Investigating the association between subjective and objective performance-based cognitive function among former collegiate football players

Intraindividual variability, subjective cognitive difficulties, and head injury history in former collegiate athletes

Objectives: The association between head injury history and subjective cognitive symptoms among contact sport athletes has been frequently reported, but links between head injury history and performance-based measures have been more variable. Dispersion-based intraindividual variability (IIV) may better align with subjective cognitive concerns and be a more sensitive measure of subtle head injury-related changes. This study investigated the associations among IIV, subjective cognitive symptoms, and head injury history. Methods: Former collegiate football players (N = 57 included in analyses; age = 38 ± 1.5 years) completed evaluations consisting of neuropsychological assessment, subjective rating of cognition (Neuro-QoL Cognitive Functioning-Short Form and Behavior Rating Inventory of Executive Function-Adult; BRIEF-A), and structured interviews of head impact history (i.e. HIEE). Three IIV indices were calculated reflecting degree of dispersion across cognitive domains: Memory-IIV, reaction time/processing speed-IIV (RT/PS-IIV), and attention/executive function-IIV. General linear models were fit to test associations among IIV, subjective measures, concussion history, and Head Impact Exposure Estimate (HIEE). Results: Greater history of concussion and RHI exposure were not significantly associated with levels of cognitive dispersion (IIV indices, p's >.05). Worse general subjective cognition was associated with greater RT/PS-IIV, and worse BRIEF-A metacognition was associated with greater memory-IIV, even when controlling for psychological distress and sleep quality. Conclusions: Results support the assessment of dispersion in cognitive performance as a useful objective measure that complements subjective cognitive symptoms. While IIV is clinically relevant for detecting subtle cognitive difficulties not captured by central tendency methods, it may only indirectly, if at all, relate to changes associated specifically with head injury history.

Critical Review of Recently Published Studies Claiming Long-Term Neurocognitive Abnormalities in Mild Traumatic Brain Injury

Mild traumatic brain injury (mTBI) is the most common claimed personal injury condition for which neuropsychologists are retained as forensic experts in litigation. Therefore, it is critical that experts have accurate information when testifying as to neurocognitive outcome from concussion. Systematic reviews and six meta-analyses from 1997 to 2011 regarding objective neurocognitive outcome from mTBI provide no evidence that concussed individuals do not return to baseline by weeks to months post-injury. In the current manuscript, a critical review was conducted of 21 research studies published since the last meta-analysis in 2011 that have claimed to demonstrate long-term (i.e., ≥12 months post-injury) neurocognitive abnormalities in adults with mTBI. Using seven proposed methodological criteria for research investigating neurocognitive outcome from mTBI, no studies were found to be scientifically adequate. In particular, more than 50% of the 21 studies reporting cognitive dysfunction did not appropriately diagnose mTBI, employ prospective research designs, use standard neuropsychological tests, include appropriate control groups, provide information on motive to feign or use PVTs, or exclude, or adequately consider the impact of, comorbid conditions known to impact neurocognitive scores. We additionally analyzed 15 studies published during the same period that documented no longer term mTBI-related cognitive abnormalities, and demonstrate that they were generally more methodologically robust than the studies purporting to document cognitive dysfunction. The original meta-analytic conclusions remain the most empirically-sound evidence informing our current understanding of favorable outcomes following mTBI.

Neuropsychological review of records in forensic cases: An AACN best practices paper with international perspectives

