The transition from Mild Cognitive Impairment of the Amnestic Type to early dementia: A phenomenological and neuropsychological case analysis.

The scientific literature on neuropsychological correlates of Mild Cognitive Impairment of the Amnestic Type (MCI-A) often reports large group findings and employs multivariate statistics to describe domains of cognitive impairment associated with the transition of MCI-A to early dementia, typically of the Alzheimer's Type (AD). Individual patients may vary, however, in terms of specific changes in their neuropsychological test performance as they transition from MCI-A to probable AD. The subjective experiences of individuals during this time of transition can also vary but rarely are reported. Tracking both the patient's subjective experiences and their performance on neuropsychological measures provides a more complete picture of the patient's clinical situation. These combined sets of information help the clinical neuropsychologist provide a more individualized and personally relevant service. We present a phenomenological and neuropsychological case analysis of a 67-year-old woman who transitioned from MCI-A to probable early AD in an attempt to illustrate how such a combined analysis is helpful in their psychological care.

Studying lack of awareness of cognitive decline in neurodegenerative diseases requires measures of both anosognosia and denial.

The cause(s) of lack of awareness of cognitive decline in neurodegenerative diseases can be multifactorial. Yet neurologically oriented research on anosognosia of cognitive decline almost exclusively assumes that the underlying disturbance of neuro-networks that support various cognitive functions accounts for the reduced self-awareness. Cultural and psychosocial factors, including the person's emotional state, however, can contribute to the underreporting or avoidance of admitting to cognitive impairments in neurodegenerative diseases. Research on the causes of lack of awareness of cognitive decline in neurodegenerative disorders needs to include these variables. We briefly present two case examples of underreporting or "unawareness" of memory difficulties in persons with mild cognitive impairment (MCI) (or minor neurocognitive disorder). One presented with classic anosognosia for memory impairment, while the other initially reported no memory impairment but later admitted to "denying" her memory difficulties secondary to anxiety. Based on these patients' clinical presentations and available research, we suggest three potential screening items that may help identify probable denial of memory impairments when studying anosognosia in MCI.

Neuropsychological and Social Characteristics of a 7 Year Old Child with Hypomelanosis of Ito Followed for 11 Years.

Hypomelanosis of Ito (HI) is a neurocutaneous disorder associated with central nervous system abnormalities, including speech delay and intellectual disability. The long term neuropsychological and social characteristics of these children are unknown. Neuropsychological observations and parental reports were obtained yearly on a child with HI from ages 7 to 18 years. Serial measures of intelligence revealed stable verbal and perceptual reasoning scores with later improvements in working memory and processing speed performance. Speech articulation improved at age 12, as did the speed of right-hand finger tapping. Improved social integration occurred, but anxiety persisted throughout this developmental period.

George P. Prigatano's contributions to neuropsychological rehabilitation and clinical neuropsychology: A 50-year perspective.

In the 1970s and 1980s, a multitude of cognitive rehabilitation programs proliferated to facilitate recovery after brain injury. However only a few programs provided a framework for ameliorating disturbances in the cognitive, psychological, and interpersonal spheres of the brain-injured patient. Greatly influenced by Leonard Diller and Yehuda Ben-Yishay's ideas and methods, George P. Prigatano began, in early 1980, a holistic neuropsychological rehabilitation program at the Presbyterian Hospital in Oklahoma City (Oklahoma). The objective of this paper is to summarize the contributions of George P. Prigatano to neuropsychological rehabilitation and clinical neuropsychology during his 50th year of practice. The main body of the paper is structured in three sections. The first section briefly explains the history of neuropsychological rehabilitation in the twentieth century and the emergence of holistic neuropsychological rehabilitation programs in the 1970s. The second section describes the contributions of George P. Prigatano to neuropsychological rehabilitation and clinical neuropsychology (written by AGM). In the third section, the second author (GPP) prepared an autobiographical statement, which attempts to summarize some of the personal and professional experiences which influenced his work. George P. Prigatano's contributions to neuropsychological rehabilitation and clinical neuropsychology are essential to understanding the therapeutic approaches currently used in the treatment of brain-injured patients.

Screening for more than level of cognitive functioning: the BNI screen for higher cerebral functions.

