Category Archives: What’s new in neuropsychology?

How Much Is This Going To Hurt? Let Me Look Into My Crystal Ball……

“Sorry, let’s check the crystal ball”

     If you’ve read this blog before, you’ve noticed my interest in our ever-changing healthcare system as it relates to the patient experience.  It’s time for an update!  In short, since passage of the Patient Protection and Affordable Care Act (ACA) in 2010, transparency of healthcare costs has been much vaunted.  I’d go so far as to say transparency was a core selling point.

     See this ironically-named page from the Centers for Medicare and Medicaid Services on the ACA and transparency for consumers:

https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/increasing-transparency02162012a.html

     As an also-ironic aside, the page boasts, that “consumers will have access to two key documents that will be written in plain language, in a standard format, to help you understand and evaluate your choices,” including “a uniform glossary of terms commonly used in health insurance coverage, such as ‘deductible’ and ‘co-payment.'”

     Unfortunately, the link to their Summary of Benefits and Coverage and the Uniform Glossary is…you guessed it: not functioning.

http://www.healthcare.gov/news/factsheets/2011/08/labels08172011a.html

     The icing on the cake is that if you somehow manage to follow the links to the Summary and Glossary page, you get this nonsensical eruption of legalese which is most definitely not transparent:

 https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/index.html#Summary of Benefits and Coverage and Uniform Glossary

      Back to the crystal ball.

     My family’s new health insurance plan is one of the high-deductible ‘catastrophic’ plans that are designed to cover very little unless and until you have the misfortune of serious illness or injury necessitating very expensive care.  I don’t want to bill the insurance company for my family’s routine minor care.  I am happy to pay, out of pocket, a reduced “direct pay” rate most clinics offer.  Seems like a win-win situation to me: the insurer pays nothing, I pay an uninflated, “actual” price, the clinic does not the expense of billing overhead and paperwork, and everyone is happy, right?

     But it appears that, unless they are not contracted with your provider at all, doctors must bill through your insurance even if

  • you do not want to use it
  • your service is not covered
  • your deductible has not been–and will likely never be– met
  • and critically: even if your payment will be HIGHER using insurance than if you were to pay directly!

I found this article on avoiding the problem: http://selfpaypatient.com/2014/01/03/insured-patients-can-save-money-by-pretending-to-be-uninsured/    Disclaimer: be careful if you try this because of the chance you actually could meet your deductible unexpectedly; your previous payments would not be ‘counted’ towards your deductible.

This is a long way of getting around to something that should not require a crystal ball: the price of your medical service.

I trotted into three different clinics with three different family members to ask the prices of three different medical services.  Before I agreed to pay the insurer’s contracted rate, I wanted to know the rate for ‘direct-pay’ patients, since I knew none of the services would be covered at all.

Not one of the three clinics could tell me the insurer’s contracted rate for the service.  They knew the direct-pay rate spot-on. So, intrigued, I got on the phone with our insurer (who I have to say, has been very professional and user-friendly aside from this issue).  I never did get a precise response. So, in short, I could not make an informed decision about my family’s care because critical information was unavailable.

This is unacceptable.  Imagine going to a store where you find a lovely pair of earrings.  The cashier says, “We’ll bill you. Could be $50.  Could be $500.”

What if they were goofy Christmas tree earrings, and you thought you could use them for the holidays?  Paying the lower price would be a reasonable judgment call, but you KNOW you don’t want them if they cost $500!  If you don’t know the price, you can’t decide whether they’re worth it.

What if you saw two shops, side by side, offering the same earrings, both unmarked?  Which ones would you buy, if you had no idea which were the better deal?

Just because healthcare is more precious and complex than a pair of earrings does not mean the costs should be any less transparent.  In fact, I’d argue the potential value, costs and benefits of healthcare make price transparency even more critical.  You should not have to look into a crystal ball to know exactly what you’re expected to pay, and exactly what you can expect to get in return.  That’s why at Neuropsychology, Inc., you are quoted a price and time frame upfront, with no hidden fees, denied payments or balance billing.  I trust you to make these decisions for yourself and your family.

One last tidbit….Here’s a clear and detailed article on surprise medical bills and how to avoid them:

https://consumerist.com/2015/09/24/a-loopholes-and-master-pricing-how-surprise-medical-bills-knock-consumers-down/

Comfort Animals….or Pets?

pet
Speaking from the perspective of one who has worked in hospitals for many years, the value of animal comfort and contact simply cannot be overstated.  For staff and patients, Pet Therapy days were always the happiest.  Pet therapy has a long history, especially in pediatric populations. I found a neat little timeline on animal therapy history– from 1792!  See it here: http://blogs.uoregon.edu/juewsm13gateway/timeline/

horse

 

Animal therapy has taken many forms.  Most commonly, animals were used to alleviate psychological distress, and responsibility for animal care was an integral part of many psychiatric and rehabilitation settings.  Animal therapy or therapeutic recreation, is also well-known to those who work with persons with physical, medical and/or intellectual/developmental disabilities.