Objective: The purpose of this American Academy of Clinical Neuropsychology (AACN) best practices paper is to provide the neuropsychological community with the fundamentals of a competent forensic review of records. Method: Narrative review addressing fundamental factors related to review of records. Examples highlighted information necessary for a forensic determination of traumatic brain injury (TBI), and the data from records that can be used to address questions regarding validity of presentation. International and intra-jurisdictional perspectives within the US were used to illustrate the necessity of adhering the review to the rules. Results: Factors identified involve ethical responsibilities, completeness in obtaining and reviewing relevant records, evaluation of credibility of the records, considerations regarding examinee self-reporting, grounding of opinions within peer-reviewed science, determination of causation in the context of litigation, and avoiding bias in reporting, as well as consideration of cultural and language factors. Different jurisdictional rules require close attention. Conclusions: Neuropsychologists need to be aware of the need for a competent review of records to obtain basic facts, maintain objectivity, and provide a context for conclusions in a neuropsychological examination report. In litigation cases, opinions based solely on review of records may be challenged for reasons that might include not having personally evaluated the plaintiff, and whether opinions meet Daubert criteria pertaining to sufficient scientific bases and facts. A thorough review in the context of examination helps deal with litigant/claimant subjectivity and malleability of self-report, and it can provide critical reasoning about other factors relevant to causation.

Long-term neurobehavioral and neuroimaging outcomes in athletes with prior concussion(s) and head impact exposure

Objective: The long-term health of former athletes with a history of multiple concussions and/or repetitive head impact (RHI) exposure has been of growing interest among the public. The true proportion of dementia cases attributable to neurotrauma and the neurobehavioral profile/sequelae of multiple concussion and RHI exposure among athletes has been difficult to determine. Methods: Across three exposure paradigms (i.e. group comparisons of athletes vs. controls, number of prior concussions, and level of RHI exposure), this review characterizes the prevalence of neurodegenerative/neurological disease, changes in cognitive and psychiatric function, and alterations on neuroimaging. We highlight sources of variability across studies and provide suggested directions for future investigations. Results: The most robust finding reported in the literature suggests a higher level of symptom endorsement (general, psychiatric, and cognitive) among those with a greater history of sport-related concussion from adolescence to older adulthood. Pathological processes (e.g. atrophy, tau deposition, and hypometabolism) may be more likely to occur within select regions (frontal and temporal cortices) and structures (thalamus and hippocampus). However, studies examining concussion(s) and RHI exposure with imaging outcomes have yet to identify consistent associations or evidence of a dose-response relationship or a threshold at which associations are observed. Discussion: Studies have not observed a simple dose-response relationship between multiple concussions and/or RHI exposure with cognitive, psychiatric, or in vivo neurobiological outcomes, particularly at lower levels of play. The relationship between prior concussion and RHI exposure with long-term outcomes in former athletes is complex and likely influenced by -several non-injury-related factors.

Relationship between self-reported concussion history, cognition, and mood among former collegiate athletes

Objective: This study explored the relationship between concussion history and cognition/mood in former collegiate athletes in middle-to-later adulthood. Method: 407 former collegiate athletes aged 50+ (M = 61.4; 62.7% male) participated in the College Level Aging AThlete Study (CLEAATS) and completed the Cognitive Function Instrument (CFI), 40-item Telephone Interview for Cognitive Status (TICS-40), PHQ-8, GAD-7, and self-report questionnaires, including concussion history. Kruskal-Wallis tests assessed for differences among groups based on concussion history (0, 1-2, 3-4, 5+ concussions). Hierarchical multiple regressions including demographic factors as covariates examined relationships between concussion history, emotional symptoms, and subjective/objective cognition. Results: Participants with 5+ concussions reported significantly greater subjective cognitive concerns and depressive symptoms than other concussion groups, but no differences were found in objective cognition. Hierarchical regression revealed concussion history and emotional symptoms explained 29% and 15% of the variance in subjective and objective cognition, respectively. The number of concussions accounted for unique variance in subjective cognition but was not significantly associated when mood symptoms were added to the model. Neither diagnosed concussions nor emotional symptoms were associated with objective cognition. Conclusions: When accounting for concussion history, those with 5+ concussions reported greater subjective cognitive symptoms than those with 0-2 concussions, and greater depressive symptoms than those with 0 concussions. Concussion history was not significantly related to subjective cognition when compared to mood, and concussion history and mood symptoms were not associated with objective cognition. Results highlight the importance of considering mood symptoms when evaluating the relationship between concussion history and cognition in former athletes.

