neuropsychological testing in occupational medicine · confronting subject prior to arrest: a. must...

Rutgers, The State University of New Jersey

Neuropsychological Testing in Occupational Medicine

When is a referral appropriate and what will neuropsychological testing

offer?

Nancy Fiedler, Ph.D.


Objectives

• Determine when to make a referral for a neuropsychological

evaluation

• Structure a relevant referral question for neuropsychological

evaluations

• Interpret typical neuropsychological reports

• Recognize the strengths and weaknesses of

neuropsychological testing

• Distinguish psychiatric from neuropsychological testing

protocols and how these domains interact to affect job

performance


Neuropsychological Tests: observable and quantifiable behaviors

• Domains of cognitive and sensory function

– Attention

– Working memory

– Motor and Processing speed

– Verbal and visual memory

– Perceptual organization

– Executive function

GENERAL INTELLIGENCE


Psychiatric Testing: self and other report

• Structured and clinical interviews (self report)

• Personality testing (MMPI, CPI)

• Acute symptom reports (e.g., SCL-90, Beck

depression)


When to refer for neuropsychological testing:

• Employee with a pattern of compromised

performance not attributable to organizational issues

such as lack of training or poor supervision

• Baseline testing of cognitive performance to monitor

progression of disease or disability

• Differentiation of compromised cognition from

stress-related cognitive complaints


The Referral Question• Employee X has exhibited a sustained pattern of

poor performance as indicated by the following:

– Attendance

– Documentation of supervisor ratings of job duties

– observable behaviors at work

• Is this employee capable of performing the following

job duties:

– Job duties of concern

– Job description with behavioral indicators


Psychiatric and/or neuropsychological deficits

• Common referral question:

– “I want a neuropsychological evaluation of this employee”

• Employee exhibiting bizarre behavior at work:

inappropriate with supervisors and students

• Reporting that others are discriminating against her

• No clear evidence of any physical illness or injury

preceding these episodes


Neuropsychological testing is not a

substitute for appropriate employee

supervision, training, and

documentation of work performance


Why Neuropsychological Tests?

• Indicators of functional impairment at exposure levels

below those that produce overt tissue or organ damage

• Simple, noninvasive methods to monitor effects of

exposure or disease

• Functional correlates of central nervous system

• Standardized, behavioral evaluation of specific

cognitive skills

• Performance compared to normative standard

• Indicator of impaired behavior that could compromise

safety on the job


Ecological Validity

• Are the decrements observed clinically

meaningful?

• What critical functions do they predict?


What is Clinical Impairment?


When does a neuropsychological decrement compromise safety?

• Tasks to be performed require vigilance and

working memory (e.g., monitor complex

operational systems)

• Driving or operating vehicles (analogy to ETOH)

• Fine motor coordination and steadiness required

to perform operations (machinery, discharge a

weapon, surgery) It depends. . .


Interpretation of Neuropsychological data must incorporate patient history and mental

status

• Psychiatric & Medical History- ETOH & Drug Use- Head Injuries- Neurologic Disorders- Major Medical Illness

• Current Mental Status- Thought Disorder- Oriented to Person, Place, & Time- Use of Prescription & Over-the-Counter Medication, Caffeine, Alcohol


Patient Characterization

• Sensory Function

- Vision

- Hearing

- Tactile Perception

- Estimate of Premorbid Intellectual Function

- school performance


When to refer for neuropsychological testing: brain injury due to accident

32 year old, single, Caucasian police officer

College education

Traumatic brain injury in MVA

Coma for one month

subarachnoid hemorrhage, subdural hematoma

Cognitive rehabilitation for 2 years

SSRI antidepressant treatment for one year

Can this employee perform his job?


Fitness for Duty: Police Duties1. Confronting subject prior to arrest:

A. Must be able to effectively communicate, sometimes in a commanding manner, to instruct a suspect or criminal

2. Must possess and carry a service weapon at all times

3 Must possess the ability to determine when deadly force shall and shall not be used

4. Observe, record, recall and report incidents and information on police matters

5. Maintain high mental alertness and readiness to act even during extended period of calm and inactivity

6. Understand and follow orders, policies and procedures


Fitness for Duty: Police Duties (Cont’d)7. Withstand and deal appropriately with high levels of stress inherent

in police work without presenting any risk to oneself or others

8. Must have the ability to organize and remember critical facts concerning the investigation

9. Must be capable of managing people in distress

10. Must be able to effectively interview/communicate with victims, suspects, witnesses and informants

11. Communication skills to verbally direct and control victims, crowds, and other emergency response personnel in any crisis to ensure the safety and preservation of life and property (loud and soft tones of voice)

12. Writing skills to depict events of police investigation


2002 Test Administration


• Psychomotor– Reaction time, vigilance, digit symbol

• Concentration & Information Processing– Digit span, mental arithmetic

Perceptual Motor & Attention/Concentration

Neuropsychological Testing in Occupational MedicinePsychomotor Skills – motor speed, eye hand coordination

Finger Tapping Grooved Peg Board


2002 AdministrationAge & Education Corrected T-Scores

01020304050607080

Finger Tapping Grooved Peg

Dominant Non-Dominant

Average


Monitor Progression of Cognitive Skills in Rehabilitation:

