Neuropsychological Assessment: CONFIDENTIAL

Neuropsychological Assessment Report

Report prepared by: TriDereka Hall

Test administered by: TriDereka Hall

Name​​: W. M.

Date of Birth​​: June 7, 1971

Date of Assessments​​: September 6th, October 4th, November 1st

Date of Report​​: November 15, 2018

Tests Administered​​: Montreal Cognitive Assessment (MoCA)

Timed Up and Go (TUG)

Waterloo Handedness Questionnaire

Western Aphasia Battery

Word Choice Test

Digit Span

Hopkins Verbal Learning Test (HVLT)

Rey-O Complex Figure,

Bells Test

Line Bisection Task

Verbal Fluency

Trail Making Test

Dysexecutive Questionnaire

Letter Number Sequencing

Referral

Mr.Willie Moss was referred for neurological assessment by his sister based on concerns

she had about abnormal behavior in his daily performance. She was told by him that he was

experiencing tremors and difficulty with writing reports for his clients as a therapist.

Background and History

Dr. Willie Moss is a 47 year old man. He holds a bachelor's degree in psychology at The

University of Tennessee at Chattanooga, a master’s degree in clinical mental health counseling,

as well as a doctorate degree in counseling. He has been a therapist now for about fifteen years

and has about five to eight clients in rotation at this practice presently. As a middle class citizen,

he also has a wife with two children of high school age, one boy and one girl.

Earlier in life, Dr. Moss had complications with seizure activity. He had to have

assessments at a local hospital and was given medication for them. After a couple years, they

became less frequent and he believed that they were taken care of. Other than having the seizures

and asthma, there were no other conditions or major surgeries he made me aware of.

Dr.Moss also described some of his own concerns about being referred for neurological

testing. In relation to daily activity, in the past month, he found that writing and making notes

about his clients had become more strenuous and difficult to manage. He also had issues with da

day-to-day tasks like brushing his teeth, brushing his hair, and simply getting out of bed in the

morning. Moss believes that these symptoms of him getting older rather than any other

explanation because all his other functions seem to be normal. Some of the other stressors in life

include thinking about his children’s futures financially and student loans.
 During the interview he gave information about his family history regarding his

immediate family. He indicated that he, himself has asthma in addition to his mother and brother.

He does not have many issues with this condition in comparison to how it was as a child

attempting to play many sports but having to stop after complications with the seizures. His

mother did not want him to risk any other injuries and was very protective of him. He also told

me that his grandmother, when she passed, had Alzheimer's. Even though she did, he hasn’t

believes he hasn’t had any issues with memory thus far.

Behavioral Observations

Aside from the testing, I made some additional notes of behavior during the interview

and assessments. I noted the following observations: frequent eye blinking, tapping of the legs

and arms, and slower/delayed movements to the next task. When he came in he didn’t have any

obvious signs of impairment that I recognized except for some slight stuttering that I attributed to

being nervous at first. Throughout the assessments this action continued, but did not cause a

excessive impairment the client. I noticed that when he talked, there was some more than normal

frequent eye blinking. I was not sure if he was aware of how often he was having this happened

and after asking him, he expressed that it felt normal. Additionally, throughout the tasks, I made

note of when he started tapping or twitching his legs and arms. It appeared to be unintentionally

but noticeable by the client and myself. Lastly, was the over slower tentative pace that he

displayed coming in and going from task to task. The assessments, in general, did not appear to

be challenging but I could see that the mobility tasks were more difficult that the others in the

cognitive and focus categories. Because he felt like his age was attributed to his slower pace, I

noted it throughout the testing.

Test Results

Montreal Cognitive Assessment (MoCA)

The Montreal Cognitive Assessment (MoCa) is a measure of general cognitive ability.

