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Lecture Notes Advanced Clinical Neuropsychology
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All lecture notes of Advanced Clinical Neuropsychology (some short notes/sentences are in Dutch, complete document in English)
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Advanced Clinical Neuropsychology college 1 1 februariIntroduction & Brain damage as a family affair Janneke Koerts
Introduction to the course
- Topics
o Introduction
The profession of clinical neuropsychologist
Cost-effectiveness
Brain damage as a family affair
o Fatigue
o Disorders of awareness
o Suicidality in patients with neurological disorders
o Sexual functioning in patients with neurological disorders
o Ethics in clinical npsy and the capability
o Research in clinical npsy
- Goal acquiring an in-depth knowledge about these common issues relevant in clinical npsy
- Exam
o Online open essay questions open book
o Literature and lectures
o Grade
o 22-03-2021
The profession of clinical npsy
- Clinical npsy specialty within professional psychology that applies principles of assessment
and intervention based upon the scientific study of human behavior as it relates to normal
and abnormal functioning of the CNS
o Two part assessment and intervention based on scientific study
- Within health care offer services to the benefit of patients with cognitive and behavioral
symptoms related to neurological, developmental and psychiatric disorders. The impact of
disorders afflicting the nervous system is considerable both globally and in Europe
o Support patients impact is high
- Europe Brain Council
o Total European costs of brain disorders (psychiatric and neurological) in 2010 €798
billion now costs are even higher
37% direct health care costs
Assessments, treatments
23% direct non-medical costs
Changes in home, living environment
40% indirect costs
Losing job
o Between different disorders stroke, mood, anxiety, addiction, depression
(expensive)
More people affected when compared to fe. Parkinson
o Groot verschil in hoeveel CNP per inwoner in EU
Title obtained in different ways in different countries impact on numbers
86% vs 17% protected by law (CP vs. CNP)
NL – protected by law 2y training to health care 4y
postdoctoral training
Young field
o Other disciplines involved doing neuropsychological assessment – CNP meest maar
anderen ook wel (jij het beste getraind)
Cognitive screening often done by other disciplines
,Cost-effectiveness
- Domains to be tested during a clinical npsy examination – many different parts we want to
look into
o Processing speed
o Attention
o Memory and learning
o Executive functions
o Visuo-spatial skills
o Speech and language functions
o Perceptual skills (auditory, visual and tactual)
o Psychomotor speed and coordination of simple motor responses
o Emotional and motivation characteristics
o Social functioning and social cognition
o Self-awareness of level of functioning and judgments psychosocial implications
- Administration of npsy tests, scoring, interpretation and report of tests results is time
consuming
o ‘Brief’ assessments take around 2 hours, extensive assessments 8 to 10 hours
(without scoring, interpretation and reporting)
Consequently – Npsy examinations are expensive
Consequently – npsy examinations might need justification (in
particular times of financial crisis)
- Costs of clinical npsy examinations (in US, at around 2000) – About the principle niet perse de
getallen
o $600.000 per year to establish and maintain small department of clinical npsy in non-
profit hospital/medical center (covering secretarial support and salaries of 4 clinical
npsy)
o Additional 20% of indirect costs (e.g. medical insurance, pension schemes)
o In total: $720.000 – (rooms, technical support, electricity, etc. not considered)
- Charges
o Costs charged for the service
o Clinical nspy provide npsy services around 25 to 30h per week – time spent on
assessment
o Fees range from $140 to $200 per hour
o Assuming 25h per week for 48 weeks (4 week vacation) – 1.200h * $140 = $168.000
o In total: $672.000 per year (4 clinical npsy) hospital would break even
o However – Charges never reflect actual fees received
- Fees
o Amount actually paid
o Amount paid is considerably lower than the charges (applies to all aspects of
medicine and health care in the US)
o Reimbursement of psychotherapy $100 per hour, nsy assessment $71 to $80 per
hours
o Assuming 1.000 h npsy assessment per year (1000x $80 = $80.000) and 250h
psychotherapy per year (250x $100 = $25.000)
Revenue produced in reality is $105.000 (or $420.000 with 4 npsy)
o However - $720.000 costs – gap of 300.000
- Additional sources of revenue
o Boost of revenue by medicolegal cases – About $3.000 per case (with 30 cases per
year (1 every 10 days) = 30 * $3.000 = $90.000)
, Forensic, TBI in court called in to give expertise additional income
o Involvement of clinical npsy in research (support by grants)
Requirements however additional effort and time (!) by/of clinical npsy
(obtaining funds, publishing, conference participation)
- Why doing?
