Neuropsychology and neuropsychological assessment are related to the study of the behavioral expression of brain function and dysfunction (Blázquez, González & Paúl, 2008). That is, according to Blázquez, González & Paúl (2008), neuropsychological assessment constitutes a method of examining advanced brain functions, through behavioral research, with the help of techniques, theoretical models and procedures of psychology, such as tests, interviews, standardized scales and questionnaires, which take into account exponential, sensitive and precise behavior.
Objectives
The main objective of neuropsychological assessment is to determine the behavioral, emotional and cognitive consequences of brain dysfunction, by analyzing cognitive deficits, preserved processes and the behavior of subjects in daily life (Blázquez, González & Paúl, 2008). According to Tirapu (2007), this allows understanding the importance of neuropsychological rehabilitation programs as a therapeutic resource.
According to Benbunan (2016), other important objectives of neuropsychological assessment include helping to diagnose neuropathology with cognitive and/or behavioral symptoms, identifying the existence and nature of cognitive impairment in early stages, making differential diagnoses, assessing the effects of surgery on the brain, evaluating the toxic effects of certain pharmacological treatments, and preparing expert reports on disability, accident or impairment.
Finally, neuropsychological assessment should answer a series of questions: Is there evidence of organic brain dysfunction? What is the nature and extent of cognitive deficits? What are the actual consequences of cognitive impairment? How does brain dysfunction affect behavior and mood? Does cognitive ability change over time? What is the impact on recovery?
What is Assessed in a Clinical Neuropsychology Study?
The first thing that is assessed is the patient's orientation (Universidad Internacional de Valencia, 2018). This allows establishing the level of consciousness and the general state of activation (Ardila & Ostrosky, 2012). During the neuropsychological assessment, orientation in time, space and person is established (Ardila & Ostrosky, 2012). According to the International University of Valencia (2018), this is assessed by asking the patient various questions, such as name, age, date of birth, identity, what happened and the reason for their consultation.
In the same way, attention is studied, which allows people to concentrate on a task and be able to finish it efficiently (Universidad Internacional de Valencia, 2018; Ardila & Ostrosky, 2012). When assessing the integrity of cognitive functions, it is necessary to establish the patient's ability to concentrate and sustain attention, before assessing more complex functions, such as memory, language or abstraction (Ardila & Ostrosky, 2012). Generally, three parts can be distinguished in the attentional process: selection, vigilance and control. According to Ardila & Ostrosky (2012), the normal functioning of these three aspects will allow subjects to perform and maintain goal-directed behavior.
Jointly, processing speed is assessed, which, is an important measure of cognitive function and refers to the speed at which our brain processes and responds to the information received (International University of Valencia, 2018). Processing speed can be affected by various neurological conditions, including diseases such as Alzheimer's disease, Parkinson's disease, multiple sclerosis, and Huntington's disease, among others. It can also be affected by traumatic brain injury, stroke, sleep disorders, and other environmental and health factors.
In terms of reading, writing, and numeracy, people with nervous system problems may not be able to read, write, or perform mathematical operations (International University of Valencia, 2018). When assessing reading, it is important to assess the ability to decode and comprehend (Ardila & Ostrosky, 2012). Generally, according to Ardila & Ostrosky (2012), poor decoding will affect comprehension, however, some patients cannot read aloud, but have sufficient comprehension.
Additionally, memory is studied, which is one of the most important areas of research in clinical neuropsychology (International University of Valencia, 2018). According to the International University of Valencia (2018), the memory that is related to the information we receive, the images we see, the sequence of events, among others, can be affected.
On the other hand, executive functions are tools that help people to perform tasks, such as cooking or shopping (International University of Valencia, 2018). Damage or dysfunction of executive functions has important consequences on the most complex behaviors in humans, from emotion adjustment and social behavior to the change of abstract thinking and metacognition (Ardila & Ostrosky, 2012). Therefore, according to Ardila & Ostrosky (2012), it is necessary to perform as complete an assessment as possible to identify deficits in the different aspects of executive functions.
Additionally, higher visual functions are assessed, since, people may not be able to recognize objects or images, or may not be able to locate a point in a space (Universidad Internacional de Valencia, 2018). Regarding motor skills, the coordination and execution of certain movements is studied. Also, according to the International University of Valencia (2018), the patient's touch and sensitivity are evaluated.
Finally, the IQ or intelligence quotient is measured (Universidad Internacional de Valencia, 2018). Generally, intelligence refers to those skills of reasoning, problem solving, abstract thinking and planning. Along with IQ, the term "emotional intelligence" is discovered, which, according to the International University of Valencia (2018), is manifested as the ability to manage one's own emotions and understand the emotions of others.
