Journal of Geriatric Mental Health

: 2016  |  Volume : 3  |  Issue : 1  |  Page : 29--35

Neuropsychological assessment of cognitively impaired Indian elderly: Challenges and implications

Samyak Tiwari1, Nisha Mani Pandey2, Priti Singh2, Sarvada Chandra Tiwari2,  
1 Department of Psychiatry, Career Medical College, Lucknow, India
2 Department of Geriatric Mental Health, KG Medical University, Lucknow, Uttar Pradesh, India

Correspondence Address:
Nisha Mani Pandey
Department of Geriatric Mental Health, KG Medical University, Lucknow - 226 003, Uttar Pradesh


Cognitive impairment in elderly is a challenging issue which needs proper attention, care and management. Neuropsychological assessments (NA) are those authentic measures that help not only in narrowing down the differential diagnosis of cognitive dysfunction, but also assist in choosing treatment modalities, evaluating the efficacy of an intervention and to assess outcome. NA may also define the patient«SQ»s functional limitations or cognitive strengths. Therefore, appropriate application of NA can improve the quality of care and management of an elderly with cognitive impairment. NA has many applications as it provides full understanding about the individual and his environment. However, in India there are many challenging issues regarding Na, which are discussed in the present article.

How to cite this article:
Tiwari S, Pandey NM, Singh P, Tiwari SC. Neuropsychological assessment of cognitively impaired Indian elderly: Challenges and implications.J Geriatr Ment Health 2016;3:29-35

How to cite this URL:
Tiwari S, Pandey NM, Singh P, Tiwari SC. Neuropsychological assessment of cognitively impaired Indian elderly: Challenges and implications. J Geriatr Ment Health [serial online] 2016 [cited 2021 Dec 1 ];3:29-35
Available from:

Full Text


Cognition is the process by which information is organized and recognized. Alteration in cognition with age is well-documented and affects a broad range of functions including intelligence, attention, language, memory, orientation, executive function, speed, etc. [1],[2] Deterioration in cognitive abilities and functional losses are common in Elderly (individuals aged 60 years and above), [3] and cognitive deficit increases with age significantly. [1],[4],[5] Further, cognitive impairment negatively affects self-independence, wellbeing, and quality of life. Thus, effective management of an elderly with cognitive impairment requires a full understanding of baseline and functional cognitive status. This is not only about enquiring about the chief complaints and challenges faced by an elderly, but also about the strengths/weaknesses that one possesses and developing management strategies to modulate these skills to optimize daily functioning and overall quality of life. Neuropsychological assessment (NA) is an authentic method for evaluation, planning, and managing treatment.

NA is a meticulous measure for evaluating one's cognitive, psychological/emotional, and behavioral functioning in a comprehensive manner. It is a standardized and objective technique which measures functional processing of various parts of the brain, and can also provide evidence for different types of damage or disease which ultimately affects a person's behavioral and emotional state. NA assesses change over time in relation to the deterioration of progressive illness or improvements due to recovery or following various kinds of treatment. [6] NA requires the use of rigorously standardized tests and scales with sound psychometric properties that allow quantification of impairments. These assessments can help in narrowing the differential diagnosis of cognitive dysfunction, choosing treatments, and evaluating the efficacy of an intervention on an ongoing basis.

 Role of Neuropsychological Assessments for Evaluating Cognitively Impaired Elderly

NA comprehensively assesses a range of cognitive domains including intelligence, learning, memory, receptive and expressive language, visuospatial reasoning, motor functioning, executive functioning, and psychopathology. [7],[8],[9] In general, NA tools incorporate both verbal and nonverbal items for assessment of various cognitive domains of the population in general and also for the elderly. Thus, it is a decisive technique for identifying cognitive decline associated with dementia and related disorders. [10],[11] Further, in addition to neurocognitive disorders like Alzheimer's Disease (AD) and other dementias, other neuropsychiatric conditions like schizophrenia, mood disorders, substance abuse, and sleep disorders are also associated with some degree of neurocognitive impairment. [12] Thus, usage and application of NA play a significant role in assessing functional status of the elderly.

