Introduction to Neuropsychology
What is Neuropsychology?
Neuropsychology lies at the intersection of the fields of neurology, psychology, and psychiatry. Placed under the umbrella of clinical psychology, this discipline focuses on understanding brain-behavior correlates through performance-based measures used to assess cognitive functioning. The neuropsychological evaluation plays an essential role in diagnosis and treatment planning through a biopsychosocial framework. Neuropsychology as a field that emerged in the early 19th century to study focal brain lesions and their impact on day-to-day functioning. With the advent of neuroimaging, neuropsychology continues to aid in connecting structural findings to cognitive functioning, assisting with differential diagnosis, prognosis, and risk predictions, and treatment planning has become more of a focus.
Training in Neuropsychology
Clinical neuropsychologists are licensed clinicians with a doctoral degree (Ph.D./Psy.D.) in clinical psychology, and additional postdoctoral training in clinical neuropsychology. Neuropsychologists receive training in functional neuroanatomy, neurobiology, psychometrics, statistics, psychopharmacology, neurologic illness/injury, therapeutic interventions, and clinical psychology. After completion of their doctoral degree and postdoctoral fellowship, neuropsychologists can opt to pursue board certification through governing boards in their region or country, such as the American Board of Professional Psychology in the United States. This certification consists of credential review, written and oral examinations, and submission of practice samples for review. Although board certification is not required for a clinician to practice neuropsychology, it is recommended by the American Academy of Clinical Neuropsychology in the United States and other professional psychology boards to promote standardized quality of training and delivery of services.
Neuropsychological Assessment and Intervention
Historically, neuropsychology has focused on the assessment of brain-behavior relationships and the diagnosis of neurologic disorders. Neuropsychological assessments are standardized measures of cognitive functioning that identify and characterize the severity of deficits while also serving to track changes over time. Scores from the assessments provide an estimate of the person’s cognitive functioning relative to a normative group with a similar demographic background, often based on age, education, sex, and occasionally also ethnic or racial identity, although more work is needed to expand and update available normative data to best serve increasingly diverse patient populations. Additionally, neuropsychological assessments inform treatment planning, as the neuropsychologist provides specific recommendations to optimize cognition and daily functioning. Furthermore, neuropsychologists provide patients with personalized and targeted suggestions for interventions and rehabilitative services that are informed by assessment findings.
In this chapter, we explore several topics relevant to neuropsychology, including an introduction to cognitive domains assessed through a neuropsychological evaluation; a brief overview of cognitive screening tools, standard assessment procedures, and referral questions; and a discussion of evidence-based neuropsychological interventions.
Neuropsychological Assessment
Cognition: Neuroanatomy and Cognitive Domains
Cognition has been described as a multifaceted process of acquiring, perceiving, and processing information. Until the late 19th century, cognition was conceived of as a single construct called “intelligence.” Over time and through rich observations and empirical study, cognition has come to be understood as a complex collection of mental processes with intricate nuances that separate how the mind perceives, calculates, decides, and functions. In our modern understanding, cognition is divided into various domains, including language (both receptive [input/acquisition of information, comprehension] and expressive functions [oral and written output]), memory and learning (encoding, storage, and retrieval), attention/executive function (e.g., problem-solving, organization, decision-making), visuospatial abilities, and social cognition. These processes work both narrowly and interdependently to provide a basis for human cognition and behavior. Cognition can also be measured and understood based on the type of stimulus that initiates a mental process, which can be divided into verbal (speech- and/or linguistic-mediated) and nonverbal functions (visually mediated). Neuropsychological assessment aims to characterize performance across these various cognitive domains and map patterns of strengths and weaknesses onto brain-behavior relations. Following is an overview of the five major cognitive domains that are often assessed in a neuropsychological evaluation along with the brain regions and networks associated with each of these domains ( Box 16.1 and Fig. 16.1 ).
Functions of the Cerebral Cortex
Frontal Lobe
Voluntary movement and motor control
Attention and working memory
Executive functions (e.g., planning/organization, decision-making, problem-solving, cognitive flexibility)
Expressive language/speech production (left)
Memory encoding and retrieval
Motivation
Personality
Temporal Lobe
Memory (all stages)
Auditory processing
Receptive language/language comprehension (left)
Affective prosody (right)
Emotional regulation
Parietal Lobe
Tactile sensation
Visual-spatial attention and perception (right)
Mental rotation and visual construction
Reading (left)
Calculation (left)
Occipital Lobe
Visual processing
Attention and Executive Functioning
Attention is the foundation for most cognitive functions, including memory, processing speed, and executive function. Attention is a complex function that includes a variety of processes that support one’s ability to focus on specific aspects of information to the exclusion of other information and distractors. The brain areas that are primarily associated with attention include the frontal and parietal lobes, specifically the dorsolateral prefrontal cortex, the posterior parietal cortex along the intraparietal sulcus, and other associated subcortical regions that connect with each other and with cortical regions. The literature on cognition and behavior has divided attention broadly into four hierarchical components: selective attention, sustained attention, divided attention, and alternating attention/cognitive flexibility. Given its complexity, attention is measured by various tests that are specific to this domain (e.g., digit and spatial span tasks, continuous performance tasks) as well as by interpretation of one’s responses and types of errors on many tests across the neuropsychological assessment that can be affected by difficulty in regulating one’s attention.
Executive functioning is a product of higher level attentional processes that support more complex cognitive tasks, including but not limited to working memory, problem-solving, planning, organization, inhibition, and self-monitoring/regulation. The brain regions that are associated with these functions primarily include the frontal lobe and its interconnected subcortical structures, including the prefrontal cortex, basal ganglia, and thalamus. Deficits in executive functions have significant implications for daily functioning and can affect both cognitive functioning and social/interpersonal functioning. For example, executive function deficits can manifest as reduced self-control and emotional dysregulation, which lead to emotional lability, irritability, or impulsivity.
