GOVERNMENT OF INDIA

CENTRAL INSTITUTE OF PSYCHIATRY

KANKE, RANCHI

NEUROPSYCHOLOGICAL EVALUATION

Chairperson: Dr. Neha Sayeed

Presenter: Trusha Shanbhag ;
Swetha P U
Date: 6th October 2023

INTRODUCTION
Neuropsychology: Derives from various Greek words to amount to: doctrine of the "nerves" (neurologie)
and the soul (psychologie).
It is the study of the processes of the brain for individuals who function normally and those who have
some disruption. One goal is to identify various regions of the brain responsible for a specific type of
processing. Neuropsychology as a specialization started in India approximately 40 years ago. The early
years witnessed the use of Western tools for assessing patients with organic brain damage. Subsequent
years saw the development of indigenous tools for use with the vast majority of the Indian population
and also a few Western tests adapted to suit the needs of the unique Indian clients. The field of
assessments has witnessed indigenous tests being developed. Currently, work within the field of
neuropsychology has focused on child, geriatric, acquired brain injury, and forensic populations with a
development of unique rehabilitations to suit needs of several clinical conditions.

What is a Neuropsychological Evaluation?

A neuropsychological evaluation typically includes an interview with a clinical neuropsychologist and
assessment with a series of neuro psychometric tests. Neuro psychometric tests measure a wide range of
abilities to determine an individual’s strengths and weaknesses. The test results are compared to
standardized norms and estimates of the person's pre-injury abilities. A neuropsychological evaluation is
often completed soon after an individual has a traumatic brain injury or if an individual seems to be
having difficulties related to an undiagnosed brain injury from the past. From the perspective of people
with brain injury and their significant others, it is important to know what a neuropsychological
evaluation is and how the results can be beneficial.
"...neuropsychological assessment relies almost entirely on tests, i.e. the elicitation of specific
behavioural responses to specific stimuli under controlled conditions." Benton, 1994.
"accurate & systematic assessment of [a] ...disorder is vital both to the researcher and the clinician (Parkin
& Leng, 1993, p.17)
Although there is variability in how neuro psycho-logical assessments are conducted, the basic purpose
is to acquire, analyze, and integrate neurological and neuropsychological data from multiple sources
(American Educational Research Association, American Psychological Association, & National Council
on Measurement in Education, 1999). Typically, a neuropsychological assessment involves records
review, interview, testing, and report writing.
Records possibly provide the neuropsychologist with a general idea of what the presenting problem will
be, and the interview is vital to gather a large and varied amount of data and clarify uncertainties in the
clinical record and initial presentation. Testing involves the administration of various procedures and
measures to patients and is based on and follows record review and interview.

NEUROPSYCHOLOGICAL ASSESSMENT APPROACHES: A BRIEF MODERN HISTORY

Lurian Approach

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Alexander Luria’s seminal work following World War II in Russia represents an important early time-
point in neuropsychological assessment. Luria’s innovative ideas that the brain underlies the ability to
carry out goal-directed behaviors and is shaped by environmental and cultural contexts (e.g., language)
led to his systematic characterization of functional brain systems (Luria, 1966). Although largely
qualitative, Luria’s primary goal was to describe the cerebral bases that support corresponding functional
systems, emphasizing the importance of understanding the multiple components that may comprise even
simple neurobehavioral functions (Luria, 1966). Luria stimulated appreciation of brain specialization and
moved away from the one-size-fits-all diagnosis of brain disease; however, his techniques were highly
flexible and nonstandardized, making it difficult to reliably reproduce across examiners and patients.
Recognizing this problem, his student, Anne-Lise Christensen, published a more structured version of
the Lurian approach, combining both qualitative and quantitative aspects of his battery (Draper, 1976).
Ultimately, Charles Golden further standardized and combined the works of both Luria and Christensen
in his development of the Luria-Nebraska Neuropsychological Battery (LNNB; Golden, Purisch, &
Hammeke, 1979), scaling down almost 2000 original measurement items to 269 items covering 14 scales
(e.g., motor, rhythm, memory, intelligence; Purisch, 2001).
In the United States, other neuropsychological assessment standardizations were also developing. In the
1950s, Arthur Benton was among the first thought leaders to criticize neurology for the lack of validated
tools to measure common neurological syndromes (e.g., aphasia, agnosia). Through his pursuit of
systematic neurobehavioral assessment, Benton developed several individual measures that are still
widely used today (e.g., Benton Visual Rention Test) and shaped the Iowa-Benton school of
neuropsychology (Tranel, 2009). Additionally, through these test developments, Benton began rais ing
awareness of the apparent import of demographic factors (e.g., age and education) on test performances.

Flexible Battery One assessment

Flexible Battery One assessment style that naturally extended from clinicians’ early instincts to describe
observed behaviors was the flexible integration of standardized measures. In the pure flexible battery
approach, neuropsychologists administer only those measures directly related to the patient’s presenting
symptoms (e.g., multiple memory measures to characterize memory symptoms). Consequently, the
administered battery inherently changes with a patient’s referral question, while the examiner pursues
the aim of being both as efficient and sensitive as possible to the presenting problem.

It uses a core battery of tests and techniques for clients with various syndromes(Sweet et al., 2002). The
focus of assessment is on the person being assessed, not on the test being used. Information collected
only represents illustrative samples of behavior (and is not meant to be exhaustive); tests are meant to be
administered and interpreted individually; and finally tests are to be used to generate hypotheses for
helping the person being evaluated. Like the fixed battery, such an approach may be empirically derived
or theoretically based or some mixture of the two. For example, a screening battery, empirically derived,
may be followed by a theoretically based complement of tests designed to test the best fit to a syndrome
type.

Fixed Battery Approach

Two major leaders in the history of neuropsychological assessment pioneered the fixed battery approach,
Ward Halstead and Ralph Reitan, his student (Reitan & Davidson, 1974). As a physiological psychologist
in the mid-twentieth century, Halstead espoused a philosophy of neuropsychological assessment that was
akin to a series of scientific experiments. He believed that there was no science in the individual event,
and emphasized the need to develop exact, systematic procedures with sufficient comparison cases to
interpret an individual test score (Reitan, 1994). Reitan similarly held strong beliefs that empiricism
should be central in neuropsychological assessment (Grant & Heaton, 2015).
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Uses the same battery of tests for every client, despite different presenting difficulties and referral
questions (Fennell, 2000). It encourages exploration of the totality of the child behavioral repertoire
including intellectual functioning, academic functioning, and social/emotional functioning through
quantitative and qualitative interviews, observations, and tests. Such an approach consider the views of
parents, family members, peers, and teachers.Formal test provide the needed quantitative data, whereas
interviews, observations, and collection of informal measures offer the qualitative informat ion necessary
for an inclusive profile (Kaufman & Kaufman, 1983, 1993).

Boston Process Approach

Another important turning point in neuropsychological practices was the development of what is now
referred to as the “Boston Process Approach” led by Edith Kaplan (Kaplan, 1988). Although the Boston
approach can be used with either flexible or fixed batteries, it is most commonly associated with and
perhaps conceptually suitable to more flexible evaluations. The Boston approach places emphasis on how
the patient comes to an answer (e.g., types of errors committed) rather than reliance on a single objective
score. In this approach, testing the limits of a patient’s cognitive abilities to elicit behaviors that may not
traditionally present during standardized testing is emphasized.

SELECTION OF NEUROPSYCHOLOGICAL TESTS:

Mental Status
The selection of a neuropsychological test depends on various factors. It is important Examination
to first conduct a screening for signs and symptoms of a neurological deficit. This should include:
Consciousness
can be attained during the initial process of history taking, interviewing and mental Emotional State
status examination (eGyanKosh, 2019). Thought Content
Memory
Sensory Perception
One must consider normative data such as age and education along with other areas Language
of interest such as the patient’s medical history, developmental milestones, Speech
Handedness
psychosocial history and the severity and progress of the patient’s history of among other areas
complaints (Heaton & Pendleton, 1981).

Tests help in the The next step is to decide the goals of neuropsychological assessments.
assessment of: Traditionally, neuropsychological assessments can be diagnostic or
 Change in mental status
descriptive. With regard to diagnostics, neuropsychological testing is
 Abnormalities in function
before abnormalities in commonly used to diagnose a variety of difficulties such as mental
structure can be detected retardation, specific learning disabilities, mild cognitive impairment, or
 Strengths and weaknesses
of patient dementia. Clinical psychologists get referrals for patients where a differential
 Ability of individual to diagnosis may be considered. In such cases, a neuropsychological testing can
stand trial
help to differentiate psychiatric from neurological difficulties. For example,
 Changes in disease process
over time depression and disorders of memory can share common clinical features:
 Understanding behavioural problems with attention and concentration, short term memory difficulties,
manifestations

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or deficits in working memory and processing speed. Thus, determining what specific brain functions are
compromised, as well as which cognitive functions are intact, can help differentiate between two disorders
(Stebbins, 2017). Another goal of neuropsychological assessment is to identify disrupted psychological
components/processes/domains in an individual and to arrive at a profile of adequacies and deficits.
Additionally, it may also be important to identify brains structures and networks that are dysfunctional and
using this information to lateralize and localize the brain lesion (Filskov & Bold, 1981).

APPROACHES TO ASSESSMENT

SCREENING HYPOTHESIS BATTERY

TESTING
APPROACH
APPROACH

FIXED FLEXIBLE

INTELLIGENCE DOMAIN
+ +
TEST TEST SPECIFIC TEST

The screening approach is a flexible and more efficient process of testing which helps to determine whether
a diagnosis can be made with less information. It is used to see if a person meets a certain criterion, and if the
person has a certain deficit in a particular domain, it helps to identify whether additional testing is necessary.
For e.g., Mini Mental Status Examination, or Clock Drawing Test can be used to screen patients before
conducting further testing (Goodglass, 1986).

The hypothesis testing approach gives a more detailed evaluation of a particular cognitive domain which is
related to the individual’s complaints. It thus gives a detailed evaluation of that specific domain and tests the
hypothesis of the presence of impairment in that area. This approach helps to gain a deeper understanding and
description of the deficits but may overlook other areas of cognition that may contribute to the domain being
studied (Dutta et al, 2016). For e.g., assessing memory complaints using PGI Memory Scale.

