The Neuropsychology Referral and Answering the Referral Question

Abstract

Neuropsychological evaluations provide a wealth of information to the referring clinician and patient, offering a host of answers to important diagnostic and treatment-related questions. The range of questions a neuropsychological evaluation can answer are broad, but generally fall under six broad categories (e.g., Lezak et al., Neuropsychological assessment, 4th edn. Oxford University Press, New York, 2004):

• 1. Diagnoses: Identifying the existence of brain dysfunction [and differentiating brain dysfunction from non-lesional psychiatric diagnosis or otherwise reversible causes of cognitive dysfunction (e.g., depression)].

  • Example: Distinguishing dementia from depression or identifying the presence of mild cognitive impairment (MCI).

• 2. Describing neuropsychological status: Detailing how a disease or lesion(s) is expressed from cognitive, behavioral and affective perspectives.

  • Example: Describing how a traumatic brain injury (TBI) has affected a patient’s cognitive and emotional functioning, including the severity and extent of neuropsychological deficits.

• 3. Treatment planning, treatment facility placement or evaluating for resource utilization.

  • Example: Identifying if a patient meets inclusion/exclusion criteria for placement in a rehabilitation facility. An increasing emphasis within neuropsychology is predicting neuropsychological outcome from proposed medical treatment (e.g., temporal lobectomy for intractable epilepsy or DBS for Parkinson’s disease).

• 4. Identifying the effects of treatment (often includes measuring change in function over time).

  • Example: Evaluation of effects of a speech/language therapy program for a patient.

• 5. Research evaluation tool: Identifying basic and central nervous system processes and/or the effects of other agents on the central nervous system.

  • Example: Evaluating the neuropsychological effects of a medication to treat epilepsy in a randomized controlled trial.

• 6. Forensic applications: Neuropsychological evaluations are increasingly being used to assist fact-finding bodies to determine if, or the extent to which, an alleged event resulted in damage to the CNS. Another use is to assist courts in evaluating if a defendant is capable of managing his/her affairs independently. Also used forensically to evaluate mental state/competence/decision making capacity of individuals, particularly those alleged to be involved in ­criminal activities

Appendices

Appendix 1 Example of Inpatient/Screening Neuropsychological Consult Report

NEUROPSYCHOLOGY SERVICE

Neuropsychological Consultation

NAME:XXX, XXXXPATIENT #:

BIRTH DATE:EDUCATION:X years

EXAM DATE:[Must document date and time of evaluation and time spent with patient]

REFERAL SOURCE:

REFERRAL INFORMATION AND RELEVANT HISTORY:

[Brief summary of presenting history and reason for referral. Should include symptoms/diagnosis warranting neuropsychological consult]

[Brief summary of presenting patient complaints, if any. The history of complaints, when the symptoms started, severity, and course should be specified].

Example might be: “Patient is a 30-year-old right handed Caucasian male status-post left middle cerebral artery ischemic stroke (date) with mild right hemiparesis and language problems referred to assist with diagnosis and treatment planning. The patient may be a candidate for a community re-integration program. Patient complained of memory and language problems and symptoms of depression.”

MENTAL STATUS AND [BEHAVIORAL OBSERVATIONS OR GENERAL CONSTITUTION]

[Detail the patient’s mental status. At a minimum, the patient’s level of arousal and orientation should be noted along with behavioral observations (gait, tremor, etc.). Quality of speech should be reviewed along with mood and affect. Presence/absence of suicidal and/or homicidal ideation, intent or plan along with hallucinations or delusions should be specified. The patient’s cooperation with the evaluation should be noted. Example provided below.]

“Patient was AAOx3 and appropriately groomed. Made good eye contact. Speech articulation, rate, rhythm, and prosody was WNL. Speech content was appropriate. Speech process was linear. Mood was euthymic and effect was full. No suicidal/homicidal ideation, plan or intent (no SI/HI, plan, or intent). No delusions or hallucinations. Insight and judgment WNL. Study is valid.”

ASSESSMENT PROCEDURES

[Specified the assessment procedures including what tests were administered. We advise the clinician to specify inclusion of symptom validity measures as such, and not identify specific test names in keeping with recent recommendations.]

NEUROPSYCHOLOGICAL FINDINGS

[Provide results of test scores here. May be separated into major domains or a brief summary. See examples below. We recommend results provided as advised in Chelune (2010).

Examples

Paragraph Format

The patient exhibited deficits in areas of attention/executive functions, verbal ­memory, and language functions. Specifically, the patient exhibited mild to moderate deficits in complex focused and divided attention tasks. Verbal immediate and delayed memory scores were mildly impaired. Language screening was functional, but there were deficits in confrontation naming and verbal fluency. Strengths were basic span of attention, gross receptive and expressive language functions, and visuoperceptual skills. Discrepancy among scores were rare in a normal population.