o When comparing costs $720.000 extra time & effort
o With income $420.000 medicolegal cases & research grants
Because of markers of values
Markers of value – why you are relevant
- Refers to money equivalent (e.g. cost saving) of the service received – by that you avoid
other health care costs, not losing job
- Comparison between costs of assessment and treatment with money saved by avoiding
other health care costs and by returning an individual to work and social responsibility
- Objective markers
o Reduce costs and liability
Example
Young man suffers TBI in an accident
Assessment shows that extent and nature of impairments reduce
man’s capacity to maintain line of work for which he was trained
Consequently – hundreds of thousands of lost dollars as a result of
brain injury
Because of npsy assessment consequences of accident documented
support during legal case – reduce costs
Capturing most of the man’s lost income via litigation
Reduction of costs for society by npsy medicolegal
assessment of around $3.000
Example
Savings associated with identification of malingerers (malingering =
intentional production of false or grossly exaggerated physical or
psychological symptoms, motivated by external incentives)
In Louisiana, US, 2000: Estimated $61 million per year paid to
malingerers of brain, back and neck injuries as well as
psychological accidental injuries
$43 million additional costs per year (e.g. unnecessary
medical treatment, trial defense costs)
Example
Savings associated with differential diagnosis on basis of npsy
assessments, e.g. between dementia and depression
Psychiatric treatment available for depression which might result
in productive lifestyle of patients
If npsy findings are indicative of early dementia patients and
families can plan for the patients’ early significant decline in
cognitive and behavioral functioning
o Supportt improve QoL – example
Male 53y old patient treated for a brain tumor (surgery and radiotherapy)
Owner of a big furniture store
After treatment NO npsy assessment
Bad financial decisions and investments
Bankruptcy after 18m post treatment with considerable debts
, Npsy assessment at this time revealed impairments in executive functioning
and WM – earlier then could have prevent the bad decisions. Overview of
everything could create understanding
Subjective complaint: co-workers and friends laugh at him since time of
surgery
o Assess the effectiveness of treatment pharmacological treatment, neurosurgery,
neurofeedback, cognitive trainings, etc.
o Guide treatment procedures – example
Npsy findings contribute significantly to decision whether patients undergo
epilepsy surgery
o Prevent the use of more expensive/additional diagnostic tools – example
Npsy findings can better predict the diagnosis AD than other techniques (i.e.
CSF and PET)
Npsy tests and MRI were the most informative techniques with 84% and 82%
correct classifications only slight increases when combined with CSF and
PET (kostenbesparend)
o Provide a continuum of care for patients – example
Clinical npsy consult with patients and their families about patients’ deficits
prepares them to deal with intermediate and long-term consequences of
patients’ brain dysfunctions
o Improve physician education and decision making – example
Patients and their families may suffer from pain, stress and economic burden
when patients return prematurely to work
- Subjective markers
o Reduce patients’ sense of psychological aloneness with daily problems
Example – relief of a patient with brain tumor (‘I am not mad’) when
describing an association between deficits and tumor location to her
o Reduce patients’ expectations, confusion and frustration about the nature of their
disturbances
Patients and families often have unrealistic expectations or wrong
understandings about deficits and their development
o Help family members feel less guilty in making decisions regarding brain-
dysfunctional adults and children
Many families struggle with the issue of placing a loved-one in a
residential/nursing home
In children – often considerable relief when parents learn that problems (e.g.
ADHD) are not the consequence of ‘poor’ parenting or psychodynamic
processes
Example – feelings of guilt and self-reproach of father who slapped daughter
in the face and who got a brain tumor diagnosed 10d later
- So it pays off for society and of course further savings by npsy treatment
Brain damage as a family affair
Introduction
- Nature and severity of problems experienced by family members differ from family to family
depending on – Many differences between families so different parts where difficulties are
experienced
o Type and severity of brain damage
o Patients’ symptoms
o Premorbid cohesiveness
o Family attitudes about illness and responsibility
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