Evaluation Process
First of all, it should be emphasized that if an optimal neuropsychological assessment has not been previously performed, an adequate intervention process cannot be achieved (Blázquez, González & Paúl, 2008). To this end, according to Blázquez, González & Paúl (2008), it is important to consider some aspects that help the neuropsychologist to understand the current state of the patient and allow him to guide the evaluation method more effectively.
Review of Previous Reports
Usually, the assessment process begins with a review of previous reports (Tirapu, 2007). According to Blázquez, González & Paúl (2008), the collection of the patient's previous data includes all available reports, medical, pharmacological, psychological, physical and logopedic treatments, and neuroimaging examinations since the onset of the disease.
All this allows understanding the cause of the injury, the initial degree of severity, the location of the brain injury, the physical, cognitive and functional status, the treatment methods and their effectiveness, the development of symptoms, and the presence or absence of complications (Blázquez, González & Paúl, 2008). Likewise, according to Blázquez, González & Paúl (2008), it allows to adapt the assessment tools to the patient's situation so that their deficiencies do not hinder the understanding of their cognitive status, since in most cases we are dealing with pathological brain injuries where the damage is generalized.
Patient and Family Interview
Once the previous reports have been compiled and the first contact has been established, the next task to be performed is to interview both the patient and his family (Blázquez, González & Paúl, 2008), which is the most powerful and economical diagnostic tool available to the professional (Tirapu, 2007). Through this tool, according to Tirapu (2007) and Bausela (2006), information is obtained on the patient's medical history, age, level of function prior to the disease, level of education and employment status.
In the same vein, information should be obtained on previous behavioral and personality patterns, in order to know the level of adaptation and rule out the presence of social maladaptation problems, such as substance abuse, impulse control deficits and poor social skills, which can help to address current emotional problems (Tirapu, 2007; Bausela, 2006). Finally, according to Tirapu (2007), part of the interview should be devoted to identifying the psychosocial consequences of the disorder in question (Tirapu, 2007).
In short, after the interview, the neuropsychologist must fully understand the patient's situation (Blázquez, González & Paúl, 2008), since, Tirapu (2007) mentions that, without sufficient knowledge it is difficult to interpret the results of any neuropsychological test and make accurate recommendations for treatment.
Assessment Methods
By administering tests alone, much relevant information is ignored, even more significant than that provided by other objective assessment methods (Blázquez, González & Paúl, 2008). Therefore, according to Blázquez, González & Paúl (2008), there are multiple ways to obtain information from the patient, which is fundamental for a comprehensive neuropsychological assessment.
Interview.
The interview provides an environment of trust, closeness, understanding and cooperation, all of which are necessary for neuropsychological assessment (Blázquez, González & Paúl, 2008). Furthermore, according to Blázquez, González & Paúl (2008), through the interview, one can understand the patient's perception of his or her situation, limitations, the degree of importance he or she attaches to them, the level of awareness of deficits and expectations.
To facilitate the collection of initial data in the first interview, different initial interview scales have been developed, which can be selected by the evaluator according to his or her level of experience (Blázquez, González & Paúl, 2008). According to Blázquez, González & Paúl (2008), interviews can be classified in two ways: structured interviews and semi-structured interviews.
The first refers to a protocol of questions, which is always applied in the same order, which means that the evaluator has almost no option for improvisation (Blázquez, González & Paúl, 2008). Generally, this method is recommended for inexperienced evaluators or when the evaluators know little about the case to be evaluated. On the other hand, semi-structured interviews involve more the evaluator's experience and constant reorientation towards the subject under study. According to Blázquez, González & Paúl (2008), in both cases guides with more or less open questions are used to guide the conversation without forgetting some important aspect.
Observation.
Throughout the evaluation process, valuable information can be extracted by simply observing behavioral and emotional aspects, adaptability to each situation and response to problematic situations (Blázquez, González & Paúl, 2008; Bausela, 2006). In this sense, it is very important to observe the patient's reaction to everyday situations, how he/she faces the problems that arise, whether he/she perceives the problem or not, whether he/she solves it spontaneously or takes some other action (Blázquez, González & Paúl, 2008). In the same way, according to Bausela (2016), the observation of the response methods, their attitudes towards the evaluation, their understanding about their current situation and the reasons for inspiring the evaluation are also aspects to be taken into account.
Standardized Batteries.
