Links To And Excerpts From “Neuropsychological Evaluations in Adults” From American Family Physician

In this post, I link to and excerpt from American Family Physician article, Neuropsychological Evaluations in Adults. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Am Fam Physician. 2019 Jan 15;99(2):101-108.

There are 92 similar articles in PubMed Central.

The above article has been cited by eight articles.

The footnotes of the above article contain outstanding further resources on neuropsychological testing.

All that follows is from the above resource.

Neuropsychologists provide detailed assessments of cognitive and emotional functioning that often cannot be obtained through other diagnostic means. They use standardized assessment tools and integrate the findings with other data to determine whether cognitive decline has occurred, to differentiate neurologic from psychiatric conditions, to identify neurocognitive etiologies, and to determine the relationship between neurologic factors and difficulties in daily functioning. Family physicians should consider referring patients when there are questions about diagnostic decision making or planning of individualized management strategies for patients with mild cognitive impairment, dementia, traumatic brain injury, and other clinical conditions that affect cognitive functioning. Neuropsychological testing can differentiate Alzheimer dementia from nondementia with nearly 90% accuracy. The addition of neuropsychological testing to injury severity variables (e.g., posttraumatic amnesia) increases predicted accuracy in functional outcomes. A neuropsychological evaluation can be helpful in addressing concerns about functional capacities (e.g., ability to drive or live independently) and in determining a patient’s capacity to make decisions about health care or finances. Most patients who underwent neuropsychological evaluation and their significant others reported that they found the evaluation helpful in understanding and coping with cognitive problems.

Family physicians are often the first health care professionals to evaluate patients with memory loss and cognitive dysfunction. Although many patients can be readily diagnosed and treated, some present significant challenges. A neuropsychological consultation can help characterize cognitive deficits, clarify diagnoses, and develop optimal management plans for patients with cognitive issues.1 Common goals of neuropsychological evaluations are provided in Table 1.2

Clinical neuropsychologists are doctoral-level psychologists who have fellowship training in assessment and intervention principles that are based on the scientific study of
human behavior as it relates to normal and abnormal brain
functioning.1 Neuropsychologists use validated puzzlebased materials, oral questions, and written tests to objectively assess multiple cognitive and emotional functions
(Table 2).

The tests are typically standardized using large
normative samples of healthy age-matched individuals,
allowing the examiner to determine the degree to which
performance deviates from expected ranges. The results of
neuropsychological testing are integrated with other sources of information to provide a comprehensive assessment of a
person’s cognitive, behavioral, and emotional functioning
as a basis for clinical decisions (Table 3).2

Neuropsychological tests are different in purpose and
scope from cognitive screening tests such as the Mini-Mental
State Examination3 (Table 4).

Screening tests usually take five to 10 minutes to complete and are designed to screen for general cognitive impairment that may warrant a more comprehensive workup. Although screening tests can indicate problems in general cognitive functioning, they have poor ability to assess for deficits in specific cognitive domains. This has been highlighted by research showing that screening test items weakly correlate with scores in the same cognitive domains on neuropsychological testing (correlations range from 0.04 to 0.46).4

Neuropsychological evaluations are often complementary
to neuroimaging and electrophysiologic procedures.5
Computed tomography and magnetic resonance imaging evaluate structural integrity within the central nervous system to identify atrophy and lesions. Electroencephalography detects
electrical activity of the brain, which is commonly used to assess for epileptic activity. Positron emission tomography identifies cerebral glucose metabolism to determine whether brain activity is reduced in specific regions. However, these
procedures have limited diagnostic sensitivity for some neurologic conditions and cannot assess the functional output
of the brain. Neuropsychological testing provides an objective assessment of the cognitive, behavioral, and emotional
manifestations from cerebral injury or disease.

Because of the unique data that neuropsychological testing provides, physicians have increasingly utilized neuropsychological services.5  .   .   .   . Commonly
referred clinical conditions and primary care referral questions are listed in Table 5.

