REPORT OF NEUROPSYCHOLOGICAL ASSESSMENT

Transcription

1 Gary G. Kay, Ph.D. Clinical Neuropsychologist WASHINGTON NEUROPSYCHOLOGICAL INSTITUTE, LLC 4900 MASSACHUSETTS AVE, NW SUITE 240 WASHINGTON, DC PH FAX REPORT OF NEUROPSYCHOLOGICAL ASSESSMENT NAME: CASE 5; PI: TEST DATE: February 10, 2012 AGE: 67 John Flyrite is a 67 year old, right handed, married Caucasian male requesting a neuropsychological evaluation for e purpose of obtaining a special issuance second class FAA Medical Certificate. The following evaluation is based upon neuropsychological testing, a review of e airman s blue ribbon copy of his FAA medical records, and a clinical interview. RELEVANT HISTORY: Mr. Flyrite sustained a subdural hematoma in a fall on e ice on February 29, FAA Records Review: The FAA reviewed Mr. Flyrite s hospital records following e head injury in February 2009 and denied him a medical certificate in October In April 2010 Mr. Flyrite was informed at e time period for recovery from a head injury of e type at he sustained for a medical certificate is two years. In May 2010, because of e financial hardship created by e lack of a medical certificate e FAA agreed to submit Mr. Flyrite s case for review. The review indicates at Mr. Flyrite prior to e February 2009 head injury had a special issuance due to his history of Type II diabetes, coronary artery disease, hypertension, stent and CABG. The review indicates at on 2/28/09 Mr. Flyrite fell backwards on e ice resulting in a 5 minutes loss of consciousness, headache and emesis. CT scan revealed a left frontal subdural hematoma. He had a Glasgow Coma Score of 15. He was treated wi Dilantin for 7 days. Two weeks post-injury he reported post concussive symptoms; slowed cognition, balance difficulty, headaches, vertigo and fatigue. On 3/27/09 a follow-up CT showed e unresolved left SDH wi a 5 mm midline shift. Mr. Flyrite chose to undergo surgical evacuation of e hematomas on 3/28/09. He was discharged on 4/1/09. A subsequent CT on 10/18/09 showed resolution of e hematomas. His neurological symptoms were reported to have also resolved. Mr. Flyrite s file was next sent to one of e FAA s neurology consultants, Dr. Henry, for review. The consultant recommended no reconsideration until 24 mons post accident (i.e., 3/1/11) and recommended at at time e airman should undergo EEG and neuropsychological testing. An EEG from January 2011 showed no abnormalities and Mr. Flyrite reported no residual symptoms. Mr. Flyrite received notification from e Federal Air Surgeon on 7/12/2011 at his application for a special issuance medical certificate was denied due to neurocognitive defects. Dr. Tilton s letter specified e examination to be conducted by a neuropsychologist. Mr. Flyrite was seen by Dr. Bill for a neuropsychological evaluation on 2/26/11. Results show poor performance on memory testing which Dr. Bill attributed to performance anxiety. He minimized e finding of Mr. Flyrite s deficient performance on CogScreen measures of response accuracy by questioning e suitability of e test for non-commercial aviators. The airman s performance on measures of processing speed was in e High Average range. [The raw data from Dr. Bill s evaluation were provided in e FAA case file and are used below for comparison to e current evaluation.] Mr. Flyrite s case was sent for review by e FAA to Dr. Jeff, a clinical neuropsychologist. Dr. Jeff issued a report of his review on 5/15/11. It was Dr. Jeff s opinion at e results of Dr.

