The Fluff test: Improved scoring system to account for different degrees of contralesional and ipsilesional personal neglect in brain damaged patients.

The Fluff test is a simple test to assess evidence of personal neglect (PN) in brain-damaged patients. While blindfolded, patients are asked to remove targets previously attached to their body and the number of targets detached provides information about possible spatial bias. This test has been widely used for clinical and research purposes. However, the current scoring system presents some limitations, which make difficult to interpret patients' performance in terms of both contralalesional and ipsilesional PN when they omit targets on the ipsilesional side. Moreover, it does not consider possible confounding variables, such as non-spatial cognitive deficits or lack of compliance that may affect patients' performance and lead to incorrect diagnosis. The present paper proposes a new scoring method overcoming the limitations mentioned above and it analyses data from a large sample of 243 brain-damaged patients. Findings showed that contralesional PN was significantly more severe, but not more frequent, following right (31%) than left (21%) brain damage. We also found evidence of left ipsilesional PN and cases of potential mis-diagnosis that would have passed unnoticed with the original scoring system. The new scoring method allows to identify different degrees of contralesional and ipsilesional PN and potential confounding variable.

Open-source open-access reaction time test (OORTT): an easy tool to assess reaction times.

The speed of information processing is one of the most reliable indices of cognitive efficiency. The most common way to evaluate this ability is to assess reaction times (RTs). The technical limitations of previous tasks, aimed at measuring RT, have motivated us to develop a new battery for their evaluation. The aim of this study is to build an open-source, open-access reaction time test (OORTT), which has the following characteristics: rapid and easy administration, robust Italian normative data based on a wide age range, a simple scoring system, compatibility with all operating systems, no license or activation costs, and based on an open-source software platform. The battery is composed of three tasks: simple reaction times (SRT), Go/No-Go (GNG) condition, and four-position reaction times (4PRT). The battery was administered to 300 healthy participants aged between 14 and 89, and 3 groups of patients: 24 right brain-damaged; 21 left brain-damaged, and 19 degenerative cognitively impaired. We have developed specific norms for each task of the test battery: SRT, GNG, and 4PRT. Compared with healthy individuals, all groups obtained lower scores. More specifically, cognitively impaired patients obtained significantly longer RTs than healthy participants as well as unilateral brain-damaged patients. In the 4PRT task, right brain-damaged patients obtained a significantly left > right difference in RTs. In conclusion, the OORTT test battery proved to be a valuable tool which can be used in the clinical environment for cases of different attentional deficits after focal or degenerative brain damage.

Unawareness for Motor Impairment and Distorted Perception of Task Difficulty.

OBJECTIVES: Anosognosia for motor impairment is a complex syndrome that can manifest itself under different forms, guiding patients' behavior and task decisions. However, current diagnostic tools tend to evaluate only more explicit aspects of anosognosia (asking the patients about their motor abilities) and fail to address more subtle features of awareness. We have developed a new assessment measure, the ECT (Errand Choice Test), where patients are asked to judge task difficulty rather than estimate their own impairment. METHODS: We assessed awareness in a group of 73 unilateral left- and right-brain damaged (30 LBD and 43 RBD, respectively) patients by means of the VATAm, which explicitly requires them to evaluate their own motor abilities, and the ECT. A control group of 65 healthy volunteers was asked to perform the ECT under two conditions: Current condition (i.e., using both hands) and Simulated conditions (i.e., simulating hemiplegia). RESULTS: A total of 27% of the patients showed different performance on the VATAm and ECT, 21% of the patients showing lack of awareness only on VATAm and 6% only on ECT. Moreover, despite the ECT identified a higher frequency of anosognosia after RBD (33.3%) than LBD (27.6%), this hemispheric asymmetry was not significant. Remarkably, anosognosic patients performed very similarly to controls in the "current condition", suggesting that anosognosic patients' ability to perceive the complexity of each task per se is not altered. CONCLUSION: Different methods may be able to tackle different aspects of awareness and the ECT proved to be able to detect less evident forms of awareness. (JINS, 2018, 24, 45-56).

Normative data for distal line bisection and baking tray task.

Line bisection is one of the tests used to diagnose unilateral spatial neglect (USN). Despite its wide application, no procedure or norms were available for the distal variant when the task was performed at distance with a laser pointer. Furthermore, the baking tray task was an ecological test aimed at diagnosing USN in a more natural context. The aim of this study was to collect normative values for these two tests in an Italian population. We recruited a sample of 191 healthy subjects with ages ranging from 20 to 89 years. They performed line bisection with a laser pointer on three different line lengths (1, 1.5, and 2 m) at a distance of 3 m. After this task, the subjects performed the baking tray task and a second repetition of line bisection to test the reliability of measurement. Multiple regression analysis revealed no significant effects of demographic variables on the performance of both tests. Normative cut-off values for the two tests were developed using non-parametric tolerance intervals. The results formed the basis for clinical use of these two tools for assessing lateralized performance of patients with brain injury and for diagnosing USN.

