What is a Neuropsychological Evaluation?

Have you or your loved one been referred for a neuropsychological evaluation? It’s natural to be intimidated or overwhelmed, but having information up front about what to expect can ease some of the anxiety.

As a neuropsychologist at the Deanna and Sidney Wolk Center for Memory Health at Hebrew SeniorLife, I encourage you to look at neuropsychological testing as a way to be empowered with information about how your brain is functioning.

In this blog post, I’ll demystify the purpose of neuropsychological assessment, how neuropsychological testing is done, who does it, what this type of testing can diagnose, how the results of neuropsychological evaluation are used, and how you should prepare.

Who conducts a neuropsychological evaluation?

The brain is a complex organ made up of highly specialized brain networks that are ultimately responsible for defining our behavior, cognition, and emotions. We know that damage to certain parts of the brain affects different types of behaviors and areas of functioning. The study of the relationship between the brain and behavior, cognition, and emotion is known as neuropsychology.

Neuropsychologists have specialized knowledge and training to understand how the brain functions and employ neuropsychological evaluations to measure the most sophisticated components of behavior in a quantitative, standardized way. We use this expertise across a person’s lifespan to evaluate, diagnose, treat, and rehabilitate patients with neurological, psychiatric, or other medical conditions. 

What makes a neuropsychological evaluation unique from other types of tests? 

A neuropsychological evaluation is a unique piece in a complex mosaic that complements the information you might have uncovered from other diagnostic exams.

For example, your primary care provider or another clinician may request a “brain image scan,” such as a magnetic resonance image (MRI), to obtain a very accurate and detailed image of every structure inside your brain. While these images may reveal physical changes in specific areas of the brain, they can’t necessarily tell you how these changes affect your daily functioning. On the other hand, your brain could appear normal but you may be experiencing a loss of function because of other medical conditions.

The neuropsychological evaluation looks at the brain’s behavioral output and tells you how cognitive and emotional functioning may be diminished by brain structural abnormalities, what consequences these brain changes have on daily life, and what could potentially be modified through actionable recommendations.

Goals of neuropsychological assessment

Neuropsychological evaluations may be recommended for various reasons, including clarifying behavior; aiding in diagnosis; helping with disease management, care, and planning; evaluating the efficacy of a therapeutic strategy; evaluating one’s capacity to make decisions; or conducting research.

Below is a list of the most common reasons: 

Help with a diagnosis 

• You or your loved one have noticed difficulties that may include:
• Learning and remembering things
• Paying attention to what's going on
• Keeping up with the pace of conversation or information
• Staying focused
• Getting words to come out the right way
• Doing things quickly or efficiently that you’ve always done
• Planning and/or initiating activities
• Following directions or getting lost

Is it normal aging? Is it stress? Is it depression? Is it anxiety? Have actual cognitive changes started appearing? Your health care provider can use the results of your neuropsychological evaluation along with the results of other tests, such as brain scans and blood tests, to arrive at a diagnosis.

Precisely determine your cognitive strengths and weaknesses

Your primary care provider will often screen your cognition with quick thinking and memory questions, kind of like you track blood pressure: it's just routine monitoring. If they see a drop or a decline, you may be referred for a neuropsychological evaluation for further investigation.

Plan treatment or other interventions

Neuropsychological evaluation can identify which cognitive abilities are weaker and should be the focus of rehabilitation, environmental modifications, or behavioral strategies. At the same time, you can identify which strengths you can use to your advantage to compensate for weaknesses. Knowing this can help you prioritize decisions about your day-to-day life based on what’s most important to you.

Establish a cognitive baseline

Neuropsychological assessment provides you with a good metric against which we can compare in the future. You or your loved one may be referred for testing when starting a new pharmacological treatment or a noninvasive medical procedure, such as transcranial magnetic stimulation, or a more invasive procedure such as brain surgery or deep brain stimulation, to determine if brain functions were positively or negatively affected. Future re-evaluation can demonstrate if there is a decline in brain function that could be due to modifiable risk factors.

How do neuropsychological tests relate to what you do in daily life?

Every day, we engage in a staggering array of activities that require many cognitive functions. Think about how many mental operations you need to manage your finances. For instance, when you use your online banking account to make a payment, you need to remember the login information for your account, know how to navigate the website and make the right clicks, what you’re paying for, who to send the payment to, and how much it will cost. The neuropsychological tests break down these complex daily life activities into more isolated processes such as your ability to remember, to pay attention, to do mental operations, to write, etc.

Here's a chart showing the most common aspects of cognitive and emotional functioning assessed during the neuropsychological evaluation, along with a description of how difficulties in these domains could affect your daily life.

