Evaluation of teleneuropsychology services in veterans during COVID-19.

This study evaluated the quality of direct-to-home teleneuropsychology (teleNP) services that offered patients choice of service modality. We conducted a quality assurance project in a sample of Veterans (N = 143) referred for a variety of referral reasons from a Midwestern Veteran Affairs Hospital. Neuropsychological evaluations were conducted between February and June 2021 during the second wave of the COVID-19 pandemic. We evaluated teleNP rate of use, factors influencing acceptability and feasibility, and cost savings. Approximately 40% of our scheduled patients completed full direct-to-home teleNP, with about 80% of our sample choosing at least one telehealth encounter as part of their evaluation. Age was a significant factor in predicting full teleNP use, with older adults preferring in-person testing. Digital divide consults (i.e., loaned tablets) led to an increase in teleNP use. Those utilizing full teleNP (interview, assessment, feedback) benefited from cost and travel distance savings. Most Veterans in our Midwestern Veteran Affairs Hospital used teleNP services during the second wave of the COVID-19 pandemic, with utilization influenced by specific patient demographics (i.e., age) and access to technology. Offering Veteran choice of assessment modality (in-person or video teleNP) was associated with significant cost reduction due to mileage savings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Neuropsychological assessment with lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) individuals: Practice, education, and training survey.

Objective: We sought to describe the LGBTQ + related education, training, and clinical practice of independently licensed neuropsychologists in the United States and to identify factors that predict affirmative neuropsychological practices. We hypothesized that LGBTQ + identity, female gender, more recent training, and extent of LGBTQ + education/training would predict use of LGBTQ + practice guidelines. Method: A workgroup of clinical psychologists with experience in LGBTQ + psychology and neuropsychology developed a survey to identify personal and professional factors that predict affirmative neuropsychological testing practices. The survey was distributed through professional organizations and listservs between August and September 2021 with 118 responses meeting inclusionary criteria. Results: The majority of participants identified as heterosexual (70.3%) and cisgender (97.5%), and most (48-63%) received LGBTQ + training post-licensure. Between 19% and 32% of participants reported never completing LGBTQ + specific education. Consistent with our hypotheses, factors predicting affirmative clinical practice behaviors were LGBTQ + education/training, and personal background (sexual minority status, female/feminine gender, and years since degree). Other significant factors included prior experience with LGBTQ + patients and primary patient population (child vs. adult). Qualitative responses indicated varying values, attitudes, and knowledge regarding collection of LGBTQ + information and modification of clinical practice. Conclusions: Neuropsychologists underutilize affirming practices as evidenced by low rates of querying pronouns, knowing whether LGBTQ + health information is available at their institutions, and adjusting evaluation and feedback approaches. We provide specific training and education recommendations to increase knowledge and skills and to address beliefs about LGBTQ + health that can serve to promote affirmative neuropsychological practice.

Affirmative neuropsychological practice with transgender and gender diverse individuals and communities.

Objective: To provide guidance and resources on how to practice culturally safe and humble neuropsychology with transgender and gender diverse (TGD) individuals and communities. Methods: We gathered a multidisciplinary team of clinicians with relevant professional and/or lived experience to review pertinent literature, discuss important concepts, and identify key resources. From this process, we outline practical steps to advance gender affirmative neuropsychological practice. Results: Professional awareness and knowledge regarding how to gather context-relevant, gender identity information is critical. TGD individuals form a heterogenous group; a one-size-fits-all approach is not adequate. It is incumbent upon neuropsychologists to engage in clinical and research practices in a manner that does not perpetuate gender minority stress and trauma. Creating an open, safe environment of care requires intentionality and careful thinking to determine what information is relevant for a particular referral question. We provide recommendations and resources for neuropsychologists. Conclusion: When neuropsychologists are proactive, responsible, and intentional, they can better provide individualized, person-centered, and trauma-informed care to TGD individuals.

Teleneuropsychology practice survey during COVID-19 within the United States.

