Neuropsychological Evaluation

Updated: Dec 20, 2023
  • Author: Atif B Malik, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Overview

Overview

A neuropsychological evaluation (NPE) is a quantitative assessment employed to measure a patient's cognitive and behavioral capabilities. The data obtained from neuropsychological tests are compared with normative data, with various demographic factors such as age, race, gender, and socioeconomic status being considered.

NPE plays a crucial role in gaining insight into an individual's psychological functioning, a capacity that is not fully captured by modern imaging techniques. [1, 2, 3]

NPE encompasses a wide range of assessments, including evaluations of intelligence, attention, memory, personality, problem solving, language, and perceptual, motor, academic, and learning abilities. These tests not only provide, as stated, valuable insights into an individual's cognitive functioning, but also aid in diagnosing cognitive deficits, understanding cognitive strengths and weaknesses, and guiding appropriate interventions. In addition, they play a role in identifying organic abnormalities in the central nervous system (CNS). Furthermore, the data obtained through NPE can serve as a guide for developing effective treatment strategies aimed at rehabilitating individuals with impairments.

With the expertise of a trained neuropsychologist, this evaluation can greatly contribute to a patient's overall well-being and recovery. The use of NPE is particularly critical when other medical conditions are present, but its employment is equally effective when no underlying medical disorder has been found. [4]

To enhance the diagnostic process, NPE tests are often complemented by information from clinical reports, physical examinations, and, increasingly, self and relative reports covering the periods before and after the onset of symptoms.

It is important to recognize that each neuropsychological test has its own strengths and weaknesses in terms of validity, reliability, sensitivity, and specificity. However, through employment of a diverse range of tests and incorporation of new in situ testing approaches, the utility of NPE has been continuously expanding. [5, 6]  This comprehensive approach enables a more accurate assessment of an individual's cognitive abilities and facilitates effective treatment planning for the patient's optimal recovery.

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Major Domains of Neuropsychological Functioning

NPE is a valuable tool for assessing various domains of cognitive functioning. The following are key function categories commonly evaluated through NPE:

  • Intellectual functioning - NPE assesses an individual's general cognitive abilities, including with regard to reasoning, problem solving, and abstract thinking
  • Academic achievement - NPE examines an individual's academic skills, including in reading, writing, and mathematics, providing insights into the person's educational performance
  • Language processing - NPE evaluates language skills, including with regard to comprehension, expression, and semantic processing, shedding light on an individual's verbal communication abilities.
  • Visuospatial processing - NPE assesses an individual's capacity to perceive and manipulate visual and spatial information, which is essential for tasks such as spatial navigation and object recognition
  • Attention/concentration - NPE measures attentional processes, including sustained attention, selective attention, and divided attention, providing an understanding of an individual's ability to focus and concentrate
  • Memory - NPE examines different aspects of memory, such as verbal and visual learning, immediate and delayed recall, and recognition memory
  • Executive functions - NPE evaluates higher-order cognitive processes involved in goal setting, planning, problem solving, inhibition, cognitive flexibility, and self monitoring
  • Processing speed - NPE assesses the speed at which an individual processes information, which reflects efficiency in completing cognitive tasks
  • Sensory-perceptual functions - NPE examines sensory processing abilities, including in visual and auditory perception, providing insights into how an individual perceives and integrates sensory information
  • Motor speed and strength - NPE evaluates fine and gross motor skills, assessing an individual's motor coordination, dexterity, and strength
  • Motivation/symptom validity - NPE includes measures to assess an individual's level of motivation and the validity of the person's reported symptoms, ensuring accurate interpretation of test results
  • Personality assessment - NPE may employ measures to understand an individual's personality traits, emotional functioning, and psychosocial adjustment, which can provide additional context for interpreting cognitive test results

These function categories encompass the primary areas evaluated through NPE. Their evaluation offers comprehensive insights into an individual's cognitive abilities and helps to inform diagnosis, treatment planning, and rehabilitation strategies.