Examining the role of depression on the relationship between performance-based and self-reported cognitive functioning after sport-related concussion

OBJECTIVE

Little is known about the relationship between neuropsychological test performance, cognitive symptom reporting, and depressive symptoms after sport-related concussion. Accordingly, this cross-sectional study examined these relationships in collegiate athletes. It was hypothesized that depressive symptoms would moderate and mediate the relationship between performance-based and self-reported cognitive functioning after concussion.

METHODS

After sustaining a sport-related concussion, 110 collegiate athletes completed a neuropsychological battery, the Post-Concussion Symptoms Scale, and the Beck Depression Inventory-Fast Screen. Neuropsychological test performance, depressive symptoms, and their interactions were entered into distinct hierarchical linear regression analyses with self-reported cognition as the dependent variable to assess moderation. Mediation was analyzed using the PROCESS macro with 5000 bootstrap samples and a 95% confidence interval.

RESULTS

There was a significant interaction between the mean memory composite and depressive symptoms when predicting cognitive symptom reporting, p = 0.047. Simple effects tests revealed that for athletes who had a lower memory composite score, an increase in depressive symptoms led to an increase in self-reported cognitive dysfunction, p < 0.001, ηp2 = 0.11. Depressive symptoms partially mediated the relationship between the memory composite and cognitive symptom reporting, indirect effect = -0.26, 95%CI[-0.58,0.001], but this relationship was not found for any other neurocognitive domain.

CONCLUSIONS

For tests of memory, depressive symptoms moderated and partially mediated the relationship between performance-based and self-reported cognitive functioning after sport-related concussion. Athletes reporting high depressive symptoms and cognitive dysfunction may need more comprehensive evaluations to inform return-to-play decisions, and depression could be a treatment target for athletes who report high levels of cognitive dysfunction after concussion.

Repetitive head-injury exposure and later-in-life cognitive and emotional outcomes among former collegiate football players: a CLEAATS investigation

This study measured the relationship between head-injury exposure and later-in-life cognitive and emotional symptoms in aging collegiate football players who participated in the College Level Aging Athlete Study. Linear regressions examined the relationship between various head-injury exposure variables (head-injury exposure estimate [HIEE], number of diagnosed concussions, and symptomatic hits to the head) and subjective cognitive function, objective cognitive function, and emotional/mood symptoms. Additional regressions evaluated the impact of emotional symptoms on subjective cognitive decline and objective cognitive function. Participants (n = 216) were 50-87 years old (M = 63.4 [8.5]), 91% White, and well-educated (bachelor's/graduate degree = 92%). HIEE did not predict scores on cognitive or emotional/mood symptom measures (p's > .169). Diagnosed concussions had a small effect on depression symptoms (p = .002, b = 0.501, R2 = .052) and subjective cognitive symptoms (p = .002, b = 0.383, R2 = .051). An emotional symptom index had a stronger relationship (p < .001, b = 0.693, R2 = .362) with subjective cognitive functioning but no significant relationship with objective cognitive function (p = .052, b = -0.211, R2 = .020). Controlling for emotional symptoms, the relationship between concussions and subjective cognitive symptoms was attenuated (p = .078, R2 = .011). Findings suggested that head-injury exposure was not significantly related to cognitive or emotional/mood outcomes in former collegiate football players and highlighted the importance of current emotional/mood symptoms on subjective cognitive function.

Subjective and Performance-Based Cognition and Their Associations with Head Injury History in Older Former National Football League Players

PURPOSE

Investigate the association between self-reported subjective and performance-based cognition among older (50-70 years) former professional American football players, as well as the relationship of cognitive measures with concussion history and years of football participation, as a proxy for repetitive head impact exposure.

