I. Background Information
1. Identifying Information
- Age
- Sex
- Handedness
- Ethnicity / Race
2. Education
- Highest Grade Completed
- Educational History (grade failure, special services)
3. Employment
- Past and current
- Any toxic exposures, injuries
- Any signs of personality or executive functioning problems.
4. Social
- Marital Status
- Children
- Living Arrangement
- Social Interactions & Behaviour
- rule out marked change in social functioning – fronto-temporal dementia or Pick’s Disease
- Hobbies/Activities
- horses – Equine diseases
- hiking/outdoors – West Nile virus or Lyme Disease
- boxing
- scuba diving – air embolism or decompression injury
- arts/crafts – toxic exposure, lead-based paints, etc.
- international travel – malaria, cysticercosis
II. Problem & History
1. Referral Source
2. Reason Referred for Neuropsychological Assessment
3. Patient’s Complaints – Physical, Cognitive, Emotional/Mood, Behavioural
- Onset, frequency, course, severity
- Attempts to compensate for cognitive problems.
- Level of awareness and insight (think: anosognosia)
4. Collateral Information (family’s report of current difficulties, functional skills)
- Accuracy of information provided by patient
5. Course of Illness (relapsing/ remitting, gradual, acute, precipitating event)
6. Past Medical History (Ask what medical specialists the patient has seen)
7. Psychiatric History
- meds
- ECT
- suicide attempts
8. Family History
9. Drug/Alcohol History
10. Legal or Criminal History (currently involved in litigation?)
11. Prior Cognitive or Psychological Evaluations
12. Current Neurological and Medical Findings
- CSF – lumbar puncture
- MRI
- CT
- EEG
- Functional imaging (fMRI, PET, Spect)
13. Medications
- Current and past
- Side-effects
- Compliance
III. Neuropsychological Examination
1. Beh. Observations
- Pathognomic signs
- neglect? perseverations? orientation? alertness?
- Gait (PD, hydrocephalus)
- Tremor? Unilateral or bilateral?
- Basic sensory functions (visual, hearing, motor, smell)
- Mood
- Language
2. Cognitive Test Data
- Mental Status (MMSE)
- Symptom Validity
- Impairment Indices (H-R)
- Overall IQ
- Processing speed & Attention
- Executive Functions
- Language
- Visual-Spatial
- Memory
- Motor and Sensory
- Special Tests: dichotic listening, Wada, achievement, adaptive functioning
3. Beh/Emotional/Mood/Psychopathology Measures
IV. Conclusions & Recommendations
1. Localization
2. Lateralization
3. Differential Diagnosis
4. Prognosis
5. Recommendations
Possible Adult Conditions To Consider:
- Neglect
- PD
- Hydrocephalus
- HD
- Lewy Body Disease
- Brain tumor (primary or secondary)
- Epilepsy / seizure disorder
- Transient global amnesia
- TBI
- Korsakoff’s
- CVA
- TIA
- SAH
- Meningitis, Encephalitis
- MS
- Agnosia, Agraphia, Apraxia, Alexia
- Aphasia
- Dementia – SDAT, FTD, DLB, PD, Pick’s Parkinson’s Plus, MID (think cortical vs subcortical)
- HIV
- Anoxia/Hypoxia
- Cerebellar Disorder
Possible Recommendations
1) Audiological Assessment, Visual Assessment, Visual Fields
2) Issue of driving
- reporting if not safe to drive?
- actual driving test (on Ontario – done by rehab specialists – OT)
3) Medications
- anti-depressants
- anxiolytics
- acetylcholinesterase inhibitors
4) Psychotherapy to address mood and anxiety disorders
5) Consultations – psychiatrist, pain specialist,
6) Compensatory strategies for cognitive deficits (memory, attention)
7) Cognitive Rehabilitation – referral to rehab facility
8) Job coaches
9) Family counselling to address changes in functioning
10) Support Groups – for information, education and peer support
11) Any special prosthetic devices (Neuropage??)
12) Surgical treatments- shunting, pallidotomy, temporal lobectomy, tumour removal
13) Genetic testing – HD
14) Addictions treatment