Until neuroimaging techniques were not invented/widely in use, NAs were generally applied to assess the extent of impairment of a particular skill. One of the fundamental uses of NA was to locate the functionally impaired areas of the brain due to brain injury or neurological illnesses. With the advent of neuroimaging techniques, the location of space-occupying lesions can now be accurately determined and thus, the focus of NA has now shifted to Measurement of cognition and behavior and also to determine the effects of any brain injury or neuropathological process. Besides its clinical and therapeutic uses, NAs also help in solving medicolegal issues of elderly. Thus, the relevance and role of NA for assessment of elderly mental health problems with special reference to diagnosing dementias and memory complaints or the identification and localization of the brain lesions are widely recognized and expanded. [13] A neuropsychological evaluation can help in narrowing the differential diagnosis of cognitive dysfunction, choosing treatments, and evaluating the efficacy of an intervention on an ongoing basis. Further, in patients with documented neurologic disorders, information from a NA can define the patient's functional limitations or residual cognitive strengths, and its application and subsequent management of deficits can improve the quality of care of the elderly.

Differentiating between normal age-related cognitive decline and disease-associated cognitive impairment in clinical practice can be challenging. In such situations, the clinicians need to recognize the modest changes in thinking abilities of the older adults as these changes may be an early warnings of neurocognitive disorders. An objective assessment of cognitive functioning is also useful for differential diagnosis, assessing presence and progression of cognitive disorders, and providing information relevant to treatment and planning.

 Need of Neuropsychological Assessment for Evaluating Cognitively Impaired Elderly

In general, referral to neuropsychological services is often made by a neurologist or psychiatrist. A referral for NA to evaluate cognitive functioning of an elderly patient can be considered:

To confirm and determine cognitive impairment.To get information about patient's strength and weaknesses related to emotional state and cognitive abilities.To facilitate the diagnostic process and clarify the impact of a particular disease.To differentiate between various diagnoses and to discriminate various etiologies of dementias and cognitive impairment.To assess the progression of cognitive decline.To measure the outcome of a particular therapy or an intervention.

In India, where the total population of elderly is 103 million (8.6% of total population) [14] around 3.7 million (3.6% of total population) [15] have one or the other cognitive disorder, NA related services are an important necessity.

 Clinical Indications and Process to be Adopted for Evaluating Cognitively Impaired Elderly

On the basis of clinical indications [Table 1], one may consider to apply the NA measures to evaluate particular problem/s.

Through NA, one can assess a variety of functions including neurocognitive, behavioral, and emotional functioning. For assessment of cognitive functioning, one needs to select, administer, and interpret the neuropsychological tests appropriately. Hence, NA is a three-tier process including:

Appropriate selection of valid and reliable tools Skillful administration and Scientific interpretation.

A thorough neuropsychological examination includes a comprehensive battery of tests. Such measures may be reliably replicated by various examiners and also be repeated over time to assess the course and outcome of an illness. In elderly, these evaluations are done for confirming clinical diagnosis, supporting early diagnosis, understand severity of symptoms, making prognosis, planning therapeutic/management/rehabilitation strategies, monitoring changes, assessing improvements/outcome, providing certificates of ability/disability, and carrying out researches, etc. NA measures consist of various psychometric properties including consistency, reliability, validity, and norms. These measures consist of various vehicles to carry out the assessments including paper and pencil tests, verbal tasks, structured and unstructured interviews, and computerized and constructional tasks. The following steps need to be adopted for NA of an elderly.{Table 1}

Identification of tool: First of all, one needs to identify the particular tool/test which is to be appliedScreening: Through screening the neuropsychologist/assessor can provide objective evidence to discern probable presence or absence of a particular psychopathologyDetailed assessment: Detailed assessment on a particular tool provides objective evidence to confirm the presence or absence of a psychopathologyScoring: Scoring on each and every item of the tool is an important task. One needs to be careful while scoring items of a particular toolAnalysis and interpretations: For providing meaning to the obtained scores, analyses of the scores are done on the basis of the available manual and norms. Further, interpretations of the scores are done for making an impression/diagnosis.

