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Neuropsychological Evaluation
Author: Atif B Malik, MD; more...
Updated: Nov 30, 2011
Overview
Neuropsychological evaluation (NPE) is a testing method through which a neuropsychologist can
acquire data about a subject’s cognitive, motor, behavioral, linguistic, and executive functioning. In the
hands of a trained neuropsychologist, these data can provide information leading to the diagnosis of a
cognitive deficit or to the confirmation of a diagnosis, as well as to the localization of organic
abnormalities in the central nervous system (CNS). The data can also guide effective treatment
methods for the rehabilitation of impaired patients.
NPE provides insight into the psychological functioning of an individual, a capacity for which modern
[1, 2]
imaging techniques have only limited ability. However, these tests must be interpreted by a trained,
experienced neuropsychologist in order to be of any benefit to the patient. These tests are often
coupled with information from clinical reports, physical examination, and increasingly, premorbid and
postmorbid self and relative reports. Alone, each neuropsychological test has strengths and
weaknesses in its validity, reliability, sensitivity, and specificity. However, through eclectic testing and
[3, 4]
new in situ testing, the utility of NPE is increasing dramatically.
Function categories
NPE is useful for measuring many function categories, including the following:
Intellectual functioning
Academic achievement
Language processing
Visuospatial processing
Attention/concentration
Verbal learning and memory
Visual learning and memory
Executive functions
Speed of processing
Sensory-perceptual functions
Motor speed and strength
Motivation/symptom validity
Personality assessment
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The table below lists examples of commonly used neuropsychological tests for the above categories.
[5, 6, 7, 8]
Table 1. Examples of Commonly Used Neuropsychological Tests (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 Wechsler Individual Achievement Test (WIAT)
achievement
Woodcock-Johnson Achievement Test
Language processing Boston Naming Test
Multilingual Aphasia Examination
Boston Diagnostic Aphasia Examination
Token Test
Visuospatial Rey-Osterrieth Complex Figure – Copy condition
processing
WAIS Block Design Subtest
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Judgment of Line Orientation
Hooper Visual Organization Test
Attention/ Digit Span Forward and Reversed
concentration
Trail Making Tests
Cancellation Tasks (Letter and symbol)
Paced Auditory Serial Addition Test (PASAT)
Verbal learning and Wechsler Memory Scale (WMS)
memory
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
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Visual learning and WMS
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
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)
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Speed of processing Simple and Choice Reaction Time
Symbol Digit Modalities Test - Written and oral
Sensory-perceptual Halstead-Reitan Neuropsychological Battery (HRNB) Tactual Performance
functions Test and Sensory Perceptual Examination
Motor speed and Index Finger Tapping
strength
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 Minnesota Multiphasic Personality Inventory (MMPI)
assessment
Millon Clinical Multiaxial Inventory
Beck Depression Inventory (BDI)
Rorschach Test
Thematic Apperception Test for Children or Adults
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Referrals for Neuropsychological Evaluation
NPE is used to quantitatively measure the cognitive and behavioral capabilities of a patient. The data
from neuropsychological tests can then be compared with normative data based on a number of
different demographic criteria, including (but not limited to) age, race, gender, and socioeconomic
status. NPE can include testing of intelligence, attention, memory, and personality, as well as of problem
solving, language, perceptual, motor, academic, and learning abilities.
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:
Head injury
Failure to achieve developmental milestones
[9, 10]
Learning or attention deficits
Exposure to drugs, alcohol, or maternal illness in utero
Exposure to chemicals, toxins, or heavy metals
Parkinson disease
Seizure disorders
Substance abuse
Strokes
[11, 12, 13, 14, 15]
Dementia
Psychiatric disorders
NPE is of limited value if a patient is severely compromised, as in advanced dementia or early in
recovery from serious brain injury (eg, TBI, stroke, anoxia, infection), although brief serial assessment
with measures such as the Galveston Orientation and Amnesia Test, high-velocity lead therapy (HVLT),
digit span, and motor speed and dexterity is very useful in tracking recovery. NPE's value is also limited
if a patient has other serious medical complications or psychiatric disorders.
Information Obtained From Neuropsychological Reports
Neuropsychological tests are a series of measures that identify cognitive impairment and functioning in
individuals. They provide quantifiable data about the following aspects of cognition:
Reasoning and problem-solving ability
Ability to understand and express language
Working memory and attention
Short-term and long-term memory
Processing speed
Visual-spatial organization
Visual-motor coordination
Planning, synthesizing, and organizing abilities
Established Applications of Neuropsychological Evaluation
Applications of NPE include the following:
Provide a differential diagnosis of organic and functional pathologies
[11, 12, 13, 14]
Assess for dementia versus pseudodementia
Determine the presence of epilepsy versus somatoform disorder (that is, nonepileptic seizures or
pseudoseizures)
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[16]
Determine the presence of traumatic brain injury (TBI) sequelae versus malingering or
unconscious highlighting
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
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
[11, 12, 13, 14, 16]
(DAT), multiple sclerosis (MS), TBI, and stroke
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.
