This document serves as both a review article and study guide for neurology residents and advanced practice providers (APPs) seeking to deepen their understanding of neurobehavioral assessment in clinical practice. It is based on the foundational work of Kaufer (2015), highlighting a multidimensional, history-centered approach to diagnosing and managing cognitive-behavioral syndromes.

I. Overview of Neurobehavioral Assessment

Neurobehavioral assessment is a multidimensional, integrative process used to evaluate changes in cognition, functional capacity, mood, emotional responsiveness, and social behavior. It is crucial for diagnosing complex disorders such as Alzheimer disease, frontotemporal degeneration, traumatic brain injury, and related syndromes.

While neuroimaging and biomarker tools are valuable, they do not replace the diagnostic power of a detailed clinical history. Neurobehavioral assessment improves diagnostic specificity, informs treatment strategies, and enhances the quality of life for patients and caregivers.

II. Core Focus: Change from Prior Functioning

The primary objective is to identify a meaningful decline from the patient's previous level of functioning. This encompasses:

Cognitive abilities (e.g., memory, language, executive function)

Functional skills (e.g., financial management, driving)

Emotional regulation

Social engagement and behavior

III. The Critical Role of Clinical History

A comprehensive clinical history-often provided by an informant-is the most important source of diagnostic insight. Patients may lack insight (anosognosia), especially in neurodegenerative diseases. Discrepancies between patient self-report and informant observations are diagnostically meaningful:

Informant > Patient + Testing Confirmed: Suggests impaired awareness, typical of Alzheimer disease or TBI.

Patient > Informant + Testing Normal: Suggests mood or anxiety-related syndromes.

Additional history domains:

Temporal onset/course (abrupt vs. insidious, static vs. progressive)

Family history (e.g., c9orf72 mutations)

Comorbid medical/neurologic conditions (e.g., hypothyroidism, stroke)

Head trauma (e.g., sports injury, LOC, chronic post-traumatic sequelae)

Social and cultural context, education level, and baseline personality

IV. Cognitive Assessment: Tools and Interpretation

• Informant-Based Tools:
  • AD8: 8-item screener predictive of dementia (score ≥2)
  • Brief Cognitive Screens:
  • MMSE: Standard but limited in MCI and non-AD dementias
  • MMX: Extended MMSE (50-point) with added recognition and figure recall
  • MoCA: Superior sensitivity to MCI and Parkinson-related cognitive changes
  • SLUMS: Emphasizes practical cognition; public domain
• Domain-Specific Tests:
  • Working memory: Digit span, months in reverse
  • Fluency: Semantic vs. letter fluency (e.g., animals vs. S-words)
  • Naming: Boston Naming Test, Northwestern Naming Battery
  • Visuomotor: Clock drawing, figure copying
  • Executive: Trails B, fluency, abstraction tasks
• Confounders to account for: hearing, vision, motor issues, language barriers, affective state, effort/motivation.

V. Functional Assessment

Assesses real-world implications of cognitive deficits:

• IADLs: Managing finances, medication, shopping, driving
• BADLs: Dressing, bathing, toileting (affected later)

Tool: Functional Activities Questionnaire (FAQ) - 10-item informant-rated IADL measure

VI. Neuropsychiatric Evaluation

Neuropsychiatric symptoms often accompany or precede cognitive decline. Differentiation from idiopathic psychiatric illness is essential.

Common symptoms: apathy, disinhibition, agitation, hallucinations

Depression: Multidimensional - hedonic tone, neurovegetative symptoms, motivation

Tools: PHQ-9, GDS-15 (GDS-15 often more sensitive in Parkinson disease)

NPI-Q: Informant-rated, assesses 10 behavioral domains and caregiver distress. Key in differentiating FTD vs. DLB profiles.

VII. Integrated Clinical Practice

According to AAN dementia quality metrics:

• Perform and document: cognitive, functional, neuropsychiatric, and mood assessments
• Include safety discussions (e.g., driving) and caregiver education
• Screenings can be initiated by trained staff prior to provider evaluation

VIII. Clinical Pearls for Residents and APPs

1. Always establish the baseline level of function
2. Investigate discrepancies in self vs. informant reporting
3. Consider early financial impairment as a sentinel sign
4. Interpret cognitive test scores in context (e.g., education, culture, test administration)
5. Document all confounders impacting test validity
6. Use MoCA or SLUMS over MMSE in MCI/Parkinson cases
7. Recognize REM behavior disorder and OSA as neurodegenerative risk indicators