Downloaded from [Link] on January 12, 2018 - Published by [Link].

com

How to do it

Neuropsychological assessment
in epilepsy
Sallie Baxendale

Department of Clinical and Abstract normed on healthy populations. Every

Experimental Epilepsy, UCL
The role of the neuropsychological assessment neuropsychological test has a ceiling and
Institute of Neurology, London
WC1N 3BG, UK in the management of people with epilepsy a floor. These are the limits of the best
has evolved considerably over the past 25 years. and worst performances possible on the
Correspondence to This paper describes some of the most common task. For example, on a ‘count to 3’ task,
Dr Sallie Baxendale,
ESRC Epilepsy Society, applications of a neuropsychological assessment the ceiling of the test would be the ability
Buckinghamshire SL90RJ, UK; ​s.​ in the diagnosis, management and treatment of to count to 3. Since well over 99% of the
baxendale@​ucl.​ac.u​ k people with epilepsy. It describes the factors that adult population can do this, it would be
influence the interpretation of neuropsychological a test with a very low ceiling. Full marks
Accepted 23 November 2017
test scores in this patient group and outlines the on the test would not distinguish the
limitations of the investigation. It gives guidelines patient whose counting limit is 4 from
for the optimal timing of a referral, together one who can solve complex quadratic
with timelines and indications for reassessment, equations in lightning speed. Most tests
and provides a checklist to help the referring are therefore standardised so that the
clinician get the most from a neuropsychological top and bottom scores are returned
assessment for their patients with epilepsy. only by 2% of the general population.
Anyone completing these standardised
tests will obtain a score that will provide
Introduction a measure of how well they are func-
The role of the neuropsychological assess- tioning compared with an age-matched
ment in the management of people with sample of their healthy peers and/or
epilepsy has evolved considerably over the patients with similar or other conditions.
past 25 years. Before the advent of MRI, These scores tend to be normally distrib-
clinicians used the patterns of cognitive uted and are converted to either z scores
strengths and weaknesses derived from a or a percentile rank to allow comparison
neuropsychological assessment to later- between tests (figure 1).
alise and localise cerebral pathology in Not all neuropsychological test scores
this group. The advances in structural and are normally distributed and some tests
functioning imaging over the past quarter may be based on pass/fail criteria or have
of a century mean that this is no longer ‘cut-off ’ points for the identification of an
the primary role of a neuropsychological abnormal pattern of response.
assessment in this population.1 Most neuropsychological assessments
However, far from hastening the demise will generate a large number of measures
of the neuropsychological assessment, of function in several cognitive domains,
new imaging techniques have enhanced including general intellectual ability,
the role of traditional tests in the clinical memory function, expressive and recep-
management of people with epilepsy. tive language skills, executive function
This paper describes the ways in which a and perceptual abilities. This creates a
neuropsychological assessment can help in cognitive profile of strengths and weak-
the diagnosis, management and treatment nesses across multiple domains.
of people with epilepsy and provides some These cognitive profiles are examined
recommendations for getting the most out to determine clinically significant deficits
the investigation for this patient population. in relation to the individual’s estimated
What is a neuropsychological premorbid level of function in each cogni-
assessment? tive domain (where appropriate) and also
To cite: Baxendale S.
Pract Neurol Epub ahead of A neuropsychological assessment in relation to the pattern and level func-
print: [please include Day comprises the administration of several tion seen in their healthy, age-matched
Month Year]. doi:10.1136/ peers.
practneurol-2017-001827 tests that have been standardised and

Baxendale S. Pract Neurol 2018;0:1–6. doi:10.1136/practneurol-2017-001827 1

 Downloaded from [Link] on January 12, 2018 - Published by [Link]

How to do it

Figure 1 The normal distribution and psychometric conversion scores.

When can a neuropsychological Rather we now understand that difficulties on

assessment help in the management of particular neuropsychological tasks represent dysfunc-
people with epilepsy? tion within the underlying network that subserves that
Table 1 describes some of the most common applications function. This disruption of function can result from
of a neuropsychological assessment in the diagnosis, many factors (figure 3).
treatment and management of people with epilepsy. The neuropsychological assessment is unique among
Interpreting the results the standard diagnostic assessments in epilepsy. The
Just as it is increasingly recognised that epilepsy is a clinical significance of the cognitive profile can only be
disorder of cerebral networks2 so we have moved away fully interpreted in the light of the outcomes of other
from a phrenological approach of assigning specific cogni- investigations. This is not the case with an MR scan
tive functions to the role of specific cerebral structures. of brain, where a cavernoma presents as a cavernoma,
regardless how a patient is feeling on the day of the
scan, or when they last had a seizure.
However, in a neuropsychological assessment a poor
score on a test can reflect many organic and non-organic
factors, some of which may be permanent (eg, under-
lying structural pathology), and others of which may be
transient (eg, postictal disturbance, interictal subclinical
electroencephalography discharges, depression, etc) or
reversible (eg, medication effects) or even specific to the
assessment itself (eg, poor motivation and test anxiety).
A skilled neuropsychologist must examine the
evidence for each of the factors illustrated in figure 3,
as well as their interactions with one another, in order
to interpret the test results for each patient. This means
the more information the neuropsychologist has about
the patient at the time of the assessment, the better
their interpretation. In most settings, neuropsycholo-
gists rely solely on the referral letter from the neurolo-
gist for this information.

