Advanced Clinical Neuropsychology
Lecture 1 Introduction
The profession of clinical neuropsychologist
“Clinical neuropsychology is a specialty within profession 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 central
nervous system. Within healthcare clinical neuropsychologists are professionals
who offer services to the benefit of patients with cognitive and behavioral
symptoms related to neurological, developmental and psychiatric disorders. The
impact of all disorders afflicting the nervous system is considerable both globally
and in Europe.” Justification why we need clinical neuropsychologists
European brain council: Total European costs of brain disorders
(psychiatric and neurological) in 2010: €798 billion. 37% direct health care costs,
23% direct non-medical costs (when having a stroke and unable to walk a
wheelchair, support for walking etc) and 40% indirect costs (not being able to go
to work anymore). Basically the message: a huge amount of costs to brain
disorders
Stroke, psychotic disorders, mood disorders, dementia, anxiety disorders and
addiction are ‘expensive disorders.’ Huge variation between disorders but overall,
costs are high.
Big variance between estimated number of active clinical
neuropsychologists and ratio of practitioners per population between countries.
Mostly because in some countries the title of neuropsychologist is protected by
law (Netherlands) and in others it isn’t. There are more requirements than just a
master’s degree to become a neuropsychologist. Another explanation is that
neuropsychology is quite young next to psychology.
Cognitive screenings are often performed by other disciplines
(pediatricians, psychiatrists, neurologists etc), full neuropsychological
assessments are mostly performed by neuropsychologists.
Cost-effectiveness
Domains to be tested during a clinical neuropsychological examination
Processing speed, attention, memory and learning, executive functions, visuo-
spatial skills, speech and language functions, perceptual skills (auditory, visual
and tactual), psychomotor speed and coordination of simple motor responses,
,emotional and motivational characteristics, social functioning and social
cognition, self-awareness of level of functioning and judgements regarding
psychosocial implications.
Administration of neuropsychological tests, scoring, interpretation and
report of tests results is time consuming. A “brief” assessment takes around 2
hours, extensive assessments 8 to 10 hours (without scoring, interpretation and
reporting). Consequently neuropsychological examinations are expensive.
Consequently neuropsychological examinations might need justification (in
particular in times of financial crisis).
Example costs of clinical neuropsychological examinations (in US, at around 2000):
Costs: $600,000 per year to establish and maintain small department of clinical
neuropsychology in non-profit hospital/medical center (covering secretarial support and
salaries of 4 clinical neuropsychologists). Additional 20% of indirect costs (e.g. medical
insurance, pension schemes). In total: $720,000 (Rooms, technical support, electricity,
etc. not considered)
Charges: Costs charged for the services. Clinical neuropsychologists provide
neuropsychological services around 25 to 30 hours per week. Fees range from $140 to
$200 per hour. Assuming 25 hours per week for 48 weeks (4 weeks vacation): 1200 hours
x $140 = $168000. In total: $672,000 per year (4 clinical neuropsychologists). Hospital
would nearly break even. However: charges never reflect actual fees received.
Fees: Amount actually paid. Amount paid is considerably lower than the charges (applies
to all aspects of medicine and health care in the US). Reimbursement of psychotherapy
$100 per hour, neuropsychological assessment $71 to $80 per hours. Assuming 1,000
hours neuropsychological assessment per year ((1000x $80 = $80,000) and 250 hours
psychotherapy per year (250 x $100 = $25,000). Revenue produced in reality is $105,000
(or $420,000 with 4 neuropsychologists) However, $720,000 costs
Additional sources of revenue: Boost of revenue by medicolegal cases: About $3,000 per
case (with 30 cases per year (1 every 10 days) = 30 x $3,000 = $90,000). Involvement of
clinical neuropsychologists in research (support by grants). Requires however
additional effort and time by/of clinical neuropsychologist (obtaining funds, publishing,
conference participation).
Why is clinical neuropsychology relevant? - Comparing costs from around
$720000 against income of around $420000, there is a gap. But it is important
because of markers of values.