Memory
Neuropsychological evaluations assess three major processes involved in memory, which are primarily mediated by frontal and temporal lobe structures, including the hippocampus and entorhinal cortex. The three stages of memory include encoding (ability to learn new information), retention/consolidation (ability to hold or store this information over time), and retrieval (ability to freely recall the learned information after a delay). Neuropsychological tests are designed to characterize memory at each of these levels to assist in differential diagnosis; these tests often include assessment of both verbal and nonverbal memory. Evidence of poor retention/consolidation often implicates dysfunction of medial temporal lobe structures and is commonly seen in early Alzheimer disease. By contrast, memory deficits primarily at the levels of encoding and retrieval with intact storage (retention/consolidation) may indicate more disruption in the frontal lobe and its connections that are more involved in attention/executive function. Broadly, encoding and retrieval deficits are nonspecific and can be seen various conditions, including vascular dementia or frontotemporal dementia, and in many other medical and neuropsychiatric conditions, including mood disorders, traumatic brain injury (TBI), and Parkinson’s disease.
Language
Assessment of the patient’s language functioning begins during the clinical interview, in which the clinician is attentive to any receptive or expressive language difficulties. If there is concern about a possible language disorder due to errors in naming objects, substitution of unintended words in a conversation, word-finding pauses, articulation difficulty, and/or difficulty comprehending language, a more systematic approach is taken to assess specific areas of impairment during a formal evaluation. The brain regions that are associated with language reception and production include the left hemisphere-dominant perisylvian (the region around the sylvian fissure) language network, which consists of parts of the frontal, temporal, and parietal lobes, including the inferior frontal gyrus, premotor cortex, and upper temporal lobe. Nonverbal aspects of language, such as facial expression, posture, and use of objects, are often mediated by the right hemisphere of the brain. Many aspects of both expressive and receptive language are assessed during neuropsychological evaluation, including but not limited to reading, writing, verbal comprehension, naming, repetition, and verbal fluency.
Visual-Spatial Functioning
Visual-spatial functioning encompasses one’s ability to locate an object while processing the distance, depth, and direction of the object in relation to self or other objects and the ability to represent and mentally manipulate objects. Most spatial cognitive functions are associated with the posterior part of the parietal lobe as well as occipital lobe, with the ability to coordinate fine motor movements with visual abilities (visual construction) also associated with the frontoparietal networks. Assessment of visual-spatial functioning in neuropsychological evaluation includes characterization of visual construction as well as the ability to understand and process essential inputs to the visual system (visual perception) along with more complex functions like spatial orientation, mental rotation, and visual-motor integration.
Social Cognition
Although not routinely assessed in depth on formal testing, social cognition is an important aspect of one’s health and overall functioning. Deficits in this domain are important in predicting and analyzing the ability to form and maintain interpersonal relationships. The brain areas that are involved in social cognitive functioning include the medial and anterior parts of the prefrontal cortex, the junction of the temporal and parietal lobes (temporoparietal junction), the fusiform gyrus, the posterior cingulate cortex, and the amygdala. Assessment of social cognitive functioning includes evaluation of theory of mind, social judgment, recognition of affect and empathy, and interpersonal behavior.
From the Primary Care Provider to the Neuropsychologist: A Stepped Model of Care
Referrals
Determining the appropriate referrals for a neuropsychological evaluation is particularly important, given the limited number of providers and the cost of services. The appropriateness of referrals tends to be optimized when referrals are triaged through specialists, such as neurologists or psychiatrists, although educating nonspecialists about how neuropsychological evaluations may be beneficial and for which patients will improve the judicious use of this often limited service. When possible, primary care providers (PCPs), including internists and family practitioners, are encouraged to make referrals as soon as they identify cognitive impairment in a patient. However, it is vital to strike a balance between early detection of and intervention for cognitive impairment and making the most efficient use of neuropsychology’s specialized skills and often limited personnel resources. Patients or family members might first notice changes from an individual’s baseline in cognitive, emotional, and/or social and interpersonal functioning. Some common markers of potential cognitive decline include short-term memory problems (e.g., repeating oneself in conversation, difficulty recalling recent events), executive dysfunction and confusion (e.g., difficulty with planning, organization, problem-solving; frequently misplacing items; trouble following directions), word-finding difficulties, navigational challenges (e.g., getting lost in familiar places), personality changes (e.g., increased irritability, disinhibition, or apathy), and decreased ability to carry out daily activities, such as driving, managing finances, organizing one’s medications and appointments, and self-care.
Currently, neuropsychology as a field is shifting toward a stepped model of care approach. Within this framework, PCPs and other providers can consult with a neuropsychologist as a Step 0. At this level, the provider is recommended to first administer a brief cognitive screener if any of the changes in cognition or daily functioning mentioned previously are noticed and then proceed to consult with a neuropsychologist if the results from the cognitive screen are concerning enough to warrant additional workup. In the United States, the Annual Medicare Wellness Guidelines suggests the use of cognitive screeners such as the Memory Impairment Screen (MIS), Mini-Cog, or the General Practitioner Assessment of Cognition (GPCog) to screen for cognitive concerns.
