This report considers the use of neuropsychological assessment of adults for neurologists

        Diseases in the brain commonly produce changes in behavior, including impairment of cognitive abilities and production of neuropsychiatric symptoms.

        Neuropsychological evaluation is a means of gathering quantitative information that can aid in the diagnosis, management, and longitudinal care of patients with neurologic disease.


Technical Issues in neuropsychological assessment

        Neuropsychological evaluation can characterize cognitive and behavioral disturbances

        Neuropsychological tests, along with other clinical tests, can be useful in interpreting dysfunction because it is objective, safe, portable, and relevant to the brain

        Assessment must consider the patientís age, education, SES, and cultural background because all of these factors affect test performance.

        A variety of other tests have been used to detect neurologic function:  the Wechsler Adult Intelligence Scale (the WAIS and WAIS-R), the Wechsler Memory Scale (the WMS and WMS-R) and, the Halstead-Reitan Battery.

        Timed-tests have a greater sensitivity to diffuse or multifocal cerebral changes than un-timed tests. 

        Internal consistency and test-retest reliability is high for the WAIS-R and WMS-R.

        Reliability for memory tests is consistently lower than for other types of neuropsychological tests.

        Standardized tests in neuropsychological assessment have construct validity.

        Localization validity (do tests results localize focal lesions) is seen in some specific neuropsychological tests; but basic cognitive processes have better localization than more complex processes.

        No neuropsychological test has shown consistent diagnostic validity (do tests accurately diagnose disease)

        Neuropsychological tests have high validity for distinguishing between abnormal and normal performance but have little capacity for distinguishing among different causes of performance impairment.

        There are limited studies that give attention to the relationships between neurological test performance and functional capacity in activities of daily living.

        Aging affects several domains of neuropsychological function such as fluid intellectual abilities, complex attentional processes, memory, psychomotor speed, word knowledge, visuospatial skills, abstract reasoning, and complex solving.

        Education, ethnicity and cultural influences, gender, psychiatric disorders, and substance abuse have an effect on neuropsychological test performance.


Neuropsychological Assessment of Specific Neurologic Disorders

        Traumatic brain injury:  neuropsychological assessment is useful in the assessment of patients with traumatic brain injury where it can aid in the detection of subtle deficits, provided information on outcome and prognosis, contribute to construction of directed rehabilitation strategies, and facilitate rehabilitation that leads to more functional independence.

        Cerebrovascular disease:  neuropsychological assessment has little role in the assessment of patients with acute stroke, but can be helpful in patients that have recovered but may have cognitive impairment.

        Dementia:  neuropsychological assessment can aid in the assessment of patients with Alzheimerís disease and other dementias; it is particularly valuable in distinguishing between normal aging and mild dementias

-verbal and construction recall tests are superior to other tests

-neuropsychological tests are currently the principle means of assessing the efficacy of drugs used to enhance cognition in patients

        Parkinsonís disease:  neuropsychological assessment is useful in Parkinsonís disease when there is a question of subtle cognitive deficits.

        HIV:  neuropsychological tests have been applied in HIV patients and have prognostic significance.

        Multiple sclerosis:  the frequency of cognitive deficits in multiple sclerosis is underestimated on the basis of routine clinical assessment, but can provide prognostic information.

        Epilepsy:  neuropsychological testing is valuable in the presurgical evaluation of patients with epilepsy who are being considered for temporal lobotomy.

        Neurotoxic exposure:  neuropsychological testing with special attention to evaluation of functions relevant to any known specific effects of the suspected agent is used for those at risk for neurotoxic disorders.

        Chronic pain:  neuropsychological tests are useful in patients with chronic pain when it assess personality and mood.

        Personality assessment in patients with neurologic disease:  personality tests are often used in addition to neuropsychological assessment, such as the MMPI

        Forensic application:  neuropsychological documentation is critical in cases where litigation concerns the presence of cognitive impairment.

-courts have become increasingly oriented toward expert testimony and standardized information and neuropsychological data.

        Malingering:  there is no established neuropsychological profile diagnostic of malingering

        In general, neuropsychological assessment is most useful in patients with more subtle deficits and for detecting deficits in patients with particularly high premorbid intelligence levels.


Neuropsychological consultations

        Potential advantages:

1.      Administration and scoring are standardized.

2.      Reliability and validity have been determined for most tests.

3.      Normative values are available for most widely used tests

4.      Knowledge of measurement error facilitates detection of change over time when patients are assessed repeatedly.

5.      Test scores can be meaningfully compared over time and among different patients.

        Neuropsychological consultation my be obtained by the clinician when:

1.      There are only mild or questionable deficits on mental status testing and more precise evaluation is needed to establish the presence of abnormalities or distinguish them from changes that may occur with normal aging.

