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  1. 1. Screening for Cognitive Impairment in the Neurologist’s Office: Computerized Neuropsychological Assessment and Other Quick Screening Tools <ul><li>Jeffrey Wilken, Ph.D. </li></ul><ul><li>Cynthia Sullivan, Ph.D. </li></ul><ul><li>Department of Veterans Affairs, Washington, DC </li></ul><ul><li>University of Maryland at College Park </li></ul><ul><li>Robert Kane, Ph.D. </li></ul><ul><li>Department of Veterans Affairs, Baltimore, MD </li></ul><ul><li>University of Maryland at Baltimore Medical Center </li></ul>
  2. 3. MS-Associated Inflammation Leads to... <ul><li>Myelin Damage </li></ul><ul><li>Axonal Damage </li></ul><ul><li>Brain Atrophy </li></ul>
  3. 4. Impact of Inflammatory Damage <ul><li>Physical and/or Sensory Symptoms </li></ul><ul><li>Neuropsychological Symptoms </li></ul>
  4. 5. The Neuropsychological Evaluation <ul><li>Cognitive Domains Assessed </li></ul><ul><ul><li>Attention: </li></ul></ul><ul><ul><ul><li>Simple attention Span </li></ul></ul></ul><ul><ul><ul><ul><li>DSp Forward </li></ul></ul></ul></ul><ul><ul><ul><li>Vigilance/sustained attention </li></ul></ul></ul><ul><ul><ul><ul><li>Continuous Performance Test </li></ul></ul></ul></ul><ul><ul><ul><li>Focused Attention </li></ul></ul></ul><ul><ul><ul><ul><li>Trail Making Test (Part A), WCST Failures to Maintain Set </li></ul></ul></ul></ul><ul><ul><ul><li>Flexible Attention </li></ul></ul></ul><ul><ul><ul><ul><li>Trail Making Test (Part B) </li></ul></ul></ul></ul><ul><ul><ul><li>Complex Attention/ Working Memory </li></ul></ul></ul><ul><ul><ul><ul><li>PASAT, Arithmetic, Letter/Number Sequencing </li></ul></ul></ul></ul>
  5. 6. The Neuropsychological Evaluation <ul><li>Cognitive Domains Assessed </li></ul><ul><ul><li>Learning and Memory: </li></ul></ul><ul><ul><ul><li>Encoding: </li></ul></ul></ul><ul><ul><ul><ul><li>California Verbal Learning Test (CVLT, acquisition trials) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Wechsler Memory Scale-III (WMS-III; Learning trials of List learning, Logical Memory, Faces, Visual Reproduction, Family Pictures) </li></ul></ul></ul></ul><ul><ul><ul><li>Consolidation </li></ul></ul></ul><ul><ul><ul><ul><li>Recognition Trials of tests described above, cued recall of CVLT </li></ul></ul></ul></ul><ul><ul><ul><li>Retrieval </li></ul></ul></ul><ul><ul><ul><ul><li>Free recall trials of tests listed above </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Delay can be anywhere from 20 minutes to 4 hours </li></ul></ul></ul></ul><ul><ul><ul><ul><li>MMSE doesn’t cut it! </li></ul></ul></ul></ul>
  6. 7. The Neuropsychological Evaluation <ul><li>Cognitive Domains Assessed </li></ul><ul><ul><li>Information Processing Speed: </li></ul></ul><ul><ul><ul><li>Psychomotor speed: WAIS Digit Symbol, Symbol Search, Computerized Assessment (ANAM) </li></ul></ul></ul><ul><ul><ul><li>Mental Processing Speed: PASAT, ACT, Computerized Assessment (ANAM) </li></ul></ul></ul><ul><ul><ul><li>Visuomotor (construction) speed: WAIS-III Block Design </li></ul></ul></ul><ul><ul><li>Motor Functioning/Speed: </li></ul></ul><ul><ul><ul><li>Fine Motor Speed (Finger Tapping), Fine Motor Coordination (Grooved Pegboard, 9 hole peg), Strength (Grip Strength/dynamometer) </li></ul></ul></ul>
