Wednesday, 18 December 2013

Better late than never?

My apologies for not maintaining this blog over 2013, I have been out of action after being diagnosed with stage II breast cancer in January. My treatment for that is now over, and I hope to have a much better year in 2014.

I'd like to share some disparate articles that appeal to my appreciation of the late Douglas Adams's theory of the " fundamental interconnectedness of all things", as expressed through his Hitckhikers Guide to the Galaxy, and Dirk Gently Holistic Detective Agency books. Of course, he may not have invented the theory, but his books were where I first encountered and enjoyed it. 

I've encountered these articles in my year off from neuropsychology, where focussing on my personal health and family has been a priority, and which has led to wide and diverse reading on a number of topics. I'm sharing them in the hope that you'll also be encouraged by some good news about treatments for conditions that we previously thought were incurable or unstoppable.

Firstly, have a look at this story from New Scientist, which talks about links between  Type II diabetes and Alzheimer's.

If we could only prevent Alzheimer's (and other diseases) in the first place, wouldn't that be great?

This page suggests that it may be possible

If you go to the home page for the ketogenic diet resource above,  you'll see a lot more about the ketogenic diet, and how it may help with childhood epilepsy, alzheimers, cancer... Well, nearly everything (which makes us scientists rightfully skeptical). If you don't  like the above page, then this article gives an overview of what seems to be a growing trend in dietary thinking

Sounds like it could be less harmful than the "healthy food pyramid" promoted since the 1970s which has seen an enormous increase in the incidence of obesity and diabetes. And we get to enjoy butter and cream again, and ditch the polyunsaturated oils... All with a view to decreasing inflammation in our cells.

A quote from Wikipedia about ketogenic diets may be of interest to neuropsychologists:
"There is some evidence that adults with epilepsy may benefit from the diet, and that a less strict regime, such as a modified Atkins diet, is similarly effective.[1] Clinical trials and studies in animal models suggest that ketogenic diets provide neuroprotective and disease-modifying benefits for a number of adult neurodegenerative disorders.[5][6] As of 2012, there is limited clinical trial data in these areas, and, outside of paediatric epilepsy, use of the ketogenic diet remains at the research stage.[7][8][9]

Of course, you can look it up on wiki yourselves, I don't want to make it too easy for you.

Finally, if our epilepsy or alzheimer patients, or people with cancer can be helped with dietary changes, there is great news on a treatment for the most aggressive brain tumours, Grade IV gliomas, or GBMs.

A letter and an article appeared  in September, showing remarkable improvements in median survival times and long-term outcomes for GBM patients given Valcyclovir, a drug used to treat cytomegalovirus, a common virus thought to be implicated in the development of GBMs, and found in many adults. The background to the research is here

The letter to the NEJM is here

And this is the abstract of the article.

Int J Cancer. 2013 Sep 1;133(5):1204-13. doi: 10.1002/ijc.28111. Epub 2013 Mar 13.

Effects of valganciclovir as an add-on therapy in patients with cytomegalovirus-positive glioblastoma: a randomized, double-blind, hypothesis-generating study.

Department of Neurology, Karolinska University Hospital, Sweden.
Cytomegalovirus is highly prevalent in glioblastomas. In 2006, we initiated a randomized, double-blind, placebo-controlled, hypothesis-generating study to examine the safety and potential efficacy of Valganciclovir as an add-on therapy for glioblastoma. Forty-two glioblastoma patients were randomized in double-blind fashion to receive Valganciclovir or placebo in addition to standard therapy for 6 months. Magnetic resonance images were obtained before and immediately and 3 and 6 months after surgery to evaluate treatment efficacy by measuring contrast enhancing tumor volume (primary end point). Survival data were analyzed for patients and controls in explorative analyses to aid the design of future randomized trials. Trends but no significant differences were observed in tumor volumes in Valganciclovir and placebo patients at 3 (3.58 vs. 7.44 cm3, respectively, p = 0.2881) and 6 (3.31 vs. 13.75 cm3, p = 0.2120) months. Median overall survival (OS) was similar in both groups (17.9 vs. 17.4 months, p = 0.430). Patients could take Valganciclovir for compassionate use after the study phase. Explorative analyses showed an OS of 24.1 months (95% CI, 17.4-40.3) in patients receiving >6 months of Valganciclovir (Val > 6M) versus 13.1 months (95% CI, 7.9-17.7, p < 0.0001) in patients receiving Valganciclovir for 0 or <6 months, and 13.7 months (95% CI, 6.9-17.3, p = 0.0031) in contemporary controls. OS at 4 years was 27.3% in Val>6M patients versus 5.9% in controls (p = 0.0466). Prolonged OS in Val>6M patients suggest that future randomized trials are warranted and should evaluate whether continuous antiviral treatment can improve outcome in glioblastoma patients.

