Tele-Neuropsychology: From Science to Policy to Practice.

OBJECTIVE: The primary aim of this paper is to accelerate the number of randomized experimental studies of the reliability and validity in-home tele-neuropsychological testing (tele-np-t). METHOD: We conducted a critical review of the tele-neuropsychology literature. We discuss this research in the context of the United States' public and private healthcare payer systems, including the Centers for Medicare & Medicaid Services (CMS) and Current Procedural Terminology (CPT) coding system's telehealth lists, and existing disparities in healthcare access. RESULTS: The number of tele-np publications has been stagnant since the onset of the COVID-19 pandemic. There are less published experimental studies of tele-neuropsychology (tele-np), and particularly in-home tele-np-t, than other tele-np publications. There is strong foundational evidence of the acceptability, feasibility, and reliability of tele-np-t, but relatively few studies of the reliability and validity of in-home tele-np-t using randomization methodology. CONCLUSIONS: More studies of the reliability and validity of in-home tele-np-t using randomization methodology are necessary to support inclusion of tele-np-t codes on the CMS and CPT telehealth lists, and subsequently, the integration and delivery of in-home tele-np-t services across providers and institutions. These actions are needed to maintain equitable reimbursement of in-home tele-np-t services and address the widespread disparities in healthcare access.

Integrating Lifestyle Factor Science into Neuropsychological Practice: A National Academy of Neuropsychology Education Paper.

OBJECTIVE: The primary aim of this paper is to review evidence and clinical implications related to lifestyle activities associated with promoting brain and cognitive health. Our review targets four key lifestyle factors: physical activity and exercise, social engagement, cognitively stimulating activity, and consuming Mediterranean-style diets. METHOD: We conducted a critical review of the lifestyle factor literature in the four domains listed earlier. We contextualize this literature review by translating findings, when possible, into evidence-based recommendations to consider when providing neuropsychological services. RESULTS: There is significant current evidence supporting the role of physical activity and exercise, social engagement, cognitively stimulating activity, and consuming Mediterranean-style diets on positive brain and cognitive health outcomes. While some null findings are present in all four areas reviewed, the weight of the evidence supports the notion that engaging in these activities may promote brain and cognitive functioning. CONCLUSIONS: Clinical neuropsychologists can have confidence in recommending engagement in physical activity, social activity, and cognitively stimulating activity, and adhering to a Mediterranean-style diet to promote brain and cognitive health. We discuss limitations in existing lifestyle factor research and future directions to enhance the existing evidence base, including additional research with historically underrepresented groups and individuals with neurological conditions.

Cognitive Reserve Moderates the Effects of Fatigue and Depressive Symptoms in Multiple Sclerosis.

To investigate cognitive reserve as a possible moderator in the relationship between fatigue and depressive symptoms in persons with multiple sclerosis (PwMS). Fifty-three PwMS (37 female; mean age, 52.66; mean education, 14.81) completed comprehensive neuropsychological testing and psychosocial questionnaires assessing the perceived effects of fatigue (Fatigue Impact Scale) and depressive symptoms (Beck Depression Inventory-Fast Screen). Cognitive reserve (CR) was operationalized as Fixed CR and Malleable CR. Fixed CR was quantified as the standardized mean of years of education and a vocabulary-based estimate of premorbid intelligence. Malleable CR was quantified as the standardized mean of cognitive exertion, exercise, and socializing items from the Cognitive Health Questionnaire. Regressions on depressive symptoms examining fatigue, both conceptualizations of CR, and their interactions were explored. A Bonferroni correction was used; results were considered significant at an alpha level of p < .01. The interactions between fatigue and both conceptualizations of CR were significant, p = .005 (Fixed CR); p = .004 (Malleable CR). Simple effects tests revealed that fatigue only predicted depressive symptoms in PwMS with low Fixed CR or low Malleable CR (p's < .001), and not in those with high Fixed or high Malleable CR (p > .01). Cognitive reserve moderated the relationship between fatigue and depressive symptoms in PwMS. Specifically, fatigue does not appear to influence depression in PwMS with high cognitive reserve. Having higher cognitive reserve (either Fixed or Malleable) may reduce the likelihood that fatigue will lead to depressive symptoms in MS.

Subgroup Analysis of Individuals with Multiple Sclerosis Showing Cognitive Resilience.

OBJECTIVE: Cognitive dysfunction is known to occur in many individuals with multiple sclerosis (MS). However, little is currently known about MS patients without cognitive impairment, including protective factors associated with intact cognition. The present study considered these issues in a sample of MS patients screened for intact subjective and objective cognitive functioning. METHODS: Two MS participant groups from a larger sample were derived: i) participants within 1 standard deviation of controls on measures of objective cognition, subjective cognition, and informant-observed subjective cognition [cognitively resilient MS group (MScr)], and ii) those classified as not cognitively resilient (MSncr). Both groups were compared with age- and gender-matched controls. RESULTS: Findings indicated that the MScr group was similar to the MSncr group on most disease and demographic variables, and level of fatigue. The MScr group showed higher estimated baseline intellectual ability and reported less anxiety, subclinical depressive symptoms, and pain interference. MScr participants also showed a trend toward more reported compensatory cognitive strategy use than MSncr participants. The MScr group showed comparable reading recognition and pain symptoms to controls. CONCLUSIONS: Our findings provide preliminary information on factors associated with cognitive resilience in MS. Future research should examine resilient individuals with MS to further clarify positive outcomes in this condition.

