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Statement of editorial PurPoSe
The Hospital Physician Neurology Board Review Manual is a peer-reviewed study guide for residents and practicing physicians preparing for board examinations in neurology. Each manual reviews a topic essential to the cur-rent practice of neurology.
PRESIDENT, GRouP PuBLISHERBruce M. White
SENIoR EDIToRRobert Litchkofski
aSSISTaNT EDIToRFarrawh Charles
ExEcuTIvE vIcE PRESIDENTBarbara T. White
ExEcuTIvE DIREcToR of oPERaTIoNS
Jean M. Gaul
PRoDucTIoN DIREcToRSuzanne S. Banish
PRoDucTIoN aSSISTaNTNadja V. Frist
SaLES & maRkETING maNaGERDeborah D. Chavis
Copyright 2009, Turner White Communications, Inc., Strafford Avenue, Suite 220, Wayne, PA 19087-3391, www.turner-white.com. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission of Turner White Communications. The preparation and distribution of this publication are supported by sponsorship control over the design and production of all published materials, including selection of topics and preparation of editorial content. The authors are solely respon-sible for substantive content. Statements expressed reflect the views of the authors and not necessarily the opinions or policies of Turner White Communications. Turner White Communications accepts no responsibility for statements made by authors and will not be liable for any errors of omission or inaccuracies. Information contained within this publication should not be used as a substitute for clinical judgment.
NoTE fRom THE PuBLISHER:This publication has been developed with-out involvement of or review by the Amer-ican Board of Psychiatry and Neurology.
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Case1:A71-Year-OldManwithMemoryLoss. . . . . . . . . . . . . . . . . . . . .2
Case2:AManwithTraumaticBrainInjury . . . . . . . . . . . . . . . . . . . . . . .5
Case4:A9-Year-OldGirlwithReadingDifficulty. . . . . . . . . . . . . . . . .12
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
NeuropsychologicalevaluationinClinicalPractice:CaseInterpretationandTreatmenteditors:AlirezaAtri,MD,PhDInstructor in Neurology, Harvard Medical School; Assistant in Neurology, Massachusetts General Hospital, Boston, MA; Neurologist, Geriatric Research Education & Clinical Center, Veterans Administration Medical Center, Bedford, MA
TraceyA.Milligan,MDInstructor in Neurology, Harvard Medical School; Associate Neurologist, Brigham and Womens and Faulkner Hospitals, Boston, MA
Contributors:Lynnw.Shaughnessy,MADoctoral Student, Massachusetts School of Professional Psychology, West Roxbury, MA
JanetC.Sherman,PhDAssistant Professor, Department of Neurology, Harvard Medical School; Clinical Director, Psychology Assessment Center, Massachusetts General Hospital, Boston, MA
MaureenK.OConnor,PsyD,ABCNInstructor, Department of Neurology, Boston University School of Medicine, Boston, MA; Director of Neuropsychology, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
Hospital Physician Board Review Manual www.turner-white.com
NeuRology BoaRd Review MaNual
Neuropsychological evaluation in Clinical Practice: Case interpretation and Treatment
lynn w. Shaughnessy, Ma, Janet C. Sherman, Phd, and Maureen K. oConnor, Psyd, aBCN
This manual is the second half of a 2-part review of neuropsychology. The first part presented an overview of the practice of neuropsychology, focusing on the goals of a neuropsychological evaluation, its methods, and the cognitive domains assessed. In clinical practice, there are 4 main goals of a neuropsychological evalu-ation: (1) to assess a patients cognitive status across a range of domains to determine areas of strength and weakness; (2) to provide assistance in addressing questions pertaining to differential diagnosis; (3) to monitor cognitive status over time through repeat neuropsychological evaluations; and (4) to provide recommendations regarding possible treatments and interventions that can help patients and their families or help determine competency for managing instru-mental activities of daily living (eg, finances, medica-tion, appointments, driving). The neuropsychologist accomplishes these goals through both qualitative observation and quantitative data obtained by adminis-tration of standardized tests.
In this manual, we present clinical cases that il-lustrate essential concepts in neuropsychology and demonstrate how neuropsychological evaluations can contribute to a patients clinical care. In each case pre-sentation, we describe the patients background, symp-tom presentation and history, behavioral observations, test scores, interpretation of results, and treatment recommendations. For each case, the test data have been converted from raw scores to percentiles. These scores reflect the percentage of people in the general population who attain a lower score; the scores can be interpreted as indicating that the patient scores better than x% of similar individuals who take the same test. To facilitate interpretation and comparison of these val-ues, the percentile ranks are classified into descriptive ranges. The ranges used are as follows:
98th percentile and above = very superior
91st97th percentile = superior
75th90th percentile = high average
25th74th percentile = average
9th24th percentile = low average
3rd8th percentile = borderline impaired
2nd percentile and below = impaired
It is notable that 3 of the 4 patients described are male; however, this is not meant to imply that the pre-sented conditions are gender specific or that males are more often referred for neuropsychological evaluation. Additionally, in an effort to provide clear and concise cases, we present cases involving individuals with aver-age estimated premorbid levels of functioning. It has been suggested that individuals with above average premorbid intelligence may possess cognitive reserve and in turn exhibit signs of memory loss or cognitive decline later in the disease process.1 This is an impor-tant concept when examining individuals with higher estimated premorbid levels of functioning, as they may score within the average range but still be experienc-ing initial symptoms of neurologic dysfunction.
cASE 1: A 71-YEAr-oLd MAn WItH MEMorY LoSS
cASE PrESEntAtIon And HIStorY
A 71-year-old right-handed man is referred for neuropsychological testing by his primary care
physician for evaluation of memory and cognitive func-tioning, assistance with differential diagnosis, and rec-ommendations regarding possible treatments and inter-ventions. The patient reports experiencing short-term memory loss for the past 3 to 4 years. Specifically, he describes some difficulty keeping track of his score when playing golf, remembering conversations, and remem-bering what he has read in the newspaper. The patient says that he feels his memory problems are minor and are caused by stress, and he notes that occasionally he
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feels his memory is improving. In contrast, the patients wife, who is present during the interview, describes a clear progression of memory problems over the past 3 to 4 years, which she feels are considerable. She explains that on 2 occasions her husband became lost while driv-ing in a familiar area. She notes that he is repetitive in conversation and asks repetitive questions. She also adds that he often forgets appointments and needs frequent reminders. The patients wife is particularly concerned about her husbands functioning after watching her mother die from AD, and adds that because of this expe-rience she is hypervigilant about any memory problems her husband might be displaying. Regarding mood, the patient denies mood disturbance or change in mood and describes numerous activities he enjoys outside of the home. However, his wife reports an increase in ir-ritability, most notably when she reminds him to take his medications or tries to help him organize his office.
Medical history is significant only for glaucoma, re-portedly well controlled through medication. Medical records indicate that the patient has been seen previ-ously by a neurologist for memory concerns, who told him that he suffers from age-related cognitive decline and subsequently reassured him that his memory dif-ficulties are normal and not progressive.
The patient graduated from college and reportedly completed school with no academic difficulties. He has been retired from his industrial managerial position for approximately 5 years. When asked about family history, the patient states he is an only child; his mother died at age 50 years from a motor vehicle accident, and his father died in his late 80s of old age. The patient reports no family history of dementia, but noted that his maternal grandmother went crazy in her elder years and lived in a nursing home until she died at age 80 years; he cannot recount the specific details.
what are the possible causes for this