See this great article on personal pet visits in hospital: http://newoldage.blogs.nytimes.com/2013/04/10/when-best-friends-can-visit/  Other common therapeutic activities include canine therapy visits to hospital wards and equine therapy.

More recently, a somewhat different, and more controversial, version has developed, referred to as Animal-Assisted or Animal-Facilitated Intervention.  This intervention emphasizes the use of assistance animals or ‘comfort’ animals, thought to reduce anxiety, at least in the short term. In fact, O’Haire, Guerin and Kirkham (2015) note that methodology is non-standardized and highly variable across settings, which makes study of the practice rather challenging; the long-term benefits, if any, are not clear.

Critics argue that comfort animals are a proxy for psychosocial maturity, and that reliance on creatures is like taking Valium instead of using cognitive behavioral techniques, or even fortitude, to reduce anxiety.  And how, they argue, will patients learn to function in “real life” carrying an animal under one arm?  Some argue that rights of those without comfort animals are taking a backseat, as they may not want to be exposed to pet dander, noise or mess.

Proponents say that if one can achieve goals (such as graduating or traveling) using a comfort animal, then the technique is a success.  I tend towards the former persuasion, with the added concern that there may be elements of the therapy that end up being unhelpful in the long-term, like over-identification with a disability or diagnostic label.  There may also well be some patient populations who are not well-suited for this intervention, but the research just has not been done.

pets

You may have seen this New York Times article on comfort animals: http://www.nytimes.com/2015/10/05/us/four-legged-roommates-help-with-the-stresses-of-campus-life.html    The story actually deals with the conflict between property damage laws and disability discrimination laws, but the Comments section is really lively and well-reasoned (well, most of it).  And you probably remember the fracas over the notorious “comfort pig” last year: http://www.cnn.com/2014/11/30/travel/emotional-support-pig-booted-flight/

 

pig

The comfort pig can maybe get his own back: apparently the emotional symbiosis works both ways: see http://www.ncbi.nlm.nih.gov/pubmed/26244335

For another take on unforeseen consequences, see this fascinating article on registration of assistance animals in California over the past decade: http://www.ncbi.nlm.nih.gov/pubmed/26287610

My personal choice of comfort animal:

tiger

[As an interesting aside, “animal hoarding” is sometimes covered in media, and would fall under the new diagnostic category of Hoarding Disorder.  The impact of animal hoarding on emotional functioning/well-being is likely a complex topic and a fascinating avenue for research given companion animal popularity.  There is little research on the topic but a recent study by Campos-Lima, et al., (2015) suggests there is little relationship between animal hoarding and OCD, or Obsessive Compulsive Disorder].

References:

Campos-Lima, A., Torres, A., Yucel, M.,….Fontenelle, L. (2015) Hoarding pet animals in OCD. Acta Neuropsychiat, 27(1) 8-13.

O’Haire, M, Guerin, N., & Kirkham, A. (2015) Animal assisted intervention for trauma. Front Psychol, Aug 7;6:1121. doi: 10.3389/fpsyg.2015.01121.

Yamamoto, M., Lopez, M., & Hart, A (2015). Registrations of assistance dogs in California for identification tags 1999-2012. PLosOne, Aug 19;10(8):e0132820. doi: 10.1371/journal.pone.0132820. eCollection 2015.

 

I Answer to You

One of the most persistently bothersome challenges in healthcare is how unresponsive medicine has become to patients.

Because payment is generally managed by a third party, like an insurer or government payer, there is little investment in keeping the customer happy–except as a means of increasing patient ratings, which can affect payments (http://healthjournalism.org/blog/2015/05/the-aca-and-patient-satisfaction-does-it-improve-care/ ). Hospitals and clinics may even parrot phrases from patient satisfaction rating scales in an effort to increase ratings, and thus reimbursement (http://kaiserhealthnews.org/news/patient-ratings-hospital-medicare-reimbursements/ ) which is not at all about your satisfaction, is it?

Handcuffed to third party payer
Handcuffed to third party payer

If you look at this professional article on patient satisfaction and payment changes  http://www.aaos.org/news/aaosnow/jun13/advocacy5.asp  there are ratings of your understanding and if you felt others listened to you (which begs the question, “Shouldn’t this be the bare MINIMUM you’d expect!?”)  But notice there is a stunning absence of any discussion of value: Did you feel your service was worth the cost? Are you happy with the decision to get this test/treatment? What would you do differently next time? Or how about in advance of any exam/treatment: What would YOU like to get from this appointment, and what’s the most important thing to you right now?

