How it's Done

What Happens First?
Usually the Primary Care Provider (PCP, or a doctor, nurse practitioner or physician's assistant) interviews family about the kinds of memory or other cognitive problems a patient is having. The PCP may do some brief cognitive testing and order a blood test panel to examine for reversible dementia's like hypothyroidism or vitamin B12 deficiency. The American Neurological Association (ANA) recommends that oversight of any dementia assessment be done by the PCP; and, the PCP may refer the patient to a neurologist, psychiatriatrist or psychologist with skills in assessing dementia and differentiating it from mild cognitive impairment and/or depression, etc. This consultant is used to perform a more in-depth assessment and report back to the PCP their findings.

The consultant will be a specialist knowledgeable about psychological functions in seniors. They include Behavioral Neurologists, Geriatric Psychiatrists, and Geriatricians–who are physicians that specialize in older adults. The consultant, or more typically their nurse, may administer screening measures like the
Mini Mental Status Exam (MMSE) and the Montreal Cognitive Assessment (MoCA). The MoCA became famous, when Admiral Ronny Johnson, MD administered it to President Trump and declared him free of neurocognitive deficits. However, screening tests can miss any subtle problems, and the PCP or consultant may then refer the patient to us for more in-depth neuropsychological evaluation. This entails a battery of tests of memory, language, reasoning and other neurocognitive functions.

Who Refers to Us:
Medicare will pay a neurologist, psychiatrist, geriatrician or psychologist to perform such testing; i.e., interpret the results, diagnose, then write and sign the final report. Thus, Medicare allows any licensed Health Care Provider (HCP) to “do neuropsychological testing.” Whether they should do this or not depends on the HCP’s professional ethics, which all say a HCP should perform only within the scope of their training and expertise. Thus, unless they underwent special training outside their field of practice, consultants will usually hand-off any psychological testing to a licensed psychologist, who has years of training in this skill area. Our largest number of referrals come from directly from PCPs, followed by neurologists, and then psychiatrists.

require a referral from a HCP before we set up an appointment with you, and bill Medicare. We recognize that the PCP is in charge of the overall assessment process, and we want to insure they know about the NP evaluation before it takes place. An exception is when the PCP first refers the patient to a consultant, who then refers to us. If the referral comes to us from a consultant, we’ll still ask for the patient’s permission to send the report to the PCP as well as the consultant. The PCP serves as your main “gate keeper” and keep track of all the specialists who get involved in your care. We’ll also send it to other involved HCPs like a psychotherapist, when indicated.

More About the Process:
Standardized tests are given exactly the same way, every time, so as to reliably allow us to compare your scores to other people similar to you in age, education and sex to look for weaknesses indicative of NCD. They provide data allowing us to compare you to standards like the average scores of other 70–80 year olds which is called a normative standard. We can determine how much worse (or better) you score using percentiles, which are described in the section of this website on Statistics.

We use multiple tests, rather than single long tests, to maintain a patient’s attention and motivation. Seniors can become irritable, and we try to keep things interesting and moving along to get their best performance.
Appointments include time taking history, testing and offering feedback/recommendations about community resources. Appointment durations vary based on each patient's speed and case complexity, on average they last 2.5 to 3 hours. After the patient leaves, we score and encode data into a computer program which Dr. Elovitz has spent 20+ years writing, which helps graphically chart and display test findings for ease of review. The evaluation results are explained in a six-to-seven page report that follows in two or three weeks. The psychometrist and supervising psychologist then both sign the report, which follows by mail (email is not allowed by HIPAA) to the PCP and other recipients.

Who Supervises the Testing Process?
Most neuropsychological (NP) evaluations are “performed” (i.e., supervised) either by a clinical psychologist with training/knowledge in NP assessment or by a neuropsychologist. Complex cases, like those in hospital geropsychiatric unit, or a patient with aphasia or a subcortical disease like Pseudobulbar Palsy (which is often mistaken for depression) may require a neuropsychologist. However, general dementia assessment is commonly done by a geropsychologist who has undergone additional training in NP evaluation specific to this type of testing. They bring a knowledge of general geriatric psychology to the table. As long as s/he is properly trained and works within the scope of their area of expertise, any psychologist can use neuropsychological tests.

In our practice we have both a geropsychologist and a developmental (lifespan) neuropsychologist, who collaborate on cases when writing reports. Dr. Eggleston, a clinical psychologist with many years of experience brings strengths in emotional and personality assessment and diagnosis. Emotional factors often exacerbate, or even cause, apparent NCD so he often collaborates with Dr. Elovitz, who specializes in brain/behavior disorders affected by age. Both do testing, but both also supervise our psychometrists who provide most of the direct services.

