Imagine taking a standardized test assessing your cognitive abilities, including memory, and attention. Now imagine completing this evaluation in a foreign language. This was the reality for many Spanish speakers in Colorado until Michelle Miranda, PhD, developed the first Spanish Neuropsychological Clinic in the state at the University of Colorado Anschutz School of Medicine in 2022.

Miranda, assistant professor of neurosurgery, is a native Spanish speaker and neuropsychologist. While completing her training in neuropsychology and in the early years of her career, she noticed a significant gap in care for Spanish-speaking patients.

“It is critical to provide a neuropsychological evaluation in the patient’s native or primary language in order to ensure an accurate assessment of their brain functions,” Miranda says. “This is because only a native-speaking clinician can truly distinguish between something like a neurological speech deficit and a regular language barrier." 

The Spanish Neuropsychological Clinic provides care for hundreds of Spanish-speaking patients every year from all over the state and from neighboring states. Because of this service, providers have access to more accurate cognitive data and Miranda can provide a more comprehensive and individualized treatment plan and more culturally sensitive recommendations for patients seen in her clinic.

What is neuropsychology?

Neuropsychology is a branch of psychology that looks at how the brain influences behavior, mood, and thinking skills through structured and standardized testing. Scores collected during a neuropsychological evaluation are compared to standardized baseline datasets from individuals in the same age range with the same level of education to establish a profile of a patient’s cognitive strengths and weaknesses across many areas. If a patient’s scores are low, the neuropsychology team looks at the pattern of those deficits to identify a neurobehavioral diagnosis that is likely causing the chief complaints. Then, recommendations for the patient’s care team are provided. Evaluations typically last about three hours.  

Patients may be referred for a neuropsychological evaluation if they are experiencing changes in memory, speech, attention, or behavior. A patient may also be referred for a neuropsychological evaluation after a serious brain injury or if a neurological condition is present.

Surgical patients, including patients undergoing deep brain stimulation (DBS) or epilepsy surgery, may be referred for an evaluation to establish a baseline and to assess cognitive factors impacting surgical outcomes, informed consent, or post-operative recovery.

Addressing a need

Spanish is the second most spoken language in Colorado with around 12% of people identifying Spanish as their first language. That number is expected to keep rising.

Before Miranda joined CU Anschutz, the neuropsychological clinic relied on interpreters to assist patients with translated English tests. She notes that identifying appropriate, valid assessments for each patient based on age, education level, and language can be particularly challenging for neuropsychologists who do not speak the patient's language.

“Even with an interpreter, subtle nuances, particularly in language can be missed,” Miranda says. “If we can provide these services in the patient’s language, we can prevent false positives or false negatives in terms of neurobehavioral diagnoses.”

Since Miranda is bilingual, she can administer tests that are designated for Spanish speakers to prevent cultural bias and avoid a misdiagnosis. She explains the importance of taking culture into account, noting the varying cultural norms and etiquette that can influence an individual’s results.

"Spanish neuropsychology is its own sub-specialty because we need to use tests and norms that are validated for the patient’s specific cultural background to ensure that their performance is evaluated fairly," Miranda says. 

The Spanish Neuropsychological Clinic is tailored to adult patients, but Miranda specializes in epilepsy and meets with patients as young as 14 years old. She sees hundreds of Spanish-speaking patients a year in her clinic — a patient volume she says is possible because of a bilingual Spanish-speaking neuropsychology technician on her team to administer, score, and record tests.

“When you provide a service to a different culture, it’s also important to think about every part of the evaluation where a patient interacts with the healthcare system — from the scheduler to the automatic appointment reminders. All of these touch points are also important to consider making bilingual in order to provide equitable services,” Miranda says.

‘Another way to save a life’

Growing up, Miranda wanted to be a physician, until her job as a counselor for children with substance abuse introduced her to psychology. After working with an adolescent struggling with a suicide attempt, she made the switch from pre-med to psychology.

“I fell in love with psychology and found that this is another way to save a life,” Miranda says.

Miranda earned a doctorate in psychology, then completed two additional years of training to become a licensed neuropsychologist. After completing her education, she helped establish the first and only Spanish neuropsychology clinic in Utah before coming to Colorado.

When she started on the CU Anschutz campus, she had to administer all the testing herself, limiting the number of Spanish-speaking patients she could see each month. Now, with a bilingual technician, Miranda can see more patients.

Miranda praises her neuropsychology colleagues at CU Anschutz for recognizing this growing need in Colorado and for their effort to make her clinic a reality.

“They worked hard to open my position up to focus on Spanish-speaking patients and meet this need, which is a rare occurrence across the country,” she says. “We see patients from all over the state and also from neighboring states.”

Miranda was elated when her clinic received its first bilingual neuropsychology fellow, who then went on to create a similar clinic for Denver Health. She says this progress is a step in the right direction for patients, regardless of where they are seeking care.

She hopes to have the opportunity to train more bilingual neuropsychologists and technicians to increase her capacity to accept referrals coming in from all over the region.

“This is a necessary service, and the Spanish-speaking groups are growing,” she says. “We are the main center for the entire state and neighboring states, and I want to provide care to as many people as possible.”