 Challenges in Application of Neuropsychological Assessment in Evaluating Cognitively Impaired Elderly

Neuropsychological evaluation helps in narrowing the differential diagnosis of cognitive dysfunction, choosing treatments, and evaluating the efficacy of an intervention on an ongoing basis. [11] It needs advanced assessment tools and specialized training to apply, analyze and interpret the results. There are several challenges in the application of NA:

Accessibility of screening and assessment tools: One of the major challenges in applying the tools can be realized after having a quick view of the available significant NA tools for evaluating cognitive impairments of Indian elderly [Table 2]. Unfortunately many of these NA tools are copyrighted and available as paid access limiting their use and application.Cultural appropriateness: Culturally appropriate NA tools for assessment of cognitively impaired elderly are essential for maintaining and managing their mental health care needs. Unfortunately, most of the screening and assessment tools have been developed in Western countries and adopted for use in India. During the process of adaptation, the items of individual tools are translated into Hindi or other regional languages and applied after validation. This practice does not provide culturally appropriate tools as there are significant sociocultural differences between Indian and Western cultures. Thus, many of items of these tests become irrelevant and other culturally appropriate aspects are missed.Challenges of normative data: Cultural influences on NA are important factors to interpret the test performance. [3] Meaningful interpretation of any NA tool can only be done when culturally appropriate norms are available or known. For example - most of the tools related to activities of daily living/instrumental activities of daily living developed in Western countries have items assessing activities of daily living skills like cooking and familiarity with use of household appliances. This is unlikely to be adaptable to the standard cultural norms of the Indian elderly population. Further, most of the tools have been developed on the basis of majority members of the society, and, therefore, the developed norms correlate to the majority. In such a situation, the minority remains neglected, and often they get poorer scores than the norm. Clinically, however, this does not imply that the particular groups of individuals lack the assessed skill.Challenges of analysis and interpretation: The analysis and interpretation of any of the NA tools need to be carefully prepared considering the background of subject's age, education, sex, and socioeconomic status. These issues often affect test performance and the form of conclusion. An illiterate elderly who has never used any kind of paper or pencil may be unable to perform a simple task of drawing a circle or clock or square and, therefore, the analysis related to such items should be done considering the subject's limitationsChallenges of skilled professionals: The literature reports that the overall numbers of clinical psychologists against the need are not up to the mark and neuropsychologists for the evaluation of elderly are negligible [15],[45] Other challenges: Lack of awareness, understanding, and knowledge regarding NAs make it more challenging for professionals to apply them. Also, as NP tools can be extensive and detailed, patient participation and appreciation of their utility in assessment and management of the conditions are essential for accurate reporting.{Table 2}

 Suggestions and Strategies to Improve Neuropsychological ASSESSMENT Services for Evaluating Cognitively Impaired Elderly

NA has an important role in assessment and management of elderly patients with cognitive deficits, and several measures can be taken to improve the clinical use and availability of NA services. Following strategies may be adapted:

