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Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 1
Neuropsychological Assessment of Cognitive Functions in Individuals with TBI: Part 2
Dean C. Delis, Ph.D.
Professor Emeritus
University of California, San Diego, School of Medicine
• California Verbal Learning Test – II• California Verbal Learning Test – Children’s Version• Delis-Kaplan Executive Function System• Delis Rating of Executive Function• Wechsler Intelligence Test for Children – IV Integrated• Wechsler Intelligence Test for Children – V Integrated
Disclosure: I am an author of the following tests and receive royalties from them:
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 2
TBI
• TBI accounts for more than 50,000 deaths per year
• TBI comprises 50% of deaths due to physical injury
Combat TBI - Prevalence
• Over 20,000 soldiers overseas have suffered from blast-related concussions caused by improvised explosive devices
• 28% of all military evacuated to Walter Reed Medical Center have TBIs
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 3
Leading Causes of TBI
Motor VehicleAccident
50%
Falls21%
Assault12%
Sports10%Other
7%
*
Concussion/TBI
Mild Moderate Severe
Altered or LOC < 30 min
&
Normal CT &/or MRI
LOC < 24 hours
&
Abnormal CT &/or MRI
LOC > 24 hours
&
Abnormal CT &/or MRI
GCS = 13-15 GCS = 9-12 GCS = < 9
PTA < 24 hours PTA < 7 days PTA > 7 days
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 4
Physiology of InjuryTwo Main Mechanisms of Brain Injuries:1. Focal: Contusion (bruise) or Hematoma (blood
mass with possible pressure effects)2. Diffuse: Diffuse axonal injury in which there is
stretching and tearing of neurons• TBI may involve both• Focal damage = More likely to be seen on CT or MRI
brain scans• Diffuse = Often difficult to be detected on CT or MRI
brain scans3. Implications for cognitive deficits:
Focal/lateralized versus more generalized cognitive impairments.
Diffuse Axonal Injury (DAI)
• Results from acceleration-deceleration forces
www.brainlaw.com
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 5
Common Areas of Assessment in the Neuropsychological Evaluation
• Verbal Attention: Simple/Complex (Working Memory)
• Visual Attention: Visual Scanning/Multi-variable
• Language Skills: Vocabulary, Reading, Spelling
• Written Math
• Visual-Spatial Perception and Construction Skills
• Verbal Learning and Memory (Stories v. Word Lists)
• Design Learning and Memory
• Verbal Abstract Thinking
• Nonverbal Reasoning
• Novel Problem Solving/Concept Formation
• Fluency of creative thinking (verbal v. nonverbal)
• Cognitive Flexibility/Multi-tasking (verbal v. nonverbal tasks)
• Processing Speed
• Motor Speed and Dexterity
Importance of Estimating Premorbid Verbal Functioning
• Definition of Acquired Deficit: A decline from a premorbid level.
– Acquired deficits in adults v. acquired deficits in children (deficit versus delay).
• Methods for estimating premorbid level of cognition should be used in a flexible manner.
• Method 1: Scores on “Hold Tests” (e.g., Reading; Vocabulary). Example of when not to use: Left temporal-parietal lesion.
• Method 2: Education-Corrected Norms. Example of when not to use: brain insult occurred prior to or while attending school.
• Method 3: Past School Records (e.g., group achievement test results). Example of when not to use: Unstable home environment.
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 6
Cognitive Domains Particularly Vulnerable to TBI
• New Learning and Memory
• Higher-Level Executive Functions
• Visual-Motor and Verbal Processing Speed
• Have in common: Complex, multi-factorial cognitive functions
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 7
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 8
CVLT II List A Trial 1 v. Digit Span Forwards
• Correlate around .90
• Digit Span Forward > Trial 1 Emotional Factor?
• Trial 1 > Digit Span Forward Rapid Auditory Processing Deficit?
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 9
Span/Slope Scenarios
20
40
60
80
100
Color Naming Word Reading Inhibition Switching
aver
age
tim
e to
com
ple
tion
(se
conds)
FLE
TLE
Control
Color-Word Interference Test
Group x condition; F[6,186] = 4.3, p< .001*Cohen’s d reported as ES estimate between FLE group and controls
*
*
d = .73*d = .71
d = .89
d = 1.15
McDonald, C. R. Delis, D. C., Norman, M. A., Wetter, S. R., Tecoma, E. S., & Iragui, V. J. (in press). Epilepsy & Behavior.
