Cognitive Testing During Mild Acute Ischemic Stroke Predicts Long-Term Return to Work.

OBJECTIVES: Many survivors of a mild ischemic stroke do not return to work or driving. Cognitive testing is commonly done to assess long-term cognitive impairment after stroke. Inpatient cognitive testing during the acute period of ischemic stroke may also be a predictor for workforce reengagement and functional outcome. MATERIALS AND METHODS: At our comprehensive stroke center, we prospectively enrolled previously working adults < 65 years old who were diagnosed with first-ever ischemic stroke, had a prestroke modified Rankin Scale (mRS) ≤ 1 and NIHSS ≤ 3. Testing performed within 1 week of stroke included the Montreal Cognitive Assessment (MOCA), Clock Drawing Test (CDT), Trail Making Tests A and B, Backward Digit Span Test, and Hospital Anxiety and Depression Scale (HADS). Other data obtained included age, gender, years of education, occupation, stroke location, stroke laterality, and presence of white matter disease on imaging. Outcome measures assessed at 3 months, 6 months, and 12 months post-stroke included return to work, return to driving, and mRS. In a logistic regression analysis, we performed both univariate and multivariate analyses. Multivariate analysis was completed on variables with p-value ≤ 0.05 in the univariate analysis. RESULTS: Of 39 total stroke patients enrolled and tested (median [IQR] age 55 [46-60] years; 77.5% male; 22.5% female), 36 completed 3-month follow up, of which 58% returned to work, 78% returned to driving, and 72% had mRS of 0-1. In multivariate analysis, a single point increase in the clock drawing task score increased the odds of return to work by 3.79 (95% CI, 1.10-14.14) and return to driving by 6.74 (95% CI, 1.22-37.23) at 3 months. MOCA and HADS were both associated with mRS ≤ 1. MOCA was associated with return to work at 6 months and CDT was associated with return to work at 12 months. CONCLUSION: Cognitive testing with CDT and MOCA in the acute period after ischemic stroke may predict common patient goals post stroke, including return to work, driving, and independence. These tools can potentially be used for prognosis and identifying those who may benefit from further interventions.

Validity of In-Home Teleneuropsychological Testing in the Wake of COVID-19.

OBJECTIVE: Teleneuropsychology (TNP) has been shown to be a valid assessment method compared with in-person neuropsychological evaluations. Interest in delivering TNP directly to patients' homes has arisen in response to the coronavirus disease 2019 (COVID-19) pandemic. However, prior research has typically involved patients tested in clinical settings, and the validity of in-home TNP testing has not yet been established. The present study aims to explore the validity and clinical utility of in-home TNP testing in a mixed clinical sample in the wake of COVID-19. METHODS: Test profiles for 111 in-home TNP patients were retrospectively compared with 120 patients who completed in-person evaluations. The TNP test battery consisted of tests measuring attention/processing speed, verbal memory, naming, verbal fluency, and visuoconstruction. TNP scores of cognitively normal (CN) patients were compared with patients with neurocognitive disorders (NCD), and score profiles were examined among suspected diagnostic groups of Alzheimer's disease (AD), Parkinson's disease (PD), and vascular disease (VaD). RESULTS: TNP test scores did not significantly differ from in-person testing across all tests except the Hopkins Verbal Learning Test-Revised Discrimination Index. Within the TNP group, significant differences between the CN and NCD groups were found for all tests, and the memory and semantic fluency tests yielded large effect sizes (d ≥ 0.8). Score profiles among the AD, PD, and VaD groups were explored. CONCLUSIONS: These findings support the validity of in-home TNP testing compared with in-person neuropsychological testing. Practice considerations, limitations, and future directions are discussed.

Application of the new MMPI-2 Malingered Depression scale to individuals undergoing neuropsychological evaluation: relative lack of relationship to secondary gain and failure on validity indices.

