Cognitive changes and dementia risk after traumatic brain injury: implications for aging military personnel.

Traumatic brain injury (TBI) is recognized as an important risk factor for the long-term cognitive health of military personnel, particularly in light of growing evidence that TBI increases risk for Alzheimer's disease and other dementias. In this article, we review the neurocognitive and neuropathologic changes after TBI with particular focus on the potential risk for cognitive decline across the life span in military service members. Implications for monitoring and surveillance of cognition in the aging military population are discussed. Additional studies are needed to clarify the factors that increase risk for later life cognitive decline, define the mechanistic link between these factors and dementia, and provide empirically supported interventions to mitigate the impact of TBI on cognition across the life span.

Automated Neuropsychological Assessment Metrics (v4) Traumatic Brain Injury Battery: military normative data.

The aim of the present study was to establish normative data for the Automated Neuropsychological Assessment Metrics (v4) Traumatic Brain Injury (ANAM4 TBI) battery in a military context. ANAM4 data from over 107,500 active duty service members ranging from 17 to 65 years of age were included in this study. The influence of the demographic variables of age and gender were also examined. These norms, stratified by age and gender, represent a more comprehensive set of norms than previously available and are provided as a representative set of norms for clinical practice. Additionally, base rates of below average performance in a normal population are provided to help inform clinical decision making.

Effects of military deployment on cognitive functioning.

Military deployment poses many risks for cognitive functioning. When deployed individuals are compared to a nondeployed control group, there is some evidence that deployment may be associated with declines in cognitive functioning. The current study examined cognitive performance before and following deployment in a large sample of active duty military personnel (N = 8002) who reported no traumatic brain injury (TBI). Cognition was assessed using the Automated Neuropsychological Assessment Metrics version 4 TBI Military (ANAM4 TBI-MIL) battery, a computer-based battery of tests measuring attention, processing speed, and general cognitive efficiency. Pre- and postdeployment scores were compared using repeated measures analyses. Although statistically significant differences were observed for all tests (with 5 of 7 tests demonstrating performance improvement), effect sizes were very small for all but 1 test, indicating that performance differences had minimal clinical significance. Likewise, determination of change for individuals using reliable change indices revealed that a very small percentage (<3%) of this presumed healthy sample showed meaningful decline in cognition following deployment. Analyses indicated that despite risks for cognitive decline while in theater, deployment had minimal to no lasting effect on cognition as measured by ANAM4 TBI-Mil upon return from deployment.

Functional magnetic resonance imaging of working memory and response inhibition in children with mild traumatic brain injury.

The current pilot study examined functional magnetic resonance imaging (fMRI) activation in children with mild traumatic brain injury (mTBI) during tasks of working memory and inhibitory control, both of which are vulnerable to impairment following mTBI. Thirteen children with symptomatic mTBI and a group of controls completed a version of the Tasks of Executive Control (TEC) during fMRI scanning. Both groups showed greater prefrontal activation in response to increased working memory load. Activation patterns did not differ between groups on the working memory aspects of the task, but children with mTBI showed greater activation in the posterior cerebellum with the addition of a demand for inhibitory control. Children with mTBI showed greater impairment on symptom report and "real world" measures of executive functioning, but not on traditional "paper and pencil" tasks. Likewise, cognitive testing did not correlate significantly with imaging results, whereas increased report of post-concussive symptoms were correlated with increased cerebellar activation. Overall, results provide some evidence for the utility of symptom report as an indicator of recovery and the hypothesis that children with mTBI may experience disrupted neural circuitry during recovery. Limitations of the study included a small sample size, wide age range, and lack of in-scanner accuracy data.

Outcome assessment in traumatic brain injury clinical trials and prognostic studies.

Large numbers of investigations have sought to evaluate prediction of outcome after traumatic brain injury (TBI) and the effectiveness of interventions designed to address post-TBI deficits. Unfortunately, failure to attend to key issues in experimental design regarding outcome assessment has limited the utility of these investigations. Increased attention to 5 issues in outcome assessment will increase the evidence base for TBI prognosis and treatment and increase the relevance of findings to end users of research such as other investigators, rehabilitation providers, policy makers, persons with TBI, and family members of persons with TBI. These 5 issues are (1) masking of outcome examiners, (2) retention of study participants, (3) use of surrogate informants to capture data from a wider range of study participants, (4) relevance of study outcomes to stakeholders, and (5) cultural considerations in outcome assessment.

