

Lashley

KS.

Brain

mechanisms

and

intelligence.

Chicago:

University

of

Chicago

Press,

1929.

25

Kandel

ER,

Schwartz

JH,

Jessell

TM.

Principles

of

Neural

Science.

3rd

ed.

New

York:

Elsevier,

1991.

26

Marr

D.

Vision.

San

Francisco,

CA:

Freeman,

1982.

27

Chomsky

N.

Rules

and

representations.

Behavioral

and

Brain

Sciences

1980;3:1-61.

28

Morton

J.

The

status

of

information

processing

models

of

language.

Philos

Trans

Roy

Soc

Lond

Biol

1981;295:

387-96.

29

Fodor

JA.

The

modularity

of

mind.

Cambridge,

MA:

MIT

Press,

1983.

30

Zeki

S,

Lamb

M.

The

neurology

of

kinetic

art.

Brain

1994;117:607-36.

31

McCarthy

RA,

Warrington

EK.

Cognitive

neuro-

psychology.

New

York:

Academic

Press,

1990.

32

McCloskey

M.

Cognitive

mechanisms

in

numerical

pro-

cessing:

evidence

from

acquired

dyscalculia.

Cognition

1992;44:

107-57.

33

Newman

SK,

Warrington

EK,

Kennedy

AM,

Rossor

MN.

The

earliest

cognitive

change

in

a

person

with

familial

Alzheimer's

disease:

presymptomatic

neu-

ropsychological

features

in

a

pedigree

with

familial

Alzheimer's

disease

confirmed

at

necropsy.

J

Neurol

Neurosurg

Psychiatry

1994;57:967-72.

34

Matarazzi

JD.

Wechsler's

measurement

and

appraisal

of

adult

intelligence.

5th

ed.

Baltimore:

Williams

and

Wilkins,

1972.

35

Crawford

JR.

Current

and

premorbid

intelligence

mea-

sures

in

neuropsychological

assessment.

In:

Crawford

JR,

Parker

DM,

McKinley

WW,

eds.

A

handbook

of

neuropsychological

assessment.

Hove,

UK:

Erlbaum,

1992:21-49.

36

Yates

AJ.

The

use

of

vocabulary

in

the

measurement

of

intellectual

deterioration.

Journal

of

Mental

Science

1956;102:409-40.

37

Nelson

HE,

McKenna

P.

The

use

of

current

reading

ability

in

the

assessment

of

dementia.

Br

J

Soc

Clin

Psychol

1975;14:259-67.

38

Schonell

F.

Backwardness

in

the basic

subjects.

London:

Oliver

and

Boyd,

1942.

39

Nelson

HE,

O'Connell

A.

Dementia:

the

estimation

of

premorbid

intelligence

levels

using

the

new

adult

read-

ing

test.

Cortex

1978;14:234-44.

40

Stem

W.

Psychologische

Methoden

der

Intelligenz-Pnufung.

Leipzig:

Barth,

1912.

41

Nelson

HE.

The

national

adult

reading

test.

Windsor:

NFER-Nelson,

1991.

42

Grober

E,

Sliwinski

M.

Development

and

validation

of

a

model

for

estimating

premorbid

verbal

intelligence

in

the

elderly.

J

Clin

Exp

Neuropsychol

1991;13:933-49.

43

Patterson

K,

Graham

N,

Hodges

JR.

Reading

in

Alzheimer's

type

dementia:

a

preserved

ability?

Neuropsychology

1994;8:395-402.

44

Spearman

C.

The

abilities

of

man.

New

York:

Macmillan,

1927.

45

Thurstone

LL.

Primary

mental

abilities.

Chicago:

University

of

Chicago

Press,

1938.

663

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

Cipolotti,

Wayrington

46

Guilford

JP.

The

structure

of

intellect.

Psychol

BuUl

1956;53:267-93.

47

Cattell

RB.

