Mohammed T. Abou-Saleh

NON-COMPUTERIZED ASSESSMENT PROCEDURES 139they generate only a single score or are limited to largely verbalmeasures. When choosing to use a cognitive screen for neuropsychologicalevaluation of a geriatric patient, it is important tobalance our desire to spare the patient a lengthy assessment timewith a genuine quest to garner the most reliable diagnostic dataavailable. This goal may best be achieved by augmenting a briefcognitive screen, with individual neuropsychological measuresaimed at the more detailed evaluation of specific cognitive abilitiesor affective characteristics.One neuropsychological screening assessment that has achievedwide acceptance with use in a geriatric population is the DementiaRating Scale (DRS) 2 . This scale yields scores for attention,initiation/perseveration, construction, conceptualization andmemory, and compares individuals’ performances to a normativebase of subjects with known Alzheimer’s disease. In providingsuch a comparison population, the instrument controls for normalaging variation. In this way, the measure offers easily referencedcut-off scores for quick classification of outcomes as beingconsistent with dementia or not.A more recent tool available to clinicians is the RepeatableBattery for the Assessment of Neuropsychological Status(RBANS) 3 . While supportive literature for its use in diagnosingdementia in the geriatric population is only now being gathered,the RBANS has the advantage of being available in parallelforms, thus allowing serial assessment. Repeatability is a valuablefeature for a cognitive screen to have, especially in documentingrecovery of function after a reversible neurological injury and indemonstrating progressive decline in the degenerative dementias.The authors refer readers to published review articles andcommercial catalogs for the clinical findings and availability ofthese and other neuropsychological screening measures.In many cases, the discrimination between dementia andpseudodementia, or the differential diagnosis between types ofdementing illnesses, cannot be achieved through use of a briefcognitive screen. In these cases, a more comprehensive test batterymay be the only method by which to quantify and qualify specificareas of deficits into a pattern consistent with a diagnostic picture.In selecting tests for such a battery, one may focus on specificsymptomatic cognitive areas or may seek to assess globalcognitive functioning with a combination of neuropsychologicalmeasures. There are numerous individual neuropsychological testsdeveloped to assess specific cognitive functional areas(Table 27.2). The combination of these tests into a clinicalbattery may be based on theoretical concepts or assessmentapproaches; some clinicians prescribe to use of standard batteries,such as the Halstead–Reitan and the Luria–Nebraska, whileothers combine individual neuropsychological measures into amore flexible or ‘‘process approach’’ battery. Whatever one’stheoretical basis, consistency and rigor in assessment proceduresremains the most effective way for a clinician to develop his/herown personal bank of base rates and characteristic result profiles.Specific Cognitive Functional AreasIntellectual functioning is one of the broader functional areasassessed and may include assessment of fluid and crystallizedknowledge. It is not a unitary entity but instead consists ofmultiple functions, including the ability to acquire, process,categorize and integrate information. Intellectual functioningintimately involves use of memory and learning, visuospatialskills, attentional abilities, expressive and receptive language, andaspects of adaptive reasoning and organizational structure.Assessment may involve evaluation of verbal intellect, non-verbal(performance) intellect, or overall intellectual abilities.Attention and concentration abilities are critical for neuropsychologicalfunctioning. More complex processing depends onTable 27.2functionsCognitive functional areaIntellectual functioningAttention/concentrationfunctioningExecutive functioningMemory and learningfunctioningLanguage functioningVisuospatial/visuomotorfunctioningJudgment of lineorientationMotor functioningEmotional/personalityfunctioningExamples of neuropsychological tests for specific cognitiveExample neuropsychological testsWAIS-R or WAIS-IIIRavens Progressive Matrices (non-verbal)Peabody Picture Vocabulary Test (verbal)Mini-Mental State Examination (MMSE)Verbal Series Attention TestContinuous Performance (2 and 7) TestStroop TestDigit SpanPASATWisconsin Card Sorting TestShort Category TestTrail Making TestVerbal Fluency/Figural FluencyWMS-R or WMS-III (logical memory andvisual reproduction)CVLT, RAVLT-R, HLVT-RSelective Reminding (Buschke or Levin)Warrington Facial Recognition MemoryBenton Visual Retention TestWestern Aphasia BatteryWepman Aphasia ScreeningMultilingual Aphasia ExaminationBoston Naming TestControlled Verbal FluencyAnimal FluencyBenton Facial RecognitionRey-O Complex FigureTrail Making TestFinger TappingGrooved PegboardGrip StrengthBoston Apraxia ExaminationGeriatric Depression ScaleBeck Depression InventoryMultiscore Depression InventoryMMPI-2these primary functions. Their scope involves speed of informationprocessing, accuracy of discrimination, selectivity and use ofa heightened state of awareness. Successful evaluation ofattention/concentration skills is necessary for proper interpretationof other neuropsychological findings, including memory andlearning.Executive functioning is a complex phenomenon, whichanswers the question of how or whether one will do something.It involves the capacity to initiate activity and the process of selfmonitoringand interpreting feedback. Executive functions includethe planning and sequencing strategies that facilitate goal-directedbehaviors. Assessment of executive functioning should includetesting at varying levels of complexity to obtain an adequatepicture of the patient’s mental flexibility.Memory and learning assessment is at the core of mostneuropsychological evaluations of the elderly. A completeevaluation should examine verbal memory (contextual and noncontextual)and visual memory (independent of constructionalability), and should address acquisition, retention and recognitionthrough somewhat independent means. The distinction betweendeficits in encoding and deficits in retrieval of newly-learnedinformation can be crucial in differential diagnosis of the variousdementias.Expressive and receptive language abilities should be assesseddirectly, including auditory and reading comprehension, repetitionskills and the ability to follow simple commands (praxis).Specific language characteristics, including visual confrontation