Neuropsychological Evaluations in Adults

 

Am Fam Physician. 2019 Jan 15;99(2):101-108.

Author disclosure: No relevant financial affiliations.

Neuropsychologists provide detailed assessments of cognitive and emotional functioning that often cannot be obtained through other diagnostic means. They use standardized assessment tools and integrate the findings with other data to determine whether cognitive decline has occurred, to differentiate neurologic from psychiatric conditions, to identify neurocognitive etiologies, and to determine the relationship between neurologic factors and difficulties in daily functioning. Family physicians should consider referring patients when there are questions about diagnostic decision making or planning of individualized management strategies for patients with mild cognitive impairment, dementia, traumatic brain injury, and other clinical conditions that affect cognitive functioning. Neuropsychological testing can differentiate Alzheimer dementia from nondementia with nearly 90% accuracy. The addition of neuropsychological testing to injury severity variables (e.g., posttraumatic amnesia) increases predicted accuracy in functional outcomes. A neuropsychological evaluation can be helpful in addressing concerns about functional capacities (e.g., ability to drive or live independently) and in determining a patient's capacity to make decisions about health care or finances. Most patients who underwent neuropsychological evaluation and their significant others reported that they found the evaluation helpful in understanding and coping with cognitive problems.

Family physicians are often the first health care professionals to evaluate patients with memory loss and cognitive dysfunction. Although many patients can be readily diagnosed and treated, some present significant challenges. A neuropsychological consultation can help characterize cognitive deficits, clarify diagnoses, and develop optimal management plans for patients with cognitive issues.1  Common goals of neuropsychological evaluations are provided in Table 1.2

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Neuropsychological evaluation can identify the onset and type of mild cognitive impairment and dementia so that early intervention can occur.

B

15, 16, 20, 22, 23

Neuropsychological evaluation can be useful in predicting the degree of driving risk in persons with dementia.

B

25

Neuropsychological evaluation can be useful in determining decision-making capacity in persons with cognitive impairment.

C

26

Neuropsychological evaluation can identify cognitive deficits, predict functional outcomes, and monitor patient recovery after traumatic brain injury.

B

20, 3138


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Neuropsychological evaluation can identify the onset and type of mild cognitive impairment and dementia so that early intervention can occur.

B

15, 16, 20, 22, 23

Neuropsychological evaluation can be useful in predicting the degree of driving risk in persons with dementia.

B

25

Neuropsychological evaluation can be useful in determining decision-making capacity in persons with cognitive impairment.

C

26

Neuropsychological evaluation can identify cognitive deficits, predict functional outcomes, and monitor patient recovery after traumatic brain injury.

B

20, 3138


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

 Enlarge     Print

TABLE 1.

Common Goals of Neuropsychological Evaluations

GoalExamples

Characterize cognitive and behavioral function

Establish cognitive baseline before or after illness, injury, or treatment

Evaluate the impact of a medical issue on cognitive, behavioral, or emotional function

Identify cognitive strengths and weaknesses to predict ability to perform daily living activities

Identify subtle cognitive deficits

Prioritize differential diagnoses

Assess for psychological contributions to symptom presentations (e.g., depression, somatoform features)

Differentiate “worried well” patients from those with cognitive impairment

Establish, confirm, or differentiate between diagnoses that affect cognition

Evaluate for dementia and differentiate between potential etiologies

Plan and monitor treatment

Help determine candidacy for neurosurgical procedures (e.g., deep brain stimulation, epilepsy surgery, ventricular shunting)

Identify cognitive strengths and weaknesses to develop appropriate compensatory strategies and accommodations

Monitor cognitive changes associated with disease progression, recovery, or treatment

Provide prognostic information and treatment recommendations for patients with cognitive disturbances

Address legal, functional, or other issues

Determine whether cognitive deficits may interfere with ability to drive, return to work, or live independently

Diagnose or confirm neurodevelopmental disabilities in young adults who are pursuing school or community support

Evaluate the veracity and degree of cognitive and psychiatric symptoms for disability, litigation, and criminal proceedings

Objectively document cognitive disturbances for capacity/competency determinations


Information from reference 2.

TABLE 1.