The

measurement

of

adult

intelligence.

Psychol

Bull

1943;40:

153-93.

48

Raven

JC.

Advanced

progressive

matrices,

sets

I

and

II.

London:

H

K

Lewis,

1965.

49

Carpenter

PA,

Just

MA,

Shell

P.

What

one

intelligence

test

measures:

a

theoretical

account

of

the

processing

in

the

Raven

progressive

matrices

test.

Psychol

Rev

1990;97:404-31.

50

Bolin

BJ.

A

comparison

of

Raven's

progressive

matrices

(1938)

with

the

ACE

psychological

examination

and

the

Otis

gamma

mental

ability

test.

Consult

Psychol

1955;19:400.

51

Wechsler

DA.

The

Wechsler

adult

intelligence

scale:

manual.

New

York:

Psychological

Corporation,

1955.

52

Wechsler

DA.

The

measurement

and

appraisal

of

adult

intelligence.

4th

ed.

Baltimore:

Williams

and

Wilkins,

1958.

53

Bornstein

RA,

Matarazzo

JD.

Wechsler

VIQ

versus

PIQ

differences

in

cerebral

dysfunction:

a

literature

review

with

emphasis

on

sex

differences.

Journal

of

Clinical

Neuropsychology

1982;4:319-34.

54

Warrington

EK,

James

M,

Maciejewski

C.

The

WAIS

as

a

lateralising

and

localising

diagnostic

instrument:

a

study

of

656

patients

with

unilateral

cerebral

lesions.

Neuropsychologia

1986;24:223-239.

55

Ryan

nT,

Paolo

AM,

Brungardt

TM.

Standardization

of

the

Wechsler

adult

intelligence

scale-revised

for

per-

sons

75

years

and

older.

Psychological

Assessments:

A

Journal

of

Consulting

and

Clinical

Psychology

1990;

2:408-11.

56

Baddeley

AD.

Human

memory

theory

and

practice.

Hove,

UK:

Erlbaum,

1990.

57

Schacter

DL.

Implicit

memory:

history

and

current

sta-

tus.

JExp

Psychol

Gen

1987;13:501-18.

58

Warrington

EK,

Weiskrantz

L.

Amnesia:

consolidation

or

retrieval?

Nature

1970;228:628-30.

59

Tulving

E.

Episodic

and

semantic

memory.

In:

Tulving

E,

Donaldson

W,

eds.

Organization

of

memory.

New

York:

Academic

Press,

1972:382-404.

60

Corsi

P.

Interhemispheric

differences

in

the

localization

of

psychological

processes

in

man

[thesis].

University

of

Montreal, Montreal,

1972.

61

Gathercole

SE,

McCarthy

RA.

Memory

tests

and

tech-

niques.

Hove,

UK:

Erlbaum,

1994.

62

Coughlan

AK,

Hollows

SE.

The

adult

memory

and

infor-

mation

processing

battery.

St

James's

University

Hospital,

Leeds:

A

K

Coughlan,

1985.

63

Wilson

BA,

Cockburn

J,

Baddeley

AD.

The

Rivermead

behavioural

memory

test.

Bury

St

Edmunds,

UK:

Thames

Valley

Test

Company,

1985.

64

Rey

A.

L'examen

clinique

en

psychologie.

Paris:

Presses

Universitaires

de

France,

1964.

65

Osterreith

PA.

Le

test

de

copie

d'une

figure

complexe.

Archives

de

Psychologies

1944;30:206-356.

66

Benton

AL.

The

revised

visual

retention

test.

New

York:

Psychological

Corporation,

1974.

67

Warrington

EK.

Recognition

memory

test.

Windsor,

UK:

NFER-Nelson,

1984.

68

Clegg

F,

Warrington

EK.

Four

easy

memory

tests

for

older

adults.

Memory

1994;2:167-182.

69

Kopelman

MD,

Wilson

BA,

Baddeley

AD.