Positive neuropsychology: The science and practice of promoting cognitive health.

Positive psychology has influenced multiple subfields within psychology and areas outside of psychology. While positive psychology's focus on positive mental health and character strengths did not appear to meaningfully impact neuropsychology in its earlier stages, more recent indications suggest that the neuropsychological literature, and perhaps the field as a whole, has begun to embrace related research and practice applications. In this context, positive neuropsychology has emerged as a neuropsychological orientation focused on the study and practice of promoting cognitive health. The present review discusses the origins of positive neuropsychology and elaborates on its six key evidence-based domains: compensatory strategy use, activity engagement, prevention of cognitive impairment, public education, exceptional cognition, and positive cognitive outcomes in neuropsychiatric populations. This broad perspective on cognitive wellness can easily be embraced by both clinicians and researchers and offers multiple directions for future growth. Ultimately, consideration of various methods to promote cognitive health can inform our understanding of optimal brain function, maximize functioning in individuals with cognitive limitations, and enhance quality of life among populations served by neuropsychologists.

Role of positive lifestyle activities on mood, cognition, well-being, and disease characteristics in multiple sclerosis.

Multiple sclerosis (MS) is a neurological condition associated with a wide variety of physical, cognitive, and mood-related symptoms. While disease-modifying treatment has been shown to reduce the severity and frequency of MS symptom relapses, engagement in certain daily activities holds promise as an adjunctive treatment to better manage disease sequelae. The present study sought to determine whether healthy nutritional choices, exercise, and social/intellectual engagement impacts functioning in individuals with MS. Two hundred and forty-eight (248) MS participants completed a questionnaire assessing factors related to cognitive health (Cognitive Health Questionnaire; CHQ). They also endorsed measures assessing disease symptoms and management, mood, and well-being/quality of life. A measure of information processing speed was administered to a subset of participants. Findings indicated that a previously derived CHQ factor comprised of healthy nutritional habits and exercise items was associated with less fatigue, better sleep, reduced pain, and improved mood and disease management. A factor with items assessing social and intellectual engagement correlated with mood, disease management, and well-being. Endorsement of items in both CHQ factors was associated with better information processing speed. Subsequent regression analyses indicated that education and mood were most predictive of nutritional habits and exercise, while MS self-efficacy was particularly associated with engagement in social and intellectual activities. In sum, these findings suggest that self-reported engagement in healthy lifestyle habits has far-reaching effects on multiple aspects of daily living and disease management in MS.

Association Between Cognitive Complaints and Vulnerability to Environmental Distraction in Multiple Sclerosis.

OBJECTIVE: Individuals with multiple sclerosis (MS) often report cognitive dysfunction, although neuropsychological evaluation findings may not correlate with subjective concerns. One factor that may explain this lack of correspondence is the controlled testing environment, which differs from busier settings where cognitive lapses are noted to occur. This study used a novel environmental manipulation to determine whether individuals with MS who report cognitive dysfunction are more vulnerable to the effects of auditory distraction during neuropsychological testing. METHOD: Twenty-four individuals with clinically definite MS or clinically isolated syndrome were administered a cognitive battery during two counterbalanced auditory conditions: quiet/standard condition, and distraction condition with random office background noise. Participants were divided into high versus low cognitive complaint groups using a median split analysis of Perceived Deficits Questionnaire responses. RESULTS: Participants with more cognitive complaints showed a decrement in performance on the oral Symbol Digit Modalities Test during the distraction condition while those with fewer cognitive complaints demonstrated stable performance across conditions. These findings remained significant after controlling for education, premorbid intellect, fatigue, and depressed mood. CONCLUSIONS: These results suggest that individuals with MS with more cognitive complaints are vulnerable to environmental distraction, particularly regarding processing speed. Incorporating random environmental noise or other distraction conditions during selected measures may enhance the ecological validity of neuropsychological evaluation results in MS.

Functional magnetic resonance imaging of executive control in bipolar disorder.

Bipolar disorder has been associated with dysfunction of executive control processes. Using functional magnetic resonance imaging, we examined brain activation during a counting Stroop task in 11 healthy adults and 11 patients with bipolar I disorder. Results revealed greater activation for the healthy than bipolar disorder group in distributed brain regions that included the right inferior and medial frontal gyri. With the exception of one area within the left posterior cingulate gyrus that was correlated with mania severity, regional activations where group differences were observed were not associated with mood symptoms in the patient group. These findings add to the growing body of evidence implicating neural circuitry subserving executive control in bipolar disorder.