Other commonly used screeners include the Mini-Mental State Examination (MMSE); the Montreal Cognitive Assessment (MoCA), which is available in 36 languages; the Rapid Cognitive Screen; the Neurobehavioral Cognitive Status Examination; and CNS Vital Signs. These screeners are brief and do not provide the depth and breadth of information that are required to come to a diagnostic conclusion. However, tools such as the MoCA and MMSE can be used as a first step to identify cognitive impairment, assist in determining the need for further evaluation and testing, and support tracking of cognition over time. Both the MMSE and MoCA broadly assess the cognitive domains that are evaluated in a full neuropsychological evaluation, such as attention/orientation, memory, language, and aspects of visual-spatial ability. However, the MoCA is more sensitive for detection of executive dysfunction. A cutoff of 26 and 29 (out of 30) are commonly used to detect mild cognitive impairment (MCI) on the MoCA and MMSE, respectively. Furthermore, if the patient’s activities of daily living are affected along with a score of <24 on the MMSE or <26 on MoCA, a diagnosis of a dementia syndrome should be considered, regardless of the underlying cause and etiology. Notably, MoCA and MMSE can also be used by nonspecialist providers to characterize deficits at specific stages of memory function, such as encoding and storage, which is useful in starting to differentiate some common conditions. Both tests have a memory component in which a list of three to five words is presented orally and asked to be recalled several minutes later. Inability to recall these words immediately after they are presented may suggest difficulty with encoding, which often affects subsequent retrieval after a delay. Both encoding and retrieval are attentionally mediated memory processes, and deficits at these levels are not necessarily indicative of a “true” memory storage problem, as is often seen in Alzheimer disease, for example. To tease apart memory encoding/retrieval deficits from storage loss, it is helpful to provide cues for any words that the patient is unable to freely recall at the delay. The MoCA includes suggested cues for both category and multiple choice, while the MMSE does not, in which case the examiner may consider providing cues to help with qualitative interpretation of results, even though the score will not change. If the patient is unable to retrieve or recognize the words they encoded even after suggested cues, this might be more suggestive of a “true” deficit in memory retention or storage as often observed in Alzheimer disease.
If concerns arise about the possibility of cognitive impairment based on patient and/or family report, clinician concern, and/or abnormal score on a cognitive screener, the next level of care may include Step 1, which entails brief neuropsychological evaluation (60–90 minutes long) or Step 2, which is a comprehensive neuropsychological evaluation (typically 90–180+ minutes long) at the discretion of the neuropsychologist. During this step of the stepped care model, the neuropsychologist collects and reviews prior medical data, including the PCP’s cognitive screener scores and observations and the reason for referral, to build a tailored neuropsychological battery of tests to effectively characterize the patient’s current cognitive functioning. On the day of the evaluation, the neuropsychologist typically conducts an initial interview with the patient and family (~45–60 minutes) before proceeding with ~1–3+ hours of cognitive testing (Step 1 or Step 2). These components are often completed on the same day with breaks as needed, or they may be split across two sessions.
The most common referral questions for neuropsychologists include characterizing cognitive strengths and weaknesses, assisting with diagnostic clarification and treatment planning, establishing a baseline of cognitive function, and monitoring cognition over time. Specific patterns of strengths and weaknesses establish a kind of cognitive profile for a given patient, and stereotypical patterns and profiles can be associated with specific clinical syndromes and disorders. For this reason, it is crucial that the referring provider communicates the specific reason and circumstances for referral. A clear and specific reason for referral enhances the utility of neuropsychological evaluation, as the neuropsychologist is then able to provide the personalized and targeted recommendations that are most beneficial for the patient and the referring provider. Another important consideration is the patient’s level of impairment and ability to tolerate neuropsychological evaluation. For example, comprehensive neuropsychological evaluation may not be clinically indicated for patients with very low scores on cognitive screeners and evidence of severe, global impairment due to floor effects (i.e., lower limits on what deficits testing is reliable in identifying); such testing may be of limited diagnostic utility in this population. Rather, these patients may be best served by tracking cognition via regular screening in ongoing follow-up with their providers.
Factors Affecting Test Performance
At Step 0, when the cognitive screeners indicate a possibility of cognitive impairment, it is important for the provider to consider confounding and/or modifiable factors that might affect the patient’s test performance. If any of these factors seem likely to interfere significantly with the patient’s ability to participate in a neuropsychological evaluation, it is recommended that they be resolved prior to Step 1.
Sleep
There is strong evidence for an association between sleep and cognitive function in adults, with poor sleep causing functional difficulties, especially in older adults. Apart from the long-term effects of sleep on cognition, there are also short-term effects that might affect the patient’s performance on neuropsychological tests. Poor sleep quality and quantity in the prior day and week can have an adverse effect on cognitive functioning with a negative impact on attention, processing speed, and executive function. Sleep disorders such as untreated obstructive sleep apnea are also associated with cognitive impairment, primarily affecting attention, executive function, and aspects of memory, which may improve with regular treatment, including sustained compliance with CPAP over several months. Therefore, PCPs are recommended to address any significant sleep-related problems, such as marked insomnia or sleep apnea, prior to referring the patient for a neuropsychological evaluation whenever possible. In addition, addressing sleep problems might resolve or mitigate the patient’s cognitive complaints, minimizing the need for a neuropsychological evaluation.
Mood
Mood and anxiety disorders can negatively affect attention/executive function, memory encoding and retrieval, and processing speed. Furthermore, these conditions can have downstream effects on motivation to engage in testing, which would affect the neuropsychologist’s ability to characterize cognitive functioning accurately and comprehensively. Therefore, assessment of affective symptoms is regularly included as part of a neuropsychological evaluation via clinical interview and self-report questionnaires (e.g., the Beck Anxiety and Depression Inventories, PHQ-9, GAD-7). However, in situations in which the patient is experiencing severe depression, anxiety, or active psychosis, neuropsychological testing might not be advised until a decrease in symptom severity is noted. More immediate measures to target and stabilize affective symptoms would be recommended in such a situation.