2 Bill s examination did not support e conclusion at Mr. Flyrite had returned to his baseline level of neurocognitive functioning. He did not feel at e data support e explanation of test anxiety as e cause of Mr. Flyrite s poor performance on verbal and spatial memory testing. Dr. Jeff compared Mr. Flyrite s CogScreen performance to at of 145 older (non-commercial; former military) pilots (average age 64 years). Wi is comparison group Mr. Flyrite s performance was still deficient on measures of memory and deductive reasoning. Performance was lower an 95% of e older pilots on 10 of 16 measures of response efficiency. Mr. Flyrite was particularly deficient on e WAIS-III measure of letter-number sequencing (i.e., a task involving working memory and sequencing). Mr. Flyrite performed well on CogScreen measures of multitasking ability. Background: Mr. Flyrite attended public schools. He dropped out of high school in e 10 grade. He reported no history of learning disabilities. He stated at he left school to find a job. He drove tractor trailers between Jersey and Maine. He later became e supervisor for a freight line. Between 1978 and 1987 he ran a video store for 3 years and en directed maintenance operations for a national dairy. He has been employed as e Fleet Superintendent for a major Eastern city. In addition, Mr. Flyrite has for many years operated a commercial flight operation at currently has 3 aircraft. Mr. Flyrite began flying at age 17. He received his pilot s license in He has held a Class II (special issuance) medical certificate. He has his multiengine and instrument ratings. He has 7000 logged flight hours. His only mishap ended wi his safely landing an aircraft on a beach. He has received no citations or warning from e FAA regarding his flight operations. Mr. Flyrite medical history is well documented elsewhere. He reports no coronary related symptoms. He also reports no cognitive difficulties. He stated at he maintains his weight between 205 and 210 pounds. His current medications include: Flomax, Metformin, Metoprolol, Pravachol, and aspirin. He denies any history of receiving care or treatment from a mental heal professional. TESTS ADMINISTERED: Wechsler Adult Intelligence Scale-IV Hooper Visual Organization Test Conners Continuous Performance Test Stroop Color and Word Test Trail Making Test Brief Visuospatial Memory Test-Revised Wisconsin Card Sorting Test Verbal Fluency Test Nelson-Denny Reading Test (Reading Fluency) California Verbal Learning Test-II CogScreen-Aeromedical Edition Beck Depression Inventory MENTAL STATUS EXAMINATION/TEST BEHAVIOR: Mr. Flyrite was alert, oriented and cooperative. He was accompanied to e appointment by his adult daughter. He was very friendly and readily established excellent rapport wi e examiner.

3 Page 3 He had no difficulty understanding or following test instructions. He appeared to be highly motivated to perform at e best of his ability. There was no clinical evidence of anxiety or depression. He was concerned at is evaluation would determine wheer or not he could remain in his aviation-related business. His affect was full and mood congruent. Thought processes were logical and goal directed. The following results are considered to accurately reflect Mr. Flyrite s current level of functioning. TEST FINDINGS: Scores are presented in terms of Raw Scores and corresponding T-scores (Mean T=50, Std Deviation T=10; Normal Cutoff T=40 (marked in yellow). In most cases T-scores are corrected for age and years of education. TEST 2/10/12 2/16/11 Hooper Visual Organization Test 25, age corr=28; T=55 Halstead Category Test 118 errors; T=29 Wisconsin Card Sorting Test Categories Completed Perseverative Responses Perseverative Errors st Trials to Complete 1 Category Failure to Maintain Set Brief Visuospatial Memory Test Trial 1 Trial 2 Trial 3 Total Recall Learning Delayed Recall Percent Retained Recognition Hits/False Alarms Stroop Color & Word Test Word Color Color-Word WAIS-IV Perceptual Reasoning Block Design Matrix Reasoning Working Memory Digit Span Arimetic Processing Speed Symbol Search Coding CVLT-II Trial 1 Trial 5 6; T>40 8; T=69 8; T=67 12; T>40 0; T>40 4; T=45 6; T=43 8; T=47 18; T=44 4; T=51 7; T= %; T>40 5/0; T>40 108; T=61 68; T=49 33; T=53 98; T=48 SS=11; T=53 SS=8; T=43 105; T=53 SS=12; T=57 SS=10; T=50 94; T=46 SS=7; T=40 SS=11; T=53 6; T=50 (Heaton 51) 10; T=50 (Heaton 49) 6; T>40 13; T=45 (WAIS-III) SS=12 SS=11 SS=10 SS=14 5; T=45 9; T=45

4 Page 4 Trials 1-5 Trial B SD Free Recall LD Free Recall Recognition Hits/FP Errors Trail Making Test Part A Part B Part C Verbal Fluency FAS (Phonemic Fluency) Animals (Semantic Fluency) Nelson-Denny Reading Test Reading Fluency CogScreen-AE Speed Scores 5 percentile Scores 15 percentile Accuracy Scores 5 percentile Scores 15 percentile Process Scores 5 percentile Scores 15 percentile LRPV Taylor Factor Scores Deductive Reasoning Motor Coordination Memory Speed & Working Memory Psychomotor Tracking Conners s Continuous Performance Test Omissions Commissions Reaction Time Reaction Time Variability RT Block Change RT ISI Change Beck Depression Inventory 3 Perceptual Reasoning: 46; T=56 (Heaton 53) 6; T=45 6; T=40 (Heaton 41) 7; T= 45 (Heaton 49) 16/1; T 60 20; T=69 108; T=47 36; T= ; T=50 2; T=30 3; T=30 20; T=66 51; T=66 32; T=46 17; T=51 23; T=62 SS=195; T=48 (10 yr ed) 3; T=37 4; T=46 5; T<30 9; T<30 0; T>45 1; T= T=35 T=63 T=34 T=39 T=49 2; T=54 15; T=48 342; T=69 6; T=48 T=51 T=53 1; T=48 5; T=42 3; T=35 8; T<30 0; T>45 3, T=45 T=29 T=68 T=32 T=41 T=52 Performance on e WAIS-IV Perceptual Reasoning Index falls in e mid-average range (PRI=98). He performed less well on a task involving abstract non-verbal reasoning (25