Return on Investment and Value Research in Neuropsychology: A Call to Arms†.

There is substantial empirical evidence to support the clinical value of neuropsychological evaluation and the incremental value of neuropsychological assessment, suggesting such evaluation is beneficial in the prediction and management of clinical outcomes. However, in the cost-conscious and evolving era of healthcare reform, neuropsychologists must also establish the economic value, or return on investment, of their services. There is already a modest body of literature that demonstrates the economic benefits of neuropsychological evaluation, which is reviewed in the current paper. Neuropsychologists will need to be able to communicate, and develop evidence of, economic value of their services; thus, this paper also discusses common concepts, terms, and models used in healthcare valuation studies. Finally, neuropsychologists are urged to incorporate these financial concepts in their clinical practice and research.

Integrative Care Models in Neuropsychology: A National Academy of Neuropsychology Education Paper.

Although collaborative, and more specifically, integrated models of care have existed for years, the 2010 Patient Protection and Affordable Care Act expanded their use, and Medicare has adopted a value-based payment system that further emphasizes service provision within the collaborative health care setting. Neuropsychology as a field is well-situated to work within the integrated health care setting, which presents both opportunities and challenges for clinical neuropsychologists. This education paper details how different neuropsychology clinical practice settings fit into an integrated care framework; discusses challenges to service delivery and fiscal viability in such settings and other health care related settings; and examines future directions for the role of neuropsychology within a dynamic health care system.

Children with heavy prenatal alcohol exposure demonstrate deficits on multiple measures of concept formation.

BACKGROUND: Children with heavy prenatal alcohol exposure have documented impairments in executive functioning (EF). One component of EF, concept formation, has not been well studied in this group. METHODS: Children (8 to 18 years) with histories of heavy prenatal alcohol exposure, with and without fetal alcohol syndrome (FAS), were compared to typically developing controls on 2 measures of concept formation and conceptual set shifting: the Wisconsin Card Sorting Test and the Card Sorting Test from the Delis-Kaplan Executive Functioning System. In addition to between-group comparisons, performance relative to overall intellectual functioning was examined. RESULTS: Children with histories of heavy prenatal alcohol exposure showed impairment on both tests of concept formation compared to non-exposed controls. These deficits included difficulty generating and verbalizing concepts, increased error rates and perseverative responses, and poorer response to feedback. However, in comparison to controls, alcohol-exposed children performed better on measures of concept formation than predicted by their overall IQ scores. Exploratory analyses suggest that this may be due to differences in how the measures relate at different IQ levels and may not be specific to prenatal alcohol exposure. CONCLUSIONS: Deficits in concept formation and conceptual set shifting were observed in alcohol-exposed children with or without the diagnosis of FAS and in the absence of mental retardation. These deficits likely impact problem solving skills and adaptive functioning and have implications for therapeutic interventions in this population.

Collaboration between neuropsychologists and speech-language pathologists in rehabilitation settings.

OBJECTIVE: The purpose of this study was to understand the barriers and facilitators of communication and collaboration between speech-language pathologists (SLPs) and neuropsychologists (NPs) in rehabilitation settings. METHOD: Focus groups were held at 3 rehabilitation hospitals. Participants were a convenience sample and were considered representatives of acquired brain injury rehabilitation teams that include SLPs and NPs. There were a total of 28 SLPs and 10 NPs in the sample. The study used a semistructured interview guide for the focus group discussions, using questions centered on major areas known to be related to interdisciplinary collaboration. Written notes and audio recordings were analyzed for recurring and strongly stated themes. RESULTS: Consistent themes emerged across focus groups, which included (1) structure of collaboration, (2) perceived roles of NPs and SLPs in assessment and intervention, (3) similarities and differences in training and philosophic perspectives, (4) barriers to successful collaboration, and (5) facilitators of collaboration. CONCLUSION: The SLPs and NPs valued the contributions of both professions in the management of patients with acquired brain injuries. Effective collaboration appeared to be influenced by several factors and is discussed. It was evident that effective communication was a key and powerful element in successful collaboration.

