Author(s): Erika Trovato, DO, Rory Siegel, DO, Julieanne Shulman, Psy D, Kenia Maldonado Vergara, DO
Originally published: September 20, 2013 Last updated: June 5, 2025
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Overview and Description

Brain injuries and various neurocognitive disorders often cause impairments in cognition, emotional control, and behavior that vary in severity and presentation throughout the course of rehabilitation. Physicians often detect these deficits using standard screening tools or other bedside evaluation tools, such as the Mini-Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA). However, in certain situations, it may be necessary to refer patients for a thorough neuropsychological evaluation.1

Formal neuropsychological assessment uses a battery of instruments to detect a wide range of cognitive impairments, some of which may not be readily detectable using brief screening instruments. Furthermore, variables such as language, level of education, ethnicity, age, and comorbidities may complicate the interpretation of results from bedside evaluations. Many neurologic and psychiatric disorders can present with specific patterns of cognitive and neurobehavioral dysfunction, which could aid in differential diagnosis. Various factors that require supplementary analysis include attention, agitation, concentration, learning and memory, language, visual perception, executive processing, psychomotor speed, sensory-motor functions, and behavioral and emotional control.2

Aims of neuropsychological assessment include

  • Providing baseline and prognostic information 
  • Correlating brain lesion location to patient’s presenting symptomatology
  • Identifying comorbid psychiatric or behavioral conditions (i.e. social and emotional functioning)
  • Monitoring progress from specific interventions or therapies
  • Identifying potential barriers to discharge home and community reintegration 
  • Assessing ability to return to school and to inform requests for specific accommodations 
  • Assessing ability to return to driving, employment, or other instrumental activities of daily living (IADL)
  • Assessing decisional capacity
  • Assessing for need and type of conservatorships or guardianships
  • Determinations of disability1-3

Neuropsychological assessment ideally includes a thorough interview, review of medical records, obtaining a psychosocial, developmental, medical and psychiatric history, and identifying a person’s prior level of function. Once completed, several specific neuropsychological and/or psychological tests are administered, which are tailored to the specific question being addressed. Depending on what is being assessed, the evaluation may last several hours and is therefore typically performed in the outpatient setting. Each test is administered in accordance with specific standardized protocols, and the scores are then compared to those of an appropriately matched group of people (i.e. age, gender, ethnicity, education, etc.). Comparisons are then made between current results and baseline estimates, which provide clinicians with important information regarding potential changes caused by disease or injury and differential diagnoses.1,2,4

Domains of cognitive functioning in neuropsychological evaluation

Cognitive DomainDescription    Commonly Used Tests
ScreeningQuick tools that help to identify probable cognitive impairments and help identify those who may benefit from comprehensive neuropsychological evaluations.• Mini-Mental State Examination (MMSE) or Modified Mini-Mental State Examination (3MS)a,b
• Montreal Cognitive Assessment (MoCa)c
• Repeatable Battery for the assessment of Neuropsychological
Status update (RBANS)d
Attention and ConcentrationAbility to focus, sustain attention or selectively attend to a particular stimulus. • Digit Span subtest, Wechsler Adult Intelligence Scale Fourth Edition (WAIS-IV)e
• Spatial Addition, Wechsler Memory Scale (WMS-IV)f
• Trail Making Test, Part Ag
• Conners Continuous Performance Test, Third Edition (CPT-3)h 
Processing SpeedSpeed and efficiency in understanding, perceiving, and responding to verbal, written, or motor-based information.• Symbol Search subtest (WAIS-IV)i
• Coding subtest (WAIS-IV)j
• Trail Making Test, Part Ak
Executive FunctioningInvolves a set of skills such as initiation, working memory, inhibition, impulse control, cognitive flexibility, problem-solving, planning, execution, and judgement.• Wisconsin Card Sorting Test (WCST)l
• Trail Making Test, Part Bm
• Controlled Oral Word Association Test (COWAT)n
• Delis–Kaplan Executive Function System (D-KEFS)n
• Iowa Gambling Taskp
Learning and MemoryAbility to take in new information (learning/encoding or registration), retain it (storage), recall or store it for later (memory). Processes by which information is retrieved and or recognized with cueing are also important to consider. Visual and verbal domains are usually assessed separately.• Wechsler Memory Scale, Fourth Edition (WMS-IV)q
• California Verbal Learning Test, Third Edition (CVLT-3)r
• Neuropsychological Assessment Battery, Memory Module (NAB)s
• Hopkins Verbal Learning Test-Revised (HVLT-R)t
• Brief Visuospatial Memory Test-Revised (BVMT-R)u
LanguageInvolves receptive and expressive abilities, including comprehension, access to semantic memory, naming objects, and the capacity to follow simple and more complex verbal instructions. Written expression is also assessed.• Boston Diagnostic Aphasia Examination, Third Edition (BDAE-3)v
• Boston Naming Test, Second Edition (BNT-2)w
• Semantic Fluencyx
• Multilingual Aphasiay Examination, Third Edition (MAE-3)y
• Peabody Picture Vocabulary Test, Fourth Edition (PPVT-4)z
• Vocabulary subtest, WAIS-IVaa • Neuropsychological Assessment Battery, Language Module (NAB)bb
Visuospatial / Visuo-constructionalAbility to perceive, analyze, and mentally manipulate visual and spatial relationships among visual stimuli or objects.  • Clock Drawing Testcc
• Block Design subtest, WAIS-IVdd
• Rey–Osterrieth Complex Figure Test Copy subtest (RCFT)ee
• Judgment of Line Orientation (J-LO)ff
Motor skillsEvaluate basic motor functions such as fine motor skills, dexterity, speed, and reaction time.  • Finger Tapping Test (FTT)gg
• Grooved Pegboard Taskshh
• 9-Hole Peg Testii
• Grip Strengthjj
• Luria Motor Testkk
Role of Neuropsychology in Rehabilitation Care – Table References