  7. 8. The Neuropsychological Evaluation <ul><li>Cognitive Domains Assessed </li></ul><ul><ul><li>Executive Functioning: </li></ul></ul><ul><ul><ul><li>Problem Solving </li></ul></ul></ul><ul><ul><ul><ul><li>Wisconsin Card Sorting Test (WCST), HRB Category Test </li></ul></ul></ul></ul><ul><ul><ul><li>Sequencing </li></ul></ul></ul><ul><ul><ul><ul><li>WAIS-III Picture Arrangement, Luria </li></ul></ul></ul></ul><ul><ul><ul><li>Abstract Reasoning </li></ul></ul></ul><ul><ul><ul><ul><li>Visual: WAIS-III Matrix Reasoning, Ravens Coloured Progressive Matrices, Ravens Standard Progressive Matrices </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Verbal: WAIS-III Similarities, parts of WAIS-III Comprehension </li></ul></ul></ul></ul>
  8. 9. The Neuropsychological Evaluation <ul><li>Cognitive Domains Assessed </li></ul><ul><ul><li>Language (Not the same as speech): </li></ul></ul><ul><ul><ul><li>Language Batteries: </li></ul></ul></ul><ul><ul><ul><ul><li>Boston Diagnostic Aphasia Exam, Western Aphasia Exam </li></ul></ul></ul></ul><ul><ul><ul><li>Verbal Fluency </li></ul></ul></ul><ul><ul><ul><ul><li>Controlled Oral Word Association Test (COWAT): FAS, CFL (lexical fluency) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Animals, Supermarket (Categorical Fluency) </li></ul></ul></ul></ul><ul><ul><ul><li>Word Finding </li></ul></ul></ul><ul><ul><ul><ul><li>Boston Naming Test </li></ul></ul></ul></ul><ul><ul><ul><li>Comprehension </li></ul></ul></ul><ul><ul><ul><ul><li>Token Test </li></ul></ul></ul></ul>
  9. 10. The Neuropsychological Evaluation <ul><li>Cognitive Domains Assessed </li></ul><ul><ul><li>General Intellect: </li></ul></ul><ul><ul><ul><li>Is it important to know about? </li></ul></ul></ul><ul><ul><ul><li>What is the IQ? How is it assessed? </li></ul></ul></ul><ul><ul><ul><li>Assessing premorbid functioning </li></ul></ul></ul>
  10. 11. Neuropsychological Dysfunction in MS
  11. 12. <ul><li>COGNITIVE domains regularly affected: </li></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Learning and Retrieval (Memory) </li></ul></ul><ul><ul><li>Information processing speed </li></ul></ul><ul><ul><li>Visuospatial perception </li></ul></ul><ul><ul><li>Executive Function </li></ul></ul><ul><li>COGNITIVE domains usually spared: </li></ul><ul><ul><li>Language/Verbal Skills </li></ul></ul>Cognitive Dysfunction in MS
  12. 13. <ul><li>COGNITIVE domains regularly affected: </li></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Learning and Retrieval (Memory) </li></ul></ul><ul><ul><li>Information processing speed </li></ul></ul><ul><ul><li>Visual spatial perception </li></ul></ul><ul><ul><li>Executive Function </li></ul></ul><ul><li>COGNITIVE domains usually spared: </li></ul><ul><ul><li>Language/Verbal Skills </li></ul></ul>Cognitive Dysfunction in MS
  13. 14. Components of Memory <ul><li>ENCODING </li></ul><ul><li>(getting the information in) </li></ul><ul><li> CONSOLIDATION </li></ul><ul><ul><li>(transferring the information into long-term store) </li></ul></ul><ul><ul><li> RETRIEVAL (getting the information out) </li></ul></ul><ul><ul><li> Free Recall vs . Recognition Memory </li></ul></ul>
  14. 15. Cognitive Dysfunction in MS <ul><li>COGNITIVE domains regularly affected: </li></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Learning and Retrieval (Memory) </li></ul></ul><ul><ul><li>Information processing speed </li></ul></ul><ul><ul><li>Visual spatial perception </li></ul></ul><ul><ul><li>Executive Function </li></ul></ul><ul><li>COGNITIVE domains usually spared: </li></ul><ul><ul><li>Language/Verbal Skills </li></ul></ul>