These are fantastic improvements in outcomes, and I hope it is borne out by further research. From reading the cancer forums, some oncologists are already prescribing Valcyte to GBM patients on the basis of this research, and the drug company may provide the drug at cost on compassionate grounds.

 I know that giving specific advice on diet is outside our area of expertise, but would it do harm to encourage our patients or their carers to be proactive in researching all lifestyle options available to them, in consultation with their doctor(s)?

If only we could also get a global consensus on halting climate change...

Wishing you all a restful and happy holiday season, and hoping to be back on deck in some capacity next year. 

Best wishes


Thursday, 13 December 2012

Useful neuropsychology texts

A list of my favourite neuropsychology text books -  the ones that are good to own are marked **. The others are worth borrowing from a library and studying if your budget doesn't stretch to buying them.

Guide to Adult Neuropsychological Diagnosis
I love this 1998 text for a clear guide to differentiating focal neuropsychological syndromes. **
Great for understanding the neuropsychological aspects of medical disorders (2010) **

Cover Graphic
Lots of great chapters in this text on a wide range of topics, with handy suggestions for interventions **
Front Cover
(2003) Great for neuropsychologists who are fascinated by Bayesian analyses and statistics. Good for others to consider as well. From the preface: "Considerable controversy exists between and within factions of neuropsychologists who hold any number of circumscribed views that they often attribute to the superiority of one training model over another. Difference include the number of tests to administer, which among the many available tests should be administered, and how administered tests should be interpreted. Some argue for a purely quantitative analysis where tests scores are compared against established standards. Others demand inclusion of qualitative measures, such as a patient's approach to the test or the way a patient constructs a drawing. Both approaches demonstrate merit. both present limitations. Common to each approach is a reliance on the scientific method for the formation and testing of hypotheses. This work explores scientific methods common to neuropsychological approaches for establishing diagnosis and predicting future or prior performances. Particular emphasis is placed on statistical methods that are readily available to clinical practitioners." (p. vii)
Rehabilitation of Neuropsychological Disorders
Nice online resources supplement this practical volume **        
The Little Black Book of Neuropsychology: A Syndrome-based Approach
Not little, but plenty of helpful content, and recent (2011). **                                      
Front Cover
Another worthwhile book that considers important issues of ecological validity       
Collaborative Therapeutic Neuropsychological Assessment
A guide to making neuropsychological assessment a therapeutic endeavour, particularly useful for those who aren't entirely comfortable with giving feedback.  
Evidence of Absence: A Guide to Cognitive Assessment in Australia
An Australian book to finish off with. Eloquent, amusing, and informative, with an excellent chapter at the end about  six not-so-easy clinical dilemmas. Thanks Simon! **

Tuesday, 27 November 2012

Why bother testing?

Neuropsychologists hopefully agree that formal testing of cognition is the best way to know if cognitive impairment is present. We also hopefully agree that intuitive speculations based on interview alone aren't very reliable, especially in cases of subtle impairment. I imagine that we have all, on one occasion or another, assumed someone was reasonably okay on the basis of the interview, only to find the opposite on testing. 

