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Zachariah Campbell

CHAPTER 15: CONCEPT FORMATION AND REASONING TEST NAME WHAT IT PROCEDURE TEST NEUROPSYCHOLOGICAL MEASURES CHARACTERISTICS FINDINGS SIMILARITIES Verbal concept Subject must explain Age related decline Sensitive to effects of brain formation what each pair of in the 70s injury, regardless of concept has in common localization General Education accounts mental ability Abstract generalization for results Exceptions for post acute rates 2 points trauma patients and Test of Those with no polysubstance abusers judgment Specific concrete evidence in dementia likeness gets 1 point had unchanged Indicator of premorbid General verbal performance until ability ability Questions can be age 75 repeated to help patient Small effect size for a TBI Reflects verbal attend to the demand Sharp drop in scores factor for a likeness between ages 75 No effect for major and 86 depressive disorder Sex effects are depressed score nonexistent associated with left temporal and frontal Differences between involvement b/c they show white and African increased glucose americans run about metabolism 2 scaled score points up through age 34 indicator of left hemisphere disease patients with anterior lesions on the right scores tend to be unaffected lower scores associated with bilateral frontal lesions vulnerable to dementia predictive of alzheimer’s disease predictors of abnormal cognitive decline in middle aged persons small decline in persons with mild cognitive impairment substantial decline with probably alzheimer’s disease NOT predictive of conversion from amnestic MCI to alzheimer’s disease Concrete minded patient do surprisingly well on this test WAIS-R NI Multiple choice format offering four responses for each item: 1) good generalization 2) concrete response 3) one is appropriate for only one of the two Given to subjects whose poor performance on the original form of the test suggested that their free responses may not be indicative of their potential or to patients incapable of making a spoken response MATRIX Visual concept Choose from a multiple core test contributing Performances by TBI REASONING formation choice array the item to the perceptual patients tend to be that best completes the reasoning composite impaired pattern score MCI group has lower No time limit, but it perceptual reasoning scores normally takes 20 factor is understood minutes as comprising 2 Sensitive to decline separate factors: associated with alzheimer’s slow, deliberative 1) Fluid type dementia subject may need 40 reasoning minutes or more 2) Visual Damage outside the frontal processing lobe: prefrontal damaged examiners instructed to patients were not prompt the subject after Mostly related to fluid disproportionately impaired about 30 seconds reasoning factors on this test as all prefrontal subgroups had matrix 2 problem types: 2x2 Age effects reasoning score that were matrix items and series performance indistinguishable from completion items those of the brain damaged comparison group On WAIS-IV problem Low average for types are mixed young adult is high Perform more like a hold throughout the test and average for ages 85- test, akin to vocabulary, increase in difficulty 89 frequently showing fairly 10 = average little change in the face of 13 = high average brain damage 16 = superior Good indicator of Strong association to premorbid intelligence raven’s progressive matrices Modest correlations with the D-KEFS Trail Making and Verbal Fluency Tests SORTING Sorting Subject is asked to sort FREE CONDITION: Immediate ancestor, the TEST: D- cards that display both sort the cards California card sorting test, KEFS Measures of perceptual features and according to as many useful in dissociating verbal initiation, printed words self-determined rules and nonverbal concept concept of as possible and to formation abilities formation, 2 versions, each has 2 state each rule modality set of cards Discriminating multiple specific SORT sclerosis patients problem Cards can be sorted in RECOGNITION: solving, two groups of three examiner sorts Alcoholics had measurable cognitive based on eight different according to each deficits flexibility, sorting rules rule and asks the perseverative subject to identify Patients with frontal lesions responsing 3 rules involve verbal or them and korsakoff patients and regulation semantic properties account for variances in of behavior results 5 rules involve perceptual properties Frontal lobe lesions and those with korsakoff’s Card size, shape and psychosis were impaired in color are among the initiating accurate sorts and other rules governing identifying sorting rules sorting possibilities Patients with frontal lesions have difficulty with many aspects of the test: strategy planning, strategy initiation, concept formation and flexibility Performance was significantly and specifically associated with left frontal lobe Those with unipolar depression or schizophrenia show poor performance INTRO: - Conceptual activities involve: o Intact system for organizing