trained in the Iowa-Benton approach may use a longer core battery, which can begin to resemble a fixed battery. Again, it is fair to say that these approaches are“blending”in some ways, to the ben- efits of all, by taking the best aspects of each school of assessment.
Although there may still be some disagreement about different schools of assessment, there is broad consensus regarding the domains of assessment that are appropriate for neuropsychological assessment. In the following section of this chapter, we will examine the domains that are typically covered in assessment, and their relationship to the aging mind and brain.
Each of these measures has different attributes. For example, the HVLT is briefer, with three learn- ing trials and a delayed recall, and the CVLT has a number of indices such as the extent to which examinees benefit from semantic cues.
As an alternative to verbal list learning and recall, a number of assessments employ story learning and recall. Perhaps the best known of these is the Logical Memory subtest from the Wechsler Memory Scale (see below). The specific stories have been revised over the years, but the funda- mental paradigm has remained the same. Examinees are asked to listen to a paragraph length story, then to recall the story immediately, and again after a delay (of 30 minutes). Two stories are read, and each is scored according to how many elements of the story were recalled/recognized, based on objective scoring criteria.
Visual memory
Visual memory is a regularly measured construct in neuropsychological assessment, and a number of commonly used measures can be used. Some of these measures examine recall of geometric designs, faces, or complex figures. For example, the Rey Osterrieth Complex Figure test (CFT) or Taylor Complex Figure (TCF) require the examinee to copy a complex figure with multiple elements, which can then be reliably scored on a 36-point scale based on location of the scored elements and distortion of the elements. Following a delay, the examinee is asked again to recall the figure, and the figure produced after a delay is scored on the same 36-point scoring system.
Performances are dramatically affected by age, thus examinees are compared only to like-aged groups. Other common visual memory tests include the Faces subtest from the Wechsler Memory scale, and recall of faces from the Recognition Memory Test. Finally, a commonly used measure of recall of simple designs is the Benton Visual Retention Test (BVRT), in which examinees are asked to produce a set of simple geometric figures that become increasingly complex as the test pro- gresses, after examining the figures for a brief period. A scoring system examines number correct, number of errors, and type of errors in producing the figures. A similar test is the Brief Visual Mem- ory Test-Revised (BVMT-R), in which the examinee is give three learning trials to recall a number of stimulus figures on a page and their location, along with delayed recall and recognition trials.
Remote memory
Most measures of memory used in current neuropsychological assessment are designed to present a new set of stimuli to the patient, and subsequently ask the patient to recall and or recognize the stimuli. However, certain conditions (e.g., progressive dementias) can include loss of remote mem- ory as part of their clinical profile. Thus, it is curious that there are relatively few measures of remote memory. Of those that do exist, several are based on public knowledge, and thus become outdated relatively quickly. For example, the Boston Famous Faces Test requires the patient to recognize and name a picture of a face. However, relatively recent faces become outdated over time, and such tests must thus be renormed regularly. A solution to this problem is to assess autobiographical memory, which is constantly updated within each individual. This is the approach of the Autobi- ographical Memory Questionnaire (AMQ). This test and other measures of remote memory are seldom seen in standard clinical assessments, however.
Memory Batteries
Perhaps the most widely used battery of memory tests is the Wechsler Memory Scale, currently in its fourth edition. This measure has grown considerably since its inception in 1945, and now includes seven subtests that result in index scores including Auditory Memory, Visual Memory, Visual Work- ing Memory, Immediate Memory, and Delayed Memory. Individual neuropsychologists may use
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one or more of the subtests in isolation, and it is not unusual to see scaled scores for subtests such as Logical Memory (immediate and delayed), Verbal Paired Associates (immediate and Delayed), or Spatial Addition.
Language
Like memory, language is a core domain in neuropsychological assessment, and thanks to the intense study of language and aphasia by experts on various fields (e.g., psychology, linguistics, neurology) there are a wide variety of measures available for use in neuropsychological assessment.
