6 Things to Know About Seeing a Neuropsychologist

You may never need to see a neuropsychologist, a psychologist who specializes in evaluating the relationships between brain function and behavior. But there are reasons why you might—doctors refer patients of all ages to neuropsychologists to obtain precise information about how changes in thinking abilities, emotions, and patterns of behavior may be affected by brain diseases or injuries.

“Neuropsychologists can identify factors affecting a person’s brain health that are treatable, and we spend a significant amount of time with patients providing detailed recommendations based on our clinical evaluation,” says Emily Sharp, PhD, division chief of neuropsychology for Yale Medicine.

She is a provider in a field that has been expanding due to a growing need for specialized assessment and treatment of cognitive and neurological conditions. “Knowing that there are treatable factors that impact memory and thinking can provide hope to patients and families,” she says.

These practitioners take the time to obtain a thorough clinical history and then administer a variety of tests to better understand a person’s thinking abilities and any symptoms related to emotional or behavioral changes. This information helps patients and their physicians in the process of treatment planning, including medication management for symptoms of Alzheimer’s disease or other forms of dementia, or surgical decisions for previously diagnosed conditions, such as epilepsy or brain tumor.

Neuropsychologists often work with older people to help determine whether their memory lapses are normal age-related changes, signs and symptoms of a progressively worsening disease like Alzheimer’s disease, or effects of depression or medications.

Below, Sharp explains the practice of neuropsychology and how it can help identify the cause of common neurological or cognitive issues.

A neuropsychologist is a type of psychologist who understands the complex links between the different parts of a person’s brain and their thinking abilities and behavior. A neuropsychologist may be a generalist who evaluates the cognitive implications of a variety of medical or neurological issues, or a subspecialist dedicated to a particular neurological condition, such as seizure disorders, movement disorders, traumatic brain injury, or neuro-oncology (tumors of the brain and nervous system). Their education includes a PhD or a PsyD (Doctor of Psychology), and their training includes an internship and two years of specialty training during a postdoctoral fellowship in clinical neuropsychology.

Neuropsychologists administer a series of cognitive tests to measure aspects of thinking, such as attention, language, memory, and problem-solving. The information they gather may be valuable in aiding the referring physician’s diagnosis or treatment decisions. “The pattern we see across the different measures allows us to understand and identify brain dysfunction,” Sharp says. “A person’s strengths and weaknesses in different cognitive areas tend to map onto different neurological disorders. For instance, there is a specific pattern of dysfunction that I would expect to see in a person with Alzheimer's versus a person with Parkinson's disease.”

Neuropsychologists also have the patient and a family member complete rating scales to determine if there have been changes in mood, sleep, or patterns of behavior. Emotional and behavioral changes can sometimes occur in individuals with progressive neurological conditions, such as dementia, or after a stroke or brain injury.

A person can be referred to a neuropsychologist by their primary care provider, geriatrician, neurologist, or other specialist who is concerned about the person’s symptom(s) and would find it helpful to have a more detailed evaluation. Often, the patient or a family member has noticed a change in their thinking, such as a progressive inability to remember things. A change in behavior or daily activities, including neglect of personal hygiene; confusion, agitation, and/or impulsiveness; or uncharacteristic inappropriate behavior, is also a reason to consult with a neuropsychologist.

While people of any age can have symptoms of cognitive dysfunction, older adults especially may worry about dementia if they have difficulty remembering appointments or finding the right word in a conversation. “In cases like these, the question would be, ‘Is this normal aging or a disease that's affecting the aging process?’” Sharp says.

Cognitive testing might clarify this or help to rule out a more serious condition. Sometimes, the diagnosis is unclear and the evaluation results provide a measurement of the patient’s baseline, which can be used for comparison to a future repeat evaluation. Evidence of progressive decline over time, as identified in yearly assessments, would be an indication of a possible neurodegenerative condition.

For patients who have already been diagnosed with a neurological condition, neuropsychologists often work as part of a multidisciplinary team. For example, a person who is going to have brain surgery for epilepsy will see a neuropsychologist to help determine the location in the brain responsible for causing the seizures. This, in combination with other tests, including brain imaging and EEG, helps neurosurgeons pinpoint the brain region where the surgery should be performed.

A pediatric neuropsychologist uses a similar series of tests to evaluate children to establish their cognitive functioning and academic abilities in relation to developmental conditions, such as Down syndrome, attention-deficit/hyperactivity disorder (ADHD), or autism spectrum disorder (ASD). The results of these tests will guide their recommendations to parents and to the child’s school, especially if special accommodations are needed.

A visit takes two to six hours—it varies, depending on the symptoms or the reason for the evaluation.

“The first part of the visit involves information-gathering,” Sharp says. “We spend about an hour asking about a person’s clinical history and listening to the patient or family talk about their concerns and factors potentially contributing to cognitive symptoms, such as sleep changes. We use this information to understand the context in which a person’s cognitive abilities may have changed over time.”

In addition to questions about any noticeable changes in memory and other thinking abilities, the neuropsychologist usually asks about a wide range of issues and daily activities, such as sleep, mood (anxiety or depression, for instance), and day-to-day functioning, including routine activities such as preparing meals, remembering medications, and driving.