perception o Well stocked and readily accessible store of remembered learned material o Integrity of the cortical and subcortical interconnections and interaction patterns that underlie thought o Capacity to process 2 or more mental events at a time o Response modality sufficiently integrated with central cortical activity to transform conceptual experience into manifest behavior o Well functioning response feedback system for continuous monitoring and modulation of output - Thinking effects cortical organization - Concept functions are linked to prefrontal cortices - CONCRETE THINKING o Inability to think in useful generalizations o Difficulty forming concepts o Unaware of subtle underlying or intrinsic aspects of a problem o Event is dealt with as if it were novel, an isolated experience with a unique set of rules - Thinking may be concrete even when patient can perform many specific reasoning tasks - Thinking is likely to be concrete when the patient has specific reasoning disabilities CONCEPT FORMATION - Focus on the quality or process of thinking - Tests have no explicit right or wrong - Response was abstract or concrete - Patients with mild, modality specific or subtle neuropsychological defects may not engage in concrete thinking generally, but only on those tasks that directly involve an impaired modality are highly complex SYMBOL PATTERNS - Deductive reasoning combines with ability for conceptual sequencing in symbol pattern tests - Subject must indicate what symbol should follow in the sequence - PMA has norms for different age and education levels - Norms for different occupational groups - Require appreciation of temporal or consequential relationships for success - Symbol completion patterns are included in many of the items in the matrix reasoning test SORTING - Common form of tests of abstraction and concept formation - Subject must sort collections of objects, blocks, tokens or other kinds of items into subgroup following instructions - Assess ability to shift concept and ability to use them - Give some indication of their ability to form and handle abstract concepts - Patients approaches and strategies are of interest - Attention is paid to whether patients sort according to a principle, whether they can formulate the principle verbally, whether it is a reasonable principle, and whether they follow it consistently SORT AND SHIFT - Requirements to form a sorting principle and apply it (sort), and then abandon it and switch to a different principle (shift) - Challenging for patients with concrete thinking - Sensitive in uncovering difficulties with abstraction and flexible thinking - Observation will clarify whether the patients primary difficulty is in sorting or in shifting - Helpful to augment numerical data with behavioral description REASONING - REASONING o Thinking with a conscious intent to reach a conclusion o Stanford Binet scales - Test of problem solving and conception formation require reasoning for success - Reasoning about content independent situations based on formal logical operations appear to be mediated by left hemisphere brain regions - Mediation of reasoning influenced by information based on previous beliefs, values, or goals appears to be within the regions of the right hemisphere and bilateral ventromedial frontal cortex CALCULATIONS - Give patients an opportunity to demonstrate that they recognize the basic arithmetic symbols and can use them to calculate problems mentally and on paper - Left hemisphere involved in the knowledge of numbers and arithmetic rules - Parietal lobes bilaterally are implicated in appreciation of numerical magnitude - Arithmetic knowledge is a form of symbolic processing which is specialized in left hemisphere - 15 minute test of written calculation - Woodcock-Johnson Tests of Achievement III & Normative Update WJ III NU o 3 calculation ▪ 1) Calculation: measurement of the ability to perform written calculation problems ranging from simple addition to calculus problems ▪ 2) Applied Problems: measurement of the ability to solve practical problems, the complex problems necessitate written calculations, covers oral and math word problems ▪ 3) Quantitative Concepts: measurement of knowledge of mathematical concepts and vocabulary by means of oral questions about factual mathematic information, operations, signs ▪ 4) The Math Fluency: subtest presents simple addition, subtraction, and multiplication problems and emphasizes speeded performance o WJ-III NU ▪ Useful with more impaired patients ▪ More problems at lower difficulty levels than the WRAT-4 ▪ Examiner may wish to make up a graded set of arithmetic ▪ Examiner can dictate some problems representing each of the 4 kinds of operation to see how well the patient can set them up - LURIA: o Inability to respond accurately at these low levels signals an impairment in symbol formulation characteristic of aphasic disturbances, or a severe breakdown in conceptual functions o Examiner is able to identify the nature of the failure on these problems by comparing solutions calculated