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Screening for Cognitive Impairment in the Neurologist’s Office: Computerized

Neuropsychological Assessment and Other Quick Screening Tools

Jeffrey Wilken, Ph.D.Jeffrey Wilken, Ph.D.Cynthia Sullivan, Ph.D.Cynthia Sullivan, Ph.D.

Department of Veterans Affairs, Washington, DCDepartment of Veterans Affairs, Washington, DCUniversity of Maryland at College ParkUniversity of Maryland at College Park

Robert Kane, Ph.D.Robert Kane, Ph.D.Department of Veterans Affairs, Baltimore, MDDepartment of Veterans Affairs, Baltimore, MD

University of Maryland at Baltimore Medical CenterUniversity of Maryland at Baltimore Medical Center

MS-Associated MS-Associated Inflammation Leads to...Inflammation Leads to...

Myelin DamageMyelin Damage

Axonal DamageAxonal Damage

Brain AtrophyBrain Atrophy

Impact ofImpact ofInflammatory DamageInflammatory Damage

Physical Physical and/orand/or Sensory Sensory SymptomsSymptoms

Neuropsychological Neuropsychological SymptomsSymptoms

The Neuropsychological Evaluation Cognitive Domains AssessedCognitive Domains Assessed

Attention:Attention:

Simple attention SpanSimple attention Span

• DSp ForwardDSp Forward

Vigilance/sustained attentionVigilance/sustained attention

• Continuous Performance TestContinuous Performance Test

Focused AttentionFocused Attention

• Trail Making Test (Part A), WCST Failures to Maintain SetTrail Making Test (Part A), WCST Failures to Maintain Set

Flexible AttentionFlexible Attention

• Trail Making Test (Part B)Trail Making Test (Part B)

Complex Attention/ Working MemoryComplex Attention/ Working Memory

• PASAT, Arithmetic, Letter/Number SequencingPASAT, Arithmetic, Letter/Number Sequencing


Learning and Memory:Learning and Memory:

Encoding:Encoding:

• California Verbal Learning Test (CVLT, acquisition trials)California Verbal Learning Test (CVLT, acquisition trials)

• Wechsler Memory Scale-III (WMS-III; Learning trials of List learning, Logical Memory, Faces, Visual Wechsler Memory Scale-III (WMS-III; Learning trials of List learning, Logical Memory, Faces, Visual Reproduction, Family Pictures)Reproduction, Family Pictures)

ConsolidationConsolidation

• Recognition Trials of tests described above, cued recall of CVLTRecognition Trials of tests described above, cued recall of CVLT

RetrievalRetrieval

• Free recall trials of tests listed aboveFree recall trials of tests listed above

• Delay can be anywhere from 20 minutes to 4 hoursDelay can be anywhere from 20 minutes to 4 hours

• MMSE doesn’t cut it!MMSE doesn’t cut it!


Information Processing Speed:Information Processing Speed:

Psychomotor speed: WAIS Digit Symbol, Symbol Search, Computerized Assessment (ANAM)Psychomotor speed: WAIS Digit Symbol, Symbol Search, Computerized Assessment (ANAM)

Mental Processing Speed: PASAT, ACT, Computerized Assessment (ANAM)Mental Processing Speed: PASAT, ACT, Computerized Assessment (ANAM)

Visuomotor (construction) speed: WAIS-III Block DesignVisuomotor (construction) speed: WAIS-III Block Design

Motor Functioning/Speed:Motor Functioning/Speed: Fine Motor Speed (Finger Tapping), Fine Motor Coordination (Grooved Pegboard, 9 hole peg), Strength (Grip Fine Motor Speed (Finger Tapping), Fine Motor Coordination (Grooved Pegboard, 9 hole peg), Strength (Grip

Strength/dynamometer)Strength/dynamometer)


Executive Functioning:Executive Functioning:

Problem SolvingProblem Solving

• Wisconsin Card Sorting Test (WCST), HRB Category TestWisconsin Card Sorting Test (WCST), HRB Category Test

SequencingSequencing

• WAIS-III Picture Arrangement, LuriaWAIS-III Picture Arrangement, Luria

Abstract ReasoningAbstract Reasoning

• Visual: WAIS-III Matrix Reasoning, Ravens Coloured Progressive Matrices, Ravens Visual: WAIS-III Matrix Reasoning, Ravens Coloured Progressive Matrices, Ravens Standard Progressive MatricesStandard Progressive Matrices

