Indications For Neuropsychological
Indications For Neuropsychological
Indications For Neuropsychological
KEY POINTS
A referral for neuropsychological assessment is appropriate
whenever there is doubt about a patients cognitive
functioning or competency.
Neuropsychologists assess a broad range of cognitive
domains, not just memory.
Neuropsychological assessment can detect pathological
processes before structural abnormalities are observable on
neuroimaging and in cases where no abnormalities can be
visualized.
Imaging studies can specify the location of many structural
lesions, but the functional implications of brain pathology
can be identified only through neuropsychological testing.
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WHAT IS NEUROPSYCHOLOGY?
Neuropsychology, the intersection of neurology, psychology, and psychiatry, is an applied
science that examines the behavioral manifestations of brain dysfunction.1
Disrupted
cognition is
a symptom of
many disorders
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Patients who
perform well
on the MMSE
are not
necessarily
healthy
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only through formal neuropsychological testing. The tests provide useful information
about the patients competency and decisionmaking capacity and have implications for the
choice of treatment.
Structural changes are not always visible. Many neurologic disorders result from
structural changes that are invisible to even
the highest-resolution scanners. Examples
include Alzheimer disease, transient ischemic
attacks, many epilepsies, and many infections
of the brain and spinal cord.
Neuropsychological assessment is also
useful in many disorders of children in which
no markers can be visualized, such as attention deficit/hyperactivity disorder, specific
verbal and nonverbal learning disabilities,
neurotoxic exposure, and some concussions
and infectious processes.13 In some instances,
neuropsychological examinations provide
objective data that help specify the diagnosis.
Even when a diagnosis can be made with
specific physical markers, neuropsychology
can play an important role. For example,
although Down syndrome is readily identified
by its physical manifestations and specific
genetic abnormality (trisomy 21), neuropsychological assessment can provide invaluable
prognostic information to families concerning
their childrens abilities.13 Once again, the
functional capabilities mean as much as the
structural abnormalities, if not more.
Symptoms often precede visible structural changes.1,2,6 If some diseases are detected early by their behavioral symptoms, physicians can often provide better care and manage symptoms better. For example, if a progressive incurable disorder such as Alzheimer
disease is diagnosed early, the patient and family members have more time to plan for the
inevitable deterioration in function.
Neuropsychological evaluation is useful
for serial assessment, providing objective
measures of progressive deterioration or
recovery following traumatic brain injuries or
strokes.13,6
Serial assessments are, however, confounded by repeated exposure to the test, a
phenomenon called practice effect or testretest effect. To counteract this effect,
researchers have estimated the amount of
improvement that might be expected on vari-
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TA B L E 1
Clinical indications
for neuropsychological assessment
Changes in memory
Amnesia
Poor short-term recall
Frequently loses items
Gets lost easily
Fails to recognize familiar persons
Poor attention and concentration
Doesnt appear to listen
Gets confused in conversations
Does poorly in complex situations
Changes in language functioning
Aphasia
Agnosia
Dysfluency
Changes in visuospatial abilities
Difficulty drawing
Difficulty navigating (using a map or understanding directions)
Misperceiving the environment
Impaired executive function
Perseverative
Poor judgment
Rigidity in thought
Changes in emotional functioning
Increased anxiety
Increased depression
Psychoses
Fluctuations in mental status
Disorientation
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REFERENCES
1. Lezak MD. Neuropsychological Assessment. 3rd ed. New York, NY:
Oxford University Press; 1995.
2. Adams RL, Parsons OA, Culbertson JL, Nixon SJ. Neuropsychology for
Clinical Practice: Etiology, Assessment, and Treatment of Common
Neurological Disorders. Washington, DC: American Psychological
Corporation; 1996.
3. Grant I, Adams K. Neuropsychological Assessment of Neuropsychiatric
Disorders. 2nd ed. New York, NY: Oxford University Press; 1996.
4. Clinical Neuropsychology [pamphlet]. Washington, DC: American
Psychological Association, Public Interest Advisory Committee, Division
40 (Clinical Neuropsychology).
5. Putnam SH, DeLuca JW. The TCN Professional Practice Survey, I:
General practices of neuropsychologists in primary employment and
private practice settings. Clin Neuropsychol 1990; 4:199244.
6. Walsh KW. Neuropsychology: A Clinical Approach. 2nd ed. New York,
NY: Churchill Livingstone; 1991.
7. Broca P. Sur la facult du langage articul. Bull Soc Anthr Paris. 1865;
6:337393.
8. Wernicke C. Der Aphasische Symptomenkomplex. Breslau, Germany:
Cohn and Weigart, 1874.
9. Brodmann K. Vergleichende Lokalisationslehre der Grosshirnrinde in
ihren Prinzipien dargestellt auf Grund des Zellenbaues. Leipzig,