Test-retest reliability and practice effects for the ANAM General Neuropsychological Screening battery.

OBJECTIVE: As the use of computer-based neurocognitive assessment is rapidly expanding, the need to systematically study and document key psychometric properties of these measures has become increasingly more salient. To meet this aim, this study examined test-retest reliability and practice effects for the Automated Neuropsychological Assessment Metrics General Neuropsychological Screening battery (ANAM GNS) in a sample of 94 community dwelling adults. METHOD: ANAM GNS was administered and then repeated (alternate form) after 30 days. Test-retest reliability, practice effects, and the standard error of measurement were calculated. Using these estimates, reliable change indices were calculated to determine degree of performance change needed to exceed chance and measurement error (with 90% confidence interval). RESULTS: The test-retest reliability for the ANAM composite score was .91. Performance significantly improved upon retest, but the effect size was small consistent with minimal practice effects. The threshold indicating change beyond chance or measurement error with 90% certainty was .9 (z-score). CONCLUSIONS: Findings suggest that the ANAM GNS has excellent test-retest reliability upon retest at 30 days. Small practice effects can be expected. Change greater than .9 standard deviations in the ANAM composite score is likely to represent meaningful clinical change. This paper presents initial psychometric data from the ANAM GNS and supports its use as a reliable measure of cognition.

Validation of ANAM for cognitive screening in a mixed clinical sample.

The Automated Neuropsychological Assessment Metrics (ANAM) is a library of computer based tests designed to measure cognitive function at a single time-point or longitudinally for detection of cognitive change. This study sought to validate ANAM as a cognitive screening tool for presence of confirmed neuropsychological diagnosis in an outpatient setting. Retrospective data analysis was conducted for 139 patients referred for outpatient neuropsychological assessment. Clinical diagnosis was made independent of ANAM test results and resulted in a diagnostic mix of both neurologic and psychologic etiologies. ANAM scores predictive of presence of confirmed diagnosis were identified using multiple logistic regression and the predictive ability of the resulting model was quantified using receiver operator characteristic analysis. Sensitivity and specificity for the ANAM when combined with anger and depressive symptom scores were 71% and 91%, respectively, with a positive predictive value of 97.5 and negative predictive value of 40.4. This combined approach provided the greatest accuracy for individual tests as well as the composite score of the ANAM in identifying those who received a subsequent clinical diagnosis. Although data should be replicated in larger samples, these results suggest that ANAM may have predictive value and may be a useful screening tool for identifying those who would likely benefit from neuropsychological services.

Classification accuracy of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2)-Restructured form validity scales in detecting malingered pain-related disability.

The symptom reports of individuals with chronic pain are multidimensional (e.g., emotional, cognitive, and somatic) and significantly contribute to increased morbidity and lost work productivity. When pain occurs in the context of a legally compensable event, reliable assessment of a patient's multifactorial symptom experience during psychological or neuropsychological evaluations is a necessity. The Validity Scales of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) have been shown useful in identifying symptom overreporting and feigning within chronic pain samples and a number of studies have emerged supporting the use of the MMPI-2-Restructured Form (MMPI-2-RF) in the detection of simulated or feigned impairment in a variety of populations. To date, only 1 other study exists examining the ability of the MMPI-2-RF to detect exaggerated complaints using a strict operationalization of malingering exclusive to chronic pain samples. The purpose of this study was to examine the classification accuracy of MMPI-2-RF Validity Scales in a group of patients with chronic pain using a criterion-groups design. The final sample consisted of 501 clinical chronic pain patients assigned to groups based on the Bianchini, Greve, and Glynn (2005) criteria for Malingered Pain-Related Disability (MPRD). Results showed that all MMPI-2-RF Validity Scales differentiated malingerers from nonmalingerers with a high degree of accuracy. At cut-offs associated with ≥95% Specificity, Sensitivities ranged from 15% (Fs) to 60% (Response Bias Scale; RBS). This study demonstrates that the MMPI-2-RF Validity Scales are capable of differentiating intentional symptom exaggeration from genuine complaints in a sample of incentivized chronic pain patients. (PsycINFO Database Record

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients.