Markers of value refers to money equivalent (e.g. cost saving) of the service
received. 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
Reduce costs and liability – Example of a 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
neuropsychological assessment consequences of accident documented.
Capturing most of the man’s lost income via litigation, reduction of costs for
society by neuropsychological medicolegal assessment of around $3000.
Another 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)
Another example, savings associated with differential diagnosis on basis of
neuropsychological assessments, e.g. between dementia and depression. Psychiatric
treatment available for depression, which might result in productive lifestyle of patients.
If neuropsychological findings are indicative of early dementia, patients and families can
,plan for the patients’ early significant decline in cognitive and behavioral functioning.
Improve quality of life – Example, male 53-year old patient treated for a brain tumor
(surgery and radiotherapy). Owner of a big furniture store. After treatment NO
neuropsychological assessment, bad financial decisions and investments. Bankruptcy
after 18 months post treatment with considerable debts. Neuropsychological assessment
at this time revealed impairments in executive functioning and working memory.
Subjective complaint: Co-workers and friends laugh at him since time of surgery
Assess the effectiveness of treatment - Pharmacological treatment, neurosurgery,
neurofeedback, cognitive trainings etc.
Guide treatment procedures – Example, neuropsychological findings contribute
significantly to decision whether patients undergoes epilepsy surgery.
Prevent the use of more expensive/additional diagnostic tools – Example,
neuropsychological findings can better predict the diagnosis Alzheimer’s disease
than other techniques (i.e., CSF and PET).
Provide a continuum of care for patients – Example, clinical neuropsychologists
consult with patients and their families about the patients’ deficits. Prepares
them to deal with intermediate and long-term consequences of patients’ brain
dysfunctions.
Improve physician education and decision making – Example, affected people
and their families may suffer from pain, stress and economic burden when
patients return prematurely to work.
Subjective markers
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.
Reduce patients’ expectations, confusion and frustration about the nature
of their disturbances – affected people and families often have unrealistic
expectations or wrong understandings about deficits and their development
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. For example, feelings of guilt and
self-reproach of father who slapped daughter in the face and who got a brain
tumor diagnosed 10 days later.
So it pays off for society, not only direct but also indirect costs. And of course:
further savings by neuropsychological treatment.
Brain damage as a family affair
International classification of functioning,
disability and health
, Nature and severity of problems experienced by family members differ from
family to family depending on: type and severity of brain damage, affected
person’s symptoms, premorbid cohesiveness, family attitudes about illness and
responsibility, financial and social support etc. Problems experienced differ
among family members (primary caretaker frequently carrying the greater part of
burden).
Families often experience emotional abandonment and caretaker feel often
worn out since affected person cannot provide emotional support, since others
who could give comfort no longer come around.
Caregiver burden: range of psychical, emotional, social and financial harms
related to the caregiving experience.
In case of dementia: many people are cared for at home by an unpaid
informal caregiver. The caregiver is usually a female family member (daughter or
spouse). Family caregivers spend 5 to 20 hours per day and, on average, 60
hours per week on caregiving.
Which behaviors are likely to create problems?
Impaired social perception and social awareness (impairments in social
cognition, e.g. diminished capacity to empathize with others or to recognize
others’ emotional reactions and needs) – Some people display a childlike
egocentricity (similar to social perspective of children who have limited
awareness that parents have needs of their own). People might be unable to
appreciate that their caretaker is tired or depressed or that their behavior
frightens their minor children. People might not appreciate the social
requirements of a setting (e.g. restaurant or church) and embarrass their
companions with noisy or inappropriate behavior. Feeling may arise that social
outings with people might cease to be worth the effort or embarrassment. Old
friends and relatives might no longer visit, isolation of affected person, caretaker
and other family members.
Impaired control – Control problems show up in different ways.
Impulsivity (most obvious manifestation), anger outburst as the most commonly
reported form of impulsivity. Almost any activity can be affected by impulsivity