Instead, time and effort revolves around keeping the third party payer happy: filling out mountainous forms, billing using complex codes and modifiers, and spending time, money and staff resources arguing over billing errors, all of which serve only to take time away from patients.  From a patient’s perspective, there is often dissatisfaction with low-value evaluation: the cost and inconvenience far outweighs utility.

Screaming. Throwing hands in air.  Healthcare.
Screaming. Throwing hands in air. Healthcare.

I always wondered how things would be if patients could more easily decide how to direct their healthcare dollars, prioritizing the services that were most valuable and critical to them, and demonstrating satisfaction by voting with their feet.

As a consumer of healthcare services, you should expect the same things from doctors that you expect from the businesses in which your money is spent.  Expertise and quality.  Convenient location. Short wait time.  Fast and reliable communications.   Responsiveness to your questions.   Sensitivity and friendliness.  If a business can’t deliver on any of those, you go elsewhere.  Alternately, you may give more weight to some factors: you’re okay with a brusque doctor as long as the care is excellent.  Or maybe cost is paramount to you, and you will trade speed for lower price.

In the current healthcare system, a third party payer comes between you and those decisions.  In fact, the only way the current system can keep its financial head above water is to severely restrict choice and individual decision-making. (I’ve even read a paper purporting choice is BAD for you, and you should settle for mediocrity to avoid the stress of excellence!).

When I opened my clinic, based on an urgent-care direct pay model, I knew it would not be the single best answer for every patient seeking neuropsychological evaluation.  But for many, it’s a revelation: you call, make an appointment (typically within a day or two), and after a pleasant, informative and efficient experience in which YOUR specific concerns and needs are addressed, your report is immediately sent to your doctors.  I can’t tell you how many patients have expressed disbelief at the convenience and ease of evaluation here, which they felt was infinitely preferable to the insurer’s options (especially since in many cases, the cost was actually the same or less!).

The bottom line is that I answer to YOU, not any insurer or government payer.  That gives me the freedom to provide you with the personalized,  superior level of service you deserve.  As the customer, your satisfaction is my greatest concern.

Just because I like fish.
Just because I like fish.

Anosognosia: Not Just a Primitive Defense Mechanism

 

If only it were this easy...
If only it were this easy…

Anosognosia is a technical term that refers to a lack of awareness of deficit.   The hallmark is a puzzling inability to recognize major symptoms, such as paralysis on one side of the body, amnesia, or marked cognitive impairment/dementia.  A related phenomenon is anosodiaphoria, which is an emotional insouciance or indifference in the face of major neurologic symptoms–not to be confused with la belle indifference, which refers to a cheerful lack of concern about disabling symptoms when there is no medical explanation for them.

Anosognosia is often associated with frontal lobe and/or right hemisphere brain insult but other regions have been studied, including the anterior insula.  Some conditions commonly associated with anosognosia are traumatic brain injury (moderate to severe), stroke, and Alzheimer’s/other dementias. See the Jenkinson, Preston and Ellis (2011) review below for a nice summary; it includes a number of assessment techniques for the condition.

In its most dramatic presentations, patients may be utterly unable to report the most startling and obvious impairment: being densely paralyzed on one side of the body, or even blindness (!).  A normal variant, called “unrealistic optimism” has even been studied!  The most important thing to remember is that anosognosia is not the same as psychological “denial” or defense mechanism where one cannot admit to and cope with impairment (think: alcohol abuse).  Very commonly my patients’ families will express frustration that their loved one is “in denial” about the injury or illness, and their attempts to provide help or feedback have been met with resistance.  I try to reframe this difficulty as a neurologic symptom, because family members may be very reluctant to “override” a loved one’s wishes or press the issue if they feel it will cause emotional distress or insecurity.

Patients with anosognosia will often produce elaborate, if incorrect, explanations of their symptoms (confabulation).  In dementia, the explanation is typically a firm belief that decline is normal age-related cognitive change that does not affect independence.   I have seen patients with dementia who adamantly and cheerfully report total independence to all their doctors, but interview with a family member reveals they cannot cook, manage money, drive, or even dress without assistance.  (This is why I always for permission to interview a family member).

If you ask stroke patients whether they had a stroke, they might respond, “That’s what they told me….”     I remember a patient of mine with stroke and dense left hemiparesis who said– as she sat, leaning far over to one side, in a wheelchair in a hospital– that she was just fine, thank you very much.  I asked if she had any weakness.  She said no.  I asked if she could in fact move her left arm.  She said yes.  There was a long silence as she sat looking at me.  I asked her to move her left arm for me.  With an effortful expression, she tried, and of course nothing happened.  I asked her why her arm didn’t move.  She said, “Well, I didn’t eat breakfast this morning, so I’m feeling weak!”

As you can imagine, the presence of anosognosia presents a unique and serious challenge to examination and treatment of patients: basically because they cannot accurately report problems, monitor/modify errors, or realistically, participate fully in rehabilitation. After all, are you going to be motivated to improve and change when you cannot recognize underlying deficits?  Also, patients are unlikely to take appropriate safety precautions when they don’t recognize problems that increase risk.