METHODS

Among older former National Football League (NFL) players ( N = 172; mean age = 60.69 ± 5.64), associations of subjective (Patient Reported Outcome Measurement Information System Cognitive Function-Short Form) and performance-based cognitive measures (Brief Test of Adult Cognition by Telephone [BTACT] Executive Function and Episodic Memory indices) were assessed via univariable and multivariable regression models, with a priori covariates of depression and race. A similar univariate and multivariable regression approach assessed associations between concussion history and years of football participation with subjective and performance-based cognitive measures. In a sample subset ( n = 114), stability of subjective cognitive rating was assessed via partial correlation.

RESULTS

Subjective ratings of cognition were significantly associated with performance-based assessment, with moderate effect sizes (episodic memory ηp2 = 0.12; executive function ηp2 = 0.178). These associations were weakened, but remained significant ( P s < 0.05), with the inclusion of covariates. Greater concussion history was associated with lower subjective cognitive function ( ηp2 = 0.114, P < 0.001), but not performance-based cognition. The strength of association between concussion history and subjective cognition was substantially weakened with inclusion of covariates ( ηp2 = 0.057). Years of participation were not associated with measures of subjective or objective cognition ( P s > 0.05).

CONCLUSIONS

These findings reinforce the importance of comprehensive evaluation reflecting both subjective and objective measures of cognition, as well as the consideration of patient-specific factors, as part of a comprehensive neurobehavioral and health assessment of older former contact sport athletes.

Ecological validity reconsidered: the Night Out Task versus the D-KEFS

INTRODUCTION

Although executive functioning (EF) correlates with execution of instrumental activities of daily living (IADLs), tests of EF have been criticized for having poor ecological validity. Attempts have been made to develop new tests that approximate naturalistic daily tasks. However, the incremental utility of such tests has not been convincingly demonstrated. The Night Out Task (NOT) is a novel measure designed to increase ecological validity. This study examined whether the NOT correlates with traditional lab- and home-based measures of EF and IADLs, and whether it outperforms traditional measures of EF in predicting IADLs.

METHOD

Participants (50 adults aged 60 to 95) completed (1) the Delis Kaplan Executive Function System (D-KEFS) and IADLs in the laboratory, and (2) ecological momentary assessment of EF and daily IADL tasks at home across three weeks (using the Daily Assessment of Independent Living and Executive Skills protocol; DAILIES).

RESULTS

The NOT correlated with a lab-based measure of EF beyond covariates, and lab-based IADLs beyond covariates and beyond the D-KEFS. However, it was unrelated to at-home variables beyond covariates. In contrast, the D-KEFS was a significant predictor of at-home IADLs, and this association was mediated by at-home EF performance.

CONCLUSION

This study provides a preliminary validation of the NOT as a correlate of office-based performances in a primarily college educated white sample. Despite its high face validity, the NOT does not appear to sufficiently tap EF processes needed for home-based IADLs as measured by the DAILIES, although small sample size limits the interpretability of this negative finding.

Self-Report versus Neuropsychological Tests for Examining Executive Functions in Youth Soccer Athletes-A Cross-Sectional Study

Cognitive diagnostics, especially the measurement of executive functions (EFs) in the context of sports and talent diagnostics, is a popular research topic. However, research is lacking on how self-reports are sufficient to examine the EFs of youth athletes for performance diagnostics. Thus, the current study aims to evaluate the relationships between neuropsychological tasks (3-back task, cued Go/NoGo task, flanker task, and number-letter task) and a self-report for examining EFs (BRIEF-SB). Furthermore, it should be investigated whether it is possible to predict the outcome of EF tasks using a self-report inventory. Therefore, 68 young professional soccer players (Mage = 14.26 ± 1.35 years) from a national youth academy were included in the study. The weak-to-moderate correlations (r = 0.000, p = 0.999 to r = −0.442, p < 0.01) and the results of sensitivity analysis (0.125 to 0.538) do not support using a self-report of EFs for cognitive performance diagnostics. The inventory is only suitable for identifying executive dysfunctions in athletes recovering from head injuries or concussions.