The neuropsychological battery approach provides the most comprehensive assessment of various cognitive
domains. For any neuropsychological examination, a battery of tests administered should include at a minimum,
an intelligence test, a personality test, and a domain specific neuropsychological test such as perceptual-motor
or memory test. This helps to provide a comprehensive evaluation of the individual. It requires detailed testing to
provide a complete profile and uses a variety of tests to assess each domain. Two major approaches to battery
assessment include the fixed battery and flexible battery. The fixed battery or standardized battery approach
uses a pre-determined set of tests for every client, despite different presenting difficulties and referral questions
(Fennell, 2000). For e.g., Luria Nebraska Neuropsychological Battery. The flexible battery approach is an
extension of the hypothesis testing approach and uses a core battery of tests which is expanded or modified to
suit the individual being tested. The assessor then chooses the next step in testing based on what has come out
of the tests already given (Sweet et al., 2002). For e.g., using a few subtests of a battery, such as memory subtests
and further using a set of tests to assess memory functions, such as Wechsler Memory Scale.

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DOMAINS OF NEUROPSYCHOLOGICAL TESTS:

Cognitive Brief Description Some Indications for Use

Domain
Intelligence Intellectual functioning and Intellectual Disability, Learning Disabilities,
cognitive strengths & weaknesses Frontal Lobe damage
Language Communication skills, Verbal Aphasia, Agnosia, Dysfluency, Children with
expression, Verbal fluency delays in language development
Memory & Acquiring new information, storage Amnesia, poor Short-term recall, frequently
Learning and retrieval of past information losing items, failing to recognize familiar
persons
Executive Planning, Working Memory, Poor judgement, poor abstraction,
Functions Mental Flexibility, Inhibitory perseverative, suspected TBI, ADHD, Autism,
Control, Verbal Fluency Psychoses, Parkinson’s diseases, OCD
Attention & Selection of relevant information, Attention Deficit Disorder, Impulsivity,
Speed of dual tasking, sustaining state of Learning Sisabilities, inability to finish work
Processing alertness, and mental speed with within a given time
which information is processed
Perceptual Abilities under visuo spatial, visual Neurodegenerative Diseases, Motor Dyspraxia,
Motor Functions perception, visuo-constructional, Learning Disabilities, difficulties in drawing and
and perceptual-motor navigating

TESTS OF INTELLIGENCE:

The relationship between intelligence and neuropsychological testing is of increasing relevance due the rise of
cognitive neuroscience approaches to the study of intelligence. Psychometric intelligence tests are frequently
included in the neuropsychological evaluations of individuals with brain damage (Gansler et al, 2017). Attempts
have been made to approach the concept of intelligence and to develop intelligence test batteries based on a
neuropsychological perspective. A few of them are discussed below.
Test Subtests Functions Caution/Remarks
Stanford Binet Test of Verbal Nonverbal Domains: 2 subtests to identify
Intelligence – 5th Early Reasoning Procedural Fluid developmental starting
Edition Verbal Absurdities Knowledge Reasoning, point each for verbal
(Roid, 2003) Verbal Analogies Picture Knowledge, (vocabulary) and non-
Age Range: 2 to 89 years Quantitative Absurdities Quantitative verbal (object series)
Indian Adaptation: Reasoning Form Board Reasoning,
domains
1960s version by S P Memory for Form Pattern Visuo-Spatial Other subtests are
Kulshrestha (Hindi); Sentences Delayed Processing, administered in increasing
‘Binet Kamat Test’ for Position & Response Working levels of difficulty
Intelligence (in Hindi, Direction Block Span Memory
Total verbal & nonverbal
Marathi & Kannada) Last Word IQ gives a full-scale IQ
Concept
Bhatia’s Performance Koh’s Block Design Test Formation Raw scores are converted
Test of Intelligence Alexander Pass along Test Planning to MA using norms table,
(C.M. Bhatia, 1955) Pattern Drawing Test Visuo Spatial which is then used to
Immediate Memory Perception calculate IQ
Age Range: >11 years Picture Construction Test Working Has been used in studies
Memory of children with learning
Long Term disabilities & ADHD
Memory
Malin’s Intelligence Verbal Performance Visuo Spatial Has 11 subtests but only 5
Scale for Indian Picture Perception, from each group are
Information,
Children (MISIC) - Completion, Perceptual required for scoring;
Comprehension,
(Arthur J Malin, 1969) Block Design, Organization, Digit Span Test can be
Arithmetic,
Object Processing omitted from verbal tests
Similarities, Speed,
(Adapted from WISC I) Vocabulary, Assembly, and used for 10 years and
Coding, Planning, above where Vocabulary
Age Range: 6 to 15 years Digit Span Working
Mazes test is not required;
11 months Memory, Computes Verbal and
Immediate Performance IQ and a
Verbal
full-scale IQ
Memory
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Wechsler Intelligence Scales:

The Wechsler scales of intelligence aim to assess the cognitive ability of children, adolescents and adults. It
provides subtest and composite scores that represent intellectual functioning in specific cognitive domains as
well as a composite score that represents general intellectual ability (full scale IQ). This also yields a Verbal
Quotient (VQ) and a Performance Quotient (PQ) which is presumed to be PQ ≈ VQ (Appendix III).

Wechsler has also suggested a method of measuring

Wechsler Deterioration Index (WDI) =
mental deterioration by comparing an individual’s
(Sum of Hold Tests – Sum of Don’t Hold Tests)
present cognitive state with his/her premorbid X 100
Sum of Hold Tests
skills. This yields a percentage of loss which can be
analysed using hold tests, which measures those abilities which remain relatively intact in adulthood even after
injury or brain lesions, while don’t hold tests measure those functions which may be prone to cognitive
deterioration.

Hold subtests are: Vocabulary (word knowledge), Information (General Knowledge), Object Assembly
(spatial relations), and Picture Completion (visual alertness).

Don’t hold tests are: Digit Span (working memory), Similarities (verbal abstraction), Digit-Symbol (rapid
eye-hand coordination) and Block Design (spatial analysis) (Levi et al, 1945).

An important aspect of the Wechsler tests is that it provides valuable information about the person’s cognitive
strengths and weaknesses. Apart from intellectual functioning, an initial impression of the individual’s self-
esteem, social skills, motivation, and anxiety can also be gained (Wechsler, 1958).

Caution: Verbal responses acquired on the subtests must be queried and clarified before scoring. Clerical and
timing errors must be monitored carefully during administration of the subtests. On the Digit Span and Letter
Number Sequencing tests, recitation should be at the rate of one per second with the pitch of voice dropping
on the last digit/letter of each trial. During the introduction of the tests, it should be stated that each task begins
with easy questions and ends with difficult ones. Verbatim responses must be recorded during Vocabulary test to
elicit essential components of the answers. On Block Design, the blocks must be oriented to the examinee’s
midline and a rotation of more than 30 degrees would be considered an error (Refer Appendix I). When a non-
essential part is pointed out in the Picture Completion test, the examiner must add to ask what the most essential
piece missing is.
Test Index/Scale Sub-Tests Function Measured
Wechsler Adult Similarities Concept Formation
Intelligence Verbal Vocabulary Abstract Reasoning
Scale (WAIS IV) Comprehension Information Lexical Knowledge
– 4th Edition Index Comprehension (supplementary) Expressive Vocabulary
India Semantic Knowledge
Block Design Nonverbal Perception
(Wechsler, 2008) Matrix Reasoning Problem Solving
Perceptual Visual Puzzles Organization
Reasoning Figure Weights & Picture Manipulation
Age Range: 16 to Index
84 years 11 Completion (supplementary tests) Fluid Reasoning
months Digit Span Sequential Processing
Arithmetic Auditory Processing
Working
Letter Number Sequencing Mental Manipulation
Memory Index
(supplementary test)
,
Attention & Concentration
Symbol Search Mental Processing
Processing Coding Visuo-perceptual Speed
Speed Index Cancellation (supplementary) Visual Scanning

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 Verbal Similarities
Comprehension Vocabulary Expressive Vocabulary
Wechsler Index Comprehension Semantic Knowledge
Intelligence Information & Word Reasoning Abstract Reasoning
Scale for (supplementary tests)
Children (WISC Perceptual Block Design Nonverbal Perception
IV) – 4th Edition Reasoning Picture Concepts Problem Solving
India Index Matrix Reasoning Organization
Picture Completion Reasoning
(Wechsler, 2003) (supplementary tests)
Age Range: 6 to Working Digit Span Sequential Processing
16 years 11 Memory Index Letter Number Sequencing Auditory Processing
months 30 days Arithmetic Mental Manipulation
(supplementary tests) Attention & Concentration
Processing Coding
Speed Index Symbol Search Visuo-perceptual Speed
Cancellation (supplementary tests) Visual Scanning
Wechsler Adult
Performance Picture Completion Visuo-perceptual Speed
Intelligence Digit Symbol Visual Scanning
Scale (WAPIS) Performance Block Design Concept Formation
(Ramalinga Scale Picture Arrangement Visuo spatial perception
Swami, 1974) Object assembly Processing Speed
(Adapted from
WAIS I, 1955)
Age Range: 16 to
90 years
Wechsler Verbal Information, Similarities,
Preschool and Comprehension Vocabulary, Comprehension Concept Formation
Primary Scale of Abstract Reasoning
Visual Spatial Block Design, Object Assembly
Intelligence – 4th Language Development
edition (WPPSI - Working Matrix Reasoning, Picture Visuo-perceptual Speed
IV) Memory Concepts Visual Scanning
(Wechsler, 2012) Fluid Reasoning Picture Memory, Zoo Locations Mental Manipulation
Age Range: 2
years 6 months to Processing Bug Search, Cancellation, Animal
7 years 7 months Speed Coding

Caution: The Koh’s Block Design has dissimilar administration guidelines along with different designs, number
of items and scoring in the original Koh’s test, in the subtest of Bhatia Performance Test of Intelligence and in
Malin’s Intelligence Scale for Indian Children (Refer to Appendix I for separate guidelines for each).

The Kaufman Scales:

Developed in the 1980’s and 1990’s, the Kaufman scales are individually administered tests, designed for many
different uses, including neuropsychological evaluation. These tests provide three types of scores: Fluid,
Crystallised and Composite IQs.

