Neuropsychologists: Who & What They Do
In this episode of Ask Dr. Mia podcast, Dr. Mia talks to her colleague, neuropsychologist and memory researcher Dr. Bonnie Sachs.
Dr. Bonnie Sachs is a board-certified clinical neuropsychologist who specializes in working with older adults with memory loss and other cognitive disorders. Her areas of focus, both clinically and in research, include mild cognitive impairment (MCI), Alzheimer's disease (AD), and other forms of neurodegenerative diseases like Parkinson's disease, Frontotemporal dementia, Vascular dementia, and Lewy Body dementia. Dr. Sachs is an Associate Professor in the Departments of Neurology and Internal Medicine, Section of Gerontology & Geriatric Medicine, and is also an Investigator with the Wake Forest Alzheimer's Disease Research Center (ADRC). Additionally, Dr. Sachs enjoys education training and she currently co-directs the Clinical Neuropsychology Fellowship Program at the Wake Forest School of Medicine.
Dr. Sachs talks about how she became interested in the field, the training for neuropsychologists, what they do, and when patients should see a neuropsychologist.
Music & disclaimer
Transcripts on www.miayangmd.com. Transcripts are automatically generated and may contain minor inaccuracies.
Email: ask@miayangmd.com
Opinions expressed are exclusive of Dr. Mia Yang and not reflective of her or guest speaker's employers or funders.
[Dr. Mia]:
Welcome back to Ask Dr. Mia podcast. Today I have my friend and my colleague, Dr. Bonnie Sachs, joining us on the podcast. She is a board certified clinical neuropsychologist and an associate professor in the department of neurology, internal medicine, geriatrics, and public health sciences at Wake Forest School of Medicine. Bonnie and I have worked together on a number of different studies. and she's been here since 2014. She specializes in working with older adults with memory loss and cognitive disorders. So welcome to the podcast, Bonnie.
[Bonnie Sachs]:
Thank you for having me Mia, I'm excited to be here.
[Dr. Mia]:
Thank you. One of the first questions I wanted to ask you is, if you can tell the listeners who may not know what a neuropsychologist is, can you share with us kind of how you got involved and interested in this field?
[Bonnie Sachs]:
Sure. So most patients I see actually don't know what a neuropsychologist is until they come in and see me. So that's not uncommon. Let me answer your first question. Sort of what is a neuropsychologist? So a neuropsychologist is someone who has a doctoral degree, a PhD in clinical neuropsychology. So that usually includes about four to five years of coursework. and clinical experiences working with patients. And then a neuropsychologist has additional training in understanding the brain structure and function, how the different parts of the brain communicate with each other. And I think most importantly, how changes in brain function, whether it's due to differing age across the lifespan or whether it's due to insult or injury to the brain, how those things affect our thinking skills, so our memory, our concentration, our language, how they affect our behavior, like how we interact with one another, and how they affect our moods or our feelings. And we as neuropsychologists also
[Dr. Mia]:
Also,
[Bonnie Sachs]:
learn
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we
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how
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learn
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how to
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use
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specialized
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specialized
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tests
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tests
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or assessments
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or assessments
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those different
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those different
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aspects
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aspects
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of
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of
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brain
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brain
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functioning.
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function. So
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So we do
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training
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do
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a clinical
[Dr. Mia]:
a clinical
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internship,
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internship,
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which is
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which
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a year
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is a
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long,
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year long,
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and then
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and then
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a two-year
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a
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fellowship
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two-year fellowship
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in neuropsychology
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in neuropsychology
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where we gain
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where
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additional
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we gain additional
[Bonnie Sachs]:
experience
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experience
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working with
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working
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different
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with
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types
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different
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of
[Dr. Mia]:
types
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patient
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of
[Bonnie Sachs]:
populations.
[Dr. Mia]:
Gotcha. So people become clinical psychologists and then sub specialize in neuropsychology.
[Bonnie Sachs]:
Absolutely, absolutely. And for your listeners who are wondering, you know, how would I even find a neuropsychologist? How do I know if someone is actually a neuropsychologist? You know, one thing, one additional thing that I have and that your listeners could look for is whether the person who you might be seeing or maybe your doctor referred you to is a board certified clinical neuropsychologist. That board certification is some additional tests and rigor that go into showing that a person is skilled and highly qualified to do the type of work that neuropsychologists do.