This test has subcategories of visuospatial/executive, naming, memory, attention, language,

abstraction, delayed recall and orientation. Dr. Moss had a score of 26 on this assessment. A

score below 26 would have indicated cognitive impairment. Within the subcategories, he lost

points in the visuospatial category where he had to draw an exact replica of a cube and also draw

a clock. He had difficulty with getting the lines straight for both drawings and specifically

missed two lines in cube drawing. He also lost points in the language section because he wasn’t

able to fully get out all the words he wanted in order to name as many words as he could in a

minute that started with the letter F. On the other tasks, he did well and received the full amount

of points.

The Timed Up and Go (TUGs)

This assessment is used as a measure of balance, mobility, and speed of movement. In the

assessment, he was asked to begin by standing up from the chair I set up, walk to a 3 meter mark,

turn, and walk back to the chair to sit down. In completing the task, I observed that Dr.Moss

walked at a slower pace than normal and had little or no arm swing. In the assessment, I

observed his postural stability, gait, stride length, and sway while timing the performance as

well. In this assessment, a time greater than or equal to 12 is an indication for risk of falling. Dr.

Moss did the task in 13.84 seconds. This indicates the he is at slight risk of falling because of the

slower pace resulting in a longer time. His actions made me aware of his unstable stature and

gave more insight to why had the slower pace coming into the interview.
Waterloo Handedness Questionnaire

Indication of hand dominance as an indicator of brain laterality is assessed in the

Waterloo Handedness Questionnaire. In this assessment, Dr. Moss was asked to indicate, for

each statement, his hand preference for certain activities. The options for answers were “Ra or

La” for always using the right or left hand, “Ru or Lu” for usually using the right or left hand,

and “Eq” for indicating that he uses both hands equally. Throughout the assessment, he indicated

that he mainly uses his right hand with a scored of +21. At the end of questionnaire, it also asks

questions referring to if he ever had any injury that changes he hand preference or if he has

received training for encouragement to use a particular hand for a certain task. He answered “no”

for both of those questions. For scoring

Western Aphasia Battery

The Western Aphasia Battery is used as a measure of language production and language

comprehension. This assessment does not have an indication of normal or impaired functioning

because we only used a sample version, but I was able to assess Dr. Moss’s language production

and comprehension. The sample we were given had three parts: spontaneous speech, auditory

verbal comprehension, and sequential commands. In the spontaneous speech, I asked him basic

questions such as “How are you today?” and “What is your name?”. Dr. Moss efficiently and

accurately answered these questions to my knowledge. He also was asked to describe a photo

that he was given with two children playing with blocks. For the picture he stated, when

describing the photo, “I see two kids playing with blocks. The two kids are a girl and a boy. Both

kids are smiling. They are sitting down too.” Lastly were sequential demands in which he had to

follow an order of tasks. For this task, I set up a bag of chips, phone, and pencil. He had to

complete tasks that stated, for example, “Point to the phone with pencil.” and “Put the pencil on
on top of the book then give it to me.” He was able to fully complete these tasks, but he went as

slower pace and had a slight shake in his hand while completing the tasks.

Word Choice Test

The Word Choice Test is a stand alone measure for suboptimal effort. In this assessment,

I had 50 cards with one word on each. Dr. Moss was instructed to state if the word presented to

him was man-made or natural. After going through all of the cards, I went through the word

choice card and said two words, in which he had a tell me which word was presented to him

before. For scoring, any score less than 47 is an indicator of possible malingering. Dr. Moss had

a score of 49 indicating that there no evidence provided for malingering. He consistently was

confident in his reponses.

Digit Span

Similar to the Letter-Numbering Sequencing, Digit Span is an assessment is a measure of

processing speed, working memory, and suboptimal effort. The assessment included two

different tasks, digit forward and digit backward. In this assessment, explained to him that I

would say a series of numbers. Then I instructed him, for digit forward, to say the numbers back

to me exactly as I said them. In the digit backward task, I said a series of numbers and instructed

him to say the numbers back to me in the opposite order. For scoring, Dr. Moss earned a score of

11 on digit forward and 6 on digit backward, when the normal function is greater than 12 on digit

forward and greater than 8 on digit backward. Because he scored 6 on digit backward, there is

possible concern but not excessive concern of impairment.