Limitations
Unlike a scan or an electroencephalography, a neuro-
psychological assessment assesses the person and not
the brain. This kind of assessment has several limita-
tions and will not yield useful results for everyone.
The following limitations should be considered when
considering referring someone with epilepsy for a
neuropsychological assessment.
1. Most of the tests we use in the UK are culturally
Figure 2 A neuropsychological assessment is not phenology. specific and have been standardised using a British

2 Baxendale S. Pract Neurol 2018;0:1–6. doi:10.1136/practneurol-2017-001827

 Downloaded from [Link] on January 12, 2018 - Published by [Link]

How to do it

Table 1 Common applications of a neuropsychological assessment in the diagnosis, treatment and management of people with epilepsy
Determine mental capacity Under the Mental Capacity Act (England and Wales, 2005), mental capacity is not universal but situation specific.
Data from a neuropsychological assessment can be used to determine whether someone has the capacity to
make decisions in various situations, ranging from consent to receive/refuse treatment to the management of their
affairs.
Assess and monitor Some antiepileptic medications can have significant cognitive side effects. A neuropsychological assessment can
medication effects be used to assess the cognitive cost/benefits of these medications, particularly for young people with respect to
their education.
Aid in the differential A very abnormal profile may indicate the presence of a functional disorder.
diagnosis of epilepsy/
psychogenic non-epileptic
attack disorder
Provide the basis for a The results of a neuropsychological assessment can be used to create a tailor made rehabilitation programme to
cognitive rehabilitation reduce the impact of any cognitive deficits with an organic basis on everyday function.
programme
Provide the basis for People with epilepsy and their carers can develop both underexpectations and overexpectations regarding the
counselling regarding likely impact of their condition on their life opportunities. A neuropsychological assessment can provide a sound
employment/educational basis to ensure someone can function at their full potential.
options
Specialist applications in These include:
epilepsy surgery ►► Lateralising/localising seizure focus in MR-negative cases
►► Preoperative prediction of postoperative cognitive changes
►► Ensuring informed consent
►► Implementation of prehabilitation for patients at high risk of a postoperative cognitive decline. Prehabilitation is cognitive
rehabilitation implemented before the loss of a function. Epilepsy surgery patients are unique among neurological patients as we
can predict both the nature and extent of the neuropsychological deficit they are likely to experience before the surgery that will
cause it. We can use a patient’s intact memory functions before they deteriorate to instil the routines and strategies they will need
after the surgery to reduce the impact of postoperative cognitive decline.

population who have English as their first language. designed to be culturally neutral, any assessment
This means that the norms are valid only for this using just these tasks will be limited. While inter-
population, that is, people who have been educated preters can be used to administer some tests, even
within the UK and for whom English is their first qualified interpreters are not trained in the stan-
language. Although there are some non-verbal tests dardised administration of psychometric tests. It is

Figure 3 Factors influencing performance on neuropsychological tests in epilepsy (ILAE, reproduced with permission).1

Baxendale S. Pract Neurol 2018;0:1–6. doi:10.1136/practneurol-2017-001827 3

 Downloaded from [Link] on January 12, 2018 - Published by [Link]