Test Index Subtests Function Measured

Kaufman Sequential Word Order, Number Recall,
Assessment Processing Hand Movements Problem Solving
Battery for Triangles, Face Recognition, Sequential Processing
Simultaneous
Children – 2nd Block Counting, Conceptual Spatial Integration
Processing
edition Thinking, Rover, Gestalt Attention
(K-ABC II) Closure, Visual Processing
(Kaufman & Atlantis, Rebus, Atlantis Processing Speed
Learning Ability Recall & Recognition
Kaufman, 2004) Delayed, Rebus Delayed
Decision Making
Pattern Reasoning, Story Planning
Age Range: 2 years Planning Ability
Completion
6 months to 12
years 6 months

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 Vocabulary, Information,
Problem Solving
Kaufman Verbal/Crystallized Comprehension, Similarities,
Arithmetic Reasoning
Adolescent and
Planning
Adult Intelligence Object Assembly, Block
Sequential Reasoning
Test (KAIT) Perceptual Design, Digit Symbol,
Long Term Memory
(Kaufman & Organization Picture Arrangement, Picture
Induction & Learning
Kaufman, 2013) Completion
Language Development
Age Range: Memory for Block Designs,
Delayed Memory
11 to 85 years Fluid Logical Steps, Mystery Code,
Visual Processing
Double Meanings

TESTS OF LANGUAGE:

Verbal Fluency Tests:

Verbal Fluency refers to production of spontaneous speech fluently without undue word finding pauses or
failures in search word. Normal speech requires verbal fluency in production of responses and formulation of
spontaneous conversational speech (Rohrer et al, 2008). This can be semantic, including objects such as animals
or fruits, or phonemic, including words beginning with a specified letter, such as F, for example. The following
are some of the most frequently used tests of verbal fluency.

Test Description Scoring Caution/Remarks

Controlled Oral Uses the three-letter Tests phonemic fluency;
Word Association set of C, F, and L or The admissible responses Proper nouns are not
Test P, R, W are summed and allowed (words of objects,
(Borkowski et al, 1967) compared to a normative places, people), same words
(previously called 1 minute is given to sample as given in the with different endings not
Verbal Associative name as many words Multilingual Aphasia allowed (e.g., run, running)
Fluency Test) as possible beginning Examination (MAE) to Examiner must quickly
(Subtest of MAE - with each one of the elicit severity write down the words given
Benton, Hamsher, & letters by the participant
Sivan, 1994) Different variations of the
Age Range: 16 to 95 test are available
years
F-A-S Test Three separate trials Normal range = 36-60 Tests phonemic fluency
(Borkowski et al., are given to recall words, <36 indicates Proper nouns such as
1967) word starting with F, impairment names and objects are not
Age Range: 16 to 95 A & S respectively in allowed, and same words
years three 60 seconds with different endings not
trials allowed
Animal Naming Test Normal range = 18-22 Mythical animal names or
(Goodglass & Kaplan, 60 seconds is given to 13-17 = borderline cartoon names are not
1983) recall names of impairment allowed
Age Range: 16 to 95 animals <12: severe impairment
years
Peabody Picture A series of pictures Total score is converted
Vocabulary Test – 4th are presented, and to a percentile rank and Test of single word
edition words are spoken to age equivalents, matched receptive vocabulary and
th describe the picture; to a normative date to see comprehension, also
(Dunn et al, 1965; 4
edition in 2007) examinee shall point severity of deviation estimates verbal ability
Age Range: 2 years 6 to the picture the
months to 90 years word describes
Token Test Tokens of different Scores >28 = No
colours, shapes are impairment Measures both Auditory
(Renzi & Vignolo, given. Verbal 25 - 28 = mild Comprehension and
1962) instructions increase 17–24 = moderate Language Comprehension
in complexity from <17 = severe or very
Age Range :>3 years simple to complex severe
commands
(Goldstein et al, 2019)

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Tests of Aphasia:

Aphasia is an acquired neurogenic language disorder resulting from an injury to the brain—most typically, the
left hemisphere. Aphasia involves varying degrees of impairment in four primary areas:

 Spoken language expression

 Spoken language comprehension
 Written Expression
 Reading Comprehension

Some of the most commonly used aphasia tests are:

Test Description/Subtest Scoring Caution/Remarks

Boston Naming When the patient is unable
Age and education
Test Individual is required to to spontaneously name an
norms are provided in
(Kaplan, Goodglass name a series of pictured item, the examiner first
the manual for children,
& Weintraub, 1983) objects, increasing order provides a categorical cue
normal adults, and
Age Range: 5 to 88 of difficulty (e.g., the beginning sound
aphasic adults
years of the target word)
Boston Diagnostic Five subtests: Norms are provided for Measures Perceptual
Aphasia each of the subtests modalities (auditory,
Examination - Conversational & which give an visual, and gestural),
Third Edition Expository speech, impression of the Processing Functions
(BDAE III) Auditory Comprehension, severity of dysfunction (comprehension, analysis,
(Goodglass & Oral Expression, Reading, relating to the specific problem-solving) and
Kaplan, 2000) and Writing domains Response modalities
(writing, articulation, and
Age Range: 18 to 79 manipulation);
years Individual subtests can be
administered
Assesses the following Used to evaluate the
Multilingual domains via 11 subtests: Scores are adjusted for presence, severity and
Aphasia age and education and qualitative aspects of
Examination – Oral Expression uses 3-point scoring aphasic disorders;
Third Edition Oral Verbal system. The raw scores Multiple versions of
(MAE - III) Comprehension converted to subtest available to help
(Benton et al, 1994) Reading Comprehension standardized scores and with pre & post testing;
Writing & Spelling compared with Helps to differentiate
Age Range: 16 to 69 Articulation & Fluency between normal aging &
years normative data
neurological deficits
Multilingual means
different languages, but
the test is only available in
English & Spanish
Has 32 tasks under 8 Scoring includes an Identifies and classifies
Western Aphasia subtests: Aphasia Quotient (AQ) different types of aphasias
Battery - Revised score that measures including global, Broca’s,
Spontaneous Speech, language ability and Wernicke’s, anomic and
(Kertesz, 2007) Repetition, Cortical Quotient (CQ) transcortical motor and
Naming & Word Finding, score which measures sensory among others
Age Range: 18 to 89 Auditory Verbal general intellectual ability Other quotient’s
years Comprehension, Scores rate severity: calculated by the test
Reading, 0-25 - very severe includes Auditory
Writing, 26-50 – severe Comprehension Quotient,
Apraxia 51-75 – moderate Oral Expression Quotient,
76 & above - mild Reading Quotient, Writing
Quotient
Also measures non-lingual
skills such as drawing,
calculation & block design
(Strauss, 2006)

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TESTS OF MEMORY & LEARNING:

Learning is any relatively permanent change in behaviour that occurs as a result of practice and experience, that
involve different types such as motor, verbal, concept, and discriminatory learning. The ability to encode, store,
and later retrieve information is a highly complex cognitive function requiring a host of learning and memory-
related skills that can be disrupted by any number of neurological and psychiatric disorders (Kramer & Delis,
1998). Memory is a very broad function which includes several distinct abilities, all of which can be selectively
impaired and require individual testing.

Semantic memory and episodic memory (collectively called declarative memory or explicit memory);
procedural memory and priming or perceptual learning (collectively called non-declarative memory or implicit
memory) all four of which are long term memory systems; and working memory or short -term memory.
Semantic memory is memory for facts, episodic memory is autobiographical memory, procedural memory is
memory for the performance of skills, priming is memory facilitated by prior exposure to a stimulus and
working memory is a form of short term memory for information manipulation Memory deficits are often the
first neuropsychological symptom in progressive dementing disorders and can be the only finding in disorders
such as mild head trauma and multiple sclerosis (Camina, & Güell, 2017).

In addition, memory problems are among the most frequent complaints of the elderly (Craik, 1984) and of
patients with major psychiatric disorders such as depression and schizophrenia (Caine, 1981; Weingartner &
Silberman, 1984). The frequency of these problems underscores the importance of memory assessment in any
intellectual or neuropsychological evaluation.

Some of the Wechsler scales used to assess memory are:

Test Subtests Function Measured Caution/Remarks

Spatial Addition Two separate
Wechsler Memory Symbol Span Auditory Memory batteries have been
Scale – IV Design Memory Visual Memory developed for the
(Wechsler, 2009) General Cognitive Screener Visual Working Memory WMS–IV, one for
Logical Memory Immediate Memory adults (16 – 69
Age Range: 16 to 90 Verbal Paired Associates Delayed Memory years) and one for
years Visual Reproduction older adults (65 – 90
years)
Wechsler Memory Complete standardization
Scale – III – India of the test along with -do- Indian norms in form
Edition Indian adaptation of the of percentile ranks
(Indian Adaptation: subtests of Logical
Pushpalatha Memory, Faces & Family
Gurappa) Pictures

Other scales for assessing memory functions:

Test Subtests/Description Scoring Caution/Remarks

PGI Memory Remote Memory
Scale (1977) Recent Memory Each subtest is scored Norms available for 20
(From PGI Mental Balance individually after which the to 69 years for different
Battery of Brain Attention–Concentration scores are added for a total education levels, separate
Dysfunction) Delayed Recall score which elicits a for each sub test
Immediate Recall dysfunction rating Based on Indian sample
Adapted from Retention for Similar Pairs specifying the presence or and made without
WMS III Retention for Dissimilar absence of brain pathology influence of foreign
Pairs methods of assessment
Age: 20 to 69
Visual Retention
years
Recognition