Anosognosia is quite refractory to treatment, once the intial spontaneous brain recovery has exhausted itself.  I was talking to my husband once years ago about this fascinating syndrome, and he replied, “Can’t you just tell them, ‘I’m your doctor, so trust me on this- you have a problem,’?”  If only!  My patients would likely reply with gently reassuring comments about how it’s true they are not 100%, but hey, who is?

To help explain the sensation my patients must have, I often ask their family members to imagine completing neuropsychological testing, after which I sit down and inform them that based on their errors (and the fact they’d bounced a check in 2014 and had a fender-bender in 2013) I am recommending someone be appointed their legal guardian and they’d no longer be able to drive or manage a checkbook.  I suspect people with anosognosia feel a bit like this when we point out deficits: no matter how often I tell you my diagnosis or point out problems, you will not incorporate or believe what I am telling you–it just does not compute.  You may even protest, “Everyone bounces a check at some point!  Everyone has a fender -bender!” After which you will take out your car keys and screech out of the parking lot (despite my warning that you’d be unsafe behind the wheel).

There is some interesting research on rehabilitation for anosognosia, focusing on third-person perspective-taking (e.g. watching a video of yourself performing an act), improving motor skills, and even pharmacotherapy (Jenkinson, Preston & Ellis, 2011).  Many specialized rehabilitation centers are able to tailor a treatment plan to fit the needs of each patient, taking into account emotional functions, family interactions, and level of unawareness.

 

References:

Gasquoine, P (2015) Blissfully unaware: anosognosia and anosodiaphoria after acquired brain injury. Neuropsychological Rehab, Feb 16, 1-25.

Jenkinson, P., Preston, C., & Ellis, S. (2011) Unawareness after stroke: review and practical guide to understanding, assessing and managing anosognosia for hemiplegia. Jrnl Clin Exp Neuropsychology, 33, 10, 1079-83.

Mak, E., Chin, R., Ng, L, Yeo, D & Hameed, S (2015) Clinical associations of anosognosia in MCI and AD. Int J Geriatric Psychiatry, March 9.

McKay, R., Buchmann, A, Germann, N, Yu, S & Burgger P (2014).  Unrealistic optimism and “nosognosia”: Illness recognition in the healthy brain.  Cortex, Dec, 61, 141-7.

McKay, R & Kinsbourne, M (2010)Confabulation, delusion and anosognosia. Cogn Neuropsychiatry,  Jan 15,1,288-318

Stone, J, Smyth, R., Carson, A, Warlow, C &  Sharpe, M (2006) La belle indifference in conversion symptoms and hysteria.  Brit Jrnl Psychiatry, March 188,  204-9.

2

Is It Like This At Saks 5th Ave?

sunset palm trees MGD©Imagine one day you determine you need a new sweater.  You have to go to Saks Fifth Avenue, because it’s the only store in your city, but you have to go between 1:00 and 4:00 p.m. on a Thursday, four weeks from now.  Because that’s when they’re open.  You find a sweater, strangely located in the shoe department.  You really need the sweater, so even though the price tag is blank, you take it to the dressing room.  The salesperson, in a hurry and very busy, races past you — she does not know the price and has no idea how to determine the price–that’s your job, she says.  That’s okay, because you happen to know from your internet research that the same sweater costs $20 at Target.  (You can’t buy it at Target, though–Target is in another city, and doesn’t take cash, checks or any of your credit cards).

You take the sweater to the register, and after completing 10 forms and waiting two hours in line, a staffer rings up your purchase.  Turns out the sweater costs $350.00.

Wait a minute, you say.  That seems like a lot.  I saw this sweater at Target the other day for $20. Why so much?  No one knows.  No one cares. You pay the $350.00 after waiting another two hours in line, only to receive a bill for an additional $75.oo in the mail six months later.  The sweater?  Mailed to your house–in the summer, about a month after you buy it.

Sound insane?  This is what shopping at Saks Fifth Avenue would be like if it were part of the American third-party payer healthcare system.

The other day, I spoke with the mother of a patient who was referred to my clinic.  When I called her to set up an appointment, it became clear that she did not know her options (such as my out-of-network clinic, a traditional private practice model, or a clinician covered by her insurance policy), so we discussed those at some length.

She could pay at the time of service for my examination: they’d be seen immediately, with same-day report.  The hours needed and costs would be defined in advance, the cost would be comparable to co-insurance (and far less than any denied claim), and she could submit paperwork for out of network reimbursement from her insurer.

Alternately, she could rely on her insurance.  She didn’t know if her plan covered pediatric neuropsychological examination (many plans do not, especially when there is any question of learning disability or school problems).  If it does cover such exams, she would need to find out who to see.  Is there an in-network clinic taking patients?  What is the wait time for an appointment?  Is it a clinic she trusts, with a board certified specialist?