Bulleted Format

Attention: Intact for basic functions. Impaired for complex attention

Memory: Impaired verbal memory. Intact visual memory.

Language: Impaired confrontation naming and verbal fluency. Unable to follow 3-step instructions. Otherwise receptive and expressive speech grossly intact. Repetition intact. No alexia or agraphia.

Visuoperceptual/visuoconstructional: Grossly intact. No constructional apraxia

Executive functions (insight, judgment, reasoning): Insight and judgment [intact, poor, etc.]. Sequencing, set-shifting, problem solving scores were normal.

Personality/psychological/emotional functioning: [brief summary of results of any personality/psychological functioning. May also include quality of life variables, as well as any behavioral apathy and other neurovegetative symptoms.

CONCLUSIONS AND RECOMMENDATIONS

[Interpretation of neuropsychological results. Statement(s) to answer the referral question(s) should be clearly specified. Diagnoses should be listed. If combined with recommendations, recommendations should flow from interpretation.] See example below, and Chelune (2010).

Neuropsychological study was [abnormal, equivocal, normal].

[If relation to neuroanatomical function is needed, specify here. For example: Data ­suggest left frontotemporal dysfunction, and consistent with reported left MCA stroke.]

[If surgical candidacy is a referral question. For example: Surgical candidacy: From a neuropsychological standpoint, the patient is a (poor, fair, good, excellent) ­candidate for (left, right, extratemporal, multilobar, corpus callosotomy, DBS, VNS, CABG, renal/hepatic transplantation, spinal fusion, morphine pump, etc.…). The patient is at (low, medium, high) risk for post-surgical (language, memory, attention/executive, psychiatric, etc.) problems.

[If feedback notation is included in same report. For example: Initial results of the neuropsychological evaluation were reviewed with ________ [as much detail as is necessary].

Diagnostic impressions: [List diagnostic conditions here. Should follow ICD-9 or DSM-IV diagnostic codes].

Recommendations

[List recommendations here]. We recommend including time spent with patient completing neuropsycho­logical evaluation. Example may be “A total of __ hours of neuropsychological services (including interviewing, administering, scoring, interpretation, and report writing) completed by Dr. ____.

Appendix 2 Example of Outpatient Comprehensive Evaluation Report

NEUROPSYCHOLOGY SERVICE

Neuropsychological Evaluation

NAME:XXX, XXXXPATIENT #:

BIRTH DATE:ETHNICITY:

EXAM DATE:EDUCATION:X years

REPORT DATE:OCCUPATION:

REFERAL SOURCE:

REFERRAL INFORMATION

[One or two sentences describing reason for referral. Should include symptoms/diagnosis warranting neuropsychological consult]

[OPTIONAL SECTION – RESULTS SUMMARY: [one or two sentences summarizing findings of neuropsychological evaluation. For example: Neuropsychological evaluation was abnormal with deficits in memory and language. (if surgical patient: Patient is a (fill in appropriate descriptor – poor/fair/good surgical candidate) (if dementia patient: Data consistent with (fill in likely etiology)]

CURRENT COMPLAINTS AND HISTORY

[Specify where data was obtained, e.g., patient and spouse]

[Brief summary of presenting complaints, if any. The history of complaints, when the symptoms started, severity, and course should be specified].

Example – bullet format:

• 1. Seizures/Epilepsy. Patient has a history of seizures since childhood. Seizures medication refractory. Seizures occur 2/month on average. Last known seizure was _____.

• 2. Attention, memory, and language problems past 2 years. Increasing problems concentrating the past 2 years. Forgets details of recent events, appointments, and repeats self. Increasing dysnomia the past 2 years. Speech problems past ____.

• 3. Depression for past year. Symptoms of depression more often than not the past year. Denied anxiety symptoms. Sleep and appetite were _____. Difficulty falling asleep and his/her appetite has decreased with loss of 15 pounals past 6 months without dealing. Energy level was _____.

MEDICAL AND PSYCHIATRIC HISTORY: [Relevant medical and psychiatric history specified. This may only be noted as “unremarkable” or “noncontributory” but may also include information about neurological exam, laboratory studies, EEG, MRI, CT, surgical/operative notes, consulting notes of other health care ­providers, previous diagnosis(es) and treatments (successful or unsuccessful). Allergies may also be stated.).