Polypharmacy
Polypharmacy is common among medically complex patients and older adults, and the impact of polypharmacy on cognition can be significant, depending on the dosages and interactions between medications and comorbid conditions. Some known effects of polypharmacy on cognition include memory problems, attention difficulties, and slowed processing speed. Benzodiazepines and medications with high anticholinergic burden are known to have cognitive side effects, and a higher anticholinergic burden has been identified as a risk factor for MCI in older adults. If there is concern for cognitive impairment in a patient treated with these or other medications with cognitive side effects, it is recommended that the provider reevaluate and simplify the medication regimen if possible and observe for any resolution or reduction of cognitive complaints prior to referring for neuropsychological evaluation. As a practical consideration, most insurances carriers in the United States do not cover neuropsychological services when known medication side effects or other common abnormalities in laboratory testing can explain better than a brain disease what may be contributing to or causing the cognitive changes.
Current Substance Use
Neuropsychology plays an important role in characterizing cognitive symptoms that may occur in the context of substance use disorders. However, because of the impact of substances on cognition, it is recommended that these patients achieve at least 6 weeks of abstinence prior to undergoing neuropsychological evaluation. More generally, patients are encouraged to abstain from taking any cognition-altering substances for at least 2 days prior to the neuropsychological evaluation to allow for the most accurate results. If sudden abstinence might pose a threat to the patient’s overall health and functioning, providers may work with the patient to make sure abstinence can be safely achieved before proceeding with the evaluation.
Medical Necessity
In addition to insurance carriers in the United States not covering the cost of neuropsychological services when a patient has active psychosis, has specific lab abnormalities, or is taking medications that have clear cognitive side effects, neuropsychological evaluations must be determined to be medically necessary. Therefore referrals for academic performance-related testing and/or evaluation of certain neurodevelopmental disorders are often not covered unless there are medical comorbidities or atypical aspects of the condition that meet a standard of medical necessity. For example, it has been determined that neuropsychological evaluation is not required to diagnose autism spectrum disorder (ASD) or attention-deficit/hyperactivity disorder (ADHD) and therefore is deemed not medically necessary by insurance carriers. Of note, given the steady increase in the prevalence and/or increase in symptoms of these neurodevelopmental disorders in the past few years, during and following the COVID-19 pandemic, it is increasingly important that individuals with ASD and/or ADHD be diagnosed in a timely manner and supported with tailored interventions. To start the diagnostic process for these conditions, a detailed developmental history, including collateral information from family members or others where possible, and use of standardized questionnaires and observation tools may be conducted by a psychiatrist or psychologist. If diagnosis remains unclear after an initial psychiatric or psychological evaluation, particularly for patients with medical and psychiatric comorbidities or lack of response to treatment, neuropsychological evaluation can play an important role in clarifying differential diagnosis and informing treatment and support services for the individual and their families.
Performance Validity and Symptom Validity
Before interpreting the test results or sometimes before proceeding with a comprehensive neuropsychological evaluation, neuropsychologists must first determine the validity of the data that were collected through assessing patient effort and engagement via behavioral observations and objective measures of performance and symptom validity. As part of a standard neuropsychological evaluation, tests known as performance validity tests (PVTs) and symptom validity tests (SVTs) are included in the test battery. PVTs measure the validity of actual task performance; SVTs measure the accuracy of symptomatic complaints on self-report measures. There are stand-alone PVTs and SVTs that can be administered along with other tests in the neuropsychological battery as well as embedded measures of performance validity that are collected as part of tests measuring other cognitive processes such as memory and attention. If there is concern about variable or low engagement and effort during testing, neuropsychologists try to understand the reasons a person might not be performing at their optimal level and address these before proceeding to further testing or perhaps elect to defer evaluation to a later date. Additionally, there are situations in which a person may feign or malinger during testing for reasons that may be known or unknown to providers. In such cases, PVTs and SVTs are utilized to detect the likelihood of low effort, feigning, and/or malingering. These may be crucial when patients are seeking an evaluation for claims of disability due to cognitive impairment and/or for other forensic or legal reasons, given higher rates of malingering in these cases than in others.
Normative Data and Cultural/Linguistic Considerations
Normative data in neuropsychology refers to a collection of test scores from a representative sample that establishes a baseline distribution for performance on a measure. This data serve as reference points to compare a particular patient’s performance to that of a relevant comparison group. Normative data is the basis for objective measurement and enables an accurate comparison of any one patient’s cognitive functioning in reference to healthy controls or to patients with similar conditions. Normative data can be presented in various forms, such as percentile ranks, z-scores, T-scores, standard scores, or scaled scores ( Fig. 16.2 ).
Given the use of normative comparisons in neuropsychology, there are some limitations to the interpretation of test scores for certain groups of individuals. The majority of the commonly used neuropsychological tests in the United States were constructed and normed with monolingual, US-educated, English-speaking individuals, thereby limiting their reliability and validity for individuals with divergent backgrounds, given the wide range of cultural and linguistic factors that can affect test performance. These factors include an individual’s primary language, bilingualism or multilingualism, quality and level of education, level of acculturation, socioeconomic status, communication style, and familiarity with test materials. Due to the increasing sociocultural diversity within the United States and other parts of the world, a growing number of neuropsychologists specialize in working with populations characterized by specific factors that are not aligned with those for whom traditional, normative tests were constructed. There is a dire need for expansion of such neuropsychological expertise and services as well as more comprehensive training in cross-cultural neuropsychology for all clinicians. Ideally, patients will complete testing in their first or primary language, which may require the services of an interpreter. It is very helpful for providers who refer for neuropsychological evaluation to note the patient’s first or primary language in the referral to ensure that interpreter services, if available, can be requested in advance. When possible, neuropsychologists work closely with medical interpreters, even while cross-cultural assessment continues to develop within the field with a need for more collaborative and focused effort in this area. Given the importance of the language in which tests are administered, some standardized tests are now available in many languages that can often be tailored to a patient’s preferred language. Other test measures are thought to be more universal and less culturally biased toward one dominant culture, although there remains a critical need for further development of tests and normative data for use with diverse populations. Limitations in use of some normative data in working with socially, culturally, and linguistically diverse populations also highlight the value of baseline neuropsychological testing, especially when a patient is at high risk for a decline. Baseline testing allows for comparison of an individual’s performances over time, with the individual’s own data providing more reliable and valid reference points for evaluating for decline.
