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)
Fiona

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 http://drrobertcochrane.com/files/amp562128.pdf

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 https://www.theaacn.org/AffiliateMembership.aspx for more details.

Tuesday 4 September 2012

House of Representatives Committees – Parliament of Australia

This page provides transcripts of all the hearings held for the Dementia Inquiry to date. House of Representatives Committees – Parliament of Australia The Canberra hearing gives an interesting account of how referrals to the Victorian CDAMS services have changed over the past 10 years, with the average MMSE score rising from 20 to 24.5 in at time, and 60% of referrals to one clinic needing neuropsychological assessment. It seems that having a free service is resulting in people being diagnosed earlier, and the average cost per patient for assessment is $1600. There is also a fantastic consumer testimony in favor of neuropsychology from the July 27th hearing in Launceston, an interesting view on NPH from a geriatrician on the same day, and my own evidence, in which I tried not to get too sidetracked by the committee's obvious interest in our field. I would appreciate advice on what an ideal dementia service would look like from our perspective, as I wasn't expecting the questions they asked about that. If I could do that part again, I would say that direct referral to a diagnostic service would be good, as GPs won't always take family concerns seriously. I have lots of admiration for GPs, but it's hard for them to spot every problem in brief consultations. So what would you suggest? Would we improve on the CDAMS model and put some long-term followup in place? What else could we recommend?

Out of the shadows – Parliament of Australia

A promising commentary on the Inquiry into dementia: early diagnosis and interventions Out of the shadows – Parliament of Australia

Friday 3 August 2012

Clinical Neuropsychology Conference

After months of preparation, I'm pleased to announce the program for our 18th annual APS College of Clinical Neuropsychologists Conference.

The committee is delighted with the quality, range and diversity of presentations.

You can see the program at the conference blog http://ccn2012.blogspot.com

Sunday 29 July 2012

Thinking, fast and slow

I've found a wonderful recent book by Nobel-prize winner and experimental psychologist Daniel Kahneman which summarises his work on cognitive biases, judgement, heuristics, and basically how we come to conclusions. You can see the Amazon listing here.




I ripped through the first three chapters on the plane from Melbourne to Launceston last night, and was excited to think that my nerdy interest in these things is shared by enough people to have made this book a best-seller. There's a summary of the book at this wikipedia site.

The thing that's new to me - even though I've read lots of articles on decision-making in neuropsychology and psychology by Paul Meehl, David Faust, and Howard Garb - is the division of thinking styles into System 1 and System 2. System 1 is the more automatic, intuitive, rapid, frequent, and stereotypic style of thinking that relies on our memories, knowledge, and, I imagine, procedural knowledge to form decisions about the world. System 2 is more slow and effortful, requires more mental effort, and is used for tasks that require logic and calculations. Not surprisingly, people tend to naturally use System 1 more easily than System 2, as System 2 is a whole lot more work. In my reading before this, System 1 was the area of clinical judgements and intuition, and System 2 was characterised by the much-maligned actuarial mode of analysing data.

The idea of these systems explains to me why there has been so much resistance by clinicians to research that says we will be more accurate diagnosticians if we rely on Bayesian analyses and prior probabilities than if we rely on our clinical intuitions, which are based on error-prone stereotypes, heuristics, and pattern recognition. That is, the work of Meehl, Faust, and Garb was strongly resisted by clinicians in the early days because it says we need to activate the energy-draining System 2 more often.

While the resistance has weakened, I still hear people argue that their clinical judgement is pretty darned good, and that the client is lost in focussing on the test data in a sophisticated psychometric way. I've always thought we need to use both clinical (intuitive) judgement and actuarial knowledge in making decisions - to say we should only be clinicians or psychometricians is throwing out the baby with the bathwater. Kahneman agrees that System 1 is excellent at some things, but his book demonstrates that learning about decision errors can help us to engage System 2 to overcome these errors that System 1 evokes - illustrated with examples from optical illusions, making financial choices, and probabilistic thinking. 