Areas of functioning	Examples of weaknesses in daily life
Learning and memory	Difficulty remembering daily plans, grocery lists, to take medications, phone numbers, directions, or current significant events
Attention and concentration	Becoming easily distracted; losing track of what is being said or done; difficulty handling more than one activity at once; experiencing brain fog; processing information more slowly
Executive functions	Difficulty organizing things, predicting, and making plans; problems with determining how long it will take to complete activities and initiating a task
Language and communication	Words don't come out easily, difficulty remembering words or finding the correct terminology to express yourself, trouble understanding what other people are saying
Visuospatial/visualconstruction abilities	Difficulties with depth perception, navigating stairs, judging distance, parking a car, or recognizing objects
Sensory motor functions	Things have gotten slower, difficulties performing complex and fine motor sequences that you used to master
Emotional functions (depression, anxiety, apathy, etc.)	Difficulties controlling and expressing your feelings, overreacting to little things, rapid mood changes, feeling irritable, indifference to things that used to be met with curiosity and interest

What happens during a neuropsychological evaluation for adults?

A neuropsychological evaluation involves the thorough study of behavior through interviews and standardized tests, along with questionnaires that provide precise and sensitive indices of the most sophisticated components of functioning:

• Attention
• Perception
• Learning and memory
• Communication and language
• Constructing and drawing
• Reasoning
• Problem-solving
• Judgment
• Planning
• Emotional processing

The three components of a neuropsychological evaluation are:

Clinical interview

This is a conversation to learn more about the specific difficulties you’re experiencing so we can administer the appropriate tests. Often, we also talk to a family member who is familiar with your situation. And because experiences in our daily life and in our past shape us, we also ask about your background, education, social history, and medical history. What did you do for work? What does your family life look like right now? What do you do on a day-to-day basis? Where are the problems really being noticed? What complaints do you have?

Neuropsychology testing

Neuropsychology testing involves administering, scoring, and interpreting formal tests of thinking and memory abilities, tailored to patients’ needs. The tests help us understand your strengths and weaknesses in several aspects of brain functioning. After you finish, the tests are scored and compared to a control group with the same age and level of education. For example, this allows us to distinguish between someone experiencing typical age-related memory loss and someone who may have Alzheimer's disease.

If a family member or caregiver accompanies you for your appointment, they’ll be asked to wait in a separate room during the testing. 

Feedback session

A follow-up appointment may be scheduled to review the findings, share impressions, and make specific recommendations.

What will I be asked to do during the neuropsychology evaluation?

Most patients worry that they may fail a test. This is not possible because these tests aren’t pass/fail. There is no requirement to study or sharpen any skills because the assessments aim to gauge your present strengths and weaknesses.

We don't use the same exact tests for everyone; we suit them to what is best for you and we make accommodations if needed. For instance, if you have difficulty hearing or a tremor that prevents you from using a pencil, we make adjustments. Testing is tailored to every individual, what they need, and what cognitive domains require more attention.

Examples of neuropsychological tests

We assess cognitive and emotional functioning in several different ways. Some tests may involve writing or drawing, while others only require verbal responses, back-and-forth questions, and answers with the professional administering the test. Other tests involve:

• Solving puzzles
• Looking at specific images or patterns
• Judging line angles and distances
• Using objects to reproduce a visual pattern
• Reproducing a complex figure
• Quickly connecting a series of dots in a specific order while maintaining accuracy

Speed plays a significant role in some tests; therefore, we time your performance and give you the go-ahead to complete it as fast as possible. Other tests are based more on accuracy to see how you reason through things, pull information together, and process more complex pieces of information.

How long does a neuropsychological evaluation take?

At the Wolk Center for Memory Health, neuropsychological evaluation takes about one and a half to two hours. In that time we provide focused, brief, and complete testing tailored to what is best for you. During the session, breaks will be provided.

The exact timing can vary depending on the complexity of the issues addressed by the evaluation and the patient's condition.

The follow-up appointment, when we review results and make recommendations, takes about one hour.

How to prepare for a neuropsychological evaluation

While there’s nothing for you to study or memorize, a few simple guidelines can help you maximize your evaluation:

• Get a good night’s sleep
• Eat a good breakfast
• Take all your medications as usual unless you are instructed otherwise
• If you use glasses, contact lenses, or hearing aids, make sure you bring them with you
• If you have had any neuropsychological testing done in the past, bring those records

Improve your quality of life with a neuropsychological assessment at the Wolk Center for Memory Health in Boston

If you’ve noticed a loss of cognitive function, have received a diagnosis that may impact cognition, or want to learn how to keep your brain healthy as you age, a neuropsychological assessment may be the answer.

Our approach to care at the Wolk Center for Memory Health is to provide a precise diagnosis for your memory loss, and with it, a focused and personalized treatment plan. We can highlight areas of daily functioning where support is required; help with care planning; recommend treatments, including medication or occupational therapy; and connect you to resources like local services, counseling, support groups, and caregiver education. The Wolk Center also provides individual and family counseling for those struggling with the experience of memory loss.

At the Wolk Center, we are committed to providing patients and families with answers, hope, and personalized interventions designed to minimize disability, slow the progression of symptoms, and maximize quality of life. Contact us for an evaluation or call 617-363-8600.