Additional domains; Emotional and neurobehavioral functioning

Emotional Functioning: A physician should also consider psychiatric comorbidities as well as motivational factors which may be impacting functioning. It is important to note that problems with emotional dysregulation or behavior after an injury could merely be a reaction to their injury and the psychological processes that ensue. Importantly, the patient’s present psychological or behavioral issue(s) can significantly impact the interpretation of cognitive results. Additionally, assessments may need to be performed over multiple sessions to minimize fatigue which could potentially suppress performance.2

Behavioral Functioning: Behavior is a complex manifestation of one’s emotional state, conception of the environment, and understanding of societal norms. Behaviors seen with traumatic brain injury recovery, for example, can include agitation, disinhibition, and confusion that often necessitate a multimodal approach to management. A cohesive approach to care in the setting of behavioral issues includes but is not limited to environmental and behavioral modification, the judicious use of medications, and constant observation.

There are multiple treatment strategies for behavioral sequelae, often led by a psychologist in collaboration with a rehabilitation treatment team.  As an example, extinction of undesirable or maladaptive behavior occurs when a behavior is performed less frequently, coupled with positive reinforcement of more desirable alternative behaviors. Care teams may also implement certain protocols or procedural methods to facilitate patient engagement and safe behaviors, particularly on an inpatient basis when cognitive status or limitations are present due to the hospital milieu. Such efforts may include maintaining a consistent sleep-wake cycle, reducing noxious environmental stimuli, staffing with consistent caretakers, and enforcing calm, reflective communication. Staff education and environmental modifications to remove stimuli that are not well tolerated by the person with brain injury need to be quickly and consistently implemented. If non-pharmacological strategies are ineffective, providers can also trial pharmacologic interventions with the assistance of their psychiatry colleagues.5-6

Neuropsychology’s Relevance to Clinical Practice

Formal neuropsychological assessment is an important part of defining cognitive strengths and weaknesses following brain injury or disease. It allows for standardization and comparison to those of a similar comparison group, often, age and education. The information gathered helps guide the rehabilitation team in optimizing functional recovery, and depending on the tool used, serial assessment allows the clinician to formally monitor recovery. When conducted early in the rehabilitation process, neuropsychological assessment can help identify factors such as resiliency or, conversely, emotional disorders that may significantly impact engagement and treatment outcomes. Interventions can then be aimed at building resiliency or addressing psychiatric comorbidities to maximize success. Formal assessment has also been shown to potentially offer information on prognosis and future productivity in brain injury patients.1,7,8