OBJECTIVE: This paper describes the BNI Screen for Higher Cerebral Functions (BNIS) and reviews studies that comment on its reliability, validity, and clinical and research utility. The ability of the BNIS to assess non-cognitive higher brain functions is also described. METHODS: We reviewed the original administration manual, studies published in the BNI Quarterly of the Barrow Neurological Institute, and peer-reviewed studies on the BNI Screen identified by an academic database, PubMed and Google Scholar. Thirty-two studies were reviewed that describe normative data, psychometric properties, sensitivity and specificity estimates, the relationship of demographic factors to test performance, and its research utility. RESULTS: The BNIS is a time efficient screening test often taking no longer than 12-18 minutes. In addition to cognitive functioning, it aids in assessing conation, awareness of memory impairment, and affects expression and perception. Sensitivity estimates ranged from 80% to 92.3%. Specificity estimates ranged from 38.9% to 90%. Its construct, concurrent, and predictive validity have been supported by a series of international studies using different language translations of the test. CONCLUSION: The BNIS is a useful screening test for identifying patients with underlying brain disorders that uniquely measures domains of functioning not sampled by other existing screening tests.

End of Life Neuropsychological Impairments and Psychological Care of Persons With Advanced Parkinsonism.

Decline in executive functioning, before frank dementia occurs, has been reported in patients with a history of stroke and malignant brain tumors. This may also be true in patients with advanced Parkinson's disease (PD). In this paper, we summarize the limited research on the motor and cognitive predictors of mortality in advanced PD. We then provide 2 case vignettes of patients with end of life advanced PD who demonstrated a substantial decline in working memory and speech festination. We contrast these patients' neuropsychological features to a third patient with advanced PD who shows no signs of impending death. Monitoring neuropsychological signs of executive dysfunction, explaining the neuropsychological dysfunctions to the patient and spouse while recognizing the past and retained cognitive competencies of the person is an important component of end of life psychological care. In the context of this type of consultation, the patient may experience an opportunity to communicate their emotional concerns prior to death which further reduces the anxiety associated with death.

Neuropsychological rehabilitation, neuroimaging and neuroplasticity: A clinical commentary.

Initial brain imaging studies on recovery of motor functioning after stroke suggested their potential prognostic value in neurorehabilitation. However, the value of brain imaging in documenting brain changes associated with cognitive and behavioral treatment effects seem less likely. Also, neuroimaging studies at that time seem to have little, if any, value for treatment planning. Advances in neuroimaging technology are beginning to challenge these initial impressions. In this clinical commentary, we propose that advances in the field of neuroimaging have relevance for the future development of neuropsychological rehabilitation. Neuropsychological rehabilitation is entering a new era that involves collaboration with neuroimaging and associated studies on neuroplasticity. We recognize that this may seem "aspirational" rather than practical in most rehabilitation settings. However, we provide examples of how this can be achieved as illustrated by collaborative efforts of clinicians and scientists in the SARAH Network of Rehabilitation Hospitals in Brazil. We also review selective papers on neuroplasticity, spontaneous recovery and diaschisis that have relevance for research which will expand and further develop the field of neuropsychological rehabilitation.

Patient Competency Rating Scale-Brazilian Revised Version (PCRS-R-BR): Normative and Psychometric Data in 154 Healthy Individuals.

Background Patient Competency Rating Scale (PCRS-R-BR) is a clinical tool to evaluate the degree of competence in cognitive skills perceived by patients with brain injuries. However, no studies have investigated the influence of sociodemographic variables on self-report and self-awareness of healthy individuals.Aim This study aimed to (1) present normative data from the PCRS-R-BR in a healthy adult Brazilian sample; and (2) investigate psychometric properties of the scaleMethod One hundred and fifty-four adults that were divided in three age groups and two education groups and their informants completed the PCRS-R-BR.Results Score on the PCRS-R-BR Patient's Form differed as a function of age with younger adults reporting less competency than older individuals. An education effect was found on Attention/Working memory Factor on the Informant's PCRS-R-BR with informants of higher education adults reporting better competency than lower education individuals. A gender effect was observed on the Informant's Form. The Informant's Form scores of informants of women were higher than the scores provided by the informants of men. PCRS-R-BR showed adequate consistency coefficients and six factors.Conclusion PCRS-R-BR scores showed acceptable validity evidence and provides information regarding how age and gender effects may influence ratings in a Brazilian sample.