mentally with paper and pencil solutions to similar kinds of problems - BENTON o Comprehensive calculation examination composed of 12 tasks o Errors are preserved on paper o Analysis of errors rather than the score will unusually provide an understanding of the patients calculation problems - SPIERS: o 5 calculation type errors ▪ PLACE HOLDING ERRORS: misinterpretation of the decimal point or the size of the number, sequence reversals or partial reversals, transposition of a number ▪ DIGIT ERRORS: substituting the wrong digit , which can occur as an analogue of the misspeaking often but not necessarily associate with aphasia or as a perseveration from another part of the problem OR omission of one or more digits ▪ BORROW AND CARRY ERRORS: due to failure to borrow or carry or performing these operations erroneously ▪ BASIC FACT ERRORS: multiplication slip ups or involve confusion about use of 0 or 1 in a problem ▪ ALGORITHIM ERRORS: show up in failure to carry out all steps in a procedure, misaligning numbers, following an incorrect sequence through the problem, or substituting one operation for another o Loss of calculation skills is common in dementia of the alzheimer type and semantic dementia o Patients with brain dysfunction and mild diffuse damage make errors due to impaired ability to self monitor automatically o Errors show up as substitutes, misplacements, omissions that are not on one side or the other pf the problem, multiplication table slip ups and not completing all steps of an operation o Patients with frontal damage produce these kinds of errors in which the underlying problem is self- monitoring o Does not occur to some frontal patients to monitor their performance and are relatively unconcerned about the quality of their productions o Alzheimer patients problems with written calculations have been attributed to self monitoring deficits rather than to faulty knowledge about arithmetic rules CHAPTER 16: EXECUTIVE FUNCTIONS TEST WHAT IT PROCEDURE TEST NEUROPSYCHOLOGICAL MEASURES CHARACTERISTICS FINDINGS TOWER TESTS Planning Subject must look ahead to Difficulty levels Frontal involvement OF LONDON disorders determine the order of depend on number moves needed to rearrange and complexity of Sensitive to brain dysfunction three colored rings or balls subgoals required to from their initial position on achieved the desired role of prefrontal cortex two of three upright sticks to arrangement a new set of predetermined other factors important for positions on one or more of Sex differences: successful performance the sticks males rely more on include working memory, visuospatial abilities response inhibition and Constraints: one piece be and females rely visuospatial memory moved at a time and only a more on executive specified number of pieces functioning left anterior lesions = lower may be left on each peg at a scores time left or right posterior lesions Scored correct if the solution performed similar normal is achieved with the comparison subjects minimum number of moves necessary right anterior lesion group performed less well than 3 trials comparison only on the 5 move patients with lesions confined to frontal lobes worked slower patients with frontal lobe lesions and frontal lobe dementia had normal planning times patients with focal lesions made more moves, trial and error strategy and were slower to arrive at a solution frontal lobe dementia made more moves, committed more rule violations, made more incorrect solutions and were slower in executing moves patients with huntington’s disease are likely to show impairment performance decline with disease progression in patients with parkinson’s disease and was associated with a specific genotype scores did not discriminate between frontotemporal dementia and dementia of the AD type in TBI patients with anterior lesions performed at the same level as comparison subjects on most complex items, but better than those with nonfrontal lesions Dorsolateral prefrontal cortex and the anterior cingulate cortex was related to task performance which is consistent with poor performance associated with lateral prefrontal lesions Lateralization differences in patients with left frontal and right temporal lesions performed worse on four move problems Frontal patients made more errors and appeared to have difficulty choosing a TOWER OF Inhibiting a Objects to be rearranged are Role in performances counterintuitive backwards HANOI prepotent give rings of varying sizes of normal young move to reach a subgoal response adults and patients Goal and general with multiple sclerosis procedures are the same as for the Tower of London In the 40-79 year Patients with anterior lesions range, age nor tended to do less well than Moved from peg to peg to education affected those with posterior lesions achieve a final goal with as responses to this task few moves as possible Problem solving One ring may be moved at a declines for elderly time people at a faster rate than some forms of memory Instead of a restriction on number of rings, restrictions lay in that a larger