[Dr. Mia]:
Got it. And Bonnie, how
[Bonnie Sachs]:
Thank
[Dr. Mia]:
did
[Bonnie Sachs]:
you.
[Dr. Mia]:
you get interested in subspecializing in neuropsychology?
[Bonnie Sachs]:
Well, you know, my path was, I started, I took a psychology class in high school, actually, and was just really fascinated with the brain. I mean, I knew I was interested in people and, you know, how people make decisions, how people learn. And when I took that class, it really sort of set me on the path. to becoming, you know, I don't think I knew I wanted to be a neuropsychologist at that time, but I started taking more courses in college. I majored in psychology in college. And you know, there's lots of different facets of psychology. You can work with children, you can do therapy, you can work with families. But when I took my first course talking about brain function and how that impacts personality and how that can. be impacted by illness or disease, I was sort of hooked and I took everything, every course I could about that. I learned everything I could. And then as I went on through graduate school, that's really when I started to be particularly interested in working with older adults who have memory disorders or changes in cognition or thinking skills as they get older. So. My path has been pretty straight. Once I got exposed, I knew that's what I wanted to do, but my interest in working with folks later in life sort of came through graduate school and then became even more fine-tuned through internship and my fellowship.
[Dr. Mia]:
Got it. So what type of patients are most likely to benefit from seeing someone like you?
[Bonnie Sachs]:
Yeah, so that's a great question. So lots and lots of folks can actually benefit from seeing a neuropsychologist. And most patients get to my office or someone like me, usually from a referral from a physician. So someone like you, Mia, or a primary care doctor, or a neurologist. And neuropsychologists really can help folks in a variety of different situations. So it could be... someone wondering if they have, maybe they or their loved one have a diagnosis of dementia, but maybe they've been getting worse and the family wants to know, is their dementia getting worse or is this something else going on too, like depression for instance. We see a lot of folks who have had acute injuries, like a stroke or a car accident, and the family wants to know, you know, can they go back to work? Or the doctor wants to know, can they go back to work? And so we can use those tools and assessments that I mentioned earlier to help understand how that person might function in day-to-day life, doing things like managing their finances or driving or going back to work. So we see folks for a variety of reasons. And really, I think one of the things that we can do that's most helpful is, providing recommendations for a family member who is concerned or for the person themselves who is concerned or for a physician who's concerned about how can we help this person or this patient function with their
[Dr. Mia]:
with
[Bonnie Sachs]:
cognitive
[Dr. Mia]:
their
[Bonnie Sachs]:
skills,
[Dr. Mia]:
cognitive
[Bonnie Sachs]:
again, thinking
[Dr. Mia]:
skills,
[Bonnie Sachs]:
and
[Dr. Mia]:
again,
[Bonnie Sachs]:
memory
[Dr. Mia]:
moving
[Bonnie Sachs]:
and
[Dr. Mia]:
their
[Bonnie Sachs]:
language
[Dr. Mia]:
memory and knowing
[Bonnie Sachs]:
most effectively
[Dr. Mia]:
those
[Bonnie Sachs]:
in their day-to-day
[Dr. Mia]:
most effectively
[Bonnie Sachs]:
life.
[Dr. Mia]:
in their days to come. Yeah, and that daily function is so
[Bonnie Sachs]:
Thank
[Dr. Mia]:
important.
[Bonnie Sachs]:
you.
[Dr. Mia]:
Can you tell us a little bit about what a typical neuropsychology appointment might be like? What are these tests? And I know that's oftentimes a point of anxiety for people who are already having some memory loss.