And once she has determined whether she can see one of these covered entities, she wondered, how much would it cost her out of pocket?  Well, of course, first you must meet your deductible.  And then there is co-insurance.   She astutely pointed out that still she could not compare pricing, because coverage and fees could vary quite a bit from plan to plan even within one company.  Then she would have to call her clinic of choice to find out how many hours they would bill for such a service and at what rate, so she’d be able to calculate her portion.

If the service was not covered, she could go to another traditional-model private clinic, and plan for very lengthy testing, a report weeks later, and a very high bill.

The absurdity of the situation was not lost on her.  It shouldn’t have to be that hard.

 sunset with palm MGD©

There’s no excuse for a healthcare and insurance system that fails to provide transparency, expediency, or simplicity.  Customer care should be the same for patients as it is for visitors in the highest-end retail stores, with clear standards for quality, pricing and value.

There is another way.  A new way.  As coverage of neuropsychological services is evaporating, and access to clinics is becoming more restricted, my clinic model is poised to fill the gap, to be here for you and your patients, for you and your family.

sunrise1

For Doctors: The Best for You and Your Patients

dochandout

This is a post especially for doctors who refer to neuropsychologists.  I recently sent out a flyer detailing this new way for your patients to access neuropsychology services, and below is a summary.

At Neuropsychology, Inc., the clinic model is value-based, not volume-based, making it the superior option for your patients who are not satisfied with their current options for consultation in Florida.  For instance, new narrow networks create backlogs and long wait times for appointments in traditional clinic models.  And decreasing reimbursement means volume is required to maintain revenue– that means less time with each patient, or overly-long evaluations that add cost without adding value.

Neuropsychology, Inc. is ideally suited to the modern healthcare environment, offering flexible, time-sensitive, empirically-based care with clinical acumen, expertise, and sensitivity.  At Neuropsychology, Inc., a board-certified neuropsychologist greets you in person in an appointment made to fit your schedule.  Emergency and urgent appointments are welcome.   Child, adult and geriatric neuropsychological evaluation is provided.  Neuropsychology, Inc. serves the North Florida region but out-of-town services are optional.

Results and feedback are provided immediately, and the referring doctor receives a report the following day.  No costly staff time is spent on authorizations, and there is no frustration with narrow networks.  There will never be a delayed denial of your patient’s claim, which can result in unexpected high bills.   This service is accessible for patients without insurance and even for those with insurance who are simply not satisfied with the options in their plans.  The fees are comparable to what your patients would pay in co-insurance and out of network fees, and claims can be submitted for out of network reimbursement or tax credit.

The clinic is located in lovely historic Riverside, with easy disabled-access entry and ample free, flat parking.

This is a clinic founded on the traditional scientist-practitioner model, and tailored to modern healthcare and customer satisfaction.

 

“Gone Girl” and the Borderline Personality Disorder

gone-girl

The book “Gone Girl” by Gillian Flynn was a hit as soon as it came off the presses in 2012, and for good reason.  It’s a razor-sharp dissection of human behavior, iced with the deliciously sadistic machinations of the main characters.  Part of its success has to do with the skin-crawlingly accurate portrayals of the deceptively mundane psychological injuries we inflict on those we love.

But most of all, I loved the slowly-unfolding portrayal of a person with Borderline Personality Disorder.  Most of the media deconstruction of the novel and film reflects on the main character’s Antisocial Personality Disorder, and most certainly she meets criteria for that diagnosis, especially as the story plays out: her deceitfulness, irritability, lack of remorse, etc.

But the borderline portrayal is sublime…….WARNING: SPOILERS AHEAD! (Although I am pretty sure I am the last person in the US to read the book, so there you are).

A quick primer on Borderline Personality Disorder (BPD).  A personality disorder is a pervasive and inflexible pattern of behavior that leads to significant repercussions, distress or impairment emotionally, interpersonally, occupationally, etc. (DSM-V).  That doesn’t mean the person with personality disorder thinks there’s a problem: he or she may feel everyone ELSE is out of their minds for complaining so much.  There are a number of different categories of personality disorder (Antisocial and Narcissistic are the two most infamous; see Magnolia [1999] for an example).

LOVE the psychopathology in Magnolia!
LOVE the psychopathology in Magnolia!

BPD is different from the former two.  It’s  marked by intense and unstable  interpersonal relationships, often with initial idealization of a new person, followed inevitably by bitter  disillusionment.  People with BPD, according to the DSM-V, “make frantic efforts to avoid real or imagined abandonment.”  I include this quote because it really is a superb description of borderline behavior, a classic.  Persons with BPD also may have a shifting, ever-changing self-identity, marked by constant change in values, goals, vocational plans, even sexual identity. You can also see emotional instability, suicidal gestures, and impulsivity.