Adaptation of available tools for Indian settings.Development of culturally validated and appropriate NA tools as per Indian contextPlan, develop, and carry out multi-centric and multilingual research studies to derive normative data for various domains of cognition, emotion, and behavior, so that variations could be minimizedParameters for different sub-groups of elderly population should also be derived so that problems of elderly could be measured properly, and management could be done in a better mannerPractical aspects need to be considered, that is, literacy level of the subject, socio-economic status, etc.There is an urgent need to improve the availability of trained professionals, and this requires enhancement of resources as well as increased availability of training for existing professionalsTo improve understanding of the need for such detailed NA testing, greater emphasis to be placed on education/awareness among patients and their relatives/caregivers.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Spar JE, Rue AL, editors. Clinical Manual of Geriatric Psychiatry. Am Psy Publcations 2009. Published by STM Books & Journals, Mumbai, India.
2Casey JE, Ferguson GG, Kimura D, Hachinski VC. Neuropsychological improvement versus practice effect following unilateral carotid endarterectomy in patients without stroke. J Clin Exp Neuropsychol 1989;11:461-70.
3Mathew R, Mathuranath PS. Neuropsychological tools and scales for evaluation of cognitive status of elderly Indian subjects. Indian J Geriatr Ment Health 2006;2:11-20.
4Rao AV. Psychiatric morbidity in the aged. Indian J Med Res 1997;106:361-9.
5Pandey NM, Tiwari SC, Singh N. Mental health morbidity in North Indian rural elderly: Issues and challenges. Indian J Geriatr Ment Health 2011;7:68-82.
6Heaton RK, Temkin N, Dikmen S, Avitable N, Taylor MJ, Marcotte TD, et al. Detecting change: A comparison of three neuropsychological methods, using normal and clinical samples. Arch Clin Neuropsychol 2001;16:75-91.
7Lezak MD. Neuropsychological Assessment. 3 rd ed. New York, NY: Oxford University Press; 1995.
8Adams RL, Parsons OA, Culbertson JL, Nixon SJ. Neuropsychology for Clinical Practice: Etiology, Assessment, and Treatment of Common Neurological Disorders. Washington, DC: American Psychological Corporation; 1996.
9Grant I, Adams K. Neuropsychological Assessment of Neuropsychiatric Disorders. 2 nd ed. New York, NY: Oxford University Press; 1996.
10Petersen RC. Mild cognitive impairment as a diagnostic entity. J Intern Med 2004;256:183-94.
11Assessment: Neuropsychological testing of adults. Considerations for neurologists. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 1996;47:592-9.
12Mathew R, Mathuranath PS. Neuropsychological Tools and Scales for Evaluation of Cognitive Status of Elderly Indian Subjects. Souenir. 1 st Annual Meet of IAGMH; 2005. p. 13-8.
13Palmer BW. The expanding role of neuropsychology in geriatric psychiatry. Am J Geriatr Psychiatry 2004;12:338-41.
14Chandramouli C. Census of India 2011 Registrar General & Census Commissioner, India, Ministry of Home Affairs; August, 2013. Available from: http://www.census_2011_age_data-final-12-09-2013. [Last accessed on 2013 Oct 06].
15Tiwari SC, Pandey NM. Status and requirements of geriatric mental health services in India: An evidence-based commentary. Indian J Psychiatry 2012;54:8-14.
16Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98.
17Brodaty H, Moore CM. The clock drawing test for dementia of the Alzheimer′s type: A comparison of three scoring methods in a memory disorders clinic. Int J Geriatr Psychiatry 1997;12:619-27.
18Copeland JR, Kelleher MJ, Kellett JM, Gourlay AJ, Gurland BJ, Fleiss JL, et al. A semi-structured clinical interview for the assessment of diagnosis and mental state in the elderly: the geriatric mental state schedule. I. Development and reliability. Psychol Med 1976;6:439-49.
19Wing JK, Birley JL, Cooper JE, Graham P, Isaacs AD. Reliability of a procedure for measuring and classifying "present psychiatric state". Br J Psychiatry 1967;113:499-515.
20Ganguli M, Ratcliff G, Chandra V, Sharma S, Gilby J, Pandav R, et al. A Hindi version of the MMSE: Development of a cognitive screening instrument for a largely illiterate rural elderly population in India. Int J Geriatr Psychiatry 1995;10:367-77.