OBJECTIVE: Identify factors influencing service delivery changes during COVID-19 and examine barriers and provider satisfaction with teleneuropsychology (teleNP). METHOD: Licensed clinical neuropsychologists within the United States recruited via neuropsychology-specific listservs (July-August 2020) to complete an online survey. RESULTS: A total of 261 individuals completed the survey. Most (76%) reported delivering in-person testing in some capacity at the time of our survey. Relatively more private practitioners identified concerns with privacy/confidentiality (45.2% vs. 17.9%; χ2(2) = 6.99, p < 0.05), legal issues (47.6% vs. 17.9%; χ2(2) = 8.06, p < 0.05), and an undesirable precedent for legal/forensic cases (59.5% vs. 15.4%; χ2(2) = 17.54, p < 0.001) compared to hospital or other medical (non-VA) practitioners. Multiple resources informed teleNP protocols, such as organization guidelines (87.6%), literature review (75.9%), webinars (72.4%), and consultation (68%). Several factors influenced test selection, including availability of normative data (70.1%), test familiarity (66.4%), administration time (63.5%), and evidence base (60.6%). Reported barriers to continuing teleNP after COVID-19 included need for improved teleNP norms (85.9%), domain coverage (84.7%), improved patient access to technology (74.1%) and further validation studies (84.1%). CONCLUSION: TeleNP may not be feasible in all settings and/or referrals. Respondents employed multiple resources in aggregating teleNP protocols and considered several factors when selecting tests. Results highlight the complex and varied decision-making processes utilized by respondents to adapt to service delivery changes. Considering the many benefits of teleNP, future research addressing some of the potentially modifiable factors (e.g., technology access, attitudes regarding teleNP) and significant development needs for teleNP itself (i.e., improved teleNP norms, further validation studies, etc.) is warranted.

Psychometric evaluation of the Hopkins Rehabilitation Engagement Rating Scale in postacute physical therapy services.

PURPOSE/OBJECTIVE: Evaluate the reliability and validity of the Hopkins Rehabilitation Engagement Scale (HRERS) in a postacute rehabilitation sample. We hypothesized that HRERS items would comprise a single factor, and would demonstrate adequate internal consistency and temporal stability, and significant relationships with key constructs. Research Method and Design: Retrospective medical record review between 2016 and 2017 of older veterans (N = 107) admitted to a community living center postacute care (CLC-PAC) rehabilitation hospital unit to address targeted physical therapy rehabilitation goals. Inclusion criteria included availability of two HRERS administrations at Time 1 (admission) and Time 2 (approximately one-month follow-up or physical therapist/CLC-PAC discharge). RESULTS: Across timepoints, HRERS items reflect a single factor of engagement, and the scale has good internal consistency at admission (Time 1, α = .759) and follow-up (Time 2, α = .877). The temporal stability of HRERS across ratings was r = .56 (p < .001). Increased pain rating (r = -.309, p < .01) and depressive symptoms (-.287, p < .01) at admission correlates with subsequent physical therapist (PT) engagement (HRERS Time 2). Low admission PT engagement correlates with less frequent PT attendance (r = -.242, p < .01) and greater number of consults placed during the CLC stay (r = -.222, p < .05). CONCLUSIONS/IMPLICATIONS: HRERS is a reliable and valid measure of PT engagement in older CLC-PAC Veterans. Findings support the administration of the HRERS at more than one timepoint during rehabilitation to inform interventions targeting select behavioral health factors such as pain and depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cognitive status as a robust predictor of repeat falls in older Veterans in post-acute care.

BACKGROUND: While repeat falls are common in post-acute care (PAC), risk factors have not been fully elucidated. AIMS: The objective of thids study is to evaluate the contribution of cognitive function to repeat falls in older PAC Veterans. METHODS: Data were collected from medical records for 91 single and 30 repeat fallers over 5 consecutive years (2011-2016). RESULTS: After controlling for demographic and medical factors, lower Mini-Mental State Exam (MMSE) score was associated with increased odds of repeat falls. MMSE scores below 20 (with age held constant at the mean) were associated with a greater than 50% chance of a repeat fall (compared to 24.7% base rate). Admission for a neurologic reason further increased risk. DISCUSSION: PAC Veterans who experience a fall have an increased risk of repeat falls with concomitant cognitive dysfunction and/or admission for neurologic reasons. CONCLUSIONS: Results support tailoring multi-component interventions for those with cognitive dysfunction utilizing standardized mental status screening upon admission.

The Montreal Cognitive Assessment in Veteran Postacute Care: Implications of Cut Scores.

