Chapter 5 Neurological Impairment - VRB

1 103 INTRODUCTIONLoss of function tables (Tables ) Neurological Impairment is measured by reference to multiple functions, manyof which are rated using tables in other chapters. The additional functionsconsidered in this Chapter are:ucognitive function (Table );ucommunication (Tables and ); andusensory function (Table ).Ratings from one functional loss table are to be combined with ratings from anyother table for a different loss of function from the same condition. Ratingsfrom functional loss tables are not to be combined with ratings from OtherImpairment tables for the same Impairment table (Table )Table lists specific Impairment ratings for a variety of Neurological conditionswhich are based on prognosis and, in some cases, pain. When ratings for thesame condition can be made from Table and a functional loss table, thehigher rating is to be 5 Neurological Impairment104 Chapter 5: Neurological ImpairmentFollow the steps below to determine the Impairment rating for neurologicalconditions:(Each step is elaborated in the following pages.)

2 Calculation of the Impairment rating for an accepted neurologicalconditionDetermine an Impairment rating for functional lossfrom the accepted Neurological condition, byapplying other applicable chapters of this a rating for Other Impairment from theaccepted Neurological condition, by applying as applicable.(Omit this step if no rating was given in Step 3.)Combine the ratings obtained in Step 1 and Step 2,by applying Chapter 18 (Combined Values Chart).Compare the resultant combined rating with therating obtained in Step 3. Take the higher an Impairment rating for functional lossfrom the accepted Neurological condition, byapplying Tables , , , , and , function Cognition means the faculty of knowledge . The cognitive function deals withsuch aspects of knowledge as acquisition (learning), retention and recall (memory),and use (reasoning and problem-solving).Table is applied only if an organic brain condition has been diagnosed.

3 It is notto be applied to assess general mental capacity in a veteran with a condition ofanother body system unrelated to the brain condition. The Impairment rating mustrelate only to cognitive deficits that were not present before the onset of the conditions are to be assessed by applying Chapter 4 (Emotional andBehavioural).Self-reports of deteriorating mental function must be interpreted with caution. Organicbrain disease is often associated with a lack of insight or a tendency to deny failingabilities. Self-reported complaints about poor memory may be more closely relatedto depressive symptoms than to true memory deficits. If there is doubt about thenature or extent of the deficit, formal psychometric testing may be 1: Determine an Impairment rating for functional loss from theaccepted Neurological condition, by applying Tables , , , , , as 5: Neurological ImpairmentLOSS OF Neurological FUNCTION:COGNITIONI mpairmentRatingsCriteriaNIL Negligible Impairment : reasoning is comparablewith that of peers.

4 Memory similar to that of peers: written notes, etc.,used in the manner of busy people of all Mild Impairment : appropriate use is made ofaccumulated knowledge and reasonable judgementis shown in routine daily activities most of the are apparent in new circumstances. Mild but demonstrable Impairment of memory:misplaces objects, and has increased difficulty inremembering names and appointments. Can learn,although at a slower rate than has little impact on everyday activitybecause of compensation through reliance onwritten notes, schedules, checklists and Moderate Impairment of memory: has frequentFIVE diffculty in recalling details of recent experiences;frequently misplaces objects; fails to follow throughwith intentions or obligations; tends to get lost moreeasily in unfamiliar areas. Compensation throughuse of aids, eg lists and diaries, is adequate. Moderate Impairment of problem solving ability,relies on accumulated knowledge.

5 Sufferssignificant disadvantage in circumstances requiringcomplex decision-making or non-routine activities, when past decision-making is not directlyrelevant. Has reduced initiative, spontaneity, andcapacity for abstract as above, but more frequent and severe. Ispartially able to compensate, but unable to functionwith complete independence, and needs somesupervision.(continued next page)No age adjustmentpermitted forthis tableFunctional LossTable 5: Neurological ImpairmentLOSS OF Neurological FUNCTION:COGNITION (continued)ImpairmentRatingsCriteriaSIXT Y Severe Impairment : has difficulty in carrying outbasic activities such as sequencing the stepsneeded for dressing and for preparing meals. Planning/organisational ability is reduced. Isunable to function independently in new orcomplex situations. Shows markedly reducedinitiative and spontaneity, and perseverativethinking. Severe memory deficiency: is unable to retain anyinformation about recent experiences.