[Bonnie Sachs]:
Yeah, absolutely. We get blamed for many a poor night's sleep before our appointments, because folks do tend to be a little bit worried and they do tend to be a little bit concerned. And so I really appreciate you focusing on this to maybe help provide some education about what to expect so that folks are maybe not so anxious when they come to see us. So again, usually we see folks here because they're referred by a physician or, you know, maybe they themselves have had concerns about their memory or their thinking skills. And so typically, we have a little bit of information about someone when they're coming to our office, but maybe not a lot. And so normally we start by explaining what the day is going to look like, and we tell folks that this appointment is not going to be like a typical doctor's appointment. We don't have any needles, there's nothing invasive that we do. What we're really wanting to do is sort of put their brain to work to see how it's functioning when we give them tasks to do that can mirror some of the things that they do in day-to-day life. So we tell them before we even start that our appointment is pretty long, it usually lasts a couple of hours. Now that timeframe may be different depending on the person's age. why they were referred, their individual sort of stamina, how they're feeling that day. But usually the appointment might last between about two to four hours, I think is pretty typical, especially if I'm, like I primarily do when working with an older adult. Then we just talk to the person who came in and if they brought family with them, which is always a great idea, we talk with them and their family. about what their concerns are. We hear a little bit about what's been going on. And again, we focus primarily on their thinking skills. So have they been forgetting more? Have they been having trouble finding words? Are they having trouble with directions or multitasking? We talk a lot about that. We also talk about how they're doing with day-to-day activities. We talk about their mood, how they've been feeling. We talk about sleep and other physical functions, which can all affect memory and thinking. we, while we're not physicians, we do talk about their medical history because again, those things can obviously impact in major ways their thinking skills. We look at their medications, we talk a little bit about their background, like how much school they completed, what type of work they did, all those things go into helping us as neuropsychologists better understand that individual. After we've done all of that, based on their concerns and the information they tell us, we choose some of these special assessments that we would like to do with the person. These are tailored to the individual person and they help us assess, again, their memory and thinking skills. These tests can be kind of frustrating, as you alluded to. They can be a little bit anxiety producing and all that can be pretty normal, but we try to make that process as smooth as possible. We tell folks that not, you're not supposed to get everything right. This isn't a test that maybe you studied for in school. Really, we want to challenge your brain to find out where your thinking skills are strong and then if there are any weaknesses, what those are. So it's normal to not get everything right and it's normal to miss some items. But again, we try to make that process as smooth as possible and as comfortable as possible because really what's important is that we get the person's best effort on all the tests. So we truly can look at their cognitive strengths and then look at where their weaknesses are. That information is what's helpful to us, helpful to them, and what's helpful to their referring provider.
[Dr. Mia]:
Got it. That's a really great description of kind of what goes on during that very long appointment. At
[Bonnie Sachs]:
Later, guys.
[Dr. Mia]:
the end of getting all of those tests, what kind of recommendations do you provide typically to patients and families and their referring clinicians? Obviously, I know that differs depending on each person, but just kind of broad categories.
[Bonnie Sachs]:
Sure, sure. It does differ depending on the person. So some of the typical recommendations that we might provide would be what we call compensatory strategies. So sort of tools and tricks that we know as neuropsychologists can help folks compensate for any areas of weakness that we identified on the testing that we did. So for instance, if someone is having some troubles with memory. We might give them some suggestions like using a whiteboard to put the date or to put important events that are coming up. So it's sort of right there really prominent for them. We might talk about using planners or reminders or alarms to help them recall important tasks like taking medication or remembering appointments. We might provide some suggestions about things that can affect cognitive functioning other than, for instance, a neurologic or a biological condition. Like we might provide some recommendations about sleep quality. Sleep is really, really important for brain functioning and for brain health and for thinking skills. And so if they're having trouble falling asleep or staying asleep, we might give some recommendations to help there. If... You know, we're seeing someone and they haven't seen a doctor or haven't discussed their memory concerns with a doctor, or maybe they have some medical conditions that don't appear to be treated well. We might make the suggestion that they need to follow up with the doctor to see if there's a reversible cause of the cognitive symptoms that they're having, or if better control of some of their medical issues, like sleep apnea, for instance, might help their thinking skills improve. Sometimes we see folks who have concerns about mood or depression and that can also impact thinking skills to some extent. And so we may make recommendations about ways to improve mood or other providers to see if medications seem like they could be indicated. And sometimes we make recommendations about safety. So if we feel that someone really has some substantial thinking. skill difficulties that might impact their ability to remember their medications or maybe they're taking too much or too little, we may make a recommendation that we don't think that they're safe to do that on their own and that we really need to make another plan, let's say involving family members to help them to help them do that safely.