The

autobio-

graphical

memory

interview:

a

new

assessment

of

auto-

biographical

and

personal

semantic

memory

in

amnesic

patients.

Clin

Exp

Neuropsychol

1989;11:

724-44.

70

Warrington

EK.

The

selective

impairment

of

semantic

memory.

QJExpPsychol

1975;27:635-57.

71

Howard

D,

Patterson

KE.

Pyramids

and

palm

trees.

Bury

St

Edmunds,

UK:

Thames

Valley

Test

Company,

1992.

72

Dunn

LM,

Dunn

LM,

Whetton

C,

Pintilie

D.

The

British

picture

vocabulary

scale.

Windsor,

UK:

NFER-

Nelson,

1982.

73

Lesser

R.

Linguistic

investigations

of

aphasia.

London:

Arnold,

1978.

74

Gainotti

G,

Caltagirone

C,

Ibba

A.

Semantic

and

phone-

mic

aspects

of

auditory

language

comprehension

in

aphasia.

Linguistics

1975;154/155:15-29.

75

Miceli

G,

Gainotti

G,

Caltagirone

C,

Masullo

C.

Some

aspects

of

phonological

impairment

in

aphasia.

Brain

Lang

1980;11:159-169.

76

Goodglass

H,

Kaplan

E.

The

assessment

of

aphasia

and

related

disorders.

Philadelphia,

PA:

Lea

and

Febiger,

1972.

77

Kertesz

A.

Westen

aphasia

battery.

San

Antonio:

The

Psychological

Corporation

Inc,

1982.

78

Porch

BE.

The

Porch

index

of

communicative

ability-

theory

and

development.

Palo

Alto,

USA:

Consulting

Psychologists

Press,

1967

(revised

1971).

79

De

Bleser

R,

Bayer

J,

Luzzatti

C.

Die

cognitive

Neuropsychologie

der

Schriftsprache.

Ein

Uberblick

zwei

deutscher

Fallbeschreibungen.

In:

Bayer

J,

ed.

Grammatik

und

Cognition.

Linguistische

Berichte,

Suppl

_

1.

Wiesbaden:

Westdeutscher

Verlag,

1987:.118-162.

80 Caramazza

A.

The

logic

of

neuropsychological

research

and

the

problem

of

patient

classification

in

aphasia.

Brain

Lang

1984;21:9-20.

81

Auerbach

SH,

Allard

T,

Naeser

M,

Alexander

MP,

Albert

ML.

Pure

word

deafness:

an

analysis

of

a

case

with

bilateral

lesions

and

a

deficit

at

the

pre-phonemic

level.

Brain

1982;105:271-300.

82

McCarthy

RA,

Warrington

EK.

Disorders

of

semantic

memory.

Philos

Trans

Roy

Soc

Lond

Biol

1994;346:

89-96.

83

Coughlan

AK,

Warrington

EK.

Word-comprehension

and

word-retrieval

in

patients

with

localised

cerebral

lesions.

Brain

1978;101:163-85.

84

Kay

J,

Lesser

R,

Coltheart

M.

PALPA

psycholinguistic

assessments

of

language

processing

in

aphasia.

Hove,

UK:

Erlbaum,

1992.

85

De

Renzi

E,

Vignolo

LA.

The

token

test:

a

sensitive

test

to

detect

receptive

disturbances

in

aphasia.

Brain

1962;85:665-78.

86

Parisi

D,

Pizzamiglio

L.

Syntactic

comprehension

in

aphasia.

Cortex

1970;6:204-15.

87

Lesser

R.

Verbal

comprehension

in

aphasia:

an

English

version

of

three

Italian

tests.

Cortex

1974;10:

247-63.

88

Bishop

D.

Test

for

reception

of

grammar.

Oxford:

Thomas

Leach,

1982.

89

McKenna

P,

Warrington

EK.

The

graded

naming

test.