Hopkins Verbal Learning Test (HVLT)

Hopkins Verbal Learning Test measures verbal memory through 3 separate tasks/parts:

immediate recall, delayed recall, and recognition. In the immediate recall task, I instructed

Dr.Moss that I was going to read a list of words for him and he needed to tell me as many as he
could remember and I wrote them down. After reading the list of words to his and letting him

recall them once, I repeated this task another two times before allowing a five minute delay.

After the completion of part 1 and a five minute delay, the delayed recall task (part 2) was

initiated. I instructed him that I would read the list of words again to him I previously read. Then

I told him to repeat those words to me and I wrote them down. After completion of this task, I

began the recognition task (part 3). I instructed him to keep in the mind the list of words and

completed a checklist of words indicating “yes or no” for each word, identifying if they were on

the original list. For example, I asked “Was ​ruby​ on the list?” and just filled in the blank with

each word on the checklist.

For part 1, a working memory impairment would be identified if there were issues with

immediate recall. Out of the 12 words, Dr.Moss gave 3 words the first time, 6 words the second

time and 6 the third time. For part 2, a long term verbal memory impairment would be identified

if there were issues in the delayed recall task and the client gives less than 6-8 words. Dr.Moss

gave 6 words, indicating that he is in normal range and not impaired. And lastly, out of the 24

checklist items, he was able to correctly identify 20 of them. Through his performance, I believe

that he is within the normal range and performance of a healthy individual. He also would mouth

the words and had an increase in the number of words remembered, indicating the use of his

working memory.

Rey-O Complex Figure

Rey-O Complex Figure measures visuoconstruction, long term spatial memory, and is

also an indicator of right hemisphere functioning. For the task, I place a picture of a figure

directly in front of Dr.Moss. I instructed him to copy the figure exactly as he saw it. I also gave

him a window of 10 seconds to study the figure before beginning to copy it and told him that he

would have to draw the figure again later from his memory. After a five minute delay, I then
asked him to draw the figure on a seperate sheet of paper without any assistance from from the

first picture. There would be indications of visuoconstruction impairment if there were

inconsistencies in the original copying of the drawing. Secondly, there would be an indication of

poor long term spatial memory impairment if there were errors in the second task of drawing the

figure after the 5 minute delay. In scoring this assessment, because the scoring is outside the

scope of our course, I mainly observed my client’s physical movements and actions throughout

the task because of previous behavioral observations.

Bells Test

The purpose of the Bells Test is to measure spatial attention and screen for hemispatial

neglect. I instructed Dr.Moss to watch me identity the bell on the demonstration sheet. For the

task, I gave him a sample of what the bell looked like and how to circle the location of it on the

sheet. In the scoring of the assessment, time to complete the task and how many bells are found

are taken into consideration and among the bells are also 264 distractors. It also asks us to take

into consideration the scanning strategy of client and the omissions. He didn’t have any

omissions, but I observed that towards the end the task, Dr. Moss began to scan the page from

left to right to find more bells and eventually finding all 35 of the bells. In addition to

discovering all 35 of the bells, it took him 3 minutes and 10 seconds.

Line Bisection Task

This task measures spatial attention and is also screening for hemispatial neglect. For the

task, I placed the sheet in front of Dr.Moss. He was instructed to mark the center of each line

with a pencil that I provided him with. After he was done, I observed his marks. The task

explains that a normal or healthy individual will mark within a ¼ range of the true center of each

line. Overall, Dr.Moss had little to no deviation indicating that he most likely doesn’t have

spatial attention impairment.

Verbal Fluency Task

Verbal Fluency Task measures initiation, cognitive flexibility, fluency/generation, and

rule-following. For the task, I explained to Dr.Moss that he would have tell me as many letters as

he could beginning with the letter F. He would not be able to say any word that was a proper

noun, number, or with the same root word or suffix. After completing this task, he would then

repeat the same process, but now saying as many words as he could beginning with the letter S.