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 10
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 11
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 12
0
20
40
60
80
100
120
140
Verbal IQ PerformanceIQ
Full Scale IQ
C.D.’s IQ Scores
0
2
4
6
8
10
12
14
Sca
led
Sco
re
Color Name Word Read Inhibition Inhib/Switch Inhib/SwitchErrors (11)
C.D.’s Scores on the DKEFS Color-Word Interference Test
Three EF profiles: Deficit only in time to completion, deficit only in errors, deficit in both
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 13
0
3
6
9
12
15
Filled Dots Empty Dots Only Switching
aver
age
num
ber
of
des
igns
ated
FLE
TLE
Controls
Design Fluency Test
F(4,126) = 2.5, p< .05; η2 = .07
*
McDonald, C. R. Delis, D. C., Norman, M. A., Tecoma, E. S., & Iragui, V. J. (in press). Discriminating patients with frontal lobe epilepsy and temporal lobe epilepsy: Utility of a new measure of design fluency. Neuropsychology.
Correct Raw Score = 8Errors = 0
Aged Scale Score = 10
Design Fluency: Condition 1Filled Dots
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 14
Design Fluency: Condition 2 Empty Dots Only
Correct Raw Score = 9Errors = 1
Aged Scale Score = 10
Design Fluency: Condition 3 Switching
Correct Raw Score = 0Set Loss Errors = 6
Aged Scale Score = 3
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 15
0
2
4
6
8
10
12
14
Sca
led S
core
s
FilledDots
EmptyDots
Switching Set LossDesigns
RepeatedDesigns
C.D.’s Scores on the DKEFS Design Fluency Test
10
30
50
70
90
110
130
Visual Scanning NumberSequencing
LetterSequencing
Number-LetterSwitching
Motor Speed
Tim
e t
o c
om
ple
tio
n (
se
co
nd
s)
FLETLEcontrols
Trail Making Test
Group x condition; F[8,248] = 9.0, p < .01, η2 = .23
*
McDonald, C. R., Delis, D. C., Norman, M. A., Tecoma, E. S., & Iragui, V. J. (in press). Is impairment in set-shifting specific to frontal-lobe dysfunction? Evidence from patients with frontal-lobe or temporal-lobe epilepsy. Journal of the International Neuropsychological Society.
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 16
C.D.’s Scores on the DKEFS Trail Making Test
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 17
Case Example: NA
• 15- year-old male
• Native American/White
• Right Handed
• Possible Fetal Alcohol Syndrome
• h/o ADHD
• WISC-IIIFSIQ = 87
VIQ = 73
PIQ = 106
VC = 75
PO = 105
FD = 75
PS = 101
D-KEFS Trail Making Test: NA’s Results
0
2
4
6
8
10
12
Scal
ed S
core
VisualScanning
NumberSquencing
LetterSequencing
Number-Letter
Sequencing
Motor Speed
Condition
Contrast Scores
NLS vs. Visual Scan = 5
NLS vs. Number Seq = 5
NLS vs. Letter Seq = 7
NLS vs. Combined = 1
NLS vs. Motor Speed = 2
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 18
PF
Age at injury: 7
Front seat collapsed, depressed bifrontal skull fracture. GCS = 8-9
Bilateral prefrontal damage, left > right
Post-Injury: Normal on most neuro-psychological tests
MRI Brain Scans of PF and His Twin Sister
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 19
PF’s Speed/Accuracy Scores on D-KEFS Tests
PF’s Scores on IQ Versus Executive Function Tests
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 20
Processing Speed Measures
• Coding• Symbol Search• Trails Visual Scanning• Trails Number Sequencing• Trails Letter Sequencing• Trails Switching• [Trails Motor Speed]
Visual-Motor Verbal
• CWIT Naming• CWIT Reading• CWIT Inhibition• CWIT Inhibition/Switching• Verbal Fluency Letter • Verbal Fluency Category• Verbal Fluency Switching
Completion Times v. Errors
Differential error rate will tell you if this Trails profile likely reflects only a visual-motor processing speed deficit or also an executive function impairment
5%
16%
9%5%
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 21
• Test of Memory Malingering• CVLT-II Forced Choice Trial• Medical Symptom Validity Test• Word Memory Test• Word Choice Test• Victoria Symptom Validity Test• Rey 15 Item Test• b Test• Dot Counting Test• Validity Indicator Profile• Hiscock Digit Memory Test• Portland Digit Recognition Test
Cognitive/Performance Validity Test
Future Embedded Performance Validity Measures
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 22
CVLT-II Scores Across Exams
Dr. Y’s Testing 7/10
93% 93%
Dr. Delis’ Testing 7/11 Dr. X’s Testing 1/09
Scores on Trail Making Tests Across Exams
69%
35%
63%
Dr. X’s Exams in 2/2012 and 10/2012 Dr. Delis’ Exam in 2/2014
5%
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 23
16%
1%
25%
63%
Ms. J’s Scores on the Color‐Word Interference Test
Criteria for Concluding that a Low Score Represents an Acquired Cognitive Impairment
1. The score represents a significant decline from an estimated premorbid level of functioning. This criterion applies better to some cognitive domains relative to others (e.g., phonemic fluency versus cognitive flexibility).