Common Goals of Neuropsychological Evaluations

GoalExamples

Characterize cognitive and behavioral function

Establish cognitive baseline before or after illness, injury, or treatment

Evaluate the impact of a medical issue on cognitive, behavioral, or emotional function

Identify cognitive strengths and weaknesses to predict ability to perform daily living activities

Identify subtle cognitive deficits

Prioritize differential diagnoses

Assess for psychological contributions to symptom presentations (e.g., depression, somatoform features)

Differentiate “worried well” patients from those with cognitive impairment

Establish, confirm, or differentiate between diagnoses that affect cognition

Evaluate for dementia and differentiate between potential etiologies

Plan and monitor treatment

Help determine candidacy for neurosurgical procedures (e.g., deep brain stimulation, epilepsy surgery, ventricular shunting)

Identify cognitive strengths and weaknesses to develop appropriate compensatory strategies and accommodations

Monitor cognitive changes associated with disease progression, recovery, or treatment

Provide prognostic information and treatment recommendations for patients with cognitive disturbances

Address legal, functional, or other issues

Determine whether cognitive deficits may interfere with ability to drive, return to work, or live independently

Diagnose or confirm neurodevelopmental disabilities in young adults who are pursuing school or community support

Evaluate the veracity and degree of cognitive and psychiatric symptoms for disability, litigation, and criminal proceedings

Objectively document cognitive disturbances for capacity/competency determinations


Information from reference 2.

Clinical neuropsychologists are doctoral-level psychologists who have fellowship training in assessment and intervention principles that are based on the scientific study of human behavior as it relates to normal and abnormal brain functioning.1  Neuropsychologists use validated puzzle-based materials, oral questions, and written tests to objectively assess multiple cognitive and emotional functions (Table 2). The tests are typically standardized using large normative samples of healthy age-matched individuals, allowing the examiner to determine the degree to which performance deviates from expected ranges. The results of neuropsychological testing are integrated with other sources of information to provide a comprehensive assessment of a person's cognitive, behavioral, and emotional functioning as a basis for clinical decisions (Table 3).2

 Enlarge     Print

TABLE 2.

Common Neuropsychological Tests by Domain

DomainTests

Academic achievement

Wide Range Achievement Test

Woodcock-Johnson Tests of Achievement

Adaptive/functional living

Independent Living Scales

Vineland Adaptive Behavior Scales

Attention and working memory

Digit span

Letter-number sequencing

Emotional functioning/personality

Minnesota Multiphasic Personality Inventory

Personality Assessment Inventory

Executive functioning

Stroop task

Trail Making Test

Wisconsin Card Sorting Test

Intelligence

Wechsler Abbreviated Scale of Intelligence

Wechsler Adult Intelligence Scale

Memory

California Verbal Learning Test

Rey Auditory Verbal Learning Test

Wechsler Memory Scale

Mental processing speed

Digit Symbol-Coding

Symbol Search

Premorbid estimation

National Adult Reading Test

Test of Premorbid Functioning

Psychomotor functioning

Grip strength test

Grooved Pegboard Test

Validity

Test of Memory Malingering

Word Memory Test

Verbal functions

Boston Naming Test

Controlled Oral Word Association Test

Visuospatial functions

Block design test

Rey Complex Figure Test and Recognition Trial

Multidomain test batteries

Neuropsychological Assessment Battery

Repeatable Battery for the Assessment of Neuropsychological Status

TABLE 2.

Common Neuropsychological Tests by Domain

DomainTests

Academic achievement

Wide Range Achievement Test

Woodcock-Johnson Tests of Achievement

Adaptive/functional living

Independent Living Scales

Vineland Adaptive Behavior Scales

Attention and working memory

Digit span

Letter-number sequencing

Emotional functioning/personality

Minnesota Multiphasic Personality Inventory

Personality Assessment Inventory

Executive functioning

Stroop task

Trail Making Test

Wisconsin Card Sorting Test

Intelligence

Wechsler Abbreviated Scale of Intelligence

Wechsler Adult Intelligence Scale

Memory

California Verbal Learning Test

Rey Auditory Verbal Learning Test

Wechsler Memory Scale

Mental processing speed

Digit Symbol-Coding

Symbol Search

Premorbid estimation

National Adult Reading Test

Test of Premorbid Functioning

Psychomotor functioning

Grip strength test

Grooved Pegboard Test

Validity

Test of Memory Malingering

Word Memory Test

Verbal functions

Boston Naming Test

Controlled Oral Word Association Test

Visuospatial functions

Block design test

Rey Complex Figure Test and Recognition Trial

Multidomain test batteries

Neuropsychological Assessment Battery

Repeatable Battery for the Assessment of Neuropsychological Status

 Enlarge     Print

TABLE 3.

Components of the Neuropsychological Evaluation

Examination of records

Family medical, neurologic, and psychiatric history

Laboratory, neuroimaging, and previous neuropsychological results (when available)

Medical, neurologic, and psychiatric history

Medication and substance use history

Reason for referral

Clinical interview with patient and collateral informant

Developmental factors that may affect current condition

Emotional, personality, and background factors that may warrant clinical attention

Impact of symptoms on daily living

Observation of neurobehavioral signs

Onset and course of symptoms

Neuropsychological testing

Administer standardized tests

Determine if data patterns reflect specific brain-behavior relations/lesion location

Examine degree of cognitive strength and dysfunction

Integrate test findings with patient background information

Score performance and convert to statistically standardized scores

Feedback

Answer patient and family questions about cognitive and behavioral functioning

Communicate findings, diagnosis, prognosis, and treatment plan with referring clinician

Discuss compensatory strategies with patient

Discuss treatment recommendations with patient

Provide results, diagnostic impression, and prognosis to patient


Information from reference 2.

