PONT: A Protocol for Online Neuropsychological Testing

Online cognitive testing in Parkinson's disease: advantages and challenges

Parkinson's disease (PD) is primarily characterized by motor symptoms. Yet, many people with PD experience cognitive decline, which is often unnoticed by clinicians, although it may have a significant impact on quality of life. For over half a century, traditional in-person PD cognitive assessment lacked accessibility, scalability, and specificity due to its inherent limitations. In this review, we propose that novel methods of online cognitive assessment could potentially address these limitations. We first outline the challenges of traditional in-person cognitive testing in PD. We then summarize the existing literature on online cognitive testing in PD. Finally, we explore the advantages, but also the limitations, of three major processes involved in online PD cognitive testing: recruitment and sampling methods, measurement and participation, and disease monitoring and management. Taking the limitations into account, we aim to highlight the potential of online cognitive testing as a more accessible and efficient approach to cognitive testing in PD.

Distinct Contributions of the Cerebellum and Basal Ganglia to Arithmetic Procedures

Humans exhibit complex mathematical skills attributed to the exceptional enlargement of neocortical regions throughout evolution. In the current work, we initiated a novel exploration of the ancient subcortical neural network essential for mathematical cognition. Using a neuropsychological approach, we report that degeneration of two subcortical structures, the cerebellum and basal ganglia, impairs performance in symbolic arithmetic. We identify distinct computational impairments in male and female participants with cerebellar degeneration (CD) or Parkinson's disease (PD). The CD group exhibited a disproportionate cost when the arithmetic sum increased, suggesting that the cerebellum is critical for iterative procedures required for calculations. The PD group showed a disproportionate cost for equations with increasing addends, suggesting that the basal ganglia are critical for chaining multiple operations. In Experiment 2, the two patient groups exhibited intact practice gains for repeated equations at odds with an alternative hypothesis that these impairments were related to memory retrieval. Notably, we discuss how the counting and chaining operations relate to cerebellar and basal ganglia function in other task domains (e.g., motor processes). Overall, we provide a novel perspective on how the cerebellum and basal ganglia contribute to symbolic arithmetic. Our studies demonstrate the constraints on the computational role of two subcortical regions in higher cognition.

Remote assessment of cognition in Parkinson's disease and Cerebellar Ataxia: the MoCA test in English and Hebrew

There is a critical need for accessible neuropsychological testing for basic research and translational studies worldwide. Traditional in-person neuropsychological studies are inherently difficult to conduct because testing requires the recruitment and participation of individuals with neurological conditions. Consequently, studies are often based on small sample sizes, are highly time-consuming, and lack diversity. To address these challenges, in the last decade, the utilization of remote testing platforms has demonstrated promising results regarding the feasibility and efficiency of collecting patient data online. Herein, we tested the validity and generalizability of remote administration of the Montreal Cognitive Assessment (MoCA) test. We administered the MoCA to English and Hebrew speakers from three different populations: Parkinson's disease, Cerebellar Ataxia, and healthy controls via video conferencing. First, we found that the online MoCA scores do not differ from traditional in-person studies, demonstrating convergent validity. Second, the MoCA scores of both our online patient groups were lower than controls, demonstrating construct validity. Third, we did not find differences between the two language versions of the remote MoCA, supporting its generalizability to different languages and the efficiency of collecting binational data (USA and Israel). Given these results, future studies can utilize the remote MoCA, and potentially other remote neuropsychological tests to collect data more efficiently across multiple different patient populations, language versions, and nations.

Contributions of Lower Structures to Higher Cognition: Towards a Dynamic Network Model

Researchers often attribute higher cognition to the enlargement of cortical regions throughout evolution, reflecting the belief that humans sit at the top of the cognitive pyramid. Implicitly, this approach assumes that the subcortex is of secondary importance for higher-order cognition. While it is now recognized that subcortical regions can be involved in various cognitive domains, it remains unclear how they contribute to computations essential for higher-level cognitive processes such as endogenous attention and numerical cognition. Herein, we identify three models of subcortical-cortical relations in these cognitive processes: (i) subcortical regions are not involved in higher cognition; (ii) subcortical computations support elemental forms of higher cognition mainly in species without a developed cortex; and (iii) higher cognition depends on a whole-brain dynamic network, requiring integrated cortical and subcortical computations. Based on evolutionary theories and recent data, we propose the SEED hypothesis: the Subcortex is Essential for the Early Development of higher cognition. According to the five principles of the SEED hypothesis, subcortical computations are essential for the emergence of cognitive abilities that enable organisms to adapt to an ever-changing environment. We examine the implications of the SEED hypothesis from a multidisciplinary perspective to understand how the subcortex contributes to various forms of higher cognition.

Feasibility and Efficacy of Online Neuropsychological Assessment

Neuropsychological testing has intrinsic challenges, including the recruitment of patients and their participation in research projects. To create a method capable of collecting multiple datapoints (across domains and participants) while imposing low demands on the patients, we have developed PONT (Protocol for Online Neuropsychological Testing). Using this platform, we recruited neurotypical controls, individuals with Parkinson's disease, and individuals with cerebellar ataxia and tested their cognitive status, motor symptoms, emotional well-being, social support, and personality traits. For each domain, we compared each group to previously published values from studies using more traditional methods. The results show that online testing using PONT is feasible, efficient, and produces results that are in line with results obtained from in-person testing. As such, we envision PONT as a promising bridge to more comprehensive, generalizable, and valid neuropsychological testing.

Best Practices and Methodological Strategies for Addressing Generalizability in Neuropsychological Assessment

Generalizability considerations are widely discussed and a core foundation for understanding when and why treatment effects will replicate across sample demographics. However, guidelines on assessing and reporting generalizability-related factors differ across fields and are inconsistently applied. This paper synthesizes obstacles and best practices to apply recent work on measurement and sample diversity. We present a brief history of how knowledge in psychology has been constructed, with implications for who has been historically prioritized in research. We then review how generalizability remains a contemporary threat to neuropsychological assessment and outline best practices for researchers and clinical neuropsychologists. In doing so, we provide concrete tools to evaluate whether a given assessment is generalizable across populations and assist researchers in effectively testing and reporting treatment differences across sample demographics.

Implicit sensorimotor adaptation is preserved in Parkinson's disease

Our ability to enact successful goal-directed actions involves multiple learning processes. Among these processes, implicit motor adaptation ensures that the sensorimotor system remains finely tuned in response to changes in the body and environment. Whether Parkinson's disease impacts implicit motor adaptation remains a contentious area of research: whereas multiple reports show impaired performance in this population, many others show intact performance. While there is a range of methodological differences across studies, one critical issue is that performance in many of the studies may reflect a combination of implicit adaptation and strategic re-aiming. Here, we revisited this controversy using a visuomotor task designed to isolate implicit adaptation. In two experiments, we found that adaptation in response to a wide range of visual perturbations was similar in Parkinson's disease and matched control participants. Moreover, in a meta-analysis of previously published and unpublished work, we found that the mean effect size contrasting Parkinson's disease and controls across 16 experiments involving over 200 participants was not significant. Together, these analyses indicate that implicit adaptation is preserved in Parkinson's disease, offering a fresh perspective on the role of the basal ganglia in sensorimotor learning.