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 Cambridge Measures Memory,
Prospective Includes 4 time based and 4 Generates scores on time- Attention and Executive
Memory Scale event based prospective based and event-based Functioning
(CAMPROMT) memory tasks along with a subscales, each scoring a Participants are allowed
filler activity using both maximum of 18 with higher to spontaneously use
(Wilson et al,
verbal and written scores reflecting better PM strategies, such as note
2005)
instructions performance taking, to help them
Age: >16 years remember
Is culture specific, not
suitable for rural Indian
population
Benton Visual The test is untimed, and the The individual is shown
Retention Test Visual Perception results are scored by form, 10 designs, one at a time,
Visual Memory shape, pattern, and and asked to reproduce
(Benton, 1945) Visual and Verbal arrangement on the paper each one as exactly as
Conceptualization Scoring method can be possible on plain paper
Age Range: >8 Short Term Retention and done using all or none from memory;
years Recall Visuo-Constructive principle OR by calculating Also used to identify
abilities errors of omission, learning disabilities –
distortions, rotations, etc seen by impairment in
visual memory domain
Measures: Firstly, a list of 15 unrelated The list is presented in
Rey Auditory Short-term auditory-verbal words over 15 trials for an even tone of voice at
Verbal Learning memory immediate recall is given. It the rate of one word per
Test Rate of learning is followed by a second list second;
Retroactive and proactive of 15 unrelated words for Dysfunction is measured
(Schmidt, 1996) Interference immediate and delayed as mild moderate or
Age Range: >16 Presence of confabulation of recall; after which the first severe based on the
years confusion in memory processes list has to be recalled number of words
Retention of Information recalled and compared to
Learning and Retrieval norms
Learning Task – 16 nouns
read aloud, at one-second
Episodic verbal learning and intervals, in fixed order, Used to examine patients
California memory over five trials to be with neuropsychological
Verbal Learning Assesses encoding, recall recalled over free, a short impairments, TBI,
Test - II and recognition delay and a 20-minute long frontal lobe syndrome,
Free and Cued Recall delay Alzheimer’s diseases and
(Delis et al., 1994) Serial Position Effects Recognition Task - 44-word schizophrenia among
(including primacy and list presented to be others
Age Range: 16 to recency) indicated as a target word
89 years Semantic Clustering or a distractor word
Intrusions, Interference and Scored on the basis of
Recognition computer scoring, with
learning curve & responses
errors
Rey Osterrieth Assesses: Reproduction of a Can be used to explain
Complex Figure Visuospatial Abilities complicated line drawing, effects of brain injury, to
Test Attention first by copying it freehand test presence of
Planning (recognition), and then dementia or study
(André Rey, Working Memory drawing after a 3-minute cognitive development
1941) Recognition short delay from memory in children
Immediate Recall (immediate recall) and then (Shin et al, 2006)
Age Range: 6 to Delayed Recall drawing after a 30-minute
89 years long delay (delayed recall)

TESTS OF EXECUTIVE FUNCTIONS:

Executive functions are complex cognitive abilities that enable the identification of goals, mental - planning,
behaviour organization, and planning actions to achieve these goals. In addition, executive functions impact
affective-emotional, motivational, and social skills. They are especially important identifying performing and
troubleshooting routine tasks, from the simplest to the most complex (García-Madruga et al, 2016).
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Some of the Executive functions comprise of Planning, Working Memory, Mental Flexibility, Inhibitory
Control and Verbal Fluency among others.

Some of the most commonly used tests to assess executive functions are:
Test Function Task Description Caution/Remarks
Sensitive to frontal lobe
Cards are classified according to
dysfunction;
Wisconsin the colour of its symbols, the shape
Classification rules should
Card Sorting Reasoning Ability, of the symbols, or the number of
not be revealed to the
Test (WCST) Set Shifting, the shapes on each card. The
examinee;
(Grant & Berg, Mental Flexibility, classification rule changes after
Has manual scoring and a
1948) Inhibitory every 10 cards and this implies that
computer scoring (4th
Control, Feedback once the participant has figured out
Age Range: 6.5 version) for 7-89 years;
Utilization the rule, the participant will start
to 89 years Feedback is given only in
making one or more mistakes when
the form of correct or
the rule changes
incorrect responses
Stroop Colour The test consists of three The booklet has to be kept
and Word Inhibiting conditions: 1) the examinee must on the table and cannot be
Test Cognitive say, as quickly as possible, the lifted; booklet cannot be
Interference words of colours that are arranged rotated for >45 degrees;
(Golden, 1978) Attention on a card 2) the examinee must say
Processing Speed the names of the colours that ‘xxxx’ Has individual & group
Age Range: 16 Cognitive words are printed in 3) the administration;
to 65 years Flexibility examinee must name the colours
Working Memory that the words “yellow”, “red”, etc. Child test – 5 to 14 years
are printed in
Highly dependent upon
motoric speed and may not
be appropriate for patients
Trail Making with marked motor
Test (TMT) – Complex impairment (Partington &
The individual is required to
Part A & B Attention Leiter, 1949)
connect randomly positioned
Visual search Pencil use only, cannot lift
numbers in Part A while letters and
(Partington & speed pencil, errors are corrected,
numbers alternately shall be
Leiter, 1938) Scanning and task is continued,
connect as quickly as possible in
Processing Speed scoring shows impairment
Part B
Age Range: 18 Mental Flexibility based on time taken
to 89 years
,
Colour Trails Test – Elia
et al 1994: 18 to 89 years,
Child Test– 8 to 16 years
(Llorente et al, 2003)
N Back Test Increasing order of
A list of letters is read out to the
(Kirchner, difficulty is presented, first
examinee who must indicate when
1958) with 1-N and 2-N & so on;
the letter is repeated. In the
Age Range: 16 Amount of cognitive
Working Memory simplest form of 1-N, the
to 65 years process increases with
participant should report when
(subtest of difficulty level
they are presented with an
NIMHANS 0 back control task to
immediately matching information
Battery, 2004) assess baseline performance
Measures
Inhibitory Identifies problems of
Behavioural Control, Planning, Dysexecutive Syndrome
Assessment Problem Solving (DES) – dysfunction in
13 tasks grouped under 6 subtests executive functions along
of the Subtests: and 2 questionnaires, has a
Dysexecutive Rule Shift Cards with cognitive, behavioural
maximum of 24 points. Total score and emotional changes
Syndrome Test is converted to standard scores,
(BADS) Action Program compared with age norms and
Test Norms available for
Wilson et al, 1996) Key Search Test classifies as impaired, borderline, patients with schizophrenia,
low average, average, high average, Dementia, Stroke,
Temporal superior & very superior
Age Range: 16 to Judgement Test Encephalitis and Anoxia
87 years Zoo Map Test Also available for
Modified Six children: for 8 to 16 years
Elements test
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 Cognitive Logical The questions on this task requires Cognitive estimation
Estimation Approximation,
Planning,
participants to provide a reasonable questions like, “how many
Test response when a specific answer is seeds are there in a
(Shallice & Semantic
Knowledge,
not available. This contrasts with watermelon”? has a
Evans, 1978) general knowledge questions, solution that is drawn
Cognitive
Age Range: 18 which have an easily retrieval exact indirectly from personal
Flexibility,
to 79 years answer experience
Mental Flexibility
The examinee receives a wood Three attempts are given
Tower of tower with three pins (large, for each problem; score of
London Test medium or small) and three balls 3 points for one attempt, 2
Planning for two attempts, 1 for
(Shallice, 1982) (red, green or blue). Starting from a
Visuo-Motor three attempts, and 0 if not
fixed position he/she must move
Coordination solved with three attempts.
Age Range: 16 the balls, one at a time, matching
to 80 years stimulus showed in a card (12
problems) (Berg & Byrd, 2002) Child test: 7 to 15 years
Includes 5 independent
subtests:
Goldstein-Scheerer Cube
The tests require the respondent to
Test, Goldstein Colour
Goldstein- Abstract Thinking copy coloured designs, to sort
Sorting Test, Gelb-
Sheerer Tests items into categories according to
Goldstein-Weigl-Sheerer
(Goldstein et al, Concept colour, form, and material, and to
Object Sorting Test, Weigl-
1945) Formation reproduce designs from memory by
Goldstein-Scheerer Colour
arranging sticks.
Form Sorting Test, and
Weigl-Goldstein-Scheerer
Stick Test

TESTS OF ATTENTION & PROCESSING SPEED:

The cognitive domain of attention covers one’s ability to selectively attend to specific information while
ignoring irrelevant information. The sub-domains of selective, sustained, divided and alternating attention,
along with continuous performance can be measured using different tests. (Description in Appendix II)

Processing speed is the ability to identify, discriminate, integrate, make decisions about information, and to
respond to visual and verbal information. It provides an estimate of how efficiently an individual can perform
basic, overlearned tasks or tasks that require processing of novel information. These tests usually do not assess
higher-level thinking; however, they frequently require some degree of simple decision-making. (Ebaid et al,
2017).

Some of the most commonly used tests of attention and processing speed are:

Test Function Description Remarks/Caution

Individuals listen to random Numbers should be
Digit Span sequences of numbers presented in random without natural
Test Assesses attention and increasing length, and immediately sequence, at the rate of one
vigilance, working repeated each sequence, for both digit per second with even
(Adapted memory DF & DB; tone of voice;
from PGI Two sets for span length are Max. score 16 (of both sets
BBD) presented, and maximum span is with a max of 8 numbers in
the number of digits the patient can each DF & DB); <8
correctly repeat on at least one set. dysfunctional
Verbal working The examinee reads a sequence of The test is discontinued
Letter memory capacity, numbers and letters and recalls the after scores of 0 on all 3
Number reading numbers in ascending order and trials of an item;
Sequencing comprehension, letters in alphabetical order Items of a trial shall never
(Adapted sequential processing, Consists of 10 items with 3 trials be repeated, corrective
from WAIS short term auditory each feedback if provided, credit
IV) memory, cognitive Max. raw score = 30 is given even if letters are
flexibility recalled before the numbers

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 Paced The patient listens to a tape
Auditory recording of digits presented one at A total of 61 numbers
Serial Attention a time who has to add each number presented in a random
Addition to the one immediately preceding order
Test Vigilance it.
(PASAT) The test taker may lose
For example, the recording might
Working Memory track of the total after
(Gronwell, present the numbers 1, 7, 5, 4. The
making an error and needs
1977) patient adds the first two numbers to be told to continue the
Adapted by (1 & 7) and responds with the
test from the last two digits
Rao et al, number 8. The patient then adds
1989 for use the second two numbers (7 & 5)
in Multiple and responds with the number 12.
Sclerosis The patient then adds the third two
numbers (5 & 4) and responds with
the number 9.
(Tombaugh, 2006)
The patient is presented with a row This measure requires
Digit Focussed Attention of numbers one through nine, each switching behaviour
Symbol Test paired with nonsense symbols between the key and the
Motoric Speed Below this key are empty boxes target boxes and motoric
(Adapted with numbers above each box. The speed and therefore may
from WAIS patient is required to transcribe the not be appropriate for
IV) symbol corresponding to the patients with marked motor
number above the box as quickly as impairment
possible.
Symbol The patient is presented with two
Search Motoric Speed target symbols and an array of May not be appropriate for
additional symbols (all are patients with marked motor
(Adapted Sustained Attention nonsense symbols). The patient is impairment
from WAIS required to respond yes if the array
IV) of additional symbols contains one Errors of omission and
or more of the target symbols and commissions are also
respond no if the array of scored
additional symbols does not
contain one or more of the target
symbols.
Letter Scoring is done on the basis
Cancellation Visual Scanning The patient is required to cancel of time taken to finish the
Test selected letters, designs, or words task (in seconds)
Visuo Motor Ability from a background of nontarget
(Adapted The numbers of errors such
from WAIS Sustained Attention letters, designs, or words. as, omissions and
IV) commissions are counted

Other tests such as Triads Test, Hand Tapping and Finger Tapping Test, and Digit Vigilance tests are also
commonly used.