As mentioned above, the specific assessment offered by neuropsychologists is invaluable in the team-based approach within the inpatient or outpatient setting, with the most common indication for consultation being for those patients with brain injuries or neurodegenerative disorders. Neuropsychologists assist with identifying both cognitive and behavioral sequelae to formulate an effective differential diagnosis.  Or their analyses of patients’ symptoms and overall post-injury function help to develop a robust approach in optimizing patient care throughout the rehabilitation journey. Additionally, further investigation into psychosocial, educational and employment histories, current psychiatric status (inclusive of substance use disorders) together embody the holistic approach of a neuropsychologist who will be an important source of referrals to care.2

While highlighting valid symptoms, neuropsychologists also have the knowledge to reveal potential underlying psychiatric behavioral issues that might confound the testing results or serve as a barrier to discharge. Concomitant disorders frequently can create challenges for neuropsychological assessment.  For example, it has been reported that the frequency of depression in the first year after traumatic brain injury ranges from 25-65%. In a similar manner, for people with stroke and early dementia, it may be difficult to decipher which disease process is contributing to a specific deficit.  Please refer to the “Dementia and Delirium” article for more details on testing for these conditions. Altogether, a neuropsychologist supplements the rehabilitation team’s ability to effectively and appropriately manage a plethora of cases through their specialized cognitive and behavioral testing.9-10

Evidence for standardized assessments

Neurocognitive disorders result from multiple etiologies and disease processes. There is a large body of research comparing the utility of various standardized tests to detect deficits and assess function in people with a variety of conditions. The O-Log and Cog-Log tests, for example, are brief bedside instruments that have demonstrated utility as serial tools to track cognitive change in the neurologic rehabilitation setting. They are both reliable measures to assess orientation and track recovery from post-traumatic amnesia.11

Additionally, numerous studies have compared the Mini-Mental State Examination (MMSE) with the Montreal Cognitive Assessment (MoCA) in assessing the neurologic rehabilitation population. While results have varied, some studies suggest the MoCA is more effective than the MMSE in identifying cognitive deficits in the first month post-stroke. However, other studies have found them roughly equivalent in the same population 3-6 months post-stroke. Following subarachnoid hemorrhage, the MoCA was found to be more sensitive in detecting cognitive impairment and to more strongly correlated with lengthier neurocognitive testing findings than the MMSE. In terms of predicting functional outcomes, the portion of the MoCA specifically assessing the visuo-executive domain has also been shown to have greater association with functional outcomes post-stroke than the total scores of either the MMSE or MoCA.12-14

Cutting Edge/Unique Concepts/Emerging Issues

Computerized neuropsychological tests are widely available to assess cognitive skills in multiple disease states and are increasingly being used to assess cognition post-concussion. However, questions of validity have been raised related to potential inadequate effort provided during baseline testing, the environment in which the test is administered, and other confounding factors.15  The addition of validity tests have been used to improve detection of insufficient effort.16  Overall, the advantages of computerized testing include lower cost, easier access to both baseline and subsequent testing, standardized administration, and less learning effect than traditional pen-and-paper testing. Disadvantages include decreased breadth of scope of cognition assessed, inability to tailor the testing environment based on performance, possible validity concerns, and the lack of information regarding the process a patient goes through in reaching an answer. Although promising, computerized testing provides useful but incomplete information about recovery from concussion, thus decisions regarding return to participation in sports continue to be multifactorial.17-18

Face-to-face evaluations were the standard setting for neuropsychological assessments. However, telehealth expanded after the COVID-19 pandemic to improve accessibility, convenience, and continuity of care. Teleneuropsychological tests are done through secure video conferencing in a clinic-based or home-based setting. While web-based teleneuropsychology (TNP) is innovative, it raises concerns about accessibility, especially for individuals in rural or low-income areas. Even among those with internet access, the reliability and validity of TNP can be affected by factors like age, technological familiarity, and device or internet quality. Growing evidence supports the reliability and validity of neuropsychological assessments via telehealth. Research indicates that cognitive functions such as attention, memory, language, and executive functions, especially those assessed verbally, can be reliably evaluated via TNP.20 However, testing executive function remotely is challenging since many traditional executive function tests require visual-motor interaction (e.g., drawing, manipulating objects), which does not translate well to remote formats. There is growing evidence to support virtual cognitive assessments. Systematic reviews have demonstrated good reliability compared with in person cognitive assessment. With time, the methodology and test accuracy will hopefully improve.19-23

