Part 4: Neuropsychological Evaluation in Clinical Practice: Case Interpretation and Treatment

Lynn W. Shaughnessy, MA, Maureen K. O’Connor, PsyD, ABCN, and Janet C. Sherman, PhD

Ms. Shaughnessy is a student, Massachusetts School of Professional Psychology, West Roxbury, MA. Dr. O’Connor is an instructor, Department of Neurosurgery, Boston University School of Medicine, Boston, MA, and Director of Neuropsychology, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA. Dr. Sherman is an assistant professor, Department of Neurology, Harvard Medical School, and clinical director, Psychology Assessment Center, Massachusetts General Hospital, Boston, MA.

References

  1. Folstein MF, Folstein SEE, McHugh PR. "Mini-mental state." A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189–98.
  2. Grober E, Lipton RB, Hall C, Crystal H. Memory impairment on free and cued selective reminding predicts dementia. Neurology 2000;54:827–32.

Question 4

    Questions 4 and 5 Refer to the Patient’s Neuropsychological Test Results


    During testing, behavioral observations reveal a mildly flat affect with some anxiety. The patient becomes more relaxed as the assessment progresses, and he is cooperative and motivated throughout the evaluation. His speach is fluent and sensible. Given his full level of effort and motivation, the test results are considered a valid indicator of his functioning at that time.
    Premorbid intellectual functioning is estimated to be within the superior range based on his educational and occupational attainment and other demographic variables, and this is consistent wiith the results of a task of oral word reading. The patient’s performance on the Mini-Mental State Examination1 (24/30) falls within the impaired range, with errors on orientation and recall of 3 words that he had successfully encoded. More detailed neuropsychological evaluation reveals average to above average performance on measures of attention, working memory, executive funcioning, and confrontation naming, suggesting intact ability within these domains. In contrast to his superior intellect and intact functioning within most domains, the patient exhibits significant difficulties on tests within the domain of memory. He has difficulty learning a 12-item word list presented accross 3 repeated learning trials and exhibits impaired performance on the delayed recall condition, remembering none of the words that had been presented. The additional structure of a recognition task does not improve performance. Although he endorses 10 correct items, he makes an increased number of false-positive responses (ie, incorrectly endorsing distracter words as having been previously heard). On a second memory measure providing increased structure in the form of a short narrativee, he also performs below expectations on immediate, delayed, and recognition trials. Memory for visual material is slightly better, with immediate recall for visual designs falling within the average range, but he displays the same pattern of impaired retention over time, with no improvement during a recognition trial. Moreover, on a memory measure thhat has been found to be highly sensitive to dementia Free and Cued Recall2), the patient performs worse than expected, with free recall of pictured objects introduced with semantic cues to enhance learning falling 18 points below normal cut-off. Although his performance improves somewhat when he is provided with cues to aid in retrieval, he continues to perform below expectations (12 points below normal cutoff). Overall, memory performance suggests reduced new learning and impaired retetnion of imformation over time. In addition to the patient’s marked memory impairment, his performance on semantic fluency measures also falls below expectations and is significantly weaker than his performance on a letter fluency measure. In contrast to his difficutly accessing semantic information on the category fluency measure, performance on a confrontation naming task is intact. On mood inventories, the patient endorses minimal symptoms of anxiety and mild symptoms of depression. His wife’s responses on rating scales pertain ing to executive functioning behaviors indicate significant difficulty with emotional control, significant apathy, and mild difficulties initiating behavior.


    Which etiology is most consistent with this patient’s pattern of memory performance on this neuropsychological evaluation?
  •   Alzheimer’s disease
  •   Depression
  •   Traumatic brain injury
  •   Vascular dementia

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