Windsor,

UK:

NFER-Nelson,

1980.

90

Kaplan

E,

Goodglass

H,

Weintraub

S.

Boston

naming

test

Philadelphia:

Lea

and

Febinger,

1983.

91

De

Renzi

E,

Ferrari

C.

The

reporter's

test:

a

sensitive

test

to

detect

expressive

disturbances

in

aphasics.

Cortex

1978;14:279-93.

92

Shallice

T,

Warrington

EK.

Single

and

multiple

compo-

nent

central

dyslexic

syndromes.

In:

Coltheart

M,

Patterson

KE,

Marshall

JC,

eds.

Deep

dyslexia.

London:

Routledge

and

Kegan

Paul,

1980:119-45.

93

Marshall

JC,

Newcombe

F.

Patterns

of

paralexia:

a

psy-

cholinguistic

approach.

Psycholinguist

Res

1973;2:

175-99.

94

Warrington

EK,

Cipolotti

L,

McNeil

J.

Attentional

dyslexia:

a

single

case

study.

Neuropsychologia

1993;31:

871-85.

95

Neale

MD.

The

Neale

analysis

of

reading

ability.

2nd

ed.

London:

Macmillan,

1966.

96

Beauvois

M-F,

Derouesne

J.

Phonological

alexia:

three

dissociations.

Y

Neurol

Neurosurg

Psychiatry

1979;42:

1115-24.

97

Baxter

DM,

Warrington

EK.

Measuring

dysgraphia:

a

graded-difficulty

spelling

test

(GDST).

Behavioural

Neurology

1994;71:107-16.

98

Shallice

T.

Phonological

agraphia

and

the

lexical

route

in

writing.

Brain

1981;104:413-29.

99

Miller

E.

Cognitive

assessment

of

the

older

adult.

In:

Birren

JE,

Sloane

RB,

eds.

Handbook

of

mental

health

and

ageing.

Engelwood

Cliffs,

NJ:

Prentice-Hall,

1980.

100

Kendrick

DC.

Kendrick

cognitive

tests

for

the

elderly.

Windsor,

UK:

NFER-

Nelson,

1985.

101

Caine

ED.

Pseudodementia:

current

concepts

and

future

directions.

Arch

Gen

Psychiatry

198

1;38:1359-64.

102

Strub

RL,

Black

FW.

Mental

status

examination

in

neurol-

ogy.

2nd

ed.

Philadelphia,

PA:

Davis,

1985.

103

Godwin-Austin

RB.

A

case

of

visual

disorientation.

Neurol

Neurosurg

Psychiatry

1965;28:453-8.

104

Warrington

EK,

Weiskrantz

L.

New

method

of

testing

long-term

retention

with

special

reference

to

amnesic

patients.

Nature

1968;277:972-4.

105 Rossor

MN.

Management

of

neurological

disorders:

dementia.

Neurol

Neurosurg

Psychiatry

1994;57:

1451-6.

106

Coughlan

AK,

Hollows

SE.

The

use

of

memory

tests

in

differentiating

organic

disorder

from

depression.

Br

Psychol

1984;145:164-7.

107

Bennett

T,

Curiel

M.

Early

neuropsychological

presenta-

tion

of

Huntington's

disease.

Int

7

Clin

Neuropsychol

1989;11:90-5.

108

Willison

JR,

Warrington

EK.

Cognitive

retardation

in

a

patient

with

preservation

of

psychomotor

speed.

Behavioural

Neurology

1992;5:113-6.

109

Goldstein

H.

Neuropsychological

investigation

of

tempo-

ral

lobe

epilepsy.

J

R

Soc

Med

1991;84:460-5.

110

Jones-Gotman

M.

Localization

of

lesions

by

neuropsy-

chological

testing.

Epilepsia

1991;32(suppl

5):S41-52.

111

McKinlay

WW.

Assessment

of

the

head-injured

for

com-

pensation.