TESTS OF PERCEPTUAL MOTOR FUNCTIONS:

Tests of nonverbal skills typically are of two sorts. One sort draws on visuo-perceptual abilities without
requiring any motor output, and the other demands constructional skills and involves motor control and
planning. Construction tasks involve the organization of skilled hand movements, accurate visual perception, and
integration of perception into kinaesthetic images and translation of kinaesthetic images into the final motor
patterns (Tükel, 2013).

Generally clinical examination of visuomotor co-ordination has been done by assessing constructional ability It
is the ability to draw or construct two- or three-dimensional figures or shapes. It is a very complex perceptual
motor ability involving the integration of occipital, parietal, and frontal lobe functions. Copying line drawings
using pencil on paper, reproducing matchstick patterns, and reconstructing block designs are all examples of
routinely used tests of constructional ability (Salmon & Bondi, 2009).
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 Test Description Function Caution/Remarks
Also measures learning disabilities,
Bender Total of 16 cards designs have intellectual disability, visual acuity,
Gestalt Test II to be reproduced by examinee Visual Acuity motor functioning screening test for
one by one on a single page with organicity, neurological impairment,
(Brannigan & a 5-point scoring system Motor emotional disturbances and memory
Decker, 2004) Evaluated visual motor maturity Functioning The page must be kept horizontally
Age – 4 to 85 in front of the examinee, an eraser
years Older version of BGT has 9 must be kept on the table and the
cards with several scoring cards should be placed on top of the
methods available. Most sheet.
common: Pascal and Hain’s. Posture of individual can be
In Hain’s method (1964) of changed, but the page cannot be
scoring the protocol is scored turned to any angle
on the basis of 15 signs. The Pascal scoring has individual scores
maximum score is 34. The score for each design, while Hain’s scoring
of 9 and above shows severe is based on signs, which are scored
dysfunction. only once for all designs
(Sousa &Rueda, 2017)
Two subtests: Determines
Behavioural Conventional and Behavioral extent of May have practice and learning
Inattention BIT-C: 6 items: line crossing, visual neglect effects when re-testing is done
Test letter cancelation, star Individual is
cancellation, figure and shape diagnosed Different versions are available with
(Wilson et al, copying, line bisection, and with visual different figures and test items
1987) representational drawing. neglect if they
BIT-B: pre-scanning, phone fail to attend
Age group: 19 dialling, menu reading, article the target
to 83 years reading, telling and setting the stimuli and
time, coin sorting, address and based on the
sentence copying, map relative spatial
navigation, and card sorting location of
targets
omitted
Benton Facial Patients are presented with a The test progresses in difficulty from
Recognition target face on one page and six Visual Object easy (a duplicate of the target face is
Test faces on the adjacent page. One Recognition presented in the six faces) to hard
of the six faces match the target (the matching face differs from the
(Benton &
face. target face in orientation and
Allen, 1968)
lighting)
Judgment of Examinees are asked to match Visuo spatial Measures a person's ability to match
Line two angled lines to a set of 11 perception the angle and orientation of lines;
Orientation lines that are arranged in a Patients with dementia and motor
semicircle and separated 18 Focussed impairment perform poorly on this
(Benton et al, Attention
degrees from each other, total test (Woodard, 1996)
1983)
30 items

Various other tests are also available which are used to assess the perceptual motor functions of an individual
such as the Peg Board Test and Perceptual Motor Abilities Test.

NEUROPSYCHOLOGICAL BATTERIES:

The development and use of neuropsychological test batteries has progressed in tandem with our understanding
of the functional organization of the brain. The battery approach to testing aims to give a comprehensive
understanding of varied cognitive domains of the individual being tested.

Some of the frequently used batteries are as follows:

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 Test Description Subtests Caution/Remarks
PGI Battery of Brain The battery gives a global Can be used to rule out
Dysfunction measure of cognitive PGI- Memory scale (10 or confirm the diagnosis
dysfunction by measuring subtests) of Organic Brain
(Pershad & Verma, the various domains of Revised Bhatia’s Short Pathology, any memory
1990) memory, information, Battery of Performance deficit, intelligence, and
comprehension, Tests of Intelligence can also be used in
Age range: 20- 45 years vocabulary, attention, Verbal Adult Intelligence rehabilitation planning
gestalt formation Scale Has a ‘PGI Battery for
processing speed, visuo Nahor-Benson Test Assessment of Mental
spatial coordination Bender Visual Motor Efficiency in the
among others Gestalt Test Elderly by Kohli,
Verma & Pershad
(1996) in English &
Hindi for >55 years
AIIMS The test consists of 160 Primary scales in this Can identify brain
Comprehensive items in Hindi spread over battery include Motor, dysfunction in
Neuropsychological 10 basic scales; Tactile, Visual, Receptive neurologic patients with
Battery in Hindi Specific scales can identify and Expressive Speech, success rates of more
(Adult & Child damage in each localized Reading, Writing, than 80%
Form) area of the brain; Arithmetic, Memory,
and Intellectual Also available in a child
(Gupta et al, 2000) Interpretation can be
Processes Scale. Out of version
made for presence of
Adults: Age Range – brain dysfunction in terms these basic content
16 to 65 years of lateralized, localized, scales, 3 other scales i.e. For elderly patients -
and diffused Pathognomonic, left AIIMS Comprehensive
Child: Age Range – 7 hemisphere, and right Dementia Assessment
to 16 years hemisphere scales Scale (Hindi)
Includes 19 subtests for Instructions are in
NIMHANS Assess motor speed, domains of Speed, English as well as one
Neuropsychological attention, executive Attention, Executive local language that is
Battery (Adults) functions, visuo-spatial functions, Kannada
relationships, Comprehension (verbal
NIMHANS battery for
(Rao, Subbakrishna & comprehension, learning Learning and memory),
children has been
Gopukumar, 2004) and memory Visuospatial
developed for the age
Construction and
range of 5–15 years
Age Range: 16 to 65 Learning and Memory
(Kar, 2004)
years (Visual)
Measures attention, Word List, Story Recall Developed for assessing
memory, executive Test (memory of logical cognitive functions in
NIMHANS functions, language, visuo- passage), Indian
neuropsychological spatial construction, and Stick Construction Test, older adults
battery for elderly parietal focal signs Digit Span, Corsi block- Long administration
(NNB-E) Visual Memory, tapping test, Category time
Immediate & Delayed fluency, Go/No-Go,
(Tripathi et al, 2013) Recall, Visuo-spatial Picture cancellation for Parietal focal signs
construction, Working sustained attention, and (agnosia/apraxia/body
Memory, Sustained schema disturbances/left
Age Range: >65 years
Attention, Inhibitory right
Control disorientation/acalculia)
Luria Nebraska 269 items divided into Can be used to diagnose
Neuropsychological Evaluates learning, fourteen scales: motor, and determine the nature
Battery experience, and cognitive rhythm, tactile, visual, of cognitive impairment,
skills, can differentiate receptive speech, including the location of
(Golden, 1981) between brain damage and expressive speech, the brain damage, to
mental illness, writing, reading, understand the patient's
Age Range: >13 years arithmetic, memory, brain structure and
intellectual processes, abilities, to pinpoint
pathognomonic, left causes of behaviour, and
hemisphere, and right to help plan treatment
hemisphere

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 Cambridge Assesses various domains 15 subtests including Scales are grouped
Neuropsychological like assessing general Spatial Working Memory Clinical scales, Summary
Test Automated memory and learning, Stockings of Cambridge scales, Localization and
Battery (CANTAB) working memory and Rapid Visual Factor scales
executive functions, visual Information Processing Accounts of
(Sahakian et al, 1988) memory, attention and Paired Associate lateralization and
reaction time, semantic Learning localization of focal
Age Range: 4 to 90 memory, decision making Delayed Matching to brain impairments and
years and response control Sample, and other tests rehabilitation
Lateralization of a lesion Includes Wechsler
Halstead-Reitan is possible Intelligence Scale, Excessive administration
Neuropsychological Aphasia Screening Test, time (up to 3 hours or
Battery Also assesses language, Trail-Making Halstead more) in some patients
executive functions, Category Test Tactual with brain damage
(Reitan & Wolfson, abstract concept learning Performance Test,
1993) ability, etc Seashore Rhythm Test, Battery for Children
Speech Sounds for 9 to 14 years
Age Range: 15+ years Perception Test, Finger
Tapping Test, Sensory
Perceptual Examination
and the Lateral
Dominance
Examination