Neuropsychological Reports
Upon completion of a neuropsychological assessment, the neuropsychologist analyzes and evaluates the collected data. This includes scoring all the administered tests, comparing the patient’s scores to selected normative data, and then conceptualizing the overall cognitive profile in the context of the patient’s developmental, medical, and psychiatric history based on information gathered during the clinical interview and chart review. The neuropsychologist then writes a comprehensive report that takes into account all biopsychosocial factors and usually describes or summarizes test results, diagnostic impressions including discussion of potential etiologies and contributing factors, and often personalized recommendations for treatment and care for the patient and family.
Interpreting Scores and Report Summaries
In the test results and summary sections of the report, the neuropsychologist might add a table with test scores or briefly discuss the scores in a narrative format. The table typically includes raw scores as well as demographically adjusted normative scores and standardized descriptive labels such as “exceptionally high,” “above average,” and “below average.” These labels themselves do not indicate impairment, as the neuropsychologist interprets these results within the patient’s specific biopsychosocial context and estimated baseline abilities to characterize impairment. It is also important to note that while most test scores fall on a normal distribution curve, some tests, such as the commonly used Boston Naming Test, have a skewed distribution that cannot be interpreted on a normal curve. With these factors in mind, the summary and/or impressions section of the neuropsychological report should synthesize the overall interpretation of test results within the specific clinical context. The referring provider is encouraged to reach out to the neuropsychologist at any time to clarify or discuss any component of the evaluation or to follow up with regard to diagnosis and treatment planning. The last section of a neuropsychological report often contains tailored recommendations for the patient, family, and treatment team, including suggestions for any further workup or evaluation based on assessment findings, designed to optimize the patient’s daily cognition and functioning, as described in detail in the next section.
Neuropsychological Intervention
Feedback Sessions
Upon completion of the neuropsychological evaluation, the first step of intervention often consists of patient follow-up with the neuropsychologist to review test results and recommendations. These feedback sessions are typically conducted by the neuropsychologist in person or increasingly via telehealth with the patient as well as any family members or relevant care partners. In certain specialty clinics, such as a center dedicated to memory disorders or cognitive and behavioral neurology, the patient may elect to follow up directly with the referring neurologist to discuss neuropsychological test results and recommendations in the context of their ongoing clinical follow-up. If connection to such a clinic does not exist, it is the responsibility of the neuropsychologist to follow up with patients directly to discuss results and recommendations from the evaluation. There is also emerging evidence of the value of embedding neuropsychological services, including both assessment and intervention, into primary care and geriatric medicine clinics to optimize clinical care and access.
In addition to discussing diagnostic impressions, feedback sessions largely focus on providing support for the patient and family and reviewing personalized recommendations, which often include a combination of compensatory strategies to optimize daily cognition; psychoeducation, which may touch upon brain-behavior relationships; healthy lifestyle behaviors; and psychological treatment approaches (e.g., cognitive-behavioral and/or mindfulness strategies) as well as suggestions for other relevant workup or follow-up with other providers (e.g., sleep study, neurologic or psychiatric follow-up) and any suggested plan for repeat neuropsychological evaluation. Provision of written communication aids during feedback may support retention of information for patients and families. Moreover, emerging research suggests that neuropsychological feedback sessions are associated with enhanced patient satisfaction, understanding of one’s condition, and improved coping, self-efficacy, mood, and quality of life.
Neuropsychological Rehabilitation
Beyond postevaluation feedback sessions, neuropsychologists are well suited to offer rehabilitation for patients in both individual and group settings. These clinical services can support the teaching and development of cognitive, mindfulness-based, and lifestyle strategies and can enhance self-efficacy and emotional well-being. They are often combined with elements of cognitive-behavioral therapy in a holistic treatment approach to optimize daily cognition and functioning. Cognitive rehabilitation strategies are often categorized as restorative (designed to improve the cognitive ability itself) or compensatory (designed to optimize function by using workaround strategies), with newer treatments increasingly incorporating metacognitive strategies as well. Rehabilitation is often conducted by neuropsychologists, clinical psychologists, and/or speech/language pathologists where available. In the following sections, we will offer a broad overview of neuropsychological rehabilitation, with a focus on cognitive training and mindfulness approaches as well as general recommendations and evidence basis for multidomain and lifestyle interventions.
Cognitive Training
Healthy older adults
Among healthy older adults, multicomponent cognitive training interventions have generally been shown to improve targeted cognitive abilities (e.g., near transfer) to a greater extent than untrained abilities (e.g., far transfer). Although different from traditional cognitive training delivered via paper-and-pencil methods, computerized cognitive training among older adults may also provide benefits to aspects of cognition, including working memory, executive function, and processing speed. Regarding mechanisms, there is some evidence that cognitive training among older adults may enhance global and regional cerebral blood flow and connectivity within the default mode and central executive brain networks and increase functional connectivity between the hippocampi and frontal and temporal regions, promoting memory function.
Mild cognitive impairment
Among older adults with MCI, cognitive training interventions are feasible; have yielded small to moderate effects on global cognition, executive function, and memory; and may promote neuroplasticity. However, it is unclear whether these improvements transfer to cognition and functioning in daily life, are maintained at long-term follow-up, or alter the disease course in MCI. Also of note, while there is some evidence basis for facilitator-mediated cognitive training in the treatment of MCI, there is scientific consensus that there is currently insufficient evidence that commercially available online “brain-training” programs prevent the onset of cognitive impairment or slow decline in MCI. That said, the application of digital cognitive training programs is an area of increasing research and clinical interest, particularly since the expansion of telehealth services during the COVID-19 pandemic.
