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Case study

In February 2015, we saw a 60-year-old woman with a family history of Alzheimer's disease. She had been experiencing memory problems and was concerned about her prognosis. After a complete evaluation, we determined her cognitive abilities were fine. Her concentration and memory problems were actually caused by significant depression, which she had been unable to describe to her primary care physician. We were able to reassure her that her condition was quite treatable with medication or therapy and send her back to her primary care provider for a referral.

Neuropsychology evaluation aids diagnosis, assessment and treatment design

By Eric Ecklund-Johnson, PhD, Caleb Pearson, PsyD, Carrie Spresser, PhD, neuropsychologists

Assessing the brain/behavior connection can lead to more informed diagnoses, better-designed accommodations and more targeted treatment for people who have memory disorders or other cognitive deficits.

Neuropsychology is a specialized field that works closely with neurologists to evaluate and provide information about the diagnosis of brain disorders, assessment of cognitive and behavioral functioning and effective treatment options. Our program focuses on evaluating patients with memory disorders, traumatic brain injuries and other changes in personality and behavior, as well as those who may be candidates for brain surgery, especially for epilepsy.

Differential diagnosis for memory disorder

We most commonly see patients with memory disorders when the patient, provider or family is looking for information about the cause, extent or specific nature of cognitive deficits. Often, neuropsychological assessment can identify retained abilities and help determine ways to provide the patient as much quality of life as possible as long as possible.

For example, we often see people with amnestic cognitive impairment – a deficit in memory that is well below where it should be based on age and education. But we may find that other abilities are preserved. Although we can be fairly confident they will develop dementia in a few years, we can help them understand now which activities they need to have supervised and which they can do independently.

Research and experience show that people with relatively preserved executive functioning – planning, reasoning and problem solving – can remain independent longer, even with significant memory impairment. We also can help scientifically analyze spatial skills to assist with decisions about when a patient should no longer be driving a car.

On the other hand, we see a fair number of cases in which we can rule out a neurological problem by determining that a mood disorder or other issue is causing a memory deficit.

Testing determines traumatic brain injury effects

Patients facing long-term effects of traumatic brain injury can benefit from neuropsychological evaluation, as well. For example, we sometimes see patients who have had a relatively mild head injury but are experiencing slow or incomplete recovery. We determine the level of neuro-behavioral deficit and whether it's due to the brain injury or other potential causes. Recent attention to the dangers of repeated concussions and chronic traumatic encephalopathy has placed neuropsychological testing in the limelight.

We saw a man who had experienced two or three concussions over his lifetime and was concerned about the long-term effects. We were able to confirm that he had no deficits in the abilities normally associated with such injuries. In fact, most of the research suggests one or two mild TBIs are not likely to cause severe, lasting deficits.

Evaluation assists with surgical planning

A carefully administered battery of tests can also assist in predicting the effects of surgery for patients with epilepsy, brain tumors and other neurological issues. We conduct a range of computerized and oral testing, including memorization, problem solving, language speed, naming and visual-spatial skills. Assessing the patient's current capabilities in these areas can help us understand the potential for increased deficits with surgery and advise the surgeon accordingly.

One of the most exciting developments in this area is the addition of neuroimaging using functional MRI and diffusion tensor imaging and tractography. The equipment is in place and we're beginning to develop a program to use it for epilepsy cases this year. Later, we expect to expand it for those with brain tumors, aneurysms and other neurological problems. Only a few centers in the United States are doing this specific type of workup.

Specialists assess validity of cognitive test results

Neuropsychological evaluation often is involved in disability determinations and other legal situations. In certain contexts, it's important to assess the validity of cognitive test results. Unlike other clinical diagnostics, the results of cognitive screening and function tests depend on the person putting forth a reasonable effort. The scoring mechanism assumes patients try their best, but the patient may be deliberately trying to affect the results. In other cases, the cognitive assessment may not be consistent with the patient's history or other clinical diagnostics. We can often help sort out the causes for dissonant results and indications.

NFL, Kansas City Chiefs connection

Our neuropsychology program is working with the NFL and the Kansas City Chiefs to identify concussion injuries and help determine when players should return to play. We look at memory, speed of thinking, ability to multitask and other factors to find sometimes subtle problems and make recommendations for safe return to play. There is a lot we don't know about the long-term effects of concussions, and we are making every effort to create a safe environment.

 

Dr. Ecklund-Johnson is senior clinical neuropsychologist and the program manager of neuropsychology for The University of Kansas Health System. He also serves as clinical assistant professor of neurology and psychiatry at the University of Kansas Medical Center.  ecklund-johnson-eric-BWP0000X 
Dr. Pearson is a clinical neuropsychologist at The University of Kansas Health System and assistant professor of neurology and psychiatry at the University of Kansas Medical Center. pearson-caleb-BWP000JK 
Dr. Spresser is a clinical neuropsychologist at The University of Kansas Health System and clinical assistant professor of neurology and psychiatry at the University of Kansas Medical Center. spresser-carrie-BWP000T7 

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