Good portrayals of someone with Borderline Personality Disorder in media are hard to find.  I have been disappointed by many of the so-called realistic portrayals of the condition: they emphasize lurid  sociopathic or psychotic behavior over the more subtle–but just as destructive–characteristics of BPD.   While you can see bad behavior and psychotic like symptoms in BPD, more typically the behaviors are less obvious: the chronic feelings of emptiness and loneliness, the rage, the demands.

RachelGettingMarriedmargot

 

 

 

Margot at the Wedding and Rachel Getting Married (something about weddings….) are two great portrayals of the fallout from BPD.

 

 

 

So in Gone Girl, most of the book is dedicated to progressively more ominous depictions of just this sort of behavior.  I recommend the book for an enthralling mystery read, but even more strongly recommend it as for students of Psychology as a great portrayal of this particular diagnosis.

A bonus: part of the book’s appeal is the He Said-She Said presentation of events.  If you live long enough, you’ll have at least one “Ah-Ha” moment where you realize that events did not occur just as you remember them, maybe even replay the events from another’s perspective. And then near-forgotten details take on new meaning, new significance.  A la “The Sixth Sense.”   It’s disorienting but also humbling. From a neuropsychological perspective, it is fascinating because it reminds one how personality can color and even distort perception and reality–in the healthy!  The characters in Gone Girl don’t have that moment of clarity until it’s far too late.

six

Is It Dementia? Comment on the NYT Story

eldercrossing

So first let me say, “Well done, Paula Span!”  I like the NYT article on differentiating signs of dementia from other problems affecting cognition: http://newoldage.blogs.nytimes.com/2014/10/21/is-it-really-dementia/?_php=true&_type=blogs&_r=0

It’s reasoned, calm, and informative, which is pretty unusual for a piece on dementia.  The author’s personal experience with caregiving and her journalistic research have given depth to her understanding of the topic.

I thought I’d add to the article with a few brief comments.  In my clinic practice I routinely assess patients whose family and/or doctors suspect they may have dementia, often meaning a progressive condition like Alzheimer’s (which is the most common type of dementia). As a neuropsychologist, I use a combination of thorough medical record review, interview of patient and family, and paper and pencil testing to answer questions such as:

“Does this patient have objective, measurable impairment, or is this purely subjective?”

“Does this pattern of impairment look organic (meaning, neurologic) or psychiatric (meaning, depression or other mental illness)?”

“What type of dementia does this seem to reflect?”   (Alzheimer’s? Dementia with Lewy bodies? Vascular dementia? Frontal temporal dementia? etc.)

“Do you see any other factors coloring the picture?” (Such as medication effects, legal problems, pain, sleep disturbance, etc.)

elderlady

When I am teaching medical and neuropsychological residents about assessment of dementia, I emphasize the importance of the clinical interview–including the questions I ask, below, which ANYONE can use, whether doctors, residents, or concerned family members.

“Looking back on it now, what was the very first thing you noticed that  made you think something was wrong?” Identifying whether the first sign was depression, or behavior change, or forgetfulness is really useful in diagnosis.

“Did it start gradually and you noticed it over time, or was it  sudden?”  This helps a great deal in determining whether a progressive condition is possible, or another process.

pills

“Have you had to take over any things your loved one has always done on his/her own? Like paying bills, taking medicines, cooking, picking out clothes, driving, making appointments?” Many families will report their loved one is totally independent.  But then you ask carefully and turns out, they are doing everything for the patient. Sometimes this is just to be helpful, but sometimes it is because the patient can no longer do these activities alone. Along those lines, I also want to know if they do those activities correctly!  Some patients “manage their own medicines” but take them all in one week, or only once a week, or they lose pills.  Or they still drive, it’s just that no one will ride with them anymore!  Cooking is a big one in the South: some patients still cook but it just isn’t the same quality.

“Did anything else happen about the time all this began?”  I sometimes find that cognitive problems started after the patient took over parenting for a grandchild, or went into foreclosure on their home, changed medicine, had surgery, or lost a job due to layoffs.

“Is your loved one like this pretty much all the time, with good and bad days, or is it more off and on?”  Alzheimer’s, and sometimes Vascular dementia have an insidious, slow progression over time, whereas other problems may have a different course, much faster, or with fluctuations or episodes, or clearing totally for a time.

“Is there any change in personality or behavior?”  Even if there is no depression or anxiety, my patients with dementia may be more irritable, hostile, argumentative, disinhibited, or even more withdrawn, disinterested or quiet.

“Has he/she been doing anything just odd, or weird lately?”  My patients may start hoarding things or eating strangely (e.g. cereal for every meal). or touching strangers.

Weird, yes. But I kinda like it!
Weird, yes. But I kinda like it!

There are also some questions I ask my patients directly, and these can very quickly determine whether there is high risk for an “organic” or neurologic problem.