Distance-mediated spatial neglect.

Unilateral spatial neglect (USN) is usually assessed by means of individual stimuli or single arrays of stimuli. Seldom are stimuli presented as multiple objects or in spatially separated blocks, except in some tests for object-based neglect. The distance between individual objects or blocks of stimuli in such stimuli is implicitly considered irrelevant. We report on the case of a patient, EC, who showed severe USN in his everyday behavior, yet performed normally on standard tests for USN. Presented with stimuli in separate blocks, he performed flawlessly with 4 cm gaps between blocks, yet ignored all leftward blocks of stimuli when the gap was larger than this. EC's dissociation between good performance on standard tasks and severe neglect with separate groups of stimuli, and the distance-mediated nature of his USN are novel observations with relevant theoretical and clinical implications.

Prose reading in neglect.

Prose reading has been shown to be a very sensitive measure of Unilateral Spatial Neglect. However, little is known about the relationship between prose reading and other measures of neglect and its severity, or between prose reading and single word reading. Thirty participants with a first stroke in the right hemisphere and clear symptoms of spatial neglect in everyday life were assessed with tests of prose reading (text in one column book-like, and in two columns magazine-like), single words reading, and a battery of 13 tests investigating neglect. Seventy percent of these participants omitted words at the beginning of the text (left end), showing Prose Reading Neglect (PRN). The participants showing PRN differed from those not showing PRN only for the overall severity of neglect, and had a lesion centred on the insula, putamen and superior temporal gyrus. Double dissociations emerged between PRN and single word reading neglect, suggesting different cognitive requirements between the two tests: parallel processing in single word reading vs. serial analysis in text reading. Notably, the pattern of neglected text varied dramatically across participants presenting with PRN, including dissociations between reading performance of one and two columns text. Prose reading proved a complex and unique task which should be directly investigated to predict the effects of unilateral neglect. The outcome of this study should also inform clinical assessment and advises given to patients and care-givers.

Luria's fist-edge-palm test: A small change makes a big difference.

Slight modifications in the instructions or administration of neuropsychological tests could result in noticeable differences in performance. A good example is offered by a test devised by Luria to assess executive functioning in motor planning, the three-step fist-edge-palm (FEP) test, which is still frequently employed in clinical settings and features in several neuropsychological test batteries such as the Frontal Assessment Battery (FAB). While Luria described the orientation of the fist as horizontal to the testing desk (hFEP), recent versions of the task indicate the fist should be vertical to the testing desk (vFEP). The current study examined whether administering the hFEP or the vFEP tests results in different performance in healthy people, and whether one version is better than the other at detecting impairments in a patient population. The hFEP proved more challenging for healthy adults than the vFEP, and people with brain damage committed more errors on the hFEP than the vFEP. Both versions correlated with executive measures but also with several other cognitive variables, indicating that the test is not a specific marker of executive functions. Although performance on the FEP is sensitive to articulatory suppression, faster pace, and the number of sequences performed, none of these conditions fully account for the differences between the hFEP and vFEP. The additional demand of the hFEP appears to be due to the less natural (i.e., automatic) orientation of the horizontal fist. In conclusion, a small change in the administration of the test, eluding Luria's instructions, grossly modified its sensitivity. Clinicians and researchers should be wary of modifying instructions or testing procedures without considering the possible consequences of such modifications.

Anosognosia and neglect respond differently to the same treatments.

Different techniques, such as optokinetic stimulation, adaptation to prismatic shift of the visual field to the right, or transcutaneous electrical nerve stimulation (TENS), have been shown to alleviate neglect, at least temporarily. We assessed the effect of these techniques on anosognosia and whether their therapeutic effect, if any, matches that on neglect. The effect of the three types of treatment on anosognosia and neglect was investigated in five patients presenting with both severe anosognosia and neglect. Patient 1 was treatment responsive to anosognosia but not to neglect, whereas patients 4 and 5 showed the reverse pattern, i.e., they were treatment responsive to neglect but not to anosognosia. This "treatment response bias" proved to be a valid means to investigate different effects of treatments in the same patient.

VATA-ADL: The Visual Analogue Test for Anosognosia for Activities of Daily Living.