FLAIR lesion volume in multiple sclerosis: relation to processing speed and verbal memory.

Information processing speed and episodic memory are two commonly affected cognitive abilities in MS. Insights into the mechanisms of and relationships between these abilities have recently come from structural neuroimaging techniques, but few studies have used fluid-attenuated inversion recovery (FLAIR), a neuroimaging sequence known to be sensitive to cortical and juxtacortical lesions in MS. We hypothesized that a volumetric index of FLAIR total lesion volume (TLV) would be associated with slowed processing speed and verbal memory dysfunction in MS. Twenty MS patients underwent FLAIR imaging and were administered measures of verbal memory and processing speed. Correlational and regression analyses indicated that TLV was directly and independently related to measures of processing speed and verbal memory, and TLV accounted for 56% of the variance in cognitive performance. These findings, considered in the context of prior work, suggest that FLAIR TLV is a useful predictor of commonly impaired cognitive functions in MS, and shows promise as a functionally relevant biomarker for disease status.

Depression and fatigue in relapsing-remitting MS: the role of symptomatic variability.

Depression and fatigue are common psychosocial sequelae of MS. An infrequently examined issue in the MS literature is the effect of MS-related symptom variability on incidence of depression and fatigue. The current study was designed to examine the relationship of variability in physical, cognitive, and social/environmental functioning with depression and fatigue in MS. Forty-eight relapsing-remitting MS patients from a larger sample completed self-report measures of depression and fatigue. They were also administered a structured interview that assessed current, best, and worst levels of functioning since being diagnosed with MS. Higher levels of symptom variability since disease onset were associated with depression and fatigue, even after accounting for MS-related physical disability. Regression analyses indicated that variability in social and environmental functioning was particularly associated with depression, and variability in physical abilities was associated with fatigue. These findings suggest that a more variable course of MS symptoms is associated with increased depression and fatigue. Focused assessment of variability in symptoms may be useful in detecting and subsequently treating depression and fatigue in MS patients.

Metamemory in multiple sclerosis: exploring affective and executive contributors.

Although previous reports have examined metamemory in various neurological groups, no study to date has examined various affective and cognitive contributors to metamemory collectively in a sample of multiple sclerosis (MS) patients. In the present study, 48 MS patients completed the Memory Functioning Questionnaire (MFQ) and were administered measures assessing depression, depressive attitudes, and executive functioning. Correlational analyses indicated that certain aspects of metamemory in MS were associated with both affective and executive variables. Structural equation modeling (SEM) analyses of three a priori models revealed the best fit with one model proposing that greater executive dysfunction and depression were associated with increased self-reported memory complaints, but via the mediating influence of depressive attitudes. Although our results suggest some objective basis for metamemory complaints in MS (i.e., executive dysfunction), they also suggest that these complaints may be exacerbated by the potentially reversible influences of depression and depressive attitudes. Treatment of depression and depressive attitudes in MS may result in MS patients having more accurate perceptions of their actual memory abilities that, in turn, may lead to improvements in their quality of life.

Relationship between coping, cognitive dysfunction and depression in multiple sclerosis.

Given its relatively high prevalence, one possible source of stress for patients with multiple sclerosis (MS) is cognitive dysfunction. The authors' study was guided by a new theoretical model suggesting that cognitive dysfunction in MS may be most likely to lead to depression when patients use high levels of avoidance coping and/or low levels of active coping. To test this model, 55 patients with definite MS were administered a neuropsychological battery and measures of depression and coping. Consistent with predictions, regression analyses showed that coping significantly moderated the relationship between cognitive dysfunction and depression. Specifically, cognitive dysfunction was most likely to be associated with depression when patients used either high levels of avoidance or low levels of active coping. Implications of these data for clinical applications and for our theoretical conceptualization are discussed and limitations of the model explored.

Contributing factors to depressed mood in Multiple Sclerosis.

By applying the behavioral theory of Lewinsohn et al. [1985. An integrative theory of depression. In: S. Reiss, & R. R. Bootzin (Eds.), Theoretical issues in behavior therapy (pp. 331-359). San Diego, CA: Academic Press.] to multiple sclerosis (MS), it was hypothesized that physical disability, fatigue, and psychosocial dysfunction would be significantly predictive of depressed mood in MS patients. Seventy-six MS patients completed the following measures: the Sickness Impact Profile (SIP), the Fatigue Impact Scale (FIS), and the mood subscale from the Chicago Multiscale Depression Inventory (CMDI). Structural equation modeling revealed that physical disability and fatigue were indirectly predictive of depressed mood via their effects on recreational functioning. Fatigue also had a direct effect on mood. If reductions in recreational activities actually cause decrements in mood, depressed mood in MS may be treatable by helping patients identify recreational activities that they can enjoy regardless of physical or fatigue-related difficulties.