Trail Making Test Part An initiative under

MATRICS Speed of Processing A; BACS Symbol NIMH’s Measurement
Consensus Cognitive Attention/Vigilance coding; Category fluency and Treatment Research
Battery Working Memory (verbal) test, animal naming test, to Improve Cognition in
Verbal Learning Continuous Schizophrenia;
(Nuechterlein & Visual Learning Performance Test: The MCCB Computer
Green, 2004) Working Memory Identical Pairs, WMS, Scoring Program
(nonverbal) spatial span subset; converts primary raw
Age: 18 and above Social Cognition Letter Number Span scores to a
Reasoning and Problem test, Hopkins Verbal corresponding T-scores
Solving Learning Test Revised, and percentiles, along
Brief Visuospatial with a graphic profile of
Memory Test Revised, the scores for each of
NAB - mazes subtest), the seven cognitive
MSCEIT managing domains
emotions branch
32 subtests under 6 Designed to test
A Developmental Includes a series of domains: cognitive functions not
NEuroPSYchological neuropsychological tests covered by general
Attention
Assessment – 2nd that are used in various ability or achievement
combinations to assess Executive Functions
Edition (NEPSY II) batteries
neuropsychological Language &
The test allows for
(Korkman et al, 2007) development in children Communication
selective assessment by
Sensorimotor Functions
selecting certain subtests
Age Range: 3 to 16 Visuospatial Functions
based on need that helps
years Learning & Memory
reduce testing time
Social Perception
Neuropsychological The NAB consists of
Assessment Battery Attention, working five domain-specific Includes a screening
(NAB) memory, processing modules: module that identifies
speed, aphasia, visuo- Attention whether further
(Stern & White, 2003) perceptual skills, visual Language assessment should be
scanning, recall, Memory conducted
Age Range: 18 to 97 recognition, planning, Spatial Helps generate
years problem solving, mental Executive Functions hypothesis of differential
flexibility, verbal fluency (Zgaljardic & Temple, diagnosis and estimate of
2010) domain functioning
(Panchal, 2019; Bhattacharya, 2013)

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OTHER TESTS WITH POSSIBLE INDICATORS OF NEUROPSYCHOLOGICAL FUNCTIONS:

A number of traditional psychological tests also have neuropsychological indicators which can alert a clinician
to the possibility of neuropsychological deficits.
 Piotrowski Signs for identifying brain impairment on Rorschach Inkblot Test (Hughes, 1948).
 TBI patients score above base rate value on MCMI –III scales of Anxiety, Dysthymia, Somatoform,
Narcissistic, Anti-social, and Passive-Aggressive (Ruocco et al, 2007, Tuokko et al, 1991).
 In TBI patients, MMPI-2 Scale of Hysteria, Schizophrenia, Psychopathic Deviance tends to be elevated
(Edmundson et al, 2016).
 Elevations on MMPI-2 scales- Hypochondriasis, Depression, Hysteria, and Schizophrenia have been
reported for workers exposed to neurotoxic substances (Butcher, 2013).

FACTORS AFFECTING NEUROPSYCHOLOGICAL TEST PERFORMANCE:

Comprehensive neuropsychology testing requires a combination of ideometric and quantitative psychometric

approaches. Ideometric approach in the context of neuropsychological assessment emphasises the patient’s
premorbid functioning with reference to education, occupation, social and occupational functioning as well as
performance on other neuropsychological tests. Factors such as the patient’s currents sensory/motor
deficiencies, motivational deficits and fatigue level are noted. On the other hand, the psychometric approach
takes a ‘here and now’ view. It interprets objective scores with reference to normative data, without considering
previous history or current functioning in other areas (Heaton & Pendleton, 1981).

While the patient is undergoing the test, the neuropsychologists must observe the factors which may contribute
to the failure of the patient in performance of a given task. Examples of such factors include unfamiliarity with
timed tests, inability to pay attention for the required length of time, inability to modulate the mental effort
required by a task, poor motivation, poor insight, premorbid characteristics such as impulsivity, unwillingness
to try out new things, etc. Another set of factors that affects patients’ level of functioning is deficits in specific
areas, which can hamper the patients’ performance in a specific test. Example of these include deficits of visuo-
spatial perception hampering performance on construction tasks, poor comprehension hampering performance
on verbal memory tests, and visual difficulties impairing performance on visual memory tests (Panchal, 2019).

Additionally, neuropsychological assessments cannot be used with individuals with profound and pervasive
cognitive deficits, such as moderate to severe mental retardation, developmental disorders such as Autism and
Down’s Syndrome. Also, it cannot be used with those individuals who are uncooperative, are over medicated,
have severe oppositional and conduct behaviour, and those who are floridly psychotic (Tiwary et al, 2016).
Thus, a comprehensive account of the patients’ premorbid functioning and current performance is essential to
understand the performance on a neuropsychological test (Lezak, 1976).

CONCLUSION:

Neuropsychological assessments play a key role in differentiating between organic and functional disorders by
highlighting discrepancies between subjective complaints and objective performance and detecting
inconsistencies in the patients' performance and the mismatch between performance and daily life activities.
The baselines of cognitive functioning provided by the neuropsychological examination is also useful in
planning the future medical and social care of the patient as well as for planning and monitoring rehabilitation
programmes. However, all the tests are not found to have high validity and reliability, as seen in recent literature.
Neuropsychological Evaluation Sayeed.N, Shanbhag.T, Unnikrishnan. S
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 APPENDIX I
Some of the most commonly used neuropsychological tests with regard to the population:

Population
Cognitive
Domain Child Adult Elderly
Peabody Picture Peabody Picture Vocabulary Test
Peabody Picture Vocabulary Vocabulary Test Boston Naming Test
Test Boston Naming Test Boston Naming Test
Language Token Test Controlled Oral Word
Controlled Oral Word Controlled Oral Association Test
Association Test Word Association Boston Diagnostic Aphasia
Boston Naming Test Test Examination
Boston Diagnostic
Aphasia Examination Western Aphasia Battery
Western Aphasia
Battery
Wechsler Memory Wechsler Memory Scale
California Verbal Learning Test Scale California Verbal Learning Test
for Children PGI Memory Scale Cambridge Prospective Memory
Benton Visual Retention Test Scale
Memory & California Verbal Benton Visual Retention Test
Learning Learning Test Rey Auditory Verbal Learning
Rey Osterrieth Complex Figure
Test Cambridge Test
Prospective Memory Consortium to Establish a
Scale Registry for Alzheimer’s Disease
Neuropsychological Battery
Benton Visual
(CERAD)
Retention Test
Cambridge Cognitive
Rey Auditory Verbal Examination (CAMCOG) based
Learning Test on Cambridge Mental Disorders
of the Elderly Examination
(CAMDEX)
Wisconsin Card Sorting Test Wisconsin Card Wisconsin Card Sorting Test
Executive Sorting Test MMSE
Functions Stroop Colour & Word Test Stroop Colour & Stroop Colour & Word Test
Word Test Trail Making Test
Tower of London Test Trail Making Test N Back Test
N Back Test Tower of London Test
Tower of London Delis Kaplan Executive
Test Functioning System (D-KEFS)
Attention Digit Span Test Digit Span Test
& Speed of Letter Cancellation Test Letter Number Digit Span Test
Processing Sequencing Letter Number Sequencing
PASAT PASAT
Letter Cancellation Letter Cancellation Test
Test
Perceptual Peg Board Test Bender Gestalt Test Bender Gestalt Test
Motor Bender Gestalt Test - II Behavioural Behavioural Inattention Test
Functions Inattention Test Benton Facial Recognition Test
Benton Facial
Recognition Test
Stanford Binet Test of
Intelligence – V Wechsler Adult Intelligence Scale (WAIS IV)
Bhatia Performance Test of
Intelligence Wechsler Adult Performance Intelligence Scale (WAPIS)
Intelligence Malin’s Intelligence Scale for
Indian Children (MISIC) Kaufman Adolescent and Adult Intelligence Test (KAIT)
Wechsler Intelligence Scale for
Children (WISC) Wechsler Abbreviated Scale of IQ (WASI)
Wechsler Preschool and
Primary Scale of Intelligence
(WPPSI)
Kaufman Assessment Battery
for Children (K-ABC II)
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 APPENDIX II

Instructions and administration guidelines for some tests:

Wechsler Adult Intelligence Scale (WAIS IV) – 4th Edition India

Test/Sub-test Administration/Instructions
Block Design Working with a specified time limit, the examinee views a design and uses red and white
blocks to recreate the design, for a total of 14 designs
The examinee is read out two words that represent common objects or concepts and is
Similarities required to describe how they are similar. “In what way are and _ alike?” If the response
is vague, follow with “What do you mean?” Or “Tell me more about it.” Continue for
18 items or till 2 consecutive failures.
For Digit Span Forward, the examinee is read a sequence of numbers and recalls the
numbers in the same order. For Digit Span Backwards, the examinee is read a sequence of
number and recalls the numbers in reverse order. For Digit Sequencing, the examinee is
read a sequence of number and recalls the numbers in ascending order. Read each trial at
Digit Span verbatim at the rate of one digit per second, dropping voice slightly on the last digit in the
sequence. If examinee starts to respond before finishing of reading of trial, say,
“Remember to wait until I’ve finished before your start.” If examinee asks to repeat, say,
“I cannot repeat the sequence. Just take your best guess.” Continue for 8 items in each
or until 3 consecutive failures.
The examinee views an incomplete matrix or series and selects the response option that
completes the matrix or series. Open the stimulus booklet and show Item and say “Look
at this picture. You will choose which one of these (point across response options) goes
Matrix here (point to box with question mark). The right answer will work going across and
Reasoning going down (point to row and column with question mark). You should only look across
and down to find the answer. Do not look diagonally.” Continue for 26 items or until 3
consecutive failures.
For picture items, the examinee names the object present visually. If vague or generalized
Vocabulary answers are given, say, “What else is it called?” For verbal items, the examinee defines
words that are presented visually and orally. Say, “Listen carefully, what does mean?”
If the response is unclear, say, “Tell me in words what that is.” Continue for 30 items or
until 3 consecutive failures.
Working within a specific time limit, the examinee mentally solves a series of arithmetic
problems. Read each item 1-5 with a corresponding picture and items 6 – 22 verbally.
Arithmetic Paper and pencil are not to be used and the examinee is discouraged from writing on the
table with a finger. Items may not be repeated and clarify if multiple answers are given.
Continue until 22 items or until 3 consecutive failures.
Working within a specific time limit, the examinee scans a search group and indicates
whether one of the symbols in the target group matches. Each item has two target
Symbol Search symbols and a search group with five symbols which have to be marked in the box given.
Ensure to do them in order and not to miss any before proceeding to the next item.
Discontinue after 120 seconds or stop the time if examinee finishes before 120 seconds.
Working within a specific time limit, the examinee views a completed puzzle and selects
three response options that, when combines, reconstruct the puzzle. Demonstrate the
task and allow sample practice, give feedback. If pieces are incorrectly oriented, say, “You
Visual Puzzles may have to turn a piece in your mind to make it fit the puzzle”. If examinee selects
lesser that 3 response options, say “You need to choose three pieces to make the puzzle.”
Continue for 26 items or until 3 consecutive failures occur.

