Dr. Brianne Bettcher is a neuropsychologist with the University of Colorado Alzheimer's and Cognition Center. Neuropsychology testing is a key ingredient of dementia treatments and dementia research studies. Dr. Bettcher explains what patients can expect, and how this branch of neuroscience informs a diagnosis.
What is Neuropsychology?
Neuropsychology is a subspecialty of psychology, with a special emphasis on the relationships between someone’s thinking and their brain and their behavior. We use a variety of different approaches and tests to try to understand these relationships.
When do patients get referred to you?
Typically, a patient will be referred to me by a neurologist, a geriatrician, or a primary care practitioner who has questions about the patient’s strengths and weaknesses in terms of their thinking. The goal is to often to better characterize and understand the cause of that thinking difficulty.
Is “thinking” the key word here?
We also look at aspects of mood and behavior, but the term “thinking” encompasses a lot of different things. I think is important to highlight that thinking is not just memory — it also includes how well you organize and plan, how fast you process information, and whether or not you are having difficulties seeing and interpreting visual information in front of you. All of this helps us build a narrative of what’s going on in that person’s brain, and helps us put pieces together to find a pattern.
How do neuropsychology test results figure into someone’s diagnosis?
The test results are one of several pieces of the assessment, including an MRI (an imaging test), the patient’s history, and their own concerns. So, the neuropsychology test results provide objective information about (and often, confirmation of) some of the difficulties the patient is reporting. But it also can give us insights into, again, the pattern of strengths and weakness. For many diagnoses, we can expect a particular pattern to occur. For instance, with classic Alzheimer’s disease, we’d expect memory problems to happen first and to often be more prominent than other types of cognitive difficulties.
How should someone prepare for their appointment?
In the context of a clinic appointment, it’s really helpful if a person comes with someone who knows them well, like their spouse or a really good friend. It’s often hard for people to reflect back on what aspects of their own thinking might be most challenging. So, having someone come with the patient is really helpful to us, as they provide additional information that the patient might not recall or might not be aware of at that time. We always want to get a timeline of the symptoms. Thinking through the first symptoms and determining what’s most concerning now is also helpful.
What happens during the appointment?
Neuropsychology appointments almost always include an interview. During the interview, I ask questions of the patient and of their partner, their friend, or their spouse, with the goal being to get a complete history, and to hear what they’re most concerned about. After that, we often start doing the actual tests. The term “test” can be a scary word for some people, but what that means is doing a computer test or a paper and pencil test of memory, planning, organization, language abilities, and spatial abilities. We try to assess all of those different domains, again, to get a sense of the pattern.
How do the tests work? It almost seems like, in effect, you can see into someone’s brain.
This question comes up a lot. We try to tease apart all of the different variables that can go into the tests. We compare the patient’s results to those from a large group of people, called a normative group, who are of the same age and education level from across the country using these same exact tests. That helps us get a relative sense of how the patient is doing.
How do you interpret the test results?
On a very basic level, I will take the results and compare them to people of the same age, background, and education level. In addition to that, I also compare them to what they’ve told me they used to do, or how they used to be doing. Both of those pieces are important, and I would never interpret data completely out of context for any person.
Can a person’s results change?
Yes. There are many different sources of change. We all have some natural variability, and a little bit of change can happen over time. But what we’re really looking at is whether or not there is a significant change for that person. If someone has Alzheimer’s disease, you might expect them to show a decline in memory and in some other areas of thinking. But the rate of that change differs from person to person. In fact, it’s very difficult for me to predict when someone is in front of me in the clinic how they will change in one or two years.
How do you explain the results to the patient?
I always try to be very transparent. It’s something I believe strongly in. However, when I sit down with a patient and their family I try to also get a sense of what they would like to get out of that feedback. Some people are interested in hearing my general impressions, and some people want to hear about each area of cognition in detail. I typically try to gain a sense from the family of how detailed they would like me to be. But regardless, I am always very transparent about what I’m thinking. The other part of my feedback includes: what does that person or that family need that I could potentially help them with, whether it’s connecting them with resources in the community or trying to guide how much supervision, or lack thereof, a patient might need?
You’ve met with many patients and conducted many tests. What have you learned about people?
I’ve learned so many things that have become part of my values. I try to help people feel as comfortable as possible with doing this assessment, to help guide them through it, and to be a resource to them. My work is a privilege — to have this window into a potentially very difficult time for a person where I can help guide them. It’s uplifting to see such beautiful family interactions in some instances, even though some are more difficult. I see patients and their families experience a full range of emotions. I see people at a very pivotal point, a potentially very vulnerable point — and they may not remember all of the things that I explain to them, but I do believe that they’ll remember how I made them feel about themselves. And to me, I will always consider it a privilege to be a part of that experience with that person.