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Advanced Clinical Neuropsychology PSMNB-1 Articles Summary
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Advanced Clinical NeuropsychologyIntroduction
Advancing the profession of clinical neuropsychology with appropriate outcome studies
and demonstrated clinical skills
Prigatano, G.P., & Morrone-Strupinsky, J. (2010)
Abstract
Healthcare economics and politics require clinical neuropsychologists to clearly document
the value of their services. Therefore, advancing clinical neuropsychology as an economically
viable profession requires carefully designed outcome studies and clear demonstration of the
value of neuropsychologists’ judgment in various patient care matters. In this paper we
propose steps for achieving these two goals.
A major issue facing clinical neuropsychology is getting financially reimbursed for the
services they provide. Two types of ‘data’ or ‘evidence’ are needed. One type of data comes
from well-designed, ‘evidence-based’ outcome studies that demonstrate the efficacy and the
cost-effectiveness of our procedures and interventions. Another crucial type of ‘data’ needed
is for individual practicing clinicians to demonstrate clearly to the referring physicians the
value of their clinical judgment in patient care. A bad end result will be two-fold. First, clients
or patients will be seen only on a ‘fee for service’ basis, which only some families can afford.
The other impact will be on expanding trend of neuropsychologists to do more ‘medical-legal’
work to survive economically.
Professional identity of neuropsychologists
Clinical application of neuropsychology is as close as or closer to its scientific roots than any
other specialty within psychology. Neuropsychologists have flourished because they have
been able to relate their discipline to a growing database in the neurosciences. The value of
our work is ultimately judged by four individuals: the patient, a relevant family member, the
referral source, and the payor for the services we provide. Our goal is not only to demonstrate
the efficacy and cost-effectiveness of our work, but also to develop and train
neuropsychologists to be scientist-practitioners who are able to blend our science with patient
and family needs and concerns.
Scope of practice of clinical neuropsychologists
Clinical neuropsychologists are actively involved in examination and assessment of
individuals from infancy through the elderly years. Neuropsychologists are progressively
becoming more interested in applying this information to the successful management of
neuropsychological disturbances in different patient populations and trying to remediate or
reverse the effects of neuropsychological disturbances. When the disturbances cannot be
successfully remediated, helping the person and family adjust to the permanent
neuropsychological disturbances and return to a productive lifestyle when possible becomes a
major focus of clinical neuropsychologists.
Previous and continuing efforts
Advancing the profession of clinical neuropsychology requires carefully designed outcome
studies, which unequivocally demonstrate the ‘objective’ (i.e. economic and scientific) value
of our work, as well as its ‘subjective’ value to the patient, family, and physician (i.e. the
degree to which they are personally satisfied with our work and are willing to pay for it).
Randomized controlled trials (RCT) are often considered the ‘gold standard’ for documenting
1
,scientific evidence of a treatment or intervention effect. There are four types of cost analysis
used in outcome research: cost-efficiency or minimization, cost-benefit, cost-effectiveness,
and cost-utilization. Intrinsic to cost-outcome research is the concept of value. Value refers to
the ‘worth’ of the service.
Future efforts
Neuropsychologists should conduct outcome studies that demonstrate neuropsychological
testing/evaluations lead to practical decisions for patients (and their families).
Clinical neuropsychologists are frequently asked to help neurologists determine if a patient’s
subjective complaints correlate with objective measures of brain functioning. The differential
diagnostic question of neurological versus psychiatric disorders persists, despite advances in
neuroimaging. Similarly, identifying patients who have epileptic versus nonepileptic seizures
could potentially save the healthcare system several million dollars per year. Additionally,
neuropsychologists sometimes conduct presurgical evaluations of patients with Parkinson’s
disease who are being considered for a deep brain stimulator to determine whether they are
demented and/or severely depressed.
Rehabilitation is another area where neuropsychology plays an important role and our impact
could be measured and quantified. Psychiatrists, as well as other physicians, may refer to
neuropsychologists to document disturbances in higher cerebral functioning after known brain
disorders that have relevance for rehabilitation planning and patient management.
Neuropsychologists predict the time that is needed for patients to achieve certain
rehabilitation goals. Also, they play a role in educating family members in order to manage a
person with known neurological disturbances. Attorneys also request neuropsychological
evaluations in a variety of medical-legal cases.
Neuropsychological test findings can lead to some practical decisions regarding patient care:
when the patient is safe to return home, or operate a motor vehicle, or adequately return to
work.
Neuropsychologists need to conduct outcome studies to demonstrate that neuropsychological
testing/evaluations lead to the development of new knowledge relevant to patient diagnosis
and care.
Levin et al. (1990) demonstrated that the two most common neuropsychological consequenses
of traumatic brain injury (TBI) were decreases in speed of processing speed and memory.
Disturbances of white matter tracts following TBI may be the basis of many
neuropsychological impairments.
Neuropsychologists need to conduct outcome studies to demonstrate that neuropsychological
knowledge/tests can be combined with neuroimaging to improve patient care.
Outcome studies are needed to demonstrate that patients have less comorbidity as a result of
surgeons having this knowledge and/or that they require much less speech and language
therapy following their operations.
Neuropsychologists need to conduct outcome studies to demonstrate that neuropsychological
interventions with patients not only reduce disability and improve the quality of life of the
patient, but also improve the quality of life of caregivers.
Patients who receive a holistic neuropsychological rehabilitation program were described as
having significantly less frequent psychiatric symptoms than patients who did not receive
such treatment. Another area of work is providing services to patients with mild cognitive
impairment (MCI) and early Alzheimer’s disease. Intervention programs may have substantial
benefit from improving and extending the period of functional competence in patients with
MCI and early dementia, as well as reducing the costs associated with inpatient care.