In looking at specific interventions in MCI, cognitive training approaches with focus on episodic memory strategies and mnemonic training as well as computerized memory–attention training, have shown promise in improving memory. In addition to memory training, speed-of-processing training may improve processing speed, attention, and working memory among older adults with amnestic MCI, which may support driving abilities and lower dementia risk. Relatedly, emerging research has suggested the potential of “gamified” cognitive training, which has improved episodic memory and motivation among adults with amnestic MCI. Moreover, multidomain and multicomponent cognitive training, including lifestyle changes, may yield modest cognitive benefits in MCI. Recent reviews have emphasized the need for studies with larger samples, adequate control groups, and long-term follow-up.
Beyond potential improvements in cognition, there is preliminary evidence that cognitive training may also improve depression, anxiety, and possibly quality of life among adults with MCI, though most studies have been small and otherwise limited with some mixed effects. One important limitation is the fact that many studies have included participants with minimal anxiety and depression at baseline. This remains an essential area for future research, particularly considering that potential improvements in mood following cognitive interventions could be conceptualized as evidence of far transfer if mood symptoms are not explicitly targeted as part of the training.
Other neurologic/neuropsychiatric conditions
In addition to MCI, cognitive training interventions have shown promise for a variety of neurologic and neuropsychiatric populations, including TBI, stroke, cancer, multiple sclerosis (MS), Parkinson’s disease, and substance use, among others. First, the Cognitive Rehabilitation Task Force (CRTF), a special interest group effort by the American Congress of Rehabilitation Medicine based in the United States, has highlighted emerging evidence for the clinical use of cognitive rehabilitation to target cognitive and socioemotional deficits after TBI or stroke, with a particular focus on comprehensive holistic rehabilitation. This treatment combines cognitive training with strategies to promote self-awareness and improve interpersonal and emotional functioning and is delivered individually and in group format. More specifically, among adults with history of TBI and stroke, the CRTF has recommended use of direct attention training as well as metacognitive training to target attention deficits and promote the transfer of skills to daily life, with an additional recommendation for use of clinician-directed, multimodal computerized training to improve attention, memory, and executive function. Indeed, cognitive rehabilitation may improve aspects of attention and subjective memory immediately posttreatment in stroke patients, for example, but there is a need for additional research to determine whether these benefits translate to daily life or persist over time.
Regarding other medical and neurologic populations, cognitive training has yielded benefits in verbal memory and processing speed among adults with cancer-related cognitive impairments. Likewise, cognitive rehabilitation may improve working memory, verbal memory, and executive function immediately after treatment, with smaller potential benefits in mood, among nondemented patients with Parkinson’s disease; additional studies are needed to determine the generalizability of these findings to daily life. In MS, strategy-oriented cognitive rehabilitation has not been shown to enhance objective cognitive measures but does seem to improve self-perceived cognition. In at least one study, this improvement persisted at a 9-month follow-up, highlighting the potential of cognitive rehabilitation to support self-efficacy. There is also preliminary evidence that memory rehabilitation strategies (e.g., associative verbal learning with supported elaborative processing, extra processing and retrieval time, explicit support to make associations) may benefit individuals with alcohol-related cognitive impairment, though more rigorous research is needed.
As one specific example of a cognitive rehabilitation program, Goal Management Training (GMT) is a standardized protocol that targets executive function and has yielded small to moderate benefits on various cognitive abilities, including executive function, working memory, long-term memory, daily functioning, and mental health. In studies of GMT, objective cognitive gains are largely maintained at follow-up, typically at least 6 months posttreatment, among a variety of neurologic populations, including individuals with acquired brain injury, as well as those with substance use disorders, MS, spina bifida, cerebrovascular disease, and ADHD and healthy, cognitively normal older adults.
In summary, cognitive rehabilitation, delivered individually or in group format, has the potential to benefit for individuals with cognitive symptoms in aspects of cognition, mood, and quality of life, including healthy older adults, adults with MCI, and various neurologic and neuropsychiatric populations, including those with history of TBI, stroke, MS, Parkinson’s disease, substance use disorders, and cancer-related cognitive impairment, though there is a need for further research to elucidate generalizability and longevity of effects. Even so, cognitive rehabilitation warrants consideration as part of tailored treatment planning for adults with cognitive concerns and may be offered by speech/language pathologists and/or clinical neuropsychologists in hospital-based settings or private practice.
Mindfulness-Based Interventions
Mindfulness is broadly defined as present-focused, nonjudgmental awareness, which may cultivate emotion regulation and enhance psychological health via improved attentional awareness and control, reduced rumination, and increased tolerance of affective distress. Mindfulness-based practices may also build cognitive reserve, which is the developed abilities of the brain, acquired through such activities as education and occupation, lifelong learning, and engagement in leisure activities, that allow individuals to better cope with cumulating brain pathology and optimize daily functioning. Studies also suggest that mindfulness can promote structural and functional changes in brain regions that are implicated in attentional and emotional regulation, though additional research is needed.
Mindfulness interventions have yielded positive effects on mood, quality of life, and cognition among adults, with mixed preliminary findings among older adults. Moreover, mindfulness-based interventions have been shown to be feasible and acceptable to middle-aged and older adults (~ages 45–85 years) with subjective cognitive decline and MCI, with mixed effects on global cognition in MCI in exploratory studies. Mindfulness-based interventions have also shown potential benefits for specific cognitive abilities in MCI, including improved reaction time, attentional control, and verbal memory, though with some variability across studies.
