Sample Adult Outline

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

Be Ready for ABPP in Neuropsychology