Visuoconstructional impairment: What are we assessing, and how are we assessing it?

Visuoconstruction (VC) is a commonly-assessed neuropsychological domain that involves the ability to organize and manually manipulate spatial information to make a design. Tests used to measure VC are considered multifactorial in nature given their multiple demands (e.g., visuospatial, executive, motor), and therefore, interpretation of VC impairment can be difficult. Additionally, a wide variety of tests and methods are used to measure VC, further complicating interpretation of results. Although clinicians and researchers spend a great deal of time studying "VC," there has been much confusion about what it is, what is being measured, and how to best measure it. The following study compared a variety of commonly-used, commercially available VC tests for similarities and differences, and also examined the underlying neuropsychological domains of each test. Rather than conceptualizing VC as a unified construct, it was proposed that categorizing VC tests into the following subtypes may improve interpretation: assembly vs. graphomotor, copy vs. draw-to-command, and complex vs. simple tasks. Using 114 mixed neurologic and neuropsychiatric patients, VC test results were assessed with the use of impairment indices, correlational analyses, standard multiple regression, and multivariate analysis of covariance. Study results revealed that the most useful distinction between VC tests appears to based on complexity level. Complex VC tasks tended to be more heterogeneous in their underlying neuropsychological domains, had greater rates of impairment, and were more demanding of executive skills. In contrast, simple VC tests tended to have lower rates of impairment and were more homogenous in function, mostly assessing visuospatial and perceptual skills. Study limitations, future directions, and clinical implications are discussed. ACKNOWLEDGMENT I have tremendous gratitude to all those at the Memory and Cognitive Assessment Program at Rhode Island Hospital who assisted me in the completion of this project. I am grateful for their efforts with data collection and appreciative of their willingness to help me with my many statistical, clinical, and conceptual questions. In addition to thanking the Program Director, Dr. Robert Stern, who oversaw the project, I would also like to give special thanks to Drs. Holly Westervelt, Geoffrey Tremont, Jennifer Davis, Lee Bishop, and Richard Temple. Furthermore, I thank Ms. Anna Podlanczuk for her valuable assistance with data management and test scoring. I want to thank my core committee members, Drs. Valentino and Boulmetis for their dedication, time, and energy in support of the project. A tremendous thank you goes out to my very supportive and loving husband, Dr. Louis Ruffolo , who provided inspiration and reassurance throughout, as well as to my daughter, Morgan, for providing a necessary balance in my life. Finally, I am very thankful for the constant support, guidance, and positive energy from my major professor, Dr. Allan Berman. And, last, but not least, I owe unlimited thanks to my ten-year mentor, Dr. Robert Stern, who not only made this project possible, but who has inspired and guided my clinical and research interests in the areas of neuropsychological assessment, test development and validation, visuoconstruction, and executive functioning.