Overview and Description
Brain injuries and various neurocognitive disorders often cause impairments in cognition, emotional control, and behavior that vary in severity and presentation. Physicians can often detect these deficits by using standard screening tools such as the Mini-Mental Status Examination or other bedside evaluation tools. However, in certain situations, it may be necessary to refer patients for a thorough neuropsychological evaluation.1
Formal neuropsychological testing using a battery of instruments detects a wider range of cognitive impairments, some of which may be subtler and not readily detectable using brief screening instruments. Furthermore, variables such as language, education, cultural backgrounds, and age may complicate the interpretation of results from bedside evaluations. Many neurologic and psychiatric disorders can present with specific patterns of cognitive (e.g. attention, concentration, immediate and remote memory, learning, language, perception, executive processing, psychomotor speed, and sensory-motor functions) and behavioral (e.g. speech, agitation, emotional control) dysfunction, which could make diagnosis and subsequently treatment easier.2
Other uses of neuropsychological and behavioral testing include:
- Providing baseline and prognostic information
- Identifying potential barriers to community reintegration
- Assessing decisional capacity
- Assessing socio-emotional control
- Monitoring progress from specific interventions or therapies
- Assessing ability to return to sports, employment, or schooling and need for accommodations
- Assessing driving ability
- Legal considerations and determining disability1-3
Formal neuropsychological assessments initially involve obtaining a medical and psychiatric history, pertinent neuroimaging results, and previous clinical interviews and evaluations. Once completed, several specific neuropsychological or behavioral tests are administered, which are tailored to the specific question being addressed. Depending on what is being tested, the evaluation may last several hours and are therefore typically performed in the outpatient setting. Each test is administered in accordance to a specific testing manual, which standardizes the results, and the scores are then compared to those of an appropriate matched group of people (i.e. age, gender, cultural backgrounds, education, etc.). These comparisons in addition to specific test results help to estimate pre-morbid cognitive abilities, which provides clinicians important information on potential changes caused by disease or injury.1,4
Cognitive Domains and Testing
Brief cognitive assessments can be performed by multiple practitioners in rehabilitation settings and can help tailor treatments to meet individual patient needs and abilities. Some cognitive tests are designed to be used serially to assess changes over time, while other tests cannot be due to test/retest validity issues. Multiple domains may be tested, including commonly impaired skills listed below, noting less frequently tested domains may be investigated as indicated by specific circumstances.
- Alertness describes one’s arousal to stimuli. This can be spontaneous, reactive to verbal or noxious stimulation, or non-alert. Deficits in alertness may arise from brain injury or specific medical interventions. The timing and fluctuations in alertness may also indicate infection or delirium if rapid or indicate disorders of consciousness if more chronic. Impairments in alertness and orientation can significantly impair cognitive testing, thus some specific testing should be done during periods of improved alertness. Current research on stroke attention deficits suggests that although there is an immediate effect of cognitive rehabilitation on attentional and alertness cognitive domains, future studies may be necessary to determine whether this benefit persists or is generalizable to activities of daily living.5
- Attention is the ability to focus on a task or object and is necessary for participation in cognitive testing. Focused or selective attention describe one’s ability to focus on a specific aspect of the environment. Sustained attention or vigilance is the length of time one can focus on a task in the setting of distracting stimuli. Divided attention or cognitive flexibility is the ability to shift back and forth between tasks smoothly. As mentioned above, research is ongoing to determine whether cognitive rehabilitation has long-lasting benefits on attention.5
- Orientation describes a patient’s awareness of their current environment, typically in terms of person, place, time, and situation. Significant alterations in orientation are more common during the immediate post-injury phase. In cases of traumatic brain injury, the time until consistent orientation to these variables, known as post-traumatic amnesia, is a strong predictor of recovery.6
- Memory is a broad term that encompasses to one’s ability to recall events and information and apply previously learned knowledge or skills to current situations. Various memory impairments are common after brain injury, and can be examined using appropriate tests.7
- Retrograde amnesia describes loss of memory preceding an injury.
- Anterograde amnesia describes loss of memory for events after an injury.
