Nimhans Neuropsychological Battery Manual Pdf

[Autumn Pitz]

Traumaticbrain injury (TBI) is a major public health concern.[1] Epidural hematoma (EDH) constitutes 10% of TBI. It is a condition when blood collects between the skull and thick membrane (dura mater) which covers the brain.[2] Collection of blood exerts pressure on the brain and causes inflammation, which damages the brain's tissue resulting in transient and long-lasting cognitive impairments in attention, comprehension, working memory fluency, set-shifting, perseveration, response inhibition and planning which affect personal, social and occupational life of the patient.[3] [4]

Variables such as age, severity of injury, and neurological status have been found to play a crucial role in clinical manifestation and outcome of EDH. Apart from these variables, gender is by far the most controversial in the literature. Earlier studies showed the absence of gender differences in problem-solving performance between college students[5] as well as nursery students.[6] Recently, gender differences have been revealed by studies examining cognitive functions and the role of gender in patients of TBI. Schopp, Shigaki, Johnstone, and Kirlpatrick.[7] concluded that men underperformed women on certain memory tasks specifically, on verbal memory, after a TBI. Research, using Traumatic Brain Injury Model Systems [8] also revealed the effect of gender on executive function, wherein women outperformed men. Women were also reported to achieve better composite scores on verbal memory in comparison to men.[9] In contrast, differing conclusions exist for gender effect on verbal and visuo-spatial domains of patients with TBI. Broshek et al[10] reported that women had more verbal and visuospatial memory deficits after an injury as compared with men. However, Harness et al[11] found that though there were insignificant gender differences in verbal recall task, women performed better on visuospatial tasks.

Review of preceding manuscript shows that gender is most controversial in the research community, especially when it comes to brain injury. Furthermore, existing literature on gender differences in neurocognitive outcome of EDH have been equivocal. Hence, current inquiry was aimed to explore gender differences in terms of comprehensive executive functions of recovered post-surgery EDH male and female patients matched for age, duration, and severity of injury using standardized assessment tools. In light of previous studies, we hypothesized that there will be gender differences in executive functions of males and females recovered post-surgery EDH patients.

To rule out any co-morbid psychiatric illnesses in the patients, MINI was used.[13] It is a structured interview schedule put together by clinicians and psychiatrists and is also an integral part of DSM IV and ICD 10.

This test battery was used to assess neurocognitive functions of participants. The NIMHANS[14] battery is also used internationally, and normative data regarding percentiles and cut-off scores have been established for Indian adults between the ages of 16 and 65. It includes the following sets of tests:

Digit Symbol Test measures sustained attention and visuomotor coordination. The test taker needs to substitute the number inside the cell with a symbol, using the key for number-symbol substitution at the top as a guide. The numbers range from 1 to 9 and are arbitrarily assigned in four rows of 25 cells each.

Color Trails test is a more cross-cultural test involving the use of focused attention. Sustained attention, perceptual tracking, and sequencing are included in part 1 of the test, and mental flexibility is involved in part 2.

Digit Span test includes forward and backward span tests. The forward span measures attention efficiency when the subject needs to repeat the numbers in the identical sequences as said aloud by the tester. In backward span, the executive function of working memory plays the major role, wherein the subject repeats the numbers in reverse order as said aloud by the tester.

N back tests involve encoding and working memory. The 1-back version requires the subject to point out if the letter (n) being narrated has been repeated n-1 time, requiring verbal storage and rehearsal. On the contrary, the 2-back version needs the subject to point out if the letter (n) has been narrated n-2 times in the sequence of intervening letters. The scores are calculated based on hits and errors made in both tests.

Tower of London test is used to evaluate mental preplanning in participants. The test entails two matching wooden boards having three round pegs with different colored beads/balls in each. First, a stimulus board (model of pegs and beads) is presented to the participant, and then the target pegs and beads have to be arranged to match the stimulus board.

Auditory Verbal Learning Test [15] measures attention, concentration during learning, and under overloaded conditions too. It contains of two lists, A and B. List A (15 words) is presented to the subject five times, followed by a recall of the list after each presentation. After five such recalls, List B of 15 different words is presented, and an immediate recall is asked. After that a recall of List A without presentation is asked, followed by a presentation of a recognition list to identify all the words belonging to List A. This test successfully measures delayed recall and recognition of stimuli too.

