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.
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.
Table 1. Examples of Commonly Used Neuropsychological Tests [7, 8, 9, 10] (Open Table in a new window)
Domain
Neuropsychological Test
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
Wechsler Individual Achievement Test (WIAT)
Woodcock-Johnson Achievement Test
Boston Naming Test
Multilingual Aphasia Examination
Boston Diagnostic Aphasia Examination
Rey-Osterrieth Complex Figure – Copy condition
WAIS Block Design Subtest
Judgment of Line Orientation
Hooper Visual Organization Test
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)
Selective Attention Test
Verbal learning and memory
Wechsler Memory Scale (WMS)
Logical Memory I and II - Contextualized prose
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
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
Wisconsin Card Sorting Test
Trail Making Test-B
WAIS Subtests of Similarities and Block Design
Porteus Maze Test
Multiple Errands Test (MET)
Mini-Mental State Exam
Speed of processing
Simple and Choice Reaction Time
Symbol Digit Modalities Test - Written and oral
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
Rey 15 Item Test
Forced-Choice Symptom Validity Testing
Minnesota Multiphasic Personality Inventory (MMPI)
Millon Clinical Multiaxial Inventory
Beck Depression Inventory (BDI)
Myers-Briggs Type Indicator (MBTI)
Thematic Apperception Test for Children or Adults
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:
Failure to achieve developmental milestones Learning or attention deficits [11, 12] Exposure to drugs, alcohol, or maternal illness in utero Exposure to chemicals, toxins, or heavy metals Neurodegenerative diseases Cerebral palsyGenetic disorders, including, but not limited to, trisomies, monosomies, and trinucleotide repeat disorders
Psychiatric disordersThe 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.
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.
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
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 specialistsAn 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 interventionsAssessment 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 childrenComparison 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]
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]