Assessing Deficits in Assessing Deficits in Cognitive FunctioningCognitive Functioning
Theodore Tsaousides, Ph.D.Theodore Tsaousides, Ph.D.
Mount Sinai School of Mount Sinai School of MedicineMedicine
New York, NYNew York, NY
NeuropsychologyNeuropsychology
The science of brain-behavior relationshipThe science of brain-behavior relationship
Dysfunctional brain Dysfunctional brain Dysfunctional Dysfunctional behaviorbehavior
Injury to the brain leads to:Injury to the brain leads to: Physical changesPhysical changes Cognitive changesCognitive changes Emotional changesEmotional changes Behavioral changesBehavioral changes
Neuropsychology: AssessmentNeuropsychology: Assessment
Evaluate degree of impact of brain Evaluate degree of impact of brain damage on behaviordamage on behavior DiagnosisDiagnosis Patient carePatient care Treatment planning/evaluationTreatment planning/evaluation ResearchResearch
Good assessment Good assessment good treatment good treatment
Neuropsychology: TreatmentNeuropsychology: Treatment
RestorationRestoration RetrainingRetraining RepetitionRepetition
CompensationCompensation Skill buildingSkill building Use of toolsUse of tools
RestructuringRestructuring Environmental adaptationsEnvironmental adaptations Changes in demandsChanges in demands
Disorders that affect the Disorders that affect the brain’s functionbrain’s function
Traumatic brain injury (TBI)Traumatic brain injury (TBI) Vascular disordersVascular disorders Degenerative disordersDegenerative disorders Toxic exposureToxic exposure InfectionsInfections Brain tumorsBrain tumors Oxygen deprivationOxygen deprivation Metabolic/endocrine disordersMetabolic/endocrine disorders Thought disordersThought disorders
Traumatic Brain InjuryTraumatic Brain Injury
DefinitionDefinition CausesCauses Incidence in the USIncidence in the US SymptomsSymptoms
Traumatic Brain InjuryTraumatic Brain Injury DefinitionDefinition
Insult to the brain…caused by external physical Insult to the brain…caused by external physical force…which results in impairment of cognitive force…which results in impairment of cognitive abilities or physical functioning (BIAA)abilities or physical functioning (BIAA)
A traumatically induced physiologic disruption A traumatically induced physiologic disruption of the brain function as manifested byof the brain function as manifested by
Loss of consciousnessLoss of consciousness Loss of memory for events before or after the Loss of memory for events before or after the
accidentaccident Alteration of mental state at the time of the accidentAlteration of mental state at the time of the accident Focal neurological deficits that may or may not be Focal neurological deficits that may or may not be
transient (ACRM)transient (ACRM)
Traumatic Brain InjuryTraumatic Brain Injury
CausesCauses
Traumatic Brain InjuryTraumatic Brain Injury
Incidence annuallyIncidence annually 1.4 million sustain TBI (based on 1.4 million sustain TBI (based on
Hospital admission and ED recordsHospital admission and ED records UnidentifiableUnidentifiable
Physician visitsPhysician visits No care soughtNo care sought Military/VAMilitary/VA Other settings (psychiatric/substance Other settings (psychiatric/substance
abuse settings; shelters; prisons)abuse settings; shelters; prisons)
TBI: Physical symptomsTBI: Physical symptoms
FatigueFatigue Sleep problemsSleep problems HeadachesHeadaches Balance problems/dizzinessBalance problems/dizziness Vision problemsVision problems Chronic painChronic pain Sexual dysfunctionSexual dysfunction
TBI: Cognitive symptomsTBI: Cognitive symptoms
AttentionAttention Processing speedProcessing speed Memory and learningMemory and learning Language and communicationLanguage and communication Executive functionsExecutive functions
TBI: Emotional symptomsTBI: Emotional symptoms
ApathyApathy AbuliaAbulia DisinhibitionDisinhibition HyperemotionalityHyperemotionality DepressionDepression AnxietyAnxiety
Behavioral symptomsBehavioral symptoms Forgetting/missing appointmentsForgetting/missing appointments Getting lostGetting lost Difficulty following instructionsDifficulty following instructions Not paying attentionNot paying attention InappropriateInappropriate ArgumentativeArgumentative OutburstsOutbursts Forgetting to take medicationForgetting to take medication ImpatientImpatient DisorganizedDisorganized ImpulsiveImpulsive
What to doWhat to do
YouYou ObserveObserve ScreenScreen ReferRefer
MeMe Review referralReview referral Conduct testingConduct testing Provide feedbackProvide feedback
First impressionsFirst impressions
Conclusions based on interactions:Conclusions based on interactions: Non-compliantNon-compliant Difficult to engageDifficult to engage Poor historianPoor historian OppositionalOppositional Makes things upMakes things up
ObserveObserve
AppearanceAppearance Is appearance unusual?Is appearance unusual?