Inhibitory Control of Adjacent Finger Movements while Performing a Modified Version of the Halstead Finger Tapping Test: Effects of Age, Education and Sex.

OBJECTIVE: Selective motor inhibition is known to decline with age. The purpose of this study was to determine the frequency of failures at inhibitory control of adjacent finger movements while performing a repetitive finger tapping task in young, middle-aged and older adults. Potential education and sex effects were also evaluated. METHODS: Kinematic recordings of adjacent finger movements were obtained on 107 healthy adults (ages 20-80) while they performed a modified version of the Halstead Finger Tapping Test (HTFF). Study participants were instructed to inhibit all finger movements while tapping with the index finger. RESULTS: Inability to inhibit adjacent finger movements while performing the task was infrequent in young adults (2.9% of individuals between 20 and 39 years of age) but increased with age (23.3% between the ages of 40 and 59; 31.0% between ages 60 and 80). Females and males did not differ in their inability to inhibit adjacent finger movements, but individuals with a college education showed a lower frequency of failure to inhibit adjacent finger movements (10.3%) compared to those with a high school education (28.6%). These findings were statistically significant only for the dominant hand. CONCLUSION: Selective motor inhibition failures are most common in the dominant hand and occur primarily in older healthy adults while performing the modified version of the HFTT. Monitoring selective motor inhibition failures may have diagnostic significance.

Self-awareness and underestimation of cognitive abilities in patients with adult temporal lobe epilepsy after surgical treatment.

INTRODUCTION: Self-awareness of cognitive, emotional, functional, and social performance is critical for compliance with treatment. However, few studies have investigated self-awareness and the associated effects on other cognitive variables in patients with temporal lobe epilepsy (TLE) after surgical treatment. AIM: This study was designed to investigate the prevalence of impaired self-awareness (ISA) in patients with TLE who have undergone surgical treatment. Associated correlations with clinical variables (frequency of seizures before surgery, time elapsed since the epilepsy diagnosis, depression, and anxiety) and verbal and visual episodic memory function and differences between patients with right and left TLE were also investigated. METHOD: Twenty-three adults with TLE after surgical treatment were assessed with the Patient Competency Rating Scale (PCRS-R-BR), the Rey Auditory Verbal Learning Task (RAVLT), and the Modified Ruche Visuospatial Learning Test (RUCHE-M). Patients were considered to have memory dysfunction if delayed recall as assessed with the RUCHE-M or RAVLT was at or below the 25th percentile. Patients were considered to have ISA if PCRS-R-BR discrepancy scores were at or above the 75th percentile. Underestimated cognitive ability (UCA) was defined as a PCRS-R-BR discrepancy percentile score ≤25. Results were analyzed using frequency, Spearman correlation, regression analyses, and the Mann-Whitney test. RESULTS: Frequency analysis of the total sample indicated ISA in 39.13% of patients (n = 9), UCA in 39.13% of patients (n = 9), and impaired verbal and/or visual memory performance in 69.56% of patients (n = 16). Moderate positive correlations were found between the frequency of seizures before surgical treatment and relatives' reports, as well as between the duration of time that had elapsed since the epilepsy diagnosis and patient reports. Negative and moderate correlations were found between the frequency of seizures and the discrepancy score, as well as between depression and patient reports. No differences in PCRS-R-BR were found between patients with right vs. left TLE. No clinical variables significantly predicted self-report or self-awareness. CONCLUSION: Patients with TLE exhibit various patterns of ISA and negative effects on cognitive function after surgical treatment. Emotional factors and relatives' reports must be considered when assessing these patients.

Maladaptive Denial of Severe Pain and Acute Orthopedic Injuries in a Patient With a Schizoaffective Disorder.

Persistent denial of severe and acute pain following orthopedic injuries has not been previously reported. We present a case of a 24-year-old woman with a history of schizoaffective disorder who suffered severe pain secondary to acute orthopedic injuries who insisted, "I am fine! There is nothing wrong with me." Her maladaptive denial resulted in an initial refusal of necessary medical/surgical care, but she eventually accepted the necessary treatments despite her persistent belief she did not need such care. Her verbalizations and behaviors were characterized by active avoidance and angry reactions when a consulting psychiatrist spoke to her regarding her clinical condition. A modified version of the Conscious Avoidance subscale of the Denial of Illness Questionnaire was useful in measuring the severity level of her denial. This case report suggests that the behavioral features of psychological denial appear different from those associated impaired self-awareness secondary to an underlying brain disorder.