TABLE 3.

Components of the Neuropsychological Evaluation

Examination of records

Family medical, neurologic, and psychiatric history

Laboratory, neuroimaging, and previous neuropsychological results (when available)

Medical, neurologic, and psychiatric history

Medication and substance use history

Reason for referral

Clinical interview with patient and collateral informant

Developmental factors that may affect current condition

Emotional, personality, and background factors that may warrant clinical attention

Impact of symptoms on daily living

Observation of neurobehavioral signs

Onset and course of symptoms

Neuropsychological testing

Administer standardized tests

Determine if data patterns reflect specific brain-behavior relations/lesion location

Examine degree of cognitive strength and dysfunction

Integrate test findings with patient background information

Score performance and convert to statistically standardized scores

Feedback

Answer patient and family questions about cognitive and behavioral functioning

Communicate findings, diagnosis, prognosis, and treatment plan with referring clinician

Discuss compensatory strategies with patient

Discuss treatment recommendations with patient

Provide results, diagnostic impression, and prognosis to patient


Information from reference 2.

Neuropsychological tests are different in purpose and scope from cognitive screening tests such as the Mini-Mental State Examination3  (Table 4). Screening tests usually take five to 10 minutes to complete and are designed to screen for general cognitive impairment that may warrant a more comprehensive workup. Although screening tests can indicate problems in general cognitive functioning, they have poor ability to assess for deficits in specific cognitive domains. This has been highlighted by research showing that screening test items weakly correlate with scores in the same cognitive domains on neuropsychological testing (correlations range from 0.04 to 0.46).4 Neuropsychological testing typically requires several hours to complete because it comprehensively examines multiple cognitive domains to provide a detailed assessment of the nature and severity of cognitive impairments. This information can contribute significantly when determining primary and secondary diagnoses and planning an individualized rehabilitation/treatment plan.3

 Enlarge     Print

TABLE 4.

Common Cognitive Screening Tests and Cutoff Scores

Mini-Mental State Examination

No longer freely available; to order: https://www.parinc.com/products/pkey/237 Common cutoff score suggestive of possible cognitive impairment: < 24

Montreal Cognitive Assessment

Freely available at: http://www.mocatest.org/ Common cutoff score suggestive of possible cognitive impairment: < 26

Saint Louis University Mental Status Examination

Freely available at: https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/assessment-tools/mental-status-exam.php

Common cutoff score suggestive of possible cognitive impairment: < 26 (< 24 if less than 12 years of education)

TABLE 4.

Common Cognitive Screening Tests and Cutoff Scores

Mini-Mental State Examination

No longer freely available; to order: https://www.parinc.com/products/pkey/237 Common cutoff score suggestive of possible cognitive impairment: < 24

Montreal Cognitive Assessment

Freely available at: http://www.mocatest.org/ Common cutoff score suggestive of possible cognitive impairment: < 26

Saint Louis University Mental Status Examination

Freely available at: https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/assessment-tools/mental-status-exam.php

Common cutoff score suggestive of possible cognitive impairment: < 26 (< 24 if less than 12 years of education)

Neuropsychological evaluations are often complementary to neuroimaging and electrophysiologic procedures.5 Computed tomography and magnetic resonance imaging evaluate structural integrity within the central nervous system to identify atrophy and lesions. Electroencephalography detects electrical activity of the brain, which is commonly used to assess for epileptic activity. Positron emission tomography identifies cerebral glucose metabolism to determine whether brain activity is reduced in specific regions. However, these procedures have limited diagnostic sensitivity for some neurologic conditions and cannot assess the functional output of the brain. Neuropsychological testing provides an objective assessment of the cognitive, behavioral, and emotional manifestations from cerebral injury or disease.

Because of the unique data that neuropsychological testing provides, physicians have increasingly utilized neuropsychological services.5 In satisfaction surveys, more than 80% of primary care physicians reported that referral questions were satisfactorily answered, and approximately 90% agreed with the diagnostic impressions and treatment recommendations.6  Overall, they found the consulting report useful, and they indicated they would continue to refer patients for neuropsychological evaluations. Commonly referred clinical conditions and primary care referral questions are listed in Table 5.6,7

 Enlarge     Print

TABLE 5.

