Neuropsychological Assessment Report Template

Clinician

Dr Eleanor Vance, Consultant Neuropsychiatrist

Patient

Arthur Pendelton (NHS Number: 482 910 3847)

Date of Birth

14/05/1956 (Age 68)

Informant

Margaret Pendelton, wife, daily contact (cohabiting)

Referral Information

Date of Assessment

24/10/2024

Referrer

Dr S. Patel, Older Adult Community Mental Health Team (CMHT)

Reason for Referral

Evaluation of progressive cognitive decline and executive dysfunction to assist with differential diagnosis (Alzheimer's disease vs vascular cognitive impairment).

Specific Referral Questions to Be Addressed

1. What is the current cognitive profile and likely underlying aetiology?
2. Does the patient retain capacity to manage complex financial affairs?

Reviewed GP summary record, CMHT clinic letter dated 12/09/2024, and MRI brain report dated 02/10/2024.

Patient Demographics

Arthur Pendelton is a 68-year-old White British, right-handed married man whose first and preferred language is English, currently living with his wife in their privately owned home.

Presenting Concerns

Mr Pendelton understands that he has been referred to the clinic to investigate his "slipping memory" and to see if there is any medical treatment to help him think more clearly.

He reports that his mind feels "foggy" and he frequently loses his train of thought mid-sentence. He describes frustration with forgetting recent conversations and misplacing everyday items, stating he feels "much slower on the uptake" than he used to be.

Insidious, gradual onset with occasional periods of sharper decline noticed by family.

Approximately 18 to 24 months.

Gradually progressive over the past two years.

No clear precipitating event identified, though symptoms became more apparent following retirement.

He has handed over household bill management to his wife and stopped driving in unfamiliar areas due to getting flustered at complex junctions.

Memory

Rapid forgetting of recent conversations, repeating questions within the same hour, and reliance on written notes for appointments. Remote autobiographical memory remains intact.

Attention and Concentration

Difficulty sustaining attention on television programmes or books; loses track of tasks if interrupted by the telephone.

Executive Function

Struggles to plan multi-step tasks such as cooking a roast dinner; reduced mental flexibility when routines are altered.

Language

Frequent word-finding pauses and occasional circumlocution, though comprehension of spoken language is preserved.

Visuospatial and Perceptual Skills

Occasional difficulty judging distances when parking the car and getting disorientated in unfamiliar shopping centres.

Processing Speed

Subjective slowing in information processing; takes significantly longer to complete crosswords and respond in group conversations.

Praxis

Intact; no difficulties reported with using cutlery, tools, or dressing.

Social Cognition

Slightly reduced empathy and occasional bluntness in social interactions, though generally retains social graces.

Informant Account

Margaret Pendelton is the patient's wife of 42 years; they cohabit and have continuous daily contact.

Mrs Pendelton confirmed her husband's account but noted the difficulties are more pronounced than he realises. She reported he frequently forgets messages from their children and has become increasingly reliant on her to structure his day. She also noted he has become more irritable when his mistakes are pointed out.

Onset noticed approximately two years ago, initially attributed to normal ageing.

Progressive decline, with a more noticeable step-down in functioning six months ago.

Significantly reduced independence in instrumental activities; requires prompting for appointments and supervision with finances.

He has withdrawn from his local golf club social committee as he struggled to follow group discussions, leading to mild social isolation.

Increased apathy, reduced initiative, and lower frustration tolerance compared to his premorbidly placid nature.

Left the gas hob on unattended twice in the last three months; became disorientated when driving at night last winter.

Mr Pendelton underestimates the frequency of his memory lapses and the extent of his reliance on his wife for daily organisation.

Mrs Pendelton reports mild carer strain and anxiety regarding the future, though she feels well supported by their adult daughter.

Neurological History

Transient Ischaemic Attack (TIA).

Diagnosed in March 2021 (presented with transient left-sided weakness resolving within 2 hours).

MRI Brain (02/10/2024): Moderate periventricular and deep white matter hyperintensities (Fazekas grade 2) consistent with chronic small vessel ischaemic disease, alongside mild bilateral hippocampal atrophy (MTA score 2).