It is also helpful for the neuropsychologist to understand the person’s background information, including but not limited to educational and occupational histories, languages spoken, and cultural context. Knowledge of these factors helps neuropsychologists use appropriate tests, correctly interpret results, make appropriate diagnoses, and offer suitable recommendations.

Cognitive testing is the second part of the visit. Patients are administered a selection of tests that target their specific concerns. “The neuropsychologist chooses from hundreds of standardized neuropsychological tests,” Sharp says. “We select ones that will best answer the referral question and that are appropriate for the patient’s age and personal background.”

Many tests start with a practice example. “We always make sure the patient understands the task before we start. What’s more, tests are not interpreted in isolation. Instead, we are looking for a pattern across numerous tests, which may indicate the cause of cognitive problems. For example, we may ask a patient to perform several verbal, visual, and motor tasks quickly to look for differences in processing speed,” Sharp says.

Other tasks may require patients to remember new information or pictures, draw figures, solve puzzles, or perform certain movements with their hands. “Some of the tests are easy, and others are challenging. Many patients say that it can feel almost like playing games,” says Sharp.

The neuropsychologist’s assessment is based on a compilation of results of many tests, each of which may target one or several different aspects of thinking and behavior, including:

• Attention
• Working memory
• Processing speed
• Executive functioning (organization, planning, judgment, problem-solving, mental flexibility)
• Language (expressive and receptive language)
• Visuospatial abilities (constructional, perceptual)
• Memory (verbal and visual)
• Motor abilities (such as hand dexterity)

Neuropsychological findings indicate which areas of the brain may not be working as well as others and provide a working diagnosis for the referring provider. The results could, for instance, confirm a patient’s memory lapses. “Memory is associated with the hippocampus structures in the brain. If you have any injury or progressive disease that affects the hippocampus, the tests will show changes in your ability to learn and remember new information,” Sharp says.

“In some cases, special neuroimaging, called an amyloid PET scan, ordered by a patient’s neurologist, might show a buildup of amyloid, which is associated with cell atrophy [death]—one of the underlying pathologies in Alzheimer’s disease,” Sharp says. “But the presence of amyloid alone isn’t enough to diagnose a patient with cognitive impairment or dementia. That's why we need both. We need the MRI and a cognitive assessment to demonstrate a patient’s actual cognitive abilities and diagnose the clinical syndrome.”

A neuropsychologist can also identify treatable factors that may be impacting a patient’s thinking and daily functioning. If an evaluation shows that they have no signs of dementia, Alzheimer’s, or any other condition, their cognitive issues may be caused by poor sleep, untreated hearing loss, depression, or a vascular condition.

Certain prescription and over-the-counter medicines can also affect cognition. Older adults may be more sensitive to medications, including some antihistamines, medications for anxiety and depression, muscle relaxers, and sleep aids. The neuropsychologist would then suggest interventions or treatments to address those potential issues.

“There is no specific preparation for the evaluation,” Sharp says. “We encourage patients to try to get a good night’s sleep and eat a healthy breakfast. They should bring their glasses and/or hearing aids so they can perform as well as possible.”

It is recommended that a patient who uses recreational marijuana or drinks alcohol avoid those substances within the 24 hours prior to the evaluation and, preferably, abstain from marijuana use for one week prior.

“We also encourage patients to relax,” Sharp says. “The tests are not pass or fail. The goal is to see how they are doing compared to other people their age. We do our best to put our patients at ease and make this as engaging and as comfortable as possible.”

An important part of a neuropsychologist’s work is making recommendations that help people with brain issues improve their cognition and have a better quality of life, Sharp says. For instance, if a patient has had a stroke, there may be a part of the brain affected that won’t recover. “But there are other outcomes that can occur after a stroke, such as aphasia [language disorder], mood disorders, sleep disorders, and/or changes in sensory function—and those factors are treatable,” Sharp says.

Whatever the person’s situation, a neuropsychologist provides personalized recommendations after the evaluation. This can be a very simple suggestion such that a patient slow down and focus on taking in new information. “Sometimes, part of the recommendation is to help people understand that they can’t do something in the same way as they once did. For instance, when you are acquiring new information, try to reduce your distraction,” Sharp says. “If you are scrolling on your phone and talking to someone at the same time, you won’t be able to take in what the person is saying. But if you focus on listening and then repeat back what the other person said, you are much more likely to remember the information later.”

"Neuropsychologists also have detailed discussions with patients about the positive impact that exercise, a healthy diet, and stress reduction can have on thinking abilities," Sharp says. “Exercise is one of the few neuroprotective activities where the research consistently shows that people who exercise regularly have better brain health than those who don't.”

While the type of exercise suggested may vary from patient to patient, Sharp recommends activities like in-person group tai chi classes for balance training and social interactions with other people, which are also important for brain health, she says.

Whatever a person’s situation, it’s important for people to be proactive in their cognitive engagement and to pursue activities they enjoy, Sharp adds. “This could be going to a museum, listening to music, or reading more. For example, there's an incredible amount of planning, organization, and visuospatial abilities that go into gardening or knitting,” she says. “We want people to have the best possible quality of life, and it helps if they engage in activities that make them happy and that are cognitively stimulating.”