Common Reasons for Patient Referrals to Neuropsychological Testing

Most frequently referred clinical conditions

Attention-deficit/hyperactivity disorder

Brain tumor

Dementia

Neurodevelopmental disorders

Seizure disorder

Stroke

Traumatic brain injury

Other medical or neurologic condition

Common primary care referral questions/expectations

Document functional limitations (e.g., driving, independent living)

Establish baseline cognitive functioning

Establish or confirm diagnosis

Examine competency or other issues that have legal complications

Provide second opinion

Provide treatment recommendations


Information from references 6 and 7.

TABLE 5.

Common Reasons for Patient Referrals to Neuropsychological Testing

Most frequently referred clinical conditions

Attention-deficit/hyperactivity disorder

Brain tumor

Dementia

Neurodevelopmental disorders

Seizure disorder

Stroke

Traumatic brain injury

Other medical or neurologic condition

Common primary care referral questions/expectations

Document functional limitations (e.g., driving, independent living)

Establish baseline cognitive functioning

Establish or confirm diagnosis

Examine competency or other issues that have legal complications

Provide second opinion

Provide treatment recommendations


Information from references 6 and 7.

Evidence for Neuropsychological Evaluations

Commonly used neuropsychological test batteries are highly reliable, with reliability coefficients often at or above 0.90 for cognitive index scores.8 Neuropsychological validity studies indicate that tests perform as anticipated in clinical situations. For example, patients with right temporal lobectomies perform below the normative mean on visual memory tests, whereas those with left temporal lobectomies perform below the normative mean on verbal memory tests.8 Patients with right parietal lobe lesions perform poorly on visuospatial constructional tests; those with left-hemisphere lesions perform poorly on expressive verbal ability tests; and those with frontal lobe lesions perform poorly on executive functioning tests.9,10 Empiric evidence for the use of neuropsychological evaluations in persons with dementia, mild cognitive impairment, traumatic brain injury (TBI), and other clinical conditions is summarized below.

DEMENTIA AND MILD COGNITIVE IMPAIRMENT

Guidelines from several organizations stress the importance of neuropsychological assessment in the diagnosis and management of dementia. The National Institute on Aging–Alzheimer's Association Workgroup recommends that neuropsychological testing be conducted when the clinical history and mental status examination do not yield confident diagnoses.11 The European Federation of Neurologic Societies–European Neurologic Society states that cognitive assessment has a key role in the diagnosis and management of dementia.12 The International Statistical Classification of Mental and Behavioural Disorders, 10th rev., and the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., state that neuropsychological testing is the preferred method for examining and documenting cognitive dysfunction.13,14 Figure 1 shows an approach to evaluating and managing patients with suspected dementia2; an alternative algorithm that includes the neuropsychological evaluation is available in a recent American Family Physician article (https://www.aafp.org/afp/2018/0315/p398.html#afp20180315p398-f1).

 Enlarge     Print

FIGURE 1.

Approach to the patient in whom there is concern about dementia.

Adapted with permission from Michels TC, Tiu AY, Graver CJ. Neuropsychological evaluation in primary care. Am Fam Physician. 2010;82(5):499.


FIGURE 1.

Approach to the patient in whom there is concern about dementia.

Adapted with permission from Michels TC, Tiu AY, Graver CJ. Neuropsychological evaluation in primary care. Am Fam Physician. 2010;82(5):499.

Neuropsychological testing can differentiate Alzheimer dementia from nondementia with nearly 90% accuracy,15 with even higher rates when demographic factors are incorporated with test data (area under the curve = 0.98).16 Neuropsychological evaluations improve diagnostic accuracy even when diagnoses are informed by imaging results and evaluation by subspecialists.17,18 Additionally, studies have shown that neuropsychological testing can differentiate dementia from psychiatric conditions with accuracy rates near 90%.19

Although Alzheimer disease is the most common cause of dementia in adults 60 years and older, dementia is often the result of other disease processes (e.g., Lewy body disease, cerebrovascular disease). Understanding the cause of a patient's dementia can guide family physicians in prescription decisions (e.g., whether to start an acetylcholinesterase inhibitor) and expectations about future symptoms and treatment needs.20 Neuropsychological testing can be a useful tool in this regard, with studies demonstrating strong accuracy in discriminating between different types of dementia.21,22 Neuropsychological testing can also distinguish mild cognitive impairment from normal functioning; sensitivity and specificity rates are approximately 75% and 80%, respectively, when well-established diagnostic criteria are used.15,23 Serial assessments can be useful for patients with mild cognitive impairment or in cases where the etiology of cognitive decline is unclear. A 12-month follow-up is often used to determine whether patterns of cognitive decline are consistent with a suspected etiology, identifying conversion of mild cognitive impairment to dementia, or to monitor the rate of cognitive change over time.5

