Analysis Of Neuropsychological Testing – Case Study

Presentation of the case history

Discuss about the Analysis Of Neuropsychological Testing.

Neuropsychological testing is a vast area covering the complexities associated with cognition and processing of information. The unravelling and the execution of the information goes through a number of mental layers. The fully processed information is then executed into a number of desirable actions. Thus, neuropsychology relates the functioning of the brain with cognition, emotion and behaviour of an individual. The nerves can be defined as a set of wires which forms an entangling network within the brain and is responsible for transforming and decoding the packets of information into useful behaviour.  

Evidences and studies have pointed at chemical imbalances along with epigenetic mechanisms to be responsible for the malfunctioning of the brain. The report here presents a detailed analysis of the neuropsychological complexities associated with a patient suffering from supranuclear palsy. The case study has been further evaluated with the help of differential diagnostic tools and mechanisms. The report presents a well investigated intervention plan for managing the challenges and the adversities associated with the disease

In the present case study the patient had been seen to be suffering from Progressive Supranuclear Palsy (PSP). The condition could be described as a gradual degeneration of the major areas of the brain resulting in loss of cognition and analytical skills in a person. The disease could not be related to specific community, race or geography and is equally present both in the males and the females. As commented by Parsons et al. (2017), no strong genetic pre-disposition or link could be found for development of PSP. Reported study and analysis have found a variant in the gene for Tau protein called the H1 Haplotype, which is present on chromosome number 17 and had been have linked with PSP. However, as argued by Sweet  et al. (2015), the presence of environmental factors and stress can also result in the accumulation of the Tau protein in the brain. The Tau protein is accumulated in an insoluble form in hyperphosphorylated form resulting in neurofibrillary of gliofibrillary tangles.

The patient here is a 66 year old Vietnamese right handed lady with ten years of formal school education and had been diagnosed with progressive Supranuclear Palsy. The patient had been able to perform her daily set of activities independently, though she became relatively slow. The patient has been prescribed Livadopa and Motilium for her current dose of medication. The Livadopa had been prescribed to her for controlling the development of parkinson’s and Parkinson like symptoms.  The patient had difficulty in breathing, sleeping and swallowing at night. The patient had been known to have a history of mild dyspraxia. Dyspraxia or developmental coordination disorder may be classified as lack of sensory perception, spatial awareness and coordination. Further test revealed right frontotemporal cortical abnormalities which made the patient more functional towards the right side. This is because the right side of the body is controlled by the left cerebrum and left side by the right cerebrum. As commented by Towns et al.  (2017), dyspraxia comes under the specific learning disabilities group affecting the concentration and the memory of the patient. The patient had shown difficulty in following the hand gestures along with poor retropulsion, where the locomotor ability of the person is affected. Additional co-morbidities such as mild ataxic high blood pressure were also reported in the patient.

Assessment of results

The patient had been seen to be suffering from a number of co-morbid conditions such as mild dyspraxia along with supranuclear palsy. The Supranuclear palsy affects the cognition and the processing power of the brain by causing gradual degeneration of the nerves (Sweet et al. 2015). Additionally, the patient had been found to possess mild ataxic high blood pressure. The effects of dyspraxia along with supranuclear palsy could be related to slowed speech and movements in the patient. The patient has shown a depressive behaviour throughout the assessment session. This could be attributed to the locomotor impairments possessed by the patient, which restricted her daily set of activities. Additionally, the patient had been suffering from sleeping and swallowing difficulties especially at night. The situation could be attributed to dysphagia where muscular and nervous tension might restrict the movement of the food down the oesophagus. As mentioned by Golden & Vicente (2013), dysphagia is often confused with the onset of Parkinson’s . However, dysphagia like symptoms could also be expressed in event of Gastroeosophagul reflux disorder.

The clinical assessment of the symptoms expressed by the 66 year old lady suffering from supranuclear palsy showed a variety of conditions which had been recorded for further analysis. The data recorded from the neuropsychological testing of the patient were evaluated further for the assessment of the severity of the clinical condition suffered by the patient. In this context, the patient had reportedly provided a borderline response to the test.  The scaled score was recorded at 4.7, the index score was recorded at 75 and the patient recorded a percentile score of 5^th, which was near to the borderline. The data recorded helped in analysis of the mental agility of the patient which further governs the responsiveness of the patient to particular treatment methods. The scores were provided based upon the patient response provided to the questions asked for the assessment of the cognitive skill sets possessed by the patient.

Assessment of Cognitive skills of the patient
Skills	Response (weak/strong/moderate)	Analysis
Recalling important information	Weak response	The patient could not recall important past events owing to progressive neural degeneration affecting her memory
Understanding important information	Moderate response	The patient could understand only the information which were broken down into simpler components
Solving close-ended problems	Moderate response	The patient could only answer  in yes or no to the questions asked for evaluation of the mental condition of the patient
Solving open –ended problems	Weak response	The patient had difficulty in analysing the lot of complex processed information in arriving at an agreeable result
Processing of information for providing answers to problems	Weak response	The patient had difficulty in handling numerical and multiple responses provided for a single question
Making of critical judgements	Weak response	The patient showed increased dependency upon the care providers for making important decision

Table 1: Assessment of cognitive skills

(Source: Towns et al. 2016)