How to do it

possible to end up with a measure of the ‘joint IQ’ often give up before we can establish the limits of
of both the patient and the translator in these situ- their capacity.
ations. Even in faithful translation, the problems
of the unrepresentative normative sample remain.
Reassessment
Clinicians should therefore be cautious when
If a patient has undergone a full neuropsycholog-
interpreting the findings from a neuropsycholog-
ical assessment, most neuropsychologists will advise
ical assessment in people who differ in important
waiting at least 9 months before attempting any reas-
respects from the normative sample of the test.
sessment. This is because practice effects can have a
2. Most neuropsychological tests are pencil and paper
significant impact on performance the second (or
tasks or require the patients to answer questions
third or fourth and so on) time around. These practice
put to them by the neuropsychologist (who then
effects can mask underlying deterioration if a reassess-
records their answers, with a pencil on paper).
ment is carried out too soon. Exceptions to this rule
Computerised test batteries are gradually being used
are specialist serial assessments that are conducted as
more widely, but technology has not transformed
part of a treatment evaluation (eg, surgical follow-up):
the neuropsychological assessment in the way that
here the standardised test batteries at each stage of
it has in other disciplines. This is because an inte-
treatment and follow-up have been carefully designed,
gral part of a neuropsychological assessment is the
employing parallel test batteries to minimise practice
observation of ‘how and why’ someone is failing on
effects. Shorter test–retest intervals can also be used in
a task, not just whether or not they can do it, and
circumstances where the initial assessment was clearly
this requires the clinician to observe closely and
compromised by factors that have since resolved, such
engage with the patient throughout the assessment.
as drug toxicity or psychological disturbance.
Because most of our tests rely on someone being
Routine reassessment is not advised for most people
able to see, hear and manipulate a pencil, our range
with epilepsy since overexposure results in reduced
of investigations is limited if someone has signif-
power of the tests to detect both impairment and
icant sensory or motor impairments. This does
change in function. If a patient has undergone an assess-
not mean that a neuropsychological assessment
ment that revealed significant memory impairment
cannot provide useful information in these cases,
with function below the second percentile, further
but it does mean that the assessment will have to
assessment a year down the line when they continue
be tailored to accommodate these impairments and
to complain of memory problems is unlikely to help in
that it may not be possible to get a reliable measure
their management, since it is likely to show the same
of function in all cognitive domains.
pattern. Unless there are other features of progres-
3. Every neuropsychological test has a ceiling and a
sive deterioration, such a patient should be referred
floor (see above). By definition, people diagnosed
for memory rehabilitation rather than undergo serial
with learning disability will have an IQ of 70 or
assessments that are highly likely to yield the same
less and will score at or below the second percen-
results. Unless you think it is likely that something has
tile on tests of intellectual function. Although not
changed, a reassessment is unlikely to help.
always the case, it is common for function in other
cognitive domains to be similarly compromised in
the learning disability population. This can result The impact of antiepileptic drugs
in a very flat neuropsychological profile, with Given the volume of the literature on the effects of
every score on every task falling below the second antiepileptic drugs on cognition, there are surprisingly
percentile. This does not mean that the individual few well-controlled studies published. As a general
does not have cognitive strengths and weaknesses rule of thumb, older medications seem to have more
but rather that the standardised tests are not sensi- impact on cognition than newer ones, and people
tive to these patterns in this population, limiting taking polytherapy seem more often to be slowed
the value of the assessment in some cases. up than those only taking one drug, but the impact
4. The patient’s motivation is by far the biggest is different for different people and there are some
factor that can limit the validity and reliability of notable exceptions to these rules. While most antiepi-
neuropsychological test scores. If a patient is not leptic drugs are associated with a degree of cognitive
willing to do their best on the tests, we will not slowing, topiramate appears to have a specific impact
get valid data. A neuropsychological assessment on verbal function and there are reports of significant
can be a tough investigation. Unless they are in reductions in verbal fluency and intellectual function in
the top 2% of the population, every patient will some patients. A recent functional MRI study reported
be pushed until they cannot answer the questions. medication-specific effects (topiramate vs zonisamide
As they reach the limits of their cognitive capacity, vs levetiracetam) on the functional neuroanatomy of
it requires increasing effort not just to give up. language and working memory networks, with topi-
Patients who are anxious and depressed or who ramate and zonisamide associated with dysfunction in
just do not see the point of the investigation will frontal and parietal cognitive networks and associated

4 Baxendale S. Pract Neurol 2018;0:1–6. doi:10.1136/practneurol-2017-001827

 Downloaded from [Link] on January 12, 2018 - Published by [Link]