• Verbal: WAIS-III Similarities, parts of WAIS-III ComprehensionVerbal: WAIS-III Similarities, parts of WAIS-III Comprehension


Language (Not the same as speech):Language (Not the same as speech):

Language Batteries:Language Batteries:

• Boston Diagnostic Aphasia Exam, Western Aphasia ExamBoston Diagnostic Aphasia Exam, Western Aphasia Exam

Verbal FluencyVerbal Fluency

• Controlled Oral Word Association Test (COWAT): FAS, CFL (lexical fluency)Controlled Oral Word Association Test (COWAT): FAS, CFL (lexical fluency)

• Animals, Supermarket (Categorical Fluency)Animals, Supermarket (Categorical Fluency)

Word FindingWord Finding

• Boston Naming TestBoston Naming Test

ComprehensionComprehension

• Token TestToken Test

The Neuropsychological Evaluation

Cognitive Domains AssessedCognitive Domains Assessed

General Intellect:General Intellect:

Is it important to know about?Is it important to know about?

What is the IQ? How is it assessed?What is the IQ? How is it assessed?

Assessing premorbid functioningAssessing premorbid functioning

Neuropsychological Neuropsychological DysfunctionDysfunction

in MSin MS

COGNITIVE domains regularly affected:COGNITIVE domains regularly affected:

AttentionAttention Learning and Retrieval (Memory)Learning and Retrieval (Memory) Information processing speedInformation processing speed Visuospatial perceptionVisuospatial perception Executive FunctionExecutive Function

COGNITIVE domains usually spared:COGNITIVE domains usually spared:

Language/Verbal SkillsLanguage/Verbal Skills

Cognitive Cognitive DysfunctionDysfunction in MS


AttentionAttention Learning and Retrieval (Memory)Learning and Retrieval (Memory) Information processing speedInformation processing speed Visual spatial perceptionVisual spatial perception Executive FunctionExecutive Function




Components of MemoryComponents of Memory

ENCODINGENCODING(getting the information in)(getting the information in)

CONSOLIDATIONCONSOLIDATION

(transferring the information into long-term store)(transferring the information into long-term store)

RETRIEVALRETRIEVAL (getting the information out)(getting the information out)

Free Recall Free Recall vsvs. Recognition Memory. Recognition Memory



AttentionAttention Learning and Retrieval (Memory)Learning and Retrieval (Memory) Information processing speedInformation processing speed Visual spatial perceptionVisual spatial perception Executive FunctionExecutive Function



Wisconsin Card Sorting Test

00

1010

1515

2020

2525

3030

MSMS ControlsControls

Perseverative ErrorsPerseverative Errors

Non-PerseverativeNon-PerseverativeErrorsErrors

Wisconsin Card Sorting Test*Wisconsin Card Sorting Test*

*Rao et al., Journal of Consulting and Clinical Psychology, 1987, 55, 263-265

Indicators of Potential NeuropsychologicalDysfunction in MS

Help in ADLs in the absence of disability.Help in ADLs in the absence of disability.

Unemployment in the absence of physical disabilityUnemployment in the absence of physical disability

Mood disorder other than depressionMood disorder other than depression

Withdrawal from usual activities/socializationWithdrawal from usual activities/socialization

Opinion of significant other personality shiftOpinion of significant other personality shift

Significantly increased likelihood of Significantly increased likelihood of cognitive dysfunction in patients with:cognitive dysfunction in patients with:

