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Neuropsychological Evaluations in Adults Ryan W Neuropsychological Evaluations in Adults Ryan W. Schroeder, PsyD; Phillip K. Martin, PhD; and Anne Walling, MB, ChB University of Kansas School of Medicine–Wichita, Wichita, Kansas 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 neu- rocognitive 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. (Am Fam Physician. 2019;99(2):101-108. Copyright © 2019 American Academy of Family Physicians.) Family physicians are often the first health care pro- of information to provide a comprehensive assessment of a fessionals to evaluate patients with memory loss and cog- person’s cognitive, behavioral, and emotional functioning nitive dysfunction. Although many patients can be readily as a basis for clinical decisions (Table 3).2 diagnosed and treated, some present significant challenges. Neuropsychological tests are different in purpose and A neuropsychological consultation can help characterize scope from cognitive screening tests such as the Mini-Mental cognitive deficits, clarify diagnoses, and develop optimal State Examination3 (Table 4). Screening tests usually take management plans for patients with cognitive issues.1 Com- five to 10 minutes to complete and are designed to screen for mon goals of neuropsychological evaluations are provided general cognitive impairment that may warrant a more com- in Table 1.2 prehensive workup. Although screening tests can indicate Clinical neuropsychologists are doctoral-level psycholo- problems in general cognitive functioning, they have poor gists who have fellowship training in assessment and inter- ability to assess for deficits in specific cognitive domains. vention principles that are based on the scientific study of This has been highlighted by research showing that screen- human behavior as it relates to normal and abnormal brain ing test items weakly correlate with scores in the same cog- functioning.1 Neuropsychologists use validated puzzle- nitive domains on neuropsychological testing (correlations based materials, oral questions, and written tests to objec- range from 0.04 to 0.46).4 Neuropsychological testing typi- tively assess multiple cognitive and emotional functions cally requires several hours to complete because it compre- (Table 2). The tests are typically standardized using large hensively examines multiple cognitive domains to provide a normative samples of healthy age-matched individuals, detailed assessment of the nature and severity of cognitive allowing the examiner to determine the degree to which impairments. This information can contribute significantly performance deviates from expected ranges. The results of when determining primary and secondary diagnoses and neuropsychological testing are integrated with other sources planning an individualized rehabilitation/treatment plan.3 Neuropsychological evaluations are often complementary to neuroimaging and electrophysiologic procedures.5 Com- CME This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz on puted tomography and magnetic resonance imaging evalu- page 86. ate structural integrity within the central nervous system to Author disclosure: No relevant financial affiliations. identify atrophy and lesions. Electroencephalography detects electrical activity of the brain, which is commonly used to Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2019 American Academy of Family Physicians. For the private, noncom- Downloaded from the American Family Physician website at www.aafp.org/afp. Copyright © 2019 American Academy of Family Physicians. For the private, noncom- ◆ 101 mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Januarymercial 15, use 2019 of one Volume individual 99, user Number of the website.2 All other rightswww.aafp.org/afp reserved. Contact [email protected] for copyright questionsAmerican and/or Family permission Physician requests. TABLE 1 TABLE 2 Common Goals of Neuropsychological Common Neuropsychological Tests Evaluations by Domain Goal Examples Domain Tests Characterize Establish cognitive baseline before or after Academic Wide Range Achievement Test cognitive and illness, injury, or treatment achievement Woodcock-Johnson Tests of behavioral Evaluate the impact of a medical issue on Achievement function cognitive, behavioral, or emotional function Adaptive/func- Independent Living Scales Identify cognitive strengths and weaknesses tional living to predict ability to perform daily living Vineland Adaptive Behavior Scales activities Attention and Digit span Identify subtle cognitive deficits working memory Letter-number sequencing Prioritize Assess for psychological contributions to differential symptom presentations (e.g., depression, Emotional Minnesota Multiphasic Personality diagnoses somatoform features) functioning/ Inventory personality Differentiate “worried well” patients from Personality Assessment Inventory those with cognitive impairment Executive Stroop task Establish, confirm, or differentiate between functioning Trail Making Test diagnoses that affect cognition Wisconsin Card Sorting Test Evaluate for dementia and differentiate between potential etiologies Intelligence Wechsler Abbreviated Scale of Intelligence Plan and Help determine candidacy for neurosurgical monitor procedures (e.g., deep brain stimulation, Wechsler Adult Intelligence Scale treatment epilepsy surgery, ventricular shunting) Memory California Verbal Learning Test Identify cognitive strengths and weaknesses Rey Auditory Verbal Learning Test to develop appropriate compensatory strat- egies and accommodations Wechsler Memory Scale Monitor cognitive changes associated with Mental processing Digit Symbol-Coding disease progression, recovery, or treatment speed Symbol Search Provide prognostic information and treat- ment recommendations for patients with Premorbid National Adult Reading Test cognitive disturbances estimation Test of Premorbid Functioning Address legal, Determine whether cognitive deficits may Psychomotor Grip strength test functional, or interfere with ability to drive, return to work, functioning other issues or live independently Grooved Pegboard Test Diagnose or confirm neurodevelopmental Validity Test of Memory Malingering disabilities in young adults who are pursuing Word Memory Test school or community support Evaluate the veracity and degree of cognitive Verbal functions Boston Naming Test and psychiatric symptoms for disability, Controlled Oral Word Association Test litigation, and criminal proceedings Objectively document cognitive disturbances Visuospatial Block design test for capacity/competency determinations functions Rey Complex Figure Test and Recogni- tion Trial Information from reference 2. Multidomain test Neuropsychological Assessment Battery batteries Repeatable Battery for the Assessment assess for epileptic activity. Positron emission tomography of Neuropsychological Status identifies cerebral glucose metabolism to determine whether brain activity is reduced in specific regions. However, these procedures have limited diagnostic sensitivity for some neu- 80% of primary care physicians reported that referral ques- rologic conditions and cannot assess the functional output tions were satisfactorily answered, and approximately 90% of the brain. Neuropsychological testing provides an objec- agreed with the diagnostic impressions and treatment rec- tive assessment of the cognitive, behavioral, and emotional ommendations.6 Overall, they found the consulting report manifestations from cerebral injury or disease. useful, and they indicated they would continue to refer Because of the unique data that neuropsychological test- patients for neuropsychological evaluations. Commonly ing provides, physicians have increasingly utilized neuro- referred clinical conditions and primary care referral ques- psychological services.5 In satisfaction surveys, more than tions are listed in Table 5.6,7 102 American Family Physician www.aafp.org/afp Volume 99, Number 2 ◆ January 15, 2019 TABLE 3 TABLE 4 Components of the Neuropsychological Common Cognitive Screening Tests Evaluation
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