Neuropsychological assessments are helpful in tracking changes that may affect daily functioning as cognitive impairment and dementia progress.5 Approximately 40% to 50% of the variance in functional decline (i.e., ability to perform personal care activities) is accounted for by cognitive decline.24 In at least 50% of cases, neuropsychological testing can indicate when a patient needs assistance with daily activities.24 Among the challenging situations in which neuropsychological evaluation can be helpful are assessing driving safety and determining health care decision-making capacity. Reduced visuospatial abilities moderately predict on-road driving performance.25 The American Bar Association and American Psychological Association concluded that neuropsychological assessment provides objective information to improve the reliability of capacity determinations.26

TRAUMATIC BRAIN INJURY

Neuropsychologists are often involved in post–acute TBI management to help determine and predict patient-specific cognitive, emotional, and adaptive functioning27 (Figure 2 2,2830). The addition of neuropsychological testing to injury severity variables (e.g., posttraumatic amnesia) increases predicted accuracy in functional outcomes.31 In moderate to severe TBI, neuropsychological status can predict functional independence, return to work, disability utilization, responsiveness to cognitive rehabilitation, and academic achievement.20,3238

 Enlarge     Print

FIGURE 2.

Approach to the patient with subacute mild traumatic brain injury.

Information from references 2, and 28 through 30.


FIGURE 2.

Approach to the patient with subacute mild traumatic brain injury.

Information from references 2, and 28 through 30.

In patients with mild TBI (concussion), in whom long-term cognitive deficits are less likely, a neuropsychological evaluation can identify psychological and other noncognitive factors that may masquerade as cognitive dysfunction and, therefore, can guide appropriate treatment recommendations.28 The Concussion in Sport Group described neuropsychological assessments as a cornerstone of concussion management, and a recent international consensus statement indicated that neuropsychological testing contributes significant information in the evaluation of mild TBI.39 Guidelines recommend that patients who report cognitive symptoms beyond 30 to 90 days after mild TBI be referred for neuropsychological assessment.28,29

Neuropsychologists routinely use performance validity tests in cases where legal issues may be confounding recovery after TBI. These tests assess the validity of a patient's reported symptoms.40 These tests appear more challenging than they actually are; even patients with severe cognitive impairment can perform with near-perfect accuracy. When using cutoff scores and clinical decision rules for multiple tests, accuracy rates are greater than 90%, indicating that results beyond cutoff scores are likely invalid.41 Given their expertise with typical and atypical sequelae of TBI and empiric methods for detecting invalid presentations, neuropsychologists are often involved in evaluating exaggeration or malingering of cognitive and emotional symptoms in TBI cases.

OTHER CLINICAL CONDITIONS THAT CAN AFFECT COGNITIVE FUNCTIONING

The American Academy of Neurology has endorsed the use of neuropsychological evaluation in the assessment and treatment of a variety of conditions, including cerebrovascular disease/stroke, Parkinson disease, human immunodeficiency virus encephalopathy, multiple sclerosis, epilepsy, neurotoxic exposure, and chronic pain.42 Research also demonstrates that neuropsychological evaluations can detect cognitive changes caused by psychiatric conditions such as schizophrenia and bipolar disorder20,43; identify cognitive changes that may emerge before motor abnormalities in the early stage of Huntington disease44; and measure cognitive changes after surgery in patients with brain tumors.45 Neuropsychological evaluations can also detect cognitive issues in patients with developmental disabilities, illnesses, and central nervous system abnormalities.27

Referring for a Neuropsychological Consultation

Referrals for neuropsychological consultation are commonly made by family physicians, neurologists, psychiatrists, and other primary care clinicians. Assessments are typically covered by health insurance if psychological, neurologic, or medical issues are suspected that could affect cognitive or neurobehavioral functioning and if referrals are related to making clinical diagnoses or developing treatment plans. Table 6 shows common indications and exclusions for insurance coverage of neuropsychological evaluations.46

 Enlarge     Print

TABLE 6.

Common Indications and Exclusions for Insurance Coverage of Neuropsychological Services

Indications for probable coverage

To determine functional abilities or impairments to establish a treatment plan

To determine if adverse effects of therapeutic substances could impair cognition

To determine if a patient can participate in health care decision making or independent living

To diagnose cognitive or functional deficits based on an inability to develop expected skills

To differentiate between psychogenic and neurologic syndromes (e.g., dementia vs. depression)

To distinguish between possible disease processes

To distinguish cognitive or neurobehavioral abnormalities from normal aging

To establish a neurologic or systemic condition known to affect CNS functioning

To establish rehabilitation or management strategies for patients with neuropsychiatric disorders

To establish the most effective plan of care

To establish the presence of cognitive or neurobehavioral abnormalities

To monitor progression, recovery, or response to treatment in patients with CNS disorders

To provide presurgical cognitive evaluation to determine the safety of the surgical procedure

To quantify cognitive or behavioral deficits related to CNS impairment

Indications for probable exclusion

Active substance abuse that could cause inaccurate test results

Adjustment issue associated with moving to a skilled nursing facility

Cognitive abnormalities are not suspected

Desired information can be obtained through a routine clinical interview

Patient is not able to meaningfully participate in the evaluation

Repeat testing is not required for medical decision making

Self-administered testing or tests used solely for screening

Standardized test batteries are not individualized to the patient's symptoms or referral question

Test results are not expected to affect medical management

Tests administered for educational or vocational purposes that do not establish medical management


CNS = central nervous system.