Gaps in Knowledge/Evidence Base

Concerns exist regarding the accuracy of the MMSE, for example, and other standardized cognitive assessments in non-white ethnic populations, with some indication they may underestimate cognitive abilities in these groups.24 However, ethnically and demographically sensitive normative data is increasingly available and utilized widely within the discipline of neuropsychology. Studies further clarifying the predictive validity of various standardized cognitive tests for functional outcomes are also emerging. While neuropsychological testing can supplement medical evaluations after brain injury, there are rarely pre-morbid results available to serve for comparison. Most deficits related to brain injury are detected only when there is decreased performance based on estimated premorbid abilities or in selected areas when compared with known cognitive profiles.

In addition, neuropsychological assessment gives a snapshot of current cognitive functioning, but it does not show cause, requiring a synthesis of medical evaluation with the results of neuropsychological testing to get a true picture of current cognitive functioning. Lastly, the efficacy of computerized neuropsychological assessment is still being evaluated, and further research is needed.

References

  1. Schaefer LA, Thakur T, Meager MR. Neuropsychological Assessment. 2021 May 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30020682.
  2. Mills A, Hsu N, Kreutzer J., Neuropsychological Assessment and Treatment Planning. In: Zasler, N. D., Katz, D. I., & Zafonte, R. D. (2022). Brain injury medicine : principles and practice. Springer Publishing Company.
  3. Pastorek NJ, Proto DA, Sander AM, Clark AN. Psychological assessment and intervention in rehabilitation.  In: Cifu DX, Kaelin DL, Kowalske KJ, Lew HL, Miller MA, Ragnarsson KT, Worsowicz GM, eds.  Braddom’s Physical Medicine and Rehabilitation. 5th Philadelphia, PA: Elsevier; 2016: 71-83.
  4. Zucchella C, Federico A, Martini A, Tinazzi M, Bartolo M, Tamburin S. Neuropsychological testing. Pract Neurol. 2018 Jun;18(3):227-237. doi: 10.1136/practneurol-2017-001743. Epub 2018 Feb 22. PMID: 29472384.
  5. Loetscher T, Potter KJ, Wong D, das Nair R. Cognitive rehabilitation for attention deficits following stroke. Cochrane Database Syst Rev. 2019 Nov 10;2019(11):CD002842. doi: 10.1002/14651858.CD002842.pub3. PMID: 31706263; PMCID: PMC6953353.
  6. Ponsford JL, Spitz G, McKenzie D. Using Post-Traumatic Amnesia To Predict Outcome after Traumatic Brain Injury. J Neurotrauma. 2016 Jun 1;33(11):997-1004. doi: 10.1089/neu.2015.4025. Epub 2015 Oct 13. PMID: 26234939.
  7. Hüsser A, Fourdain S, Gallagher A. Neuropsychologic assessment. Handb Clin Neurol. 2020;174:239-249. doi: 10.1016/B978-0-444-64148-9.00017-X. PMID: 32977881.
  8. Sherer M, Novack TA, Sander AM, et al. Neuropsychological assessment and employment outcome after traumatic brain injury: a review. The Clinical Neuropsychologist. 2002; 16(2): 157-178
  9. Wortzel H, Brenner L., Neuropsychiatric Symptoms and Syndromes. In: Zasler, N. D., Katz, D. I., & Zafonte, R. D. (2022). Brain injury medicine : principles and practice. Springer Publishing Company.
  10. Hüsser A, Fourdain S, Gallagher A. Neuropsychologic assessment. Handb Clin Neurol. 2020;174:239-249. doi: 10.1016/B978-0-444-64148-9.00017-X. PMID: 32977881.
  11. Penna S, and Novack TA. Further validation of the orientation and cognitive logs: their relationship to the mini-mental state examination. Archives of Physical Medicine and Rehabilitation, 2007; 88: 1360-1361
