Screening for Cognitive Impairment in the Neurologists Office: Computerized Neuropsychological Asses

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Screening for Cognitive Impairment in the
Neurologists Office Computerized
Neuropsychological Assessment and Other Quick
Screening Tools

• Jeffrey Wilken, Ph.D.
• Cynthia Sullivan, Ph.D.
• Department of Veterans Affairs, Washington, DC
• University of Maryland at College Park
• Robert Kane, Ph.D.
• Department of Veterans Affairs, Baltimore, MD
• University of Maryland at Baltimore Medical Center

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MS-Associated Inflammation Leads to...

• Myelin Damage
• Axonal Damage
• Brain Atrophy

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Impact ofInflammatory Damage

• Physical and/or Sensory Symptoms
• Neuropsychological Symptoms

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The Neuropsychological Evaluation

• Cognitive Domains Assessed
• Attention
• Simple attention Span
• DSp Forward
• Vigilance/sustained attention
• Continuous Performance Test
• Focused Attention
• Trail Making Test (Part A), WCST Failures to
  Maintain Set
• Flexible Attention
• Trail Making Test (Part B)
• Complex Attention/ Working Memory
• PASAT, Arithmetic, Letter/Number Sequencing

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The Neuropsychological Evaluation

• Cognitive Domains Assessed
• Learning and Memory
• Encoding
• California Verbal Learning Test (CVLT,
  acquisition trials)
• Wechsler Memory Scale-III (WMS-III Learning
  trials of List learning, Logical Memory, Faces,
  Visual Reproduction, Family Pictures)
• Consolidation
• Recognition Trials of tests described above, cued
  recall of CVLT
• Retrieval
• Free recall trials of tests listed above
• Delay can be anywhere from 20 minutes to 4 hours
• MMSE doesnt cut it!

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The Neuropsychological Evaluation

• Cognitive Domains Assessed
• Information Processing Speed
• Psychomotor speed WAIS Digit Symbol, Symbol
  Search, Computerized Assessment (ANAM)
• Mental Processing Speed PASAT, ACT, Computerized
  Assessment (ANAM)
• Visuomotor (construction) speed WAIS-III Block
  Design
• Motor Functioning/Speed
• Fine Motor Speed (Finger Tapping), Fine Motor
  Coordination (Grooved Pegboard, 9 hole peg),
  Strength (Grip Strength/dynamometer)

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The Neuropsychological Evaluation

• Cognitive Domains Assessed
• Executive Functioning
• Problem Solving
• Wisconsin Card Sorting Test (WCST), HRB Category
  Test
• Sequencing
• WAIS-III Picture Arrangement, Luria
• Abstract Reasoning
• Visual WAIS-III Matrix Reasoning, Ravens
  Coloured Progressive Matrices, Ravens Standard
  Progressive Matrices
• Verbal WAIS-III Similarities, parts of WAIS-III
  Comprehension

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The Neuropsychological Evaluation

• Cognitive Domains Assessed
• Language (Not the same as speech)
• Language Batteries
• Boston Diagnostic Aphasia Exam, Western Aphasia
  Exam
• Verbal Fluency
• Controlled Oral Word Association Test (COWAT)
  FAS, CFL (lexical fluency)
• Animals, Supermarket (Categorical Fluency)
• Word Finding
• Boston Naming Test
• Comprehension
• Token Test

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The Neuropsychological Evaluation

• Cognitive Domains Assessed
• General Intellect
• Is it important to know about?
• What is the IQ? How is it assessed?
• Assessing premorbid functioning

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Neuropsychological Dysfunction

• in MS

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Cognitive Dysfunction in MS

• COGNITIVE domains regularly affected
• Attention
• Learning and Retrieval (Memory)
• Information processing speed
• Visuospatial perception
• Executive Function
• COGNITIVE domains usually spared
• Language/Verbal Skills

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Cognitive Dysfunction in MS

• COGNITIVE domains regularly affected
• Attention
• Learning and Retrieval (Memory)
• Information processing speed
• Visual spatial perception
• Executive Function
• COGNITIVE domains usually spared
• Language/Verbal Skills

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Components of Memory

• ENCODING
• (getting the information in)
• CONSOLIDATION
• (transferring the information into long-term
  store)
• RETRIEVAL (getting the information out)
• Free Recall vs. Recognition
  Memory