5 Page 5 percentile) an on a task requiring visuospatial analysis and constructional abilities (63 rd percentile). Mr. Flyrite was administered e Hooper Visual Organization Test, anoer measure of perceptual organization. On is measure he performed in e mid-average range for his age (70 percentile). CogScreen-Aeromedical Edition: Mr. Flyrite s performance on CogScreen was compared to commercial airline pilots from major US airline between e ages of 54 and 60. This group is not only younger an Mr. Flyrite, e pilots on average have completed 7 years more of formal education. Therefore, e CogScreen norms are likely to underestimate his level of functioning. Speed: In 2011 Mr. Flyrite performed at or below e 5 percentile on only one measure of response speed; Ma. At e current evaluation he performed at or below e 5 percentile on 3 measures; a measure of working memory (Previous Number Alone) on a measure of deductive reasoning (SAT Discovery), and on a measure of letter/number sequencing (Visual Sequence Comparison). His score on e sequence comparison task was markedly slower (from 3.41 seconds to 4.26 seconds). His average response speed on e Previous Number Alone task increased from 0.77 seconds to 1.07 seconds. On e oer hand, his total number of speed scores at or below e 5 percentile improved from 5 to 4 and falls in e Normal range. Accuracy: There is evidence of some decline in response accuracy compared to e 2/11 exam. On e Manikin Test he dropped from 75% accuracy to 58% accuracy. On e Matching to Sample Test, a measure of visual working memory his score dropped from 100% accuracy to 75% accuracy. On e Ma test his accuracy remained at 40%, which is deficient compared to e pilot norms. On e oer hand, ere was some improvement in his accuracy on a test at requires reading and following written instructions (from 71.8% to 87.5% accuracy) and on e measure of delayed symbol-digit recall (from 16% to 33%). Process: At e prior exam and at e current examination Mr. Flyrite performed in e Normal range on measures of psychomotor coordination and tracking and showed no tendency toward impulsivity. He continues to demonstrate good mulitasking ability. However, his ability to rapidly solve a deductive reasoning task requiring mental flexibility remains weak but wiin e Normal range (17.5 percentile). Taylor Factor Scores: Overall scores remain e same as ey were in There was a slight improvement in e deductive reasoning score (T increase by 6), and small drops (T decline by 2) in e areas of Memory and Speed/Working Memory. Overall, on ese factors which are predictors of flight performance in older pilots, Mr. Flyrite is functioning above e 5 percentile on all 5 measures. Note at e LRPV score is heavily influenced by age and erefore of less validity for an individual of Mr. Flyrite s age. Attention/Information Processing Speed. Mr. Flyrite performed in e Average range on WAIS IV measures of processing speed (PSI=94; 34 percentile) and working memory (WMI=105; 63 percentile). A review of subtest scores shows a significant decline in Mr. Flyrite s peformance on e Symbol Search Test (SS=10 to SS=7). His current score on is measure of visual rd

