 Most of you here would know what neuropsychologists are and what we do. We're basically just psychologists who've got a little bit of extra training in how the brain works, what changes the brain might be experiencing, what might be causing those changes, and what we can actually do about those changes. And as a neuropsychologist, the model that I find really, really helpful in explaining both to clients, to families what's going on is a model that looks at the brain working in three basic systems. Those systems are arousal, reception and storage of information, integration and feedback of general behaviour, general information patterns. So if we're looking at those basic areas, the arousal systems, it's just this, your brain stem. If we go back a little bit, I can just go back up to this reception and storage of information. This is the posterior lobes. So these brains store information. They receive information, they integrate it and they hang on to it if our brains are working. These parts of the brain are the frontal part of the brain. This part of the brain is the one we actually use to integrate, to regulate, to plan, to problem solve. We've talked about cognition, we've talked about the different aspects of cognition earlier today. But when we're thinking about how all these things work together, what we need is a simple framework to be able to explain to ourselves and also to explain to our clients and our families how the brain is actually functioning, what changes might be happening. Another really important thing to bear in mind is the lateralisation of the brain. This is left hemisphere and right hemisphere. Now the left hemisphere is actually specialised for one particular task and that's sequencing, zooming up on information, analysing things in detail. The right hemisphere, the non-dominant hemisphere, is looking at the big picture. It's almost like a wide angle lens that's looking at everything in the world, trying to focus on that information but in a very wide angle sense. Left hemisphere is focusing on the detail. So if you can imagine you've got a little bird that's trying to pick at a worm in the garden, the left hemisphere for the bird is focusing on the task which is the microscopic analytical task. Left hemisphere is working very well, sequencing. The right hemisphere is checking the outside world where's the danger coming from. The left hemisphere is operating too much in that balance. I'm focusing on the worm and that's very dangerous for me because I'm going to miss the hawk. So when we're looking at the types of things from a driving perspective, we're saying what are the skills that are involved in driving? How do they fit together with what we're doing? So that's basically a neuropsychological framework that helps us to try and understand the problems that clients bring to us and how we work with clients to try and adapt some of their behaviours. So what's a neuropsychological assessment? Basically a neuropsychological assessment is like any assessment. We're looking at behavioural observations, what we see, what the person brings into the room, presentation, appearance, voice, what the client tells us, what they're talking about, what they're talking about, their symptoms, what other people are telling us, their informant reports. Now the stuff at the bottom, the neuropsychometric assessment, is something I think that we'll focus on a little bit more detail later on. But those four elements are involved in all of our clinical interventions and we'll have different levels of information for all of those. We might not have some information as strongly as we'd like or as detailed as we like, but nevertheless these are the sorts of frameworks that we're trying to use to piece together. If we're relying only on one particular aspect of this information, we've got a very weak clinical assessment. So we need a stronger clinical assessment. We're looking at what's going on. So again neuropsychologically, we look at functions. How's the brain actually functioning? Obviously arousal, what's happening, motivation, what's the person actually bringing into the room? And we talked about speed of processing earlier on and those sorts of things. Attention, concentration, language, dominant hemisphere, non-dominant hemisphere, memory and executive functioning. So we're looking at all those sorts of things that we're seeing and we're talking to people and listening to people which want to watch these things and see how these things might actually relate to these particular types of functions and how we might put this together in our report or our assessment or our integration of what's going on and how we can help the people and the families that we're working with. Okay. What do we know about the research, neuropsychology and driving? Okay. Generally speaking these are the things that have been sort of reported in the literature. Double MSc, general cognition, things like full-scale IQ test, attention concentration, the types of tests that you may be familiar with, things like trials A, which is just a sequencing of one number to another in a certain time span. We actually measure the time they do it. Digit span, that's the number of digits I can actually repeat back to you. 53792, 53792, that's attentional capacity. Digit span backwards is a measure of working memory. 531, 135. We'll be looking at a couple of cases in a few minutes and we'll be trying to work out what's going on for there. Language, things like the Boston naming test, so the speeches amongst us will be very familiar with that. Things like vocabulary, word knowledge, general knowledge, those sorts of types of things. Now the visual spatial skills were really particularly interesting in those as far as driving is concerned. Things like block design, we're arranging patterns for blocks, picture completion where we're looking at tasks or pictures and saying what's missing from this particular picture. And something that most of us will be familiar with, clock drawing. Clock drawing is often used and reported in the literature as a good measure of visual spatial skills. Memory, logical memory, read a story, get people to repeat the story back to us. Word list, list of words, 10 words, 15 words, get them to repeat them back to us. Executive skills, trails B, verbal fluency. Verbal fluency, how many words can you give me beginning with a certain letter? Bang, off you go. No words, no swear words, no capital