ring may not be placed on a smaller ring Common strategy requires Parkinson patients tended to establishing subgoals and a develop a solution plan counterintuitive backward slowly, taking and learning an move inefficient path that led to a correct solution and retained Subgoals involved a move that solution on later testing that is essential for the solution of the puzzle but Amnesic patients performed does not place a ring into its normally on both trials goal position Huntington’s disease had TOWER OF Procedural adds a fourth ring and the consistently normal TORONTO and skill same size rings have performances learning different colors, Late stage huntington patients instructions require the were defective on both set of subject to keep lighter trials colored rings on top of darker ones as they move Frontotemporal dementia the set of four blocks from showed impaired the left one of three pegs to performances with diminished the peg on the right associated glucose utilization in frontomedial and frontolateral regions Patients with bilateral frontal lobe lesions did poorly on task, implicating difficulties with forming goals, comparing one’s current state to a desired future state, inhibiting a prepotent response, and executing decisions CONTROLLED Self 3 word naming trials CFL has more difficult Letter fluency tasks is a left ORAL WORD regulation and has less lateralized frontal pattern ASSOCIATION 2 sets of letters C-F-L and performance (COWA) P-R-W variability than the Word fluency is a sensitive FAS form indicator of brain dysfunction Words beginning with the first letter of these 2 sets CFL and PRW forms Frontal lesions depress fluecy have high frequency, second are equivalent for scores with left frontal lesions letter has lower frequency, college students resulting in lower word third letter has lower production than right frequency Education has a greater influence Asks subject to say as many Bilateral lesions even lower words as they can think of Women especially verbal productivity that begin with the given well educated women letter of the alphabet have a slight Left dorsolateral and superior advantage medial frontal lobe lesions Practice trial ends when the witched categories less subject has volunteered two Suppressing a frequently but produced appropriate S words which habitual response in normal cluster sizes lets examiner to determine favor of a novel whether the subject Deficits occur with left comprehends the task Initial responses temporal lobe epilepsy before attempting a scored depended on rapid trial access of words from Both left and right temporal semantic memory lobe partial resections for Examiner counts both errors with little effort while seizure control declines in and repetitions last half minute COWA performance and performances productivity one year later Repeated words that count depended on exceeded preoperative levels as repetitions do no occur strategies for effortful for both groups successively searching of semantic memory Reduced verbal fluency in TBI Greater number of words patients is associated with are produced earlier measures of severity Diffuse axonal injury contributor to cognitive inflexibility Mild TBI patients have deficits on letter fluency tests Phonemic fluence sensitive to presence of TBI Reduced capacity to generate words associated with all major dementing processes, like alzheimer’s disease, parkinsons’ disease and multiple sclerosis CATEGORY Self Declines with age Include focal temporal lobe FLUENCY reflection lesions and Alzheimer Hispanics and African disease americans named the fewest animals, Patients with alzheimer’s Chinese and disease, impairment has been Vietnamese the most attributed to a breakdown in semantic knowledge about Sex differences categories appear for categories with men producing more animals, birds Patients with frontotemporal and tools and women dementia, MRi data related produce more animal fluency to left vegetables, fruits, and frontal/temporal atrophy furniture Huntington patients were Exceed phonetic equally impaired on both deficits types of tasks, failures were due to reduced general initiation and or retrieval capacities TBI patients with temporal lobe damage had reduced category fluency Frontal damage had equivalent deficits on letter and category versions With depression, semantic fluency was more depressed than letter fluency Fluency finding reflects slowed thinking EXECUTIVE FUNCTIONS - Intrinsic to the ability to respond in an adaptive manner - 4 components o Volition o Planning and decision making o Purposive action o Effective performance - Defective executive behavior typically involves a cluster of deficiencies - Frontal lobe damage association - Associated to orbital and/or medial structures - Subcortical and cortical damages - Disturbances result from anoxic conditions that involve limbic structures and can be the consequence of alcohol abuse or inhalation of organic solvents - Korsakoff patients with lesions in thalamic nuclei and other subcortical components of the limbic system ehibit disturbances