In:

Crawford

JR,

Parker

DM,

McKinlay

WW,

eds.

A

handbook

of

neuropsychological

assessment.

Hove,

UK:

Erlbaum,

1992:381-92.

112

Miller

H.

Mental

after

effects

of

head

injury.

Proceedings

of

the

Royal

Society

of

Medicine

1966;59:257-61.

113

Lees

J,

Smith

E.

Cognitive

deficits

in

the

early

stages

of

Parkinson's

disease.

Brain

1983;106:257-270.

114

Grant

I,

McDonald

WI,

Trimble

MR,

Smith

E,

Reed

R.

Deficient

learning

and

memory

in

early

and

middle

phases

of

multiple

sclerosis.

Y

Neurol

Neurosurg

Psychiatry

1984;47:250-5.

115

Cummings

J,

Benson

D,

Read

S.

Aphasia

in

dementia

of

the

Alzheimer

type.

Neurology

1985;35:394-7.

116

Spinnler

H,

Della

Sala

S.

The

role

of

clinical

neuropsy-

chology

in

the

neurological

diagnosis

of

Alzheimer's

disease.

Neurol

1988;235:258-71.

117

Haxby

J,

Grady

C,

Koss

E,

et

al.

Longitudinal

study

of

cerebral

metabolic

asymmetries

and

associated

neu-

ropsychological

patterns

in

early

dementia

of

the

Alzheimer-type.

Arch

Neurol

1990;47:753-60.

118

Swearer

J,

O'Donnell

B,

Drachman

D,

Woodward

B.

Neuropsychological

features

of

familial

Alzheimer's

disease.

Ann

Neurol

1992;32:687-94.

119

Martin

A.

Neuropsychology

of

Alzheimer's

disease:

the

case

for

subgroups.

In:

Schwartz

M,

ed.

Modular

deficits

in

Alzheimer

type

dementia.

Cambridge,

Mass:

MIT

Press,

1990:143-75.

120

Rossor

MN,

Kennedy

AK,

Newman

S.

Heterogeneity

of

familial

Alzheimer's

disease.

In:

Boller

F,

Forette

F,

Khachaturian

Z,

eds.

Heterogeneity

of

Alzheimer's

dis-

ease.

Berlin:

Springer-Verlag,

1992:81-7.

664

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

doi: 10.1136/jnnp.58.6.655

1995 58: 655-664 J Neurol Neurosurg Psychiatry

L Cipolotti and E K Warrington

Neuropsychological assessment.

http://jnnp.bmj.com/content/58/6/655.citation

Updated information and services can be found at:

These include:

service

Email alerting the box at the top right corner of the online article.

Receive free email alerts when new articles cite this article. Sign up in

Notes

http://group.bmj.com/group/rights-licensing/permissions

To request permissions go to:

http://journals.bmj.com/cgi/reprintform

To order reprints go to:

http://group.bmj.com/subscribe/

To subscribe to BMJ go to:

group.bmj.com on July 15, 2011 - Published by jnnp.bmj.com Downloaded from

... Aerobic exercise has been proposed as effective in improving working memory score of the T2DM participants, if they are not having brain damage 21 . Perhaps, T2DM individuals pass through stages of neuronal changes in specific brain regions such as the hippocampus and prefrontal cortex, which explained reasons behind cognitive deficits 22,23 . ...

... In patients with T2DM, the functional connectivity between the hippocampus and other brain regions gets reduced 24,25 which results in decline in cognitive performance in T2DM, which is associated with a reduction in functional connectivity 24 . T2DM individuals if do not face problems of any memory failure, they may not have any cognitive deterioration 21 . In these cases, as Cipolotti, & Warrington 21 postulated, these T2DM individuals could engage in elaborative encoding, and could develop their own encoding strategy, in order to enhance in their level of working memory 22,23 . ...