letters, no words beginning, if I give you a letter like B you can't give me Ballarat and if you give me bed you can't give me bedroom, bedspread. There's many different words as you can. And people with executive difficulties have a great deal of difficulty in that task, they break the rules all the time. Interesting. Okay, what do we know about driving research in neuropsychological assessments? Well actually there are quite significant effect sizes for all of the domains with on-road tests, off-road tests and carer reports of driving abilities for all domains. That's general cognition, language including memory, visual spatial, all of those things pretty high 0.4 which is about 20% of the variance, so something significant. However, when we take the control groups out, when we just look at people with dementia, people with TBI, people with significant problems, those effect sizes disappear. They disappear because what we're dealing with is a specific population. So we're then sort of saying, well okay, how can we contribute to anything when the actual population that we're looking at are not representative of the population at large. We're dealing with specialized populations. So what do we do in the clinical settings? These are the places we work. Cannons, clinics, TBI clinics, ABI clinics. What do we actually do? Well we do what we all do. We come back to case studies. We come back to the individual person, in the individual problem, in the individual setting and say okay, what can we do about this? These are two cases here that we've seen recently through the memory clinic. 75 year old, two year history of marked language difficulties. CT here I think was showing a trophic changes, right hemisphere as well as left. 72 year old woman, three year history of language problems, increasing social withdrawal over the last 12 months. MRI was normal for that second case. So there's a bit of a trick here. One of these is still driving and passed a driving assessment. One of these cases had a number of accidents and stopped driving. So what can we actually get from the data? If we look at the double MSc, double MSc 25 out of 30, there's the pentagons underneath that, doing visual spatial stuff. On the right, well my right, double MSc 21 over 30, same thing. Qualitatively, what are we seeing? Not a lot of difference. Clocks. One's driving, one's not. What do you think clinically from looking at that? Pass the driving test. On-road and off-road. Okay, when we look at clinical observations, 75 year old was passive compliant, word fighting difficulties. 72 year old, active anxious, again with word fighting difficulties. ADLs in terms of activities of data living from the self, both reported no problems. Informants reporting problems in 16 of the 30 areas. We use structured informant questionnaires to look at these. So when we asked them about driving ability, how are you going? Yeah, fairly easy. No problems. When we asked the informant, very difficult. Fairly easy. So we start to think, hmm, okay, let's factor this into the equation. General cognition, as we said, 25 out of 30 double MSc, 21 out of 30. Look at IQ, overall IQ scale. So looking at 14th percentile for one, 7th percentile for the other. Attention digit span, one's in the average range, A's in the average range, B is in the borderline range, around about 6th, 5th percentile, something like that. Language, one is actually quite reduced. We've used a VIQ for this, which is a verbal intelligent quotient. Looking at the 18th percentile for the other, looking at the 1st percentile. So, you know, 100 people in a room, this woman's language skills, well, she'd be the lowest in the 100 people in the room. Visual spatial skills, you know, so-so. One's low average, one's borderline. And that's looking at things like picture completion and tasks like that. New learning, both significantly reduced. New lists and stories, recalls and those sorts of things. When we look at memory, which is the ability to recognize information over time, not to retrieve or recall, but to recognize, did I say this to you? Was Bell on the list? Was Bird on the list? Yes, no. Recognition for both of these people is intact. They were able to quite clearly identify information that was given to them and be accurate about that. Executive skills. Verbal executive skills are both quite reduced. Non-verbal executive skills, you know, visual spatial executive skills, if you like. Not too bad. Low average, average. Mood. Okay, what are we looking at? 4 out of 15. Wouldn't worry you too much. Nought out of 15. On the geriatric depression scale, which is sort of self-report measure. Okay. Ray complex figure copy. This is the 75-year-old. So all we're asking to do is, can you copy this for us? Make it the best copy you can. Take your time. Okay, so that's what the first one did. That's what the second one did. Now, it took her 11 and a half minutes to do that. Now, 11 and a half minutes is an important piece of behavioral observation, because this would normally take about two minutes, three minutes. So a long, long time. Very meticulous. Very detailed. Very slow. Both were pretty piecemeal. Pretty disorganized. Okay, so what we do is a structured copy. We actually make it easier for them, because I'm trying to work out, is it executive difficulties? Is it planning? Is it organization? Or is it visual perceptive difficulties? And what you can see here, for the first person, structured copy makes it easier. I do the structure. I write out the sort of the reds and the greens and the blues, put up the sequence at the top, and say, look, you copy this in this order for me. That's what they do. So again, 75-year-old, five-year-old, not too bad. 73-year-old. I gave her five breaks because her sequencing, verbal IQ and the sequencing and digits backwards were so poor, I felt she needed more structure and more guidance in being able to achieve a successful outcome for her, which she did. Not a bad copy. Okay, three-minute recall. So we say, oh, you've given us something else to do. And then say to them, okay, that's the thing that I just asked you to copy just now. Can you remember of that? The one on the left and the one on the right? Yeah. So that's given me an idea about memory and what's sticking, what's not sticking. On the right, I'm seeing a bit of fragmentation. On the left, I'm seeing a bit of perseveration. In the clinic, what we came up with, I think was consensus provisional