OrientationOrientation Person, place, time, (situation, object)Person, place, time, (situation, object)
SpeechSpeech Receptive language (unable to follow Receptive language (unable to follow
instructions)instructions) Fluency (word finding problems)Fluency (word finding problems)
ObserveObserve Attention/concentrationAttention/concentration
Distractibility (distracted by things around)Distractibility (distracted by things around) Spacing out (need to repeat yourself often)Spacing out (need to repeat yourself often)
MemoryMemory Short-term (forgets what was just said)Short-term (forgets what was just said) Prospective memory (forgets to get things done)Prospective memory (forgets to get things done) Past memories (remembers things inaccurately)Past memories (remembers things inaccurately)
Thought ProcessThought Process Logical & coherent (responses make no sense)Logical & coherent (responses make no sense) Blocking (unable to come up with answers)Blocking (unable to come up with answers) Tangentiality (cannot stay on track)Tangentiality (cannot stay on track)
ObserveObserve Cognitive functioningCognitive functioning
Vocabulary (vocabulary is consistent with education)Vocabulary (vocabulary is consistent with education) General information (also consistent with education)General information (also consistent with education)
Emotional stateEmotional state Overwhelmed and anxiousOverwhelmed and anxious DepressedDepressed ApatheticApathetic HyperemotionalHyperemotional
Special preoccupations/experiencesSpecial preoccupations/experiences Obsessions (perseverations)Obsessions (perseverations) Bodily preoccupations (physical symptoms)Bodily preoccupations (physical symptoms) Paranoid thoughtsParanoid thoughts
Insight/judgmentInsight/judgment Reasoning (poor social judgment/decision making)Reasoning (poor social judgment/decision making)
ScreenScreen
Brain Injury Screening Questionnaire Brain Injury Screening Questionnaire (BISQ)(BISQ) Part One (lifelong)Part One (lifelong)
Blow to the head?Blow to the head? In a car crashIn a car crash Being hit by a falling objectBeing hit by a falling object Being assaulted or muggedBeing assaulted or mugged
Hospitalized or in the ER?Hospitalized or in the ER? ConcussionConcussion Near drowningNear drowning
Altered mental state?Altered mental state?