- Registration of information occurs immediately after being provided information. If registration fails, there will be no recall of the information.
- Semantic memory involves conceptual and factual knowledge.
- Procedural memory is the ability to learn behaviors and cognitive skills at an automatic, unconscious level.
- Working memory involves retaining information while concentrating on another task, and then utilizing that information in a functional environment.
- Remote memory or memory of one’s distant past is typically well-preserved following brain injury.2,7
- Executive functioning is the ability to engage in problem-solving or task planning from initiation to completion. Executive functioning consists of judgment, reasoning, concept formation, abstraction, initiation, fluency, planning, organization, mental flexibility, and impulse control.2,8
- Language encompasses fluency, repetition, naming, verbal comprehension, reading, and writing. Language disorders, known as aphasias, can impact other cognitive domains and complicate the interpretation of results obtained from cognitive testing. Some studies suggest that non-language domains such as attention and executive functioning can even impact people with chronic aphasia. Offering choices and using nonverbal means of testing may help determine whether cognitive deficits exist in the setting of aphasia.2,9
As previously described, neuropsychological testing assesses cognitive skills and is better suited to detect impairments not easily identified through bedside examination or brief screening tools. Neuropsychological testing ideally includes a thorough diagnostic interview, review of medical records, obtaining a social, developmental, and psychiatric history, and identifying a person’s perceived level of function. Neuropsychological testing typically focuses on several domains, noting there can be overlap with both cognitive and behavioral testing.1
Some of the more commonly tested neuropsychological domains include:
- Emotional wellbeing and adjustment
- Attention and concentration
- Generalized intelligence and fund of knowledge
- Executive functioning
- Visuospatial reasoning
- Psychomotor speed
Results of neuropsychological testing provide information on brain lesion location and correlate results to the person’s symptoms. For example, focal lesions usually target specific cognitive domains whereas diffuse brain injuries have more global impacts on cognition and affect multiple domains. Additionally, visual memory can be impaired in patients with oculomotor dysfunction or occipital lesions, and executive functioning deficits can be found in those with frontal lobe injuries. It is important to consider that a person’s performance on neuropsychological testing should reflect their best effort. Testing may need to be performed over multiple sessions to minimize fatigue which could potentially cause inappropriately poor results. In addition to detecting impairments, neuropsychological testing also provides important information regarding areas of relative strength, which can be utilized to compensate for areas of identified weaknesses. Research has also demonstrated the predictive ability of neuropsychological screening to identify people with mild TBI who are at increased risk for poor rehabilitation outcomes.10 As a result, testing can help direct therapeutic interventions across several disciplines and help providers develop accommodations in school or work environments that enhance successful community reintegration.
Behavioral Domains and Testing
Behavior is a complex manifestation of one’s emotional state, conception of the environment, and understanding of societal norms. Agitation, disinhibition, and confusion are commonly observed during early recovery from brain injury, necessitating a multimodal approach to management that includes but is not limited to environmental and behavioral modification, the judicious use of medications, and constant observation. Structured behavioral assessments are usually accomplished by employing observational tools.11, 12
There are multiple treatment strategies for behavioral impairments related to neurocognitive dysfunction. As an example, extinction of an undesirable or maladaptive behavior occurs when a behavior is performed less frequently coupled with positive reinforcement of more desirable alternative behaviors. In the acute rehabilitation setting, reinforcement strategies may not be possible or convenient. Instead, care teams may implement “delirium precautions” to reassure patients. This includes maintaining a consistent sleep-wake cycle, reducing noxious environmental stimuli, staffing with consistent caretakers, and enforcing calm communication. Staff education and environmental modifications to remove stimuli not well tolerated by the person with brain injury need to be quickly and consistently implemented. If non-pharmacological strategies are ineffective, providers can trial medication changes.11, 12
Relevance to Clinical Practice
Formal neuropsychological testing 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 age and education. The information gathered helps guide the rehabilitation team in optimizing functional recovery, and depending on the tool used, serial testing allows the clinician to formally monitor recovery. When conducted early in the rehabilitation process, neuropsychological testing can help identify factors such as resiliency or 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 testing has also been shown to potentially offer information on prognosis and future productivity when conducted in the early weeks to months following brain injury.1,13,14
