Name: Susan Lancaster
Client Name: Ben
Age Range: Adulthood
My current patient is a 70 year old African American male named Ben. He
stopped exercising, watching his diet, and has gained 25 pounds after retiring.
He also wears glasses for nearsightedness and has had a recent stroke. During
his hospital stay, a PET scan was given and the results confirmed that he had a
unilateral stroke which involved the left hemisphere and temporal-parietal, including
part of Broca’s area. When the stroke occurred he was also not rendered
unconscious but did experience post-stroke amnesia. Although, his amnesia seems
to be improving, his physician still referred him to my office for a
neuropsychological examination during his stay in the hospital.
Upon greeting Ben, he shook with his
left hand and seemed to be experiencing an issue with movement of his right
hand and arm. When trying to communicate with me, he also exhibited slow and
slurred speech along with difficulty in forming articulated sentences. Since,
this occurred, I gave him a brief assessment by asking him to identify and name
certain objects around the office. The results indicated that he was having
difficulty with word finding and naming of these objects. Therefore, I further
tested him by using the Mini-Mental Status Exam or MMSE. He acquired 24 points
out of 30 due to having issues with counting and spelling backward, recalling
words from memory, identifying the correct date and day of the week, and when
trying to draw the two intersecting figures.
I than spoke to his
wife and she stated that Ben may be experiencing issues with hearing loss,
unclear thinking, memory, and coordination because he is bumping in to things
on his right side. She also requested to have his intellectual abilities
assessed. Therefore, since Ben
suffered from a
left side stroke, he may experience a reduction in some functions which are required to
successfully perform certain tasks. Since, this is the case the
overall purpose of this work will be to first identify some tests that may be used to measure Ben’s current level
of sensory perception, cognitive speed, constructional ability, verbal and
spatial memory, verbal fluency, intelligence, achievement, personality,
possible malingering, and daily functioning. Upon completion,
I will then provide my recommendations for rehabilitation
and a prognosis of his expected recovery.
TESTING & ASSESSMENT
Repeatable Battery for Assessment of
Neuropsychological Status (RBANS) – Since, Ben was previously tested with the
MMSE and certain deficits were measured, the RBANS could also be used to measure Ben’s current level of Fluid
Intelligence, Crystallized Intelligence, and Memory. If there are deficits
within these areas of functioning, it could also indicate Dementia. One other major benefit of using a screener is that it can
identify specific tests that may be best for Ben’s individual needs. Therefore, only certain tests that are
provided in this work would be needed.
Halstead-Reitan Battery (HRB) – This can be used to measure Ben’s visual, auditory, tactual
input, verbal communication, spatial/sequential perception, analysis of
information, formation of mental concepts, judgment, motor output, attention,
concentration, and memory. The Halstead-Reitan is typically used to evaluate
individuals with suspected brain damage and may also be a good way to acquire
useful information which confirms that damage is due to a stroke, the location
of that damage, and if it’s getting worse, getting better or staying the same.
Therefore, one other major benefit of this test is that it can confirm which
side of Ben’s body is affected by touch, sound, or visible movement. There are
also eight tests that are included in this particular battery which are as
follows:
1. Category Test – This
test can be administered to study Ben’s current level of abstract reasoning by
measuring functions that involve
visual, auditory, tactual input, verbal communication, spatial and sequential
perception, analysis of information, forming mental concepts, making judgment,
motor output, attention, concentration, and memory. His score will be
determined by the number of errors and specific cutoff values for age and
education level.
2. Tactile Performance Test /
Seguin-Goddard Formboard – This is a form board based test that could be used
to evaluate Ben’s current level of sensory ability, motor functions, memory for
shapes and spatial location, along with his brain's ability to transfer
information between the right and left hemispheres. When using this test it can
also confirm brain damage and which side of Ben’s brain it may have occurred
on.
3. Speech Sounds Perception Test (SSPT) – This test involves 60 different nonsense
syllables which are presented by a tape recording. One main thing that
this could be used for is to measure Ben’s current level of focused attention.
This could also provide information concerning the acuteness vs. chronicity of
Ben’s specific brain damage.