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Examples of Commonly Used Neuropsychological Tests

Table 1. Examples of Commonly Used Neuropsychological Tests [7, 8, 9, 10] (Open Table in a new window)

Domain

Neuropsychological Test

Intellectual functioning

Wechsler Scales

Wechsler Adult Intelligence Scale-Revised (WAIS-R)

Wechsler Adult Intelligence Scale-III (WAIS-III)

Wechsler Intelligence Scale for Children-IV (WISC-IV)

Stanford-Binet Intelligence Scale-IV

Academic achievement

Wechsler Individual Achievement Test (WIAT)

Woodcock-Johnson Achievement Test

Language processing

Boston Naming Test

Multilingual Aphasia Examination

Boston Diagnostic Aphasia Examination

Token Test

Visuospatial processing

Rey-Osterrieth Complex Figure – Copy condition

WAIS Block Design Subtest

Judgment of Line Orientation

Hooper Visual Organization Test

Attention/concentration

Digit Span Forward and Backward

Trail Making Tests

Cancellation Tasks (Letter and symbol)

Paced Auditory Serial Addition Test (PASAT)

Vanderbilt Assessment Scale

Behavior Assessment System for Children (BASC)

Serial Sevens

Selective Attention Test

Verbal learning and memory

Wechsler Memory Scale (WMS)

Logical Memory I and II - Contextualized prose

Verbal Paired-Associates

WMS-III Verbal Memory Index

Rey Auditory Verbal Learning Test - Rote list learning (unrelated words)

California Verbal Learning Test - Rote list learning (related words)

Verbal Selective Reminding Test - Selective reminding (unrelated words)

Hopkins Verbal Learning Test

Buschke Selective Reminding Test

Verbal Reasoning Test

Visual learning and memory

WMS

Visual Reproduction I and II

WMS-III Visual Memory Index

Rey-Osterrieth Complex Figure - Immediate and delayed recall

Nonverbal Selective Reminding Test

Continuous Recognition Memory Test

Visuo-Motor Integration Test - Block design

Word Recognition Test

Working Memory Test

Word List Memory Test

Executive functions

Wisconsin Card Sorting Test

Category Test

Stroop Test

Trail Making Test-B

WAIS Subtests of Similarities and Block Design

Porteus Maze Test

Multiple Errands Test (MET)

Serial Sevens

Mini-Mental State Exam

Speed of processing

Simple and Choice Reaction Time

Symbol Digit Modalities Test - Written and oral

Sensory-perceptual functions

Halstead-Reitan Neuropsychological Battery (HRNB) Tactual Performance Test and Sensory Perceptual Examination

Motor speed and strength

Index Finger Tapping

Grooved Pegboard Task

Hand Grip Strength

Thurstone Uni- and Bimanual Coordination Test

Motivation

Rey 15 Item Test

Dot Counting

Forced-Choice Symptom Validity Testing

Personality assessment

 

Minnesota Multiphasic Personality Inventory (MMPI)

Millon Clinical Multiaxial Inventory

Beck Depression Inventory (BDI)

Rorschach Test

Myers-Briggs Type Indicator (MBTI)

Thematic Apperception Test for Children or Adults

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Referrals for Neuropsychological Evaluation

Whom to refer for NPE

Neuropsychological testing provides diagnostic clarification and grading of clinical severity for patients with obvious or supposed cognitive deficits. Often these include patients with a history of any of the following problems:

The utility of NPE may be limited if a patient is severely compromised, as in cases of advanced dementia or during the early stages of recovery from significant brain injury (eg, traumatic brain injury [TBI], stroke, anoxia, infection). However, in tracking recovery progress, brief serial assessments using measures like the Galveston Orientation and Amnesia Test, high-velocity lead therapy (HVLT), digit span, and assessments of motor speed and dexterity can be highly valuable. It is important to note that NPE may also have limited value if a patient presents with severe medical complications or concurrent psychiatric disorders. In such cases, additional considerations and specialized assessments may be required to accurately evaluate the patient's cognitive and behavioral capabilities.