Some individuals are not well suited for formal neuropsychological assessment for various reasons, such as intolerance to lengthy and comprehensive testing batteries. A more concise battery of cognitive tests may be an acceptable alternative while still providing predictive value regarding functional outcome up to one year after traumatic brain injury. Even a simple test of recall of three words following a 24-hour delay has been shown to have predictive value for psychosocial distress and return to productivity following brain injury.15,16
Agitation, aggression, disinhibition, and impulsivity can pose challenges for care providers and for the patient’s loved ones. These behaviors interfere with treatment compliance, meaningful engagement in therapy, and consequently with outcomes. Effective behavioral assessment involves ongoing monitoring of intervention efficacy and collaboration among rehabilitation team members. It also helps family members identify triggers of problematic behaviors which can guide feedback and education on how to respond effectively.11, 12
Evidence for specific standardized tests
Neurocognitive disorders result from multiple etiologies and disease processes. There is a growing body of research comparing the utility of various standardized tests to detect deficits and assess function in people with a variety of brain injuries. The O-Log and Cog-Log tests are brief bedside instruments that have demonstrated utility as serial tools to track cognitive recovery or decline in the neurologic rehabilitation setting. They are both reliable measures to assess orientation and track recovery from post-traumatic amnesia.17
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.18-20
Concomitant disorders can create challenges for neuropsychological testing. For example, in 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” chapter for more details on testing for these conditions. Pediatric brain injury poses unique challenges because cerebral function at this age is in a rapid phase of change. Many factors play a role in cognitive development, such as biological age, developmental age, and environment. Children injured at an early age may have more challenges acquiring new cognitive skills, in spite of neuroplasticity. Therefore, it is important that tests are appropriate for biological as well as developmental age and that interpretation of results is based on age-matched norms. Repeat testing is warranted at times of transition, particularly when there is an increase in cognitive expectation in school and during early teenage years when abstract reasoning and executive functions normally develop.21
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. For example, ImPACT, Concussion Sentinel, and Headminder Concussion Resolution Index tests are just some of the instruments available to detect changes in cognition following a concussion if pre-injury test results are available for comparison. These can be administered anywhere there is access to a computer, mouse, and a quiet testing environment. Furthermore, research investigating the validity of computerized (CogState Brief Battery) vs paper-pencil (MOCA) cognitive assessments revealed the CogState Brief Battery is a valid alternative for clinicians who wish to measure cognitive skills following acute ischemic stroke.22 Lastly, in the field of primary care, there has been positive experiences with the Computer Assessment of Mild Cognitive Impairment (CAMCI) in identifying early signs of dementia. Overall, these results suggest primary care providers can consider computerized cognitive testing in their offices for their patients.23
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.24 The addition of validity tests have been used to improve detection of insufficient effort.25 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 testing subject 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 needs to be multifactorial.26,27
Lastly, teleconferencing is another emerging concept for neuropsychological and cognitive testing. Evidence suggests neuropsychological testing by video teleconference is a feasible and reliable means of conducting assessment with populations that would otherwise lack access due to remote location or difficulties with traveling. Implemented widely during the Covid-19 pandemic, teleconferencing has changed the practice of medicine. However, while there is evidence to support virtual cognitive assessments, there are gaps in diagnostic certainty. A systematic review of 121 studies revealed only two demonstrated good reliability compared with in-person cognitive assessment of dementia. With time, the methodology and test accuracy will hopefully improve.28,29
Gaps in Knowledge/ Evidence Base
Limited evidence exists regarding the accuracy of the MMSE and other standardized cognitive assessment tests in non-white ethnic populations, with some indication they may underestimate cognitive abilities in these groups.30 Future studies are also needed to further clarify the utility of the various standardized cognitive tests in predicting functional outcomes as well as correlating performance on brief assessments with formal neuropsychological batteries following brain injury. 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 pre-morbid abilities or in selected areas when compared with others.