... In these cases, as Cipolotti, & Warrington 21 postulated, these T2DM individuals could engage in elaborative encoding, and could develop their own encoding strategy, in order to enhance in their level of working memory 22,23 . Combined introduction of exercise training regime may lead to higher-order cognitive competence, in the form of enhancement in visual motor integration and configurational ability 21 . ...

... outcome. As spelled out by Cipolotti and Warrington (1995), "objective" methods to document how "… brain damage can selectively disrupt some components of a cognitive system (p. 655 )" represent critical reference points for establishing brain-behavior relations. ...

... Accordingly, these are the candidate ROIs to volumetrically examine in mTBI as depicted in this "cone of vulnerability." These regions, quantified volumetrically, would also meet the Cipolotti and Warrington (1995) standard for neuropsychology by providing an "objective" metric for making neuropsychological inference to brain structure and function and demonstrating how "damage" may alter neuropsychological outcome. ...

• Erin D. Bigler

Region of interest (ROI) volumetric assessment has become a standard technique in quantitative neuroimaging. ROI volume is thought to represent a coarse proxy for making inferences about the structural integrity of a brain region when compared to normative values representative of a healthy sample, adjusted for age and various demographic factors. This review focuses on structural volumetric analyses that have been performed in the study of neuropathological effects from mild traumatic brain injury (mTBI) in relation to neuropsychological outcome. From a ROI perspective, the probable candidate structures that are most likely affected in mTBI represent the target regions covered in this review. These include the corpus callosum, cingulate, thalamus, pituitary-hypothalamic area, basal ganglia, amygdala, and hippocampus and associated structures including the fornix and mammillary bodies, as well as whole brain and cerebral cortex along with the cerebellum. Ventricular volumetrics are also reviewed as an indirect assessment of parenchymal change in response to injury. This review demonstrates the potential role and limitations of examining structural changes in the ROIs mentioned above in relation to neuropsychological outcome. There is also discussion and review of the role that post-traumatic stress disorder (PTSD) may play in structural outcome in mTBI. As emphasized in the conclusions, structural volumetric findings in mTBI are likely just a single facet of what should be a multimodality approach to image analysis in mTBI, with an emphasis on how the injury damages or disrupts neural network integrity. The review provides an historical context to quantitative neuroimaging in neuropsychology along with commentary about future directions for volumetric neuroimaging research in mTBI.

... The identification of brain-behavior relationships is a central aim of clinical and experimental neuropsychology. Such investigations are predicated on fundamental assumptions in the field: (a) the cerebral cortex possesses a high degree of specialization, (b) brain function can be inferred via a modularity approach to analyzing complex cognitive skills, and (c) brain damage can selectively disrupt subcomponents of a cognitive system (Cipolotti & Warrington, 1995). Investigating prefrontal cortex modularity of EF in nonpatient samples is a prerequisite for understanding the nature of those systems under neuropathological circumstances. ...

... The neural correlates found for the D-KEFS in this study support the unitary-diverse dialectic of EF. Our findings are consistent with the evidence that brain volume is related to neuropsychological ability, but also further distinguishes how the brain and behavior are related (Cipolotti & Warrington, 1995). The aggregate of D-KEFS scores was more disparately associated with prefrontal volumes, whereas individual D-KEFS scores were more narrowly but strongly related to specific ROIs. ...