  15. 16. Cognitive Dysfunction in MS <ul><li>COGNITIVE domains regularly affected: </li></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Learning and Retrieval (Memory) </li></ul></ul><ul><ul><li>Information processing speed </li></ul></ul><ul><ul><li>Visuospatial perception </li></ul></ul><ul><ul><li>Executive Function </li></ul></ul><ul><li>COGNITIVE domains usually spared: </li></ul><ul><ul><li>Language/Verbal Skills </li></ul></ul>
  16. 17. Cognitive Dysfunction in MS <ul><li>COGNITIVE domains regularly affected: </li></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Learning and Retrieval (Memory) </li></ul></ul><ul><ul><li>Information processing speed </li></ul></ul><ul><ul><li>Visuospatial perception </li></ul></ul><ul><ul><li>Executive Function </li></ul></ul><ul><li>COGNITIVE domains usually spared: </li></ul><ul><ul><li>Language/Verbal Skills </li></ul></ul>
  17. 18. Wisconsin Card Sorting Test
  18. 19. 0 10 15 20 25 30 MS Controls Perseverative Errors Non-Perseverative Errors Wisconsin Card Sorting Test* *Rao et al., Journal of Consulting and Clinical Psychology , 1987, 55 , 263-265
  19. 20. Cognitive Dysfunction in MS <ul><li>COGNITIVE domains regularly affected: </li></ul><ul><ul><li>Attention </li></ul></ul><ul><ul><li>Learning and Retrieval (Memory) </li></ul></ul><ul><ul><li>Information processing speed </li></ul></ul><ul><ul><li>Visuospatial perception </li></ul></ul><ul><ul><li>Executive Function </li></ul></ul><ul><li>COGNITIVE domains usually spared: </li></ul><ul><ul><li>Language/Verbal Skills </li></ul></ul>
  20. 21. Indicators of Potential Neuropsychological Dysfunction in MS <ul><li>Help in ADLs in the absence of disability. </li></ul><ul><li>Unemployment in the absence of physical disability </li></ul><ul><li>Mood disorder other than depression </li></ul><ul><li>Withdrawal from usual activities/socialization </li></ul><ul><li>Opinion of significant other personality shift </li></ul>
  21. 22. <ul><li>Significantly increased likelihood of cognitive dysfunction in patients with: </li></ul><ul><ul><li>Greater overall T2 lesion area 1 </li></ul></ul><ul><ul><li>Greater T1 and T2 lesion load 2,3 </li></ul></ul><ul><ul><li>Greater number of juxtacortical lesions 4 </li></ul></ul>Relationship Between Cognitive Dysfunction and Lesion Load 1 Rao SM, Leo GJ, Haughton VM, St Aubin-Faubert P, Bernardin L. Correlation of magnetic resonance imaging with neuropsychological testing in multiple sclerosis. Neurology 1989; 39 : 161-166. 2 Comi G, Rovaris M, Falautano M, Santuccio G, Martinelli V, Rocca MA, Possa F, Leocani L, Paulesu E, Filippi M. A multiparametric MRI study of frontal lobe dementia in multiple sclerosis. Journal of the Neurological Sciences 1999; 171 : 135-144. 3 Rovaris M, Filippi M, Falautano M, Minicucci L, Rocca MA, Martinelli V, Comi G. Relation between MR abnormalities and patterns of cognitive impairment in multiple sclerosis. Neurology 1998; 50 : 1601-1608. 4 Lazeron RH, Langdon DW, Filippi M, van Waesberghe JH, Stevenson VL, Boringa JB, Origgi D, Thompson AJ, Falautano M, Polman CH, Barkhof F. Neuropsychological impairment in multiple sclerosis patients: The role of juxtacortical lesion on FLAIR. Multiple Sclerosis 2000; 6 : 280-285.