One-year follow-up after cognitive rehabilitation


01020304050607080

Finger Tapping Grooved Peg

Dominant Non-Dominant

2003 AdministrationAge & Education Corrected T-Scores

Average


Job duties and cognitive rehabilitation

• Capacity to carry and use a weapon

• Ability to remember details of incidents

• Make judgments of when force is required

• Slowed motor speed• Memory function

within average range• Processing speed

and working memory within average range

• Comprehension and problem solving within normal range


Deterioration of Work Performance

58 year old, married, Caucasian male

Master’s degree in social work

20 year history of alcohol abuse: dependence and

blackouts

11 year history of anxiety and depression

Stable SSRI treatment


Job Performance: interaction of psychiatric and neuropsychological deficits

• Memory loss at work – forgetting conversations;

frequent questions

• Lack of supervisory direction for employees

• Difficulty completing tasks that were previously

routine


Verbal and Visual Memory -The ability to register, store, and retrieve learned information

• Verbal MemoryWord lists or associations: List A (Monday List)

drill chivesplums tangerinesvest chiselparsley jacketgrapes nutmegpaprika apricotssweater plierswrench slacks

Short Stories: Story AAnna Thompson / of South / Boston /, employed / as a cook/ in a school /cafeteria /, reported / at the City Hall / Station / that she had been held up /on State Street/ the night before/ and robbed/ of fifty six dollars/.


Job duties vs. neuropsychological results

• Forgets conversations and work instructions

• Poor supervision of employees

• Difficulty completing tasks that were once routine

• Verbal memory impairment

• Depression• Processing speed is

slowed


Progressive Dementia

• 30 year old, black, single female

• College graduate in chemical engineering

• Employed as an environmental engineer

• Severe headaches caused by cerebral aneurysm

• Left frontal craniotomy to repair the aneurysm

• Vocational rehabilitation for one year

• Hospitalized for paranoid ideation

• Stelazine, cogentin, tenormin


Work Performance

• Unclear written correspondence

• Inaccuracies in work

• Requires close supervision

• low mood and poor attitude in response to

criticism


01020304050607080

Infor

mation

Digit S

panVoc

abula

ryArit

hmeti

c

Compreh

ensio

nSim

ilarit

ies

Pictur

e Com

pletio

n

Pictur

e Arra

ngemen

tBloc

k Desi

gn

Object

Asse

mblyDigi

t Sym

bol

Verbal

Perfor

mance

Full Sca

le

Age/Education Corrected T-Score

WAIS-R

Average


Executive Function

Ability to think in concepts and to generalize from

specific instances; ability to plan and think ahead

based on anticipated consequences

• Proverbs - What does this saying mean?

“Shallow brooks are noisy”

• Similarities -

In what way are an ORANGE and a BANANA alike?


Executive Function

• Card Sorting -

• Tower Tests -


01020304050607080

Trail Making Test A Trail Making Test B

Age/Education Corrected T-Score

Mental Flexibility

Average


Verbal Learning and Memory

02468

1012141618

Trial 1

Trial 2

Trial 3

Trial 4

Trial 5

Trial B Free Cued

Free Cued HitsPese

rv.

Number Correct Perseverations

List A Immediate Short Delay Long Delay Recog.


Matching job duties with neuropsychological results• Job title: engineer• Written reports

contain significant errors

• Does not notice errors in spite of numerous corrections

• College education as normative base

• Complex learning impaired: arithmetic, conceptual problems/abstract thinking

• High perseverations on verbal learning


Psychiatric vs. Organic Brain Syndrome

• 46 year old, married, high school educated,

Caucasian male

• Exposed to chlorodifluromethane (Freon 22) in work

as a refrigerator mechanic

• No loss of consciousness but pt. Reported fearing he

would die

• Numerous symptoms including poor concentration,

dizziness, depression, fatigue, panic, poor memory


Indices of Poor Effort:

• Test of Memory Malingering

• Recognition memory worse than recall of newly

learned information

• Symptoms are inconsistent with injury

• Performance on easier tasks is worse than on more

difficult tests

• Inconsistent performance


0

20

40

60

80

100

120

Verbal C

omprehen

Percept. O

rganiz

Working Memory

Process. S

peed

Auditory Im

med

Visual Im

med.

Immed. M

emory

Auditory-Dela

y

Visual-D

elay

Auditory Reco

g.-Dela

y

Genrl. Mem

ory

Working Memory

WAIS-III WMS III

Index Score Summary


0

10

20

30

40

50

60

Trial 1

Num

ber

of C

orre

ct R

espo

nses

Patient No Cognitive ImpairmentTraumatic Brain Injury Dementia

Test of Memory Malingering


MMPI-2

30405060708090

100110120

Hysteria

Depressio

nHypochondria

sis

Masculin

ity/Fem

inityParanoia

Psychasthenia

Schizophren

ia

ManiaSocia

l Intro

version

T-Score

Average


Continuum of Effects

• Test Sensitivity in descending order

– Mood and symptoms

– Motor speed

– Psychomotor speed/latency of response

– Working memory & vigilance

– Learning and memory

– Executive function and judgment

– Intelligence


Conclusions

• Neuropsychological tests can predict the ability to perform specific job duties, but are best for jobs that require skills similar to what the tests evaluate

• Questions of fitness for duty need to be accompanied by behavioral descriptions of job duties and evidence of on-the-job employee behavior

• Behavioral data rather than diagnoses are most informative about the ability to perform a job – testing can provide such data

neuropsychological testing in occupational medicine · confronting subject prior to arrest: a. must...

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