Cognition

A neuropsychological evaluation is important for a variety of reasons. It provides information regarding the person's amenability to treatment. For example, individuals who have a mental deficiency, have suffered neurological injury, or have dementia as the result of alcoholism or habitual drug use are unlikely to profit from insight-oriented treatment. In addition, in the early stages of substance withdrawal, cognitive assessment can determine whether mental confusion is present, in which case the benefit of participation in individual or group therapy is likely to be minimal. Importantly, emotional and behavioral changes associated with neurological impairment may impede rehabilitation. Hence, clarifying cognitive impairment due to CNS injury and dysfunction has important ramifications for treatment planning and aftercare, including long-term rehabilitation.

Tarter and Edwards (1987) proposed a three-stage assessment procedure for documenting neuropsychological functioning. At the outset, neuropsycho-logical screening provides the opportunity to determine whether there is evidence of a CNS disturbance. If a neurocognitive impairment is not observed, the evaluation is terminated, thereby saving substantial time and cost. The second stage of evaluation involves delineation of cognitive abilities and limitations. In standardized batteries, complemented when necessary by specialized tests, cognitive capacity is quantified across multiple domains. Typically, this includes speech and language, attention, psychomotor efficiency, learning and memory, and abstract reasoning. The results at this stage can inform about lesion localization and lateralization. Several standardized neuropsychological batteries are currently in wide use. The Halstead-Reitan Battery (Reitan, 1955), Luria-Nebraska Neuropsychological Test Battery (Golden, 1981), and the Pittsburgh Initial Neuropsychological Test System (Goldstein, Tarter, Shelly, & Hegedus, 1983) are examples of multidomain assessment batteries. Based on the profile of results describing cognitive strengths and weaknesses, a decision is made regarding the need for focused comprehensive testing. This is the third and last stage of assessment. In-depth information is obtained regarding a particular cognitive domain. The results inform about "real-life" prospects of success. Moreover, the results inform about potential risks to the person. For example, it is important to describe psychomotor impairments fully if the client works with power machinery. Visuoperceptual disturbances must be comprehensively documented if the person drives a car. Similarly, if the clinician identifies a learning or memory deficit, it has direct ramifications for educational and vocational rehabilitation. The reader is referred to Nixon (1999) for a discussion of instrument selection for neuropsychological evaluation.

In interpreting the results of a neuropsychological evaluation, it is important to be cognizant of the multifactorial etiology of any identified impairment. Not only do alcohol and other drugs act directly on the brain but their habitual consumption may also induce organ-system injury, which in turn disrupts integrity of the brain. For example, cirrhosis, independent of alcoholism, causes hepatic encephalopathy, Thus, neuropsychological deficits commonly found in alcoholics may be, in large part, the result of advanced liver disease (Tarter, Van Thiel, & Moss, 1988). This fact is not inconsequential, because treatment of low-grade hepatic encephalopathy caused by alcoholic liver disease has been tentatively shown to improve cognitive capacities (McClain, Potter, Krombout, & Zieve, 1984). Thus, medically significant problems that potentially disrupt brain functioning should be recorded and incorporated into the treatment plan.

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