diagnosis of dementia for both, both people based on the fact that memory impairment or new learning. And what we're seeing here is new learning impairment. These people are impaired in learning new information. And then one or more of the following cognitive disturbances, language disturbance, definitely. And also, sort of, executive sequencing deficits as well. Criteria, the, sorry, the cognitive deficits impair social and occupational functioning. Both are withdrawn. Both are having difficulties needing monitoring. One was sort of putting electric kettles on the stove, electric stove, trying to heat them up. And, of course, is characterized by gradual onset and continuity decline. Provisionally, we're saying, yeah, we think they meet the criteria. So when we're going back and saying, okay, what are these sorts of four pillars that we're looking at? Clinical observations, client reports, informant reports, and neuropsych assessment, what are the significant things that we're seeing? How much is the cognitive picture? What's the behavioral picture? What's the mood picture? Weighing those bits of information up in our heads. Okay, using, I would hope, our framework that we're trying to use. Okay. So this is probably one of the most significant features. On the left, we've got the sort of the 75-year-old initial copy. On the right, we've got the 72-year-old copy that took 11 minutes. Now, the copy that took 11 minutes, double MSc was 21 out of 30. Double MSc on the copy on the left was 25 out of 30. So cognitively, we'd be thinking that the 25 out of 30 on the left is actually functioning better than the lady on the right. Now, the lady on the right has also got quite significant language impairment. She's in the first percentile, so significantly impaired in terms of language hesitancy, speech, word-finding difficulties, stuttering, poor concept formation, those sorts of things. Okay, where to from here? What does that actually mean in clinical practice? What do we actually do when we look at it? Well, these are the sorts of things. When we look at visual spatial skills, these are actually the things that we're looking at. The core simple, all sorts of tasks that we actually want people to do that give us some idea of what's going on for the non-dominant hemisphere. So it's the visual spatial hemisphere, if you like, the right hemisphere we're particularly looking at. Depth perception, pattern formation, pattern recognition, how can they make sense of this? Unfortunately, I didn't give the stimulus on the right to both of these people. I did give the stimulus or the series on the left to one of these people, the lady who's not driving, and she was completely unable to piece together any of those stimuli, any of those guest out figures. They're called guest out figures. They're incomplete figures. She'd be saying things like, oh, it's just a jumble of stones. It's a jigsaw puzzle. Because they're asked to identify what the object is. And she's saying, well, it's just a jumble. It's a mess. It's stones, or it's a jigsaw puzzle. So really quite impaired in those sorts of types of things. The one on the right is a three-dimensional drawing. And just looking at the sort of the types of things that we're getting people to do, that three-dimensional perceptual stuff seems to be quite a significantly difficult task for complex visual spatial skills. It's a simple task. We draw a cube and ask them to copy it. Just as a suggestion, those are the sorts of types of things that clinically would be raising some sorts of questions with people that you might be seeing. If they're not doing the cube on the right, I'll be thinking, what else do I need to do? What else is happening here? But having said that, when we're looking at how do we actually make the clinical differentiation between these people, what do we actually do with this? Well, in terms of the three basic systems, going back to where we started at the beginning, the interventions are actually quite significant because with a lady who was 72, it appeared to me that there was significant behavioral overlay. The 21 out of 30 doesn't make sense in terms of lots of other things that we're seeing. And interestingly, in the session we were doing the neuropsychic assessment, I actually did an intentional redirection and arousal reduction exercise to bring her arousal levels down, and her speech improved markedly. There was a marked improvement in that. So I'm starting to think there's a fair behavioral overlay for the other lady, the sort of the younger lady getting the 21 out of 30, and I'm thinking she certainly has a significant dementia, if you like, but there's an emotional behavioral reaction on top of that, which is amplifying the symptoms that she's actually perceiving. And she has actually improved a little bit over some with talking to the family. And using this sort of model there, arousal, reception storage of information and planning program responses, because the particular, if you like, the frontal lobes and the arousal mechanisms is the one that gets in the way of actually receiving and storing information. So if we can get people to actually reduce those, even if they're actually impaired in some of their functions, they can actually maximize those hard-wired posterior parietal and temporal functions, if that makes sense at all. So in terms of neuropsych, it is a little bit about finding out what's going on, putting it into a cognitive framework, putting it into a neuropsychological framework, and saying, what do we actually do about it? And assessment by itself is all well and good. It's time-intensive. What do we actually do about it? What value is it? And I think the title of this sort of talk was on the lines what does neuropsychological assessment tell us? Well, it's actually, how does neuropsychological assessment help? What's the value? What's the value to the family? What's the value to the person themselves? It's the primary question that we're looking at. And again, it's as plain as the nose on your face. Okay. This is quite a came across today in my diary, actually. So I thought that was really appropriate. The most important motive for work is pleasure in work. Pleasure is a result and the knowledge of the value of the work to the community. So obviously people in a health care setting, in a public health care setting, I think that's really appropriate for the guys that are here today. So thanks again. Thank you.