Closing the Gap in Neuropsychological Testing

Neuropsychological testing is an in-depth assessment of brain function conducted when there are concerns about a patient’s cognition. A neuropsychological assessment will often be conducted after a patient fails a cognitive screener. However, there's a significant gap in terms of accuracy and comprehensiveness when comparing a screener, which can take minutes, to a neuropsychological evaluation that takes several hours. 

But if neuropsychological tests are accurate and comprehensive, what's the problem? 

The issue stems from the limitations surrounding in-depth testing—because while primary care providers (PCPs) and neurologists can administer common cognitive screeners, neuropsychological testing requires a referral to a neuropsychologist. This may lead to months-long referral wait times, disrupted continuity of care, and barriers to accessibility. 

Despite these roadblocks, neurologists indicate that their patients don't have many other options—neuropsychological testing is the most commonly available investigation for patients with mild cognitive impairment (MCI). In one survey, about 73% of neurologists stated that neuropsychological testing is available as a next step in response to concerns about cognitive impairment (Ganesh et al., 2020).

In order to improve MCI patient outcomes and deliver effective treatments and care more efficiently, there's a need for cognitive testing within the gap between screeners like the MoCA—that aren't sensitive enough to detect subtle signs of decline—and neuropsychological testing, which is in-depth but can take much valuable time. 

In this article, we cover the strengths and limitations of traditional neuropsychological testing and how it compares to newer computerized tests.

Use Cases for Conducting Neuropsychological Assessments

Goals of a neuropsychological evaluation can include pinpointing the cause of a patient's cognitive impairment and measuring the severity of a known condition. Once the results are interpreted, the data can be used to support the diagnosis, treatment, and researching of neuropsychiatric conditions like:

• MCI and dementia: Testing can assess cognitive functions like memory, attention, language, and executive function to diagnose and monitor the progression of a patient's cognitive decline.
• Traumatic brain injury: A neuropsychological test can measure the degree of cognitive impairment caused by brain damage, and the results can be used to assist in the patient's rehabilitation planning.
• Stroke: An assessment can determine a stroke's impact on cognitive performance, particularly in the areas of attention, memory, language, and visuospatial abilities.
• Parkinson's disease (PD): Neuropsychological batteries can be used to evaluate a patient's cognitive function, which is impaired in many cases of PD, with tests that check for auditory processing, working memory, and overall processing speed. 
• Multiple sclerosis (MS): Assessments help a neurologist identify the cognitive impairments caused by MS, focusing on measuring verbal and nonverbal skills, motor skills, concentration, memory, and problem solving.
• Epilepsy: Neuropsychological evaluations can assess cognitive functions to optimize seizure management and patient quality of life.
• Attention deficit hyperactivity disorder (ADHD): Testing evaluates a patient's attention, impulse control, and executive functions, aiding in diagnosis and treatment planning.

What Is an Example of a Neuropsychological Test?

A comprehensive neuropsychological assessment typically involves workflows that include a medical record review and clinical interview, followed by a series of cognitive tests.

• Medical record review: A detailed review where the neurologist goes over the patient's medical and psychiatric history, any medications they are taking, and sometimes laboratory and neuroimaging results.
• Clinical interview: The neurologist interviews the patient and/or other people close with the patient with a focus on outlining concerns, their impact on daily life, potential causes, and observing behavioral patterns. 
• Cognitive assessment: The patient is given a variety of cognitive tests to perform. These typically pen-and-paper forms or physical objects, and focus on areas like attention, problem solving, memory, language, visuospatial abilities, and executive functions. The tests may also evaluate mood and behavior, as depression and anxiety are often comorbid with other conditions that can cause cognitive impairments.

How Reliable and Accurate is a Neuropsychological Evaluation for Dementia Detection?

Compared to other kinds of cognitive tests for dementia, a neuropsychological evaluation often delivers results with a high degree of accuracy. For example, one meta-analysis found that memory-focused neuropsychological evaluations accurately distinguish people with Alzheimer’s disease from healthy controls over 80% of the time (Weissberger et al., 2017). 

A neuropsychological test is a powerful tool for dementia detection, and when performed at the right time it can be vital to supporting a diagnosis. However, limitations such as lengthy referral wait times and the time required to conduct the tests themselves can potentially delay diagnosis—leaving a chronically ill patient without clear answers for months or even years.

Limitations of Neuropsychological Assessments

While a neuropsychological test is a reliable tool on paper, it's the real-world context surrounding the test that limits its effectiveness.