From the respective cognitive assessment of the patient based upon memory and processing of complex information the following evaluations can be done. Thus, for most of the domains weak to moderate responses have been obtained. The patient failed to recall any past memories and could only recollect vaguely on provision of sufficient aid. As commented by Hom & Nici (2015), the same could be attributed to the gradual and progressive degeneration of the nerves. However, a number of challenges are faced in the provision of care and support services to the patients suffering from progressive neurodegenerative disease.  In this context, the cognition and decision making skills of the patient is affected. This results in increased dependency upon the care and support services. The care providers need to follow a strict scheduling for handling the care and management process of the one with impaired cognition. This often gives rise to a situation of conflict where the decisions taken for promoting the health interests of the support users are not readily accepted. As commented by Fazio et al. (2015), implementation of informed decision making practices could help in provision of more cooperative services to the support users. In this context, lack of communication often becomes a limiting factor where the support professionals looking after the care needs of the patients may not be able to receive complete and relevant information due to language barriers. Here, the woman could barely speak or understand English.

Assessment of Cognitive skills of the patient

The patient had a past history of developmental coordination disorder. Thus, the patient had been subjected to a spectrum of disabilities, which affected her growth and optimal development. Therefore, a simple argument could be made, where the patient became a victim to progressive supranuclear palsy owing to long history of dyspraxia. The patient had difficulty in swallowing as an exaggeration of the symptoms of PSP. The patient was also put on medication such as Livadopa. The Livadopa had been seen to reduce the effect of Parkinson’s like symptoms within an individual (Uzzell et al. 2013). In this context, multidisciplinary treatment options could be used for provision of effective solution to the clinical distress faced by the patient over here. The patient had been suffering from PSP along with exhibiting mild conditions for dyspraxia. Therefore, the awareness to response and the decision making skills of the patient could be severely impaired. This might affect the data collection procedure, where the patient may not be able to report sufficient details to the care and support service provider. Thus, using evidence based tools such as the Montreal Cognitive Assessment (MOCA) can be used to analyse the mental health of the patient. The MOCA test is used to analyse the mild cognitive impairments in individuals (Wiblin, Lee& Burn, 2017). It accesses the parameters such as attention, memory, language skills, concentration along with thinking, calculating and visuoconstructional skills of an individual. The time allotted for administering the test is a maximum of is approximately 10 minutes. A score of 26 or above is considered normal, however a score much below could indicate moderate to severe cognitive impairments. In this context the patient recorded a score of 18 which is much below the normally accepted standard. Further patient data and analysis have been provided though a table later.

The assessment method adopted here was simply questioning and reinstating the mere facts to the patient in order to generate suitable responses which could be evaluated further for designing of a suitable care plan for the patient. The MOCA framework mainly focuses upon counselling methods for providing support and relief to the aggrieved patient. It justifies the systematic diagnosis part where repeated questions are being asked to the patient in order to arrive at the main problem statement.

The intervention plan which could be implemented over here includes a SBAR tool where the situation and patient background is assessment to provide a suitable recommendation. The method could be simply implemented in order to analyse the loopholes present in the system in the reporting and provision of effective treatment for PSP and associated co-morbidities. In this context, effect communication procedures established within the clinical contexts can help in the use of psychoanalytical and psychodynamic procedures for providing a comprehensive care treatment plan. In this respect, the implementation of such methods can help in addressing the specific concerns raised by the patient and their respective families. This helps in providing more autonomy to the support user where the support user can choose from a wide area of clinical and pharmacological treatment choices available.

Differential diagnosis

Here, the patient had been suffering from supranuclear palsy where excessive accumulation of the tau protein results in neurofibrillary tangles. The patient provides moderate responses to close ended questions, to understanding complex information only with the help of an aid. Therefore, the cognition and decision making skills of an individual is severely impacted under a degenerative disease. As commented by Salvatore et al. (2014), increased dependence on other for decision making can reduce the autonomy of a service user. This could result in the development of feelings of depression and agitation in an individual. In this context, the registered nurse looking after the needs and concerns of the patient  need to be well connected with the doctors , psychologists, neurologists or other health care professionals. This helps in providing catering to the emergency needs and demands of the support users. The assessments methods could be expanded with due consultation with the doctors and other healthcare professionals. As mentioned by Sako et al. (2017), inculcation of suitable diagnostic and pharmacological intervention can help in catering to the developing needs of patient care.

Conclusion

On a concluding note, looking after the ones suffering from progressive neurodegenerative requires increased cooperation from a number of healthcare channels along with expertise in the areas of providing suitable intervention and care procedures for looking after the diverse and complex issues faced by the patient. The patient here had been suffering from a number of clinical and co-morbid conditions. Therefore, detailed medical along with diagnostic interventions are required on a regular basis. This would help in accessing the progressive improvement or deterioration in the health of the patient. Thus, implementation of effective frameworks along with accessing the cognitive responses of the patient to a set of activities can help in providing additional level of support services to the patient.

References

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Towns, S. J., Hahn-Ketter, A. E., Halpern, J., & Block, C. K. (2017). Trainee perspectives on postdoctoral recruitment in clinical neuropsychology: reflections on commentaries by Bodin and Grote (2016) and Nelson et al.(2016). The Clinical Neuropsychologist, 1-6.

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