Impaired Self-Awareness and Denial During the Postacute Phases After Moderate to Severe Traumatic Brain Injury.

While a number of empirical studies have appeared on impaired self-awareness (ISA) after traumatic brain injury (TBI) over the last 20 years, the relative role of denial (as a psychological method of coping) has typically not been addressed in these studies. We propose that this failure has limited our understanding of how ISA and denial differentially affect efforts to rehabilitate persons with TBI. In this selective review paper, we summarize early findings in the field and integrate those findings with more recent observations (i.e., 1999-2019). We believe that this synthesis of information and expert clinical opinion will inform future research on ISA and denial as well as approaches to rehabilitation for persons with TBI.

Kinematic recordings while performing a modified version of the Halstead Finger Tapping Test: Age, sex, and education effects.

Introduction: This study attempts to demonstrate that kinematic recordings of finger movements help explain the well-known effects of age, education, and sex on the Halstead Finger Tapping Test (HFTT). Method: High-speed kinematic recordings were obtained on 107 healthy adults (ages 21 to 80 years) while they performed a modified version of the Halstead Finger Tapping Test (HFTT). The number of "valid" taps and "invalid" taps (i.e., lever movements that did not produce an increase in the mechanical number count), tapping speed variability, "learning" and "fatigue" effects was obtained. Results: Previous age, education, and sex effects were replicated. Males had faster start and stop times when finger tapping and these measures correlated with the number of valid taps per 10 s. Educational level correlated with start times, not stop times. Age correlated only with the number of valid taps. Variability of tapping movements correlated with the number of invalid taps, but not valid taps. Females had more invalid taps than males. Fatigue and learning effects were independent of the person's age, education, and sex. Conclusion: Kinematic recordings of finger tapping help explain the well-known age, education, and sex effects on finger tapping speeds. A modified method of administrating the HFTT is also introduced to assess fatigue and learning effects while performing this task.

Subjective ratings of cognitive and emotional functioning in patients with mild cognitive impairment and patients with subjective memory complaints but normal cognitive functioning.

In a retrospective chart review, 39 patients referred for a clinical neuropsychological examination were identified as showing either mild cognitive impairment of the amnestic type (MCI-A; N = 21) or subjective memory complaints but with normal memory function (SMC; N = 18). During the clinical interview, patients and informants were routinely asked to make subjective ratings regarding the patient's cognitive and affective functioning in everyday life. The purpose of this study was to determine whether these two patient groups (and their informants) significantly differed in their subjective reports about level of cognitive and affective difficulties. It was predicted that SMC patients would report higher levels of cognitive and emotional dysfunction than MCI-A patients. It was further predicted that MCI-A patients would underreport cognitive difficulties (compared to informant reports); SMC patients would demonstrate the opposite pattern. Results supported these predictions and suggest that routine assessment of subjective experiences of patients in conjunction with informant ratings may aid clinical diagnosis, particularly when the primary complaint is a decline in memory.

From meaning to symptom reduction: contemporary approaches to psychotherapy after traumatic brain injury / Del sentido a la reducción de síntomas: enfoques contemporáneos de la psicoterapia después de un trauma cráneo encefálico

Introduction: During the last decades, psychological interventions have become central components of rehabilitation programs for Traumatic Brain Injury (TBI). Nevertheless, due to a wide variability of therapeutic approaches there is little agreement regarding which approach is more suitable, or whether key elements from different psychotherapies should be integrated. This article critically reviews several contemporary approaches that are dominant in the literature. Methods: In order to accomplish such goal, an all-time search on Web of Science and Google Scholar was carried, using TBI and Psychotherapy as key words (n = 72). Results: The main finding of this paper is that theoretical and technical variability among psychotherapies reflects differences in the 'level of care' that is targeted: symptom reduction, behavioral problem reduction, quality of life and meaning reconstruction. Four contemporary approaches to psychotherapy [cognitive behavioral, third wave cognitive behavioral, narrative and psychodynamic] are then briefly described, by presenting their main theoretical tenets, the level of care they target, and the existing evidence that supports their efficacy. Finally, the implications of using a 'levels of care' perspective when addressing the 'effectiveness' debate is considered, as well as the need to familiarize future clinicians with more integrative models of psychological support after TBI.