Patient-Specific Factors and Normative Data
Results of an NPE must be considered in the context of the patient’s age, education, sex, and cultural
background. These factors can affect test performance and limit the conclusions that can be drawn from
the evaluation. In addition, issues such as reliability, validity, sensitivity, and specificity need to be
considered.
Large, population-based norms are available for relatively few measures. Those measures that do
boast such norms, such as major intellectual and academic instruments, are of limited usefulness within
a neuropsychological test battery. Ideally, patients should be compared with population-based norms,
as well as with local norms and subgroup norms (ie, specific patient populations) to examine strengths
and weaknesses. However, significant gaps can be found in the normative data for all age, educational,
and intellectual ranges. Major deficiencies have also existed in the development of appropriate
measures and norms for minority populations.
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
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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
Generally, findings suggest that performance on tests of motor function, speed of cognitive processing,
cognitive flexibility, complex attention, and memory are related positively to real-world success.
The amount of variance accounted for by cognitive factors alone, however, is typically quite small.
Exceptions occur when comparisons made between results of formal NPE and real-world criteria are
limited to very simple, very circumscribed, and/or very well-defined functions. Consequently, situational
assessment is seen as a critical adjunct to neuropsychological assessment, especially at higher levels
of cognitive functioning.
Neuropsychological tests, with very few exceptions, were not developed with an eye toward ecologic
validity. They were developed as indicators of brain function or dysfunction and generally were validated
against neurosurgical, neurologic, and neuroradiologic data. Nevertheless, many tests have proven to
be good predictors of future behavior and, therefore, have demonstrated ecologic validity.
A qualitative process approach may improve the ecologic validity of the neuropsychological test battery.
For example, testing the limits with measures of memory and executive functioning allows the examiner
to understand better what a person can do under relatively ideal circumstances (not “what,” but “how”).
The test itself may have little demonstrable ecologic validity, but an accurate analysis and insightful
interpretation of findings can be highly valid from an ecologic perspective.
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
abnormalities 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 specificity of the test
For any evaluation, it is important to understand the rates of each of the 4 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.
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Overcoming problems in assessing executive function
Perhaps the major drawback of NPE is the lack of ecologic validity when assessing executive
[17]
functioning. NPE is generally conducted within calm and quiet testing rooms where the subject is
clearly presented with the task to be completed, is informed of time restrictions, and is prompted to start
and stop behaviors. Under these conditions, a subject may achieve a score that indicates no executive
dysfunctions, although the individual may be particularly drained from the mental exertion. Completing
tasks in the real world, however, requires several executive functions that are not tested in traditional
NPE, including recognizing that a task must be completed, starting the task, switching tasks, adapting to
changes, and stopping a task.
However, changes in executive tests have dramatically increased the environmental validity of
executive NPE. These changes include a growing emphasis on subject self reporting of premorbid and
postmorbid functioning, as well as premorbid and postmorbid reports from relatives and significant
others in the subject’s life. Often, however, the self report is not sufficient, for executive dysfunctions
may be unknown to the subject, or else they may be ego-syntonic.
A dramatic approach to overcoming the problem of ecologic validity is found in the Multiple Errands Test
(MET). The test takes place in a shopping mall and requires the subject to conduct 3 tasks
simultaneously, such as buying an item, meeting at a certain location at a certain time, and acquiring
available information (such as a foreign currency exchange rate). This evaluation tests the subject’s
abilities in planning, task initiation, and task switching, and even requires the subject to interact with
other individuals in an effective manner. The test has shown considerable sensitivity and specificity, and
subjects with neurologic deficits have performed considerably worse than controls. A version of this test
has also been created for the hospital setting.
Contributor Information and Disclosures
Author
Atif B Malik, MD Medical Director, Department of Pain Medicine, Washington Adventist Hospital
Atif B Malik, MD is a member of the following medical societies: American Pain Society and North
American Spine Society
Disclosure: Nothing to disclose.
Coauthor(s)
Megan E Turner West Virginia University School of Medicine
Megan E Turner is a member of the following medical societies: American Medical Student
Association/Foundation
Disclosure: Nothing to disclose.
Craig Sadler Research Assistant, Center for the Study of Traumatic Stress, The Henry M Jackson
Foundation for the Advancement of Military Medicine
Disclosure: Nothing to disclose.
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Additional Contributors
Patrick J Potter, MD, FRCP(C) Associate Professor, Physical Medicine and Rehabilitation, The
University of Western Ontario; Consulting Staff, Department of Physical Medicine and Rehabilitation,
St Joseph's Health Care Centre
Patrick J Potter, MD, FRCP(C) is a member of the following medical societies: American Paraplegia
Society, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical
Association, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal
College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.
Richard Salcido, MD Chairman, Erdman Professor of Rehabilitation, Department of Physical
Medicine and Rehabilitation, University of Pennsylvania School of Medicine
Richard Salcido, MD is a member of the following medical societies: American Academy of Pain
Medicine, American Academy of Physical Medicine and Rehabilitation, American College of
Physician Executives, American Medical Association, and American Paraplegia Society
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Reference Salary Employment
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