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 24
Criteria for Concluding that a Low Score Represents an Acquired Cognitive Impairment
1. The score represents a significant decline from an estimated premorbid level of functioning. This criterion is better applied to some cognitive domains relative to others (e.g., phonemic fluency versus cognitive flexibility).
2. The score is significantly lower not only from a statistical perspective, but also from a base rate perspective.
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 25
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 26
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 27
Criteria for Concluding that a Low Score Represents an Acquired Cognitive Impairment
1. The score represents a significant decline from an estimated premorbid level of functioning. This criterion is better applied to some cognitive domains relative to others (e.g., phonemic fluency versus cognitive flexibility).
2. The score is significantly lower not only from a statistical perspective, but also from a base rate perspective.
3. The score represents an internally consistent cognitive deficit according to known brain-behavior relationships.
16%
1%
25%
63%
Ms. J’s Scores on the Color‐Word Interference Test
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 28
Criteria for Concluding that a Low Score Represents an Acquired Cognitive Impairment
1. The score represents a significant decline from an estimated premorbid level of functioning. This criterion is better applied to some cognitive domains relative to others (e.g., phonemic fluency versus cognitive flexibility).
2. The score is significantly lower not only from a statistical perspective, but also from a base rate perspective.
3. The score represents an internally consistent cognitive deficit according to known brain-behavior relationships.
4. The score is a relatively consistent finding across repeat neuropsychological exams.
CVLT-II Scores Across Exams
Dr. Y’s Testing 7/10
93% 93%
Dr. Delis’ Testing 7/11 Dr. X’s Testing 1/09
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 29
R.S.’s Scores on Various Cognitive Tests
90%
Dr. Delis’ Testing 8/13
Tests Often Not Affected by Brain Damage
Tests Vulnerable to Brain Damage
75%
87%
16%
8%
R.S.’s Scores on Various Cognitive Tests
90%
Dr. Delis’ Testing 8/13 Dr. X’s Testing 1/14
Tests Often Not Affected by Brain Damage
91%
84%
75%
87% 86%
16%
5%8%
Tests Vulnerable to Brain Damage
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 30
My Recommendations for Report Writing
Include a table describing normative data for each test
The normative data for the neuropsychological tests were taken from the following studies:
Test Number of normal subjects
Demographic Correction
Reference
WAIS-IV 2,200 Age Wechsler, 2008
WMS-IV 1,400 Age Wechsler, 2009
ACS 1,400 to 2,200 Age Wechsler, 2009
WRAT-4 3,000 Age Wilkinson & Robertson, 2006
BNT 531 Age, Gender, Education
Heaton et al., 1999
WCST 899 Age, Gender, Education
Heaton et al., 1993
CVLT-2 1,087 Age and Gender Delis et al., 2000
D-KEFS 1,750 Age Delis et al., 2001
Motor Tests 1,212 Age, Gender, Education
Heaton et al., 2004
MMPI-2 RF 2,600 Gender Ben-Poraf & Tellegen, 2008
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 31
My Recommendations for Report Writing
• Mildly Impaired• Moderately Impaired• Severely Impaired
Results Section of Report
• Mildly below average• Moderately below average• Severely below average
Include a table describing normative data for each test
My Recommendations for Report Writing
• Mildly Impaired• Moderately Impaired• Severely Impaired
Results Section of Report
• Mildly below average• Moderately below average• Severely below average
Include a large table with all main standardized scores and percentile ranks
Include a table describing normative data for each test
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 32
Cognitive Validity Measures Raw