in executive behavior - Dysfunction are immobilized by apathy and inertia - Parkinson patients display diminished conceptual flexibility and impaired initiative and spontaneity - Patients with right hemisphere damage who can talk a good game are neither inert nor apathetic - Executive functions can break down at any stage in behavioral sequence - Systematic examination of the capacities help to identify the stage or stages at which a break down in executive behavior takes place - Major obstacle to examining executive functions is the paradoxical need to structure a situation in which patients can show whether and how well they can make structure for themselves - Cognitive tests allow subject little room for discretionary behavior - The challenge is how to transfer goal setting, structuring and decision making from the clinician to the subject VOLITION - VOLITION: complex process of determining what one needs or wants and conceptualizing some kind of future realization of that need or want - Capacity for intentional behavior - Requires capacity to formulate a goal or an intention - Motivation is a necessary precondition - Awareness of oneself is an aspect - Deficiencies in self-initiated behavior may occur - Persons who lack volitional capacity simply don’t think of anything to do - Can be apathetic or unappreciative of themselves as distinctive persons - Unable to initiate activities - Persons may be fully capable of performing complex activities and yet not carry them out unless instructed to do so - People whose volitional capacity is only mildly impaired can do their usual chores and engage in familiar games and hobbies without prompting o They are unable to assume responsibilities requiring appreciation of long term or abstract goals and don’t enter into new activities independently - When deficits are subtle it becomes important to identify the presence of volitional defect o Passivity or apparent withdrawal are obvious behavioral problems - Examiner must try to distinguish unmotivated, undirected and disinterested anergia occurring on an organic basis from characterological or psychiatric disorders that seem similar - Examiner must rely on observations of these patients in the normal course of the examination - Reports are best sources of information about patients capacity for generating desires, formulating goals and forming intentions - Examination should include both patient and those who know the patient best - Examiner will see these patients in their living situation as they go about every day activities PLANNING AND DECISION MAKING - One must be able to conceptualize changes from present circumstances, deal objectively with onself in relation to the environment and view the environment objectively - Planner must be able to conceive of alternatives, weigh and make choices and entertain both sequential and hierarchical ideas - Impulse control and intact memory functions are necessary - Requires capacity for sustained attention - Patients who are unable o form a realistic intention can’t plan - Patients who generate motives and goal directed activity fail to achieve goals because of abilities required for effective planning is impaired PURPOSIVE ACTION - Translation of an intention - Requires actor to initiate, maintain, switch and stop sequences of complex behavior in an orderly and integrated manner - Disturbances can thwart the carrying out of reasonable plans regardless of motivation, knowledge, or capacity to perform the activity - Disturbances are not likely to impede impulsive actions - Provide an important distinction between impulsive and consciously deliberate actions - Overlearned, familiar, routine tasks expected to be much less vulnerable to impaired brain functioning o Particularly when the brain impairment is in the frontal lobes - Patients who have trouble programming activity may display a marked dissociation between their verbalized intentions and their actions - Programming difficulties may affect large scale purposive activities or the regulation and fine tuning of discrete intentional acts or complex movements - Trouble performing discrete actions tend to have difficulty carrying our broader purposive activities - Iowa Scales of Personality Change o Assess real life disturbances in aspects of purposive action o Executive Decision Making Deficits ▪ LACK OF INITIATION ▪ LACK OF PERSISTENCE: difficulty sticking with a task and completing projects. Tasks may take much longer than necessary ▪ PERSEVERATION: patients get stuck and keep repeating the same activities over and over or try the same approach to a problem even if it isn’t working ▪ LACK OF STAMINA SCALE: patients become more tired or weary than would most people of similar age under similar circumstances, interferes with their ability to complete activities EFFECTIVE PERFORMANCE - Performance is as effective as the performer’s ability to monitor, self correct and regulate the intensity, tempo and other qualitative aspects of delivery - Patients with brain disorders often perform erratically and unsuccessfully - Patients can’t correct their mistakes because they don’t perceive them - Sensory or motor dysfunctions can distort or disrupt motor responses - Pathological intertia may perceive their errors and yet do nothing to correct them - Defective self monitoring can spoil any kind of performance - Real life problems with self monitoring and effective performance identified - Iowa Scale of Personality Change assessing insensitivity and social inappropriateness - Other ISPC scales show o LACK OF INSIGHT: patients underestimate or are unaware of behavioral and cognitive problems, blame the difficulty on circumstances or on other people but they underestimate the change and how it interferes with day to day life o IMPATIENCE: patient gets upset over minor delays that would not bother most people, patients tend to keep getting more and more upset rather than trying to accept the situation and is associated with poor frustration tolerance, exacerbating interference with effective performance TESTING PERFORMANCE EFFECTIVNESS - Every test performance during examination can provide info about this aspect of self-awareness - Self monitoring defects may appear in cramped writing - Missed or slipped responses on paper and pencil tests - Speech in quick little bursts - Incomplete sentences and thoughts - Tests on which subjects can check their written responses for accuracy as they are working on them EXECUTIVE FUNCTIONS: WIDE RANGE ASSESSMENT - Naturalistic observation - Leading consideration is always economy - Exams are expensive, patients wear out and time is limited o Compel examiners to choose carefully will provide maximal info in a reasonable amount of time - Provide valuable and comprehensive info CHAPTER 8: NEUROBEHAVIORAL VARIABLES AND DIAGNOSTIC ISSUES DIFFUSE AND FOCAL EFFECTS - Diffuse brain diseases do not affect all brain structures equally - Rare to find a focal injury in which some diffuse repercussions do not take place - Diffuse brain injury is most obvious when it results from a condition carried by the circulatory system o Presented in: ▪ most moderate to severe closed head injuries, particularly those sustained under conditions of rapid acceleration or deceleration as in falls from heights or moving vehicle accidents ▪ infection ▪ anoxia ▪ hypertension ▪ intoxication ▪ degenerative, metabolic and nutritional diseases - behavioral expressions of diffused brain dysfunction o memory o attention o concentration disabilities o impaired higher level complex reasoning resulting in conceptual concretism and inflexibility o general response slowing o emotional flattening or lability o symptoms tend to be severe immediately after an injury or the early stages of a sudden onset disease OR appear as subtle and transient problems that increase in duration and severity - focal brain injury sources o trauma o space-displacing lesions o localized infections o cerebrovascular accidents o systemic conditions ▪ severe thiamine deficiency - focal signs accompany an acute exacerbation of a systemic disorder o diabetes  confusing diagnostic picture until underlying disorder is brought under control and symptoms subside - symptoms of diffuse damage almost always accompany focal lesions of sudden onset - first sign of a progressive localized lesion o may be some slight specific behavioral impairment that becomes more pronounced and inclusive o diffuse behavioral effects resulting from increased intracranial pressure and circulatory changes may obliterate the specific defects due to local tissue damage - focal lesions can be distinguished by lateralizing signs o when lesion extends to both hemispheres, damage is apt to be asymmetrical resulting in predominance of one lateralized symptom pattern o functions are significantly impaired while other functions remain intact o examiner can safely conclude that the cerebral insult is focal SITE AND SIZE OF FOCAL LESIONS - few patients with primary focal lesions have damage confined to the identified area o lesion site is more likely to predict nature of the accompanying neuropsychological deficits than is its size - site was more important in determining language behavior - lesion size may be factor in the severity of articulatory impairment o severity of deficit may be best estimated for a specific function by taking into account jointly both size and hemisphere side of lesion o size differs between the hemispheres and the importance of hemispheric contributions differs with the task - TBIs are rarely “clean” b/c damage is widespread o Size of the lesion may be determinant of residual functional capacity within the context of diffuse injury o Tumors don’t respect the brain’s midline ▪ They can be erratic in their destruction of nervous tissue o Information about where in the brain a discrete lesion is located is viewed as a partial description that identifies the primary site of damage o Patterns of behavior or neuropsychological test performance often may not meet textbook expectations for a lesion in the designated area - Disorders that are made of multiple focal