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Information Obtained From Neuropsychological Reports

Neuropsychological tests play a critical role in identifying and assessing cognitive impairment and functioning in individuals. These tests provide valuable and quantifiable data pertaining to various aspects of cognition, including:

  • Reasoning and problem-solving ability - These tests evaluate an individual's capacity to think logically, solve problems, and make sound judgments based on available information
  • Language comprehension and expression - Assessments in this domain measure an individual's ability to understand and use language effectively, including with regard to verbal fluency, semantic knowledge, and comprehension skills
  • Working memory and attention - These tests gauge an individual's capacity to maintain and mentally manipulate information, as well as the ability to sustain attention and concentrate on specific tasks
  • Short-term and long-term memory - Assessments of memory capabilities provide insights into an individual's ability to acquire, retain, and retrieve information over short and long periods of time
  • Processing speed - These tests measure the speed at which an individual can accurately process and respond to visual or auditory stimuli, reflecting the person's cognitive efficiency
  • Visual-spatial organization - Assessments in this area examine an individual's ability to perceive and mentally manipulate visual information, including spatial relationships and object recognition
  • Visual-motor coordination - These tests evaluate an individual's ability to integrate visual perception with motor skills, such as hand-eye coordination and fine motor control
  • Planning, synthesizing, and organizing abilities - Tests within this domain assess an individual's capacity to strategize, synthesize information, and effectively organize thoughts and actions towards achieving specific goals

By assessing these key cognitive domains, neuropsychological tests provide a comprehensive evaluation of an individual's cognitive abilities and functioning. This information is invaluable in diagnosing cognitive impairments, understanding a person's cognitive strengths and weaknesses, and informing targeted interventions and treatment plans.

Alcohol-related cognitive impairment

A literature review by Heirene et al assessing the efficacy of neuropsychological tools in the evaluation of alcohol-related cognitive impairment (ARCI) reported the following [18] :

  • Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE) - These tests have some efficacy in identifying the presence of ARCI and in distinguishing between alcohol-related–impairment gradations
  • California Verbal Learning Test (CVLT) and Rivermead Behavioral Memory Test (RBMT) - Detailed memory assessment can be derived through these tests; the CVLT and RBMT-3 are useful for distinguishing between Korsakoff syndrome, persons who are not alcohol dependent, and persons with alcohol dependence who have been diagnosed with mild alcohol-associated cognitive impairment that does not fit the criteria for Korsakoff syndrome or alcohol-related dementia
  • Behavioral Assessment of the Dysexecutive Syndrome (BADS) - This test provides a particularly comprehensive evaluation of executive function
  • Wechsler Adult Intelligence Scale (WAIS) - This is the most commonly used intelligence assessment tool in patients with ARCI, as well as the best validated
  • Nijmegen-Venray Confabulation List (NVCL-20) - This should be the tool of choice in the evaluation of confabulation
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Established Applications of Neuropsychological Evaluation

Applications of NPE include the following:

  • Provide a differential diagnosis of organic and functional pathologies

  • Assess for dementia versus pseudodementia [13, 14, 15, 16]

  • Determine the presence of epilepsy versus somatoform disorder (that is, nonepileptic seizures or pseudoseizures)

  • Determine the presence of traumatic brain injury (TBI) sequelae [19] versus malingering or unconscious highlighting

  • Distinguish between cognitive deficiency caused by indifference (as is occasionally seen in depression patients) and that caused by other diseases and disorders

  • Guide rehabilitation programs and monitor patient progress

  • Guide the therapist in referring to specialists

An NPE also provides data to guide decisions about the patient's condition, such as the following:

  • Competency to manage legal and financial affairs

  • Capacity to participate in medical and legal decision making

  • Ability to live independently or with supervision

  • Ability to return to work and school affairs

  • Candidacy for transplantation [20]

In addition, data from an NPE can be used to guide the following assessments and procedures:

  • Evaluation of the cognitive effects of various medical disorders and associated interventions

  • Assessment of tests for diabetes mellitus, chronic obstructive pulmonary disease (COPD), hypertension, human immunodeficiency virus (HIV) infection, coronary artery bypass graft (CABG), and clinical drug trials

  • Assessment of CNS lesions and/or seizure disorders before and after surgical interventions, including corpus callosotomy, focal resection (eg, topectomy, lobectomy), and multiple subpial transection

  • Monitoring of the effects of pharmacologic interventions

  • Documentation of the cognitive effects of exposure to neurotoxins

  • Documentation of adverse effects of whole brain irradiation in children

  • Comparison with guidelines for electroconvulsive therapy (ECT) influenced by standardized evaluation of memory

  • Standard protocols for assessment of specific disorders, such as dementia of the Alzheimer type (DAT), multiple sclerosis (MS), TBI, and stroke [13, 14, 15, 16, 17, 19, 20, 21]

Developmental disorders (eg, specific learning disabilities) require detailed assessment of cognition, academic achievement, and psychosocial adjustment for proper identification and as a guide to their management. Academic placement in special education and resource classrooms may be needed.