[Review of developmental, social, educational, occupational history provided. One may also make a statement about patient’s ability to complete activities of daily living (ADLs). Can be brief, for example “Patients medical and psychiatric history was reviewed and detailed in chart. Otherwise unremarkable. Developmental history unremarkable. Patient worked as an engineer and retired in 2003. Patient is independent in ADLs and is driving.]

CURRENT MEDICATIONS: [list medications and dosages]

MENTAL STATUS AND GENERAL CONSTITUTION

[Detail the patient’s mental status. At a minimum, the patient’s level of arousal and orientation should be noted along with observations about gait and station, stature, and hygiene. Quality of speech should be reviewed along with mood and affect. Presence/absence of suicidal and/or homicidal ideation, intent or plan along with hallucinations or delusions should be specified. The patient’s cooperation with the evaluation should be noted.]

[A comment about task engagement or validity of the study may be made here or in the neuropsychological results section. An example is given below.]

Appearance: well groomed. Appeared stated age. Of normal height and build.

Gait/station: normal.

Tremor: No obvious tremor observed.

AAOx4: Yes

Speech: articulation and rate, rhythm, intonation, and prosody WNL.

Speech Content: generally appropriate to context.

Speech Process: organized and goal-directed.

Mood: euthymic

Affect: consistent with mood

Suicidal/Homicidal Ideation Plan or Intent: denied

Hallucinations/Delusions: None

Judgment: within normal limits

Insight: within normal limits

Test Taking Behavior: Cooperative and appeared to give adequate effort. Study is valid.

ASSESSMENT PROCEDURES

[Specified the assessment procedures including what tests were administered. We advise the clinician to specify inclusion of symptom validity measures as such, and not identify specific test names.]

SENSORY/MOTOR AND PERCEPTUAL FUNCTIONING

[Results from sensorimotor and perceptual testing, if completed, specified here. This may also include results from neurological exam, if completed. Presence of finger agnosia, visual field defects, etc. and motor exam (motor speed, dexterity, and/or grip strength.] Example is below.

Sense of smell: intact to several common scents.

EOM: appeared grossly intact.

Visual fields: grossly full to confrontation.

Light touch: Sensation intact in face and hands, and no extinction with bilateral simultaneous stimulation.

Auditory: intact, bilaterally

Ideomotor apraxia: None (or Yes, present)

Agraphasthesia: None (or Yes, present)

Finger agnosia: None (or Yes, present)

R/L orientation: Intact (or Impaired)

Grip strength: [description of performance. Example “Average, bilaterally.”]

Finger tapping speed: [description of performance]

Manual dexterity: [description of performance]

NEUROPSYCHOLOGICAL FUNCTIONING [OR RESULTS]

[Provide results of test scores here. May be separated into major domains or a summary of performances provided]. See examples below. We recommend the inclusion of a summary table of neuropsychological scores (including standardized scores) be included in most neuropsychological reports either imbedded or as an appendix. Base rate information regarding the frequency in which score differences are observed in healthy samples and/or if results exceed reliable change scores (if known) may be included. No references needed. [Note: the reporting base rate and/or discrepancy information provided following recommendations for evidenced-based neuropsychology practice (Chelune 2010)].

Paragraph format

Premorbid functioning estimated to be high average to superior. General cognitive functioning was average. The patient exhibited deficits in areas of attention/executive functions, verbal memory, and language functions. Specifically, the patient exhibited mild to moderate deficits in complex focused and divided attention tasks. Verbal immediate and delayed memory scores were mildly impaired. Language screening was grossly functional, but there were deficits in confrontation naming and verbal fluency. Strengths were basic span of attention, receptive and expressive language functions, and visuoperceptual skills.

Bulleted format

Premorbid functioning: Estimated to be high average to superior in general cognitive ability.

General Cognitive: High average compared to age-matched peers. Indices of verbal and nonverbal abilities were high average and average, respectively (Verbal Comp.= 115, 84th %; Perceptual Reasoning=100, 50th %).

Processing Speed: WNL.

Attention: Intact for basic functions. Impaired for complex attention

Memory: Impaired verbal memory. Intact visual memory. Differences in scores infrequent in healthy sample.

Language: Impaired confrontation naming and verbal fluency. Unable to follow 3-step instructions. Otherwise receptive and expressive speech grossly intact. Repetition intact. No alexia or agraphia.

Visuoperceptual/visuoconstructional: Grossly intact. No constructional apraxia

Executive functions (insight, judgment, reasoning): impaired. Insight and judgment [intact, impaired, etc.]

Brief Results Section Example

The patient exhibited deficits in areas of attention/executive functions, verbal memory, and language functions. Specifically, the patient exhibited mild to moderate­ deficits­ in complex focused and divided attention tasks. Verbal immediate and delayed memory scores were borderline to impaired compared to age-matched peers. Language screening was functional, but the patient exhibited deficits in confrontation naming (BNT = 38/60) and phonemic and semantic verbal fluency scores.

