The reliability of the Montreal Cognitive Assessment using telehealth in a rural setting with veterans

Background

Telehealth neuropsychological services can increase the availability of specialised care for individuals in rural areas where barriers to these services are faced. As this practice becomes more commonplace, the reliability and validity of neuropsychological assessment administered by telehealth continues to be established. The Montreal Cognitive Assessment, a screener for general neurocognitive dysfunction, may be particularly useful since this measure can be given by telehealth with minimal adaptation.

Methods

Veterans from a rural area of the country who were referred to an outpatient neuropsychology clinic were administered the Montreal Cognitive Assessment either in-person or by telehealth by a clinician. A second clinician observed the administration in-person or by telehealth and independently scored the each participant’s performance. The inter-rater reliabilities across conditions were compared to assess for differences between in-person and telehealth consultations.

Results

The inter-rater reliability of the Montreal Cognitive Assessment across the three conditions of interest was acceptably high and values ranged from r = 0.88 to r = 0.98. Reliability correlations were compared and no significant differences among the conditions were observed ( p’s > 0.10). Beyond reliability, univariate comparison of the absolute mean differences of clinician scores showed no significant differences among the actual raw scores of the three conditions tested, indicating good accuracy ( p = 0.56).

Conclusions

The inter-rater reliabilities of Montreal Cognitive Assessment scores across conditions were all acceptably high, and administration of the Montreal Cognitive Assessment using telehealth technology did not significantly alter the total scores. Overall, the lack of significant differences suggests that administering the Montreal Cognitive Assessment by telehealth is reliable, accurate and well received by participants.

Discomfort and exertion associated with prolonged wear of respiratory protection in a health care setting

The nature of discomfort and level of exertion associated with wearing respiratory protection in the health care workplace are not well understood. Although a few studies have assessed these topics in a laboratory setting, little is known about the magnitude of discomfort and the level of exertion experienced by workers while they deliver health care to patients for prolonged periods. The purpose of this study was to determine the magnitude of discomfort and level of exertion experienced by health care workers while wearing respiratory protection for periods up to 8 hr when performing their typical occupational duties. This project was a multiple cross-over field trial of 27 health care workers, aged 24-65, performing their typical, hospital-based occupational duties. Each participant served as his/her own control and wore one of seven respirators or a medical mask for 8 hr (or as long as tolerable) with interposed doffing periods every 2 hr. Self-perceived discomfort and exertion were quantified before each doffing: self-perceived level of discomfort using a visual analog scale, and self-perceived level of exertion using a Borg scale. Overall, and as would be expected, discomfort increased over time with continual respirator use over an 8-hr period. Interestingly, exertion increased only marginally over the same time period. The relatively low level of exertion associated with eight respiratory protective devices, including models commonly used in the U.S. health care workplace, is not likely to substantially influence workers' tolerability or occupational productivity. However, the magnitude of discomfort does appear to increase significantly over time with prolonged wear. These results suggest that respirator-related discomfort, but not exertion, negatively influences respirator tolerance over prolonged periods. Discomfort may also interfere with the occupational duties of workers.

Anxiety and depression severity are related to right but not left onset Parkinson's disease duration

Depression and anxiety have both been associated with relative left frontal hypoactivation and the motor symptoms of Parkinson's disease typically begin in a lateral or asymmetrical fashion. Hence, PD patients with right hemibody onset may experience heightened depression and anxiety. However, research is mixed regarding whether right or left hemibody onset PD is associated with elevated levels of depression and anxiety. This literature, though, has not considered the potential moderating variable of disease duration. We hypothesized that disease duration would be positively correlated with measures of depression and anxiety in right but not left hemibody onset PD patients. The results indicated that scores on the Geriatric Depression Scale, Beck Depression Inventory-II, and the State Trait Anxiety Scale - State correlated positively with disease duration, but only in the right hemibody onset group of PD patients. Thus, right hemibody onset PD is associated with more severe depressive and anxiety symptoms, but only when disease duration is considered.

DYNAMIC LATERALIZATION: HOSTILITY, CARDIOVASCULAR REGULATION, AND TACHISTOSCOPIC RECOGNITION

This experiment tested a hypothesis linking the right cerebral regulation of hostility and cardiovascular arousal. It also replicates related research regarding hostility, cardiovascular regulation, and auditory recognition (Shenal Harrison, 2003) through the visual modality. Thirty low- and high-hostile participants (n = 30) were identified using the Cook Medley Hostility Scale (CMHS). Only right-handed male participants with no significant medical or psychological history completed the experiment. All participants completed the cold pressor paradigm. Cardiovascular measures (systolic blood pressure [SBP] and diastolic blood pressure [DBP]) were recorded and tachistoscopic lexical recognition procedures were administered before and after the physical stressor. The primary finding of this research was greater left cerebral activation (decreased cardiovascular reactivity) following the tachistoscopic lexical recognition tasks and greater right cerebral activation following the painful (cold pressor) stressor.