Information from reference 46.

TABLE 6.

Common Indications and Exclusions for Insurance Coverage of Neuropsychological Services

Indications for probable coverage

To determine functional abilities or impairments to establish a treatment plan

To determine if adverse effects of therapeutic substances could impair cognition

To determine if a patient can participate in health care decision making or independent living

To diagnose cognitive or functional deficits based on an inability to develop expected skills

To differentiate between psychogenic and neurologic syndromes (e.g., dementia vs. depression)

To distinguish between possible disease processes

To distinguish cognitive or neurobehavioral abnormalities from normal aging

To establish a neurologic or systemic condition known to affect CNS functioning

To establish rehabilitation or management strategies for patients with neuropsychiatric disorders

To establish the most effective plan of care

To establish the presence of cognitive or neurobehavioral abnormalities

To monitor progression, recovery, or response to treatment in patients with CNS disorders

To provide presurgical cognitive evaluation to determine the safety of the surgical procedure

To quantify cognitive or behavioral deficits related to CNS impairment

Indications for probable exclusion

Active substance abuse that could cause inaccurate test results

Adjustment issue associated with moving to a skilled nursing facility

Cognitive abnormalities are not suspected

Desired information can be obtained through a routine clinical interview

Patient is not able to meaningfully participate in the evaluation

Repeat testing is not required for medical decision making

Self-administered testing or tests used solely for screening

Standardized test batteries are not individualized to the patient's symptoms or referral question

Test results are not expected to affect medical management

Tests administered for educational or vocational purposes that do not establish medical management


CNS = central nervous system.

Information from reference 46.

Although availability can sometimes be limited, particularly in rural settings, a listing of neuropsychologists certified by the American Academy of Clinical Neuropsychology is available at https://theaacn.org/directory. To reduce patient stress and optimize outcomes, physicians should briefly discuss with patients the reason for the referral, the anticipated benefit of the assessment, and the general testing format. Some patients might initially be apprehensive, but surveys show that more than 90% of patients rated their experience as positive or neutral.47 Roughly 80% of patients and their significant others reported that they found the evaluation helpful in understanding and coping with cognitive problems; more than 90% reported being satisfied with the evaluation; and approximately 90% indicated that they would refer others.48 A brief pamphlet for patients who are being referred for testing is available at http://www.div40.org/pdf/NeuropscyhBroch2.pdf.

This article updates a previous article on this topic by Michels, et al.2

Data Sources: PubMed, PsychInfo, National Guideline Clearinghouse, and U.S. Preventive Services Task Force were the primary sources for the article. Key words included neuropsychological, neuropsychology, cognitive, cognition, dementia, mild cognitive impairment, brain injury, and concussion. Search dates: July 26, 2017, to October 12, 2018.

Editor's Note: Dr. Walling is an Associate Medical Editor for AFP.

The Authors

show all author info

RYAN W. SCHROEDER, PsyD, is an associate professor in the Department of Psychiatry and Behavioral Sciences at the University of Kansas School of Medicine–Wichita....

PHILLIP K. MARTIN, PhD, is an assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Kansas School of Medicine–Wichita.

ANNE WALLING, MB, ChB, is a professor emerita in the Department of Family and Community Medicine at the University of Kansas School of Medicine–Wichita.

Address correspondence to Ryan W. Schroeder, PsyD, University of Kansas School of Medicine, 1010 N. Kansas St., Wichita, KS 67214 (e-mail: rschroeder2@kumc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. American Academy of Clinical Neuropsychology (AACN) practice guidelines for neuropsychological assessment and consultation. Clin Neuropsychol. 2007;21(2):209–231....

2. Michels TC, Tiu AY, Graver CJ. Neuropsychological evaluation in primary care. Am Fam Physician. 2010;82(5):495–502.

3. Roebuck-Spencer TM, Glen T, Puente AE, et al. Cognitive screening tests versus comprehensive neuropsychological test batteries: a National Academy of Neuropsychology education paper. Arch Clin Neuropsychol. 2017;32(4):491–498.