A standardized neuropsychological assessment battery can be defined as a series of tests that systematically examine the most important cognitive functions in order to identify and typify the presence of brain damage (Tirapu, 2007). In this way, according to Blázquez, González & Paúl (2008), a profile of preserved and impaired cognitive abilities can be defined.
The advantages of this method include the ability to study certain syndromes and neuropsychological alterations in a relatively short time (Blázquez, González & Paúl, 2008), the possibility of having a large database that, on the one hand, facilitates obtaining profiles that characterize various lesions and, on the other hand, better control over a number of variables that affect the performance of individuals (Tirapu, 2007). Finally, according to Tirapu (2007), there is a global assessment of cognitive functions, where it is possible to identify not only the main deficits, but also the skills retained in each patient.
However, because each battery tends to focus on only one or two processes, this method has some shortcomings, such as the lack of theoretical basis or limitations of the information provided (Blázquez, González & Paúl, 2008). Likewise, it does not allow for a comprehensive assessment of a person's broad cognitive spectrum. Therefore, although they help to simplify the work, according to Blázquez, González & Paúl (2008), they do not contain the most sensitive tests to assess each cognitive function, since several of the tests are usually sensitive for some cognitive functions, but not for others.
Specific Batteries.
Specific batteries are tools used to assess specific cognitive processes (Blázquez, González & Paúl, 2008). There are a large number of tests and instruments on the market to assess these characteristics, so the selection of the most appropriate tool should be based on sensitivity, the clinical characteristics of the patient and the reliability and validity of the test. Similarly, according to Blázquez, González & Paúl (2008), when very specific information about the patient's process is needed and the usual protocol cannot answer all the questions, specific batteries are used.
Specific Tests.
The use of these tests depends on the need for a detailed exploration of the main cognitive processes (Blázquez, González & Paúl, 2008). If the most sensitive tests close to the patient's educational level are chosen, a fairly detailed profile of deficits and preserved abilities can be obtained. It should be noted that, except in laboratory situations, where it may be easier to assess specific and isolated processes, generally, according to Blázquez, González & Paúl (2008), it is difficult to separate cognitive components and processes, because most of the neuropsychological assessments used are multifactorial.
Functional Scales.
Neuropsychological assessment based solely on neuropsychological tests, and which does not also evaluate the problems that the patient has in daily life, would not be a complete assessment (Blázquez, González & Paúl, 2008). Therefore, according to Blázquez, González & Paúl (2008), the use of functional scales will provide another type of information related to the effects of various impairments that the patient has and the autonomy he/she has in basic, instrumental and advanced activities.
According to Blázquez, González & Paúl (2008), this information can change the interpretation of the assessment results and the subsequent approach through a more direct assessment of everyday problems, collected through interviews, questionnaires, assessment scales, lists, memory diaries, direct observation, among others.
Behavioral Scales.
Depending on the cause of the patient's brain dysfunction, it is sometimes necessary to examine possible changes at the emotional, behavioral and personality level, however, the patient's premorbid personality may interact with the neurological or neuropsychiatric disorder itself (Blázquez, González & Paúl, 2008). For this study, according to Blázquez, González & Paúl (2008), scales or functional analysis can be used, either by relatives of the patient or by direct observation.
Selection of Assessment Instruments
In order to determine which scale, test or type of battery should be used for a particular patient, a great deal of information must be obtained about the cause of the injury and even the changes observed by the patient and his or her relatives (Blázquez, González & Paúl, 2008). In some cases, according to Blázquez, González & Paúl (2008), a prior neuropsychological evaluation is required.
Although all this information can serve to guide the evaluation of different cognitive processes and propose possible prior hypotheses, caution should be exercised and, despite having a preconceived idea, all cognitive processes should be screened in detail because this will provide more objective results (Blázquez, González & Paúl, 2008). Thus, according to Tirapu (2007), a fundamental issue that should be analyzed is the establishment of a series of fundamental criteria to be taken into account when choosing assessment tools.
Social and Cultural Characteristics.
Factors such as age, previous cultural level, nationality or mother tongue are variables that can determine, to a large extent, the results of the assessment (Blázquez, González & Paúl, 2008). According to Blázquez, González & Paúl (2008), assessment instruments are validated by means of a global sample that meets a series of characteristics, so the results only represent this sample and a comparable sample.
Pathology Characteristics.