6 Page 6 perceptual speed falls in e Borderline range (16 percentile for his age). He continues to perform well on measures of Working Memory. Mr. Flyrite continues to perform in e Superior range on a measure of visual attention (Trail Making Test Part A, 20 seconds; T=69). He was considerably slower (36 seconds) when performing an all letter version of e Trail Making Test (Part C) which is oerwise comparable to Part A. Discrepancies between Part A and Part C (all letters) are associated wi injuries to e language dominant hemisphere. Initial trial recall on memory tests provides a measure of working memory. On ese measures Mr. Flyrite demonstrated Normal working memory. Mr. Flyrite was also administered a test of sustained attention / vigilance. His reaction times were markedly fast (97 percentile) and he did not make an abnormal number of commission or omission errors. The Conners CPT interpretive report indicates at results are not indicative of problems wi impulsivity or vigilance. Memory. On a word list learning test (California Verbal Learning Test-II) Mr. Flyrite performed in e Normal range. His performance improved significantly on a measure of delayed recall. In 2011 he recalled only 3 of e 16 list words following a 20 minute delay. At is evaluation he recalled 7 of e 16 words following e delay. He demonstrated normal learning and retention. Memory for spatial information was tested wi e Brief Visuospatial Memory Test-Revised. He demonstrated normal learning and retention of e designs and eir relative spatial locations. Note at ere was also an improvement in CogScreen delayed recall of symbol-digit paired associates. Language. The finding of a difference of large magnitude between Part A and Part C of e Trail Making Test, can be an indicator of acquired left hemisphere dysfunction. There was no oer evidence of language-related deficits. Mr. Flyrite performed in e expected range on measures of verbal fluency. He also performed in e expected range on a measure of reading fluency. Executive Functions: Mr. Flyrite s performance on e CogScreen measure of deductive reasoning and mental flexibility improved to e 7 percentile (compared to e younger commercial pilot normative sample). He performed very poorly on e Halstead Category Test (108 errors). He appeared to be unable to use deductive reasoning to find e underlying response rules. In contrast, on a test wi more simple conceptual rules, e Wisconsin Card Sorting Test, he again performed in e Normal range and showed no evidence of perseveration or of difficulty maintaining set. On is test he demonstrated at he can appropriately to feedback and find an alternate solution. On e Stroop Test he performed in e Average range and showed no evidence of a Stroop Interference effect. His good scores on e Verbal Fluency tests and on measures of working memory is furer evidence of intact executive functions. His performance on Part B of e Trail Making Test deteriorated significantly. In 2011 he required only 51 seconds to complete e task. At is evaluation he required 108 seconds and made 1 error. Nearly e entire minute was spent trying to correct a letter sequencing error. He had skipped e letter I, drawing a line from 9 to J, and had difficulty correcting is error. It appeared at e difficulty was not due to an executive function problem but to a difficulty wi letter sequencing which was confirmed wi Part C of e Trail Making Test. Personality. Personality testing was not conducted. On e Beck Depression Scale Mr. Flyrite reported no problems associated wi depression or anxiety.

7 Page 7 SUMMARY AND RECOMMENDATIONS: Mr. Flyrite performed well on measures of perceptual reasoning and organization. On novel tasks requiring abstract non-verbal reasoning (WAIS-IV Matrix Reasoning & Category Test) Mr. Flyrite had considerable difficulty. Wi less complex concepts and when tasks had a constructional component he had no difficulty. Mr. Flyrite generally performed well on measures of information processing speed. He is relatively slow in sequencing letters. This is likely a residual effect of his left hemisphere injury. Overall his processing speed falls in e Average to Low Average range. Under speeded conditions Mr. Flyrite s response accuracy suffers. He had difficulty under ese conditions wi mental spatial rotation, visual working memory, and wi reading and following written instructions. There was no change in his performance on mental arimetic testing. His Ma performance on e WAIS-IV is in e Average range. His reading speed improved slightly, but is slower an e younger commercial pilot norms. On CogScreen predictors of flight performance Mr. Flyrite continues to have weaknesses (again compared to e younger commercial pilot norms) on measures of deductive reasoning, memory and (to a lesser extent) processing speed. Overall his performance on ese factors is above e 5 percentile compared to ese pilot norms. At e prior evaluation Mr. Flyrite had particular difficulty wi memory. At is evalution he performed normally on e California Verbal Learning Test-II and on e Brief Visuospatial Memory Test. His delayed recall score on CogScreen showed improvement. The oer area causing concern from e prior evaluation was Mr. Flyrite s executive functions. Considering e location of his hematoma, frontal lobe functions are understandably an area of concern. Mr. Flyrite s CogScreen Discovery subtest score was in e low Normal range. He performed well on e Wisconsin Card Sorting Test, Stroop Test, Verbal Fluency Test, and on measures of working memory. There was no indication of deficits in mental flexibility or tendencies toward perseveration, impulsivity, or proactive interference. On e oer hand, Mr. Flyrite was found to perform poorly on e Halstead Category Test and had relative difficulty wi e WAIS-IV Matrix Reasoning test. These findings indicate at he is limited in his ability to solve abstract non-verbal reasoning tasks. This is likely a longstanding cognitive difficulty which is known to also be impacted by normal aging. Mr. Flyrite s difficulty wi Part B of e Trail Making Test appears to be a result of his difficulty wi letter sequencing, which may be a mild residual deficit from his left hemisphere injury. Based on ese findings I recommend at Mr. Flyrite be granted a special issuance 2 Class nd FAA Medical Certificate. It appears likely at e only residual deficit from his head injury is a mild deficit in letter sequencing.

8 Page 8 Thank you for referring Mr. Flyrite for neuropsychological assessment. If you have any furer questions please don't hesitate to contact me. Gary G. Kay, Ph.D. Clinical Neuropsychologist