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Rutgers, The State University of New Jersey
Neuropsychological Testing in Occupational Medicine
When is a referral appropriate and what will neuropsychological testing
offer?
Nancy Fiedler, Ph.D.
Neuropsychological Testing in Occupational Medicine
Objectives
• Determine when to make a referral for a neuropsychological
evaluation
• Structure a relevant referral question for neuropsychological
evaluations
• Interpret typical neuropsychological reports
• Recognize the strengths and weaknesses of
neuropsychological testing
• Distinguish psychiatric from neuropsychological testing
protocols and how these domains interact to affect job
performance
Neuropsychological Testing in Occupational Medicine
Neuropsychological Tests: observable and quantifiable behaviors
• Domains of cognitive and sensory function
– Attention
– Working memory
– Motor and Processing speed
– Verbal and visual memory
– Perceptual organization
– Executive function
GENERAL INTELLIGENCE
Neuropsychological Testing in Occupational Medicine
Psychiatric Testing: self and other report
• Structured and clinical interviews (self report)
• Personality testing (MMPI, CPI)
• Acute symptom reports (e.g., SCL-90, Beck
depression)
Neuropsychological Testing in Occupational Medicine
When to refer for neuropsychological testing:
• Employee with a pattern of compromised
performance not attributable to organizational issues
such as lack of training or poor supervision
• Baseline testing of cognitive performance to monitor
progression of disease or disability
• Differentiation of compromised cognition from
stress-related cognitive complaints
Neuropsychological Testing in Occupational Medicine
The Referral Question• Employee X has exhibited a sustained pattern of
poor performance as indicated by the following:
– Attendance
– Documentation of supervisor ratings of job duties
– observable behaviors at work
• Is this employee capable of performing the following
job duties:
– Job duties of concern
– Job description with behavioral indicators
Neuropsychological Testing in Occupational Medicine
Psychiatric and/or neuropsychological deficits
• Common referral question:
– “I want a neuropsychological evaluation of this employee”
• Employee exhibiting bizarre behavior at work:
inappropriate with supervisors and students
• Reporting that others are discriminating against her
• No clear evidence of any physical illness or injury
preceding these episodes
Neuropsychological Testing in Occupational Medicine
Neuropsychological testing is not a
substitute for appropriate employee
supervision, training, and
documentation of work performance
Neuropsychological Testing in Occupational Medicine
Why Neuropsychological Tests?
• Indicators of functional impairment at exposure levels
below those that produce overt tissue or organ damage
• Simple, noninvasive methods to monitor effects of
exposure or disease
• Functional correlates of central nervous system
• Standardized, behavioral evaluation of specific
cognitive skills
• Performance compared to normative standard
• Indicator of impaired behavior that could compromise
safety on the job
Neuropsychological Testing in Occupational Medicine
Ecological Validity
• Are the decrements observed clinically
meaningful?
• What critical functions do they predict?
Neuropsychological Testing in Occupational Medicine
What is Clinical Impairment?
Neuropsychological Testing in Occupational Medicine
When does a neuropsychological decrement compromise safety?
• Tasks to be performed require vigilance and
working memory (e.g., monitor complex
operational systems)
• Driving or operating vehicles (analogy to ETOH)
• Fine motor coordination and steadiness required
to perform operations (machinery, discharge a
weapon, surgery) It depends. . .
Neuropsychological Testing in Occupational Medicine
Interpretation of Neuropsychological data must incorporate patient history and mental
status
• Psychiatric & Medical History- ETOH & Drug Use- Head Injuries- Neurologic Disorders- Major Medical Illness
• Current Mental Status- Thought Disorder- Oriented to Person, Place, & Time- Use of Prescription & Over-the-Counter Medication, Caffeine, Alcohol
Neuropsychological Testing in Occupational Medicine
Patient Characterization
• Sensory Function
- Vision
- Hearing
- Tactile Perception
- Estimate of Premorbid Intellectual Function
- school performance
Neuropsychological Testing in Occupational Medicine
When to refer for neuropsychological testing: brain injury due to accident
32 year old, single, Caucasian police officer
College education
Traumatic brain injury in MVA
Coma for one month
subarachnoid hemorrhage, subdural hematoma
Cognitive rehabilitation for 2 years
SSRI antidepressant treatment for one year
Can this employee perform his job?