Mindfulness-based interventions may positively affect the disease course in MCI through various direct and indirect mechanisms, including potential direct impacts on brain structure and function, inflammatory processes, and gene expression, and indirectly through effects on stress and mood. The potential impact of mindfulness on improving the connectivity between brain regions in defined networks is of particular interest, given evidence that reduced activity in some networks, namely, in the default mode network in MCI and early Alzheimer disease, has been linked to disease progression. Among adults with MCI, emerging research suggests that mindfulness-based interventions may enhance functional connectivity within default mode network regions (posterior cingulate cortex, bilateral medial prefrontal cortex, left hippocampus), improve brain network efficiency (in the insula, right cingulate gyrus, and left superior temporal gyrus), and potentially reduce hippocampal atrophy, which is a commonly used marker of disease progression in Alzheimer disease.
Beyond potential cognitive benefits, there is preliminary evidence that mindfulness-based interventions may also improve mood, coping skills, and quality of life in MCI, perhaps by promoting acceptance of aging and cognitive changes and cultivating a stance of nonjudgment and curious observation of present experiences and thoughts. That said, more research is needed to better understand mechanisms of change and to clarify whether observed effects are specific to mindfulness rather than to psychoeducation, for example, which is an often-used control group.
In addition to MCI, mindfulness-based interventions have shown promise in improving aspects of cognition, mood/anxiety, and quality of life in several neurologic and psychiatric populations, including individuals with Parkinson’s disease, MS, depression, anxiety, and cancer-related cognitive impairment. From a cognition standpoint, mindfulness- and acceptance-based interventions have yielded moderate to large effects on attention and memory at immediate posttreatment in MS, though more rigorous studies are needed to replicate findings and determine the longevity of effects. Preliminary studies have shown similar findings for individuals with Parkinson’s disease, with the potential of mindfulness to improve aspects of attention and executive function, particularly among those with higher compliance to prescribed home practice. Likewise, mindfulness-based strategies and psychoeducation have been found to improve attention and executive function, respectively, among adults with cancer-related cognitive impairments. Mindfulness-based interventions may also enhance aspects of executive function, namely, cognitive flexibility, among individuals with generalized anxiety disorder and depression.
In sum, preliminary research suggests that mindfulness-based interventions over weeks to months may improve specific cognitive abilities, including aspects of attention, executive function, and memory, and enhance emotional functioning and quality of life for adults, older adults, and adults with various neurologic and psychiatric conditions. Additional studies with larger samples, adequate control groups, and long-term follow-up are needed. From a neuropsychological perspective, mindfulness-based strategies offer a low-risk intervention strategy with the potential to enhance emotional and cognitive well-being as individuals learn skills to manage stress and hone attentional abilities, with implications for improving daily cognition and quality of life and enhancing enjoyment of daily activities. Practically, mindfulness-based strategies may be incorporated as part of individual psychotherapy, be delivered via group therapy, and/or be self-paced through a variety of available books and online materials, the latter approach likely being best suited to motivated and higher functioning individuals and/or those with a supportive care partner or team at home.
Multidomain and Lifestyle Interventions
In addition to suggestions for cognitive training and/or mindfulness interventions, neuropsychological recommendations frequently highlight the importance of healthy lifestyle behaviors for adults of all ages, particularly for those with history of vascular risk factors and/or who are otherwise at risk for dementia. During feedback sessions, neuropsychologists often provide psychoeducation about the importance of healthy lifestyle behaviors to optimize cognition and brain health and may incorporate motivational interviewing strategies to enhance the adoption and maintenance of these behaviors within the context of brain health.
The importance of engaging in healthy lifestyle behaviors and managing vascular risk factors is most often discussed in the context of dementia prevention. A recent study reported that approximately 40% of dementia cases in the United States were associated with 12 modifiable risk factors, particularly among Black and Hispanic individuals (low education, hearing loss, TBI, excessive alcohol use, smoking, depression, social isolation, diabetes, air pollution, hypertension, obesity, and physical inactivity, with the strongest impact from the latter three). Considering this and the lack of strong evidence to date that pharmacological therapies for MCI are significantly effective or will alone be sufficient for care, there is increasing interest in preventive, nonpharmacologic interventions. These include lifestyle modifications, such as exercise, diet, cognitive and social engagement, and aggressive and early control of cardiovascular risk factors such as hypertension. For example, a large population-based case-control study found that moderate exercise in midlife or late life was associated with a reduced risk of MCI. Moreover, physical exercise has yielded positive effects on cognition among individuals with MCI, though there is a need for additional large, well-controlled trials to determine the specific qualities of effective exercise, including type, dose, and intensity.
Besides exercise, there is emerging interest in the impact of diet on cognition, with preliminary evidence showing that the MIND diet, which focuses on intake of green leafy (and other) vegetables, berries, whole grains, olive oil, nuts, beans, poultry, and fish, may enhance cognition and reduce the risk of cognitive decline and dementia in older adults, possibly by decreasing oxidative stress and inflammation. Notably, results of studies implementing the MIND diet for prevention of cognitive decline in older adults have been mixed, and more research is warranted. Additionally, recommendations to increase social, cognitive, and community and cultural engagement are relevant, as these factors may also reduce dementia risk.
To date, there have been a few randomized controlled trials that have employed multiple “brain-healthy” behaviors in cognitively normal older adults and/or those who are at risk for dementia, with varying success. In one large study, a 2-year multidomain intervention (prescribed diet, exercise regimen, cognitive training, and vascular risk monitoring) improved or maintained cognition among older adults who were at risk for dementia (ages 60–77 years) relative to a control group who received general health advice. In that study, the FINGER study, treatment effects were also observed in BMI, diet, and physical activity. That said, in a different 3-year trial of older adults, a multidomain intervention (physical activity, cognitive training, nutritional advice) or omega-3 supplementation, either alone or in combination, had no effects on cognition relative to placebo, highlighting the importance of continued research in this area.
