Neuropsychological evaluation consists of a clinical evaluation to understand an individual’s cognitive strengths and deficits. A neuropsychological evaluation may be completed for various reasons such as educational planning, documenting deficits due to a neurologic injury, or establishing the presence of a neurologic injury. To complete a neuropsychological evaluation, the individual must be able to follow simple directions, answer simple questions, and cooperate with the examiner. Due to these restrictions, neuropsychological evaluation cannot be completed with an individual who is in a coma, who is paralyzed and unable to speak, or who refuses to cooperate with the procedure.
Neuropsychological evaluation is often used to help in rehabilitation treatment planning and discharge planning. The results of a neuropsychological evaluation can be used to determine if the individual is able to make competent decisions, is able to return to competitive employment, able to drive a vehicle, etc. Recommendations can be made regarding the individual’s need for supervision, structure, and support.
Neuropsychological evaluation consists of standardized tests that allow an individual’s performance to be compared to others to determine his/her level of functioning. These tests look at functions such as auditory attention, working memory, learning slope, auditory memory, visual memory, problem solving, complex/divided attention tasks, visual processing, language skills, and motor skills. By comparing the individuals scores on these tasks areas of deficit can be identified and related to areas of brain injury/neurologic dysfunction.
In the early stages of recovery, neuropsychological evaluation will consist of determining the individual’s level of alertness and responsiveness. As she/he becomes more interactive, basic tests will determine if he/she is able to follow directions, to respond to stimuli, and to interact with the environment. Serial evaluations are beneficial to track the individual’s recovery over time and her/his response to therapeutic interventions. When a child has a brain injury, serial neuropsychological evaluation are important to track changes in his/her cognitive functioning, and her/his ability to reach expected stages of brain maturation.
Neuropsychological evaluations are often used to establish the degree of cognitive damage caused by a traumatic brain injury and how the damage will impact the individual’s ability to work, complete self-care independently, live independently, and interact with others. At times, the neuropsychological evaluation will be used to establish the presence or absence of cognitive deficits secondary to traumatic brain injury. This can happen when the objective measures, such as CTs or EEGs, have not demonstrated clear evidence of the degree of damage that has occurred. Tests of motivation are used during these evaluations to help determine if the individual is putting forth full effort, or possibly attempting to exaggerate the degree of deficit. A neuropsychologist will also examine the pattern of deficits to determine if the pattern is internally consistent, and if the pattern is consistent with the reported injury.
CT – Computerized Tomography
CT is used to initially evaluate potential damage to the skull and to the brain structures. It consists of multiple x-rays of the brain that can be taken in various orientations to highlight various areas of the brain. It is extremely useful in identifying areas of blood in the brain, and changes to the ventricles.
MRI – Magnetic Resonance Imaging
MRI is use to evaluate damage to the brain structures. The MRI consists of a reading of the magnetic impulses emitted from proteins in the brain and is very sensitive to the gray/white matter of the brain, and areas of chronic blood.
An angiogram is comprised of x-rays taken of the brain’s vascular structure. A dye is injected into the blood stream to help highlight the vascular structure of the brain.
EEG – Electroencephalogram
An EEG reveals the electrical impulses transmitted throughout the brain. Contact leads are attached to various spots on the skull to record the electrical impulses in each area of the brain. Brainwaves are detected as are epileptiform discharges and spikes. These can be tracked to a specific brain area and reflect the actual functioning of the brain.
QEEG – Qualitative Electroencephalogram
A QEEG is a more complex version of the traditional EEG. The QEEG is intended to be able to evaluate the brainwave patterns throughout the brain and compare them to samples of individuals with other neurologic issues.
PET Scan – Positron Emission Tomography
A PET scan uses a radionuclide tracer to produce positrons that emit two gamma rays that are detected. The tracer tends to be a glucose analog which allows the PET scan to detect the active uptake of glucose and image the actual function of the brain. This shows what areas of the brain remain active following an injury.
SPECT scan – Single Photon Emission Computed Tomography
The SPECT scan is similar to a PET scan with the exception that only one gamma ray is detected. It is a functional scan of the brain and will show areas of the brain that are actively using glucose demonstrating an increased level of activity.