A study by Weaver et al indicated that when used in the assessment of post-stroke cognitive impairment, the MMSE produces findings associated mainly with infarct locations in the left middle cerebral artery territory. [22]

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Patient-Specific Factors and Normative Data

When the results of an NPE are interpreted, consideration should be given to various contextual factors such as the patient's age, education, sex, and cultural background. These factors can influence test performance and constrain the conclusions that can be drawn from the evaluation. Additionally, aspects like reliability, validity, sensitivity, and specificity should be carefully considered.

Large, population-based norms are available for only a limited number of measures, and the utility of those measures within a neuropsychological test battery is restricted. It is ideal to compare patients with population-based norms, local norms, and subgroup norms (eg, specific patient populations) to identify strengths and weaknesses. However, there are notable gaps in normative data across all age, educational, and intellectual ranges, and deficiencies persist in the development of appropriate measures and norms for minority populations. [23]

The European Consortium on Cross-Cultural Neuropsychology (ECCroN) issued a position statement emphasizing the need for the development, validation, and standardization of more widely applicable and culturally sensitive tests. The consortium discourages the use of "race-based norms" and instead advocates for assessments that consider a wide range of variables, including linguistic factors, literacy, education, migration history, acculturation, and other cultural factors. The ECCroN also stresses the importance of improved cultural sensitivity training for neuropsychologists and the "implementation of guidelines for interpreter-mediated neuropsychological assessment in diverse populations in Europe." [24]

A study by Hansson et al demonstrated that employing a collaborative and therapeutic approach to NPE for pediatric patients with neurodevelopmental disorders can lead to a reduction in self-reported psychiatric symptoms. The study involved children suspected of having neurodevelopmental disorders and utilized the Beck Youth Inventories (BYI). Findings indicated that children who underwent the collaborative and therapeutic approach reported fewer psychiatric symptoms on most BYI subscales compared with those who received parental support measures or were on a waiting list for help. Moreover, at 6 months' follow-up, a decrease in self-reported symptoms was still observed on the BYI anger and anxiety subscales. [25]

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Reliability, Validity, Sensitivity, and Specificity

Reliability

Reliability refers to the consistency with which the same information is obtained via the test or set of tests. In the absence of intervening variables (eg, illness, injury, new learning), scores should remain stable even in the event of certain other variables, such as the following:

  • Interrater reliability - Administration of the test by different examiners
  • Intrarater reliability - Administration of the test by the same examiner on more than 1 occasion
  • Test-retest reliability - Administration of the test to the same patient on different occasions

Validity

Validity refers to how well the test measures what it purports to measure. Specific types of validity that may be questioned include the following:

  • Construct validity - Does the test measure what it is supposed to measure
  • Concurrent validity - Do new tests correlate highly with existing tests or independent measures of the construct in question
  • Face validity - Does the test appear to measure what it is supposed to measure
  • Localization validity - Does the test localize focal lesions accurately
  • Ecologic validity - Does the test predict real-life ability

Research findings consistently suggest that a positive relationship exists between real-world success and performance on neuropsychological tests assessing motor function, cognitive processing speed, cognitive flexibility, complex attention, and memory. However, it is important to note that the amount of variance accounted for by cognitive factors alone is typically limited, except when very simple, specific, and well-defined functions are examined. Consequently, the integration of situational assessment is deemed crucial, particularly in the evaluation of higher levels of cognitive functioning.