6 Newlearning is not possible after attention has beendirected elsewhere. Is unable to work or liveindependently, needing supervision to avoidharm, eg from fire caused by forgetting to putout cigarettes or to turn off appliances. Hasextreme difficulty in keeping track of finances,scheduled activities, social relationships, Gross Impairment : is unable to initiate and sustainactivities without supervision. Supervision andprompting are required for virtually all dailyactivity. Is unable to plan a course of action forthe simplest activity. Gross amnesic syndrome: is unable to acquire orrecall new information. Constant supervision andcare are required. Unable to recognise family,own reflection in mirror, etc. Is disoriented infamiliar from one Functional Loss table may be combinedwith ratings from any other table for a different loss offunction. Ratings from Functional Loss tables are not to becombined with ratings from Other Impairment tables forthe same age adjustmentpermitted forthis tableFunctionalLoss Table (cont d)107 Chapter 5: Neurological ImpairmentTable addresses memory and new learning ability as well as reasoning andproblem-solving abilities.

7 This requires:uadequate levels of motivation and attention;urestraint of impulsive tendencies;uability to organise, categorise and shift responses;uuse of feedback to modify behaviour; anducapacity to evaluate final ratings reflect increasing grades of has two elements: comprehension and expression. Compre-hension means understanding . It includes understanding of speech andgestures, recognition of sights and sounds, spatial and temporal orientation. Expression is the capacity to convey the content of one s mind to and expression are to be rated separately, by applying and respectively. Impairment ratings from these tables are to be combinedwhen criteria from both are applicable. Impairment ratings from these tables arenot to include communication deficits that were present before the onset of and are to be applied to rate Neurological or neuromuscularconditions as well as local lesions involving the mechanisms of speech may also be restricted by vision loss, hearing loss, or loss ofhand function.

8 Ratings are then to be made from Chapter 8, Chapter 7, or Chapter3 respectively, instead of Tables and is to be applied to rate limitation of auditory or visual one Impairment rating is to be given from this table. If more than onecriterion is applicable that which results in the higher rating is to be is to be applied to rate limitation of speech production, as well aswritten and unspoken methods of expression. Only one Impairment rating is tobe made from this table. If more than one criterion is applicable, that whichresults in the higher rating is to be of speech production takes into account:uaudibility: the ability to speak loudly enough to be heard;uintelligibility: the ability to articulate and to link phonetic units of speechwith sufficient accuracy to be understood;ufunctional efficiency: the ability to speak quickly enough, and to sustain therate for a period; anduretrieval and manipulation of language elements: expression of 5: Neurological ImpairmentLOSS OF Neurological FUNCTION:COMPREHENSIONI mpairmentRatingsCriteriaNILN ormal or nearly normal understand movies, radio programs or groupdiscussions, but with some difficulty.

9 Comprehensionis good in most situations, but understanding is difficultin large groups, or when tired and upset. Has difficultycoping with rapid changes of Can understand speech face-to-face, but confusionor fatigue occurs rapidly in any group. Is unable tocope with rapid change in topic, or with complextopics: is able to grasp the meaning of TV serials,but not more complex ideas. Mild dyslexia: is able to grasp the meaning of basicnewspaper and magazine articles, but has difficultyunderstanding details. Is unable to follow thestoryline in Can understand only simple sentences, and followFIVE simple conversation when some points are repeated. Moderate dyslexia: reading comprehension islimited to sentences and short paragraphs. Canfollow simple two-to-three line instructions, andcope with shopping (and other) lists, but nothingmore Can understand only single words. Shows someunderstanding of slowly-spoken simple sentencesfrom context and gesture, although frequentrepetition is needed.

10 Severe dyslexia: is able to read single words, tomatch words to pictures and to read labels and signs,but is unable to read Unable to understand simple instructions or yes/noquestions, even with gesture. Unable to read single words, labels or from one Functional Loss table may be combined withratings from any other table for a different loss of from Functional Loss tables are not to be combinedwith ratings from Other Impairment tables for the age adjustmentpermitted forthis tableFunctional LossTable 5: Neurological ImpairmentLOSS OF Neurological FUNCTION:EXPRESSIONI mpairmentRatingsCriteriaNILN ormal or nearly normal is of sufficient intensity and vocal quality formost everyday needs, eg: normal speech, but unable to shout; or needs to repeat self at times; or is unable to produce some phonetic units; or speech is sustained over a 10-minute period, butwith difficulty that includes hesitation and word-retrieval problems.