ACS Word Choice Test 50/50 >25 Cum %ile Clin Samp
CVLT-2 Forced Choice 15/16 5 Cum %ile Norm Samp
Reliable Digit Span 14 >25 Cum %ile Clin Samp
WMS-IV VR Recog 6/7 51-75 Cum %ile Norm Samp
Attention Standardized Score Percentile Rank
WAIS-IV Digit Span Total ASS = 15 95
Forward ASS = 16 98
Backward ASS = 14 91
Sequencing ASS = 12 75
D-KEFS Trails Visual Scanning ASS = 11 63
WAIS-4 Symbol Search ASS = 10 50
Language
WASI-II Vocabulary T = 59 82
NAB Naming Spontaneous (31/31) T = 53 62
WRAT-4 Reading (Grade = 12.9) SS = 100 50
WRAT-4 Spelling (Grade = >12.9) SS = 112 79
D-KEFS CWIT Color Naming ASS = 13 84
D-KEFS CWIT Word Reading ASS = 13 84
WASI-II VCI SS = 105 63
Arithmetic
WRAT-4 Math Comp (Grade = >12.9) SS = 104 61
Spatial Cognition
WMS-4 VR Copies (43/43) >75 cum %ile Norm Samp
WASI-II Block Design T = 53 62
WASI-II PRI SS = 105 63
Visual-Motor Processing Speed
WAIS-IV Coding ASS = 12 75
WAIS-4 Symbol Search ASS = 10 50
WAIS-IV PSI SS = 105 63
Memory
WMS-IV LM1 (35/50) ASS = 14 91
WMS-IV LM2 (29/50) ASS = 13 84
WMS-IV LM Recog (T=25/30; Hits=14/15; FP=4/15)
51-75 cum %ile Norm Samp
WMS-IV VR1 (35/43) ASS = 10 50
WMS-IV VR2 (27/43) ASS = 10 50
WMS-IV VR Recog (6/7) 51-75 cum %ile Norm Samp
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 33
CVLT-2
List A 1-5 Total (49) T = 49 46
Raw Z-score
List A Trial 1 4 -1.5
List A Trial 2 8 -0.5
List A Trial 3 11 0
List A Trial 4 13 0.5
List A Trial 5 13 0
List B 6 0
Short Delay Free 9 -0.5
Short Delay Cued 10 -1
Long Delay Free 8 -1.5
Long Delay Cued 8 -1.5
Semantic Cluster -0.4 -1
Serial Cluster (bidirection) 1.1 0.5
% Primacy 31% 0.5
% Middle 47% 0
% Recency 22% -1
Slope (1-5) 2.3 1.5
Slope (1-2) 4 0.5
Consistency 92% 1
Repetitions Total 7 0.5
Intrusions Total 1 -0.5
Recognition Hits 12 -2
False Positive Total 1 -0.5
Recog Discrim Total 2.5 -0.5
Response Bias Total 0.6 1.5
Forced Choice Accuracy 15/16 5 Cum %ile Norm Samp
Executive Functions Standardized Score Percentile Rank
D-KEFS Verbal Fluency
Letter Fluency (62) ASS = 18 99
Category Fluency (59) ASS = 18 99
Switching Total Resp. (21) ASS = 19 99
Switching Accuracy (20) ASS = 18 99
Total Set Loss Errors (0) ASS = 13 84
Total Repetition Errors (3) ASS = 10 50
WASI-II Similarities T = 48 42
WASI-II Matrix Reasoning T = 54 66
WCST-128
Perseverative Responses (3) T = 54 66
Categories (6) > 16 Cum %ile Norm Samp
Failure to Maintain Set (0) > 16 Cum %ile Norm Samp
Total Errors (9) T = 54 66
Total Other Responses (0)
D-KEFS CWIT
Color Naming ASS = 13 84
Word Reading ASS = 13 84
Inhibition ASS = 14 91
Inhibition /Switching ASS = 14 91
Color Naming Errors (0) 100 cum %ile Norm Samp
Word Reading Errors (1) 10 cum %ile Norm Samp
Inhibition Errors (1) ASS = 11 63
Inhibition/Switching Errors (0) ASS = 12 75
D-KEFS Trails
Visual Scanning ASS = 11 63
Number Sequencing ASS = 12 75
Letter Sequencing ASS = 14 91
Number-Letter Switching ASS = 13 84
Visual Scanning Omission Errors (1) 15 cum %ile Norm Samp
NL Switch Sequencing Errors (0) 100 cum %ile Norm Samp
NL Switch Set-Loss Errors (1) 24 cum %ile Norm Samp
NL Switch Total Errors (1) ASS = 10 50
Motor Speed ASS = 13 84
MOTOR
Finger Tapping DH (raw ave = 40.4) T = 41 18
Finger Tapping NDH (raw ave = 40.2) T = 48 42
D-KEFS Trails Motor Speed ASS = 13 84
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 34
My Recommendations for Report Writing
• Mildly Impaired• Moderately Impaired• Severely Impaired
Results Section of Report
• Mildly below average• Moderately below average• Severely below average
Please: Include a large table with all main standardized scores and percentile ranks
Discussion Section of Report
• Mildly Impaired• Moderately Impaired• Severely Impaired
Include a table describing normative data for each test
Thank You
Assessment of Cognitive Functions – TBIDr. Dean Delis
9/7/2016
Copyright 2016. Pearson Education and its affiliates. All rights reserved. 35
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