I've recently been disturbed to hear that some neuropsychologists think formal testing of mood isn't necessary, that the sensitivity and specificity of our tests aren't as important as our intuitions, that the best way to determine mood is simply by asking the patient how they feel, and not worrying about complicated tests of mood.

The following article from Medscape shows that neurologists aren't very good at detecting depression and cognitive impairment compared to how well it is detected by using formal measures of mood and cognition. By inference, that probably applies to our profession as well. This shouldn't be news to anyone.

Medscape from WebMD - Email This
A link to the following Medscape article was sent to you by: Fiona Bardenhagen
Neurologists' Diagnostic Accuracy of Depression and Cognitive Problems in Patients With Parkinsonism
BMC Neurology, 2012-06-15
I'm sad that this article needs to be shared, it's probably not the best reference to remind us of the science behind psychology. 

However, I'm posting it because it came today, after an uplifting conference, and because it's important to remember that we are psychologists, and that the thing that distinguishes us from neurologists, psychiatrists, and all other professions who deal with the brain is our training in psychological assessment, test theory, psychometrics, biases, validity, reliability, sensitivity, specificity, and our knowledge that behaviour can be measured in a meaningful way. That we can measure states and traits that people deny or are unaware of through our techniques. And that we can combine this scientific study of mood, behaviour, and cognition with a holistic appreciation of the individual patient that we have gained through our careful interviews and history-taking with the patient and informants. 

As someone who appreciates the science of our profession, I don't say that we should discount our clinical skills and intuitions. I believe we should be aware of where they come from - are they based on biases, hunches, hermeneutics, clinician's illusions, or are they based on careful the study and application of  evidence over time? If we come to an intuitive conclusion about someone, it's probably a good idea to examine the reasons for and against that conclusion, so that we're not led astray by unscientific assumptions. (See Kahneman's book on decision-making, mentioned on this blog, for the evidence behind my belief.) And it's probably a good idea to include some brief, formal measure of mood for every patient you see, just to be more sure that they are not minimising how they feel when you ask them. 

yours in patient-centered care (sounds cheesy, but that's what this is about)

Sunday, 14 October 2012

Multiple chronic diseases

Most neuropsychologists have encountered the difficulties in differential diagnosis for patients with complex comorbidities and chronic disease. There can be so many things that may contributing to cognitive dysfunction that it's hard to pin it down on one cause.  This article talks about how people with multiple chronic conditions suffer from our fragmented and highly specialised medical system, where cardiologists, rheumatologists, neurologists, endocrinologists, and other specialists are great at the disorders they treat, but find it harder to provide integrated care to people with multiple conditions.

I like the idea at the end of the article, of "comprehensive care physicians" who work in hospitals to coordinate care between different specialists. Good physicians do this already, of course, but it's not an easy task, and the information obtained doesn't always filter down to the multidisciplinary team (MDT) who are looking after the patient during their hospital admission. Better communication and documentation of coordinated interdisciplinary care would make a big difference to people with multiple conditions, and I fantasise that ehealth records may make this easier. Though it would be even better if clinicians could pose questions to each other about patient care, to clarify any scenarios not included in the reports included in the patient file.

My hospital has recently opened an Integrated Care Service, and I'm engaged in preliminary discussions about how we can get a interdisciplinary MDT set up to provide services to people with neuro disorders, irrespective of their aetiology - while fragmentation into disease types might work in large cities with no workforce problems, in regional areas, we can't afford to be picky about which patients they see. Health professionals with competencies in neuroscience are scarce, and we need to work together for the betterment of all patients. Well, that's the fantasy, anyway. Funding is still directed to whichever disease has the strongest lobby group, but we'll try to be creative...Memory groups and cognitive skills training groups are one way ahead, and I'm grateful to colleagues like Sharon Naismith, Laurie Miller, Dana Wong and Glynda Kinsella for the research they've shared about the benefits of interventions for people with brain disorders or early cognitive changes.

Thursday, 4 October 2012

Lobbying for neuropsychology funding

I was invited to write an article about neuropsychology and dementia funding for Hospitals and Aged Care Magazine a couple of months ago. The article is viewable here:

Why dementia funding must include neuropsychological assessments.