[Dr. Mia]:
Got it. And I know Bonnie, you're not only a clinician, but also a researcher. Could you tell us a little bit about what type of research topics and projects that you're working on?
[Bonnie Sachs]:
Yeah, absolutely. So I'm working in research in a couple of different areas, but one of the main areas that I'm interested in is how do the things that we do every day impact our thinking skills and our brain health as we get into later life. So a lot of times we'll call these lifestyle factors. But how do things like exercise or social engagement and connection with other people, or cognitive activity, like doing puzzles or reading. How do those things help us in late life? Are they protective against things like dementia or cognitive loss in late life? I'm also interested in how things like overall health and controlling or improving our health. may contribute to cognitive health in late life. So things like blood pressure control, control of cholesterol, physical activity, how those may be useful in promoting good cognitive function in late life. And I'm also interested in how we as neuropsychologists and folks interested in cognitive functioning more broadly, how we can use things like technology to both help us stay cognitively sharp, but how we as neuropsychologists can use technology to reach people that we might not normally be able to reach because of distance from the medical center or a variety of reasons, but how we as a field can use these tools to help us reach our patients better and understand them better.
[Dr. Mia]:
Yeah, one common question I get is whether there are any brain games or any sort of cognitive training that would be helpful for people who are experiencing memory loss. What do you think?
[Bonnie Sachs]:
Yeah, so there's some research on this actually, and really the research shows that, you know, there's no one brain game that we have to do to try to help our cognition in late life. So you don't have to go out and purchase the newest, you know, brain game that's advertised on TV, or you don't have to subscribe to this particular website. But really the important thing is challenging your brain. And I think also doing while you're challenging your brain, doing something that you enjoy. So if you like crossword puzzles or if you like Sudoku or if you like, you know, whatever sort of computer game that you're doing, as long as it challenges your brain and as long as you enjoy it, I really think that's the key ingredient. So, you know, whether that, you know, again, you want to take up a new language or you want to learn a new instrument or you want to. Challenge yourself with a card game. I think all of that is great. It's just about keeping your brain active.
[Dr. Mia]:
I'm glad that I've been providing the right information to patients that corresponds
[Bonnie Sachs]:
Thank you, and have
[Dr. Mia]:
with what you said.
[Bonnie Sachs]:
a good day.
[Dr. Mia]:
Because I think if people ask me to do crossword puzzles, I'll just fail and give up because those are not my favorite.
[Bonnie Sachs]:
Yeah, I agree. I think you have to enjoy it too. If you're doing something that you don't enjoy, you're more likely to put it down or quit or give up on it. So if you enjoy it and it challenges your brain, I think you're on the right track.
[Dr. Mia]:
Yeah, and I know there are a lot of patients where sometimes I have a really difficult time figuring out in the in the clinic and through, you know, the, the more basic levels of memory testing that I do, whether it's something related to the level of education, the quality of education, or maybe some patients where English is not their first language. Can you talk about kind of what How do neuropsychologists try to figure out some of these additional challenges that may be confounding their memory performance?
[Bonnie Sachs]:
Yeah, that is a great question. I'm glad that you asked that. So, you know, part of what neuropsychologists do, we have the luxury of having these really long appointments where we get to delve into some of those things where, you know, many geriatricians or neurologists or especially primary care physicians can't, you know, don't have the ability to dig into that level to understand their patient like that. And all of those things that you mentioned are really important. So, Certainly, someone might perform differently on some of these tests of thinking if they have not completed very much school or certainly if they can't read. They might perform differently on the tests if, like you said, English is a second language. And so when we evaluate these patients and when we do our assessment, we have ways of understanding that and we have ways of accounting for that. in many instances. So some of that is, we can sort of formally take that into account by the use of something that we call norms. And norms are really how we understand how a given person might perform on these tests if they're healthy. So as we talked about earlier, there's a normal change in thinking skills as you age. So Mia, if I gave you these tests, it wouldn't be appropriate for me to compare you to someone who's 18 or someone who's 88. I would wanna know how is Mia doing compared to folks of a similar age and background. And so when we see folks who have very, very low levels of education or very, very high levels of education, we try to use a similar point of comparison for those people, because what we really wanna know is How is this person doing in these different areas of memory and thinking based on sort of who they are and their own personal characteristics? So it's really important to take into account all of those things. And in that clinical interview where we get to know them a little bit, we ask about those things, how much schooling they did, when they were in school, how did they do in school? Did they have any troubles that are lifelong, like troubles with reading or troubles with attention deficit? And so it's really important that we as neuropsychologists have a good understanding of that so that we can use the best tools to assess them and to produce the most valid results so that we can really understand how that individual person is doing.
