Common Approaches To Neuropsychological Evaluation

Neuropsychological assessment approaches fall broadly into three categories: (i) the fixed battery (or cognitive-metric) approach; (ii) the process (or hypothesis-testing) approach; and (iii) the flexible battery approach. These approaches can readily be conceptualized as differing along two dimensions: test selection and administration/interpretation. Test selection may be fixed or flexible; administration and interpretation are characterized, respectively, as standardized and actuarial at one extreme, and as nonstandardized and qualitative at the other extreme. Each approach has strengths and weaknesses (Table 1).

The fixed battery approach falls at the extremes of fixed test selection, standardized administration, and actuarial interpretation. It is best exemplified by the Halstead-Reitan Battery (4). The process, or hypothesis-testing, approach emphasizes qualitative aspects of neuropsychological functions, which are found in developmental and cognitive psychology. Champions of the process approach promote "testing the limits" with patients and assessing the component processes of cognition, rather than relying exclusively upon summary scores. In other words, the process approach views critically how a task is solved and how the solution unfolds over time, rather than the achievement score quantifying the quality of the end product.

Although the fixed battery and process approaches dominated neuropsychol-ogy, initially, the flexible battery has recently emerged as the most commonly used approach to neuropsychological evaluation (5). Flexible batteries benefit from the strengths of the fixed battery and process approaches by striving to quantify the qualitative aspects of cognition and task performance (6). In this way, the flexible battery approach capitalizes on advances in cognitive neuroscience while remaining firmly grounded in psychometric theory. In addition, the flexible battery approach incorporates a standard battery of tests from which the clinician can tailor the evaluation to address particular patients' needs and/or explore given domains of function in

TABLE 1 Advantages and Disadvantages of the Three Major Approaches to Neuropsychological Assessment

Fixed

Flexible

Process

Comprehensiveness

-

±

+

Ease of administration

+

-

-

Compatibility with research database

+

±

-

Ease of training technical personnel

+

-

-

Cost

-

+

±

Time required

-

+

±

Information about cognitive mechanisms

underlying impairment

-

+

+

Normative data

±

±

±

Ease of incorporating new technical

developments

-

+

+

Information redundancy

+

-

-

Comparability of scores across tests

±

±

-

Abbreviations: +, advantage/strength; -, disadvantage/weakness; ±, test battery dependent.

Abbreviations: +, advantage/strength; -, disadvantage/weakness; ±, test battery dependent.

TABLE 2 Commonly Used Neuropsychological Tests by Cognitive Domain Assessed

Cognitive domain

Test

Premorbid estimates

Neuropsychological screening Intelligence

Attention and working memory Executive function Memory

Language

Visuoperception

Motor and sensory-perception

Mood state and personality

Quality of life, coping, and stressors

Barona Demographic Equations; North American Adult Reading Test; Wechsler Test of Adult Reading; Wide Range Achievement Test Mattis Dementia Rating Scale; Repeatable Battery for the

Assessment of Neuropsychological Status Kaufman Brief Intelligence Test; Raven's Progressive Matrices; Wechsler Abbreviated Scale of Intelligence; Wechsler Adult Intelligence Scale Auditory Consonant Trigrams; Brief Test of Attention; Continuous Performance Tests; Digit and Visual Spans; Paced Auditory Serial Addition Test; Stroop Testa Cognitive Estimation Test; Delis-Kaplan Executive Function System; Halstead Category Test; Trailmaking Testa; Tower of London; Wisconsin Card Sorting Test Benton Visual Retention Test; California Verbal Learning Test; Rey Auditory Verbal Learning Test; Rey Complex Figure Testa; Wechsler Memory Scalea; Hopkins Verbal Learning Test

Boston Naming Test; Controlled Oral Word Association Test; Sentence Repetition; Token Test; Complex Ideational Material

Benton Facial Recognition Test; Benton Judgment of Line

Orientation; Hooper Visual Organization Test Finger Tappinga; Grooved Pegboarda; Hand Dynamometer3;

Sensory-Perceptual Examination Beck Anxiety Inventory; Beck Depression Inventory; Hamilton Depression Scale; Minnesota Multiphasic Personality Inventory; Profile of Mood States; State-Trait Anxiety Inventory Parkinson's Disease Questionnaire; Coping Responses Inventory; Ways of Coping Questionnaire; Life Stressors and Social Resources Inventory aTests may not be appropriate for patients with marked motor impairment. Source: From Ref. 30.

greater detail as desired. Many clinicians utilize a small fixed battery and then elaborate this battery depending upon the referral question, the patient's ability to cooperate with certain tasks, patient and family concerns, and presenting diagnoses.

The particular components and length of a neuropsychological evaluation will vary across clinical settings, but typically include the following:

■ A clinical interview and review of records to ascertain relevant biopsychosocial background information;

■ Informal observations regarding patient behavior, sensorimotor functions, cognition, and affect;

■ The administration of psychometric tests to measure intelligence, attention and executive functions, language, learning and memory, visuospatial perception, praxis, motor and sensory-perception, mood state, quality of life, and personality/coping variables (Table 2 lists a sample of tests and the domains of functioning they evaluate);

■ An integration of findings and recommendations into oral and/or written feedback that is provided to the patient, family, and healthcare providers.

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