Introducción: Durante las últimas décadas, las intervenciones psicológicas se han convertido en un elemento central de los programas de rehabilitación para personas que han adquirido un Trauma Cráneo Encefálico (TEC). Este artículo revisa críticamente los enfoques contemporáneos predominantes en la literatura a la luz del concepto de "niveles de cuidado". Método: Se realizó una revisión bibliográfica entre los años 1985 y 2014 utilizando los motores de búsqueda Web of Science y Google Scholar, usando TEC y Psicoterapia como palabras claves. 72 artículos fueron seleecionados para revisión. Resultados: Existe una amplia variabilidad teórico/técnica en los enfoques utilizados en esta población, reflejando diferencias en los niveles de cuidado: reducción de síntomas, reducción de problemas conductuales, calidad de vida y reconstrucción de sentido vital. Cuatro enfoques psicoterapéuticos contemporáneos (cognitivo-conductual, cognitivo-conductual de tercera generación, narrativo y psicodinámico) son brevemente descritos, presentando sus supuestos teóricos, el nivel de cuidado que consideran como objetivo, y la evidencia existente que apoya su efectividad. Finalmente, se discuten las implicancias de utilizar una perspectiva de 'niveles de cuidado' en el debate sobre efectividad de la psicoterapia en personas con TEC, así como la necesidad de familiarizar futuros neuropsicólogos clínicos con modelos genéricos de apoyo psicológico para esta población.

Performance of a Brazilian sample on the Portuguese translation of the BNI Screen for Higher Cerebral Functions.

INTRODUCTION: The Barrow Neurological Institute (BNI) Screen for Higher Cerebral Functions (BNIS) has been translated into several languages and found useful in evaluating multiple domains of cognitive and affective dysfunction, particularly in neuro-rehabilitation settings. Normative data from countries with high literacy rates have reported strikingly similar mean level of performance scores on this test, with age typically correlating higher with total score performance than education. In the present study, we obtain convenience sample normative data from a native Brazilian population on a Portuguese translation of the BNIS (i.e., BNIS-PT). METHOD: The BNIS was translated into Portuguese by two native speaking Portuguese neuropsychologists who were also fluent in English. It was then administered to 201 normally functioning native Brazilian individuals who varied considerably in age and formal educational training. RESULTS: The mean BNIS total score was similar to what previous studies reported, but primarily in younger adults with at least 12 years of formal education. In this Brazilian sample, the correlation of educational level and BNIS total score was r = .68, p < .001. The correlation of age and BNIS total score was r = -.36, p < .001. This is the opposite pattern to that observed in previous standardization studies. The strong correlation of education with performance in various subtests was observed in all age groups (ages ranging from 15 to 85 years). CONCLUSION: This standardization study provides guidelines for calculating expected average performance levels on the BNIS-PT for Brazilian individuals with varying degrees of age and education. Educational level positively correlated with test performance on the BNIS-PT and was repeatedly observed to overshadow the effects of age, suggesting its important role in the development of higher cerebral functions in multiple domains in a Brazilian sample of normally functioning individuals.

Impaired Self-Awareness of Motor Disturbances in Parkinson's Disease.

Traditionally, anosognosia for cognitive or motor impairments in patients with Parkinson's disease (PD) was viewed as unlikely unless the patient was demented. More recent research has suggested that a portion of non-demented PD patients (30%-50%) in fact have impaired subjective awareness (ISA) of their motor impairments (ISAm). This empirical finding has implications for the clinical neuropsychological examination of PD patients and raises theoretical questions relevant to the broader study of anosognosia seen in other patient groups. The purpose of this paper is to primarily review our own research in this area and to summarize research findings of other investigators who have examined ISA in PD patients. Our secondary goal is to demonstrate the relevance of assessing ISA when conducting a neuropsychological examination of PD patients. Our findings suggest ISAm in PD patients is related to motor signs of right hemispheric dysfunction, but the brain imaging correlates of ISA for hypokinesias appear different than those obtained for ISA for dyskinesia in this patient group.