  12. Van Heugten, CM, Walton L, Hentschel U. Can we forget the Mini-Mental State Examination? A systematic review of the validity of cognitive screening instruments within one month after stroke. Clinical Rehabilitation. 2015; 29(7): 694-704.
  13. Schwizer, TA, Al-Khindi T, Macdonald RL. Mini-Mental State Examination versus Montreal Cognitive Assessment: Rapid assessment tools for cognitive and functional outcome after aneurysm subarachnoid hemorrhage.  Journal of the Neurological Sciences.  2012; 316: 137-140.
  14. Toglia J, Fitzgerald KA, O’Dell MW, Mastrogiovanni AR, Lin CD. The Mini-Mental State Examination and Montreal Cognitive Assessment in Persons with mild subacute stroke: Relationship to functional outcome.  Archives of Physical Medicine and Rehabilitation.  2011; 92: 792-798.
  15. Abeare CA, Messa I, Zuccato BG, Merker B, Erdodi L. Prevalence of Invalid Performance on Baseline Testing for Sport-Related Concussion by Age and Validity Indicator. JAMA Neurol. 2018;75(6):697–703. doi:10.1001/jamaneurol.2018.0031
  16. Erdodi L, Korcsog K, Considine C, Casey J, Scoboria A, Abeare C. Introducing the ImPACT-5: An Empirically Derived Multivariate Validity Composite. J Head Trauma Rehabil. 2021 Mar-Apr 01;36(2):103-113. doi: 10.1097/HTR.0000000000000576. PMID: 32472832.
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  18. Moser RS, Iverson GL, Echemendia RJ, et al. Neuropsychological evaluation in the diagnosis and management of sports-related concussion. Archives of Clinical Neuropsychology. 2007; 22: 909-916.
  19. Watt JA, Lane NE, Veroniki AA, Vyas MV, Williams C, Ramkissoon N, Thompson Y, Tricco AC, Straus SE, Goodarzi Z. Diagnostic accuracy of virtual cognitive assessment and testing: Systematic review and meta-analysis. J Am Geriatr Soc. 2021 Jun;69(6):1429-1440. doi: 10.1111/jgs.17190. Epub 2021 May 4. PMID: 33948937.
  20. Yıldırım E, Büyükişcan ES, Kalem ŞA, Gürvit IH. Remote Neuropscyhological Assessment: Teleneuropsychology. Noro Psikiyatr Ars. 2024 May 25;61(2):167-174. doi: 10.29399/npa.28535. PMID: 38868842; PMCID: PMC11165610.
  21. Koay JM, Spat-Lemus J, Cornwell MA, Sacks-Zimmerman A, Mandelbaum S, Kohn A, McLean E, Meli G, Bender HA. The Evolving Need for Neuropsychology in Neurosurgical Settings: Challenges Facing Transformative Care. World Neurosurg. 2023 Feb;170:277-285. doi: 10.1016/j.wneu.2022.09.099. PMID: 36782426.
  22. Fatima H, Helphrey J, Ahmed D, Tamez I, Cullum CM. Comparison of Telehealth Versus Face-to-Face Administration of the Oral Trail Making Test in Older Adults with and without Cognitive Impairment: A Brief Report. Arch Clin Neuropsychol. 2025 Jan 21:acaf002. doi: 10.1093/arclin/acaf002. Epub ahead of print. PMID: 39838602.
  23. Brearly TW, Shura RD, Martindale SL, Lazowski RA, Luxton DD, Shenal BV, Rowland JA. Neuropsychological Test Administration by Videoconference: A Systematic Review and Meta-Analysis. Neuropsychol Rev. 2017 Jun;27(2):174-186. doi: 10.1007/s11065-017-9349-1. Epub 2017 Jun 16. PMID: 28623461.
  24. Khan, F and Tandros G.  Complexity in cognitive assessment of elderly British minority ethnic groups: Cultural perspective.  Dementia.  2014; 13(4): 467-482.

Original Version of the Topic

Brian T. Kucer, MD, Todd Lewis, PhD. Cognitive / behavioral / neuropsychological testing. 9/20/2013

Previous Revision(s) of the Topic

Kimberly Hartman, MD, Allison Blough, MD. Cognitive / behavioral / neuropsychological testing. 7/3/2018

Steven Flanagan, MD, Jason Kessler, MD, Julia Tsinberg, MD, Danni Lu, MD. Cognitive/Behavioral/Neuropsychological Testing. 6/16/2022

Author Disclosure

Erika Trovato, DO
Nothing to Disclose

Rory Siegel, DO
Nothing to Disclose

Julieanne Shulman, Psy D
Nothing to Disclose

Kenia Maldonado Vergara, DO
Nothing to Disclose