4. Reitan-Indiana Aphasia Screening Test – Aphasia
can be defined as a loss of ability to comprehend or use spoken or written
language due to brain damage. The test involves a set of questions that most
normally impaired individuals would be able to understand. The overall purpose
of this test would be to measure any language-related difficulties, non-verbal
tasks, and right/left confusion that Ben may be experiencing.
5. Reitan-Klove Sensory-Perceptual Examination – This test has auditory, tactile, and visual components. One specific component involves measuring the ability to specify which side of the body is affected by touch, sound, or visible movement. Therefore, it may confirm that Ben is unable to perceive stimulation on the right side of his body.
6. Rhythm Test
/ Seashore
Rhythm Test – This is
a nonverbal auditory perception test that could be used to measure Ben’s
current level of attention and concentration when listening to patterns of
sounds. This particular testing method is also extremely sensitive to brain
dysfunction.
7. Trail Making Test / Trails A & B – This test can be
administered to assess Ben’s current ability to hold several tasks in mind at the same time and
overall level of cognitive speed. This is because it will
measure Ben’s level of scanning and
visuomotor tracking, cognitive flexibility and divided attention. The process
would include two separate parts that are identified as A and B. Part A will
require him to first draw lines that connect consecutively numbered circles on
a work sheet and Part B will require him to connect the same number of these
circles on a different worksheet, while alternating between the two sequences.
He will also be advised to connect these circles as fast as he can without
lifting his pencil from the worksheet. The scores will be based on his level of
memory and the time that it takes to complete these tasks. The purpose of this
test will be to determine if Ben’s level of working memory and cognitive speed
have been affected.
8. Ancillary Test / WAIS-III
– This is a revision to the WAIS-R and could be administered to study Ben’s
current level of intelligence. Its main
composite scores involve Verbal
IQ, Performance IQ, Full Scale IQ Verbal Comprehension, Working Memory,
Perceptual Organization, and Processing Speed.
Paced Auditory Serial
Addition Test (PASAT) – This can also be used to assess
Ben’s level of working memory, attention and cognitive speed but overall, it is
very difficult. Therefore, I don’t believe that this is the best method
for Ben because he may show invalid deficits, due to lack of comprehension for difficult
tasks.
Tinkertoy Test – This
can be used to measure Ben’s ability to complete planning, initiating, and
structuring of behaviors. It is mostly used with patients that may have
dysfunction due to neurodegenerative diseases and can also
measure constructional ability. This is because it would be completed by asking
Ben to construct whatever he wants with 50 Tinkertoys.
Rey Osterreith Complex Figure Test – This
test would be completed by asking Ben to copy a complicated line drawing from memory. When using this test, it can
identify whether he may be experiencing deficits with constructional ability, visuospatial abilities, memory, planning, attention and working memory. If he did show signs of difficulty when
trying to use these functions in a normal manner, then it may also indicate the
presents of Dementia.
California Verbal Learning Test
(CVLT) – This
could be used to assess Ben’s current level of verbal and spatial memory. It
would be performed by first asking him to read a specific list aloud which
contains sixteen common words, with each belonging to one of four categories.
Once, this was completed I would then ask him to recall as many of these items
as possible. I would then record this number and whether or not he was able to
make adequate use of category information. One other major benefit of using
this test is that if Ben was unable to make use of category information, then
this may indicate Alzheimer’s Disease or if he made repetition errors, then
this may indicate Parkinson's Disease.
Boston Naming Test – This
could be used to measure the overall impact of Ben’s left-side stroke on his
level of verbal fluency. It would be completed by asking him to identify a
series of pictures that are included in 60 large ink drawings. One, major
strength of this test is that it can measure
Ben’s current level of visual-perceptual abilities and language production.
However, one limitation is that it may measure varying results if used on
patients from different cultures.
FAS – This can be used to measure Ben’s current
level of verbal fluency. It would be completed by having him recall and produce
words for letters F, A and S within 60 seconds. If he experienced lower word
production, then this is an indication that he may have left frontal lesions. One,
major strength is that it can be used to quickly determine whether Ben needs to
be referred to a pathologist or speech therapist for further testing and
treatment. However, one limitation is that it cannot differentiate between depressed
patients and those with dementia.