Common tests include standard tests of fluency, repetition, reading, writing, comprehension, and naming. Certain batteries are commonly used in this context (for example the Boston Diagnostic Aphasia Examination, the Multilingual Aphasia Examination).
Fluency Fluency is often measured in relation to either letters or semantic categories. As an exam- ple of the former, a patient may be asked to name as many words as he or she can that start with a certain letter, within a certain time (typically one minute). As an example of the latter, the patient may be asked to name as many types of items in a semantic category (e.g., animals, or tools) as he or she can in a given amount of time. Both of these types of tasks are sensitive to changes associated with age, and have been shown to be sensitive to early decline in common diseases associated with the elderly (for example Alzheimer’s disease).
Repetition Since repetition is so often impaired in cases of language disorder or aphasia, it is com- monly found in neuropsychological assessments. Reflecting the importance of this capacity, there are a number of different tests of repetition available in the typical neuropsychology battery, includ- ing repetition of numbers, automatisms, and sentences. For example, digit span from the Wechsler adult intelligence scale can be found in many assessments. The Sentence Repetition test from the Multilingual Aphasia Examination, is a common example of a repetition test. Many of these tests begin with simple two- or three-word sentences, and progress to increasingly longer sentences to repeat. Normative data are based on educational and age-adjusted groups, in order to directly com- pare a given patient to his/her cohort.
Comprehension Testing of aural and reading comprehension is a common feature in neuropsy- chological assessment of the elderly. Such testing not only has implications for diagnostic criteria of certain diseases, but also has practical implications. For example, a patient with a comprehension defect is unlikely to be able to understand his or her options with respect to medical, financial, or other decisions that they may be asked to make. This allows either the neuropsychologist or the referring healthcare provider to connect the patient with local resources for further management.
An example of an aural comprehension test is the Token Test. This is a test of items of increasing difficulty, in which a patient is asked to manipulate tokens of various sizes, colors, and shapes in specific ways. The commands to manipulate the tokens become increasingly difficult and lengthy, thus setting a fairly high ceiling for a perfect performance on this test.
A second test of comprehension that is commonly seen in neuropsychological assessments is the Complex Ideational Test from the Boston Diagnostic Aphasia Examination. This test at face value appears to be much more“ecologically valid”than the Token Test, since the patient is asked to comprehend and respond to initially simple, but increasingly complex, sentences and paragraphs.
A third set of tests worthy of mention is from the Multilingual Aphasia Examination. These tests include Aural Comprehension of Words and Phrases, and Reading Comprehension of Words and Phrases. Each of these tests uses a multiple-choice format for the patient to indicate comprehension of simple stimulus items.
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Naming Word finding and naming defects are well-known early signs of degenerative disease, as is often seen in older individuals. Perhaps the best known test of naming is the Boston Naming Test from the Boston Diagnostic Aphasia Examination. In this test the patient is asked to name 60 items, and is provided with either phonemic or semantic cues if they are unable to do so within a fixed amount of time. This procedure helps to disambiguate between deficits in naming versus deficits in recognition, which is helpful in the examination to know where the disorder lies.
A second naming test is the Visual Naming test from the Multilingual Aphasia Examination.
This is a test of naming common items, and the patient is asked the name of the items themselves and some parts of the item. Responses are scored according to how many correct items are pro- vided by the subject, and are compared to age- and education-based norms.
Visual functions
Basic visual acuity adequate to complete testing is assumed in neuropsychological testing, and is often assessed to reassure adequate vision is present. Assuming this is the case, a number of higher level visual functions are commonly employed in a neuropsychological assessment, and can be expected to be measured in most examinations. A number of domains of visual function are typ- ically reported, including the presence or absence of visual field defects, spatial neglect or inatten- tion, and higher-level functions such as perception, praxis, and visual construction skills. Some neuropsychological assessments include observations on complex visual syndromes such as the vis- ual agnosias and Balint syndrome.