Gaps in Screening

Patients are often referred for a neuropsychological evaluation after failing a cognitive screening test performed by a PCP or neurologist. The problem is that many traditional cognitive screeners like the MMSE, MoCA, and SLUMS tend to detect visible signs of cognitive decline rather than subtle deficits, especially in educated patients. Highly educated patients can identify a lion or draw a clock, even if cognitive issues are starting to affect their everyday lives or herald further decline. 

While the MoCA aims to make up for this limitation with a standard cutoff of 26—this nearly perfect score is required to pass, in order to detect subtler decline. But the cutoff has been debated because it can lead to inflated false positives in certain age ranges, education levels, and racial groups (Carson et al., 2017; Ratcliffe et al., 2022).

Therefore, patients who fail initial screeners may get limited value out of a neuropsychological examination, because failure indicates they may already be in a later stage of cognitive decline. 

Confirmation of decline can grant them access to resources to seek out treatments, social services, support workers, clinical trials, care homes, or caregiver support, yet these too require time to arrange, so identifying needs earlier is key to patient quality of life. It's clear that a faster, more accessible solution is needed to fill the gap and identify even subtle decline as soon as possible.

Long Referral Wait-Times

The average referral time for a neuropsychological test in the US can be 5 to 10 months for adults (Han et al. 2014) and 12 months or longer for children (Cass et al. 2020), leading to underutilization of cognitive testing and poor patient outcomes. 

By that time, a case of MCI may advance to later stages. Additionally, if their neuropsychological test is inconclusive, the patient may have to wait another 12 months for a follow-up to determine whether their cognitive decline is consistent with a suspected etiology, leading to more wasted time as their condition deteriorates.

Length of Testing

A complete neuropsychological evaluation can take between 6 to 8 hours over one or more sessions. Many patients who are referred for MCI testing are older adults, who tend to have other health concerns, limited ability to travel, and a preference for being given choices about how and where they are tested (Wong et al., 2019). Putting them through an 8 hour test has a high chance of affecting their stress levels and their mood, potentially skewing the results of the test and leading to inaccurate results (Dorenkamp et al., 2018).

Disrupted Continuity of Care

There's a chance that a patient's continuity of care may be disrupted because of a lack of support between appointments (CMPA). Ideally, a patient who has cognitive concerns can complete cognitive testing and receive the diagnosis and treatment for their condition within the same clinic. But most clinics aren't equipped to perform interviews, screening, testing, and results interpretation. 

Instead, the results are sent between multiple PCPs and specialists. For example, the patient may have to make another appointment with their PCP after testing with a neuropsychologist, leading to more wait times. There's also a chance that a PCP may be unfamiliar with the details of neuropsychological tasks, requiring careful communication between providers for proper interpretation (Mercury et al., 2007). 

These disruptions can contribute to misdiagnoses, delayed or ineffective treatment, and poorer quality of life for the patient.

Dr. Williams at the Kerlan-Jobe Centre for Sports Neurology was able to improve continuity of care, deliver same-day cognitive results, and reduce referrals by 10%. Learn more by reading his case study.

Lower Patient Completion Rates

The wait time and duration of a neuropsychological test can lead to lower patient completion rates resulting in ineffective diagnosis and treatments. Because of the various barriers surrounding neuropsychological testing and the stigma of cognitive health care concerns, patients may be more resistant to follow through on neuropsychological appointments. 

Dr. McCoy at Yukon Neurology was able to reduce administration time for robust neuropsychological testing from 6 hours down to 2 hours. Learn more in this case study.

Reduced Accessibility

Many neuropsychological tests have been developed and validated primarily in Western cultures. This limits the accessibility of neuropsychological tests, as the evaluations may not be equally applicable to patients from minority groups or those with different educational backgrounds. 

Neuropsychologists consider these variables when interpreting results, but the effects of cultural factors are often underestimated, and fully eliminating bias requires advances in the tests themselves (Fernández et al., 2017). Whether or not cognitive tests are offered in multiple languages, at accessible reading levels, and with auditory and visual instructions, can all affect a patient’s ability to complete a cognitive assessment. 

These factors, especially when compounded, can create stress for the patients and lead to inaccurate results. Implementing tools that take steps towards a more patient-centered care approach can help reduce these barriers.

Comparing Creyos and Neuropsychological Testing

Neuropsychological testing is a useful tool for the accurate diagnosis and treatment of MCI, dementia, and various other neurological conditions, but it comes with a set of limitations. These limitations are largely due to the gap in time between a patient expressing cognitive concerns and the months-long wait for a neuropsychological testing appointment—which usually takes hours to complete.

To close the gap in neuropsychological testing, providers working with patients who have cognitive concerns may want to consider additional solutions, like the Creyos cognitive assessments. These computerized assessments provide more detailed information than screeners, while also being much quicker to administer than neuropsychological tests. 