Wechsler Adult Intelligence Scale IV
(WAIS-IV) – I could use this to measure Ben’s
overall level of intelligence. When using this test, I would acquire
measurements via four index scores
that represent major components, along with two broad
scores. These are as follows:
1. Full Scale IQ (FSIQ) – This is a score that will identify
Ben’s total performance of VCI, PRI, WMI, and PSI.
2. General Ability Index (GAI) – This is the score of six
subtests which are included in the VCI and PRI. There are also 10 subtests within each of the four
components and five
supplemental subtests that can be measured, if needed. The four components are
as follows:
Verbal Comprehension Index (VCI)
This will measure Ben’s level of verbal comprehension and includes: Similarities
(subtest) - abstract verbal reasoning, Vocabulary
(subtest) - learned, comprehension and verbal expression, Information
(subtest) - general information
that is acquired from culture, and Comprehension
(supplemental) - abstract social conventions, rules and
expressions.
Perceptual Reasoning Index (PRI)
This will measure Ben’s level of perceptual reasoning and includes: Block
Design (subtest) - spatial
perception, problem solving, and visual abstract processing, Matrix Reasoning (subtest) - spatial/inductive reasoning,
nonverbal abstract problem solving, Visual Puzzles (subtest) - spatial
reasoning only, Picture Completion (supplemental) - how
quickly one perceives visual details, and Figure Weights (supplemental) - analogical/quantitative
reasoning.
Working Memory Index (WMI)
This will measure
Ben’s level of working memory and includes: Digit Span (subtest) - mental control,
concentration and attention, Arithmetic (subtest) - concentration
when manipulating mathematical problems, and Letter-Number
Sequencing (supplemental) - attention, mental control and
concentration.
Processing Speed Index (PSI)
This will measure Ben’s level of processing speed and includes: Symbol Search (subtest) - visual
perception, visual analysis and scanning speed, Coding (subtest) - visual/motor
coordination, motor/mental speed, visual working
memory, and Cancellation (supplemental) - visual
and perceptual speed.
Wide Range
Achievement Test 4
(WRAT4) – This is
designed to assess patients that are between 5 and 94 years of age and it measures functions that are needed for things like proper communication,
effective learning, thinking, reading, spelling words, and doing mathematical
calculations. Therefore, I could use this test in combination
with previous records and current interviews from collaterals to measure Ben’s
overall level of achievement.
Minnesota Multiphasic Personality Inventory (MMPI) – This is a
paper and pencil inventory that can be used to assess Ben for possible
psychological and psychiatric symptoms associated with his overall
personality. However, the MMPI is not perfect so a revised version can also be
used which is called the MMPI-2. This contains 567 test items and new scales were added to measure
further traits that may be associated with abnormal behavior. This test also
establishes a higher degree of overall construct validity because the revision
process was carried out while addressing and establishing evidence of both
convergent and discriminant validation. Furthermore, when using this
test, the L Scale (L) could measure
malingering which may occur if Ben exaggerates
or lies about his current condition due to certain motivational factors.
Test
of Memory Malingering (TOMM) – This test could
be used to measure unexpectedly poor performance, unexpectedly low effort and also
identify
malingering over true memory impairments. The test includes two learning trials
along with one retention trial and can be administered by hand or via a
computer.
Wisconsin Card Sorting
Test (WCST) – This
can be used to measure Ben’s executive functions and according to (Lezak, Howieson
& Loring. 2004),
these are needed for “volition, planning, purposeful action, and checking” (p.
611). The process will include
a number of stimulus cards that
are different in design, quantity and color which will be presented to him. I
will then decide whether he needs to match the cards based on color, quantity
or design. He will then be given additional cards and will need to match each
to one of the stimulus cards, while making separate piles of cards for each
one. During this process, he will not be told how the cards are supposed to be
matched, but will be told if he is right or wrong. Throughout this test, the
matching rules will also change and he will receive scores based on things like
how long it takes him to learn the new matching rules and other errors. The
overall purpose of this test would be to measure Ben’s current level of abstract
thinking, concept reasoning and formation.
STROOP Test – This can be used to assess Ben’s working memory and
attention along with performance of response inhibition, response conflict,
and/or selective attention. Since, these additional functions can be measured
the scores will also identify his overall level of concentration effectiveness.