Neuropsychological tests were primarily developed as indicators of brain function or dysfunction and were typically validated against neurosurgical, neurologic, and neuroradiologic data. While they were not originally designed with a strong focus on ecologic validity, many tests have demonstrated the ability to predict future behavior and thus exhibit such validity.

To enhance the ecologic validity of the neuropsychological test battery, a qualitative process approach can be adopted. For instance, testing the limits by utilizing measures of memory and executive functioning enables a better understanding of an individual's ability to perform under relatively ideal circumstances, emphasizing not just "what" they can do but also "how" they do it. Although the test itself may not demonstrate high ecologic validity, a thorough analysis and an insightful interpretation of the findings can yield ecologically valid insights.

A study conducted by Hirst et al surveyed 654 members of the National Academy of Neuropsychology and the International Neuropsychological Society to determine the consistency of validity testing practices in neuropsychological assessments. The results indicated that the adherence to validity testing recommendations by neuropsychologists varied. Specifically, practitioners working with pediatric and geriatric patients tended to follow the recommendations less frequently than did those working with nongeriatric adults. Additionally, longer-practicing neuropsychologists were found to be less likely to adhere to validity testing recommendations compared with those who had less experience. [26]

Sensitivity and specificity

Sensitivity refers to a test’s ability to detect the slightest abnormalities in CNS function and is a reflection of the test’s true positive rate, that is, its ability to identify persons with a disorder. Specificity refers to the ability to differentiate patients with a certain abnormality from those with other disorders or with no abnormality, as indicated by the true negative rate. A score on any test can be a true positive, false positive, true negative, or false negative. Such results signify the following:

  • True positive - Requires high sensitivity to dysfunction, allowing dysfunctions to be detected
  • False positive - Indicates sensitivity to dysfunction but lacks specificity to a particular dysfunction
  • True negative - Requires high specificity, allowing negative to be distinguished from others
  • False negative - Indicates a lack of sensitivity, without regard to the specificity of the test

For any evaluation, it is important to understand the rates of each of the four result categories. The Stroop Test, for example, shows a relatively high level of specificity, with a high true negative rate (95.7%) and low false positive rate (4.3%). However, its sensitivity is questionable, as it has a relatively low true positive rate (30.8%) and high false negative rate (69.2%).

Each test has strengths and weaknesses in its ability to detect a minimal CNS dysfunction (sensitivity) while being able to indicate a specific CNS dysfunction (specificity). Timed measures of cognitive and/or motor processing are generally sensitive to diffuse cerebral dysfunctions, although the specificity of these tests is generally poor to moderate. Measures of cognitive and/or motor processing that are not timed are generally less sensitive to diffuse dysfunctions but are very useful in identifying specific brain lesions.

Overcoming problems in assessing executive function

The lack of ecologic validity in assessing executive functioning is a significant limitation of NPE. [27] Traditional NPE is typically conducted in controlled testing environments, where subjects are presented with clearly defined tasks, informed of time restrictions, and prompted to initiate and cease behaviors. While individuals may under these conditions achieve scores indicating no executive dysfunction, they may still experience mental exhaustion due to the cognitive exertion involved. Moreover, in real-world situations, several executive functions that are not typically assessed in traditional NPE come into play, including task recognition, task initiation, task switching, adaptation to changes, and task cessation.

Fortunately, advancements in executive tests have substantially enhanced the environmental validity of executive NPE. These improvements include an increased focus on subject self reporting of premorbid and postmorbid functioning, as well as the acquisition of reports regarding the observations of relatives and significant others in the subject's life. However, relying solely on self reporting may not be sufficient, as individuals may be unaware of their executive dysfunctions or may have a subjective acceptance of their impairments. [27]

An innovative tool that addresses the issue of ecologic validity is the Multiple Errands Test (MET). This test takes place in a real-world setting, such as a shopping mall, and requires subjects to simultaneously perform three tasks, such as purchasing an item, meeting at a specific location within a designated time frame, and gathering relevant information (eg, foreign currency exchange rates). The MET assesses an individual's abilities in planning, task initiation, task switching, and effective interpersonal interactions. It has demonstrated significant sensitivity and specificity, with individuals with neurologic deficits performing notably worse than controls. A modified version of this test has been developed for use in hospital settings. [27]

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