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition;emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; andrecognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.

Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients.

In December 2017, the National Academy of Neuropsychology convened an interorganizational Summit on Population Health Solutions for Assessing Cognitive Impairment in Geriatric Patients in Denver, Colorado. The Summit brought together representatives of a broad range of stakeholders invested in the care of older adults to focus on the topic of cognitive health and aging. Summit participants specifically examined questions of who should be screened for cognitive impairment and how they should be screened in medical settings. This is important in the context of an acute illness given that the presence of cognitive impairment can have significant implications for care and for the management of concomitant diseases as well as pose a major risk factor for dementia. Participants arrived at general principles to guide future screening approaches in medical populations and identified knowledge gaps to direct future research. Key learning points of the summit included: recognizing the importance of educating patients and healthcare providers about the value of assessing current and baseline cognition; emphasizing that any screening tool must be appropriately normalized and validated in the population in which it is used to obtain accurate information, including considerations of language, cultural factors, and education; and recognizing the great potential, with appropriate caveats, of electronic health records to augment cognitive screening and tracking of changes in cognitive health over time.

Assessing change with the Automated Neuropsychological Assessment Metrics (ANAM): issues and challenges.

Accurately documenting cognitive change is important, as neuropsychologists are routinely asked to determine cognitive change following disease progression or medical intervention. Computerized testing batteries, such as the Automated Neuropsychological Assessment Metrics (ANAM), are good tools for assessing change, because they allow for randomization of stimuli, creating near limitless alternate forms and reducing practice effects. The question remains, however, as to how best to determine reliable change in performance using ANAM. The current study compared the use of Reliable Change Index (RCI) and regression based methods (REG) calculated from 28 individuals with migraine. These methods then were applied to an independent sample of 25 individuals with migraine assessed with ANAM at baseline, headache, and following pharmacologic treatment. Traditional repeated measures analyses revealed declines in cognitive efficiency following migraine onset on two of four ANAM tasks and significant improvement on all ANAM tasks following treatment. Rates of deterioration and improvement did not significantly differ between RCI and REG methods, although were slightly different across the ANAM tasks used in this study. A combined ANAM score categorized the most individuals as demonstrating cognitive change, revealing that 60% of subjects declined in performance following headache and 84% improved following migraine treatment.

Identifying and monitoring cognitive deficits in clinical populations using Automated Neuropsychological Assessment Metrics (ANAM) tests.

In this article we review studies in which Automated Neuropsychological Assessment Metrics (ANAM) measures were used to screen for impairment in various clinical populations. These clinical groups include patients with multiple sclerosis, systemic lupus erythematosus, Parkinson's disease, Alzheimer's dementia, acquired brain injury, and migraine headache. Data are also presented from a group of outpatient referrals unselected with respect to clinical condition. Findings support the use of ANAM as a screening procedure for identifying the impaired patient.

Cognitive Screening Tests Versus Comprehensive Neuropsychological Test Batteries: A National Academy of Neuropsychology Education Paper†.

The American Medical Association Current Procedural Panel developed a new billing code making behavioral health screening a reimbursable healthcare service. The use of computerized testing as a means for cognitive screening and brief cognitive testing is increasing at a rapid rate. The purpose of this education paper is to provide information to clinicians, healthcare administrators, and policy developers about the purpose, strengths, and limitations of cognitive screening tests versus comprehensive neuropsychological evaluations. Screening tests are generally brief and narrow in scope, they can be administered during a routine clinical visit, and they can be helpful for identifying individuals in need of more comprehensive assessment. Some screening tests can also be helpful for monitoring treatment outcomes. Comprehensive neuropsychological assessments are multidimensional in nature and used for purposes such as identifying primary and secondary diagnoses, determining the nature  and severity of a person's cognitive difficulties, determining functional limitations, and planning treatment and rehabilitation. Cognitive screening tests are expected to play an increasingly important role in identifying individuals with cognitive impairment and in determining which individuals should be referred for further neuropsychological assessment. However, limitations of existing cognitive screening tests are present and cognitive screening tests should not be used as a replacement for comprehensive neuropsychological testing.