Rivermead
Behavioral Memory Test (RBMT-E) – This test
could be used to measure Ben’s current level of memory when it comes to
completing everyday activities, such as remembering things. Two examples of
this could be to determine if he can remember an upcoming appointment or where
keys are located. One major benefit of this method is
that it can also be used to monitor any changes that may occur with his
condition over time.
RECOMMENDATIONS
Regardless, of which test method/s may be used, I believe
that Ben will show some type of cognitive deficit within certain areas of
cognition. This is because if he is currently exhibiting symptoms that may be
associated with sensory
perception, cognitive speed, constructional ability, verbal and spatial memory,
verbal fluency, intelligence, achievement, personality, and/or daily
functioning. In general, it can also be difficult to offer
rehabilitation for patients that experience cognitive deficits after a stroke.
However, in some cases, the patient may re-gain some or most of this lost
ability when treated with a combination of medication and rehabilitation.
Therefore, if assessment
scores determine that Ben has deficits with certain functions, the following
recommendations would be made:
1. I would refer
Ben for therapy that can teach him ways to compensate for existing memory
problems and prescribe a medication that is used for Alzheimer’s to try and
increase his level.
2. I would ask his wife to make modifications
to his home environment so it is easier to maneuver the area without crashing
into things.
3. I would refer
Ben for therapy that can increase his level of functioning within several
areas.
4. I would refer
Ben to a hearing specialist to determine his level of current hearing ability.
5. I would refer
Ben to a dietitian so he can learn how to eat better and lose weight.
6. I would also
advise Ben to consider joining a local exercise program to address his weight.
7. I would refer
him to a physical therapist to address the loss of ability with his right side.
PROGNOSIS
If it is confirmed that Ben is suffering from cognitive
deficits due to a left sided stroke, it is difficult to predict what his
long-term condition might be. However, since he was never rendered unconsciousness
and was able to verbally speak and follow commands after the stroke, he may have a much easier time gaining back some or even all
of the cognitive abilities that have been lost. However, one major disadvantage
is that Ben may not recover completely due to his age. This is because when brain
damage occurs, it can be easier to heal and recovery when the patient is
younger and in excellent health. Therefore, I am not confident that Ben will fully
recovery from the effects of his stroke. Although, if he follows all
recommendations on a regular basis, and has a good support system among family
members, health professionals, and school staff, his condition may improve at a
substantial level.
SUMMARY
This paper addressed a 70 year old African American male named Ben. He had
stopped exercising, watching his diet, and gained 25 pounds after retiring. He
also wears glasses for nearsightedness and had a recent stroke. During his
hospital stay, a PET scan confirmed that he had a unilateral stroke which involved
the left hemisphere and temporal-parietal, including part of Broca’s area. When
the stroke occurred he was also not rendered unconscious but did experience
post-stroke amnesia. Although, his amnesia has improved, his physician still
referred him to my office for a neuropsychological examination during his stay
in the hospital.
When greeting Ben, he shook with his
left hand and experienced an issue with movement of his right hand and arm.
When trying to communicate, he also exhibited slow and slurred speech along
with difficulty in forming articulated sentences. I then gave him a brief
assessment by asking him to identify and name certain objects around the office
and he had difficulty with word finding and naming of objects. Therefore, I
further tested him with the Mini-Mental Status Exam or MMSE. He acquired 24
points out of 30 due to having issues with counting backward, spelling backwards,
recalling words from memory, identifying the correct date and day of the week,
and when trying to draw the two intersecting figures. His wife also stated that
Ben may be experiencing issues with hearing loss, unclear thinking, memory, and
coordination because he is bumping in to things on his right side so she wanted
his intellectual abilities assessed.
Therefore, in order to determine if Ben
is experiencing
a reduction in functions which are required to successfully perform certain
tasks, I first identified certain tests that may be used to measure his current
level of sensory perception, cognitive speed, constructional ability, verbal
and spatial memory, verbal fluency, intelligence, achievement, personality,
possible malingering, and daily functioning. Upon completion, I also provided recommendations for rehabilitation and an overall
prognosis for Ben’s expected recovery.
Reference:
Lezak, M., Howieson, D., & Loring, D. (2004). Neuropsychological
Assessment (4th ed.).
Oxford:
Oxford University Press.
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