The effects of movement direction and hemispace on estimates of distance traveled

BACKGROUND/HYPOTHESIS

The degree of attention directed to a stimulus and the presence of anisometric representations can alter the perception of the magnitude of a stimulus. We wanted to learn if normal right-handed subjects' estimates of distance traveled are influenced by the right-left direction or hemispace of movements.

METHODS

We had blindfolded participants estimate the distance their arm was moved in a rightward or leftward direction, in right and left hemispace. Since we wanted subjects to estimate the distance traveled rather than compute the distance between the start and finish points, the subjects' arms were passively moved in sinusoidal trajectories at a constant speed.

RESULTS

Subjects estimated leftward movements as longer than rightward movements, but there was no effect of hemispace. COMMENTS/CONCLUSIONS: People often attend more to novel than routine conditions and therefore participants might have overestimated the distance associated with leftward versus rightward movement because right-handed people more frequently move their right hand in a rightward direction and learn to read and write using rightward movements. Thus, leftward movements might be more novel and more attended than rightward movements and this enhanced directional attention might have influenced estimates of magnitude (distance).

Finger Agnosia in Alzheimer Disease

BACKGROUND AND OBJECTIVE

The purpose of this study was to learn if a deficit of finger naming (finger agnosia or anomia) is a sensitive test for Alzheimer disease (AD) and the best means of testing for finger agnosia.

METHODS

The subjects were 38 patients with AD and 10 matched normal controls. All subjects were asked to name the thumb, index, and pinky fingers.

RESULTS

No control subject had trouble naming any of these fingers, but 37% of the AD subjects did. When AD patients had difficulty with finger naming, they always had trouble naming the index finger.

CONCLUSIONS

In the absence of stroke, the inability to name the index finger seems as an indicator of dementia. Although brief, this test is not extremely sensitive test for AD.

Testosterone Therapy in Men With Parkinson Disease

BACKGROUND

Testosterone deficiency has been reported in patients with Parkinson disease (PD), Alzheimer disease, and Huntington disease. It is not known whether testosterone therapy (TT) in men with borderline hypogonadism and neurodegenerative diseases will be of substantial benefit. Previously, we reported that testosterone deficiency is more common in patients with PD compared with age-matched control subjects, and we also reported in 2 small open-label studies that some nonmotor symptoms responded favorably to TT.

OBJECTIVE

To define the effects of TT on nonmotor and motor symptoms in men with PD and probable testosterone deficiency.

DESIGN

Double-masked, placebo-controlled, parallel-group, single-center trial.

PATIENTS

Two experimental groups: patients with PD who were receiving either TT or placebo.

INTERVENTIONS

Participants received either the study drug by intramuscular injection (200 mg/mL of testosterone enanthate every 2 weeks for 8 weeks) or placebo (isotonic sodium chloride solution injections). In patients in each group, the testosterone serum concentration was obtained at each study visit. During 2 study visits, testosterone levels were blindly evaluated and the intramuscular testosterone dose was increased by 200 mg/mL if the free testosterone value failed to double from the baseline value.

MAIN OUTCOME MEASURES

The primary outcome variable was the St Louis Testosterone Deficiency Questionnaire, and secondary outcome measures included measures of mood, cognition, fatigue, motor function, and frequency of adverse events. At the end of the double-blind phase, all patients were offered open-label TT and were followed up after 3 and 6 months.

RESULTS

Fifteen patients in the placebo group (mean age, 69.9 years), receiving a mean total levodopa equivalent dose of 924 mg/d, had a baseline free testosterone level of 47.91 pg/mL, compared with 15 patients in the TT group (mean age, 66.7 years), receiving an average total levodopa equivalent dose of 734 mg/d, who had a baseline free testosterone level of 63.49 pg/mL. Testosterone was generally well tolerated. More subjects in the TT group experienced lower extremity edema (40% vs 20%). In 2 patients, 1 in each group, prostate-specific antigen levels were elevated from baseline. The improvement in the TT group compared with the placebo group (1.7 vs 1.1) on the St Louis Testosterone Deficiency Scale was not statistically significant. In addition, there were no significant differences in motor and nonmotor features of PD between the 2 groups, although a few subscales showed improvements (Hopkins Verbal Learning Test, P<.04; and Backward Visual Span subtrial, P<.03). However, long-term open-label TT resulted in delayed but sustained improvement in subjects in the TT group who continued to receive treatment (n = 6) compared with subjects in the placebo group who elected not to receive TT (n = 3).

