La evaluación neuropsicológica del anciano

• Autores: Esther Baldera Cruz, Gabriela Galindo Villa Molina
• Localización: Salud mental, ISSN 0185-3325, Vol. 27, Nº. 3, 2004, págs. 9-18
• Idioma: español
• Enlaces
  • Texto completo (pdf)
• Resumen
  • español

    Este artículo presenta al lector un panorama general sobre el sustento teórico que respalda la práctica clínica neuropsicológica dirigida, en particular, a los pacientes de la llamada ¿tercera edad¿. Asimismo, describe una serie de técnicas, estrategias y pruebas comúnmente útiles en el diagnóstico neuropsicológico de esta población, y en cada caso se señalan sus alcances y limitaciones. A lo largo del texto, las autoras mencionan las indicaciones de un estudio neuropsicológico y los retos que hay que enfrentar en el trabajo clínico con los pacientes.

    Por medio de este artículo, las autoras pretenden demostrar que la práctica neuropsicológica requiere conocimiento, flexibilidad, curiosidad y creatividad en el trabajo cotidiano pues, aun dentro de la situación más rutinaria, cabe la posibilidad de que el neuropsicólogo encuentre constantemente nuevas ideas sobre el funcionamiento del cerebro y sobre las mejores estrategias para valorar a cada paciente según sus características individuales.

    En el terreno de la salud mental, la evaluación neuropsicológica cumple un papel importante en la semiología de los síntomas neurológicos frente a los de índole psiquiátrica. Así, ésta es útil para identificar trastornos neurológicos en pacientes no psiquiátricos; para documentar el estado cognoscitivo del paciente en las distintas condiciones neurológicas, y para identificar y localizar zonas de compromiso funcional, que en ocasiones escapan a los registros para clínicos convencionales. La evaluación neuropsicológica es útil también al estudiar enfermedades que no modifican en sus estadios iniciales la anatomía del cerebro, como las demencias o las encefalopatías tóxicas.

    A lo largo de esta exposición, las autoras buscan documentar por qué la exploración neuropsicológica sistematizada es una vía de acceso al conocimiento científico del estado funcional del cerebro. Con este propósito, se describen los principios teóricos y los conceptos básicos que sustentan la práctica clínica del neuropsicólogo, partiendo del hecho de que en el presente no es posible la observación directa del funcionamiento integral del cerebro en personas vivas. Los neurocientíficos han adquirido la mayoría de sus conocimientos sobre el estado y el funcionamiento cerebral vivo por medio de métodos de observación indirecta y exploración neuropsicológica. En este sentido, se trata de un método sistematizado de evaluación cerebral por medio de su producto conductual.

    Se señala que la observación neuropsicológica se basa en muchas de las mismas técnicas, constructos y teorías de la psicología. Ello implica el estudio intensivo del comportamiento por medio de entrevistas, pruebas psicométricas y cuestionarios, que proporcionan índices de la conducta relativamente confiables y sensibles. El carácter distintivo entre psicología y neuropsicología radica en el marco conceptual de referencia, que en el caso de la segunda toma como punto de partida el funcionamiento cerebral.

    Como parte de los aspectos teóricos fundamentales de la neuropsicología, las autoras enfatizan el cambio del concepto unidimensional de organicidad hacia una concepción multidimensional, y como un fenómeno susceptible de medirse mediante una aproximación sistémica, que pondere la presencia de los diversos factores que repercuten en el comportamiento de un individuo.

    Se analiza también el concepto de comportamiento con el propósito de sistematizar el estado cognoscitivo y conductual de los pacientes.

    En torno a la valoración neuropsicológica del anciano, se describen las indicaciones específicas y la manera en que se seleccionan los instrumentos para integrar una batería de estudio pertinente. Por último se mencionan los métodos de evaluación más utilizados en México.

  • English

    This article presents a general panorama of the theoretical framework underlying the clinical neuropsychological assessment practice involving elderly patients. Also, it describes a series of techniques, strategies and tests commonly used in the neuropsychological diagnosis of this population, indicating their capacities and limitations. Throughout the text, the authors mention the characteristics of a neuropsychological study and the challenges to be dealt with in the clinical work with patients.