How to do it

impaired performance on associated tasks.3 We should

Key points
also consider the indirect impact of antiepileptic drugs
on cognition. The mood disturbance reported by some ►► Being clear about what you want from a neuropsycho-
people taking levetiracetam can also lead to poor logical assessment and how the results will affect your
cognitive function for some. The prescribing neurol- management of a patient before you refer will ensure
ogist should carefully consider the cognitive profile that the results you get back are useful.
of any antiepileptic drug, particularly when consid- ►► Prepare the patient. Preparation for the assessment
ering changes that could have dramatically impact on begins in the neurology consultation, when you decide
academic performance at key stages of an person’s life. to refer; the better prepared the patient, the more valid
the results will be.
Getting the most from a ►► Think carefully before you refer for a reassessment;
neuropsychological assessment neuropsychological assessments should be used spar-
The following checklist will help neurologists to get ingly to maintain the sensitivity of the tests.
the most out of a neuropsychological assessment. ►► There are no magic bullets when it comes to cognitive
dysfunction in epilepsy. Ensure the patient has realistic
Think about the clinical question you want the expectations of any neuropsychological investigations
neuropsychological assessment to address that you may request.
Whether it is establishing a cognitive baseline before
medication changes, capacity to consent to treat- have been referred. Bear in mind that if you typically
ment or advice about employment options, the more have difficult clinical consultations with a patient, these
specific the questions you ask in your referral, the more difficulties will be magnified under the stressful condi-
tailored the subsequent assessment will be. A usual tions of a cognitive assessment and it may not be possible
rule of thumb is that the more general the referral, the to get valid results.
more general the report you will get back. Referrals do
not have to be limited to just one question—often the And finally
same results can be used in a number of ways—but it is There are no magic bullets when it comes to cogni-
only by asking the questions that the neuropsycholo- tive dysfunction in epilepsy. Memory problems,
gist will know what you want from the results. difficulties with attention and concentration, and
executive dysfunction are often an integral part of
Give as much information in the referral as possible
the condition because seizures and cognitive difficul-
Remember that many factors contribute to a neuro-
ties are both a manifestation of a common under-
psychological profile. If your neuropsychologist does
lying brain pathology. To make things worse, the
not have ready access to the patient’s clinical history,
cognitive problems associated with the pathology
include as much clinical information as possible in
are often exacerbated by the treatments aimed at
your referral. This information does not need to be
reducing the seizures, be they antiepileptic medi-
tailored specifically to the neuropsychologist: just
cations or surgery. Clinicians often mistake this for
include copies of the most recent clinic letters. Any
common knowledge, but it is remarkable how many
screening data that you have administered in the clinic
people with epilepsy report that these aspects of their
(Hospital Anxiety and Depression Scale, Quality of
condition have never been explained to them. When
Life in Epilepsy Scale, Addenbrookes Cognitive Exam-
people with epilepsy complain of memory problems
ination, Montreal Cognitive Assessment) are useful
in the clinic, education about the wider manifesta-
but not essential, as most neuropsychological assess-
tions of the condition should begin there and then,
ments will include measures in these domains.
to ensure realistic expectations of any further inves-
Prepare the patient
tigations you may request.
Tell your patient why you want them to have the tests
Competing interests SB received a speaker honorarium for
and how you think these will help. Give them some idea a presentation at an epilepsy meeting funded by UCB in
of what to expect. It is part of a neuropsychologist’s job November 2015.
to explain the nature of the tests and to establish a good Provenance and peer review Commissioned; externally peer
rapport with the patient before they start testing them, reviewed. This paper was reviewed by John Paul Leach,
Glasgow, UK.
but the neurologist can do a lot of the ground work to
ensure a valid assessment by ensuring the patient is on © Article author(s) (or their employer(s) unless otherwise stated
in the text of the article) 2018. All rights reserved. No commercial
board, at least with the rationale behind the assessment, use is permitted unless otherwise expressly granted.
before they arrive. If a patient arrives with a good idea
of why they have been referred and how the results of References
the tests will be used to help manage their condition, 1 Baxendale S, Thompson P. Beyond localization: the role of
their motivation to complete the tests to the best of their traditional neuropsychological tests in an age of imaging.
ability will be better than if they have no idea why they Epilepsia 2010;51:2225–30.

Baxendale S. Pract Neurol 2018;0:1–6. doi:10.1136/practneurol-2017-001827 5

 Downloaded from [Link] on January 12, 2018 - Published by [Link]

How to do it
2 Wilson SJ, Baxendale S. Reprint of: The new approach to 3 Wandschneider B, Burdett J, Townsend L, et al. Effect of
classification: rethinking cognition and behavior in epilepsy. topiramate and zonisamide on fMRI cognitive networks.
Epilepsy Behav 2016;64:300–3. Neurology 2017;88:1165–71.

6 Baxendale S. Pract Neurol 2018;0:1–6. doi:10.1136/practneurol-2017-001827

 Downloaded from [Link] on January 12, 2018 - Published by [Link]

Neuropsychological assessment in epilepsy

Sallie Baxendale

Pract Neurol published online January 11, 2018

Updated information and services can be found at:

[Link]

These include:

References This article cites 3 articles, 0 of which you can access for free at:
[Link]
#ref-list-1
Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Notes

To request permissions go to:

[Link]

To order reprints go to:

[Link]

To subscribe to BMJ go to:

[Link]