As mentioned earlier, the presence or absence of motor and sensory deficits, the degree of alertness and awareness, as well as the degree of cognitive impairment or the stage the patient is in should be considered (Blázquez, González & Paúl, 2008). Many assessment tools require patients to show motor performance or verbal response, however, if the patient does not have fluent motor or speech performance ability, it will not help. In this case, according to Blázquez, González & Paúl (2008), there are two options, one is to make the test management method more flexible and the other is to preselect instruments with comparable assessment objectives, thus eliminating patient limitations.
Objective of the Neuropsychological Assessment.
Depending on the objective, one or another methodology, one or another tests and scales will be used, it will be more or less detailed, a prognosis will be established or not, and the functional impact will be evaluated or not (Blázquez, González & Paúl, 2008). According to Blázquez, González & Paúl (2008), the choice of tools may be more or less extensive, limited to a single process or may encompass a global view of all cognitive functions.
Sensitivity.
The selected instrument must be sensitive enough to detect relevant or significant changes (Blázquez, González & Paúl, 2008; Ardila & Ostrosky, 2012). Likewise, it should specify the scope of the changes and the areas in which they occur. According to Blázquez, González & Paúl (2008), this is fundamental both in the rehabilitation process and in understanding the evolution of the disorder, in order to add new treatment elements to the rehabilitation program or revise those that are not developing satisfactorily.
Specificity.
This refers to the ability of the tool to assess the specific process whose functioning is to be understood (Blázquez, González & Paúl, 2008). That is, if the language test only measures language or if the memory test only measures memory (Ardila & Ostrosky, 2012). However, according to Ardila & Ostrosky (2012), there is no completely specific test, since, all test scores are affected by different abilities.
Reliability.
The test should be selected according to the reliability shown (Blázquez, González & Paúl, 2008). The first type, is the intrasubject, where the test results are reproduced at different times by the same subject. Subsequently, according to Blázquez, González & Paúl (2008), there is the intersubject, in which the test results are reproduced by passing them to different subjects.
Finally, there is the test-retest, where, the test is applied twice to the same subject and the correlation between the scores in the first and second application is calculated (Ardila & Ostrosky, 2012). However, the score is expected to be higher in the second test. According to Ardila & Ostrosky (2012), the test-retest effect depends on several factors, for example the specific tests and the time elapsed between the first and second application.
Ecological Validity.
This type of validity refers to the need to use tests that can assess, to the greatest extent possible, the impact of cognitive dysfunction in daily life (Blázquez, González & Paúl, 2008). In other words, it attempts to assess the relationship between the subject's performance on the test and the ability to function in the real world (Tirapu, 2007). Sometimes, according to Blázquez, González & Paúl (2008), this need is particularly important.
Time Available for Assessment.
Selected protocols are time-consuming and may involve several sessions (Blázquez, González & Paúl, 2008). In most cases, the neuropsychologist is not available all this time or the patient's characteristics make it impossible to use some of the tests included in the protocol. However, in other cases, according to Blázquez, González & Paúl (2008), the purpose of the evaluation may require the use of a complete protocol to describe in detail the patient's overall performance.
Hypothesis Formulation
Neuropsychological assessment is a method based on reasonable assumptions that can be tested (Benedet, 2002). This process should be guided by the neuropsychologist's understanding of the cognitive functions involved in the performance of each task (Benedet, 2002), since, according to Blázquez, González & Paúl (2008), neuropsychologists should ask questions throughout the assessment process, formulate hypotheses, modify the assessment, attempt to test the hypotheses, and answer the questions posed.
Interpretation of Assessment Results
A detailed explanation of the results obtained is essential for a subsequent diagnosis of the impairment of certain cognitive processes and the existence of preserved abilities (Blázquez, González & Paúl, 2008). However, interpreting test results does not only mean determining whether the score obtained is higher or lower than the established standard value. There may be a large number of variables that are important such as, for example, the patient's attitude, emotional state, cultural level, fatigue, among others (Blázquez, González & Paúl, 2008). In other words, according to Bausela (2006), the results of the tests must be incorporated into a comprehensive model that satisfactorily interprets the data obtained.
At the end of this stage, according to Benedet (2002), the data provided by the neuropsychological assessment can be used to promote basic knowledge of neuropsychology in general and, of course, can also help in the clinical diagnosis of patients and the establishment of scientifically supported rehabilitation plans.
References
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Bausela, E. (2006). La evaluación neuropsicológica: procedimiento, instrumentos y variables. Redalyc.org. Recuperado 31 January 2021, a partir de https://www.redalyc.org/pdf/771/77100703.pdf
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Tirapu, J. (2007). La evaluación neuropsicológica. Scielo.isciii.es. Recuperado 16 January 2021, a partir de http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1132-05592007000200005
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