Although physicians commonly utilize screening instruments to identify cognitive problems and psychological issues in patients with various neurological etiologies, occasions arise when referral to a neuropsychologist is needed for more comprehensive assessment. Screening instruments, such as the Mini-Mental State Examination, are sensitive to moderate to severe cognitive impairment but relatively insensitive to milder forms of impairment; they are also susceptible to lower educational levels.
Neuropsychologists have specialized training in brain-behavior relationships and perform comprehensive cognitive evaluations in addition to providing treatment. Cognitive screening, therefore, can be useful to indicate the need for a consult for further, more formal testing.
Neuropsychological assessment requires the use of standardized instruments to assess cognitive function, behavior, and mood and personality. These functions can be organized into specific major domains such as intelligence, attention/concentration, learning and memory, language, visuospatial and perceptual functions, executive functions, psychomotor speed, and emotional/mood. Many standard test instruments measure more than one functional domain, and some disorders are associated with dysfunction within more than one domain. Depending on the referral question, academic skills also may be assessed. Where suboptimal effort or malingering is suspected, tests of symptom validity also should be considered to determine the probability of exaggeration or fabrication of cognitive dysfunction.
Comprehensive assessment begins with a detailed medical record review, including medical history, medications, laboratory results, and neuroimaging reports, and in-depth clinical interview. The clinical interview includes behavioral observations and may last one to two hours. A wide variety of neuropsychological test instruments (primarily paper-pencil tests) are then administered; most are done sitting at a table or bedside in a hospital. Evaluations can vary from less than one hour to 6 to 8 hours of face-to-face contact, depending on the information sought and the patient’s stamina and motivation. In general, more comprehensive evaluations are longer and are performed on an outpatient basis.
The neuropsychological evaluation is tailored to the needs of the individual client. The neuropsychologist selects, administers, and interprets the particular battery or tests that will yield the most comprehensive understanding of an individual's strengths and weaknesses and/or answer the referral question and offer recommendations. Test batteries can be either "flexible" or "fixed." Flexible test batteries are more common and may revolve around a core set of tests with additional tests employed, as needed, to address specific issues. A flexible battery approach permits test selection on a case-by-case basis. Some clinical neuropsychologists, however, utilize a fixed battery approach such as the Halstead-Reitan Battery (HRB) or the Luria-Nebraska Neuropsychological Battery (LNNB), although this is less common.
Tests are administered in a standardized manner (meaning the same for everyone), and scores are compared to the patient’s normative group (typically controlled for age, or education). A neuropsychological evaluation is not limited to testing but also involves some estimate of the patient’s premorbid functioning and personality. This is accomplished by a review of prior test scores, medical records, educational/employment evaluations, and interviews with family members when available.
Neuropsychological assessment is performed for several reasons. The following are some of the goals and benefits:
Patients with brain injury can benefit from neuropsychological assessment as part of an interprofessional team approach to care. As mentioned above, cognitive assessment can help dictate a treatment plan, monitor recovery, and help determine when a person is ready to return to work, driving, or sports.
Another clinical population for which assessment is valuable is older patients with long-standing memory concerns along with other cognitive deficits with or without corresponding brain atrophy. These cases may require an assessment to help determine a differential diagnosis as well as aid in decision-making. Other groups with reported memory and other cognitive problems also may require dementia assessment and consideration of psychological factors contributing to a patient’s symptoms (e.g., dementia versus depression).
Psychological factors can be overlooked in neurological patients. These may include mood changes such as depression or anxiety including post-traumatic stress disorder, or behavioral dysfunction such as agitation, poor initiation, or wandering. Emotional and behavioral sequelae can be the direct result of underlying neurological impairment. For example, patients with left frontal strokes or those localized to subcortical areas of the brain can experience an “organic depression.” Alternatively, damage to frontal areas also may result in behavioral disturbances such as disinhibition, impulsivity, abulia, and emotional lability. A comprehensive neuropsychological assessment, in this case, would also assess for neuropsychiatric sequelae.
Forensic issues, such as that of capacity (competency, in legal terms), also can arise in medical settings. Decision-making capacity, whether for a medical procedure, designation of a health care agent, or disposition, is a clinical finding regarding a patient’s decisional abilities. Although people are presumed to have capacity, cognitive impairment and/or psychiatric disturbances can impair one’s capacity to make decisions. Neuropsychologists often are called in to help assess capacity; this always involves an interview with the patient and any collaterals, as well as an assessment of functional abilities. A full neuropsychological assessment is not always required, although some evaluation of cognition usually is performed.
Many other patients with neurological and/or psychiatric etiologies can benefit from neuropsychological assessment. In children, neuropsychologists often work with the school system to provide accommodations for deficits.
Sensory deficits such as poor visual acuity or visual field cut, or hearing impairment and motor deficits (e.g., ataxia) need to be taken into consideration when assessing any of the above populations, as tests require visual and verbal input and sometimes writing or manual manipulation of stimuli.
Another issue is that of cross-cultural competence. Although beyond the scope of this article, neuropsychologists must ensure that patients have fluency with the language in which they are being tested. When they do not, alternatives such as referral to bilingual neuropsychologists or use of interpreters need to be considered. Tests also should be in the patient's language.
Health professionals may not always be aware when a referral to a neuropsychologist is needed. Neuropsychologists have specialized training in brain-behavior relationships and perform comprehensive cognitive evaluations in addition to providing treatment. Cognitive screening can be useful to indicate the need for a consult for further, more formal testing. The healthcare team should be aware of this option to provide the best outcomes for patients.
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