No history of neurosurgery.

No history of seizures.

One mild head injury aged 22 following a rugby tackle; brief concussion with no loss of consciousness and post-traumatic amnesia of less than 10 minutes.

No history of CNS infection.

General Medical History

Hypertension, hyperlipidaemia, and Type 2 Diabetes Mellitus (T2DM).

Obstructive sleep apnoea (OSA) diagnosed in 2019; compliant with nocturnal CPAP.

Bilateral presbycusis (wears hearing aids, corrected) and presbyopia (wears reading glasses, corrected).

Mild chronic mechanical lower back pain, severity 3/10, managed conservatively over the past 10 years.

Laparoscopic cholecystectomy (2014); right inguinal hernia repair (2018).

Admitted to Acute Medical Unit for 24 hours in March 2021 for TIA workup.

Psychiatric History

Moderate depressive episode with anxiety (currently in partial remission).

Reactive depression in 2005 following bereavement.

First contact aged 49 via GP.

Completed 8 sessions of Cognitive Behavioural Therapy (CBT) in 2005 with good resolution of symptoms.

No previous psychiatric admissions.

Denies any current or historical self-harm, suicidal ideation, or attempts.

No history of delusions or hallucinations.

Currently under the care of the Older Adult CMHT.

Medication

• Sertraline 50 mg PO OD
• Atorvastatin 20 mg PO ON
• Ramipril 10 mg PO OD
• Clopidogrel 75 mg PO OD
• Metformin 500 mg PO BD

Good adherence, now managed via a weekly dosette box overseen by his wife.

Sertraline increased from 25 mg to 50 mg three months ago.

Citalopram 20 mg PO OD stopped in 2006 following recovery from depressive episode.

None reported.

Takes over-the-counter Vitamin D3 1,000 IU PO OD and omega-3 fish oil capsules.

Substance Use History

Currently consumes 6 units per week (two glasses of wine at weekends). History of heavier social drinking in his 40s (approx. 25 units/week). Longest period of abstinence was 3 months post-TIA in 2021.

Ex-smoker; smoked 15 cigarettes/day for 20 years, ceased in 1998.

Denies current or historical cannabis use.

Denies any history of illicit substance use.

No history of substance dependence.

Developmental History

Born at full term via normal vaginal delivery; no perinatal complications or low birth weight reported.

Met all early motor and language milestones within normal limits.

Unremarkable childhood health; no history of febrile convulsions or meningitis.

None reported.

No history of neurodevelopmental conditions.

Educational History

Attended mainstream state primary and grammar schools.

Achieved 8 O-Levels and 3 A-Levels (Maths, Physics, Geography).

No learning difficulties identified.

Strong aptitude for mathematics and technical drawing; average performance in languages.

Completed a BSc (Hons) in Civil Engineering (2:1) at university.

Premorbidly high functional literacy and numeracy; currently experiences some difficulty with complex mental arithmetic.

Occupational History

Retired (ceased work at age 65).

Senior Structural Engineer for a municipal council.

Worked in civil engineering for 40 years, spending the last 18 years as team lead for local infrastructure projects.

Planned retirement at age 65.

Senior management / professional engineering level.

None noted prior to retirement, though he mentioned finding new software systems harder to learn in his final year of work.

Receives state and occupational pensions; not currently claiming Attendance Allowance.

None; Lasting Power of Attorney (LPA) for health and finance is currently being drafted.

Social and Personal History

Lives in a two-storey detached house with his wife.

Married for 42 years; two adult children who live locally and visit weekly, and three grandchildren.

Strong family support network; maintains contact with two close former colleagues.

Attends a fortnightly men's walking group and goes for coffee with his wife regularly.

Premorbidly avid bridge player and DIY enthusiast; has stopped playing bridge due to difficulty tracking cards, now prefers gardening and watching sport.

More passive in social settings and reluctant to initiate conversations in large groups.

None.

No formal care package; all support provided informally by spouse.

Holds a full UK driving licence; currently restricts driving to local, familiar daylight routes. Advised during session regarding DVLA notification requirements if a formal cognitive diagnosis is confirmed.