In addition, testing 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 role of computerized neuropsychological testing in concussion management is still being defined, and further research is needed to determine the efficacy of teleconferencing and virtual cognitive testing.
- Schaefer LA, Thakur T, Meager MR. Neuropsychological Assessment. 2021 May 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 30020682.
- Harvey PD. Domains of cognition and their assessment. Dialogues Clin Neurosci. 2019;21(3):227-237. doi:10.31887/DCNS.2019.21.3/pharvey
- 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.
- 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.
- 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.
- 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.
- Budson AE, Price BH. Memory dysfunction. New England Journal of Medicine. 2005; 352: 692-699.
- Rabinovici GD, Stephens ML, Possin KL. Executive dysfunction. Continuum (Minneap Minn). 2015 Jun;21(3 Behavioral Neurology and Neuropsychiatry):646-59. doi: 10.1212/01.CON.0000466658.05156.54. PMID: 26039846; PMCID: PMC4455841.
- Schumacher R, Halai AD, Lambon Ralph MA. Assessing and mapping language, attention and executive multidimensional deficits in stroke aphasia. Brain. 2019 Oct 1;142(10):3202-3216. doi: 10.1093/brain/awz258. PMID: 31504247; PMCID: PMC6794940.
- Walker WC, Stromberg KA, Marwitz JH, et al. Predicting Long-Term Global Outcome after Traumatic Brain Injury: Development of a Practical Prognostic Tool Using the Traumatic Brain Injury Model Systems National Database [published correction appears in J Neurotrauma. 2020 Mar 15;37(6):905]. J Neurotrauma. 2018;35(14):1587-1595. doi:10.1089/neu.2017.5359
- McCauley SR, Wilde EA, Miller ER, Frisby ML, Garza HM, Varghese R, Levin HS, Robertson CS, McCarthy JJ. Preinjury Resilience and Mood as Predictors of Early Outcome Following Mild Traumatic Brain Injury. Journal of Neurotrauma. 2013; 30: 642-652.
- Karol RL. Principles of behavioral analysis and modification. In: Zasler ND, Katz DI, Zafonte RD, eds. Brain Injury Medicine, Principles and Practice. 1st New York, NY: Demos; 2007:818.
- 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.
- 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
- Hanks RA, Millis SR, Ricker JH, et al. The predictive validity of a brief inpatient neuropsychologic battery for persons with traumatic brain injury. Archives of Physical Medicine and Rehabilitation. 2008; 89: 950-957
- Dawson DR, Levine B, Schwartz ML, Stuss DT. Acute predictors of real-world outcomes following traumatic brain injury: a prospective study. Brain Inj. 2004 Mar;18(3):221-38. doi: 10.1080/02699050310001617406. PMID: 14726283.
- 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
- 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.
- 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.
- 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.
- 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.
- Gagnon MM, Laforce R Jr. Computerized vs. Paper-Pencil Assessment of Cognitive Change following Acute Ischemic Stroke. J Neurol Disord. 2016 Dec 1;4(8):317. doi: 10.4172/2329-6895.1000317. PMID: 28649579; PMCID: PMC5482710.
- Millett G, Naglie G, Upshur R, Jaakkimainen L, Charles J, Tierney MC. Computerized Cognitive Testing in Primary Care: A Qualitative Study. Alzheimer Dis Assoc Disord. 2018 Apr-Jun;32(2):114-119. doi: 10.1097/WAD.0000000000000219. PMID: 29140858.
- 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
- 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.
- Broglio SP, Ferrara MS, Maccioccci SN, Baumgartner TA, Elliot R. Test-retest reliability of computerized concussion assessment programs. Journal of Athletic Training. 2007; 42: 509-514.
- 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.
- Wadsworth, HE, Galusha-Glasscock JM, Womack KB, Quiceno M, Weiner MF, Hynan LS, Shore J, Cullum CM. Remote neuropsychological assessment in rural American Indians with and without cognitive impairment. Archives of Clinical Neuropsychology. 2016; 31: 420-425.
- 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.
- 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
Nothing to Disclose
Jason Kessler, MD
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Julia Tsinberg, MD
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Danni Lu, MD
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