21Tiwari SC, Tripathi RK. Hindi cognitive screening test (HCST). Indian J Geriatr Ment Health 2011;7:83-96.
22Nasreddine Z. The Montreal Cognitive Assessment-MoCA©; 2003-2014. Available from: http://[email protected]. [Last accessed on 2015 Mar 15].
23Reitan RM. Validity of the trail making test as an indicator of organic brain damage. Percept Mot Skills 1958;8:271-6.
24Spreen O, Strauss E. A Compendium of Neuropsychological Tests. Administration, Norms and Commentary. 2 nd ed. New York: Oxford University Press; 1998. p. 533-47.
25Arnett JA, Labovitz SS. Effect of physical layout in performance of the trail making test. Psychol Assess 1995;7:220-1.
26Tombaugh TN. Trail Making Test A and B: Normative data stratified by age and education. Arch Clin Neuropsychol 2004;19:203-14.
27Tariq SH, Tumosa N, Chibnall JT, Perry HM III, Morley JE. The Saint Louis University Mental Status (SLUMS) Examination for detecting mild cognitive impairment and dementia is more sensitive than the Mini-Mental Status Examination (MMSE) - A pilot study. Am J Geriatr Psych 2006;14:900-10.
28Roth M, Tym E, Mountjoy CQ, Huppert FA, Hendrie H, Verma S, et al. CAMDEX. A standardised instrument for the diagnosis of mental disorder in the elderly with special reference to the early detection of dementia. Br J Psychiatry 1986;149:698-709.
29WHO. WHO Schedules for Clinical Assessment in Neuropsychiatry Version 2.1. Geneva: World Health Organization; 1996.
30Morris JC. The clinical dementia rating (CDR): current version and scoring rules. Neurology 1993;43:2412-4.
31Wechsler D. Wechsler Adult Intelligence Scale. 3 rd ed. London: The Psychological Corporation; 1998.
32Dwarka P, Verma SK. Handbook of P G I Battery of Brain Dysfunction (PGI BBD). National Psychological Corporation 1990.
33Tripathi R, Kumar JK, Bharath S, Marimuthu P, Varghese M. Clinical validity of NIMHANS neuropsychological battery for elderly: A preliminary report. Indian J Psychiatry 2013;55:279-82.
34Golden CJ, Hammeke TA, Pruisch AD. A manual for administration and interpretation of the Luria-Nebraska neuropsychological battery. Los Angeles: Western Psychological Services; 1980.
35Gupta S, Khandelwal PN, Tandon PN. The development and standardization of a comprehensive neuropsychological battery in hindi (adult form). J Pers Clin Stud 2000;16:75-109.
36Tariot PN, Mack JL, Patterson MB, Edland SD, Weiner MF, Fillenbaum G, et al. The behavior rating scale for dementia of the consortium to establish a registry for Alzheimer′s disease. The behavioral pathology committee of the consortium to establish a registry for Alzheimer′s disease. Am J Psychiatry 1995;152:1349-57.
37Ganguli M, Chandra V, Gilby JE, Ratcliff G, Sharma SD, Pandav R, et al. Cognitive test performance in a community-based nondemented elderly sample in rural India: The Indo-U.S. Cross-national dementia epidemiology study. Int Psychogeriatr 1996;8:507-24.
38Mathuranath PS, George A, Cherian PJ, Mathew R, Sarma PS. Instrumental activities of daily living scale for dementia screening in elderly people. Int Psychogeriatr 2005;17:461-74.
39Fillenbaum GG, Chandra V, Ganguli M, Pandav R, Gilby JE, Seaberg EC, et al. Development of an activities of daily living scale to screen for dementia in an illiterate rural older population in India. Age Ageing 1999;28:161-8.
40Piotrowski C. A review of the clinical and research use of the Bender-Gestalt test. Percept Mot Skills 1995;81:1272-4.
41Rosen WG, Mohs RC, Davis KL. A new rating scale for Alzheimer′s disease. Am J Psychiatry 1984;141:1356-64.
42Sahakian BJ, Morris RG, Evenden JL, Heald A, Levy R, Philpot M, et al. A comparative study of visuospatial memory and learning in Alzheimer-type dementia and Parkinson′s disease. Brain 1988;111(Pt 3):695-718.
43Stroop JR. Studies of interference in serial verbal reaction. J Exp Psychol 1995:18;643-62.
44Trenerry MR, Crosson B, DeBoe J, Leber WR. Stroop neuropsychological screening test manual. Odessa, FL: Psychological Assessment Resources, 1989.
45Desai NG, Tiwari SC, Nambi S, Shah B, Singh RA, Kumar D, et al. Urban mental health services in India: How complete or incomplete? Indian J Psychiatry 2004;46:195-212.