lesions can disruptive to neurological function and cognition o Totality of white matter lesion burdern becomes predictive of cognitive impairment o Applies to increasing multifocal white matter pathologies associated with aging, vascular decline and compromise in cognitive functioning TIME - Trends in patterns of improvement or deterioration depend on nature of the cerebral insult, age of patient and function under study - Length of time following symptom or disease onset must be taken into account in any evaluation of neuropsychological examination data NONPROGRESSIVE BRAIN DISORDERS NEUROPSYCHOLOGICAL CHARACTERISTICS OF ACUTE BRAIN CONDITIONS - Recency of the insult may be the most critical factor - Patients make the most rapid gains in the first weeks and months - Patients with serious injuries associated with a prolonged coma regain consciousness o After several week they are often confused, unable to track the sequence of time or events, emotionally unstable, unpredictably variable in their alertness and responsiveness, behaviorally regressed and likely to display profound cognitive deficits - Less severely affected patient symptoms of acute disorganization recede and noticeable improvement takes place from day to day during the first few weeks or months - Patients with less severe injuries experience confusion to some degree o Confusion accompanied by disorientation, unreliable concentration, poor memory and recall for recent experiences, fatigability, irritability and labile affect - Most common behavioral characteristics of an acute brain lesion in conscious patients are impaired retention, concentration and attention, emotional lability and fatigability o Behavioral reintegration usually takes place the first month or two following brain injury NEUROPSYCHOLOGICAL CHARACTERISTICS OF CHRONIC BRAIN CONDITIONS - Patients condition rarely remains fixed - Cognitive functions continue to improve during the first six months or year o Spontaneous improvements continue beyond a year tend to be slight o Level and degree of deficit persist o Status of cognitive functions at one month for stroke or a year following moderate to severe TBI is unlikely to change ▪ Improvement for patients with more severe TBI may extend beyond a year ▪ Improvement in all areas to premorbid levels is rare o Cognitive rehabilitation improve cognitive status o Patients with neurological compromise are often able to adapt to their limitations and make reasonably good adjustments over a lifetime - Improvement does not follow a smooth course but tends to proceed by inclines and plateaus as different functions improve at different rates o Old memories and well learned skills generally return most quickly o Recent memory, ability for abstract thinking, mental flexibility and adaptability are more likely to return more slowly - Brain injured patients test scores are likely to fluctuate considerably over time and between functions o 5 years poststroke, stability in cognitive performance was the norm for the majority of survivors o DEGREE OF IMPROVEMENT in the course of the first year can significantly improve 2 year outcome predictions for TBI patients o Unwise to make binding decisions or judgment concerning legal, financial, or vocational status until several years have passed - Functions that appear to be intact may deteriorate over the succeeding months and year o Following an initial improvement and a plateau period of several years or more, some mental deterioration may take place o Following a career in contact sports a dementing condition may evolve that appears to be attributable to many and frequently repeated head injuries o Highest levels of cognitive activity having to do with mental flexibility, efficiency of learning and recall, and reasoning and judgment about abstract issues or complex social problems o Prior brain injury may also increase vulnerability to such degenerative disorders - Few symptoms distinguish the behavior of person suffering chronic brain injury of adult onset with sufficient regularity to be considered characteristic o Common complaints are of temper outbursts, fatigue and poor memory o Rest and a paced activity schedule are the patient’s antidotes o Patients who read and write are capable of self discipline can aid failing memory - Reality of memory complaints is not apparent o Complaints may reflect the patients feelings of impairment more than an objective deficit o Common chronic problem is an abiding sense of unsureness about mental experiences (PERPLEXITY) o Express this probable indirectly with hesitancies and statements of self doubt or bewilderment - Another difficulty is defective self-awareness which limit vocational options and interfere with rehabilitation efforts - Depression troubles many patients who were not rendered grossly defective by their injuries o First experienced within the year following the onset of brain injury but can remain high for decades o Severity and duration vary depending on a host of factors both intrinsic and extrinsic o Patients whose permanent disabilities