  22. 23. Total T2 Lesion Area (sq cm) Number of Cognitive Tests Performed < 5 th Percentile of Controls * * Rao et al., Neurology , 1989, 39 , 161-166
  23. 24. Atrophy as a Predictor of Cognitive Dysfunction <ul><li>Brain atrophy has been found to be an independent predictor of cognitive dysfunction 1,2 </li></ul><ul><li>Recent research suggests that, in fact, central atrophy, as measured by third ventricle width, was more strongly predictive of cognitive dysfunction than either global atrophy or lesion load. 3 </li></ul><ul><li>Quantitative analysis of MRIs of patients with MS suggests that atrophy of the superior frontal lobes is associated with cognitive morbidity 3,4 </li></ul><ul><li>Zivadinov et al. Neuroradiology . 2001;43:272. </li></ul><ul><li>Zivadinov et al. J Neurol Neurosurg Psychiatry . 2001;70:773. </li></ul><ul><li>Benedict et al. Arch Neurol . 2004;61:226. </li></ul><ul><li>Benedict et al. J Neuropsychiatry Clin Neurosci . 2002;14:44. </li></ul>
  24. 25. 10 9 8 7 6 5 4 3 2 7 6 5 4 3 2 VERBAL SPATIAL TRIALS Normal Ventricular Size (N=19) Mild Ventricular Dilatation (N=19) Mod./Severe Ventricular Dilatation (N=9) Mean words recalled Mean items recalled Atrophy And Memory Performance* *Rao et al., Archives of Neurology , 1985, 42 , 678-682
  25. 26. Assessment Of Cognitive Dysfunction <ul><li>In the office? What can be done during a neurological examination? </li></ul><ul><ul><li>Screening batteries are available, but training is essential and supervision is highly recommended. </li></ul></ul><ul><ul><li>If you independently use formal or informal screening batteries, ongoing consultation with a neuropsychologist is strongly recommended. </li></ul></ul>
  26. 27. Assessment Of Cognitive Dysfunction <ul><li>MS Functional Composite ( NMSS Clinical Outcomes Assessment Task Force, 1997) </li></ul><ul><ul><li>3 measures (includes PASAT) </li></ul></ul><ul><ul><li>used as outcome measure in clinical trials, </li></ul></ul><ul><ul><li>administered and scored by non-neuropsychologist </li></ul></ul>
  27. 28. MS Functional Composite <ul><li>Timed 25 Foot Walk </li></ul><ul><li>9 Hole Peg Test </li></ul><ul><ul><li>average of right and left arms </li></ul></ul><ul><li>Paced Auditory Serial Addition Test </li></ul><ul><ul><li>number correct, 3 sec. version </li></ul></ul>
  28. 29. 25 50 75 100 Easy (3s) Hard (2s) Percent Correct Paced Auditory Serial Addition Test (PASAT) Control Multiple Sclerosis 4 6 3 1 9 5 “ 10” “9” “4” “10” “14”
  29. 30. Assessment Of Cognitive Dysfunction <ul><li>NPSBMS (Neuropsychological Screening Battery for Multiple Sclerosis, Rao, 1991) </li></ul><ul><ul><li>Can be administered by subdoctoral personnel after brief training (30 min) </li></ul></ul><ul><ul><li>30-40 minutes to administer,used to screen patients in clinical setting </li></ul></ul><ul><ul><li>administered and scored by non-neuropsychologist </li></ul></ul><ul><ul><li>Not good for research needing repeated measures </li></ul></ul>
  30. 31. Neuropsychological Screening Battery for Multiple Sclerosis <ul><li>Taps 4 Cognitive Domains </li></ul><ul><ul><li>1. Sustained Attention and Concentration </li></ul></ul><ul><ul><li>2. Verbal Learning and Recall </li></ul></ul><ul><ul><li>3. Visuospatial Learning and Recall </li></ul></ul><ul><ul><li>4. Semantic Fluency </li></ul></ul><ul><ul><li>Impairment suspected if 2 or more tests are failed (test performance falls below the 5 th percentile) </li></ul></ul>
