A number of different models of assessment have been proposed. Whereas some of these models have fared better than others over time, from a historical perspective it can be seen that current approaches to neuropsychological assessment have greater similarities than in the past. Although some of the theoretical underpinnings and practices in these models may vary somewhat, many of the specific instruments are shared, with many neuropsychologists choosing to utilize what they consider to be the best aspects of each approach.
Related to this, an important distinction still exists in clinical neuropsychology between so-called fixed batteries and flexible batteries. In a fixed battery, specific tests are used in virtually all cases, and these tests as well as the overall battery have known sensitivity and specificity with respect to diagnostic questions. The most widely recognized of these fixed batteries is the Halstead–Reitan Neuropsychological Battery (HRNB).9The approach was developed by Ward Halstead and his student Ralph Reitan in the mid-20th century, and has had a major influence in the practice of 131 Neuropsychological Assessment of Aging Individuals
neuropsychology in North America. The theoretical approach and the battery have several advan- tages. For example, the HRNB is detailed and comprehensive, often taking five or more hours to administer, and covering a wide variety of neuropsychological functions. The battery was devel- oped empirically based on extensive and careful studies of the sensitivity and specificity of tests and combinations of tests. The user is provided with an impairment index which yields an estimate of the likelihood of brain dysfunction. The proliferation of the battery and the approach is likely due in part to the fact that it has clear guidelines for test selection, administration rules, and inter- pretation guidelines, and can be taught by postgraduate training/education.
The fixed battery approach has several inherent advantages compared to other models of assess- ment. For example, given a comprehensive battery, it is unlikely that clinicians will miss impairments that were not initially suspected, since the battery covers a wide range of domains. For example, a clinician may not initially suspect a language impairment, but since all patients receive an assessment of language such an impairment is unlikely to be missed. Further, research with the battery remains relatively straightforward, even in a retrospective study, since all tests are administered to all subjects.
An alternative to be fixed battery approach is the flexible approach, most commonly associated with the Boston school of neuropsychological assessment.10In this approach to neuropsycholog- ical assessment, a unique emphasis is placed on how a patient comes to an answer, as opposed to simply whether the answer is correct or incorrect. The Boston school, otherwise know as the proc- ess approach, places great emphasis on the process of thinking and problem solving. This school of assessment is less associated with specific tests than the HRNB, although a number of tests have been developed by this school (e.g., the Boston Diagnostic Aphasia Examination). Further, specific tests have been examined at length by advocates of the Boston school,11with an emphasis on aspects of a process approach that help to more richly understand a given patient’s condition.
The flexibility of this mode of assessment is its greatest strength. Clinicians are free to follow their instincts, to interpret behavior that may not be formally scored or acknowledged in other approaches to assessment, and to use instruments that fit the clinical situation including the referral question, the results of earlier findings on tests, unique aspects of the patient (e.g., where a given lesion may be based on neuroimaging), and patient needs (e.g., a truncated examination for an ill or elderly patient with limited stamina).
However, research with this approach can be more difficult than with the fixed battery approach, since not all tests may be used with a given patient population, and the administration and inter- pretation of tests may be unique to the clinician. Further, given the greater possibility of idiosyn- cratic interpretation of tests, the reliability of diagnostic impressions may come under greater scrutiny with this approach. Nonetheless, the Boston process approach permeates many interpre- tations of clinical findings, which is a testament to the popularity and strengths of the method.
A third approach to assessment can be seen in the Iowa-Benton approach.12,13A distinguishing characteristic of this approach is the use of a small, fairly standard battery of several tests, typically comprising no more than 30–45 minutes of assessment, followed by a detailed and customized assessment based upon a number of factors including the patient’s known medical conditions, pre- senting complaints, questions posed by the referral source, and findings from the core battery. Spe- cific measures used in both the core battery and the extended assessment are well-validated, with known psychometric characteristics. In the case of elderly patients care is taken to use measures that are normed for appropriate age groups. Unlike a fixed battery, the core battery used in this approach changes over time as tests become outdated, new tests emerge, or research suggests that certain tests may be of greater or lesser value in diagnostic accuracy. The current core tests used in the Iowa-Benton approach is represented in Table 7.1, with a sampling of the armamentarium of tests available and used for extended assessment in Table 7.2.
While each of the above three approaches has had significant influences on the field of neuro- psychological assessment, it is probably fair to say practitioners are currently more alike than they have been in the past. That is, a person trained in the Halstead–Reitan approach may well include other measures based on the specific referral question or patient complaints, whereas an individual
132 R. D. Jones
Table 7.1 List of available measures in the Iowa-Benton approach.
Test Orientation
Time
Personal information Place
Recent presidents Recent news
Intellect and Achievement WAIS-IV
Similarities Comprehension Information Vocabulary Block design Matrix reasoning Visual puzzles Picture completion Figure weights
Picture arrangement (WAIS-III) Digit span
Arithmetic
Letter-number sequencing Symbol search
Coding Cancellation WTAR WRAT-IV
Word reading
Sentence comprehension Spelling
Math computation Memory and Dementia Dementia Rating Scale
Rey Auditory Verbal Learning Test Hopkins Verbal Learning Test-R California Verbal Learning Test-II Complex Figure Test
Benton Visual Retention Test Wechsler Memory Scale-III
Logical Memory I Logical Memory II
Logical Memory II-Delayed Recognition Faces I
Faces II Spatial span Language Writing samples
Multilingual Aphasia Exam (MAE) Controlled Aural Word Association Visual Naming
Sentence Repetition Token Test
(Continued)
133 Neuropsychological Assessment of Aging Individuals
Table 7.2 Common“core”battery in the Benton Neuropsychology Laboratory.
Orientation WAIS-IV
Similarities Block design Matrix reasoning Digit span Coding Symbol Search WRAT-reading
Rey auditory verbal learning test Complex figure test
Benton Visual Retention Test Controlled Aural Word Association Boston Naming Test
Complex ideational material Trailmaking Test
Beck Depression Inventory Table 7.1 (Continued)
Reading Comprehension of Words and Phrases Aural Comprehension of Words and Phrases Boston Diagnostic Aphasia Exam (BDAE)
Boston Naming Test Complex Ideational material Reading Sentences and Paragraphs Iowa-Chapman Speed of Reading Test Category Fluency/ Animal Fluency Vision
Rosenbaum Visual Acuity Screen Facial recognition
Judgment of line orientation Useful field of view Clock Drawing Motor
Grooved Pegboard Test Executive Functions Trailmaking Test
Wisconsin Card Sorting Test Booklet Category Test Stroop Test
Mood and Personality Beck Depression Inventory Beck Anxiety Inventory Geriatric Depression Scale MMPI-2
Iowa Scales of Personality Change Effort and Symptom Validity TOMM
SIMS
Word Memory Test
Smell Perception and Naming Smell Identification Test
134 R. D. Jones
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.