BACKGROUND: The Montreal Cognitive Assessment (MoCA) is often used for cognitive screening across health care settings, especially in rehabilitation centers, where assessment and treatment of cognitive function is considered key for successful multidisciplinary treatment. Although the original MoCA validation study suggested a cut score of <26 to identify cognitive impairment, recent studies have suggested that lower cut scores should be applied. OBJECTIVES: To examine the percentage of positive screens for cognitive impairment using the MoCA in a veteran postacute care (PAC) rehabilitation setting and to identify the most accurate MoCA cut score based on criterion neuropsychological measures. METHODS: We obtained data from 81 veterans with diverse medical diagnoses who had completed the MoCA during their admission to a PAC unit. A convenience subsample of 50 veterans had also completed four criterion neuropsychological measures. RESULTS: Depending on the cut score used, the percentage of individuals classified as impaired based on MoCA performance varied widely, ranging from 6.2% to 92.6%. When predicting performance using a more comprehensive battery of criterion neuropsychological tests, we identified <22 as the most accurate MoCA cut score to identify a clinically relevant level of impairment and <24 to identify milder cognitive impairment. CONCLUSIONS: Our findings suggest that a MoCA cut score of <26 carries a risk of misdiagnosis of cognitive impairment, and scores in the range of <22 to <24 are more reliable for identifying cognitive impairment.

Influence of Cognition on Length of Stay and Rehospitalization in Older Veterans Admitted for Post-Acute Care.

OBJECTIVES: Evaluate the relative contribution of cognitive test performance to post-acute care (PAC) length of stay (LOS) and rehospitalization while controlling for key demographic, medical, and functional outcomes. METHODS: Retrospective medical record review of 160 older Veterans, including cognitive test performance (Addenbrooke's Cognitive Examination-Revised [ACE-R]), on admission to a Veterans Administration Hospital Community Living Center (CLC) PAC. RESULTS: Individuals with impaired scores on the ACE-R had a longer LOS (10 median days longer; U = 2,547.00, p = .028). Of those rehospitalized, 71.4% (n = 20) screened positive for cognitive impairment. Key medical factors explained the largest amount of variance in CLC-PAC LOS (29.8%), followed by admission ADL (activities of daily living) dependency (4.6%) and ACE-R total score (3.30%). DISCUSSION: Cognitive screening should be considered on PAC admission, with impairment on ACE-R predicting geriatric rehabilitation outcomes such as risk of increased LOS and rehospitalization.

Translational MRI Volumetry with NeuroQuant: Effects of Version and Normative Data on Relationships with Memory Performance in Healthy Older Adults and Patients with Mild Cognitive Impairment.

NeuroQuant (NQ) is a fully-automated program that overcomes several existing limitations in the clinical translation of MRI-derived volumetry. The current study characterized differences between the original (NQ1) and an updated NQ version (NQ2) by 1) replicating previously identified relationships between neuropsychological test performance and medial temporal lobe volumes, 2) evaluating the level of agreement between NQ versions, and 3) determining if the addition of NQ2 age-/sex-based z-scores hold greater clinical utility for prediction of memory impairment than standard percent of intracranial volume (% ICV) values. Sixty-seven healthy older adults and 65 mild cognitive impairment patients underwent structural MRI and completed cognitive testing, including the Immediate and Delayed Memory indices from the Repeatable Battery for the Assessment of Neuropsychological Status. Results generally replicated previous relationships between key medial temporal lobe regions and memory test performance, though comparison of NQ regions revealed statistically different values that were biased toward one version or the other depending on the region. NQ2 hippocampal z-scores explained additional variance in memory performance relative to % ICV values. Findings indicate that NQ1/2 medial temporal lobe volumes, especially age- and sex-based z-scores, hold clinical value, though caution is warranted when directly comparing volumes across NQ versions.

Population Base Rates and Disease Course of Common Psychiatric and Neurodegenerative Disorders.

Knowledge of population base rates of neurological and psychiatric disorders is fundamental for diagnostic decision making. Consideration of relevant probabilistic information can improve diagnostic efficiency and accuracy. However, such data continue to be misused or underutilized, which can lead to misdiagnoses and negative patient outcomes. The aim of the current review is to create an easily accessible and comprehensive reference of existing age of onset as well as prevalence and incidence data for common neurodegenerative and psychiatric disorders in adults. Relevant epidemiological data were compiled from well-respected and frequently-cited textbooks and scholarly studies. Reviews were collected from PubMed, and publicly-available sources were gathered from Google Scholar. Results are organized and presented in several tables and a figure, which can be used as a diagnostic guide for students and clinicians across healthcare disciplines.

Self-Reported Health and Safety Awareness Improves Prediction of Level of Care Needs in Veterans Discharged From a Postacute Unit.