I hope that those of you with more sophisticated publication track records, and high standards for neuropsychological articles, will forgive the casual, non-scholarly tone, and that you'll share it with people to help argue for why people with brain disorders need better access to publicly funded neuropsychological services in Australia. It's possible to "like" the article on Facebook, and to share it on LinkedIn and other networks.

We neuropsychologists need to think about how we can educate the media about the plight of our patients, and that we can get a groundswell behind us... to provide access to medically necessary neuropsychological   assessment, diagnostic, and intervention services.

Wednesday, 3 October 2012

Psychological assessments shown to be as valid as medical tests

My office spring-cleaning has revealed more useful resources: this time, a brief article from the APA Monitor on Psychology titled: Psychological assessments shown to be as valid as medical tests.

The article cites the 2001 report of the APA's Psychological Assessment Work Group, viewable as a pdf at

Although the article is now a decade old, it is still relevant today. Here's the first part of the abstract:

This article summarizes evidence and issues associated with psychological assessment. Data from more than 125 meta-analyses on test validity and 800 samples examining multimethod assessment suggest 4 general conclusions: (a) Psychological test validity is strong and compelling, (b) psychological test validity, is comparable to medical test validity, (c) distinct assessment methods provide unique sources of information, and (d) clinicians who rely exclusively on interviews are prone to incomplete understandings. 

Of course the strength of psychological assessments is nothing new to neuropsychologists, and this AACN position paper cites evidence about the utility of  neuropsychological assessments in diagnosing dementia (pp.10-11). However, it seems we need to get that information out to the broader public, including health advisors and policy-makers. For example, at the recent National Dementia Research Forum that I attended in Canberra, there was lots of information about biomarkers and diagnosis of dementia, but I didn't hear any speakers mention the empirically-demonstrated value of repeat neuropsychological assessments in the early diagnosis of dementia. In the Australian Institute of Health and Welfare report on Dementia in Australia, a search of the pdf available here found no mention of neuropsychology, except in the appendices or references.

We still don't have Medicare rebates for neuropsychological assessments in this country - which is a major barrier to early diagnosis of brain disorders across the lifespan.  I'm still hopeful that someone in the Medicare Benefits Office will take up our proposal (viewable here), and work out that a saving of $30,000 per patient with an early, neuropsychological-assisted diagnosis of dementia means that it is worth creating neuropsychology assessment, feedback and intervention Medicare items for all Australians with suspected brain dysfunction. This wouldn't be cost-shifting from State to Federal health systems, it would be creating better access to specialist psychological services for the thousands of people with brain conditions who cannot access them now.

The state health systems do not employ enough neuropsychologists to meet the demand for neuropsychological services. Our neuropsychology workforce is underutilized, with the majority of our neuropsychologists working in part-time jobs in the public sector,  because there aren't enough full-time positions. New graduates take on positions as research assistants or think of leaving the country because they feel pessimistic about ever getting full-time jobs. Ironically, it is hard to fill positions in South Australia or regional NSW or Victoria,  but even if new graduates took up those positions, there's probably not enough positions for the graduates, and there's definitely not enough neuropsychologists to provide the early diagnostic services needed by the estimated 1400 new cases of dementia each week in this country. Not to mention all the ABIs or other neurological conditions where cognition, behaviour, and emotion are affected.

If our clients could access Medicare, then every neuropsychologist who works in part-time public practice would be able to see one or two more patients per week: patients who aren't eligible for hospital-based services, and who can't afford to pay even the measley sum of $600 for a comprehensive assessment that takes the neuropsychologist 8 to 10 hours... Patients from rural, regional, and remote areas would be able to travel to see a neuropsychologist for an assessment if there's no service at their local hospital. Services would be available for urban dwellers who do not meet the intake criteria for hospital neuropsychology services (which often have prohibitively long outpatient waiting lists, if they have an outpatient service at all).