Evidence for Neuropsychological Evaluations

Commonly used neuropsychological test batteries are
highly reliable, with reliability coefficients often at or
above 0.90 for cognitive index scores.8 Neuropsychological
validity studies indicate that tests perform as anticipated
in clinical situations.


Guidelines from several organizations stress the importance of neuropsychological assessment in the diagnosis
and management of dementia [and of mild cognitive impairment].  .   .   .   . The International Statistical Classification of Mental and Behavioural Disorders, 10th rev., and the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., state that neuropsychological testing is the preferred method for examining and documenting cognitive dysfunction.13,14 Figure 1 shows an approach to evaluating and managing patients with suspected dementia2; an alternative algorithm that includes the neuropsychological evaluation is available in a recent American Family Physician article(*.

*Evaluation of Suspected Dementia, NATHAN FALK, MD, ARIEL COLE, MD, AND T. JASON MEREDITH, MD. Am Fam Physician. 2018;97(6):398-405

Neuropsychological testing can differentiate Alzheimer dementia from nondementia with nearly 90% accuracy,15 with even higher rates when demographic factors are incorporated with test data (area under the curve = 0.98).16 .  .  . Additionally, studies have shown that neuropsychological testing can differentiate dementia from psychiatric conditions with accuracy rates near 90%.19

Although Alzheimer disease is the most common cause of dementia in adults 60 years and older, dementia is often the result of other disease processes (e.g., Lewy body disease, cerebrovascular disease). Understanding the cause of a patient’s dementia can guide family physicians in prescription decisions (e.g., whether to start an acetylcholinesterase inhibitor) and expectations about future symptoms and treatment needs.20
Neuropsychological testing can be a useful tool in this regard, with studies demonstrating strong accuracy in discriminating between different types of dementia.21,22

Neuropsychological testing can also distinguish mild cognitive impairment from normal functioning; sensitivity and specificity rates are approximately 75% and 80%, respectively, when well-established diagnostic criteria are used.15,23 Serial assessments can be useful for patients with mild cognitive impairment or in cases where the etiology of cognitive decline is unclear. A 12-month follow-up is often used to determine whether patterns of cognitive decline are consistent with a suspected etiology, identifying conversion of mild cognitive impairment to dementia, or to monitor the rate of cognitive change over time.5


Neuropsychologists are often involved in post–acute TBI management to help determine and predict patient-specific
cognitive, emotional, and adaptive functioning27 (Figure 2 2,28-30).

The addition of neuropsychological testing to injury severity variables (e.g., posttraumatic amnesia) increases predicted
accuracy in functional outcomes.31 In moderate to severe TBI, neuropsychological status can predict functional independence, return to work, disability utilization, responsiveness to cognitive rehabilitation, and academic achievement.20,32-38

In patients with mild TBI (concussion), in whom long-term cognitive deficits are less likely, a neuropsychological evaluation can identify psychological and other noncognitive factors that may masquerade as cognitive dysfunction and, therefore, can guide appropriate treatment recommendations.28 The Concussion in Sport Group described neuropsychological assessments as a cornerstone of concussion management, and a recent international consensus statement indicated that neuropsychological testing contributes significant information
in the evaluation of mild TBI.39 Guidelines recommend that patients who report cognitive symptoms beyond 30 to 90 days after mild TBI be referred for neuropsychological assessment.28,29


The American Academy of Neurology has endorsed the use
of neuropsychological evaluation in the assessment and
treatment of a variety of conditions, including cerebrovascular disease/stroke, Parkinson disease, human immunodeficiency virus encephalopathy, multiple sclerosis, epilepsy, neurotoxic exposure, and chronic pain.42

Referring for a Neuropsychological Consultation

Referrals for neuropsychological consultation are commonly
made by family physicians, neurologists, psychiatrists, and
other primary care clinicians.

Although availability can sometimes be limited, particularly in rural settings, a listing of neuropsychologists certified by the American Academy of Clinical Neuropsychology is available at

A brief pamphlet for patients who are being referred for testing is available at

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