Two of the more common measures of visual function include Benton’s Facial Recognition Test (FRT) and Judgment of Line Orientation Test (JLO). Although the FRT is more a test of visual discrimination rather than recognition per se, it has been associated with dysfunction of the ventral visual stream, as can be seen in prosopagnosia and other recognition defects. The test requires the patient to discriminate between faces based on increasingly limited visual cues.
Conversely, the JLO test has been associated with the dorsal visual stream, and is commonly impaired in conditions such as visual variant Alzheimer’s disease or bilateral watershed strokes in the posterior circulation. The patient is required to judge spatial angles with increasingly limited spatial cues.
Finally, it is common to see tests of visual construction, such as the accuracy of drawing a com- plex figure; examples include the Rey Complex Figure test or the Taylor Complex Figure Test.
Importantly, all of these measures have practical implications for key daily activities, the most stud- ied of which is driving.
Executive functions
Executive functions are ubiquitous in a standard neuropsychological assessment, since the con- struct itself is so broadly defined. Executive functions encompass functions such as judgment, allo- cation of cognitive resources, problem-solving, social relations, decision-making, and the capacity to hold in mind two or more ideas simultaneously.
Perhaps the most common measure of executive functions is the Wisconsin Card Sorting Test (WCST). The test requires a patient to sort cards into various categories, based on characteristics of stimuli on the cards. It is the task of the patient to determine which characteristic is correct, based on sequential feedback after each time he or she sorts a card. The test is viewed as a measure of problem-solving based on feedback, and the ability to learn over time based on this feedback.
A second set of common tests includes the so-called“tower tests.”These tests include the Tower of London test and a Tower of Hanoi test, and fundamentally require the patient to move discs of decreasing size from one side of an array to another without putting a larger disk on a smaller disk.
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This measure is normally viewed as an index of problem-solving based on sequential success or failure experiences.
A third measure of executive functions that can be seen in many if not most neuropsychological assessments is the Trail Making Test. This is a well-established measure, with two parts. Part A involves requiring the patient to rapidly connect numbers sequentially that are scattered on the page, whereas part B requires the patient to alternate between letters and numbers while sequentially connecting randomly scattered stimuli on the page. This test is commonly seen as a measure of “working memory,” particularly part B of this measure, which involves keeping two processes in mind at once.
Finally, there is a widely used measure of executive function that involves using multiple tests.
The Delis–Kaplan Executive Function System (DKEFS) uses multiple measures of executive func- tion to assess various constructs, all within the domain of executive functions. The test involves several of the types of tests noted above, including a tower test, the Trail Making Test, and addi- tional measures to provide extensive information regarding an individual’s executive skills.
Mood and personality
Mood and personality measures are common if not virtually universal in neuropsychological assess- ments. Although there are multiple measures that can be seen, some of the most common include the Minnesota Multiphasic Personality Inventory–2 (MMPI-2), the Beck Depression Inventory, and the Geriatric Depression Scale. The latter two measures are paper and pencil measures of depression that are completed by the patient. The Geriatric Depression Scale is aimed at an older population by taking into account that some common symptoms of depression may simply be nor- mal aging (e.g., less energy). The MMPI-2 is a broad measure of personality, including both valid- ity indices that detect overreporting, underreporting, and other response biases, as well as 10 clinical scales the refect constructs such as depression, anxiety, social isolation, somatic con- cerns, and others.
Effort and exaggeration
For many years certain measures have included indices of effort and exaggeration (for example the MMPI-2) and more recently it has become evident that standard measures of these domains should be included in assessment. In recent years a distinction has been made between measures of symptom validity and effort validity. Measures of the former include the Symptom Validity Scale of the MMPI (formerly known as the Fake Bad Scale), and the Structured Inventory of Malingered Symptomatology. These measures examine the extent of unlikely or pathological responding, which can raise questions about the validity of a patient’s self-report. Concerns have been raised, however, that these measures may in fact be elevated in patients with bona fide neurologic disease.
Effort validity tests include measures such as Test of Memory Malingering, the Word Memory Test, and the Portland Digit Recognition Test. These measures aim to detect noncredible perfor- mances that may reflect either lack of effort or in some cases malingering.