Complex Figure Test [16] assesses visuospatial/constructional ability and visual memory ability through immediate recognition and recall of a complex figure of lines that are abstract in nature. Accordingly, it is scored depending on the overall copied structure and multiple subcomponents of the reproduced drawing.

Auditory working memory was evaluated by Letter Number Sequencing Test[17] that includes auditory stimuli by using subtests Wechsler Memory Scale 3rd edition includes 11 subtests, i.e., 6 primary subtests and 5 optional ones. Dr. Pushpalatha Gurappa (NIMHANS, Bengaluru) has adapted it according to the Indian population to assess immediate, delayed recall, and working memory.

A database of TBI patients of the past 3 to 5 months was reviewed, revealing that 216 patients with EDH were operated. The screened data revealed that 17 patients were deceased, 21 patients had severe TBI, 11 did not fall in the age range of 20 to 60 years, and 18 were illiterate. Other 9 patients were excluded because of medical illnesses, 15 patients had some co-morbid neurological conditions (1 patient reported for CVA, 2 had stroke, 2 reported having hippocampal sclerosis, 4 had stroke, and 6 patients had dementia), 8 patients were excluded because of co- morbid psychiatric illness (generalized anxiety disorder-1, bipolar disorder- 2 and five patients had depression), 17 patients had record of substance abuse and 2 patients were intellectual disable. Exclusion was also based on disagreement with participation in the study. The patients recruited using the inclusion criteria mostly suffered TBI due to injury in road accidents. Seventy-three such patients were enrolled, out of which 11 were unable to complete the entire assessment. The clinical and demographic details of the participants recruited are listed in [Table 1].

Mean scores showed that males to be higher in total time and total error than females on tests of attention (divided and sustained), concentration, and mental speed measured by the Color Trails Test and Digit Symbol Test; however, differences between group mean are insignificant. On test of working memory, female group scored better as significant differences were found on N-Back (2 Back) and digit span-backward. Here, again male group took more time and committed more errors than the females. On COWA (total response), a significant difference was revealed as females scored higher than males. Both genders performed equally on WCST (except percentage perseverative responses), Stroop test, and Tower of London Test, which suggest no difference in the planning aspect of executive functioning among both genders.

The present study investigated gender differences in executive functions among patients operated for EDH. Most patients in this study had a history of frontal lobe involvement, which is considered the seat of executive functions [attention, reasoning, judgment, problem- solving]. It is shown that disruptions in executive functions become more evident in patients with frontotemporal lesions followed by a TBI.[20] [21]

A left-hemispheric laterality in females compared with the right-hemispheric laterality in males reflects the cognitive sex differences regarding verbal-working memory tasks.[25] This finding is per the previous research concluding superior performance of females in verbal task performance.[26] The pediatric population also showed a similar trend in which girls with TBI performed significantly better than boys on verbal skills and working memory tasks.[27] Females also outperform on sub-tests of verbal ability[28] and other tasks such as sentence formations, spellings, reading, and pronunciation.[29] These cognitive sex differences also highlight a better performance by females in verbal episodic memory tasks[30] and in remembering past episodes.[31]

However, keeping in view contradictory findings of other research where women showed attenuated recall of verbal stimuli compared with men,[25] further research is suggested to come to a generalization.

Authors have also noted that females perform better on tasks involving executive functions of strategic planning, organized searching, and set-shifting, such as the Wisconsin Card Sorting Test and in other frontal lobe functions. Females have better percentage perseverative responses on WCST than males. Research suggests that females hold a higher ground in self-regulation and adapt to environmental changes[36] due to better performance on six WCST scores (errors, categories, perseverative errors, perseverative responses, to conceptual level responses and trials to first category). This suggests, females have fewer deficits in their set shifting ability post-surgery and were able to maintain some aspects of mental flexibility better than males after TBI.[37] Females are concluded to outperform males on WCST irrespective of educational levels and ethnicity, highlighting an independent gender effect. [9]

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