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Cognitive Dysfunction in MS

• COGNITIVE domains regularly affected
• Attention
• Learning and Retrieval (Memory)
• Information processing speed
• Visual spatial perception
• Executive Function
• COGNITIVE domains usually spared
• Language/Verbal Skills

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Cognitive Dysfunction in MS

• COGNITIVE domains regularly affected
• Attention
• Learning and Retrieval (Memory)
• Information processing speed
• Visuospatial perception
• Executive Function
• COGNITIVE domains usually spared
• Language/Verbal Skills

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Cognitive Dysfunction in MS

• COGNITIVE domains regularly affected
• Attention
• Learning and Retrieval (Memory)
• Information processing speed
• Visuospatial perception
• Executive Function
• COGNITIVE domains usually spared
• Language/Verbal Skills

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Wisconsin Card Sorting Test
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Wisconsin Card Sorting Test
Perseverative Errors Non-Perseverative Errors
30
25
20
15
10
0
MS
Controls
Rao et al., Journal of Consulting and Clinical
Psychology, 1987, 55, 263-265
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Cognitive Dysfunction in MS

• COGNITIVE domains regularly affected
• Attention
• Learning and Retrieval (Memory)
• Information processing speed
• Visuospatial perception
• Executive Function
• COGNITIVE domains usually spared
• Language/Verbal Skills

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Indicators of Potential NeuropsychologicalDysfun
ction in MS

• Help in ADLs in the absence of disability.
• Unemployment in the absence of physical
  disability
• Mood disorder other than depression
• Withdrawal from usual activities/socialization
• Opinion of significant other personality shift

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Relationship Between Cognitive Dysfunction and
Lesion Load

• Significantly increased likelihood of cognitive
  dysfunction in patients with
• Greater overall T2 lesion area1
• Greater T1 and T2 lesion load2,3
• Greater number of juxtacortical lesions4

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.
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Number of Cognitive Tests Performed lt 5th
Percentile of Controls
Total T2 Lesion Area (sq cm)
Rao et al., Neurology, 1989, 39, 161-166
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Atrophy as a Predictor of Cognitive Dysfunction

• Brain atrophy has been found to be an independent
  predictor of cognitive dysfunction1,2
• 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
• Quantitative analysis of MRIs of patients with MS
  suggests that atrophy of the superior frontal
  lobes is associated with cognitive morbidity3,4

• Zivadinov et al. Neuroradiology. 200143272.
• Zivadinov et al. J Neurol Neurosurg Psychiatry.
  200170773.
• Benedict et al. Arch Neurol. 200461226.
• Benedict et al. J Neuropsychiatry Clin Neurosci.
  20021444.

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Atrophy And Memory Performance
VERBAL SPATIAL
7
10 9 8 7 6 5 4 3 2
6
5
Mean words recalled
Mean items recalled
4
3
Normal Ventricular Size (N19) Mild Ventricular
Dilatation (N19) Mod./Severe Ventricular
Dilatation (N9)
2
TRIALS
Rao et al., Archives of Neurology, 1985, 42,
678-682
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Assessment Of Cognitive Dysfunction

• In the office? What can be done during a
  neurological examination?
• Screening batteries are available, but training
  is essential and supervision is highly
  recommended.
• If you independently use formal or informal
  screening batteries, ongoing consultation with a
  neuropsychologist is strongly recommended.

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Assessment Of Cognitive Dysfunction

• MS Functional Composite (NMSS Clinical Outcomes
  Assessment Task Force, 1997)
• 3 measures (includes PASAT)
• used as outcome measure in clinical trials,
• administered and scored by non-neuropsychologist

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MS Functional Composite

• Timed 25 Foot Walk
• 9 Hole Peg Test
• average of right and left arms
• Paced Auditory Serial Addition Test
• number correct, 3 sec. version

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Paced Auditory Serial Addition Test (PASAT)
Percent Correct
100
Control
75
4 6 3 1 9 5
Multiple Sclerosis
50
10 9 4 10 14
25
Easy (3s)
Hard (2s)
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Assessment Of Cognitive Dysfunction

• NPSBMS (Neuropsychological Screening Battery for
  Multiple Sclerosis, Rao, 1991)
• Can be administered by subdoctoral personnel
  after brief training (30 min)
• 30-40 minutes to administer,used to screen
  patients in clinical setting
• administered and scored by non-neuropsychologist
• Not good for research needing repeated measures

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Neuropsychological Screening Battery for Multiple
Sclerosis