“Tell me what medicines you are taking.”  I look for my patient to just be able to tell me what the medicines are FOR, not names or doses.  Often persons with dementia fail to remember many medications or do not recall what they are for.

“Tell me what’s been going on in the news lately? What are people talking about?”  This is the great equalizer: everyone has something to say, whether it is a CEO who reads the Wall St. Journal, or a homemaker in a farming town who sees her friends at the local hairdresser.   My patients with dementia will often say, “I don’t watch the news,” or “I don’t know–it’s all bad.”  I look for them to be able to name a couple of recent events, and these can be local or national or international stories.

“Are you worried about these problems, or do you think everyone is making a mountain out of a molehill?”  Alzheimer’s dementia is commonly associated with a neurological (not psychological) lack of awareness of deficit: patients are convinced there is nothing wrong and strenuously deny cognitive problems.  Or they may admit to some minor problems but attribute it all to getting older.

A final comment is the adage that “normal aging is…..normal.”  There are some normal changes in thinking skills as we age, but things like rapid forgetting, loss of independence due to confusion, difficulty using appliances, and hallucinations, among other signs, are not at all part of normal aging and should be evaluated.

 

CTE and Domestic Violence: Reason Is Conspicuously Absent

Today’s headline was stark: Boston University researchers have found a link between traumatic brain injury and domestic violence. Temporal lobe lesions were reported in retired football players, which researchers speculated explains players’ aggressive behavior towards family members.  This perfect storm of NFL crises has been labeled “the dream meme,” referring to the explosive and headline-making nature of the problems.

The anterior temporal lobe is the suspect region, according to advance press from the HBO “Real Sports” segment airing tonight.  The anterior temporal lobe is a pretty complex area of the brain, important for memory, social behavior and semantic processing.

See this link for more: http://www.jneurosci.org/content/33/10/4213.full

And this one: http://braincoretherapy.com/wp-content/uploads/2014/01/Wong.pdf

These are both great articles on temporal/anterior temporal functions and anatomy.

But there is more to the story.

What's missing? Discussion of non-CTE factors and other correlates of tau...
What’s missing? Discussion of non-CTE factors and other correlates of tau…

 

First, tau deposition is not specific to traumatic brain injury or concussion.  It can be seen in neurodegenerative disease, psychiatric illness, substance abuse, and even normal aging.  There are people with reported CTE-like findings who never sustained concussion,  persons with multiple concussions who do not exhibit the pathology or symptoms of CTE, and the majority of retired NFL players do not show evidence of brain damage (see the Casson et al article below for a recent study).

The definition of the CTE disease entity itself is evolving and not entirely clear.   The symptoms listed under “CTE” are so broad and nonspecific that any number of unrelated neurologic and psychiatric  conditions would meet the criteria.

And perhaps most importantly from a neuropsychological perspective, there is no dearth of factors that can explain the behavior noted by CTE researchers, such as mental illness, drug use (including steroids),alcohol use and dementia.  Paul Oliver, the former San Diego Chargers player who tragically committed suicide at such a young age, was described by family at the time of his death as depressed over his release from the team, but today’s new story quotes as leading researcher as saying, “These guys used to be fine. They were entirely reasonable at all times of day,” presumably until CTE led to behavior changes.  There is a conspicuous absence of potential non-CTE contributing factors in the media coverage–and even in the BU research.

Finally, traumatic brain injury is not a progressive condition.  The endlessly variable combination of biomechanical forces, insult to brain tissue, neurotransmitter changes and cellular response are sometimes followed by secondary  processes like increased brain pressure, fluid collection, infection or ischemia, but these all generally take place at the time of injury or soon afterward–not months and years later.  The idea that CTE is the progressive expression of discrete events goes against what we know about the course of recovery from traumatic brain injury.

So for now, take the media hype with a grain of salt.  In my opinion, more deserving of media attention are the patients who have sustained documented severe TBI with profound permanent consequences.  They have invisible wounds that effectively destroy their lives and the lives of their loved ones, with little social understanding of their disabilities.  And in many cases, the resources available to them are woefully inadequate.

References:

http://www.nydailynews.com/sports/football/study-cte-linked-domestic-violence-article-1.1978936

Casson, I, Viano, D., Haacke, E., Kou, Z, LeStrange, D Is there chronic brain damage in retired NFL players? Sports Health, 2014 Sept 6(5).

Karantzoulis, S, Randolph, C Modern CTE in retired athletes: What is the evidence? Neuropsychol Rev 2013, Dec 23(4).

Solomon, G, Zuckerman, S CTE in professional sports: Retrospective and prospective views.  Brain Injury 2014 Oct 14: 1-7.

 

Does Social Media Change Your Brain/Make You An Addict/Cause Dementia/Cure Dementia?

What could possibly go wrong?
What could possibly go wrong?