BISQ – Part OneBISQ – Part One
BISQ – Part TwoBISQ – Part Two
Part Two (within past month)Part Two (within past month) Physical symptomsPhysical symptoms
Having trouble falling asleep or staying asleepHaving trouble falling asleep or staying asleep Having double vision or blurred visionHaving double vision or blurred vision
Cognitive symptomsCognitive symptoms Being easily distractedBeing easily distracted Difficulty following instructions, written or oralDifficulty following instructions, written or oral
Behavioral symptomsBehavioral symptoms Feeling impatient or irritableFeeling impatient or irritable ArguingArguing
BISQ – Part TwoBISQ – Part Two
BISQ – Part TwoBISQ – Part Two
ScreenScreen
Positive screen ≠ diagnosisPositive screen ≠ diagnosis
Positive screen = need to evaluate Positive screen = need to evaluate furtherfurther
Other short measuresOther short measures
Mini-Mental State Examination (MMSE)Mini-Mental State Examination (MMSE) Dementia Rating Scale 2 (DRS-2)Dementia Rating Scale 2 (DRS-2) Repeatable Battery for the Assessment Repeatable Battery for the Assessment
of Neuropsychological Status (RBANS)of Neuropsychological Status (RBANS) NART/WTARNART/WTAR TONI-3TONI-3 WASIWASI
ReferRefer PhysiatristPhysiatrist
Most knowledgeable specialty re: TBIMost knowledgeable specialty re: TBI Assessment of physical symptomsAssessment of physical symptoms Referrals to neuro & rehab psychology, PT, OT, SpeechReferrals to neuro & rehab psychology, PT, OT, Speech
NeurologistNeurologist ImagingImaging Neurological impairmentsNeurological impairments
NeuropsychologistNeuropsychologist Assessment of cognitive/emotional/behavioral functioningAssessment of cognitive/emotional/behavioral functioning
PsychiatristPsychiatrist Assessment of extent of psychiatric comorbidityAssessment of extent of psychiatric comorbidity Not always aware of TBI and its consequencesNot always aware of TBI and its consequences
Review referralReview referral
PreparationPreparation Review referral questionReview referral question
DiagnosticDiagnostic DescriptiveDescriptive
Obtain medical records (incl. imaging)Obtain medical records (incl. imaging) Obtain academic recordsObtain academic records
Clinical observationsClinical observations
Review referralReview referral
Clinical interviewClinical interview Patient’s backgroundPatient’s background Social historySocial history Present life historyPresent life history Medical historyMedical history Current medical statusCurrent medical status Circumstances surrounding the Circumstances surrounding the
examinationexamination
Conduct testingConduct testing Test selectionTest selection
Goals of assessmentGoals of assessment Validity and reliabilityValidity and reliability Sensitivity and specificitySensitivity and specificity Parallel formsParallel forms Time and costTime and cost Non-standardized assessmentNon-standardized assessment
Conduct testingConduct testing Cognitive DomainsCognitive Domains
Processing speed Processing speed AttentionAttention Visual/Perceptual skillsVisual/Perceptual skills Verbal/Reading skillsVerbal/Reading skills Intellectual functioningIntellectual functioning Memory and learningMemory and learning Executive functioningExecutive functioning
Emotional functioning/PersonalityEmotional functioning/Personality
Provide feedbackProvide feedback Review and integrate assessment Review and integrate assessment
resultsresults Write reportWrite report Follow-up interview with patientFollow-up interview with patient Others involved in care presentOthers involved in care present Client-friendly languageClient-friendly language ValidateValidate EditEdit
ConclusionConclusion Damage to the brain causes physical, Damage to the brain causes physical,
cognitive, emotional, and behavioral deficitscognitive, emotional, and behavioral deficits Several conditions can cause damage to the Several conditions can cause damage to the
brainbrain TBI is a TBI is a commoncommon but often but often unidentifedunidentifed
conditioncondition Cognitive deficits of TBI often manifest as Cognitive deficits of TBI often manifest as
“behavioral problems”“behavioral problems” Proper screening and identification implies Proper screening and identification implies
appropriate treatmentappropriate treatment
First impressions revisitedFirst impressions revisited Conclusions based on clinical Conclusions based on clinical
observation and screening:observation and screening: Non-compliant = Non-compliant = Difficult to engage = Difficult to engage = Poor historian =Poor historian = Oppositional =Oppositional = Makes things up = Makes things up =
ReferencesReferences Fischer, J.S., Hannay, J.H., Loring, D.W., & Lezak, M.D. (2004). Fischer, J.S., Hannay, J.H., Loring, D.W., & Lezak, M.D. (2004).
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Thank you for your attentionThank you for your attention
Theodore Tsaousides, Ph.D.Theodore Tsaousides, Ph.D.
Instructor/Rehabilitation Instructor/Rehabilitation NeuropsychologistNeuropsychologist
Mount Sinai School of MedicineMount Sinai School of Medicine
e: e: [email protected]@mssm.edu
p: 212-241-6547p: 212-241-6547