Neuropsychological Testing in Occupational Medicine
Fitness for Duty: Police Duties1. Confronting subject prior to arrest:
A. Must be able to effectively communicate, sometimes in a commanding manner, to instruct a suspect or criminal
2. Must possess and carry a service weapon at all times
3 Must possess the ability to determine when deadly force shall and shall not be used
4. Observe, record, recall and report incidents and information on police matters
5. Maintain high mental alertness and readiness to act even during extended period of calm and inactivity
6. Understand and follow orders, policies and procedures
Neuropsychological Testing in Occupational Medicine
Fitness for Duty: Police Duties (Cont’d)7. Withstand and deal appropriately with high levels of stress inherent
in police work without presenting any risk to oneself or others
8. Must have the ability to organize and remember critical facts concerning the investigation
9. Must be capable of managing people in distress
10. Must be able to effectively interview/communicate with victims, suspects, witnesses and informants
11. Communication skills to verbally direct and control victims, crowds, and other emergency response personnel in any crisis to ensure the safety and preservation of life and property (loud and soft tones of voice)
12. Writing skills to depict events of police investigation
Neuropsychological Testing in Occupational Medicine
2002 Test Administration
Neuropsychological Testing in Occupational Medicine
• Psychomotor– Reaction time, vigilance, digit symbol
• Concentration & Information Processing– Digit span, mental arithmetic
Perceptual Motor & Attention/Concentration
Neuropsychological Testing in Occupational MedicinePsychomotor Skills – motor speed, eye hand coordination
Finger Tapping Grooved Peg Board
Neuropsychological Testing in Occupational Medicine
2002 AdministrationAge & Education Corrected T-Scores
01020304050607080
Finger Tapping Grooved Peg
Dominant Non-Dominant
Average
Neuropsychological Testing in Occupational Medicine
Monitor Progression of Cognitive Skills in Rehabilitation:
One-year follow-up after cognitive rehabilitation
Neuropsychological Testing in Occupational Medicine
01020304050607080
Finger Tapping Grooved Peg
Dominant Non-Dominant
2003 AdministrationAge & Education Corrected T-Scores
Average
Neuropsychological Testing in Occupational Medicine
Job duties and cognitive rehabilitation
• Capacity to carry and use a weapon
• Ability to remember details of incidents
• Make judgments of when force is required
• Slowed motor speed• Memory function
within average range• Processing speed
and working memory within average range
• Comprehension and problem solving within normal range
Neuropsychological Testing in Occupational Medicine
Deterioration of Work Performance
58 year old, married, Caucasian male
Master’s degree in social work
20 year history of alcohol abuse: dependence and
blackouts
11 year history of anxiety and depression
Stable SSRI treatment
Neuropsychological Testing in Occupational Medicine
Job Performance: interaction of psychiatric and neuropsychological deficits
• Memory loss at work – forgetting conversations;
frequent questions
• Lack of supervisory direction for employees
• Difficulty completing tasks that were previously
routine
Neuropsychological Testing in Occupational Medicine
Neuropsychological Testing in Occupational Medicine
Verbal and Visual Memory -The ability to register, store, and retrieve learned information
• Verbal MemoryWord lists or associations: List A (Monday List)
drill chivesplums tangerinesvest chiselparsley jacketgrapes nutmegpaprika apricotssweater plierswrench slacks
Short Stories: Story AAnna Thompson / of South / Boston /, employed / as a cook/ in a school /cafeteria /, reported / at the City Hall / Station / that she had been held up /on State Street/ the night before/ and robbed/ of fifty six dollars/.
