Laura A. Rabin
Neuropsychological Evaluation
Mr. B., a 62-year-old man, visits his primary care practitioner with concern about his memory and concentration abilities, disrupted sleep, and low energy level. He began to notice these problems about 6 to 8 months ago, and he feels they have been worsening. His cognitive problems are interfering with his ability to be productive in his professional art studio. For example, he misplaces art supplies and cannot settle into reading a book as he used to because his mind wanders. He has also lost interest in socializing. Mr. B. has a history of hypertension and hypercholesterolemia, both well controlled with medication. He and his spouse of over 30 years divorced 2 years ago, and his two grown children, with whom he reportedly is close, live in other parts of the country. On the Folstein Mini-Mental State Examination (MMSE), Mr. B. was fully oriented, aware of his circumstances and current events, and scored a 28/30. His only errors were the inability to recall one of three words after a brief distractor task and misstating the floor of the clinic (reporting “second” instead of “third”). He reportedly lives alone and carries out all complex activities of daily living without assistance.
Many individuals visit primary care practitioners with complaints about aspects of cognition. With rapid advances in medicine and technology, in particular the proliferation of sophisticated neuroimaging techniques, one may question the usefulness and added value of a neuropsychological assessment with its paper-and-pencil tests, questionnaires, and comprehensive test reports. In today’s complex health care environment, in which meeting patient needs often requires the work of interdisciplinary teams of health care professionals, what role does the neuropsychologist play? This chapter attempts to answer these and other questions related to the role of neuropsychological assessment in primary care settings. The chapter begins with brief overview of the field of clinical neuropsychology, its evolution as a health care specialty, and the role of its practitioners in collaborative practice efforts. It also addresses the expertise and unique perspective on patient care that neuropsychologists bring to the treatment of patients with a range of psychological, cognitive, behavioral, and medical issues. We return to Mr. B. later in our discussion.
Overview of Clinical Neuropsychology
Clinical neuropsychology is an applied science concerned with the behavioral expression of central nervous system dysfunction.1 The field of neuropsychology has strong interdisciplinary ties to clinical psychology, neuroscience, and medicine, especially behavioral neurology and psychiatry. Neuropsychology emerged in the 20th century, combining information about neurologic patients with psychological techniques, such as the objective observation of behavior and the use of standardized assessment instruments to characterize and quantify cognitive impairment and its behavioral consequences. Initially, the primary goals of neuropsychological assessments were to localize, lateralize, and detect the site of lesions in patients with brain damage through noninvasive, standardized techniques and to aid in diagnosis and quantification of the cognitive deficits associated with specific neurologic disorders. With the advent of neuroradiologic procedures (e.g., computed tomography [CT], positron emission tomography [PET], magnetic resonance imaging [MRI] and functional magnetic resonance imaging [fMRI]), the objective of neuropsychological evaluations expanded to include analysis of patients’ neurocognitive strengths and weaknesses, description of the functional consequences of brain dysfunction, prediction of risk of future cognitive decline, remediation of neurocognitive impairment, and introduction of compensatory interventions to maximize remaining abilities.1–4
Neuropsychology has undergone tremendous growth in recent decades. There are likely more than 2000 neuropsychological tests available, although a much smaller number (approximately 50 to 100) receive widespread and regular use by neuropsychologists. In addition, there are national and international scientific and professional organizations, books and journals that distribute basic and applied research, doctoral and postdoctoral training programs, and board certification procedures. Ongoing efforts to advance neuropsychology have included collaborations with medical and governmental agencies to establish billing codes and reimbursement guidelines for services, the facilitation of multicultural assessment practices, the establishment of honors to acknowledge excellence in the field, and the development of national and international conventions and conferences.1–4
Professional Functions and Roles
Most neuropsychologists possess a doctoral degree in clinical psychology with a specialization in neuropsychology gained through advanced coursework and training at the doctoral, internship, and postdoctoral levels in basic and applied neuroscience, neuroanatomy, research methods, and psychometry. In addition to being licensed psychologists (a minimum requirement for all practicing neuropsychologists), neuropsychologists increasingly seek board certification through the American Board of Clinical Neuropsychology (ABCN) or the American Board of Professional Neuropsychology (ABPN).5,6
Neuropsychologists address important clinical problems through the application of knowledge about brain-behavior relationships. Clinical work consists primarily of cognitive assessment, diagnosis, and treatment of neurologic, psychiatric, and general medical conditions.1,4,7 Because psychological states are inextricably connected with cognition and functional status, neuropsychologists are also trained to examine emotional and personality functioning. In addition, neuropsychologists increasingly receive specialized training in the use and interpretation of neuroimaging data.8 Even with the widespread use of sophisticated techniques to image the structure, function, and pharmacology of the brain, traditional neuropsychological assessment continues to play a key role in diagnosis and characterization of the behavioral sequelae of brain dysfunction. Indeed, many neurologic and psychiatric disorders result from brain changes not visible on even high-resolution scanners (e.g., transient ischemic attacks, mild concussions, attention and learning disabilities). Furthermore, the location and extent of structural lesions may not accurately predict subsequent cognitive and behavioral changes; individuals with brain lesions that appear similar on imaging studies may have vastly different neuropsychological profiles.8 Thus, detailed characterization of cognitive and functional capacities may be as important to patient care as quantification of structural and functional brain abnormalities.