Information The examinee answers questions that address a broad range of general knowledge topics.
Read each item in verbatim and repeat if necessary. If response is vague, say, “What do
you mean?’ or “Tell me more about it.” Continue for 26 items or until 3 consecutive
failures.
Coding Using a key, the examinee copies symbols that are paired with numbers within a specific
time limit. Use demonstration item to explain and repeat if necessary. If a mistake is made
and examinee asks what to do, say, “That’s ok. Just keep working as fast as you can.”
DO not discourage from making spontaneous corrections until it is repeatedly done. If
a row is omitted or started from reverse order, say, “Do them in order. Don’t miss any.”
Discontinue after 120 seconds or stop the time if examinee finishes before 120 seconds.

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 Bhatia’s Performance Test of Intelligence
Test/Sub-test Administration/Instructions
Place four cubes before the examinee. Explain how they are all alike and coloured in a
particular way. Let the examinee handle and examine the cubes. Show card No. l and say
that a design like this has to be prepared with the cubes. Even if an attempt is made to
prepare the design, the examiner should demonstrate this design to every examinee. Mix
up the blocks. Now ask examinee to prepare design No. l as already shown. Note the
Koh’s Block time. If the examinee succeeds in the above within the time limits namely 2 minutes,
Design Test proceed to design No. 2 and ask to construct it without any demonstration or help from
examiner’s side. Proceed in this manner with successive designs. When the examinee fails
in a particular design within the time limit, demonstrate the design after failure has
occurred. Do not discuss. Do not allow to try this design, pass on to the next which of
course, must again be tried independently by the examinee. When the examinee comes
to design No.6, give five more blocks making the total nine; and when examinee comes to
design No. 8, give the remaining seven making the total sixteen. Stop the test when
failure has been recorded twice in succession. The time limit for designs Nos. 1-5/ is 2
minutes each and for designs Nos. 6-10 is 3 minutes each.
Take the first and the smallest box, and the card No. l. Point out to the examinee that
the red block has been placed near the blue end and the blue blocks near
the red end. Explain that the red block must come to the red side and the blue blocks
to the blue side as in the card. Emphasize that blocks have not to be lifted but may only
be moved. Demonstrate the solution of the first box to every examinee. Again, place the
card No. l and the box and ask the examinee to do as you have already just
demonstrated. Record success or failure within the time limit. Proceed to design Nos.2,
Alexander Pass 3 etc. with the appropriate boxes, and after having placed the blocks properly in the initial
Along Test position as required in the test. The initial position is obtained by simply reversing the
coloured ends of the box. The coloured ends of the box must however be finally placed
before the examinee as in the Design Card, which must be presented to the examinee
with the number of the card. When the examinee fails in a particular design within the
time limit, demonstrate the design after failure has occurred. Do not discuss and do not
allow to try this design again. Pass on to the next which of course must again be tried
independently. Stop the test when failure has been recorded twice in succession. The
time limit for designs 1 to 4 is 2 minutes each and for designs 5 to 8 is 3 minutes each.
There are eight patterns of increasing difficulty from the 1st to 8th. Give the following
instructions to the examinee. “Here is paper and a pencil, I shall show a figure to you”
Place a card before the examinee. Let the card be so displayed, the number of the card
appears at the top before you. “And now, make a figure like this without lifting your
pencil when once you have started drawing.” The card should remain in full view of the
examinee throughout. Let the examinee try successive patterns. Stop when failure is
recorded twice in succession. Provide a plain white sheet of paper to the examinee on
Pattern which to draw the patterns. Successive patterns may be drawn on the same sheet as long
Drawing Test as there is room. Put the name of the examinee at the top corner. Allow a maximum of
2 minutes for each of the first four patterns. Allow a maximum of 3 minutes for patterns
Nos. 5 to 8. The examinee may make as many attempts on the paper within the time
limit. Demonstrate the first pattern, if necessary. It is only meant to give the examinee
confidence and facility in drawing. When a failure occurs in one of the patterns,
demonstrate this, but do not let the examinee try this pattern again. Pass on the next.
Stop when failure is recorded in two successive designs. Watch the examinee while he is
drawing. If a line is repeated or the pencil is lifted, remind examinee of the conditions.
Ask to commence after proper thought. If a drawing is made wrong, cross it out and ask
to start afresh. Encourage examinee to try as many times within the time limit before you
record a failure in a particular pattern. The solutions are given at the back of the cards.
Examiners must try out the patterns first. Examiners must know solutions other than
those given which may also be possible and thus it should be familiar.
Immediate For the Direct: Hindi consonants have been taken as the units of sounds, because they
Memory for put the literate and the illiterate at par. Give the instructions to the examinee: “I will say
Sound something. Listen attentively. Report it after I have finished.” We start with two letters
or sounds. This is merely to give practice to the examinee. Read out distinctly and with
even intonation. Processed with more letters till failure is recorded. Under each heading,
we have given three alternative sets of letters. If failure is recorded in the first set, try the
second and the third alternative set. If failure is recorded in all the three alternatives, a
final failure is recorded, and we stop. We do not proceed up the series anymore. For
Reversed: The instructions in this part are: Whatever I say you must say backwards. If I
say "Ka Cha", you say "Cha Ka". Explain this reversal process clearly to the examinee if

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 necessary, using another set of two syllables as a second example. Proceed up the series
till failure is recorded. Failure means a failure in all the three alternatives of a particular
set.
The general instructions will be: “Here are a number of pieces (specify 2,4,6,8,12, as the
case may be) of a picture. Put the pieces together to form a picture”. Start with the 1st
sub-test. Most individuals will be able to do this themselves without any aid, but, in any
case, demonstrate and explain clearly what is to be done. This first sub test is only to give
practice and to let the examinee understand clearly what is required to be done. Pass on
Picture them to the 2nd (Picture divided into four parts) 3rd (Picture divided into six parts), 4th
Construction (Picture divided into eight parts), and 5th the last (Picture divided into twelve parts).
Test Follow the usual procedure i.e., if failure occurs in a sub test demonstrate and then pass
on the next. Stop with two successive failures. If the examinee is able to pass the first
three subtests then in the fourth and fifth sub-tests in case of failure, record not only
failure but the number of pieces the examinee was able to fit in correctly within the limit,
i.e., for example 6 out of 8 or 7 out of 8 in the case of the fourth sub test and 6 out of
12, or 9 out of 12 etc. in the case of the fifth sub-test. The time limit is 2 minutes each
for sub-tests 1 to 3 and 3 minutes each for sub-tests Nos. 4 and 5. Record both the time
taken by the examinee and failure success.
Malin’s Intelligence Scale for Indian Children (MISIC)
Test/Subtest Administration/Instructions
VERBAL
Information The test consists of questions about factual knowledge of persons, places, and common
phenomena. It has total of 30 questions. Questions 1-5 are used for children below 8
years old or suspected mental defects. Each item is scored 1 or 0. The subject above 8
years is given credits for question 1-5 directly, if the subject passes items 6,7 & 8.
Discontinue the test after 5 consecutive failures.

Example – How many ears you have?

Comprehension The test consists of questions about certain practices and behaviour under certain
situations. It measures conventional knowledge and knowledge of social appropriateness.
It has total 14 questions. The test is discontinued after 3 consecutive failures.

Each item is scored from 0-2. Items 1-5 are scored 2 points if the subject takes personal
responsibility; and 1 point if the subjects knows what is to be done, but the responsibility
is shirked away. For item 6-14, 2 points are given when the subject gives 2 good reasons,
and 1 point when the subject gives one reason.

Example- What should you do if you cut your finger?

Arithmetic The test consists of questions based on a simple mathematical calculation which are
solved mentally. Problems 1-3 are for the subjects below 8 years or suspected mental
defectives. Discontinue after 3 consecutive failures.

Each item is scored 1 or 0. Credit is given to the subject for the first 3 items if the
subject above 8 years solves the item 4 and 5 correctly.

Example – If I break this pencil in half, how many pieces there will be?
Analogies & Analogy: The test consists of 4 incomplete sentences based on analogies that the subject
Similarities has to complete. The test is for subjects below 8 years old. Each correct analogy is given
a score of 2. Example- Lemon is sour, but sugar is ?

Similarity- The test consists of questions where the subject has to find the similarity
between the two things. It measures verbal concept formation. This test is for subjects
above 8 years. Discontinue the test after 3 consecutive failures or return to the analogy.
Each item is scored from 0-2, depending on the answer. If the subject answers the 3
items correctly in similarity, the subject is given the credit for 4 analogies.
Vocabulary The test consists of the question that measures the subject’s general intelligence. It
reflects the subject’s breadth of experience and ideas developed over the years. The test
has 40 items. Discontinue the test after 5 consecutive failures.

Each item is scored from 0 to 2. Except item 1-6 which are scored as 0 or 2. Subject can
start directly from 10th item. The subject is credited 2 points directly for the previous 9
items if he/she gives 2-point definition for 10th– 14th items.

Example- cycle, shoe, etc.

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 Digit Span In this test the subject is told a sequence of number verbally. The subject is supposed
to repeat the number in the same order. The test is divided into 2 types. They are:

Digit Span Forward- the digits are repeated as they are called out.

Digit Span Backward- the digits are repeated in the reverse order.

The score of the test is the highest number of digits repeated without error, both
forward and backward digits together.
NONVERBAL
Picture The test consists of twenty pictures in which some part of each picture is missing. The
Completion subject is supposed to tell which part of the picture is missing. The subject gets fifteen
seconds to examine each picture. The test is discontinued after four failures.
Block Design The test consists of 7 coloured blocks and a booklet with pictures of the block arranged
according to specific geometric designs. The subject has to arrange the blocks according
to the design shown in the picture. The task requires concept formation.