Neuropsychological Testing in Occupational Medicine
Neuropsychological Testing in Occupational Medicine
Job duties vs. neuropsychological results
• Forgets conversations and work instructions
• Poor supervision of employees
• Difficulty completing tasks that were once routine
• Verbal memory impairment
• Depression• Processing speed is
slowed
Neuropsychological Testing in Occupational Medicine
Progressive Dementia
• 30 year old, black, single female
• College graduate in chemical engineering
• Employed as an environmental engineer
• Severe headaches caused by cerebral aneurysm
• Left frontal craniotomy to repair the aneurysm
• Vocational rehabilitation for one year
• Hospitalized for paranoid ideation
• Stelazine, cogentin, tenormin
Neuropsychological Testing in Occupational Medicine
Work Performance
• Unclear written correspondence
• Inaccuracies in work
• Requires close supervision
• low mood and poor attitude in response to
criticism
Neuropsychological Testing in Occupational Medicine
01020304050607080
Infor
mation
Digit S
panVoc
abula
ryArit
hmeti
c
Compreh
ensio
nSim
ilarit
ies
Pictur
e Com
pletio
n
Pictur
e Arra
ngemen
tBloc
k Desi
gn
Object
Asse
mblyDigi
t Sym
bol
Verbal
Perfor
mance
Full Sca
le
Age/Education Corrected T-Score
WAIS-R
Average
Neuropsychological Testing in Occupational Medicine
Executive Function
Ability to think in concepts and to generalize from
specific instances; ability to plan and think ahead
based on anticipated consequences
• Proverbs - What does this saying mean?
“Shallow brooks are noisy”
• Similarities -
In what way are an ORANGE and a BANANA alike?
Neuropsychological Testing in Occupational Medicine
Executive Function
• Card Sorting -
• Tower Tests -
Neuropsychological Testing in Occupational Medicine
01020304050607080
Trail Making Test A Trail Making Test B
Age/Education Corrected T-Score
Mental Flexibility
Average
Neuropsychological Testing in Occupational Medicine
Verbal Learning and Memory
02468
1012141618
Trial 1
Trial 2
Trial 3
Trial 4
Trial 5
Trial B Free Cued
Free Cued HitsPese
rv.
Number Correct Perseverations
List A Immediate Short Delay Long Delay Recog.
Neuropsychological Testing in Occupational Medicine
Matching job duties with neuropsychological results• Job title: engineer• Written reports
contain significant errors
• Does not notice errors in spite of numerous corrections
• College education as normative base
• Complex learning impaired: arithmetic, conceptual problems/abstract thinking
• High perseverations on verbal learning
Neuropsychological Testing in Occupational Medicine
Psychiatric vs. Organic Brain Syndrome
• 46 year old, married, high school educated,
Caucasian male
• Exposed to chlorodifluromethane (Freon 22) in work
as a refrigerator mechanic
• No loss of consciousness but pt. Reported fearing he
would die
• Numerous symptoms including poor concentration,
dizziness, depression, fatigue, panic, poor memory
Neuropsychological Testing in Occupational Medicine
Indices of Poor Effort:
• Test of Memory Malingering
• Recognition memory worse than recall of newly
learned information
• Symptoms are inconsistent with injury
• Performance on easier tasks is worse than on more
difficult tests
• Inconsistent performance
Neuropsychological Testing in Occupational Medicine
0
20
40
60
80
100
120
Verbal C
omprehen
Percept. O
rganiz
Working Memory
Process. S
peed
Auditory Im
med
Visual Im
med.
Immed. M
emory
Auditory-Dela
y
Visual-D
elay
Auditory Reco
g.-Dela
y
Genrl. Mem
ory
Working Memory
WAIS-III WMS III
Index Score Summary
Neuropsychological Testing in Occupational Medicine
0
10
20
30
40
50
60
Trial 1
Num
ber
of C
orre
ct R
espo
nses
Patient No Cognitive ImpairmentTraumatic Brain Injury Dementia
Test of Memory Malingering
Neuropsychological Testing in Occupational Medicine
MMPI-2
30405060708090
100110120
Hysteria
Depressio
nHypochondria
sis
Masculin
ity/Fem
inityParanoia
Psychasthenia
Schizophren
ia
ManiaSocia
l Intro
version
T-Score
Average
Neuropsychological Testing in Occupational Medicine
Continuum of Effects
• Test Sensitivity in descending order
– Mood and symptoms
– Motor speed
– Psychomotor speed/latency of response
– Working memory & vigilance
– Learning and memory
– Executive function and judgment
– Intelligence
Neuropsychological Testing in Occupational Medicine
Conclusions
• Neuropsychological tests can predict the ability to perform specific job duties, but are best for jobs that require skills similar to what the tests evaluate
• Questions of fitness for duty need to be accompanied by behavioral descriptions of job duties and evidence of on-the-job employee behavior
• Behavioral data rather than diagnoses are most informative about the ability to perform a job – testing can provide such data