Neuropsychological Tests: What’s Involved

Some memory lapses are normal as you age, but if you are concerned about your forgetfulness, there is a range of tests that can evaluate your cognition. These tests aim to identify possible cognitive impairment—or rule it out—as early as possible, but for some individuals the results are inconclusive. “In these cases, more thorough neuropsychological tests are an option, says Jane Martin, MD, associate professor of psychiatry and director of the Clinical Neuropsychology Division at Mount Sinai.

Initial Screening Tests

The simplest cognition tests can be carried out by your primary care doctor as part of your annual wellness check. Depending on which test your doctor utilizes, you may be asked to repeat or categorize a list of words, orient yourself in the present by stating the date and recalling a current news story, count down backwards from a high number, and draw a clock face.

Mental-status screening is the next step, and goes beyond a simple memory test to evaluate your cognitive functioning. Options include the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA), which differ in their emphasis. The MMSE relies on reading, writing, and verbal responses, while the MoCA focuses less on language and includes more measures that evaluate executive function (the ability to plan, organize and perform tasks).

For many people, the MMSE or MoCA are sufficient to detect memory and cognitive impairment or provide reassurance that their memory lapses are due to normal aging. However, Dr. Martin says there are issues with both. “The MMSE is good at detecting language impairments—however, these are less likely to be a problem in early Alzheimer’s disease,” Dr. Martin explains. “Instead, it’s executive function and memory that tend to suffer. Thus, it’s possible for people with early AD to do well on the test. The MoCA does test executive function, meaning that it’s better at picking up subtle cognitive deficits that the MMSE may miss—however, studies show it may overdiagnose people whose cognition is normal.”

In addition, these tests may not be sensitive enough to detect cognitive deficits in highly educated people, and also can suggest problems where none exist in people with low literacy levels, those with vision and/or hearing impairments, and those for whom English is not the primary language. “In these cases—particularly when there is a discrepancy between test results and cognitive functioning as reported by an individual or their care partner—neuropsychological tests may provide clarification,” Dr. Martin says.

Neuropsychological Testing

A neuropsychological evaluation includes an interview with the doctor, followed by a battery of tests that assess your learning and memory, executive skills, attention and concentration, language, visual-spacial skills, motor and sensory skills, and mood/personality. Depending on your symptoms, some of these areas may be examined more closely than others. “Most people find the evaluation quite interesting, but it can be a little intimidating,” Dr. Martin says. “Try to get a good night’s sleep ahead of the test, and leave in plenty of time so you aren’t stressed by a rushed journey to the clinic. Take snacks, and if you use glasses or hearing aids, be sure to bring these with you.”

The evaluation will take several hours, but you’ll be able to take breaks if you become tired. First you’ll spend some time speaking with the doctor, so that he or she can get an idea of your symptoms, functioning, and medical history. “If your spouse or another family member accompanied you to the test, they may be included in the interview if they can provide helpful additional information about your symptoms and functioning,” Dr. Martin says. “They might be able to comment on your ability to carry out independent activities of daily living, such as paying bills, managing medications and appointments, and performing household tasks.”

The neuropsychological testing portion of the evaluation involves performing various pen-and-paper and computerized tests, some of which are similar to those included in the MMSE and MoCA. “You’ll do these tests in a quiet room, away from any distractions,” Dr. Martin says. “The questions are intended to challenge you, but try to avoid becoming frustrated if you can’t complete them all.”

Gaining Insight

The aim of neuropsychological testing is to check how well the different areas of your brain are working, both independently and together. “Different cognitive conditions tend to result in different strengths and weaknesses or patterns across the tests, so if your results indicate a problem your doctor may be able to differentiate between different causes,” Dr. Martin notes. For example, fluctuating attention, visual-spatial impairments, and some mood/behavior disturbances (delusions, hallucinations) are more likely to occur with Lewy body dementia. Conversely, deficits in episodic memory (your recollection of personal experiences from your past) and short-term memory may be early symptoms of Alzheimer’s disease, and also can indicate the progression of mild cognitive impairment (mild memory issues that can be a precursor for Alzheimer’s disease).

Identifying specific types of dementia is important for managing the disease, given that some of the drugs used to treat Alzheimer’s worsen the symptoms of Lewy body dementia. “It also is useful to get some insight about your mental strengths and weaknesses, since this knowledge will enable you and your doctor to develop a plan for managing and/or treating your memory and cognitive issues,” Dr. Martin observes. “Such a plan can be useful even if your test results suggest you are experiencing normal age-related changes in your memory and thinking abilities.”

After the Test

Neuropsychological test results are essentially a snapshot of your abilities at the time you take the test. “Depending on what you find out, there may be strategies you can follow to improve your cognition or compensate for deficits,” Dr. Martin says. “You may also be advised to have annual follow-up evaluations to assess any further changes in your memory and cognition.”

Getting tested for Alzheimer’s disease or another form of dementia is likely to evoke considerable anxiety. If your test results are concerning, you may feel a mixture of anger and fear—or, paradoxically, a sense of relief that you now have a diagnosis for symptoms that may have worried you for some time. As you come to terms with your diagnosis, you may experience depression, and a sense of loss. Others find a sense of purpose, and resolve to live life to the fullest. It may help to speak to people who are going through a similar situation as you, and can provide perspective that helps you move past your diagnosis—the Alzheimer’s Association (www.alz.org) has online forums, and can put you in touch with local support groups.

We don’t yet have treatments that can halt the progression of Alzheimer’s disease and other forms of dementia. However, an early diagnosis gives you time to think about what really matters to you. This time is invaluable for considering what kind of practical help you’ll need to maintain your well-being and independence for as long as possible, your future care needs, and how how best you can address legal and financial affairs as the condition progresses.

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