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what is neuropsychology? a short description NEUROPSYCHOLOGY By Anthony H. Risser, Ph.D. Published in slightly different form in "Hospital News of Central New York" (February 1991). CONGRESS and then-President Bush designated the 1990s as "The Decade of the Brain. " This pronouncement, made in 1990, reflected significant gains made in the diagnosis and treatment of neurological disease, but was also designed to draw attention and resources to the significant work ahead in advancing neuroscientific knowledge and bettering patient care. WHAT? Clinical neuropsychology at its core involves pursuing the diagnosis of changes in cognition and behavior after known or suspected brain damage. It is one of the clinical specialties in the neurosciences. Identifying the nature of brain-behavior abnormalities, understanding the consequences of these changes in the daily life of the individual, and contributing to effective and cost-efficient clinical management of affected patients are basic goals of neuropsychological consultation. The components that provide for quality-assured neuropsychological service cannot be presented in a short article, but some general features follow. WHO? A neuropsychologist is a specialist with formally trained expertise in the differential diagnosis of disorders of higher cerebral functioning. These disorders include dementia, amnestic syndrome, aphasia, and specific disorders of attention. Neuropsychologists have established neuropsychology units, clinics, and departments in a variety of acute-care, neurological, and rehabilitative medical settings with ever increasing frequency since the middle of the 20th century. Neuropsychology consultation is one modality in the diagnostic workup of patients with any of a wide variety of complaints and clinical presentations. WHY? Referrals from general practitioners, medical specialists (especially neurologists), and other psychologists commonly include the child with a suspected learning disability, the young adult recovering from a traumatic brain injury, or the elderly patient suspected of having a neurodegenerative disease (e.g., Alzheimer's disease). Other referrals may be made to: determine the presence of any cognitive deficits of a patient hospitalized after a stroke, evaluate a neurosurgical patient before and after surgery, aid in developing an intervention program for a patient with documented cognitive deficits, examine whether the memory complaints of a patient are of a nature and severity to suggest an organic etiology. "Interpretation of the findings from this in-depth evaluation allows for a differential diagnosis of neurobehavioral functioning. It permits a clearer and more reliable manner of distinguishing, for example, those cognitive losses associated with dementia from the experience of memory problems often seen in a significant depression in an elderly patient." Neuropsychological findings are examined in the context of available historical, neurological, radiological, psychiatric, and other data, depending upon the needs of patient care. My own experiences of providing neuropsychological services suggest that physicians, nurses, and therapists will make frequent use of results from neuropsychology consultation--once the service is available at a facility. Like many of my colleagues, I have found that some of the more common reasons for a referral to be made for neuropsychology consultation in medical settings are: rule out dementia, rule out cognitive deficit(s) due to focal brain damage, acute mental status changes, dementia vs. depression or dementia vs. acute confusion? can the patient attend to and learn tasks in therapy?, can the patient return to independent functioning?, can the patient return to work? HOW? In order to respond to these questions, a neuropsychologist must first obtain the patient's performance on a number of standardized psychometric test instruments that were created to examine key aspects of normal cognition and were validated on samples of patients with documented brain disease. The normally functioning brain is amazingly well-integrated. Our normal, conscious awareness of our own behavior is seamless. The reader of this paragraph, for example, would be hard-pressed to attempt to distinguish the separate processing of linguistic, attentional, visuoperceptual, sensorimotor, and intellectual features that are integrated into his or her understanding of the text. It simply happens. Deconstruction of behaviors and performances into their cognitive components can be accomplished, however, by the careful use of these well-designed and validated instruments. They help determine whether a patient's performance reflects the range of normality expected given his or her age, educational level, and other demographic features or are actually defective or otherwise significantly abnormal. A typical neuropsychological examination will evaluate: orientation, general intellectual functioning, ability to learn and remember new information, attentional capacity and concentration, language, visuoperception, sensorimotor functioning, ability to self-monitor and correct one's behavior, academic achievement, personality functioning. These evaluations are long when compared to other examinations patients will endure during hospitalization, oftentimes involving three-to-six hours of formal testing. The length of time, however, affords a neuropsychologist the unique ability to investigate in detail functions which can be touched upon only briefly in a bedside examination or in the mental-status screening portion of a physical examination. Interpretation of the findings from this in-depth evaluation allows for a differential diagnosis of neurobehavioral functioning. It permits a clearer and more reliable manner of distinguishing, for example, those cognitive losses associated with dementia from the experience of memory problems often seen in a significant depression in an elderly patient. Determining that the word-retrieval problems of a patient recovering from a stroke, for example, reflect a residual confusion rather than being a specific type of aphasia can aid in the appropriate allocation of inpatient rehabilitation resources. Determining the severity of any deficits and their functional complications in a patient's daily life is useful data to provide for both discharge-disposition planning and the education of the patient and family members. In every case, the neuropsychologist will tailor the examination to obtain diagnostic and treatment-recommendation information not otherwise available. An effective neuropsychological service can provide services to address a range of inpatient and outpatient demands, diagnostic and treatment demands, and the demands generated both within a hospital setting and throughout the broader community of health care, academic, and rehabilitation agencies. The century has turned and "The Decade of the Brain" is behind us now. In our new century, we will learn more and more about the brain. Neuropsychological diagnostic and treatment consultation will continue to provide a unique part in the multidisciplinary care of the patient with known or suspected brain disease. Anthony H. Risser, copyright 2002-2003

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