Greater overall T2 lesion areaGreater overall T2 lesion area11

Greater T1 and T2 lesion loadGreater T1 and T2 lesion load2,32,3

Greater number of juxtacortical lesionsGreater number of juxtacortical lesions44

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 1 Rao SM, Leo GJ, Haughton VM, St Aubin-Faubert P, Bernardin L. Correlation of magnetic resonance imaging with neuropsychological testing in multiple sclerosis. testing in multiple sclerosis. NeurologyNeurology 1989; 1989; 3939: 161-166. 2 Comi G, Rovaris M, Falautano M, Santuccio G, Martinelli V, Rocca : 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. MA, Possa F, Leocani L, Paulesu E, Filippi M. A multiparametric MRI study of frontal lobe dementia in multiple sclerosis. Journal of the Journal of the Neurological SciencesNeurological Sciences 1999; 1999; 171171: 135-144. 3 Rovaris M, Filippi M, Falautano M, Minicucci L, Rocca MA, Martinelli V, Comi G. : 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. Relation between MR abnormalities and patterns of cognitive impairment in multiple sclerosis. NeurologyNeurology 1998; 1998; 5050: 1601-1608. 4 : 1601-1608. 4 Lazeron RH, Langdon DW, Filippi M, van Waesberghe JH, Stevenson VL, Boringa JB, Origgi D, Thompson AJ, Falautano M, Polman 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. CH, Barkhof F. Neuropsychological impairment in multiple sclerosis patients: The role of juxtacortical lesion on FLAIR. Multiple Multiple SclerosisSclerosis 2000; 2000; 66: 280-285.: 280-285.

0

1

2

3

4

5

6

7

0-7.5 7.5-23.7 >23.7

Total T2 Lesion Area (sq cm)

Number of Cognitive Tests Performed < 5th Percentile of Controls*

*Rao et al., Neurology, 1989, 39, 161-166

Atrophy as a Predictor of Cognitive Dysfunction

Brain atrophy has been found to be an independent predictor of Brain atrophy has been found to be an independent predictor of cognitive dysfunctioncognitive dysfunction1,21,2

Recent research suggests that, in fact, central atrophy, as measured by Recent research suggests that, in fact, central atrophy, as measured by third ventricle width, was more strongly predictive of cognitive third ventricle width, was more strongly predictive of cognitive dysfunction than either global atrophy or lesion load.dysfunction than either global atrophy or lesion load.33

Quantitative analysis of MRIs of patients with MS suggests that Quantitative analysis of MRIs of patients with MS suggests that atrophy of the superior frontal lobes is associated with cognitive atrophy of the superior frontal lobes is associated with cognitive morbiditymorbidity3,43,4

1. Zivadinov et al. Neuroradiology. 2001;43:272.2. Zivadinov et al. J Neurol Neurosurg Psychiatry. 2001;70:773.3. Benedict et al. Arch Neurol. 2004;61:226.4. Benedict et al. J Neuropsychiatry Clin Neurosci. 2002;14:44.

1010

99

88

77

66

55

44

33

22

77

66

55

44

33

22

VERBALVERBAL SPATIALSPATIAL

TRIALSTRIALS

Normal Ventricular Size (N=19)Normal Ventricular Size (N=19)

Mild Ventricular Dilatation (N=19)Mild Ventricular Dilatation (N=19)

Mod./Severe Ventricular Dilatation (N=9)Mod./Severe Ventricular Dilatation (N=9)

Mea

n w

ord

s re

call

edM

ean

wo

rds

reca

lled M

ean i tem

s recal ledM

ean item

s recalledAtrophy And Memory Performance*Atrophy And Memory Performance*

*Rao et al., Archives of Neurology, 1985, 42, 678-682

Assessment Of CognitiveDysfunction

In the office? What can be done during In the office? What can be done during a neurological examination?a neurological examination? Screening batteries are available, but training is essential and Screening batteries are available, but training is essential and

supervision is highly recommended.supervision is highly recommended.

If you independently use formal or informal screening batteries, If you independently use formal or informal screening batteries, ongoing consultation with a neuropsychologist is strongly ongoing consultation with a neuropsychologist is strongly recommended.recommended.


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

MS Functional Composite

Timed 25 Foot WalkTimed 25 Foot Walk

9 Hole Peg Test 9 Hole Peg Test average of right and left armsaverage of right and left arms

Paced Auditory Serial Addition TestPaced Auditory Serial Addition Test number correct, 3 sec. versionnumber correct, 3 sec. version

25

50

75

100

Easy (3s) Hard (2s)

Per

cen

t C

orr

ect

Paced Auditory Serial Addition Test (PASAT)

Control

Multiple Sclerosis

4 6 3 1 9 5

“10” “9” “4” “10” “14”


NPSBMS (Neuropsychological Screening Battery for Multiple NPSBMS (Neuropsychological Screening Battery for Multiple Sclerosis, Rao, 1991)Sclerosis, Rao, 1991) Can be administered by subdoctoral personnel after brief Can be administered by subdoctoral personnel after brief

training (30 min)training (30 min) 30-40 minutes to administer,used to screen patients in 30-40 minutes to administer,used to screen patients in

clinical settingclinical setting administered and scored by non-neuropsychologistadministered and scored by non-neuropsychologist Not good for research needing repeated measuresNot good for research needing repeated measures