OBJECTIVE: To study awareness of problems with one's own Activities of Daily Living (ADL) following stroke by means of a novel instrument-the Visual-Analogue Test for Anosognosia for Activities of Daily Living (VATA-ADL). METHODS: The new test overcomes some of the methodological problems of traditional structured interviews and self-rating questionnaires. In particular, to account for possible verbal communication difficulties, each question is illustrated by a drawing and a 4-point visual-analogue Likert scale. The patient's self-rating is compared with that given by informants (personal or professional caregiver) to acquire a measure of metacognition of one's own problems in performing everyday tasks. RESULTS: The VATA-ADL was validated in 61 dyads of older people and their informants. A group of 80 post-acute stroke patients and their informants then completed the test. Informant ratings correlated highly with traditional ADL scales, the questionnaire items showed high internal consistency (α = .95) and loaded onto one factor. By comparison to informants' assessments, the patients showed a generally poor appreciation of their functional disabilities. Thirty-nine patients overestimated their abilities (anosognosia) whereas nine showed underestimation of their abilities. CONCLUSIONS: Anosognosia (overestimation of abilities) for ADL is frequent, even in post-acute stages post-stroke. Some other patients underestimated their abilities, indicating that poor metacognition of one's own abilities in brain damaged patients is bi-directional. Both types of misestimation may have clinical consequences worth considering for the wellbeing of patients and their carers.

Wakeful rest benefits before and after encoding in anterograde amnesia.

Objective: Studies have shown that patients with anterograde amnesia forget less episodic information after a delay if encoding is immediately followed by an unfilled period of wakeful rest. This benefit has been attributed to the reduced interference with the consolidation process. However, this account cannot directly explain improved retention in healthy adults resulting from pre-encoding rest. While benefits resulting from pre- and post-encoding rest can be alternatively explained via improved distinctiveness at retrieval, it has yet to be established whether both benefits are observable in amnesics. The aim of the current study was to assess whether amnesic patients showed improved retention of prose material after 10 min following both pre- and post-encoding unfilled intervals of wakeful rest. Method: Twelve patients with anterograde amnesia were recruited. Participants completed four conditions. A short prose passage was aurally presented in each condition. Prose presentation was preceded and followed by a 9-min delay interval. Delay intervals were either filled (spot-the-difference task) or unfilled (wakeful rest). Prose retention was assessed immediately after presentation and after 10 min. Results: Prose retention was consistently better when wakeful rest followed prose encoding in comparison to a condition where an effortful task was encountered both before and after encoding. Conclusions: Post-encoding wakeful rest alone substantially improves retention in amnesic patients. While pre-encoding wakeful rest elicits inconsistent benefits in amnesics, reduced retention following both pre- and post-encoding task engagement suggests that pre-encoding activity may still be relevant. Overall, our findings support consolidation interference explanations of forgetting in anterograde amnesia. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Anosognosia for motor impairment following left brain damage.

Anosognosia for motor impairment has been linked to lesions of the right hemisphere. However, left hemisphere damaged patients have often been excluded from investigation because of their associated language deficits. In this study we assessed anosognosia for motor disorders in a group of left hemisphere damaged patients using 2 tools that assess the presence of unawareness-a structured interview that is a common method of assessment of anosognosia in clinical settings, and a new tool, the Visual-Analogue Test for Anosognosia for Motor Impairment (VATAm; Della Sala, Cocchini, Beschin, & Cameron, in press). The structured interview relies heavily on language and enquires about general motor ability whereas the VATAm is less dependent on language abilities and enquires about specific motor tasks. Results suggest that the frequency of anosognosia in left brain damaged patients may have been underestimated due to methodological reasons, and that anosognosia for motor impairment can also be associated with lesions of the left hemisphere.

Closing-In Behavior and Motor Distractibility in Persons with Brain Injury.

OBJECTIVE: This study investigates closing-in behavior (CIB), a phenomenon observed in graphic copying tasks when responses encroach upon or overlap the model. The behavior is most common amongst individuals with dementia and amongst pre-school children. We explored the relationship between CIB and the 'distractor effect' in reaching, whereby salient visual stimuli can influence the spatial trajectory of the reach. METHOD: A group of individuals with overlap-CIB (n = 9), without CIB (n = 9) and healthy controls (HC; n = 6) underwent a task-irrelevant and a task-relevant distractors and the deviation of the movement trajectory towards the distractor location was measured in both tasks. RESULTS: Individuals with graphic CIB showed more distractor-directed veering during reaching than did individuals without CIB or HC, provided that the distractor was relevant for the reaching task. CONCLUSIONS: These results strengthen the relationship between CIB and the distractor effect and reinforce the hypothesis that CIB represents a disinhibited tendency to act towards the focus of attention.

Effect of prism adaptation on neglect hemianesthesia.