Scoring- the subject is given four points plus bonus according to the table for design 1
to 7. No points are given for the incomplete design.

Object This test consists of puzzles that the subject has to rearrange in meaningful design. It
Assembly requires visual-motor co-ordination, plan fullness and concept formation. The test has
four puzzles. They are manikin, horse, face and auto.

Separate scoring instructions are given in the manual for each design, and points are
awarded for number of pieces fit together correctly.
Coding The test consists of certain symbols that are paired with numbers or shapes. The subject
has to learn them and pair with the appropriate corresponding numbers. Concentration
and speed of work are important factors in this test. The test has two parts, Coding A &
Coding B.

Coding A: this part is for subjects under 8 years or suspected mental defects. The test
should be completed in 120 seconds. The score is the number of designs completed in
that time. (Excluding samples) If the subject completes the test before time bonus point
is given.

Coding B: this part is for subjects above 8 years. This section has to be completed in 120
seconds. 1 point is given for each correct response.

Mazes The test requires the subject to trace through the maze and reach the end point. The test
has 5 mazes which have to be completed in the given time limit.

Scoring- maze A, B, C are given 2 points if solved without error. 1 point if completed
with 2 errors. Mazes 1-5 are given 3 point without error, 2 points if one error is
committed, 1 point if two errors committed and 0 points when the subject passes the
maximum allowed error.
The examinee is seated and told that he must generate words beginning with a consonant.
Controlled Oral A practise trial is given with the consonants other than the ones used in the test. “I am
Word going to say a letter of the alphabet, and I want you to say as quickly as you can all of the
Association words you can think of that begin with that letter. You may say any word at all except
Test proper names such as the names of people or places. So, you would not say ‘Rahul’ or
‘Rampur.’ Also, do not use the same words again with a different ending, such as ‘run’
and ‘running.’ For example, if I say R you could say rat, river, or run. Can you think of
any other words beginning with the letter R?” If the participant says another appropriate
word that begins with R, tell participant “That is fine,” mark “Sample Completed,” and go
on to the timed test. If the participant is unable to complete the sample, do not go onto
the timed test. Do not score.

“Now I’m going to give you another letter, and again, say all the words beginning with
that letter that you can think of. Remember, no names or people or places, just ordinary
words. Also, if you should draw a blank, I want you to keep on trying until the time limit
is up. You will have a minute for each one. The first letter is C. Ready, go.”

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 Token Test

Wisconsin Card Seat the client at the table so that he or she is across from and facing the examiner. Open
Sorting Test the record booklet to the second page without making it visible to him. Stimulus cards
are then presented in the client’s perspective in a left to right order beginning with the
red triangle followed by 2 green stars, the three yellow crosses and the four blue circles.
While placing the stimulus cards the client is instructed, that the test is a little unusual
because the examiner is not allowed to tell how to do it. The examinee is then asked to
match each of the cards in the decks to one of the four key cards. The examinee is
supposed to take the top card from the deck and place it below the relevant key card.
Examiner is not allowed to tell how to match the cards but tells if the examinee is correct
or incorrect. If incorrect, the examinee is instructed to leave the card where it is placed
and try to get the next card correct. There is no time limit on this test.
Stroop Colour Word Page: “This is a test of how fast the client can read the words on the page. The
& Word Test client reads down the columns starting with the first one until he reaches the end of the
column. If the examinee can finish all the columns before the examiner says “stop” the
client is to return to the 1st column and begin again. If the examinee makes an error the
examiner says “No” to which the examinee corrects the error and continues without
stopping.

Colour Page: “This is a test of how fast the client can name the colours on the page.
The client reads down the columns starting with the first one until he reaches the end of
the column. If the examinee can finish all the columns before the examiner says “stop”

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 the client is to return to the 1st column and begin again. If the examinee makes an error
the examiner says “No” to which the client corrects the error and continues without
stopping.

Colour Page: “This is a test of how fast the client can name the colour of the ink of the
words on the page. The client reads down the columns starting with the first one until
he reaches the end of the column. If the examinee can finish all the columns before the
examiner says “stop” the client is to return to the 1st column and begin again. If the
examinee makes an error the examiner says “No” to which the client corrects the error
and continues without stopping.
Trail Making Both parts of the Trail Making Test consist of 25 circles distributed over a sheet of paper.
Test (A & B) In Part A, the circles are numbered 1 – 25, and the patient should draw lines to connect
the numbers in ascending order. In Part B, the circles include both numbers (1 – 13) and
letters (A – L); as in Part A, the patient draws lines to connect the circles in an ascending
pattern, but with the added task of alternating between the numbers and letters (i.e., 1-
A-2-B-3-C, etc.). The patient should be instructed to connect the circles as quickly as
possible, without lifting the pen or pencil from the paper. Time the patient as he or she
connects the "trail." If the patient makes an error, point it out immediately and allow the
patient to correct it. Errors affect the patient's score only in that the correction of errors
is included in the completion time for the task. It is unnecessary to continue the test if
the patient has not completed both parts after five minutes have elapsed.
Step 1: Give the patient a copy of the Trail Making Test Part A worksheet and a pen or
pencil
Step 2: Demonstrate the test to the patient using the sample sheet (Trail Making Part A
– SAMPLE)
Step 3: Time the patient as he or she follows the “trail” made by the numbers on the
test.
Step 4: Record the time.
Step 5: Repeat the procedure for Trail Making Test Part B

APPENDIX III

Definitions of the most frequently measured cognitive functions:

Domain Definition
Attention It is the behavioural and cognitive process of concentrating on a discrete aspect of
information, whether deemed subjective or objective
Complex A person's ability to maintain information. in their mind for a short time and to
Attention manipulate that information.
Selective Attention A cognitive process in which a person attends to one or a few sensory inputs while
ignoring the other ones.
Sustained The ability to focus on one specific task for a continuous amount of time without being
Attention distracted.
Alternating The ability to switch your focus back and forth between tasks that require different
Attention cognitive demands.
Divided Attention A type of simultaneous attention that allows us to process different information sources
and successfully carry out multiple tasks at a time.
Focussed Attention The brain's ability to concentrate its attention on a target stimulus for any period of
time.
Visuospatial Cognitive processes necessary to "identify, integrate, and analyse space and visual form,
Processing details, structure and spatial relations" in more than one dimension.
Visual Scanning The ability to efficiently, quickly, and actively look for information relevant to your
environment.
Spatial Intelligence The ability to mentally manipulate objects in space and to imagine them in different
locations and positions.
Visual Acuity The sharpness, clearness and focus of a person's vision.
Planning The identification of a sequence of actions required to achieve a goal and includes
thinking about alternatives and choosing the most effective one.
Inhibitory control The inhibition of a prepotent response, which facilitates the choice of an adequate
response and avoids errors.
Mental Flexibility The ability of alternating between mental sets or tasks and changing strategies within
the same task.
Working Memory A system of temporary Short-term storage, maintenance and manipulation of
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 information necessary for performing complex cognitive tasks such as learning,
reasoning, language comprehension, and reasoning.
P/K*100 Ratio of Pass Along scores and Koh`s Block design’s score as calculated on the PGI
BBD and multiplied by 100 to obtain the performance quotient.
PQ-VQ The difference between performance quotient and verbal quotient when found to be
15 or greater is indicative of organic dysfunction.
Verbal Fluency Production of spontaneous speech fluently without undue word finding pauses or
failures in search word.
Processing Speed The ability to identify, discriminate, integrate, make decisions about information, and
to respond to visual and verbal information.
Planning Identification of a sequence of actions required to achieve a goal and includes thinking
about alternatives and choosing the most effective one.
Auditory The ability to understand what is heard and attach meaning to it. The tone of the voice,
Comprehension pauses between words, emphasis used, and the rhythm and pattern of speech all impact
the meaning.
Free Recall The process in which a person is given a list of items to remember and then is tested
by being asked to recall them in any order.
Cued Recall Retrieving information from long-term memory using aids or cues. Cues can be external
stimuli, such as words, sentences, incomplete pictures, letters within a word, and so on,
as long as they have some kind of connection to the to-be-remembered (target)
information.
Delayed Recall The ability to recall specific information after a period of rest or distraction from that
information.
Immediate Verbal The capacity to recognize, recall and regurgitate small amounts of information (the 7
Memory ±2 rule) shortly after its occurrence.
Short Term The temporary store of information held in memory for about 30 seconds while it is
Memory being processed for long-term storage.
Long Term The relatively permanent memory store of information which is categorized in various
Memory ways and can be drawn upon as needed.
Lexical Encompasses all the information that is known about words and the relationships
Knowledge among them.
Semantic General information that one has acquired; that is, knowledge that is not tied to any
Knowledge specific object, event, domain, or application.
Recent Memory System for temporarily storing and managing the information required to carry out
complex cognitive tasks such as learning, reasoning, and comprehension. Recent
memory is involved in the selection, initiation, and termination of information-
processing functions such as encoding, storing, and retrieving data.
Remote Memory Refers to memory for the distant past, measured on the order of years or even decades.
It encompasses episodic (autobiographical), personal semantic, and general semantic
memory involving historical people and events.
Recognition Identification of someone or something or person from previous encounters or
knowledge.
Serial Position When participants are presented with a list of words, they tend to remember the first
Effect few and last few words and are more likely to forget those in the middle of the list.
Primacy Effect The tendency to recall information presented at the start of a list better than
information at the middle or end.
Recency Effect The tendency to recall more recent information than does earlier-presented
information.
Executive A set of cognitive processes that are necessary for the cognitive control of behaviour:
Functions selecting and successfully monitoring behaviours that facilitate the attainment of chosen
goals.
Concept The process by which a person abstracts a common idea from one or more examples
Formation and learns the defining features or combination of features that are characteristic of a
class.
Abstract A cognitive mechanism for reaching logical conclusions in the absence of physical data,
Reasoning concrete phenomena, or specific instances.
Expressive The words that a person can express or produce.
Vocabulary
Problem Solving The act of defining a problem; determining the cause of the problem; identifying,
prioritizing, and selecting alternatives for a solution; and implementing a solution.
Fluid Reasoning The capacity to think logically and solve problems in novel situations, independent of
acquired knowledge.

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