Reference values for performance on the Automated Neuropsychological Assessment Metrics V3.0 in an active duty military sample.

The Automated Neuropsychological Assessment Metrics (ANAM) is a computerized measure of processing speed, cognitive efficiency, and memory. This study describes performance and psychometric properties of ANAM in an active duty, healthy military sample (N = 2,371) composed primarily of young (18-46 years) adult males. Rarely have neuropsychological reference values for use with individuals in the military been derived from a large, active duty military population, and this is the first computerized neuropsychological test battery with military-specific reference values. Although these results do not provide demographically corrected, formal normative data, they provide reference points for neuropsychologists and other health care providers who are using ANAM data in research or clinical settings, with patients of comparable demographics to the present sample.

Cognitive Performance Scores for the Pediatric Automated Neuropsychological Assessment Metrics in Childhood-Onset Systemic Lupus Erythematosus.

OBJECTIVE: To develop and initially validate a global cognitive performance score (CPS) for the Pediatric Automated Neuropsychological Assessment Metrics (PedANAM) to serve as a screening tool of cognition in childhood lupus. METHODS: Patients (n = 166) completed the 9 subtests of the PedANAM battery, each of which provides 3 principal performance parameters (accuracy, mean reaction time for correct responses, and throughput). Cognitive ability was measured by formal neurocognitive testing or estimated by the Pediatric Perceived Cognitive Function Questionnaire-43 to determine the presence or absence of neurocognitive dysfunction (NCD). A subset of the data was used to develop 4 candidate PedANAM-CPS indices with supervised or unsupervised statistical approaches: PedANAM-CPSUWA , i.e., unweighted averages of the accuracy scores of all PedANAM subtests; PedANAM-CPSPCA , i.e., accuracy scores of all PedANAM subtests weighted through principal components analysis; PedANAM-CPSlogit , i.e., algorithm derived from logistic models to estimate NCD status based on the accuracy scores of all of the PedANAM subtests; and PedANAM-CPSmultiscore , i.e., algorithm derived from logistic models to estimate NCD status based on select PedANAM performance parameters. PedANAM-CPS candidates were validated using the remaining data. RESULTS: PedANAM-CPS indices were moderately correlated with each other (|r| > 0.65). All of the PedANAM-CPS indices discriminated children by NCD status across data sets (P < 0.036). The PedANAM-CPSmultiscore had the highest area under the receiver operating characteristic curve (AUC) across all data sets for identifying NCD status (AUC >0.74), followed by the PedANAM-CPSlogit , the PedANAM-CPSPCA , and the PedANAM-CPSUWA , respectively. CONCLUSION: Based on preliminary validation and considering ease of use, the PedANAM-CPSmultiscore and the PedANAM-CPSPCA appear to be best suited as global measures of PedANAM performance.

360 Degree advocacy: a model for high impact advocacy in a rapidly changing healthcare marketplace.

In an era of rapid changes in the healthcare marketplace the specialty of clinical neuropsychology faces a substantial increase in advocacy challenges. These include maintaining both access to services and a favorable practice climate as new healthcare structures and payment models evolve. The issue of regional variability complicates an effective response to these challenges from national professional organizations. One response to the challenge of regional variability is to strengthen our national organizations' capacity to engage in coordinated and effective advocacy, and to partner with state and regional neuro/psychological associations. The Inter-Organizational Practice Committee (IOPC) was formed in 2012 to meet this need. The IOPC has developed a model of 360 Degree Advocacy that coordinates local, regional, and national resources for high-impact, efficient advocacy. This paper describes the 360 Degree Advocacy model, and walks readers through an example of the model in action, successfully responding to a threat to patient access and practice climate with a regional Medicare carrier.