During the task, I used my phone to time it and wrote down the words he said within 15 second

increments. For example, in the first task, during the 0-15 second window, he said “face, fear,

friend, and foe.” And during the 16-30 second window, he said “flower and freak.” Throughout

this task he did not break any rules, indicating that he pays attention to rules and had proper

executive function. The test indicates that a normal respondent would have at least 4 words

during the first 15 seconds and 14-18 words overall during the 60 seconds. Dr. Moss had 4 words

during the first 15 seconds in the first task but 3 in the second task. Overall, he provided 14

words in the first task and 16 in the second. The results of the study indicate that his functions

are in the normal range.

Trail Making Test

For the Trail Making Test, it is a measure of processing speed and task switching. The

assessment is given in two parts (Trail A & Trail B). In both parts, there are 25 circles. In part 1

(Trail A), the number 1-25 are in the circles and I instructed Dr.Moss to draw a line beginning at

1 to each number, in ascending order. In part 2 (Trail B), there are the number 1-13 and letters

A-L. I instructed in this task to draw a line to connect the dot from the number to the letter in

ascending order (i.e. 1-A-2-B-3-C). (Before each of the task, I also demonstrated how it should

be done.) For the task, I observed the number of errors and the time it took to complete.

Throughout the task, Dr.Moss frequently had to lift his pencil and stop because the tremors he
began to experience during the task. The assessment indicates that the average time for part 1 is

29 seconds, with greater than 78 seconds being a deficient. In part 2, the average time to

complete is 75 seconds and a deficient being more than 273 seconds. For part 1, it took Dr.Moss

1 minute and 34 seconds to complete and part 2 took him 2 minutes and 35 seconds to complete.

And in Trail B, I observed that he made 2 errors but corrected them right after.

Dysexecutive Questionnaire

The Dysexectuive Questionnaire was used as a self-reported measure of executive

impairments in daily life activities. The questionnaire does not have scoring where I can indicate

normal or actions declaring impairment. It, instead, give me more information about his original

concerns. The assessment has 20 items on a five point scale (never-very often). In the

Dysexeutive Questionnaire, he marked “fairly often” next to the statements such as “I tend to be

restless,and ‘can’t sit still’ for any length of time.”, and “I find it difficult to stop myself from

doing something even when I know that I shouldn’t.” He explained further to me that he made

these choices because his tremors cause him to feel restless in a sense and also, he isn’t able to

control motor functions making him do things he isn’t supposed to do. He didn’t find that none

of the other questions were difficult to answer.

Letter Number Sequencing

Measure of attention, processing speed, and working memory. In this assessment, I

explained that he would be given a group of numbers and letters, and I instructed Dr.Moss to tell

me the numbers first, in order, starting with the lowest number. Then I wanted him to give the

alphabetical order of the letters. In this assessment, Dr.Moss became frustrated and did not get

very far into the scoring. He earned a score of 10, with a score of 14 or better being within

normal range, 10-14 an indicator of possible concern. Lastly, a score of 10 or lower is an

indicator of possible impairment. There a slow decline in performance after he began to

experience complexity of the task.

Summary of Performance

Cognitive (Memory & Language)

Overall, Dr. Willie Moss had normal performance on cognitive assessments such as the

Verbal Fluency Task, Western Aphasia Battery, Letter-Number Sequencing, Hopkins Verbal

Learning Test, and Montreal Cognitive Assessment. Although he had mainly normal

performance on theses assessments, I did note the behavioral observations that make have

affected him from maybe receiving higher than normal scores on some assessments. During the

tasks, he had small, inconsistent language/speech errors such as hesitation and stuttering. For

example, in the Verbal Fluency Task, where it assesses cognitive flexibility, it indicates that

fewer than 4 words in the first 15 seconds is an indication of issues of initiation. In the first 15

seconds of his performance, he had exactly four words but had a stutter during that time that

delayed him from saying other words before the next 15 seconds. The only other concern I had

was in the Western Aphasia Battery because of his motor functions in the “sequential

commands” section. There was mobile difficulty rather than language comprehension.

