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Appendix - A case study example
Referral
A 76-year-old woman was referred for a neuropsychological assessment of her suitability for cognitive therapy for treatment of anxiety and mild depression.
Interview
She was oriented in person, but not for time, believing the year to be 1988 (not 1998). She was cooperative and well motivated. Her manner and affect were appropriate and there was no evidence of word-finding difficulties or problems with communication.
Brief neuropsychological screening
The Middlesex Elderly Assessment of Mental State (Golding, 1989) was used to screen for neuropsychological dysfunction in different areas. She failed on 6 sub-tests (orientation, spatial construction, fragmented letters, easy and hard unusual views, and verbal fluency), suggesting the need for a more extensive neuropsychological assessment.
Premorbid estimate
The National Adult Reading Test - Revised gave her an estimated full-scale IQ of 123 (in the superior range).
Current intellectual functioning
A short form of the Wechsler Adult Intelligence Scale - Revised, (Crawford et al, 1992) gave the following sub-test age-scaled scores (mean=10; s.d.=3). Verbal skills: comprehension=7, similarities=9, prorated IQ=84; performance skills: block design=3, object assembly=3, prorated IQ=67; prorated full-scale IQ=77. Overall her intellectual function had decreased very significantly from the premorbid level, particularly in relation to performance IQ. The latter was characterised by the presence of constructional apraxia.
Memory
In the Rey Auditory Verbal Learning Test she recalled four of the 15 words presented, relying largely on recalling the most recent words in the list. After five attempts, this increased to seven words. After a delay of 20 minutes, three words were recalled. This suggested overall a moderate impairment.
Executive functioning
She scored 21 words on the Controlled Oral Word Association Test, approximately consistent with her verbal IQ. She was also tested on the Hayling (inhibition) and Brixton (spatial anticipation) tests. Her scores on both tests were in the impaired range.
Conclusions
There was widespread intellectual decline affecting performance IQ more than verbal IQ, with specific constructional apraxia. She had a moderate memory impairment and executive dysfunction. This pattern was consistent with early dementia, with established impairment in three or more areas of neuropsychological function. A reassessment of her functioning would have been undertaken in 6 months and a behavioural, rather than strictly cognitive-behavioural, approach to managing her anxiety and depression.
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Multiple choice questions
1. Neuropsychological assessment of older adults:
1. is highly specific in terms of differential psychiatric diagnosis
2. can provide a baseline from which to monitor cognitive deterioration
3. can aid the differential diagnosis between dementia and depression
4. is the primary outcome measure for all forms of neurorehabilitation
5. can be used to determine the persons' strengths and weaknesses.
2. When assessing older adults:
1. explaining the purpose of the assessment and establishing rapport take longer
2. a fixed battery of tests is recommended
3. performance on psychometric tests developed for this group is usually unaffected by visual or hearing loss
4. the format is generally the same as for younger adults if a more extensive assessment is used
5. more extensive procedures can be used with an intelligent person with early dementia.
3. Brief neuropsychological batteries:
1. have not been developed specifically for older adults
2. can be used as screening instruments if more extensive assessment is not possible
3. are not particularly useful for use with older adults
4. have shown poor reliability
5. should be interpreted with caution with respect to individual items.
4. Intellectual assessment in older adults:
1. is not particularly useful
2. can establish a level of overall ability against which to compare specific functional deficits
3. is unreliable if shortened by selecting specific sub-tests of an intelligence battery
4. with dementia can be enhanced using tests to determine premorbid intellectual ability
5. is catered for in the new Wechsler Adult Intelligence Scale-III.
5. Memory dysfunction in older adults:
1. is too common in normal people to be used to detect neuropsychological dysfunction
2. can be assessed using tests for younger adults, if normative data are available
3. can be comprehensively assessed, but some batteries are too taxing for this client group
4. is one of the most common neuro- psychological disturbances
5. is an area lacking specialist tests specifically for this client group.