Neuropsychological Assessment of Patients With Low Educational Level

By: Luis Quintanar Rojas and Yulia Solovieva, Posgrade in Neuropsychology, Autonomous University of Puebla, Mexico

This study presents examples of neuropsychological tests by patients with brain damage in the left and right hemisphere with low educational level. The study shows examples of executions of neuropsychological tasks created for the evaluation of functioning of anterior and posterior brain zones. The types of errors of patients during fulfillment of neuropsychological items are compared according to global and analytic perceptual strategies. Such comparisons point out that patients with low educational level can show different clinical pictures as a consequence of brain damage. The necessity of analyses of particular cases of different types of brain damage in patients with different educational level is emphasized.

Introduction
Neuropsychological assessment of patients with brain damage with low educational level is rather rare in developed countries; it is also not frequent to find points of comparison between executions of neuropsychological tests by patients with different grades of educational level. Still it is important to stress that in non-developed countries the population with low educational level is more than significant.

As for Mexico, 16 million people are illiterate officially and extra officially. It can be assumed that population of functional illiterates (people who do not use reading and writing in their day to day life) is more that 30 million. Additionally, this population does not have any access to even elementary health service. Neuropsychological assessment of such patients is rare in Mexico due to poor living conditions and absence of financial support and special interest from official institutions. Considering this, it is necessary to mention that to find pure illiterates with brain damage and submit them to complete neuropsychological assessment could be very difficult.

Different studies with normal population have shown that formal education has a special effect on brain organization, particularly on hemispheric specialization related to verbal and spatial abilities (Lecours, 1998; Ostrosky & Cols., 1985; Quintanar & Cols., 2002). In cases of brain pathology in illiterate population it was found that right hemisphere damage produces more language disturbances than left hemisphere damage (Cameron, Currier y Haerer, 1971; Matute, 1988; Lecours, 1998).

Neuropsychological analysis of performances of normal subjects with different educational level is an important chapter of contemporary clinical research. In studies to obtain the data about brain organization of psychological activity, for example, the hypothesis that there is less hemispheric organization of language in illiterate subjects (Eisenson, 1962; Critchley, 1970; Lecours & Cols., 1988). 

Some studies (Quintanar & Cols., 1995, 2002) have shown that many neuropsychological tasks were inaccessible both for men and women, especially graphic tasks. Among these tasks “copy and continuation of the sequence”, “copy of the house”, “drawing by instruction”, “copies of objects”, “reproduction of series of figures” and verbal tasks were “repetition of verbal series”, “comprehension of orders”, “determination of verbal sounds in a word” and “audio-verbal retention in conditions of interference”.

According to Ardila (2000) educational level is the most significant factor in diversity of execution of neuropsychological tasks. Some researchers believe that the difficulties observed in the fulfillment of these types of tasks are due to the absence of learning activity which provides the development of voluntary organized movements (Ardila, Roselli y Rosas, 1989; Ostrosky y Cols., 1985).

From this perspective it is rather interesting to study clinical manifestations of the difficulties related to cases of brain damage of different localization in subjects with low educational levels. The objective of the present article is to caracterize types of neuropsychological syndromes detected by neuropsychological assessment in two patients with brain damage in the left and right hemisphere with low and high educational level.

Subjects
The study reports 2 cases of Mexican patients (women) with brain damage with low educational level, with left and right localization of brain damage (table 1). 
Table 1. Characteristics of patients.

Case

Age

Educational level

Magnetic resonance

Neurological diagnostic

Neuropsychological diagnostic

R.S.

23

3 years

Lesion in temporal lobe RH

Ischemic infart

Acustic-mnesic and motor afferent aphasia

J.C.

73

3 years

Lesion in temporal lobe LH

Ischemic infart

Complex aphasia with elements of motor efferent and afferent, sensorial and amnesic

Methods of Assessment
Neuropsychological tasks used during our assessment were elaborated on the basis of representation of brain functioning as a material support of realization of specific cultural actions, such as writing, reading, drawing and so on (Quintanar & Solovieva, 2002).

In any case of fulfillment of a task there is a virtual functional system including brain components: sequential motor organization, global and analytic spatial strategies, phonematic and kinestesic analysis and synthesis, programming and control of voluntary execution (Luria, 1969; Quintanar & Cols., 2002; Akhutina, 2002).

All neuropsychological tasks can be divided in two main groups or two brain functional blocks according to Luria (1973): evaluation of functioning of anterior and posterior brain mechanisms. As an example of a task helpful for evaluation of anterior brain mechanisms or third functional block (in Luria’s terminology) are:

1) The task of copy and continuation of graphic sequence (model 1).

2) The task of free drawing, drawing by instructions or copy of series objects of the same category or complex objects with spatial perspective. 
Specific errors, which point out problems with functioning of anterior functions of programming and control and sequential organization of movements or third brain block, in general are:

  1. Graphic perseverations in all the tasks.
  2. Simplification of the task.
  3. Losing of the goal of the task.
  4. Luck of motor fluency.
  5. Impulsive execution.

