Guidelines for Neuropsychological Testing and Referrals
Neuropsychological testing is an important diagnostic tool that is used to evaluate adults with a variety of concerns relating to cognition, attention, learning, education, and personality. Many of the patients who are referred for neuropsychological evaluations suffer from memory disorders, but testing can also be used to help patients with a range of diagnoses including neurodegenerative diseases like dementia, psychiatric conditions such as depression, and cognitive changes following medical illness or surgery, or to provide baseline cognitive functioning assessments.
“Referrals for neuropsychological evaluations are appropriate any time a clinician, caregiver, or close informant notices an abrupt change in a patient, such as sudden confusion, disorientation, memory deficits, distractibility, or a personality change,” says Katherine Burdick, PhD, Associate Professor of Psychiatry and Chief of Neurocognitive Research at Mount Sinai.
Jane Martin, PhD, Assistant Professor of Psychiatry, who directs the Neuropsychological Testing and Evaluation Center at Mount Sinai, says they are available to help anyone who has a cognitive concern. Some of the typical referral questions they receive include: Is this normal aging or dementia? Is this depression, Alzheimer’s disease, or mild cognitive impairment?”
Neuropsychological evaluations are often overlooked by clinicians who are focused on treating the more acute symptoms such as ordering an imaging procedure or trying to manage a severe depressive episode. However, Drs. Burdick and Martin say it is important that patients are evaluated as soon as the illness has been diagnosed and they become stable. For example, a young man who is being hospitalized for the first time with psychosis should be assessed as soon as his acute symptoms have been treated.
“Our rule is the sooner the better,” says Dr. Burdick. “It is important to get a baseline assessment because there will be changes over the course of the patient’s illness. Having that initial information about their functioning can help greatly with treatment planning.”
Many of the patients who are referred for evaluations are having difficulty functioning within the community and may be unable to work or cook their own meals. “The inability to conduct activities of daily living is a big red flag,” says Dr. Martin. “These patients should be seen immediately.”
In addition, if there is ever any concern about a patients’ IQ they should be tested. Some patients with borderline intellectual disability may quality for additional services.
Dr. Burdick also says it is important that clinicians are very specific when they write a referral question for testing. Generalized questions such as “is there brain damage?” are difficult for an evaluator to answer. However, detailed descriptions such as: “I notice a decline in cognitive functioning— do you think this is a result of the patient’s history of Schizoaffective Disorder, and if so, how should we guide his treatment planning?”
Patients with significant medical comorbidies such as HIV/AIDS, hypertension, diabetes, lupus, or other ailments with possible central nervous system effects should be tested. Physicians should also refer patients with medical histories that include head trauma, extensive drug and alcohol abuse, or prescription drug use that can lead to brain compromise. Severe chronic illnesses can be associated with cognitive decline. An evaluation can help identify if there is any deficiency and track the severity and timing of any problems.
Others, who do not show any signs of memory decline, but have a family history of dementia, may be referred simply to get a baseline. “It is important that people undergo neuropsychological testing before they show signs of memory decline,” says Dr. Martin. “Having a baseline of cognitive functioning is important in order to compare future test results when there is a more serious memory complaint.”
The purpose of neuropsychiatric evaluations is to provide clinicians with helpful recommendations regarding treatment. Some examples include: evaluating if a patient with cognitive and spatial difficulties is safe to drive a car; assigning someone to oversee bill paying and finances; consulting with a psychopharmacologist to treat mood symptoms of depression or anxiety; and meeting with a social worker to assess the level of care and supervision that is necessary.
Evaluations also provide detailed feedback for patients. For example, a person that has difficulty with attention and memory may be advised to use mnemonic devices at the grocery store such as BAT to remember to buy bananas, apples, and tea; to repeat information they need to remember such as a doctor’s appointment back in their own words and to write it down; to use visualization and landmarks to remember where their car is parked at the mall; or to audiotape their classes if they can comprehend auditory information more easily than visual information.
Neuropsychological evaluations typically include a thorough interview with the patient and a comprehensive battery of standardized tests—primarily paper and pencil tests—that assess attention, concentration, memory, language, reasoning or executive functioning, as well as learning strengths and weaknesses. The assessment may also include measures of intellectual functioning such as IQ, and instruments to assess mood, behavior, and stress levels. The interview and testing process typically takes three to four hours for a memory and cognitive evaluation. Additional testing hours are required when psychological and educational testing is necessary.
“The goal of the evaluation is to provide the referring doctor with a written report that contains objective information about the patient’s functioning based on the test results, along with detailed recommendations regarding treatment, referrals, and activities of daily living,” says Dr. Martin. “We hope that this information can be used to guide better treatment options and ultimately, help ensure a better quality of life for each patient.”