When someone has suffered a brain injury, once they have been evaluated in the trauma unit, they are often admitted to the neurologic intensive care unit. On that unit, they will be continually monitored for signs that they are becoming more responsive. The staff will observe the brain injured patient for signs that they are opening their eyes, moving their extremities, attempting to speak, etc. The individual will often be intubated for protection of their airway which may include sedation that will reduce their responsiveness. This sedation is usually administered intravenously, and the neurologist will have the medications stopped for a period of time prior to evaluating their neurologic functioning. As the individual becomes more medically stable, they will eventually be transferred to a general medical floor where they will continue to be monitored, but will not require the same intensity of medical interventions.
Medications in survivors of traumatic brain injuries (TBI) should be used sparingly with the focus being on ameliorating or decreasing, psychiatric symptoms, behavioral manifestations and maladaptive behaviors that can interfere or impede the rehabilitative process. Survivors of TBI can present with a myriad of psychiatric symptom manifestations, with the most common ones being depression, explosivity (violent behaviors), which may be situational as well as out of the blue, apathy, lack of interest, anhedonia, particularly in individuals with frontal lobe trauma. In individuals with dominant hemisphere trauma, symptoms may include psychosis (being out of touch with reality), auditory or visual hallucinations, delusions (having fixed firm beliefs) which may be paranoid or persecutory in nature, symptoms of bipolarity with manic qualities such as pressured speech, racing thoughts, poor concentration, increased energy with alterations in circadian rhythms are common in survivors of TBI with the most common symptoms being insomnia, difficulty falling asleep, maintaining sleep or reversal of sleep-wake cycle. Survivors of TBI may experience a change in personality either regressive or expansive of underlying pre-morbid personality traits. It is not unusual for survivors of TBI to develop dis-inhibition and may act out in a sexually inappropriate manner towards self or others. From a cognitive stand point, survivors of TBI usually experience deficits in recent memory, recall and working memory. With executive dysfunction, i.e. difficulty with organization, there is an inability to complete tasks in a sequential fashion, attention deficit, poor concentration and difficulty with abstract concepts, frequently found as sequelae to TBI, particularly frontal lobe injuries. What the family members or support group of a survivor should remember is that symptoms and behaviors change with time from the date of injury. What is initially seen in terms of symptoms-behaviors will change, improve or fluctuate, as time goes by. Most individuals reach maximum medical improvement 1 ½ to 2 years from the date of injury.
In an effort to help survivors of TBI and their loved ones understand the advantages and disadvantages of psychiatric medications, Dr. Villalba, M.D. FAA CAP, has compiled a brief synopsis of same, with emphasis on how these medications affect an individual who has had a TBI. The emphasis, however, is that there is no such thing as “one size fits all” treatment, and what is effective for one individual may not be effective or even contraindicated in another.
In conclusion, survivors of TBI should be treated if at all possible with the least amount of medications. Symptoms and maladaptive behaviors that interfere with the rehabilitative process should be treated. Initial reasons for treatment will usually change as the survivor undergoes rehabilitation and nears maximum medical improvement (MMI). Attempts (when possible) to taper or wean off of psychiatric medications as the individual’s date of injury progresses should be made. Polypharmacy and the use of two or more medications of the same class should be avoided. The clinician and the loved ones of the survivor should be cognizant of the fact that psychiatric manifestations are common in TBI and not always permanent, but may represent a bump in the road in the rehabilitative process.
Behavior Services in Brain Injury Rehabilitation
A significant number of individuals who have suffered brain injuries have problematic behaviors following their acute rehabilitation. These behaviors may include increased anger, aggression, agitation, inappropriate sexual behaviors, drug use, or self-injury. To address these types of behaviors, Behavior Services begin by blocking the harmful actions and determining the goal of the behavior. Behavior Specialist will study the actions that precede the behavior, the actual behavior itself, and the consequences of the behavior. The individual’s behaviors can then be modified by adjusting the environmental factors that generally precede the action, teaching the individual alternate methods to respond to the factors, and providing desired results for the appropriate alternative responses. This may require multiple repetitions and extended time to ensure that the individual has adopted the new actions and uses the appropriate acceptable responses consistently.