Neuropsychological Screening Battery for Multiple Sclerosis

Taps 4 Cognitive DomainsTaps 4 Cognitive Domains 1. Sustained Attention and Concentration1. Sustained Attention and Concentration 2. Verbal Learning and Recall2. Verbal Learning and Recall 3. Visuospatial Learning and Recall3. Visuospatial Learning and Recall 4. Semantic Fluency4. Semantic Fluency

Impairment suspected if 2 or more tests are failed Impairment suspected if 2 or more tests are failed (test performance falls below the 5(test performance falls below the 5 thth percentile) percentile)


ANAM Computerized Screening Battery as an MS screen ANAM Computerized Screening Battery as an MS screen (Wilken et al., 2003)(Wilken et al., 2003) 25-30 minutes to administer25-30 minutes to administer administered and scored by non-neuropsychologistadministered and scored by non-neuropsychologist Interpreted by neuropsychologistInterpreted by neuropsychologist correlates highly with traditional measurescorrelates highly with traditional measures

Wilken, J.A., Kane, R., Sullivan, C.L., et al. The utility of computerized neuropsychological assessment 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. of cognitive dysfunction in patients with relapsing-remitting multiple sclerosis. Multiple Sclerosis,Multiple Sclerosis,

2003; 2003; 99: 119-127: 119-127


In the office? What can be done during In the office? What can be done during a neurological examination?a neurological examination? Can be billed as extended neurological visit. Can be billed as extended neurological visit.

Neuropsychologists like to use standardized tests with norms, but Neuropsychologists like to use standardized tests with norms, but testing takes a long time and is not feasible in your office.testing takes a long time and is not feasible in your office.

There are some quick ways to look at different functional domains, There are some quick ways to look at different functional domains, but these are “quick and dirty”, no normsbut these are “quick and dirty”, no norms

Require a little work up front (very quick), but can be used with Require a little work up front (very quick), but can be used with every pt to screenevery pt to screen


In the office? What can be done during a In the office? What can be done during a neurological examination?neurological examination? Given lack of norms, only a screen. Pt will have to serve as own control. 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 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 follow pt over time and see if any patterns of decline relative to past performanceperformance

Techniques for triage/screening only. If poor performance, recommend Techniques for triage/screening only. If poor performance, recommend more extensive workup. Cannot be used for disability claimsmore extensive workup. Cannot be used for disability claims

Even when just performing informal screening, it is strongly Even when just performing informal screening, it is strongly recommended that you consult with a neuropsychologist recommended that you consult with a neuropsychologist


In the office? What can be done during In the office? What can be done during a neurological examination?a neurological examination? To look at attention:To look at attention:

1 Trial of PASAT1 Trial of PASAT

Mental Control (WMS)…days backwards, backwards serial 7’sMental Control (WMS)…days backwards, backwards serial 7’s

Cancellation test (public domain)Cancellation test (public domain)


In the office? What can be done during a In the office? What can be done during a neurological examination?neurological examination? To look at MemoryTo look at Memory

Short word list with recognition, 10 minute delayShort word list with recognition, 10 minute delay

• Make up a list of 10 common, easy, unrelated words. 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 Read list to pt 3 times, have pt give list back 3 times (allows you to look at learning curve)learning curve)

• Use same list for every patient (maybe even collect your own norms)Use same list for every patient (maybe even collect your own norms)

• 10 minute delay10 minute delay

• Need a recognition trial (yes/no, multiple choice), helps look at retrieval versus Need a recognition trial (yes/no, multiple choice), helps look at retrieval versus consolidationconsolidation


In the office? What can be done during In the office? What can be done during a neurological examination?a neurological examination? To look at languageTo look at language

Word finding on the MMSE not enoughWord finding on the MMSE not enough

Instead, have 5-10 objects available, used for every patientInstead, have 5-10 objects available, used for every patient

Verbal (lexical) Fluency (FAS, CFL), 1 minute per wordVerbal (lexical) Fluency (FAS, CFL), 1 minute per word

Verbal (semantic) Fluency (Animals, Supermarket)Verbal (semantic) Fluency (Animals, Supermarket)


In the office? What can be done during In the office? What can be done during a neurological examination?a neurological examination? To look at Motor Speed/ Processing SpeedTo look at Motor Speed/ Processing Speed