4. Moafmashhadi P, Koski L. Limitations for interpreting failure on individual subtests of the Montreal Cognitive Assessment. J Geriatr Psychiatry Neurol. 2013;26(1):19–28.

5. Braun M, Tupper D, Kaufmann P, et al. Neuropsychological assessment: a valuable tool in the diagnosis and management of neurological, neurodevelopmental, medical, and psychiatric disorders. Cogn Behav Neurol. 2011;24(3):107–114.

6. Temple RO, Carvalho J, Tremont G. A national survey of physicians' use of and satisfaction with neuropsychological services. Arch Clin Neuropsychol. 2006;21(5):371–382.

7. Sweet JJ, Benson LM, Nelson NW, Moberg PJ. The American Academy of Clinical Neuropsychology, National Academy of Neuropsychology, and Society for Clinical Neuropsychology (APA Division 40) 2015 TCN professional practice and ‘salary survey’: professional practices, beliefs, and incomes of U.S. neuropsychologists. Clin Neuropsychol. 2015;29(8):1069–1162.

8. Wechsler D. WMS-IV Technical and Interpretive Manual. 4th ed. San Antonio, Tex.: Pearson Education; 2009.

9. Warrington EK, James M, Maciejewski C. The WAIS as a lateralizing and localizing diagnostic instrument: a study of 656 patients with unilateral cerebral lesions. Neuropsychologia. 1986;24(2):223–239.

10. Baldo JV, Shimamura AP, Delis DC, Kramer J, Kaplan E. Verbal and design fluency in patients with frontal lobe lesions. J Int Neuropsychol Soc. 2001;7(5):586–596.

11. McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement. 2011;7(3):263–269.

12. Sorbi S, Hort J, Erkinjuntti T, et al.; EFNS Scientist Panel on Dementia and Cognitive Neurology. EFNS-ENS guidelines on the diagnosis and management of disorders associated with dementia. Eur J Neurol. 2012;19(9):1159–1179.

13. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva, Switzerland: World Health Organization; 1993.

14. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

15. Weissberger GH, Strong JV, Stefanidis KB, Summers MJ, Bondi MW, Stricker NH. Diagnostic accuracy of memory measures in Alzheimer's dementia and mild cognitive impairment: a systematic review and meta-analysis. Neuropsychol Rev. 2017;27(4):354–388.

16. Wolfsgruber S, Jessen F, Wiese B, et al.; AgeCoDe Study Group. The CERAD neuropsychological assessment battery total score detects and predicts Alzheimer disease dementia with high diagnostic accuracy. Am J Geriatr Psychiatry. 2014;22(10):1017–1028.

17. Hentschel F, Kreis M, Damian M, Krumm B, Frölich L. The clinical utility of structural neuroimaging with MRI for diagnosis and differential diagnosis of dementia: a memory clinic study. Int J Geriatr Psychiatry. 2005;20(7):645–650.

18. Visser PJ, Scheltens P, Verhey FR, et al. Medial temporal lobe atrophy and memory dysfunction as predictors for dementia in subjects with mild cognitive impairment. J Neurol. 1999;246(6):477–485.

19. Swainson R, Hodges JR, Galton CJ, et al. Early detection and differential diagnosis of Alzheimer's disease and depression with neuropsychological tasks. Dement Geriatr Cogn Disord. 2001;12(4):265–280.

20. Watt S, Crowe SF. Examining the beneficial effect of neuropsychological assessment on adult patient outcomes: a systematic review. Clin Neuropsychol. 2018;32(3):368–390.

21. Ramirez-Gomez L, Zheng L, Reed B, et al. Neuropsychological profiles differentiate Alzheimer disease from subcortical ischemic vascular dementia in an autopsy-defined cohort. Dement Geriatr Cogn Disord. 2017;44(1–2):1–11.

22. Gurnani AS, Gavett BE. The differential effects of Alzheimer's disease and Lewy body pathology on cognitive performance: a meta-analysis. Neuropsychol Rev. 2017;27(1):1–17.

23. Chandler MJ, Lacritz LH, Hynan LS, et al. A total score for the CERAD neuropsychological battery. Neurology. 2005;65(1):102–106.

24. Fields JA, Machulda M, Aakre J, et al. Utility of the DRS for predicting problems in day-to-day functioning. Clin Neuropsychol. 2010;24(7):1167–1180.

25. Reger MA, Welsh RK, Watson GS, Cholerton B, Baker LD, Craft S. The relationship between neuropsychological functioning and driving ability in dementia: a meta-analysis. Neuropsychology. 2004;18(1):85–93.

26. American Bar Association; American Psychological Association. Assessment of older adults with diminished capacity: a handbook for psychologists. 2008. https://www.apa.org/pi/aging/programs/assessment/capacity-psychologist-handbook.pdf. Accessed August 19, 2018.