[Dr. Mia]:
Yeah, those are all really important background information to know for each individual patient. And the norms are something that I've always been fascinated. I'm just curious, how do neuropsychologists find what's a quote unquote normal person? Where did these norms come from?
[Bonnie Sachs]:
Yeah, that's a great question. So the tests that we use, the assessments that we use, as much as I'd like to take credit for them myself, I didn't design them. The tests are developed in a couple of important ways. So they are tested out or developed on large, large groups of people who are healthy and kind of remain healthy over time. those groups of people are from different areas of the country. They have a wide range of educational background. They have different racial and ethnic makeups. There's men and women or if they're children, there's girls and boys. There's very specific and very thorough procedures that go into developing these tests and these norms. The point of that again is that we the tests and the norms that we use to be representative of the person that's sitting across from our desk, you know, on any given day. And part of the training of becoming a neuropsychologist is understanding those tests and understanding the norms and evaluating the available tests and normative data to make decisions, again, that are in the best interest of your patient so that we can gain the most accurate and valid information about them. So that's why, you know, in some ways it's really important to have all of that training that I talked about, both as a clinical psychologist and then as that specialty training as a neuropsychologist because that's where some of this expertise really comes into play.
[Dr. Mia]:
Got it. So do the neuropsychologist who sort of develop some of these tests, get this data from large cohort studies where they may have recruited a lot of patients for, I don't know, heart health, and then test our memory or they, they do their own studies recruiting participants specifically for memory related testing or norm building or a combination of both.
[Bonnie Sachs]:
Well, I think there could be lots of different ways. So some of the tests that I'm thinking of or was speaking about, when the tests are developed, the test makers or publishers want to understand how healthy folks are performing on these tests. Again, because when we see folks, the question that we're often asked is, you know, is mom's memory normal for her age, right? So we wanna know how people are doing compared to healthy individuals. It is important though sometimes that we understand that, you know, not everyone is super, super healthy, right? We understand that a lot of the folks we see have many medical... comorbidities, we call them. They may, you know, a large portion of the population has high blood pressure, a large portion of the population has, you know, high cholesterol or maybe, you know, things of that nature. And so some researchers publish norms on folks that are more like the average bear, so to speak. And so really, you know, there's sort of two different things. So there's the folks who develop the tests. We wanna know how these tests operate when we, administer them to healthy folks. We want to have a good baseline of healthy folks across the lifespan, you know, a diverse group of individuals. And then there are studies, research studies, that are published that might produce norms for a specific segment of the population or things of that nature. So really it's a little bit of both.
[Dr. Mia]:
Got it. Well, thank you so much, Bonnie. This is really interesting. And I learned a lot about what it takes to become a neuropsychologist. Anything else you wanted to add to our conversation today?
[Bonnie Sachs]:
I think the only thing I might add is that coming and getting neuropsychological testing while it can be a little bit intimidating as we talked about or a little bit nerve wracking as we talked about, really the goal is to just get a really good understanding of how your brain is working, where your strengths and weaknesses are, and to really help. an individual person and their healthcare team function as best as they can. And again, whether that's providing some recommendations around how to keep that person safe, or how to keep that person independent, or how to keep them having the best quality of life, that's really what neuropsychologists, I think, aim to do in their recommendations. A lot of times we do help come up with a diagnosis, whether that's someone has... they're normal for their age, they're doing great, or maybe they have mild cognitive impairment, or maybe there is a diagnosis of dementia. We do help crystallize that diagnosis for many, many patients that we see, but really I think the strength of our assessments come in. characterizing folks in that great detail like we talked about, which then allows us to produce some recommendations that are helpful to them to keep them safe, to keep them independent, to keep them having as good a quality of life as possible.
[Dr. Mia]:
Thank you so much and thanks for all that you do. And we'll see you all next time.
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