CONCLUSIONS

Testosterone therapy was generally well tolerated in elderly men with PD and probable testosterone deficiency. While there was no significant difference in the motor and nonmotor scales between the TT and placebo groups at the end of 8 weeks compared with baseline, this may be due to several study limitations, including small sample size, a strong placebo effect with intramuscular therapy, and short follow-up that did not allow measurement of delayed effects of TT in some subjects. Until more definitive studies are reported, practitioners should be particularly cautious in treatment of low testosterone concentrations in men with PD and borderline testosterone deficiency, and careful consideration should be given to the risks vs the benefits of TT.

Hostility and facial affect recognition: Effects of a cold pressor stressor on accuracy and cardiovascular reactivity

The effects of hostility and a cold pressor stressor on the accuracy of facial affect perception were examined in the present experiment. A mechanism whereby physiological arousal level is mediated by systems which also mediate accuracy of an individual's interpretation of affective cues is described. Right-handed participants were classified as high hostile (N = 28) or low hostile (N = 28) using the Cook Medley Hostility Scale. The high-hostile group met joint selection criteria. Only high-hostile participants who showed cardiovascular reactivity to the cold pressor, with systolic BP change exceeding the group mean were included. Groups were further subdivided into cold pressor and non-cold pressor test conditions. It was predicted that high-hostile men, relative to low-hostile men, would show decreased perceptual accuracy when presented with happy, angry, and neutral facial configurations within the left visual field (LVF). Results indicated that high-hostile men were less accurate than low-hostile men in the LVF. Further, pre-stress accuracy scores in the high-hostile men were similar to the post-stress accuracy scores of the low-hostile men. The lateralization of affective function and the role of physiological arousal in affective facial perception are discussed.

Primacy and Recency Effects Found Using Affective Word Lists

This experiment tested hypotheses linking the right cerebral regulation of hostility and affective verbal learning. First, patterns of recall for positive, negative, and neutral affective list learning among high- and low-hostile individuals were examined. It was expected that low-hostiles would recall more items from the positive list and that high-hostiles would recall more words from the negative affective list. Also, independent of groups, it was expected that there would be a primacy effect for negative words and a recency effect for positive words. Exploratory analyses examined the relation between hostility and primacy and recency effects on the positive and negative word lists. High- and low-hostile participants (n = 65) completed the positive list learning task, the negative list learning task, or the neutral list learning task. Data analyses revealed no significant difference between the high- and low-hostile groups on the different affective lists. However, results of the present investigation reliably demonstrated the predicted primacy and recency effects. There was a primacy effect for the negative affective list and a recency effect for the positive affective list. These findings are consistent with previous research investigating the acquisition pattern of affective verbal learning.

Quantitative EEG diagnostic confirmation of expressive aprosodia

Quantitative electroencephalography (QEEG) was used to confirm predictions emanating from the neuropsychological examination of an adolescent with expressive aprosodia. Previous research has indicated that expressive deficits in prosody can be caused by cerebral damage to the right hemisphere region homologous to Broca's area. The neuropsychological evaluation of this individual indicates probable right anterior cerebral dysfunction. Taken together, a priori hypotheses included a relative deficit in cerebral arousal of right-relative to left-frontotemporal regions. EEG results confirm the hypothesis and provide case study evidence for both: (a). right anterior mediation of prosodic expression as well as (b). support for the inclusion of QEEG as part of a clinical neuropsychological evaluation.

The neuropsychology of depression: a literature review and preliminary model

Neuropsychological research provides a useful framework to study emotional problems, such as depression, and their correlates. This paper reviews several prominent neuropsychological theories. Functional neuroanatomical systems of emotion and depression are reviewed, including those that describe cerebral asymmetries in emotional processing. Following the review, a model that is composed of three neuroanatomical divisions (left frontal, right frontal, and right posterior) and corresponding neuropsychological emotional sequelae within each quadrant is presented. It is proposed that dysfunction in any of these quadrants could lead to symptomatology consistent with a diagnosis of depression. The proposed model combines theories of arousal, lateralization, and functional cerebral space and lends itself to scientific methods of investigation. Accordingly, research, prevention, and treatment programs in accordance with the proposed model may promote an improved understanding of the neuropsychological mechanisms involved in depression.