• Taps 4 Cognitive Domains
• 1. Sustained Attention and Concentration
• 2. Verbal Learning and Recall
• 3. Visuospatial Learning and Recall
• 4. Semantic Fluency
• Impairment suspected if 2 or more tests are
  failed (test performance falls below the 5th
  percentile)

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Assessment Of Cognitive Dysfunction

• ANAM Computerized Screening Battery as an MS
  screen (Wilken et al., 2003)
• 25-30 minutes to administer
• administered and scored by non-neuropsychologist
• Interpreted by neuropsychologist
• correlates highly with traditional measures

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
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Assessment Of Cognitive Dysfunction

• In the office? What can be done during a
  neurological examination?
• Can be billed as extended neurological visit.
• Neuropsychologists like to use standardized tests
  with norms, but testing takes a long time and is
  not feasible in your office.
• There are some quick ways to look at different
  functional domains, but these are quick and
  dirty, no norms
• Require a little work up front (very quick), but
  can be used with every pt to screen

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Assessment Of Cognitive Dysfunction

• In the office? What can be done during a
  neurological examination?
• 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
• Techniques for triage/screening only. If poor
  performance, recommend more extensive workup.
  Cannot be used for disability claims
• Even when just performing informal screening, it
  is strongly recommended that you consult with a
  neuropsychologist

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Assessment Of Cognitive Dysfunction

• In the office? What can be done during a
  neurological examination?
• To look at attention
• 1 Trial of PASAT
• Mental Control (WMS)days backwards, backwards
  serial 7s
• Cancellation test (public domain)

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Assessment Of Cognitive Dysfunction

• In the office? What can be done during a
  neurological examination?
• To look at Memory
• Short word list with recognition, 10 minute delay
• Make up a list of 10 common, easy, unrelated
  words.
• Read list to pt 3 times, have pt give list back 3
  times (allows you to look at learning curve)
• Use same list for every patient (maybe even
  collect your own norms)
• 10 minute delay
• Need a recognition trial (yes/no, multiple
  choice), helps look at retrieval versus
  consolidation

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Assessment Of Cognitive Dysfunction

• In the office? What can be done during a
  neurological examination?
• To look at language
• Word finding on the MMSE not enough
• Instead, have 5-10 objects available, used for
  every patient
• Verbal (lexical) Fluency (FAS, CFL), 1 minute per
  word
• Verbal (semantic) Fluency (Animals, Supermarket)

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Assessment Of Cognitive Dysfunction

• In the office? What can be done during a
  neurological examination?
• To look at Motor Speed/ Processing Speed
• 9 Hole Peg Test
• Digit Symbol Modalities Test (public domain)

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Neuropsychological Evaluation Limitations of
Screening Batteries

• Cannot adequately address specific issues
  involving vocational counseling, disability
  determination, competency, and rehab planning
  (Rao, NSBMS Manual)
• Not suitable for Differential Diagnosis
• Not enough information for complicated functional
  analysis

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Assessment Of Cognitive Dysfunction

• Comprehensive Neuropsychological Examination
• 3-5 hours, addresses differential diagnosis,
  disability questions
• administered/interpreted by clinical
  neuropsychologist
• Should expect full report with conclusions (e.g.,
  MS or depression) as well as recommendations (for
  work, school, etc).
• 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.

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Assessment Of Cognitive Dysfunction

• Why to refer for a Comprehensive
  Neuropsychological Evaluation
• Diagnosis of MS-related cognitive decline,
  determination of domains affected, often
  validating to pt and family
• Differential Diagnosis (e.g., functional vs. MS,
  Alz vs MS)
• Functional analysis to determine home/school/work
  needs and accommodations (often, the only way to
  force help)
• Disability evaluation (Most often, the only way
  to get disability)
• Assist the treatment team in determining
  capability of pt to follow through on treatment,
  live independently

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Assessment Of Cognitive Dysfunction

• Comprehensive Neuropsychological Evaluation
• Whom do you refer to?
• 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.

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The Neuropsychological Evaluation

• Sections of the Neuropsychological Report
• Conclusions
• MUST ANSWER THE REFERRAL QUESTION!!!!!!
• Should be relevant to the referral source/needs
  of the patient
• Should include an opinion on diagnosis
• 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)

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The Neuropsychological Evaluation

• Sections of the Neuropsychological Report
• Recommendations
• REPORT MUST CONTAIN RECOMMENDATIONS
• Recommendations should be relevant with respect
  to the referral question
• Recommendations should be possible!
• Should discuss healthcare providers who can help
  the patient.