The American Academy of Clinical Neuropsychology (AACN) has its own Facebook page, which is ironic since I wrote a short comment on social media and the brain for the AACN page, coming soon to:

https://www.facebook.com/AmericanAcademyofClinicalNeuropsychology/timeline?ref=page_internal

A number of websites have recently posted articles on the impending doom that awaits us due to society’s use of social media and the Internet (see several listed below).  When two popular social issues collide –mental health and social media—there’s a journalistic feeding frenzy. And frankly, at the rate new studies on brain functioning come out, there’s a constant stream of comment-worthy neuroscience news to follow.

A good headline is a must.
A good headline is a must.

The recent Huffington Post story listed five ways our use of Internet and social media is “changing the brain:”

  • Gamers show behaviors similar to gambling/drug addicts;
  • Facebook makes you depressed;
  • Teens who spend a lot of time on the internet are at greater risk for self-harm;
  • Information processing is negatively impacted by Internet use…
  • Or is cognitive processing improved with Internet stimulation?

Reasonable cautions for interpretation of such research are as follows:

Video games are no more fine-tuned to create addiction than other addictive products, like gambling, alcohol and smoking; proneness to addictive behavior is not a new phenomenon.  There are no ill effects associated with supervised, limited use of video games in situations where there is not already a great deal of psychological disturbance, and in fact some studies have suggested there are cognitive benefits.  This applies to Internet use more broadly as well: excessive use has been associated with problems, while structured, targeted use may improve skills–at least temporarily, within the narrow range of the specific task being practiced.

As for Facebook, people with heavier use of social media, or the Internet in general, may report greater unhappiness and loneliness.  But spending more time online may reflect life circumstances and stressors that result in one’s withdrawal, not the other way around.  Furthermore, there are plenty of studies that do not support the theory that social media use increases loneliness.

In research, an oft-repeated mantra is “correlation does not imply causation.”  Read Nate Silver’s “The Signal and the Noise;” he describes seasonal increases in ice cream sales and forest fires as an example: there is a correlation, but buying ice cream certainly does not trigger fires.silver

As for the Facebook study detailed in Time magazine,  it shows that intense Facebook users show greater activity in an area of the brain that processes social reward.  There is a correlation: it does not mean Facebook use changes brains or induces addiction.  More simply: what came first, the chicken or the egg?  Anyway, the wickedly smart “Neuroskeptic” blog on discovermagazine.com  notes that everything changes brain activity (reading, thinking, walking, smelling, seeing, etc.). The question is whether something changes brain activity or structure longer-term, or permanently.

The interesting aspect of the Facebook “addiction” study is the point that intermittent reinforcement strengthens behaviors.  An intermittent schedule of reward increases the likelihood of that behavior, and make it harder to extinguish.  Think of children who escalate tantrums, knowing that if they flail wildly enough, the parent will eventually be mortified or exhausted enough to relent and allow the desired reward.

scream-cartoon-painting

So people who get Facebook ‘likes’ may well respond with more Facebook activity to gain more ‘likes’ or social reward, especially if they are “reward-dependent”  types to begin with.  Intermittent reinforcement is not only about addictive or pathological behavior: it’s also an important aspect of risk-taking and decision-making in our everyday lives.  After all, not everyone can be like Dr. Spock (“All I know is logic”).

spock

For the record, I think a very valid question is whether or how ubiquitous use of Internet and smartphone technology will eventually affect our hardwiring as human beings.  For instance, people now video events routinely: your child skateboarding, a famous person walking by, heavy rain, you name it.   So, not only is there a division of attentional resources (making sure your camera is working right, versus focusing on the actions at hand), but there is potentially an emotional disconnect: are you less invested in being ‘in the moment’ if you know events are being recorded for instant and constant review?   And if so, how does this impact the complex system we’ve evolved for encoding/retrieval of new information?  No way to answer that for now.

Another example: anyone but me love the movie “Strange Days” with Ralph Fiennes?  A neat part of the futurist movie involves the black market sale of recorded events in which the viewer can immerse himself, for a real-time, visceral experience (e.g., running on the beach, or naughtier things).  One point was that memories are supposed to fade; human beings can’t evolve if they are trapped in a loop of reliving the past.  Well, now that we can keep a video record of the minutiae of our lives using smartphones, is there a knock-on effect?  And if so, is it an individual effect, temporary?  Or over generations will it become the norm, so that humans allocate less neuronal energy for encoding or retrieval, and more for simultaneous processing?

References:

http://healthland.time.com/2013/08/31/this-is-your-brain-on-facebook/

http://www.huffingtonpost.com/2013/10/30/shocking-ways-internet-rewires-brain_n_4136942.html

http://www.ncbi.nlm.nih.gov/pubmed/24399164

http://www.ncbi.nlm.nih.gov/pubmed/22937167

http://www.ncbi.nlm.nih.gov/pubmed/25221117

http://www.ncbi.nlm.nih.gov/pubmed/25215212