Prism adaptation (PA) has proven to be effective in alleviating many signs of unilateral spatial neglect (USN). Generally, the principal improvement after PA treatment was found to be in the high-level cognitive function. Nevertheless, some evidence has also been found for it in somatosensory function. We have aimed to test the influence of PA on neglect hemianesthesia, a condition in which the high-level neglect-related deficit mimics hemianesthesia. Twenty-one USN patients were enrolled in the study. Each patient performed two sessions of PA, one with neutral glasses and one with prism glasses using a cross-over design. Sensitivity on the upper limb was tested using two methods. The first task was the sensibility subtest which was derived from the standard clinical examination. The second was the perceptual and motor electro-cutaneous threshold on the forearms using an electro-cutaneous stimulator. Four neuropsychological tests were used to diagnose USN and to check improvement: Star cancellation, Line bisection, Sentence reading and the Comb & Razor test. Comparing prism with sham conditions, our results show significant improvements in double extinction and in the electro-cutaneous perceptual threshold only for the contralesional hand. No improvement was found for the ipsilesional hand, for the motor threshold, and for neutral glasses. Significant improvement was found in personal neglect. Replication of the task in a subgroup of patients confirmed the primary results. The improvements in somatosensory perception together with the amelioration of personal neglect suggest that PA also has a specific effect on the neglect hemianesthesia.

Anosognosia for prospective and retrospective memory deficits: Assessment and theoretical considerations.

OBJECTIVE: Patients who suffer from memory loss after an Acquired Brain Injury (ABI) may also suffer from anosognosia, or unawareness of their memory loss. How we define and measure anosognosia can have critical implications for its study and clinical assessment. Commonly used measures often lack standardization and reliability checks for responses. Moreover, these methods rely heavily on cognitive abilities (e.g., language abilities) that are often affected after brain injury. The aim of this study is to elucidate how to best conceptualize and detect anosognosia for memory loss by introducing a new method of assessment, the Visual-Analogue Test for Anosognosia for memory impairment (VATAmem). METHOD: A total of 51 patients (M = 61 years, M = 13 years of education) with memory difficulties after ABI were recruited from outpatient clinics. A total of 73 informants were also recruited (M = 51 years old, M = 13 years of education). Both patients and informants evaluated the severity of patients' everyday memory mistakes on the VATAmem, for prospective and retrospective memory deficits by using visual analogue scales, vignettes, and check questions to ensure reliability. RESULTS AND CONCLUSION: A total of 30% of the patients were deemed unaware of their memory deficits. Patients were less aware of their prospective (29%) than their retrospective memory difficulties (18%). The new method of assessment provided by the VATAmem reduced possible false positives and enhanced reliability. We conclude that careful consideration of methodology is a key step to interpreting anosognosia findings within a theoretical framework. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Closing-in behavior: Compensation or attraction?

OBJECTIVE: Closing-in behavior (CIB) defines the abnormal misplacement of the copy performance, positioned very closed to or on the top of the model. This symptom is observed in graphic copying by patients suffering from different neurological diseases, most commonly dementia. The cognitive origins of this behavior are still a matter of investigation, and research of the last 10 years has been focused on exploring 2 main accounts of CIB, the compensation and the attraction hypotheses, providing evidence in both directions. While the first account defines CIB as a compensatory strategy to overcome visuospatial and/or working memory deficits during copying tasks, the attraction hypothesis looks at CIB as primitive default behavior in which attention and action are closely coupled and movements are performed toward the focus of attention. METHOD: We explored these 2 hypotheses in a sample of patients with and without CIB, and controls in 5 experiments: Experiments 1 and 2 tested the attraction hypothesis and, respectively, the prediction that CIB can be elicited in a noncopying dual task condition loading upon attentional resources or by irrelevant attentional grabbing stimuli. The other experiments investigated the compensation hypothesis manipulating the distance between model and copying space (Experiment 3), the task demand (single or dual task loading on verbal working memory; Experiment 4), the task requirements (copying and tracing) and visual demand (visual copy and memory; Experiment 5). RESULTS: The results support the attraction hypothesis of CIB. CONCLUSIONS: CIB reflects an impairment of the attention and action system, rather than a compensatory strategy. (PsycINFO Database Record

A lateralized bias in mental imagery: evidence for representational pseudoneglect.

One hundred right-handed healthy individuals were asked to imagine a familiar scene (the Piazza del Duomo, Milan) from two opposite viewpoints and report what they could see. For elements that should be visible from the participants' viewpoint, more elements were reported from the left side of the image than from the right, irrespective of view. These results establish that there is a lateralized bias in reporting the details in mental images--representational pseudoneglect. This bias is in the opposite direction and significantly smaller than the bias seen in individuals with representational neglect following right hemisphere damage. Representational pseudoneglect appears analogous to perceptual pseudoneglect and the two may share an underlying mechanism. The results are interpreted as indicating that pseudo-representational neglect arises as the result of a bias in the allocation of attention to the imagined scene.