I share this blog with you in the spirit of my late grandfather who was named Elias. He was “Leo” to many, a kind, timid, and humble man whom my family lost far too soon to complications from Alzheimer’s disease. I don’t recall the events chronicling his decline, as we lived in separate cities during that time. What I do know is that the disease progressed in him fairly rapidly. It was only a few short years from the approximate time of onset to his death. My family supported him in the best ways we knew how, seeking medical care for the remainder of his life and doing what we could to keep him content. Lacking in his care, however, were efforts to monitor the disease progression. We had no idea what neuropsychological testing was or how it was used in geriatric care. For this reason and others, I offer a broad overview about this very important topic.
Let’s talk numbers; the World Health Organization (WHO, 2023) estimates that more than 55 million people across the globe are diagnosed with one form of dementia. Over 60 percent of these individuals represent countries dominated by lower and middle household incomes. With awareness on the rise, approximately 10 million new cases are reported each year. Dementia represents a class of neurological conditions referred to as neurocognitive disorders (NCD). Defined as a significant decline in one or more areas of cognitive functioning (Emmady, Schoo, & Tadi, 2022), these diagnoses fall into two categories: mild or major (NCD), depending on severity level. The effects of dementia differ from those indicative of normal aging; its onset is insidious initially and, over time, progresses more rapidly if left untreated. It encompasses structural changes in the brain that are degenerative in nature. Alzheimer’s is the most common form of dementia (Schachter & Davis, 2000), followed by frontotemporal dementia among individuals under 65 (Young et al., 2018).
According to the American Psychiatric Association (APA, 2013), age is the number one risk factor for developing dementia. Behind age are vascular disease and traumatic brain injury. Studies show a person’s lifestyle choices play a role in their vitality and have notable implications for brain health (e.g., Dhana et al., 2020). Conditions such as hypertension, diabetes, and obesity, for instance, heighten a person’s chances of developing dementia (WHO, 2023). As such, understanding one's physical health history is critical.
Cortical atrophy and protein buildup are diagnostic markers in Alzheimer’s patients. Whereas these effects can only be confirmed postmortem, neuroimaging allows for the examination of structural changes and gives rise to specific areas of the brain that are affected. Functionally, localizing these structural changes may offer insight into what the disease may manifest. If changes are detected in the left hemisphere of the brain, for example, language is likely to be affected. Neuropsychological testing extends the benefits of imaging technology by affording us a deeper understanding of how the disease is functionally impacting the individual.
People present for testing in a few ways. Neurologists and primary care physicians sometimes refer their patients for a neuropsychological evaluation when cognitive changes are suspected, while other times, family and caregivers make the initial request following observed changes to memory, language, personality, and/or behavior in their loved ones. Diagnostically, brain functioning is categorized into six domains that structure the testing process. These include complex attention, executive functioning, learning and memory, language, perceptual-motor, and social cognition (APA, 2013).
Neuropsychologists use a variety of tests designed to measure these functions, thereby yielding rich details about an individual’s mental status. In addition to these performance areas, a thorough health history is taken into account, with input offered by caregivers and the individual being tested. As noted, this comprehensive process aims to create a snapshot of the patient’s brain functioning and the extent of any changes from the individual’s suspected baseline.
In addition to understanding physical health, the initial interview with the patient is a critical step that affords me the chance to learn how the reported changes interfere with their everyday life. Naturally, I often hear families and patients describe problems with short term memory. Complaints typically surround the person’s tendency to repeat themselves or forget commitments. Word finding is another commonly reported concern. For instance, a person might forget the name of items they use on a daily basis. Families sometimes tell me their loved one has forgotten how to operate basic technology with which they are already familiar, including devices like a remote control or microwave. It is important to distinguish this from learning new technology, including newer smartphones, as this is developmentally expected in aging individuals. After the interview, patients present for the comprehensive assessment that can last anywhere from one to two days. Results are summarized in a report and, along with next steps, are reviewed with the patient and caregiver(s) at a later appointment.
Testing is helpful because it can serve as a baseline of functioning that is followed up on periodically. The recommended frequency will vary, depending on the nature of the disease progression. The same tests should be administered because it allows for explicit progress monitoring. When stakeholders, including a patient’s care team, systematically understand the rate of progression, treatment decisions are made with greater confidence.
In sum, cognitive testing is a vital component of a person’s care plan. It is a rich diagnostic tool that can aid in the early detection of decline, while informing treatment decisions in ways that could not be achieved otherwise. It acts in concert with and informs the care provided by neurologists and other physicians. Advancements in medicine continue to acknowledge its importance and value in geriatric care.
If you have concerns about yourself or a loved one, please don’t hesitate to reach out to us at hello@wbma.cc or call 301-576-6044.
Licensed Psychologist, Clinical Neuropsychology