Who Administers the Tests:

When you go to the doctor’s office, you may see several people like a medical technician who checks your weight and asks you about changes in your medical state, followed by a nurse who takes your blood pressure and does an EKG, then a nurse practitioner or physician’s assistant may see you. At some visits, you may never even see the physician who supervises and signs off on all this. Similarly, test administration is often done by “technicians” as Medicare calls them, but in psychology they are referred to as psychometrists. They set up the testing site, administer and score the tests, check historical details, etc. and now-a-days insure sanitary conditions for patient contact.

The psychometrist typically has a bachelor’s degree in psychology and has been specifically trained in administering and scoring the tests we use. However, our psychometrists either are training for or already have a master’s degree and are often post-doctoral; e.g., gaining experience and earning a living while waiting to take licensing board exams, or retired professionals from other fields. We have a retired dentist who brings a wealth of medical knowledge from his training and the decades he practiced, but now is he is doing something much different and having fun which is good since he won’t get rich. Regardless of who administers the tests all interpretation, diagnosing, treatment planning and report writing is done by either a geropsychologist or a neuropsychologist who communicates the findings via a written report to the referring PCP or consultant. Of course, we will also send a copy of that report to the patient and family if requested.

In our Memory Centers we are referred hundreds of evaluations per year and it is simply not possible for one or two psychologists to personally administer all the dementia testing needed to serve SE Massachusetts, given the volume. Dr. Elovitz’ closest neuropsychologist colleague who is willing to see seniors is in Dartmouth, over an hour from Cape Cod – and he has a three year-long wait list! We know, we know…with all the retirees on Cape Cod (Barnstable is 16th oldest county in the nation)
why aren’t there more psychologists dedicated to seeing seniors and doing neurocognitive evaluations?

Why Aren’t Psychologists Interested in Working with Seniors?
The short answer is they are interested, but can’t afford to. The very low reimbursement rate allowed by Medicare makes it hard to attract any psychologist to work with seniors on Cape Cod, or anywhere. Medicare allows around $30-$40 less per hour then your car mechanic charges; and, then Medicare only pays 80% of that amount, making us chase some secondary insurer for the remaining 20%.

Most clinical neuropsychologists stay in Boston or the metropolitan area where they can work with the 20+ hospitals in the city and/or find academic positions to supplement their clinical income. Of the 7% of HCPs no longer accepting Medicare, the majority are mental health providers like psychiatrists and psychologists. Medicare has reduced our fees for testing by more than 40% over the last 15 years, which is how they afford to give PCPs increases to stay in the Medicare system. Currently, the Medicare pays less for testing then MassHealth (Medicaid) pays for testing services to indigent people. There’s more about this, should you be interested, in the section on the website about insurances.

The only way to afford to do NP testing, especially in a rural area like the Cape & Islands, is to use a basic standardized battery of tests (adding additional tests as called for in individual cases), and to use psychometrists to administer and score them. To the best of our knowledge, we are the only full-time providers left in Southeastern Massachusetts doing “dementia” evaluations, and our psychometrists make that possible. Medicare sets the rules, and payment fees and we must abide by them. Of course they pay even less when a psychometrist does the testing than when a psychologist personally does it. But, a FT psychologist can only personally see about eight patients per week, and while each of our psychometrists can add another eight patients per week we still have a long wait list.

Neurocognitive Testing–how long and where?
Neuropsychological (or Neurocognitive) evaluation takes about 3-4 hours face-to-face contact with the patient and family. At the Memory & Attention Center, we spend an entire morning or afternoon with the patient and family. A care provider or family member should be available to provide history if the patient is not capable of doing so, alone. Feedback at the end of the testing may be provided to the patient and family, as appropriate. You can see why a psychologist could personally only do two per day, over four days and use the fifth day of the work week to write reports.

Neurocognitive testing can be done in our office, but a home-based assessment is often better for senior citizens who have difficulty traveling. In addition, it is useful to see the individual in their home setting to offer recommendations about independence and functional capacity. Medications can be checked for accuracy, as the pill bottles in the home often do not correspond to the list the patient brings in to show their doctor. This author often looks for, with the patient's permission, over-the-counter (OTC) drugs and supplements in the medicine chest or on the bedside table, that can cause memory difficulty. People do not consider these "drugs" (they are) and there are dozens' of OTC remedies tied to worsening or even causing dementia. Rarely do people tell their doctors about their OTC remedies. For detailed information about home vs. office visits, see the next section of this website on “Where it’s Done.” Of course, home visits are limited at this time due to COVID.

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