Answers to 7 questions about using neuropsychological testing in your practice
What assessments are available to you? How do findings inform your care of patients?
3 How does neuropsychological testing help with the differential diagnosis? As an example, one area in which cognitive testing can be beneficial is in geriatric psychiatry.Dementia. Aging often is accompanied by a normal decline in memory and other cognitive functions. But because subtle changes in memory and cognition also canbe the sign of a progressive cognitive disorder, differentiating normal aging from early dementia is essential. Table 2 summarizes typical changes in cognition with aging.
Neuropsychologists, through knowledge of psychometric testing and the brain−behavior relationship, can help you detect dementia and plan treatment early. To determine if cognitive changes are progressive, patients might undergo re-evaluation—typically, every 6 to 12 months—to ascertain if changes have occurred. Mood disorders. Neuropsychological evaluation can be useful in building a differential diagnosis when determining whether cognitive symptoms are attributable to a mood disorder or a medical illness. Cognitive deficits associated with an affective disturbance generally include impairments in attention, memory, and executive functioning.4 The severity of deficits has been linked to severity of illness. When patients with a mood disorder demonstrate localizing impairments or those of greater severity than expected, suspicion arises that another cause likely better explains those deficits, and further medical testing then is often recommended. Medical procedures. Increasingly, neuropsychological assessment is used to assist in determining the appropriateness of medical procedures. For example, neurosurgical patients being considered for deep brain stimulation, brain tumor resectioning, and epilepsy surgery often are referred for preoperative and postoperative testing. Treating clinicians need an understanding of current cognitive status, localization of functioning, and psychological status to make appropriate decisions about a patient’s candidacy for one of these procedures,and to understand associated risk.
4 How is neuropsychological testing used for dispositional planning? The
results of cognitive and psychological testing have implications for dispositional
planning for patients who are receiving psychiatric care. The primary issue often is
to determine the patient’s level of independence and ability to make decisions about his affairs.5
Neuropsychological testing can help determine if cognitive deficits limit aspects of functional independence—for example, can the patient live alone, or must he live with family or in a residential care facility? Generally, the greater the cognitive impairment, the more supervision and assistance are required. This relationship between cognitive ability and independence in activities of daily living has been demonstrated in many groups of psychiatric patients, including older adults with dementia,6 patients with schizophrenia,7 and those with bipolar disorder.8
Specific recommendations can be made regarding management of finances, administering medications, and driving. To formulate an appropriate dispositional plan, the referring psychiatrist might integrate recommendations from the neuropsychological assessment with findings of other evaluations and with information that has been collected about the patient.
5 Can neuropsychological testing be used to refer a patient for neurological and cognitive rehabilitation? Yes. The neuropsychologist is singularly qualified to make recommendations about a range of interventions for cognitive deficits that have been identified on formal testing.
Typically, recommendations for addressing cognitive deficits involve rehabilitation
focused on development and use of compensatory strategies and modification to promote brain health.9,10 Rehabilitation therapy typically is aimed at increasing functioning independence and reducing physical and cognitive deficits associated
with illness (eg, traumatic brain injury [TBI], stroke, orthopedic injury, debility).
Patients who have a TBI or who have had a stroke often have comorbid psychiatric problems, including mood and anxiety disorders, that can exacerbate deficits and impede engagement in rehabilitation. The neuropsychological evaluation can determine if this is the case and if psychiatric consultation is warranted to assist with managing symptoms.
Premorbid psychiatric illness can affect rehabilitation. Formal neuropsychological testing can assist with parsing out deficits associated with new-onset illness compared with premorbid psychiatric problems. The evaluation of a patient before he begins rehabilitation also can be compared with evaluations made during treatment and after discharge to 1) assess for changes and 2) update recommendations about management.
Recommendations about cognitive interventions might include specific compensatory strategies to address areas of weakness and capitalize on strengths. Such strategies can include using internal mnemonics, such as visual imagery (ie, using a visual image to help encode verbal information) or semantic elaboration (using semantic cues to aid in encoding and recall of information). Methods can help train patients to capitalize on areas of stronger cognitive functioning in compensating for their weaknesses; an example is the spaced-retrieval technique, which relies on repetition of information that is to be learned over time.11
Perhaps the most practical strategies for addressing areas of weakness are nonmnemonic-based external memory aids, such as diaries, notebooks, calendars, alarms, and lists.12 For example, for a patient with a TBI who has impaired memory, recommendations might include using written notes or a calendar system; using a pillbox for medication management; and using labels to promote structure and consistency in the home. These strategies are meant to promote increased independence and to minimize the effect of cognitive deficits on daily functioning.