  31. 32. Assessment Of Cognitive Dysfunction <ul><li>ANAM Computerized Screening Battery as an MS screen (Wilken et al., 2003) </li></ul><ul><ul><li>25-30 minutes to administer </li></ul></ul><ul><ul><li>administered and scored by non-neuropsychologist </li></ul></ul><ul><ul><li>Interpreted by neuropsychologist </li></ul></ul><ul><ul><li>correlates highly with traditional measures </li></ul></ul>Wilken, J.A., Kane, R., Sullivan, C.L., et al. The utility of computerized neuropsychological assessment of cognitive dysfunction in patients with relapsing-remitting multiple sclerosis. Multiple Sclerosis, 2003; 9 : 119-127
  32. 33. Assessment Of Cognitive Dysfunction <ul><li>In the office? What can be done during a neurological examination? </li></ul><ul><ul><li>Can be billed as extended neurological visit. </li></ul></ul><ul><ul><li>Neuropsychologists like to use standardized tests with norms, but testing takes a long time and is not feasible in your office. </li></ul></ul><ul><ul><li>There are some quick ways to look at different functional domains, but these are “quick and dirty”, no norms </li></ul></ul><ul><ul><li>Require a little work up front (very quick), but can be used with every pt to screen </li></ul></ul>
  33. 34. Assessment Of Cognitive Dysfunction <ul><li>In the office? What can be done during a neurological examination? </li></ul><ul><ul><li>Given lack of norms, only a screen. Pt will have to serve as own control. Do not make too much of one bad time (could be exacerbation). Best to follow pt over time and see if any patterns of decline relative to past performance </li></ul></ul><ul><ul><li>Techniques for triage/screening only. If poor performance, recommend more extensive workup. Cannot be used for disability claims </li></ul></ul><ul><ul><li>Even when just performing informal screening, it is strongly recommended that you consult with a neuropsychologist </li></ul></ul>
  34. 35. Assessment Of Cognitive Dysfunction <ul><li>In the office? What can be done during a neurological examination? </li></ul><ul><ul><li>To look at attention: </li></ul></ul><ul><ul><ul><li>1 Trial of PASAT </li></ul></ul></ul><ul><ul><ul><li>Mental Control (WMS)…days backwards, backwards serial 7’s </li></ul></ul></ul><ul><ul><ul><li>Cancellation test (public domain) </li></ul></ul></ul>
  35. 36. Assessment Of Cognitive Dysfunction <ul><li>In the office? What can be done during a neurological examination? </li></ul><ul><ul><li>To look at Memory </li></ul></ul><ul><ul><ul><li>Short word list with recognition, 10 minute delay </li></ul></ul></ul><ul><ul><ul><ul><li>Make up a list of 10 common, easy, unrelated words. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Read list to pt 3 times, have pt give list back 3 times (allows you to look at learning curve) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Use same list for every patient (maybe even collect your own norms) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>10 minute delay </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Need a recognition trial (yes/no, multiple choice), helps look at retrieval versus consolidation </li></ul></ul></ul></ul>
  36. 37. Assessment Of Cognitive Dysfunction <ul><li>In the office? What can be done during a neurological examination? </li></ul><ul><ul><li>To look at language </li></ul></ul><ul><ul><ul><li>Word finding on the MMSE not enough </li></ul></ul></ul><ul><ul><ul><li>Instead, have 5-10 objects available, used for every patient </li></ul></ul></ul><ul><ul><ul><li>Verbal (lexical) Fluency (FAS, CFL), 1 minute per word </li></ul></ul></ul><ul><ul><ul><li>Verbal (semantic) Fluency (Animals, Supermarket) </li></ul></ul></ul>