OBJECTIVES: To evaluate the differential value of a self-reported health and safety awareness measure relative to other medical, psychosocial, and cognitive factors in predicting level of care (LOC) needs after hospital discharge. DESIGN: Retrospective medical record review. SETTING: Community living center postacute care (CLC-PAC) unit at a Veterans Affairs hospital. PARTICIPANTS: A total of 175 veterans admitted to the Veterans Affairs hospital or directly to the CLC-PAC from home. METHODS: Cognitive status was assessed with the Mini-Mental State Examination, Digit Span Backward subtest, Trail Making Test (Part B), and Hopkins Verbal Learning Test-Revised. Self-report of health and safety awareness was measured with the Independent Living Scales Health and Safety (ILS-HS) subscale. Additional demographic and admission-related variables were coded, along with medical comorbidity, with the Charlson Comorbidity Index and depression using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision Depression Checklist. MAIN OUTCOME MEASUREMENTS: Increased level of care was collected from social work and occupational therapy notes and defined as increased assistance with activities of daily living or nursing home placement comparing prehospitalization with CLC-PAC discharge. RESULTS: A total of 19% (n = 34) of residents required increased LOC on CLC-PAC discharge. The ILS-HS was a significant predictor of increased LOC above and beyond age and Mini Mental Status Examination score; for each standard deviation decrease in ILS-HS, there was an increased likelihood of greater LOC (odds ratio 0. 54, 95% confidence interval 0.35-0.83). Other neuropsychological tests (memory, executive functioning) did not significantly improve the model. CONCLUSIONS: The inclusion of the ILS-HS to a standard cognitive screen (Mini Mental Status Examination) can improve prediction of increased LOC. Although select aspects of memory and executive functioning independently contribute to increased LOC prediction, the ILS-HS likely measures a unique aspect of cognitive functioning that may be specific to discharge planning needs in CLC-PAC residents. LEVEL OF EVIDENCE: II.

Delirium Detection and Impact of Comorbid Health Conditions in a Post-Acute Rehabilitation Hospital Setting.

Misdiagnosis and under-detection of delirium may occur in many medical settings. This is important to address as delirium clearly increases risk of morbidity and mortality in such settings. This study assessed whether Veterans who screened positive on a delirium severity measure (Memorial Delirium Assessment Scale; MDAS) differed from those with and without corresponding medical documentation of delirium in terms of cognitive functioning, psychiatric/medical history, and medication use. A medical record review of 266 inpatients at a VA post-acute rehabilitation unit found that 10.9% were identified as delirious according to the MDAS and/or medical records. Of the Veterans who screened positive on the MDAS (N = 19), 68.4% went undetected by medical screening. Undetected cases had a higher number of comorbid medical conditions as measured by the Age-Adjusted Charlson Index (AACI) scores (median = 9, SD = 3.15; U = 5.5, p = .003) than medically documented cases. For Veterans with a score of 7 or greater on the AACI, the general relative risk for delirium was 4.46. Delirium is frequently under-detected in a post-acute rehabilitation unit, particularly for Veterans with high comorbid illness. The relative risk of delirium is up to 4.46 for those with high medical burden, suggesting the need for more comprehensive delirium screening in these patients.

Assessing fidelity of treatment delivery in group and individual 12-step facilitation.

Twelve step facilitation (TSF) is an emerging, empirically supported treatment, the study of which will be strengthened by rigorous fidelity assessment. This report describes the development, reliability and concurrent validity of the Twelve Step Facilitation Adherence Competence Empathy Scale (TSF ACES), a comprehensive fidelity rating scale for group and individual TSF treatment developed for the National Drug Abuse Treatment Clinical Trials Network study, Stimulant Abuser Groups to Engage in 12-Step. Independent raters used TSF ACES to rate treatment delivery fidelity of 966 (97% of total) TSF group and individual sessions. TSF ACES summary measures assessed therapist treatment adherence, competence, proscribed behaviors, empathy and overall session performance. TSF ACES showed fair to good overall reliability; weighted kappa coefficients for 59 co-rated sessions ranged from .31 to 1.00, with a mean of .69. Reliability ratings for session summary measures were good to excellent (.69-.91). Internal consistency for the instrument was variable (.47-.71). Relationships of the TSF ACES summary measures with each other, as well as relationships of the summary measures with a measure of therapeutic alliance provided support for concurrent and convergent validity. Implications and future directions for the use of TSF ACES in clinical trials and community treatment implementation are discussed.