    Through this article, the authors try to demonstrate that daily neuropsychological practice demands knowledge, flexibility, curiosity and creativity, because the neuropsychologist has the promise that, even in routine situation, he/she will constantly gain insight into the functioning of the brain, as well as the best strategies for evaluating the patient according to his/hers individual characteristics.

    In the mental health field, the neuropsychological evaluation plays an important role not only in the semiology of the neurological symptoms in contrast to psychiatric ones, but also in identifying neurological upheavals in non-psychiatric patients; in documenting the cognitive status of the patient in the different neurological conditions, and in identifying and locating zones of functional commitment that sometimes escape conventional clinical records.

    The neuropsychological assessment is useful too when studying diseases that in their initial stages do not modify the anatomy of the brain, such as toxic encephalopaties and dementias.

    Also, the authors provide evidence to support that systematized neuropsychological exploration renders information of the functional state of the brain. So, theoretical principles and basic concepts sustaining the clinical practice of the neuropsychologist are described, starting from the fact that the direct observation of the functioning of the brain as a whole in live people is not currently possible. Neurocientists base most of their knowledge of the different states the brain adopts while functioning on methods of indirect observation. The neuropsychological exploration is, in this sense, a systematized method to evaluate cerebral functioning through behavior, its final product.

    The neuropsychological observation is based on many common techniques, constructs and theories of psychology. It also implies an intensive study of behavior by means of interviews, tests and questionnaires, that provide relatively reliable and sensible indices of behavior. The distinguishing character between psychology and neuropsychology lies within the conceptual framework of reference, that takes as a departure point cerebral functioning.

    As a part of the fundamental theoretical aspects of neuropsychology, the authors analyze the change from the unidimensional concept of organicity to their conception in multidimensional terms, viewed as a phenomenon susceptible of being measured through a systemic approach, weighing the presence of the diverse factors that impact on the behavior of an individual. The concept of behavior, understood mainly in threedimensional terms, is also analyzed and integrated into different components, in order to systematize the cognitive status and the behavior of the patients.

    In relation to the neuropsychological evaluation of the elderly, the specific indications are described, such as the diagnosis of dementia versus depression or type of dementia; the measurement of cognitive decline, once the presence and the type of upheaval have been documented; or when the natural history of a suffering is studied to gain insight into its handling for research purposes.

    In general terms, a classic pattern of aging in healthy subjects is described, where on one of the extremes dementia is identified as one of the most serious upheavals of the elderly. Circumscribing dementia, the authors dedicate some lines to the topic of memory, given the importance that the study of this function has within the evaluation of aged patients. The components of memory and its theoretical scheme are analyzed from the perspective of clinical evaluation.

    The declaratory memory and the memory of procedures are described in detail, in relation to the cortical and subcortical structures that give them biological sustenance, including the different stages.

    On the other hand, starting from a conceptual frame, this article provides the clinical neuropsychologist with a methodology to select from the evaluation instruments currently available those that turn out to be the most appropriate to assay each patient. In agreement with the literature, a large amount of instruments are available for such a purpose. In Mexico, most instruments used at present have not been standardized for this population, probably due to the expensive cost of such study. Besides intra- and intercultural differences among groups, the authors discuss various problems neuropsychologists must overcome when evaluating patients in Latin America. These are a consequence of the lack of standardization of the instruments, a fact that gives the qualitative interpretation of the results a crucial role in diagnosis.

    This paper also emphasizes the relevance of clinical interviews, both those carried out with the patients, and with their relatives, as a diagnosis tool, in order to delimit the particular reason which prompted the need of an evaluation. The clinical interview provides the physical, mental and psycho-social characteristics of the patient and the type of neurological or psychiatric pathology at issue. Using the interview as a starting point, the clinician designs an evaluation method according to which he/she will have to select the instruments.

    Finally, the authors enlist a set of evaluation instruments, among which there are some that have been translated or adapted to Spanish and are currently used in Mexico and other Latin American countries.