Objective: Designed to measure a diversity of executive functioning (EF) through classical neuropsychological tests, the Delis-Kaplan Executive Function Scale (D-KEFS) allows for the investigation of the neural architecture of EF. We examined how the D-KEFS Tower, Verbal Fluency, Design Fluency, Color-Word Interference, and Trail Making Test tasks related to frontal lobe volumes, quantifying the regional specificity of EF components. Method: Adults from the Nathan Kline Institute-Rockland Sample (NKI-RS), an open-access community study of brain development, with complete MRI (3T scanner) and D-KEFS data were selected for analysis (N = 478; ages 20-85). In a mixed-effects model predicting volume, D-KEFS task, D-KEFS score, region of interest (ROI; 13 frontal, 1 occipital control), were entered as fixed effects with intercepts for participants as random effects. Results: "Unitary" EF (aggregate of D-KEFS scores) was positively associated with superior frontal, rostral middle frontal, and lateral orbitofrontal volumes; a negative association was observed with frontal pole volume (| z-score slope | range = 0.040 to 0.051). "Diverse" EF skills (individual D-KEFS task scores) were differentially associated with two or three ROIs, respectively, but to a stronger extent (| z-score slope | range = 0.053 to 0.103). Conclusions: The neural correlates found for the D-KEFS support the prefrontal modularity of both unitary (aspects of EF ability common to all tasks) and diverse EF. Our findings contribute to emerging evidence that aggregate measurements of EF may serve broader but less robust frontal neural correlates than distinct EF skills. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

... 灵活性涵盖许多不同的类型 [9~11] , 认知灵活性作为 执行功能(executive function)的重要组成部分已受到研 究者的广泛关注. 认知灵活性这一概念最早被定义为 根据情况变化的需求产生或变换反应方式的能力 [12] , 关于执行功能的研究已经对认知灵活性在心理方面的 作用和发展进行了系统阐述 [13,14] . [22] . ...

... A hypothesis testing approach is common in which a series of tests are given, guided by a clinical and cognitive conceptual framework (Cipolotti and Warrington, 1995;Luria, 1972;Shallice, 1988). First, it is assumed that there is a high degree of functional specialization within the cerebral cortex. ...

A neuropsychological assessment aims to determine the impact of a known or suspected brain-related condition on thinking skills (cognition), behavior and mood. This is undertaken by clinical interview and via administration of a set of psychometric scales and tests designed to ascertain current level of function and detect changes, impairments, problems or symptoms experienced by the individual in any aspect of cognition or behavior, or in mood. The purpose may be to assist with neurological diagnosis, to identify, monitor or manage neuropsychological impairments, or to devise rehabilitation management strategies or interventions.

• Cheng Sun
• Yunsong Han
• Lin Luo
• Huixuan Sun

The study aimed to assess the effect of indoor air temperature on cognitive work performance of acclimatized people during the middle of heating season in severely cold region in China. How does temperature affect work performance was also investigated through subjective surveys. Eighteen acclimatized and healthy participants (10 males and 8 females) carried out tasks in a climate chamber under six temperatures (18°C, 20°C, 22°C, 24°C, 26°C and 28°C). They completed 11 neuro-behavioural tests, including perception, learning and memory, thinking, expression and executive function tests, and subjective surveys on thermal sensation, emotion, health, workload and enthusiasm. Results showed that temperature has an effect on the variation on the neuro-behavioural performance depending on task types and difficulties. Temperature could influence the response time significantly more than accuracy when tasks were performed without feedback. Under adverse environment, people would feel (slightly) cool or warm, feel less enthusiastic to work, and would have more negative emotions, perceived sick building syndrome to be more serious and would have evaluated performance as worse. They would also perform badly on neuro-behavioural tests. Subjective surveys were important supplements to objective evaluation on the effect of indoor environment factors on work performance.

• Sheena McDonald
• Allan Little
• Gail A Robinson

Rebuilding Life after Brain Injury: Dreamtalk tells the survival story of Sheena McDonald, who in 1999 was hit by a police van and suffered a very severe brain injury. Sheena's story is told from her own, personal standpoint and also from two further unique and invaluable perspectives. Allan Little, a BBC journalist and now Sheena's husband, describes both the physical and mental impact of the injury on himself and on Sheena. Gail Robinson, Sheena's neuropsychological rehabilitation specialist, provides professional commentaries on Sheena's condition, assessment and recovery process. The word Dreamtalk, created by Allan to describe Sheena's once "hallucinogenic state", sets the tone for this book. It humanises and contextualises the impact of brain injury, providing support and encouragement for patients, professionals and families. It presents exclusive insights into each stage of recovery, spanning coma, altered consciousness, post-traumatic amnesia and rehabilitation; all showing how she has defied conventional clinical expectations and made an exceptional recovery. This book is valuable reading to those who have suffered a brain injury and also to professionals such as neurologists, neuropsychologists, physiotherapists, occupational therapists and speech therapists working in the field. © 2019 Sheena McDonald, Allan Little & Gail Robinson. All rights reserved.