27. Lezak MD, Howieson DB, Bigler ED, Tranel D. Neuropsychological Assessment. 5th ed. New York, NY: Oxford University Press; 2012.

28. Vos PE, Battistin L, Birbamer G, et al. EFNS guideline on mild traumatic brain injury: report of an EFNS task force. Eur J Neurol. 2002;9(3):207–219.

29. U.S. Dept. of Veterans Affairs; U.S. Dept. of Defense. VA&sol;DoD clinical practice guideline for the management of concussion—mild traumatic brain injury. Version 2.0. 2016. https://www.healthquality.va.gov/guidelines/Rehab/mtbi/mTBICPGFullCPG50821816.pdf. Accessed August 19, 2018.

30. Centers for Disease Control and Prevention. Updated mild traumatic brain injury guideline for adults. https://www.cdc.gov/traumaticbraininjury/pdf/tbi_clinicians_factsheet-a.pdf. Accessed August 19, 2018.

31. Spitz G, Ponsford JL, Rudzki D, Maller JJ. Association between cognitive performance and functional outcome following traumatic brain injury: a longitudinal multilevel examination. Neuropsychology. 2012;26(5):604–612.

32. Skandsen T, Finnanger TG, Andersson S, Lydersen S, Brunner JF, Vik A. Cognitive impairment 3 months after moderate and severe traumatic brain injury: a prospective follow-up study. Arch Phys Med Rehabil. 2010;91(12):1904–1913.

33. Sherer M, Novack TA, Sander AM, Struchen MA, Alderson A, Thompson RN. Neuropsychological assessment and employment outcome after traumatic brain injury: a review. Clin Neuropsychol. 2002;16(2):157–178.

34. Bercaw EL, Hanks RA, Millis SR, Gola TJ. Changes in neuropsychological performance after traumatic brain injury from inpatient rehabilitation to 1-year follow-up in predicting 2-year functional outcomes. Clin Neuropsychol. 2011;25(1):72–89.

35. Sandry J, Chiou KS, DeLuca J, Chiaravalloti ND. Individual differences in working memory capacity predicts responsiveness to memory rehabilitation after traumatic brain injury. Arch Phys Med Rehabil. 2016;97(6):1026–1029.e1.

36. Fulton JB, Yeates KO, Taylor HG, Walz NC, Wade SL. Cognitive predictors of academic achievement in young children 1 year after traumatic brain injury. Neuropsychology. 2012;26(3):314–322.

37. Mazaux JM, Masson F, Levin HS, Alaoui P, Maurette P, Barat M. Long-term neuropsychological outcome and loss of social autonomy after traumatic brain injury. Arch Phys Med Rehabil. 1997;78(12):1316–1320.

38. Dikmen SS, Machamer JE, Powell JM, Temkin NR. Outcome 3 to 5 years after moderate to severe traumatic brain injury. Arch Phys Med Rehabil. 2003;84(10):1449–1457.

39. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med. 2005;39(4):196–204.

40. Martin PK, Schroeder RW, Odland AP. Neuropsychologists' validity testing beliefs and practices: a survey of North American professionals. Clin Neuropsychol. 2015;29(6):741–776.

41. Larrabee GJ. False-positive rates associated with the use of multiple performance and symptom validity tests. Arch Clin Neuropsychol. 2014;29(4):364–373.

42. Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: neuropsychological testing of adults. Considerations for neurologists. Neurology. 1996;47(2):592–599.

43. Torrent C, Martínez-Arán A, Amann B, et al. Cognitive impairment in schizoaffective disorder: a comparison with non-psychotic bipolar and healthy subjects. Acta Psychiatr Scand. 2007;116(6):453–460.

44. Robins Wahlin TB, Lundin A, Dear K. Early cognitive deficits in Swedish gene carriers of Huntington's disease. Neuropsychology. 2007;21(1):31–44.

45. Talacchi A, Santini B, Savazzi S, Gerosa M. Cognitive effects of tumour and surgical treatment in glioma patients. J Neurooncol. 2011;103(3):541–549.

46. Optum. Medicare coverage summary: psychological and neuropsychological testing. https://www.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/mcs/ptMCS.pdf. Accessed April 12, 2018.

47. Bennett-Levy J, Klein-Boonschate MA, Batchelor J, McCarter R, Walton N. Encounters with Anna Thompson: the consumer's experience of neuropsychological assessment. Clin Neuropsychol. 1994;8(2):219–238.

48. Westervelt HJ, Brown LB, Tremont G, Javorsky DJ, Stern RA. Patient and family perceptions of the neuropsychological evaluation: how are we doing? Clin Neuropsychol. 2007;21(2):263–273.

 

 

Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Jan 15, 2020

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article