The Creyos assessments bridge the gap between initial screening tests and neuropsychological evaluations, allowing providers to easily incorporate them into a more thorough testing process. Additionally, the results are easy to interpret, don't require special training, and are instantly tabulated and compared to an 85,000 person normative database for age-specific results and pinpoint precision. 

Creyos cognitive task results provide domain-level information comparable to a full neuropsychological exam.

• One study found that a 30-minute computerized assessment that included Creyos tasks was comparable to a 2-3 battery consisting of tasks common in neuropsychological testing, such as Weschler scales, the Wisconsin Card Sorting Task, and the Trail Making Test. 
• Another study demonstrated additional concurrent validity between automated Creyos testing and “gold standard” in-person neuropsychological assessments. 

Creyos testing can be performed directly within a PCP, neurology, or neuropsychology clinic, providing detailed information to help decide which patients truly require a longer neuropsychological examination.

Introducing Creyos: Dementia Screen, Test, and Care Plan

Creyos has a variety of cognitive solutions available to expedite the screening and diagnostic process, deliver accurate results, and support patient care and quality of life. Each tool is scientifically backed and evidence-based, offers easy-to-interpret data, is fast to implement, and is conveniently accessible to patients and PCPs anywhere via an online platform.

Screen

An accurate two-task cognitive screener that's more convenient than the MoCA or MMSE, taking less than three minutes to complete. The Creyos Health dementia screener is capable of detecting subtle signs of MCI and dementia, and doesn't require training to interpret. The screening results will indicate whether further assessment is recommended to aid in the potential diagnosis of dementia. 

Test

If further assessment is required, Creyos offers a 20 minute assessment that provides detailed information about the presence of MCI and dementia—effectively filling the gap between a quick cognitive screener and a complete neuropsychological test. 

The assessment is a detailed and scientifically validated six-task cognitive testing protocol, combined with questionnaires to measure activities of daily living, subjective cognitive concerns, and mental health symptoms. Once complete, it generates an easy-to-interpret report based on DSM-5 criteria for neurocognitive disorders, allowing healthcare providers to gather and decipher patient data much faster than a multi-hour neuropsychological evaluation. 

The test also includes instruments to identify mental health comorbidities, allowing providers to gather more comprehensive data about the patient and inform their decision on whether the patient needs additional neuropsychological evaluation.

Care Plan

For patients who need care planning, Creyos Health comes with a built-in cognitive care plan. The care plan is based on guidelines by the Alzheimer's Association, and allows PCPs to provide support for caregivers and enhance patient quality of life from the comfort of their own home. It can also be used to track treatment effectiveness and monitor patient symptoms over time, so PCPs can collect longitudinal data and make objective clinical decisions.

When to Use Creyos

There are many ways to use the Creyos Health platform to improve screening and close the gap between screening and neuropsychological testing. For example, the 20-minute Creyos dementia assessment can be used to identify mental health comorbidities, allowing PCPs to check the relationship between a patient’s cognition and mental health results prior to a full neuropsychological evaluation. 

Neurology clinics and neuropsychologists can leverage the speed of the Creyos assessment to bring more cognitive testing in-house, minimize unnecessary referrals, and reduce the overall time of cognitive testing to less than an hour. 

Compared to traditional neuropsychological testing, the computerized cognitive testing at Creyos is able to provide healthcare professionals with a fast and easy-to-interpret method of gathering objective data on a patient's cognition, while also supporting continuity of care by storing vital information on a single accessible healthcare platform.

Advantages of Creyos Health

• Scientifically robust tests with objective results
• Shorter than traditional neuropsychological testing
• Can be administered at home or at the clinic
• No certification required to administer the test
• Gamified, accessible, and approachable user experience for patients and clinicians
• Non-memorizable and ideal for retesting
• Reports that are easy to interpret
• Electronic medical record (EMR) integrations

Final Thoughts: Delivering Robust Cognitive Care, Efficiently

A neuropsychological exam can aid in determining the causes and consequences of dementia or MCI in a patient, but its limitations mean it is not appropriate for every patient expressing concerns about cognition. Long referral wait times may leave older patients with chronic illnesses untreated for over half a year, and the added stress of an 8-hour test may end up affecting the results anyway—leading to more wait times for follow-up tests. 

Instead of relying solely on neuropsychological testing to gather results, PCPs and neurologists can now overcome some of the limitations in neuropsychological testing with highly sensitive computerized assessments. With digital testing, PCPs can gather accurate, objective data on a patient, and use that information to determine whether further neuropsychological testing is necessary. By closing the gap, PCPs stand to save their patients time and deliver vital treatment and planning before dementia progresses into its later stages.