  37. 38. Assessment Of Cognitive Dysfunction <ul><li>In the office? What can be done during a neurological examination? </li></ul><ul><ul><li>To look at Motor Speed/ Processing Speed </li></ul></ul><ul><ul><ul><li>9 Hole Peg Test </li></ul></ul></ul><ul><ul><ul><li>Digit Symbol Modalities Test (public domain) </li></ul></ul></ul>
  38. 39. Neuropsychological Evaluation: Limitations of Screening Batteries <ul><li>Cannot adequately address specific issues involving vocational counseling, disability determination, competency, and rehab planning (Rao, NSBMS Manual) </li></ul><ul><li>Not suitable for Differential Diagnosis </li></ul><ul><li>Not enough information for complicated functional analysis </li></ul>
  39. 40. Assessment Of Cognitive Dysfunction <ul><li>Comprehensive Neuropsychological Examination </li></ul><ul><ul><li>3-5 hours, addresses differential diagnosis, disability questions </li></ul></ul><ul><ul><li>administered/interpreted by clinical neuropsychologist </li></ul></ul><ul><ul><li>Should expect full report with conclusions (e.g., MS or depression) as well as recommendations (for work, school, etc). </li></ul></ul><ul><ul><li>REIMBURSEMENT IS MORE FREQUENT THAN MIGHT BE BELIEVED. NEEDS TO BE A MEDICAL DIAGNOSIS (340, MS) AND A CPT CODE FOR NEUROPSYCHOLOGICAL TESTING (96117) BILLED BY A NEUROPSYCHOLOGIST. SOMETIMES, PRE-CERT NEEDED. </li></ul></ul>
  40. 41. Assessment Of Cognitive Dysfunction <ul><li>Why to refer for a Comprehensive Neuropsychological Evaluation </li></ul><ul><ul><li>Diagnosis of MS-related cognitive decline, determination of domains affected, often validating to pt and family </li></ul></ul><ul><ul><li>Differential Diagnosis (e.g., functional vs. MS, Alz vs MS) </li></ul></ul><ul><ul><li>Functional analysis to determine home/school/work needs and accommodations (often, the only way to force help) </li></ul></ul><ul><ul><li>Disability evaluation (Most often, the only way to get disability) </li></ul></ul><ul><ul><li>Assist the treatment team in determining capability of pt to follow through on treatment, live independently </li></ul></ul>
  41. 42. Assessment Of Cognitive Dysfunction <ul><li>Comprehensive Neuropsychological Evaluation </li></ul><ul><ul><li>Whom do you refer to? </li></ul></ul><ul><ul><li>Ph.D. level clinical neuropsychologist experienced in the assessment of MS-related cognitive problems. For certain types of difficulties (e.g., speech/language), some other specialists will assess some aspects of cognitive functioning. </li></ul></ul>
  42. 43. The Neuropsychological Evaluation <ul><li>Sections of the Neuropsychological Report </li></ul><ul><ul><li>Conclusions: </li></ul></ul><ul><ul><ul><li>MUST ANSWER THE REFERRAL QUESTION!!!!!! </li></ul></ul></ul><ul><ul><ul><li>Should be relevant to the referral source/needs of the patient </li></ul></ul></ul><ul><ul><ul><li>Should include an opinion on diagnosis </li></ul></ul></ul><ul><ul><ul><li>Should ALSO include a functional analysis (what is the patient capable of? What might they have trouble with? Should reflect needs of patient as indicated in the referral section) </li></ul></ul></ul>
  43. 44. The Neuropsychological Evaluation <ul><li>Sections of the Neuropsychological Report </li></ul><ul><ul><li>Recommendations: </li></ul></ul><ul><ul><ul><li>REPORT MUST CONTAIN RECOMMENDATIONS </li></ul></ul></ul><ul><ul><ul><li>Recommendations should be relevant with respect to the referral question </li></ul></ul></ul><ul><ul><ul><li>Recommendations should be possible! </li></ul></ul></ul><ul><ul><ul><li>Should discuss healthcare providers who can help the patient. </li></ul></ul></ul>

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