Wife has taken over online banking and bill payments over the last 6 months; Mr Pendelton still uses a debit card for small daily purchases.

No safeguarding concerns identified.

Family History

Maternal grandmother developed late-onset Alzheimer's disease in her 80s; father died of a cerebrovascular accident (stroke) aged 74.

Mother had recurrent depressive episodes managed in primary care.

None known.

Paternal uncle had Type 2 Diabetes Mellitus and ischaemic heart disease.

Premorbid Functioning

Estimated to be in the High Average range based on grammar school education, university degree in engineering, and senior professional occupation.

Monolingual English speaker.

Reads broadsheet newspapers daily, though now mostly skims headlines; previously completed cryptic crosswords daily.

None impacting test interpretation.

Current Functional Status

Basic Activities of Daily Living

Independent with washing, showering, and grooming.

Independent in selecting clothes and dressing, including fastenings.

Eats well; independent with feeding.

Fully continent of bladder and bowel.

Mobilises independently without aids; normal gait.

Instrumental Activities of Daily Living

Can make hot drinks and simple snacks (e.g., toast), but wife prepares all main meals due to his difficulty coordinating timings and safety concerns with the hob.

Completes light chores such as vacuuming and lawn mowing when prompted.

Can purchase 2–3 items from the local shop with a written list, but becomes overwhelmed by large supermarket shops.

Requires significant support; struggled to reconcile bank statements and missed two utility bill payments last year.

Relies on a dosette box filled by his wife and requires verbal prompts for evening doses.

Drives locally; no longer uses public transport independently in unfamiliar areas.

Can make and receive calls on his smartphone, but frequently forgets passwords and struggles to navigate emails on his computer.

Wife manages all household correspondence and appointment scheduling.

Marked decline in complex IADLs (finances, meal preparation, technology use) compared to high premorbid independence.

Current Mood and Mental State

Describes his mood as "mostly alright, just frustrated with myself," rating it 6/10.

Mild situational anxiety when placed under time pressure or in unfamiliar environments.

Sleeps approximately 7 hours per night with CPAP; wakes feeling reasonably rested.

Appetite normal; weight stable.

Reports increased mental fatigue by mid-afternoon, often requiring a 30-minute nap.

Reduced initiative; requires prompting from his wife to start gardening or household tasks, though enjoys them once engaged.

Occasional brief irritability when corrected by his wife, quickly followed by remorse.

No disinhibition or compulsive behaviours reported.

Mental State Observations

Neatly dressed in casual clothing, well-groomed, wearing bilateral hearing aids and spectacles. Appeared his stated age.

Polite, cooperative, and pleasant throughout. Good eye contact; rapport was easily established.

Spontaneous speech was normal in rate and volume, generally coherent, but punctuated by occasional word-finding pauses and mild circumlocution.

Mood was euthymic subjectively; affect was mildly constricted and occasionally anxious when discussing his cognitive lapses, but reactive to humour.

No delusions, overvalued ideas, or suicidal ideation elicited. Preoccupied with his cognitive decline.

None observed or reported.

Orientated to person and place; knew the month and year, but was two days out on the exact date and day of the week.

Good partial insight; acknowledges memory and processing difficulties, though underestimates their functional impact on household safety and finances compared to his wife's account.

Behavioural Observations During Interview

Engaged well with the interview process and appeared motivated to provide accurate information.

Became mildly flustered and self-critical when unable to recall the exact dates of his medical history, frequently turning to his wife for verification.

Showed signs of cognitive fatigue during the final 15 minutes of the 60-minute interview, with slower response latencies.

Became briefly tearful when discussing giving up his role at the golf club and his fear of becoming a burden to his wife.

Maintained adequate focus in the quiet clinic room; minimal distractibility observed.

Required occasional repetition of multi-part questions, performing better when questions were kept brief and singular.

Demonstrated occasional word-finding pauses (e.g., struggled to retrieve the word "stethoscope") and mild circumstantiality when describing his work history.

Mild performance anxiety and afternoon cognitive fatigue should be considered when scheduling and interpreting formal psychometric testing; morning testing sessions with regular breaks are recommended.