Cognition in epilepsy patients with hypothalamic hamartomas.

Many patients with epilepsy caused by hypothalamic hamartomas (HHs) have cognitive impairments during the course of the disease or following neurosurgical treatment. The purpose of this study was to assess cognitive function in these patients, as well as factors influencing preoperative cognitive performance and cognitive outcome after neurosurgical treatment. Using the two largest and most detailed neuropsychology datasets on HH and epilepsy from two centers, we retrospectively report on cognitive functions in 48 patients with structural epilepsy due to HH (mean age ± standard deviation [SD] 20 ± 12 years, range 5-53 years, median 16 years; disease duration mean 17 ± 11 years). Intelligence, verbal learning and recall, and speed and executive functions (processing speed and cognitive flexibility) were assessed before and on average 19 (±11) months after surgery (interstitial radiosurgery: N = 22; neurosurgical resection/disconnection: N = 26). Prior to neurosurgical treatment, 52% of patients showed impaired executive and 62% showed reduced verbal memory functions. A trend for a detrimental effect of higher drug load on cognitive functioning was found. After neurosurgical treatment, intellectual functions for the entire cohort tended to increase. This correlated with improved seizure frequency and decreased number of antiepileptic drugs (AEDs). However, postoperative outcomes for individual patients were highly variable, with significant deteriorations in 17% (processing speed) to 34% (cognitive flexibility and verbal learning), and performance increases in 17% (intellectual functioning) up to 39% (processing speed) of the patients. Higher levels of presurgical performance were significant predictors of cognitive decline after surgery. These results are highly relevant for patient consultation and may help with therapeutic decisions.

Memory and executive functions correlates of self-awareness in traumatic brain injury.

OBJECTIVE: The purpose of this study was to investigate the contribution of executive functions (EF) components and episodic and working memory variables, as well as clinical and demographic factors, to awareness of cognitive ability in traumatic brain injury (TBI). METHODS: Sixty-five TBI patients (mild: n = 26; moderate/severe: n = 39) took part in the study. Independent stepwise regression models were calculated for EF and memory predictors, with awareness being measured by patient/informant discrepancy in the Patient Competency Rating Scale. RESULTS: Models with EF variables indicated that semantic verbal fluency and age are the best predictors of awareness, whereas models including mnemonic functions suggested verbal delayed episodic recall and TBI severity as predictors. CONCLUSIONS: These results are discussed in relation to clinical implications, such as the need to focus efforts of rehabilitation in the cognitive abilities related to awareness, and theoretical models.

Behavioural and neuroimaging correlates of impaired self-awareness of hypo- and hyperkinesia in Parkinson's disease.

INTRODUCTION: Anosognosia or impaired self-awareness of motor symptoms (ISAm) has been rarely investigated in Parkinson's disease (PD). We here studied the relationship between ISAm during periods with and without dopaminergic medication (ON- and OFF-state), and clinical, neuropsychological, and neuroimaging data to further elucidate behavioural aspects and the neurobiological underpinnings of ISAm. METHODS: Thirty-one right-handed, non-demented, non-depressed PD patients were included. ISAm was evaluated using a recently developed scale that assesses awareness of dyskinesia, resting tremor, and bradykinesia. The test was applied during both ON- and OFF-states. Multiple correlation analyses between ISAm and behavioural data were conducted. In addition, imaging of glucose metabolism using 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) was performed to investigate the neural basis of ISAm. A multiple regression approach was applied to investigate metabolism alterations related to ISAm. RESULTS: In the OFF-state, higher ISAm was associated with left-sided disease onset, older age, and shorter disease duration. Concerning FDG-PET data, there was a significant negative correlation between higher OFF-state ISAm and decreased glucose metabolism in the right inferior frontal gyrus (IFG). In the ON-state, ISAm was not significantly correlated with clinical or behavioural data. However, there was a significant correlation between higher ISAm and an increased metabolism in the bilateral medial frontal gyrus, left IFG, right superior frontal gyrus and right precentral gyrus. CONCLUSION: The results support the role of the right hemisphere in awareness of motor symptoms in the OFF-state. In the ON-state, dopaminergic medication and dyskinesia influence ISAm and relate to metabolism changes in bilateral frontal regions.