The Malingered Depression (Md) scale for the MMPI-2 (Steffan, Clopton, & Morgan, 2003) was recently developed to detect attempts at malingering depressive symptomatology. The Steffan et al. cutoffs for the Md scale were derived through comparisons of undergraduate malingering simulators with depressed undergraduates. In order to explore the potential utility for neuropsychological practice, we examined the Md scale among 160 individuals with and without a context of secondary gain referred for neuropsychological evaluation. Md results were compared to other MMPI-2 validity indices and performance on effort testing. While Md was found to correlate highly with other validity indices from the MMPI-2, it was also correlated significantly with measures of depression, both in individuals with and without a secondary gain context. Md scores were not significantly different between secondary gain and no secondary gain groups, whereas FBS and L were significantly different. The effect of passing or failing validity indicators on rates of Md scores exceeding the Steffan et al. cutoffs was limited. Only among the few individuals exceeding a high threshold on the F scale or combinations of F, FBS, and effort indicators was it common to also surpass the Md cutoff. Overall, Md showed relatively little relationship to either secondary gain status or cognitive malingering in our sample. Given that such factors do not necessarily produce high scores on Md, the utility of the scale to clinical neuropsychologists appears low.

Unawareness of deficits in Alzheimer's disease and other dementias: operational definitions and empirical findings.

Individuals with dementia frequently demonstrate decreased awareness of their cognitive difficulties. Empirical research examining this phenomenon has addressed a number of aspects of unawareness in Alzheimer's disease and other dementias, including occurrence in various disorders; possible neuroanatomical substrates; relationship to general cognitive functioning, executive functioning, and psychiatric symptomatology; and progression over time and across cognitive domains. Limitations of the current research literature are discussed, particularly issues surrounding operational definitions of unawareness and the current limited understanding of the role of the frontal lobes. A number of conclusions regarding unawareness that appear to be supported by the current body of empirical research and possible future directions are discussed.

Confirmatory factor analysis of the behavioral dyscontrol scale in a mixed clinical sample.

The Behavioral Dyscontrol Scale (BDS) is a brief measure of executive functioning originally designed for use primarily with older adults. Previous research suggests that factors derived from exploratory factor analysis of the BDS have clinical utility and are theoretically meaningful; however, the factor structure has not been previously submitted to confirmatory analysis, and there are several potential methodological problems with the previous exploratory factor analysis. In this study, we conducted a confirmatory factor analysis of the BDS. Findings were largely consistent with the original exploratory analysis (Grigsby, Kaye, & Robbins, 1992) in suggesting a three-factor model, although the three-factor model was a better fit if factors were allowed to correlate with one another. The findings of this study lend support to the current practice of using factor scores in clinical and research applications.

Development and exploratory analysis of the Neurorehabilitation Program Styles Survey.

OBJECTIVE: To develop a survey instrument that assesses implementation of key components of outpatient neurorehabilitation programs and test the capacity of this instrument to differentiate between rehabilitation approaches. DESIGN: The Neurorehabilitation Program Styles Survey (NPSS) was administered to 18 outpatient facilities: 10 specialized and 8 discipline-specific outpatient neurorehabilitation programs. Scores were compared between types of programs using independent samples t tests. RESULTS: The NPSS showed good reliability and contrasted groups validity, significantly differentiating between types of programs. CONCLUSIONS: The NPSS holds considerable promise as a tool for distinguishing among different types of brain injury programs, and for assessing the differential effectiveness of specialized versus discipline-specific outpatient brain rehabilitation programs. Future research on the NPSS will assess the stability of the instrument over time, its content validity, and capacity to differentiate the full continuum of neurorehabilitation programs.

Functional Outcome Questionnaire for Aphasia: overview and preliminary psychometric evaluation.

OBJECTIVE: To perform a preliminary evaluation of a questionnaire designed to assess functional outcomes of treatment for aphasia. METHODS: The Functional Outcome Questionnaire for Aphasia (FOQ-A) is an inventory consisting of 32 caregiver-completed items rating the person with stroke's ability to perform various communication behaviors on a 5-point scale. The total score for the FOQ-A is reported as a mean of all completed items. The FOQ-A was administered by research assistants to caregivers of patients with left hemisphere stroke (n = 18). RESULTS: The FOQ-A showed acceptable initial reliability and validity properties. As predicted, the FOQ-A displayed high positive correlations with standardized functional communication measures. The FOQ-A also showed only weak associations with other measures (health-related quality of life, caregiver strain). CONCLUSIONS: Overall results of our preliminary psychometric examination of the FOQ-A were promising. The findings suggested that the FOQ-A may be a sensitive measure of functional communication abilities and does not appear to be biased heavily by caregiver strain. Plans for further evaluation of the FOQ-A are discussed.