9 Hole Peg Test9 Hole Peg Test

Digit Symbol Modalities Test (public domain)Digit Symbol Modalities Test (public domain)

Neuropsychological Evaluation: Limitations of Screening Batteries

Cannot adequately address specific issues Cannot adequately address specific issues involving vocational counseling, disability involving vocational counseling, disability determination, competency, and rehab determination, competency, and rehab planning (Rao, NSBMS Manual)planning (Rao, NSBMS Manual)

Not suitable for Differential DiagnosisNot suitable for Differential Diagnosis

Not enough information for complicated Not enough information for complicated functional analysisfunctional analysis


Comprehensive Neuropsychological ExaminationComprehensive Neuropsychological Examination 3-5 hours, addresses differential diagnosis, disability questions3-5 hours, addresses differential diagnosis, disability questions administered/interpreted by clinical neuropsychologistadministered/interpreted by clinical neuropsychologist Should expect full report with conclusions (e.g., MS or Should expect full report with conclusions (e.g., MS or

depression) as well as recommendations (for work, school, etc).depression) as well as recommendations (for work, school, etc). REIMBURSEMENT IS MORE FREQUENT THAN MIGHT BE REIMBURSEMENT IS MORE FREQUENT THAN MIGHT BE

BELIEVED. NEEDS TO BE A MEDICAL DIAGNOSIS (340, MS) AND A BELIEVED. NEEDS TO BE A MEDICAL DIAGNOSIS (340, MS) AND A CPT CODE FOR NEUROPSYCHOLOGICAL TESTING (96117) BILLED CPT CODE FOR NEUROPSYCHOLOGICAL TESTING (96117) BILLED BY A NEUROPSYCHOLOGIST. SOMETIMES, PRE-CERT NEEDED.BY A NEUROPSYCHOLOGIST. SOMETIMES, PRE-CERT NEEDED.


Why to refer for a Comprehensive Neuropsychological EvaluationWhy to refer for a Comprehensive Neuropsychological Evaluation

Diagnosis of MS-related cognitive decline, determination of domains affected, often validating to pt Diagnosis of MS-related cognitive decline, determination of domains affected, often validating to pt and familyand family

Differential Diagnosis (e.g., functional vs. MS, Alz vs MS)Differential Diagnosis (e.g., functional vs. MS, Alz vs MS)

Functional analysis to determine home/school/work needs and accommodations (often, the only way Functional analysis to determine home/school/work needs and accommodations (often, the only way to force help)to force help)

Disability evaluation (Most often, the only way to get disability)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 Assist the treatment team in determining capability of pt to follow through on treatment, live independentlyindependently


Comprehensive Neuropsychological EvaluationComprehensive Neuropsychological Evaluation

Whom do you refer to?Whom do you refer to?

Ph.D. level clinical neuropsychologist experienced in the assessment of MS-related Ph.D. level clinical neuropsychologist experienced in the assessment of MS-related cognitive problems. For certain types of difficulties (e.g., speech/language), some cognitive problems. For certain types of difficulties (e.g., speech/language), some

other specialists will assess some aspects of cognitive functioning.other specialists will assess some aspects of cognitive functioning.


Sections of the Neuropsychological ReportSections of the Neuropsychological Report

Conclusions:Conclusions:

MUST ANSWER THE REFERRAL QUESTION!!!!!!MUST ANSWER THE REFERRAL QUESTION!!!!!!

Should be relevant to the referral source/needs of the patientShould be relevant to the referral source/needs of the patient

Should include an opinion on diagnosisShould include an opinion on diagnosis

Should ALSO include a functional analysis (what is the patient Should ALSO include a functional analysis (what is the patient capable of? What might they have trouble with? Should reflect needs capable of? What might they have trouble with? Should reflect needs of patient as indicated in the referral section)of patient as indicated in the referral section)


Sections of the Neuropsychological ReportSections of the Neuropsychological Report

Recommendations:Recommendations:

REPORT MUST CONTAIN RECOMMENDATIONSREPORT MUST CONTAIN RECOMMENDATIONS

Recommendations should be relevant with respect to the referral Recommendations should be relevant with respect to the referral questionquestion

Recommendations should be possible!Recommendations should be possible!

Should discuss healthcare providers who can help the patient.Should discuss healthcare providers who can help the patient.

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