Summary and Future Directions
Neuropsychology as a field has evolved to encompass a wide range of assessment and intervention approaches to support patients and families in optimizing cognitive and emotional health while continuing to assist in differential diagnosis, treatment planning, and close tracking of cognition over time. Moving forward, there is a need to expand available normative data to support increasingly diverse patient populations and a need to continue to update assessment tools for measuring cognition. The COVID-19 pandemic highlighted the value and feasibility of tele-neuropsychology, which will likely continue to be a valuable option for some patients and allows for flexible, hybrid approaches to evaluation (e.g., completion of initial interview and some testing virtually with completion of additional in-office testing on a separate day if clinically indicated). Unfortunately, availability of neuropsychological services is often limited and therefore involves long wait times. This has highlighted the need for a stepped model of care to triage the patients who will most benefit from neuropsychological assessment. Monitoring of cognition can start in the PCP or nonspecialist office with regular questioning of patients and care partners on any observed changes in daily cognitive or behavioral functioning. Whenever possible, nonspecialist providers can also incorporate cognitive screeners as a valuable first step when there is concern about possible cognitive decline, either reported by the patient or family or observed by the physician. Any available datapoints from cognitive screeners allow for broad tracking of cognition over time while also helping to inform the neuropsychological battery for patients who are referred for more comprehensive evaluation. Relatedly, many clinics are incorporating integrated clinic models, with close collaboration and consultation between neuropsychologists and other treatment providers to streamline the initial diagnostic workup and optimize patient care. As part of a clinical workup, neuropsychological evaluation can assist with differential diagnosis and facilitate early detection of neurologic and neuropsychiatric diseases, which is of critical importance to allow for preventive treatment approaches and connection to supportive resources. This is becoming increasingly important with the advent of potential disease-modifying treatments for early Alzheimer disease, for example.
Regarding neuropsychological interventions, cognitive training and mindfulness-based interventions warrant inclusion as treatment approaches for adults, older adults, and adults with various neurologic and neuropsychiatric conditions with the potential to benefit aspects of cognition, mood, and quality of life. Emerging research in MCI suggests that cognitive training may benefit global cognition, memory, working memory, and executive function, while mindfulness may enhance aspects of attention, psychomotor function, and possibly memory. Similarly, cognitive training and mindfulness interventions have shown preliminary promise in enhancing cognition (i.e., aspects of attention, memory, and executive function) and mood among individuals with history of TBI, stroke, Parkinson’s disease, MS, depression, or anxiety and those with cancer-related cognitive impairment, among others. These treatments are generally considered feasible and low-risk; however, there remains a need to clarify whether the improvements transfer to daily life, are maintained over time, or significantly affect the disease course. Both mindfulness and cognitive training interventions may reduce stress and promote structural and functional changes in brain regions associated with cognitive control, attention and emotional regulation, and memory, though the underlying mechanisms are not yet well understood. Beyond cognitive training and mindfulness, multidomain lifestyle interventions have shown preliminary promise in reducing cognitive decline among older adults who are at risk for dementia.
Looking ahead, there remains a need for high-quality research to elucidate the effects of cognitive training, mindfulness, and lifestyle interventions on cognition and mood in healthy, neurologic, and psychiatric populations. Questions remain regarding optimal treatment duration and frequency, longevity of effects, impact on disease trajectory, and underlying mechanisms. It will also be important to determine whether current outcome measures best capture the impact of these interventions or need to be expanded. Clinically, patients with subjective or mild cognitive symptoms (due to various etiologies) may be especially well suited to engage in mindfulness or cognitive interventions, perhaps in addition to lifestyle modifications and/or pharmacologic strategies. Indeed, emerging research has highlighted the value of multidomain interventions (e.g., combinations of cognitive stimulation/training and mindfulness, neurofeedback, exercise and diet modifications, music therapy), which may improve cognition and increase gray matter volume and cerebral blood flow in adults with MCI, for example.
It has also been suggested that future research consider modifications of conventional mindfulness-based approaches to tailor treatment for older adults and neurologic populations, such as conducting mindfulness-based interventions with patients and supportive partners and/or combining elements of mindfulness with aging-related education. In addition, other mind-body interventions, such as yoga, tai chi, qigong, biofeedback, meditation, music-guided imagery, and dance, are feasible in adults with cognitive complaints, having the potential to benefit aspects of cognition (e.g., attention, executive function, verbal memory), mood, and possibly underlying physiology (e.g., levels of insulin-like growth factor–1).
Moving forward, there will likely be continued emphasis on holistic neuropsychological rehabilitation, including incorporation of emotion regulation strategies and cognitive-behavioral therapy into cognitive rehabilitation programs. Already, there is evidence that combined approaches may yield benefits on mood and quality of life among individuals with acquired brain injury, while CBT as well as cognitive rehabilitation and training may improve subjective cognition among adults with cancer-related cognitive symptoms. Another emerging area of work is the potential of virtual reality rehabilitation programs, which have shown some initial benefit on cognition among adults with TBI as well as MCI.
There remain important challenges of (1) how to translate and scale research findings into optimal treatment delivery systems in clinic- and community-based settings and (2) how to foster motivation for adoption and maintenance of cognitive rehabilitation strategies, mindfulness practices, and healthy lifestyle behaviors in daily life among individuals who are not involved in research. One such approach may be to frame these interventions in the context of brain health and cognitive and emotional well-being and draw on principles from motivational interviewing to support person-centered, values-based change, ideally with the support of a clinical psychologist or neuropsychologist, at least initially, to foster goal setting and treatment engagement.
Taken together, neuropsychological interventions, including cognitive training, mindfulness-based approaches, and lifestyle and combined or multidomain interventions, represent promising, low-risk treatment strategies that have the potential to improve cognition and mood, reduce stress, and enhance brain structure and function for a variety of healthy, at-risk, neurologic, and psychiatric populations. Future research, including the study of combined treatment approaches and the use of longitudinal designs, may clarify effects and underlying mechanisms, including the potential impact of these treatments on disease trajectories, to further inform and tailor clinical recommendations for neuropsychological intervention.
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