Neuropsychologists need to conduct outcome studies to demonstrate the economic impact of
not receiving neuropsychological assessments and interventions in a timely fashion.
2
,This can readily be seen in the detection of patients with dementia, allowing patients with
brain injury to go back to driving and work prematurely, and not providing services for
children in time-efficient way that ultimately results in greater morbidity for those children
over the course of their lifetime.
Table 1 Primary clinical skills, see article
Final points
1. Find your professional niche
2. Recognize that neuropsychologists are not mini neurologists, psychiatrists, or
radiologists
3. Evaluate the concept of value in healthcare economics
Fatigue
Fatigue in multiple sclerosis: mechanisms, evaluation, and treatment
Braley, T.J., & Chervin, R.D. (2010)
Abstract
Among patients with multiple sclerosis (MS), fatigue is the most commonly reported symptom,
and one of the most debilitating. Despite its high prevalence and significant impact, fatigue is
still poorly understood and often under-emphasized because of its complexity and subjective
nature. In recent years, an abundance of literature from specialists in sleep medicine,
neurology, psychiatry, psychology, physical medicine and rehabilitation, and radiology have
shed light on the potential causes, impact, and treatment of MS-related fatigue. Though such
a diversity of contributions clearly has advantages, few recent articles have attempted to
synthesize this literature, and existing overviews have focused primarily on potential causes
of fatigue rather than clinical evaluation or treatment. The aims of this review are to
examine, in particular for sleep specialists, the most commonly proposed primary and
secondary mechanisms of fatigue in MS, tools for assessment of fatigue in this setting, and
available treatment approaches to a most common and challenging problem
Multiple sclerosis (MS) is an inflammatory disease of the central nervous system that results
in myelin destruction and axonal degeneration in the brain and spinal cord. None of the
therapies reverse the preexisting tissue damage or control chronic symptoms, such as fatigue,
that are common to all subtypes of MS. Fatigue is considered to be one of the main causes of
impaired quality of life and occupational productivity. It remains poorly understood and
underemphasized for several reasons. First, fatigue is a subjective symptom without a unified
definition. Ambiguity also arises because no gold standard exists by which to measure fatigue.
Finally, fatigue in MS patients may be multifactorial. It is associated with increased
prevalence of other conditions that contribute to fatigue, including depression and several
sleep disorders.
Primary mechanisms
The most commonly proposed primary mechanism of fatigue in MS involve the immune
system of sequalae from central nervous system damage.
- Cytokine influences: cytokines implicated in the disease are thought to be strong
mediators of fatigue.
- Endocrine influences: both low cortisol and low DHEA levels have been implicated in
chronic fatigue syndrome, and low DHEA levels are found in patients with lupus and
rheumatoid arthritis.
3
, - Axonal loss and altered cerebral activation: magnetic resonance spectroscopy studies
have shown significant reductions in NAA/Cr rations in comparison with non-fatigued
MS patients, suggesting axonal loss as a contributing factor. MS-related fatigue also
may arise at least in part from compensatory reorganization and increased brain
recruitment.
- Sleep disorders: restless leg syndrome, sleep disorders in breathing, chronic insomnia
and circadian rhythm abnormalities. The frequency of sleep disturbance is increased
among patients with MS as compared to the general population. Risk for insomnia
may arise secondary to pain, spasticity, depression, anxiety, nocturia, medication
effects, or primary sleep disorders such as RSL or periodic limb movement disorder.
- Depression: depression commonly accompanies MS, with a prevalence of up to 50%.
Depression itself can manifest with fatigue and symptoms often mistaken for fatigue
(loss of motivation, anhedonia).
- MS subtype and disability: fatigue appears to be more severe in patients with
progressive subtypes of MS.
- Iatrogenic mechanisms: medication used to treat symptoms of MS have the potential
to cause fatigue.
Fatigue rating scales
- The Chalder Fatigue Scale (The Fatigue Scale): one of most well-known fatigue
scales, created for chronic fatigue.
- Krupp’s Fatigue Severity Scale (FSS): initially designed to identify common features
of fatigue in both MS and lupus patients, it assesses the impact of fatigue on multiple
outcomes, with a physical focus. Requires subject to rate their level of fatigue and its
effects on daily functioning.
- The Modified Fatigue Impact Scale (MFIS): gained recognition among MS specialists
as a reliable tool. It measures physical, cognitive and psychosocial functioning.
A diagnostic approach to fatigue
A systematic approach to the assessment and treatment of fatigue in patients with MS is
summarized in Figure 1.
- Initial questioning: if the patient does not volunteer fatigue, one suggested approach is
to ask the patient about his level of energy or tiredness.
- Sleepiness assessment: fatigue and sleepiness may be difficult to distinguish. If the
problem is reported to be worse during sedentary, monotonous activities than during
extended physical activity, sleepiness is more likely than fatigue.
- Depression screening
- Fatigue quantification
- Other medical conditions: iron studies, vitamin B12&D and folate levels, thyroid
studies
Pharmacologic treatment
- Amantadine: well tolerated and mild side-effect profile
- Pemoline: central nervous system stimulant with dopaminergic effects. Associated
with liver toxicity.
- Modafinil: wake-promoting agents approved by the FDA for narcolepsy, shift-work
sleep disorder and sleep apnea. At recommended doses, modafinil is generally safe
and well tolerated, but increased risk of adverse psychiatric and cardiovascular effects
have been reported.
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