2.      There is a need to quantify the patientís deficits.

3.      When there is a need to characterize the strengths and weaknesses of a patient as part of constructing a management or rehabilitation plan, or when making recommendations about returning to school or work.

4.      When the neuropsychologist can provide the specific rehabilitation or other therapeutic services required.

5.      When neuropsychological data can provide a more comprehensive profile of function that may assist in diagnosis.

6.      When the patient is being considered for epilepsy surgery.

7.      When there is litigation that concerns the patientís cognitive status.

        Neuropsychological reports should contain the numerical data and the neuropsychologistís interpretation of information.

        Neuropsychological assessments by themselves are insufficient as a basis for decisions regarding medical therapy and recommendations concerning specific medical tests to be ordered or pharmacologic agents to be used and should not be expected or provided as a part of the neuropsychological assessment.

        Clinicians should perform their own mental status examinations on patients before referral to a neuropsychologist.









                                                                                                             Article Summary     1


















     Article Summary of Assessment:

                                                 Neuropsychological Testing of Adults

                                                     Amerika Adams, Stephene Porras,

                                                   Cristina Collazo, and Michelle Young

                                                        Loyola Marymount University











                                                                                                             Article Summary     2

            Neuropsychological tests can be used to assess cognitive and behavioral problems in individuals, which may be useful for clinicians treating a patient.  Neuropsychological tests are objective, portable, reliable, and safe.  Yet these tests should not be used alone when diagnosing a patient.  Some examples of neuropsychological tests are the Wechsler Adult Intelligence Scale (WAIS), Wechsler Memory Scale (WMS), and the Halstead-Reitan Battery.  Like other psychological tests, neuropsychological tests should be used along side other types of mental, physical, and clinical evaluations.  

            Neuropsychological assessments have advantages compared to ďbedsideĒ mental testing that make them very helpful under various circumstances.  To begin with administration and scoring of neuropsychological tests are standardized and normative data is used.  Most neuropsychological tests used today have established reliability and validity.  Neuropsychological tests have been known to have high validity when it comes to identifying abnormal and normal brain deficits.  Also, tests scores can be compared over time for the same patient or compared with different patients. 

            With so many advantages clinicians should gather neuropsychological consultation for various reasons.  When a patient is portraying minimal or questionable mental deficits clinicians may need a more in depth evaluation.  By turning to neuropsychological tests a more precise assessment can be determined about whether the patient has abnormalities or is just portraying normal mental deficits that may occur under circumstances such as stress or aging.  It is also helpful for clinicians to use neuropsychological tests when they need to determine the number of deficits the patient exhibits.  This is especially helpful in identifying whether the patientís disorder is recovering or declining.  When it is necessary to determine a patientís strengths and weaknesses neuropsychological tests may help identify a rehabilitation or management plan to aid in the patients recovery process.  Neuropsychological tests can even provide an in depth profile of the patients disorder that can be used alongside other data to aid the process of diagnosis.  Lastly, when a patient may have to undergo epilepsy surgery neuropsychological assessments are critical.  They can also be very useful in helping patients with dementia, Parkinsonís disease, multiple sclerosis, traumatic brain injury, stroke, and HIV.   

            The use of neuropsychological assessments should depend on the state of the patient.  Patients who have severe mental deficits should undergo only short and specific assessments.  On the other hand, patients with less severe deficits may have to undergo more in depth and extensive tests.  Although clinicians should keep in mind that in depth neuropsychological testing may exaggerate brain dysfunction in patients.

            Even though there are many advantages to using neuropsychological assessments clinicians should remain cautious when following such evaluations.

Neuropsychological assessments should also remain flexible because there are many factors that can contribute to a tests outcome.  When a clinician is choosing a test to administer and interpret they should keep several factors in mind.  The severity of a patientís abnormalities, the age of the patient, related emotional of physical disorders, effects of medication, history of disabilities, history of substance abuse, and the nature of


                                                                                                             Article Summary     3


the brain disorder can all affect a tests results.  It is important for a clinician to consider all these factors before administering or interpreting a neuropsychological test.  It is also important for a clinician to recognize that using neuropsychological assessments alone is not sufficient enough to base a patientís evaluation on. Other medical and laboratory tests should be used along with neuropsychological tests to provide an adequate evaluation of a patient.