Investigation of the laterality of hostility, cardiovascular regulation, and auditory recognition

This experiment tested a hypothesis linking the right cerebral regulation of hostility and cardiovascular arousal. First, replication of previous research supporting heightened cardiovascular (systolic blood pressure [SBP] and diastolic blood pressure [DBP]) reactivity among high hostile participants was partially successful. Second, dynamic variations in functional cerebral asymmetry in response to emotional linguistic processing was measured. Thirty low- and high-hostile, undergraduate volunteer participants (n = 30) were identified using the Cook Medley Hostility Scale (CMHS). Only healthy, right-handed male participants completed the experiment. All participants completed the negative affective auditory verbal learning test (AAVLT). Cardiovascular measures (SBP and DBP) were recorded and dichotic listening procedures were administered before and after the cognitive affective stressor. The results support greater left cerebral activation among both groups following the dichotic phoneme listening tasks and greater right cerebral activation among both groups following an emotional linguistic (affective verbal learning) cognitive stressor.

Grip-strength, fatigue, and motor perseveration in anxious men without depression

OBJECTIVE

To investigate the influence of anxiety without depression on functional motor asymmetry in adult men. Thus, left-and right-hand grip strength, fatigue across trials, and motor perseveration was examined among 60 right-handed men, half of whom had been classified as anxious without depression (HI, n = 30) and the other half as nonanxious without depression (LO, n = 30).

BACKGROUND

There is substantial empirical support for the notion that individuals with negative affect experience relative right anterior activity. Moreover, previous studies using other groups of interest (e.g., depression and hostility) have found evidence of functional motor asymmetry that is supportive of relative right anterior activation during negative affect. Less is known about functional motor asymmetry among individuals that report anxiety without depression.

METHOD

To obtain indices of perseveration, strength, and fatigue, HI and LO anxious subjects were asked to successively squeeze a hand dynamometer. Dependent measures (in kg) were derived from performance with the left and right hands across trials.

RESULTS

In contrast to LO anxious subjects, HI anxious subjects did not demonstrate right-hand superiority for grip-strength. Moreover, significant positive correlations existed between grip strength and trait anxiety scores for LO anxious subjects, but not for HI anxious subjects.

CONCLUSIONS

The data are partially supportive of differences in functional motor asymmetry between HI and LO anxious individuals. The findings are interpreted as supportive of relative right anterior activity (and possibly decreased left anterior activity) among individuals that report elevated levels of anxiety. Implications for relative right-hemisphere activity and decreased left anterior activity are discussed, and alternative explanations are introduced.

Quantitative electroencephalography (QEEG) and neuropsychological syndrome analysis

The ideographic, syndrome analysis and the nomothetic, standardized test battery approaches to neuropsychological assessment are compared and contrasted within the context of advances in noninvasive technology readily available for use within the examiner's office. By demonstrating the relative strengths and benefits of syndrome analysis, it is suggested that this approach provides a thorough and efficient method of neuropsychological assessment. Subsequently, the utility of an a priori hypothesis testing process approach as a critical technique in syndrome analysis will be supported. It will be proposed that QEEG procedures provide a useful method for further substantiating conclusions generated from a syndrome analysis approach to neuropsychological assessment. Two cases are described demonstrating the utility and flexibility of the QEEG as a confirmatory test of localization following syndrome analysis. In summary, the contributions that neuropsychologists make to the understanding of brain-behavior relationships may be strengthened by combining neuropsychological and neurophysiological assessment methods.

The Affective Auditory Verbal Learning Test: peripheral arousal correlates

The present study assessed the usefulness of the affective list alternatives to the Rey Auditory Verbal Learning Test (RAVL) in the induction of physiological arousal. It was anticipated that affective verbal learning would lead to arousal patterns characteristic of different emotions (Izard, 1977), with significant increases in blood pressure following negative list learning and significant decreases following positive list learning. Since diastolic blood pressure increased significantly following the learning of negatively valanced words and decreased significantly following the learning of positively valanced words, this was supported. Given the abundance of research on lateral asymmetries in emotional and verbal processing, the affective list alternatives to the RAVL may provide an objective means for evaluating individual differences in affective verbal learning as well as the induction of emotion. The Affective Auditory Verbal Learning Test (AAVL) may potentially provide a tool for assessment of cerebral dysfunction in the clinic or in the assessment of affective disorders.

QEEG assisted neuropsychological evaluation of autism

The present case study utilizes neuropsychological procedures, quantitative electroencephalography (QEEG) and magnetic resonance imaging (MRI) to identify neural substrates of "autism" in a 25 year old Caucasian male. A priori hypotheses formed from a neuropsychological evaluation were supported by data from QEEG and MRI. Specifically, the neuropsychological evaluation was suggestive of left anterior deactivation and right frontal activation. Consistent with these results, QEEG data revealed relative activation of the right frontal region, while MRI results were suggestive of multiple small focal areas over the left frontal region and a teardrop shaped area of low attenuation across the right frontal region. The possible relation of right cerebral dysfunction and autism is discussed.