• T.L. Bennett
• M. P. Curiel

A dissociation between choreoathetoid movements and cognitive impairment is demonstrated through case presentation of two women with early symptoms of Huntington's Disease. The two individuals showed strikingly similar patterns of impairment on an extended Halstead-Reitan Battery. However, one exhibited prominent choreoathetoid movements, and the other showed none. Performance on tests that depended on fine motor speed, either directly or adjunctly, was significantly impaired. Logical analysis and flexibility of thinking were also compromised. Memory impairment, while present, while present, was not as pronounced as that reported by previous investigators. None of the MMPI clinical scales were significantly elevated. Deviations in the present study from earlier reports were related to duration of symptoms prior to assessment. The data reported in this paper were collected as part of the initial diagnostic process.

• L. L. Thurstone

This publication is the opening number of a series which the Psychometric Society proposes to issue. It reports the first large experimental inquiry, carried out by the methods of factor analysis described by Thurstone in The Vectors of the Mind 1. The work was made possible by financial grants from the Social Science Research Committee of the University of Chicago, the American Council of Education, and the Carnegie Corporation of New York. The results are eminently worthy of the assistance so generously accorded. Thurstone's previous theoretical account, lucid and comprehensive as it is, is intelligible only to those who have a knowledge of matrix algebra. Hence his methods have become known to British educationists chiefly from the monograph published by W. P. Alexander8. This enquiry has provoked a good deal of criticism, particularly from Professor Spearman's school ; and differs, as a matter of fact, from Thurstone's later expositions. Hence it is of the greatest value to have a full and simple illustration of his methods, based on a concrete inquiry, from Professor Thurstone himself.

• Martin N Rossor
• A M Kennedy
• S. K. Newman

Alzheimer's original description in 1907 portrayed a 51-year-old woman who died following a dementing illness and who was found to have senile plaques and neurofibrillary tangles throughout the cerebral cortex. Her clinical features were those of profound memory impairment and language and visuospatial deficits. There was no family history reported.

• Rosaleen Anne McCarthy
• Elizabeth K. Warrington

This chapter presents an introduction to cognitive neuropsychology. The term cognitive neuropsychology is applied to the analysis of those handicaps in human cognitive function that result from brain injury. Cognitive neuropsychology is essentially interdisciplinary, drawing both on neurology and on cognitive psychology for insights into the cerebral organization of cognitive skills and abilities. Cognitive function is the ability to use and integrate basic capacities such as perception, language, actions, memory, and thought. The focus of clinical cognitive neuropsychology is on the many different types of highly selective impairments of cognitive function that are observed in individual patients following brain damage. The functional analysis of patients with selective deficits provides a very clear window through which one can observe the organization and procedures of normal cognition. Clinical cognitive neuropsychology has been successful in demonstrating a large number of dissociations between the subcomponents of cognitive skills. This enables to conclude that such components are dependent on distinct neural systems.

In diesem Beitrag stellen wir zwei Fälle mit unterschiedlichen erworbenen Störungen der Schriftsprache vor, eine Patientin mit „Tiefendyslexie" (§ 3.1) und einen Patienten mit „Oberflächendysgraphie" (§ 3.2).

Source: https://www.researchgate.net/publication/15589804_Neuropsychological_assessment

Posted by: quentincaissiee016157.blogspot.com