Such kinds of errors are frequently related to left (anterior) localization of brain damage. 
Model 1. Copy and continuation of graphic sequence.

Model 1. Copy and continuation of graphic sequence. 

The tasks helpful for evaluation of posterior brain mechanisms or second functional block according to A.R. Luria are:

  1. Drawing of complex objects with spatial perspective, such as house, cube and so on.
  2. Graphic orientated associations (animals, vegetables),
  3. Drawing of concrete objects from one category.

Specific errors, which point out problems with functioning of posterior brain mechanisms of spatial analysis (analytic perceptive strategy) and synthesis (global or holistic perceptive strategy) or second functional third brain block are:

  1. Luck of spatial integration of an image.
  2. Luck of significant essential details of an image.
  3. Problems with spatial distribution of details in an image.
  4. Difficulties with left and right orientation in an image.
  5. Impossibility of evocation of concrete proper image, substitution of one image by another close image.

Such types of difficulties are normally related to right (posterior) localization of brain damage.

Results and discussion
Case 1. R.S.

Example 1. Copy and continuation of graphic sequence.

Example 1. Copy and continuation of graphic sequence.

We can see that the patient is unable to copy and continue the graphic sequence; the patient only repeats the last element of the sequence.  It is possible to think of impossibility of planning and programming of voluntary activity, but it is also possible to explain the errors by perceptive difficulties or lack of global strategy. It is important to observe the examples 2-5 in order to make a conclusion about the nature of neuropsychological syndrome.

We can see that the patient draws something between a bag and a house; it is impossible to represent concrete image by instruction; details of the image belong to another object common for a patient.

Example 2. The task of free drawing of a bag. 
Example 2. The task of free drawing of a bag.

Example 3. Free drawing of a cock.
Example 3. Free drawing of a cock. 

Example 4. Free drawing of a dog.

Example 4. Free drawing of a dog. 

Difficulties with representation of essential details can be observed in both examples. The patient cannot represent concrete images of the animals very common to him. For example, the patient is not sure how to integrate the eye of the cock and the head and legs of a dog; both drawing are disintegrated and do not have clear space shape.

Example 5. Copy of a cube. 
Example 5. Copy of a cube.  

It is easy to notice lack of perspective in the copy and impossibility to integrate complex spatial relations of the proposed object.

 

Case 2. J.C. 

Example 6. Copy and continuation of graphic sequence.
Example 6. Copy and continuation of graphic sequence.

In this example we can observe perseverations and simplification of the task: instead of two precise elements of the sequence (triangle and square) the patient represents only lines without any sense and repeats the  same kind of execution constantly.

 

Example 7. Copy of a house. 
Example 7. Copy of a house.

 

In the example we can see that the problems of a patient is not so much the perspective or essential details, but lack of organizational strategy and planning of the drawing. Another strong difficulty is simplification of the task: instead of a complex figure with perspective as the patient executes common childish drawing of a house without any perspective. Perseverations are also evident in this example.

Example 8. Free drawing of an animal and a cat.

Example 8. Free drawing of an animal and a cat.  

The results obtained during neuropsychological assessment of patients with a low educational level permit us to establish some characteristics of neuropsychological syndromes caused by left and right injury. 

We can compare according to localization of brain injury. In executions of patients with left and right brain damage, a typical disintegration of global and local strategy can be noticed (table 2).

Table 2. Comparison of neuropsychological syndromes of the patients.
Localization of brain damage

Characteristics of executions

Left

Perseverations, pathological inertia, impossibility to pass from one movement to another, absence of essential details in image production.

Right

Impossibility to conclude graphic image, confusion between images and impossibility to produce precise image, difficulties with representation of essential details in concrete objects.

The results show that our patients have severe difficulties in fulfillment of neuropsychological tasks. Nevertheless, specific mistakes can be also noticed. The patient with a low educational level with right hemisphere damage shows difficulties of production of images (problems with global strategy) and also with representation of essential details.

Patient with a low educational level with left hemisphere damage shows different difficulties: perseverations and stereotype repetitions, analytic perceptive problems (impossibility to represent essential characteristics of the concrete objects).

We conclude that it is necessary to continue with neuropsychological assessment of patients with different educational levels and different localization of brain injury in order to precise clinical manifestations and to realize comparison of specific difficulties of the patients.  

Conclusions
1) Brain organization of psychological activity depends on different factors: educational level and localization of brain damage. 
2) Some subjects with low education (left handed) with brain damage in right hemisphere may have difficulties with both analytic and global strategy of perception. 
3) The executions of patient with brain damage in left hemisphere may have difficulties in functioning both of anterior and posterior brain mechanisms. 
4) Subjects with a low educational level can show different clinical pictures as the consequence of brain damage.

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