People with brain disorders miss out on access to the specialist psychological assessments they need to help with diagnosis and interventions, but people with mental health disorders can see psychologists for 10 or more hourly intervention sessions. Where is the equity in that???

The AACN position paper I mentioned above has a workable list of inclusion and exclusion criteria for neuropsychological services - neuropsychologists need to carefully screen referrals to ensure that we only see the patients where we can make an unique contribution, where no other professional can answer the referral questions. If we don't, we risk being swamped by inappropriate referrals, and we can focus on the patients who really need us to help shed the light of understanding and knowledge on their hitherto incomprehensible problems. We also need to debate amongst ourselves if neuropsychological assessment is necessary for every case of brain dysfunction - if someone has a confirmed diagnosis of MS or epilepsy, for example, we need to be able to argue why they need a neuropsychological assessment where education about the condition may suffice. Again, the AACN position paper sets out some good decision-rules for   rejecting referrals, for example, when

  • The patient has been diagnosed previously with brain dysfunction, and there is no expectation that the testing would impact the patient's medical management (p.5) 
Or for accepting referrals in cases of
  1. Deterioration in mental status or previous level of functioning, or 
  2. Onset of new abnormal neurological or psychiatric symptoms, or 
  3. Failure to adapt as expected to changing environmental conditions, or reasonable expectation that new symptoms or symptom exacerbation will occur as a result of changing environmental conditions. 
  4. In younger persons (children, adolescents, and young adults), an abnormally prolonged plateau in the course of normal development, suspected to be caused by central nervous system impairment. (p.6)
Our specialist skills are appreciated by neurologists, neurosurgeons, psychiatrists, geriatricians, paediatricians, and other medical specialists, it doesn't look like anyone is singing our praises loudly enough when it comes to government reports and health policy. Who would like to help?

Responding to perceived unethical practices in clinical neuropsychology

I found a great article while cleaning up my office this morning (patient files need to take priority over printed articles in my locked filing cabinets, until I can find an admin person who's willing to scan all my files for electronic storage!)

The article  by Chris Grote, Jeff Lewin, Jerry Sweet, and Wilfred van Gorp was published in The Clinical Neuropsychologist in 2000, and you can find a link to the first page here: Taylor & Francis Online :: COURTING THE CLINICIAN Responses to Perceived Unethical Practices in Clinical Neuropsychology: Ethical and Legal Considerations - The Clinical Neuropsychologist - Volume 14, Issue 1. **

In searching for the link, I came across this second article, which elaborates on ethical issues involved in the practice of forensic neuropsychology. You can access the full text of the second article here Grote & Parsons (2005): Avoiding ethical misconduct

While these articles are not very recent, they address issues that often concern neuropsychologists who see "neuropsychological" reports written by other psychologists that appear to fall below the standards of the profession, or which do not seem to be supported by scientific literature or test data (among other things).

Knowing what to do in these situations is difficult, and these two articles help clarify the ethical issues involved, and various ways to respond to these issues.

I'd like to see a push to restrict usage of the term "neuropsychological assessment" and "neuropsychological report" to qualified neuropsychologists only. The tests we used can be used by any psychologist, but to interpret them neuropsychologically requires specialist training and experience in the science of neuropsychology. In the words of JK Rowling: "it's not the wand that makes the wizard, it's the wizard that makes the wand". Our tests aren't magical by themselves, it's our specialist knowledge and understanding of the complex interplay of biopsychosocial, neurological, psychometric, neuropsychological factors, and individual differences that allow neuropsychologists to do neuropsychological assessments. Any other psychologist using our tests is just doing a test of cognition, intelligence, or memory. Unless they study neuropsychology at an advanced level, they simply don't know what they don't know about the brain, cognition, and behaviour.

**If you're a member of the APS, you should be able to access the full text with the APS-sponsored EBSCOhost service. Otherwise, if you don't have institutional access to this journal on-line, you could join the AACN as an affiliate member for USD100 and get a free subscription to TCN (including online access to back issues). This will also get you onto the excellent AACN listserve - see for more details.