Assessment Tools and Approaches
Concomitant with the expansion of neuropsychological services has been the development of a large collection of objective instruments to evaluate capacities such as intelligence, academic achievement, verbal and language skills, processing speed, attention and working memory, learning and memory, executive functioning, reasoning and problem solving, visuospatial and visuoconstructive abilities, perception, sensory and motor skills, mood, and personality.1 There are also numerous well-validated cognitive effort tests available to identify cases in which patients are motivated (either consciously or unconsciously) to present themselves as more impaired than is actually the case. If a test taker’s effort or level of motivation is suboptimal, then the validity and reliability of the entire assessment may be called into question.4,9
Box 188-1 presents a sample of some commonly used neuropsychological tests. Whenever possible, testing measures are published, standardized, well normed, up-to-date, and accepted as reliable and valid tools in the field. Many instruments in common use today are adaptations of techniques that have been used for decades. For example, the most widely used intellectual and memory assessment batteries (i.e., Wechsler Adult Intelligence Scale, Fourth Edition [WAIS-IV] and Wechsler Memory Scale, Fourth Edition [WMS-IV]) are similar in overall content to the original versions developed in 1955 and 1947, respectively. In many cases, revisions reflect changes made to accommodate advances in the quality of normative data, the effects of cultural and educational factors on test scores, and empirical findings that guide interpretation of test performance.1,10,11
In addition to paper-and-pencil tests, neuropsychologists routinely use subjective rating scales, questionnaires, and tests of personality and emotional functioning. Direct observations of individuals in their natural environments and performance-based tests of everyday activities provide more direct and face-valid assessments of individuals’ functional capacities but are associated with drawbacks that limit routine use.7 Computerized cognitive tests and test batteries are increasingly discussed in the literature, although actual use of computerized instruments has not matched expectations.12,13 Currently there are two main approaches to computerized testing: (1) the adaptation of existing examiner-administered instruments to computerized administration and/or scoring formats; and (2) the development of new computerized tests and test batteries that measure aspects of cognition not easily captured through paper-and-pencil tasks. This may include tests designed to assess domains such as attention, vigilance, and speed of information processing or the use of video and computer graphics to provide realistic simulations of the cognitive tasks performed in everyday life.12,13 A comprehensive review of computerized neuropsychological instruments and their advantages and limitations is beyond the scope of this chapter, but it is crucial that such evaluations be conducted in accordance with American Psychological Association guidelines concerning reliability and validity of tests, normative data, and user qualifications.14
With regard to test selection, a flexible battery composed of variable but routine groupings of tests for different types of patients is preferred. Tests are selected on the basis of hypotheses generated through a clinical interview, observation of the patient, and review of medical records. The flexible approach has the advantage of preventing unnecessary testing. Because patients often find neuropsychological testing stressful and fatiguing, which can negatively influence performance, advocates of the flexible approach argue that tailoring of test batteries to particular patients can provide more accurate information. Far fewer neuropsychologists opt for a completely flexible approach, based on the needs of the individual case, or a fixed or standardized battery, which uses the same grouping of tests for all patient types and referral questions.1,4,15
Neuropsychology Within Primary Care Settings
Box 188-2 presents common neuropsychological assessment goals.
Box 188-2
Neuropsychological Assessment Goals
• Objectively measure complaints of cognitive difficulties
• Establish a baseline level of neuropsychological functioning
• Monitor changes in cognition over time (document recovery or progression of symptoms)
• Assist in differential diagnosis and determination of the severity of a condition
• Test the effects of medication, remediation, or other intervention on cognition and function
• Determine the extent to which pain problems interfere with cognitive functioning
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