Strengths were in basic attention functions, general cognitive (intellectual) functioning was average, and visuoperceptual and visuoconstructional skills were entirely intact.

PSYCHOLOGICAL AND PERSONALITY FUNCTIONING

[Provide results of any psychological or personality testing done. See example below]

The patient completed the BDI-2 and STAI. He reported mild to moderate symptoms of depression and anxiety. The patient denied rumination and appeared well adjusted.

CONCLUSIONS AND DIAGNOSTIC IMPRESSIONS

[Interpretation of neuropsychological results. Statement(s) to answer the referral question(s) should be clearly specified. Diagnoses should be listed. If combined with recommendations, recommendations should flow from interpretation.] See example below.

Neuropsychological study was [abnormal, equivocal, normal]. [If abnormal, describe what was abnormal].

For example: The study was abnormal due to deficits in attention/executive functions, verbal memory, and language functions. There were mild to moderate symptoms of depression. Strengths included the patient’s basic span of attention, nonverbal “visual” memory, visuoperceptual and visuoconstructional skills.

[If relation to neuroanatomical function is needed, specify here. For example: Assuming normal neuroanatomical functional organization, data suggest left frontotemporal dysfunction, and consistent with history of left temporal mesial temporal scelrosis.] [In dementia example. Neuropsychological data are generally consistent with a dementia of the Alzheimer’s type. A less likely possibility is a frontotemporal dementia (FTD) process. History of symptoms argues against FTD].

[If surgical candidacy is a referral question, clearly specify neuropsychological opinion. For example: Surgical candidacy: From a neuropsychological standpoint, the patient is a (poor, fair, good, excellent) candidate for (left, right, extratemporal, multilobar, corpus callosotomy, DBS, VNS, CABG, renal/hepatic transplantation, spinal fusion, morphine pump, etc.]. The patient is at (low, medium, high) risk for post-surgical (language, memory, attention/executive, psychiatric, etc.) problems. The patient is likely a good candidate for [additional diagnostic/laboratory procedures to further evaluate for potential risks to the patient.].

[If feedback notation is included in same report. For example: Initial results of the neuropsychological evaluation were reviewed with the patient, and all questions were answered to his/her/their satisfaction. As much detail as is necessary is appropriate here.].

Diagnostic Impressions: [List diagnostic conditions here. Should follow ICD-9 or DSM-IV diagnostic codes].

RECOMMENDATIONS

[List recommendations for the patient’s care here.] These will vary widely depending upon the individual patient. However, some common domains for recommendations are provided below:

• 1. Referral for further work-up of condition.

• 2. Recommend consultation by another specialist/subspecialist

• 3. Initiate treatment for psychiatric/psychological symptoms

• 4. Initiate treatment/rehabilitation for cognitive deficits

• 5. Cognitive ability to make medical, legal, and/or financial decisions (capacity is a legal term and decided by a court – not a neuropsychologist).

• 6. Cognitive and/or behavioral prognosis based on available data

• 7. Rehabilitation/treatment recommendations

  • Summary of deficits with prognosis for recovery

  • Participate in medical treatment

  • Behavioral management

  • 1:1 Supervision/therapies

  • Suicide precautions

  • Escort to and from all activities

  • Relaxation

  • Minimal stimulation

  • Shortened therapy sessions

  • Cognitive rehab.

  • Neglect training

  • Attentional training

  • Orientation group/training

  • Memory notebook training

  • Problem solving training

• 8. Occupational recommendations/driving restrictions

  • Capacity to return to work (school if child)

  • Schedule to return if unable to return to full time work

  • Accommodations necessary for successful re-integration

• 9. Reference of local, state, regional, national, or international support and advocacy groups of any known disorders/conditions.

• 10. Specify diagnosis for Americans with Disabilities Act (ADA) and/or Individuals with Disabilities Education Act (IDEA 2004).

  • Specify need for IEP (based on diagnosis/diagnoses)

  • Specify what accommodations and/or adaptations may be helpful to the patient academically, socially, emotionally, and/or vocationally.

• 11. [If appropriate, make statement(s) about return to work/school. If not return to work/school now, when, and if accommodations (as above) are likely to be needed.].

• 12. [Specify if follow-up is needed].

[Closure of report and include information, if appropriate, for further contact and information if desired. Include information about services provided [Services included: Neuropsychological evaluation (_____ hours including administering, scoring, interpretation and report writing). Psychometrician-based neuropsychological assessment (____ hours).]