Focus (Attention & Executive Function)

The assessments, Word Choice Test, Digit Span Test, and Dysexecutive Questionnaire,

measured either attention or general executive function. Dr. Moss displayed mainly normal

performance in these assessments, scoring 47 in the Word Choice Test when normal function in

47 or higher. And on the digit span test, he scored 11 on digit forward and 6 on digit backward,

when the normal function is greater than 12 on digit forward and greater than 8 on digit
backward. Because he scored 6 on digit backward there is possible concern but not excessive. In

the Dysexeutive Questionnaire, I noted that he marked “fairly often” next to the statements such

as “I tend to be restless,and ‘can’t sit still’ for any length of time.”, and also another one referring

to having difficulty stopping a task he shouldn’t be doing. Dr.Moss expressed to me that he

marked “fairly often” on these statements because when he had tremors, he wasn’t able to stop

those actions and it also made him restless in a sense.

Spatial (Spatial Attention and Balance/Mobility)

Dr.Willie Miss had the primarily difficulty in these assessments. The assessments in this

section include the following: Time Up & Go, Rey-O Complex Figure, Waterloo Handedness

Questionnaire, Bells Test, Line Bisection Task, and Trail Making Test. The Rey-O Complex

Figure assessment indicated that he had motor difficulty copying down the figure which caused

him to provide less of the figure after the 5 minute delay. He was so focused on copying the

figure without shaking, that I believe he couldn’t remember all the figure when it came to

producing it second time. There was similar performance in the Bells Test, Line Bisection, and

Trail Making Test. There was normal performance on these task, but he took more time trying to

complete them because of tremors and stiffness in his hands at the time of the assessment. In the

Waterloo Questionnaire, scoring positive 21, he indicated that most of his activity was with his

right hand and almost never uses the left hand beside from a few tasks. Lastly, the Time Up &

Go assessment, as a measure of balance, mobility, and speed of movement, indicated that

Dr.Moss had impairments in these areas. During the assessment he had a little difficulty rising up

from the chair and took 13.84 second to complete the task, with more than 12 seconds being an

indication for a risk for falling.

Prognosis & Recommendations

In the referral, my client had concerns about his tremors and difficulty writing while he

was in sessions with his clients. He also had concerns about difficulty being able to get out the

bed in the morning, in addition to other daily tasks. After testing and observation, I have

connected my findings to some symptoms of Parkinson's. My conclusion is connected to the

observations from the following assessments: Time Up & Go, Western Aphasia Battery, Rey-O

Complex Figure, Trail Making Test, and Dysexeutive Questionnaire.

Considering that Dr. Moss was in mainly in normal range for cognitive and focus aspects

of the neuropsychological testing, I can connect his issues to spatial, balance, and stability but

more testing should be done over time in the cognitive area of memory and language as well. In

some assessments such as the Letter Number Sequencing and Verbal Fluency Task, he had just

the minimum requirements to be considered normal and I believe with his education as a

therapist and doctor for 15 years these numbers would be higher. It could possible that these

areas are declining and need to be monitored.

For the future, I recommend that he continue to monitor his actions day to day. From

observations that were made in the Time Up & Go (TUGs) assessment and Western Aphasia

Battery related to his mobility, it appears to be some progression is his loss of balance and

stability. Because of these observations, his family should also take some precautions with daily

movements and tasks. Their support is going to be crucial to his life if, after more, testing, he is

diagnosed with Parkinson’s disease. In the referral, Dr.Moss made statements that described him

having trouble doing daily tasks like getting up out the bed in the morning and cooking. I believe

that it is important to start now some more movements into his life. His job does not require a lot
of mobility, which can be increasing the problem. It may be helpful in the morning to do some

daily stretching, and overall making some additional healthy lifestyle choices like exercising

more during the week and a healthy diet. Until more testing is done, these actions should be

performed and if it’s determined that he has Parkinson’s he will need additional treatments such

as physical therapy, medication, or Deep Brain Stimulation.

 Appendix

Figure 1.

Figure 2.