are considerable have either lost some capacity for self appreciation and reality testing or are denying their problems o Depression resolves becomes muted with time and others may be successfully treated with pharmacotherapy - Heightened irritability is another complaint o Reflects poor social functioning and greater impairment in activities of daily living o Irritability accompanies fatigue and mitigated with rest - Decreased tolerance for alcohol should be anticipated o Persons who drink postinjury are unlikely to be “light” or social drinkers PREDICTING OUTCOME - Outcome varies by nature and type of neurological or neuropsychiatric - Self report and the presence and severity of sensory and motor symptoms are most often used in clinical practice - Neuropsychologcal data and evaluations of the status of particular impaired functions such as speech, serve as outcome measures - Social outcome criteria varies with age o Usual criterion of good outcome for younger adults and most TBI patients = return o gainful employment o Criterion of older people and stroke patients = degree of independence, self care, and whether the patient could return home rather than to a care facility VARIABLES INFLUENCING OUTCOME - Severity is the most important variable in determining the patient’s ultimate level of improvement - Age may effect outcome at the age extremes but have little influence within the young to middle aged adult range o PREMORBID COMPETENCE: both cognitive and emotional/social may contribute to outcome and is related to cognitive reserve o GENERAL PHYSICAL STATUS: may be associated with outcome for stroke patients o NUTRITION: both pre and postmorbid is another physical status that can significantly affect a patient’s potential for improvement o Physical impairments are outweighed by emotional and personality disturbances in determining the quality of the psychosocial adjustment following TBI o Positive mood along with high levels of consciousness and normal speech are early predictors of good outcome for stroke o EARLY STROKE REHABILITATION: has been associated with higher levels of improvement but how early is “early” has yet to be defined o FAMILY SUPPORT: contributes to good outcomes for both trauma and stroke patients ▪ Family support and social stimulation may depend on how well the patient is doing rather than serve as an independent predictor of outcome success o SIDE OF LESION: ▪ Right hemisphere stroke patients have poorer outcomes than those with left sided injury ▪ Patients with right hemisphere damage, those who show the inattention phenomenon tend to be more impaired and improve less than those not troubled by it ▪ Left hemisphere strokes show greater improvement and takes place right handed aphasic patients ▪ Left frontal lobe is wider than the right MECHANISMS OF IMPROVEMENT - How improvement occurs based on behavioral constructs refer to the neurologic substrates of behavior - Compensatory techniques and alternative behavioral strategies enable patients to substitute different and newly organized behaviors to accomplish activities and skills that can no longer be performed as originally developed or acquired o Techniques evolve quite unconsciously and become useful for many brain injured patients o Major focused of rehabilitation programs - Reflect receding DIASCHISIS EFFECTS o For certain functions, areas in the intact hemisphere homologous to the lesioned areas appear to be able to take over at least come of the functions that were rendered defective PROGRESSIVE BRAIN DISEASES - Behavioral deterioration follows an often bumpy but predictable downhill course for sets of functions that deteriorate at varying rates - When diagnosis is known we question when will it happen o Past observations provide some rules of thumb - Conditions that are progressing rapidly are likely to continue to worsen at a rapid rate whereas slow progressions tend to remain slow - Newly diagnosed benefit from an early baseline assessment with one or two reexaminations at 2-4 or 6 month intervals - Biopsy takes much of the guesswork out of estimating the rate of progression - Severity of disorder bears some relationship to the type of tumor \ - Direction of growth is not as predictable SUBJECT VARIABLES AGE - Oldest age group have increased greatly in the past decade - Higher education is associated - Active lifestyle in a favorable environment preserve cognitive health - Emotional comfort and habits and interests - Conditions can affect cognition o Common in elderly people - Genetics play a role NORMAL COGNITIVE AGING - Age related cognitive decline when they are in their 20s to 30s - Divergent findings due to different methodological approaches - For ease and efficiency most studies use a CROSS SECTIONAL DESIGN comparing different age groups o Confound aging effects and cohort differences in culture, environment, medical status, education and experience ▪ Cohort effects were stronger than age effects on cognitive measures - LONGITUDINAL DESIGN: elimi
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