If you'd like to know the things you don't know, if knowing how to reduce your cognitive errors and biases so that you can be a better objective scientist-practitioner, if you want to be the best neuropsychologist you can be, then this book is definitely worth it. And its best-seller status means that it might just give us a link to people who are as mystified by the brain as I am by economics and business - see a review of the book by an economist here.


Saturday 28 July 2012

Imagining the future: Neuropsychology 3.0

I found this amazing article in my office the other day - and had the time to read it on the plane. It maps out some potential directions for neuropsychology, and give links to some resources that will probably consume many happy hours of our time.

You can see the free full-text article here.
- or paste this into your browser if the link above doesn't work: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3044645/

The net is giving us unprecedented ability to share and develop resources - this could see us develop national norms for neuropsychological data, and help us to improve our practices and knowledge more rapidly than before.

An article worth reading a few times. Thanks, Bob Bilder!

Practice resources: Neuropsychology in primary care

I'm delighted to share this article with everyone - it's a nice, clear description of how neuropsychologists can help in a primary care setting, but it's so good, I'm going to make it available on my open-access neuropsychology directory at my hospital. It has some practical suggestions about what we can do, and some nice algorithms for capacity assessments, TBI, and other conditions.
Excellent reading, and a useful resource :)

Monday 23 July 2012

Neuroethics

The articles in the latest edition of this journal look fascinating!

I wish there was enough time to read everything I wanted to...

Follow this link to the editorial, titled The Ethics of Neuroeducation: Research, Practice and Policy  


Wednesday 4 July 2012

Transcripts of Inquiry into Dementia: Early Detection and Interventions


You may be interested in reading the transcripts of the three hearings held so far in the Parliamentary Inquiry into Dementia: Early Diagnosis and Intervention.


A quick search of the Adelaide hearing returned no matches for the search term "neuropsychol", the Sydney hearing mentioned it once, but we were very well-represented by David Stokes at the Melbourne hearing, with his APS colleagues Leah Collins and Li Bo making some good points (see page 17 of the Melbourne transcript). 

The final part of the transcript, with Dr Jenny Torr, an psychiatrist who specialises in intellectual disability, shows an area of need for neuropsychological services, and concerns about people with brain damage and intellectual disability falling through the cracks in the system.

It's so frustrating that we don't have more neuropsychology courses in this country, and that it's so hard to access our services for many of the people who need us. In the US, there has been a massive increase in the proportion of medicolegal work done by neuropsychologists, and in Australia, the best-paid neuropsychologists in private practice do medicolegal or insurance work. This kind of work would rarely result in the early detection of dementia. People with progressive neurological conditions often miss out on early diagnosis and intervention, unless they're lucky enough to be able to access a neuropsychologist in the public system, or afford a private assessment. 

I'm hopeful that raising awareness of the role of neuropsychology in early diagnosis of dementia will help bring about improvements in access to neuropsychologists by people in need, and in scholarships and increased support for training of neuropsychologists.

Thanks to David Stokes and the APS team for advocating for the role of neuropsychologists in early diagnosis.

happy reading!


Monday 25 June 2012

Neuropsychology classics I: Frontal lobology


This paper is a classic to me. It came out in 1992, and apart from being amusing, it immediately struck a chord in my fledgling neuropsychological mind. In it, Anthony David states that  "The frontal lobes constitute approximately one-third of the brain. Therefore, localising a disturbance to this region is rather like a person directing a visitor to an address marked 'Europe.'"


You can read this succinct paper here:
http://bjp.rcpsych.org/content/161/2/244.full.pdf


Reading it again, 20 years on, there are still valid arguments for describing what we mean when we see "frontal" or "executive" dysfunction. Is it poor planning and organization, disinhibition, emotional control, self-monitoring, or any one of a number of behaviours that have come to be synonymous with frontal dysfunction? What is more helpful to understanding a patient - the label of frontal impairment or dysexecutive syndrome, or a clear and individualised description of the actual problems the person is encountering?




Sunday 24 June 2012

Neuropsych practice resources II: Consumer-focused psychological assessment

Another favourite article for the reflective neuropsychologist who wants to provide excellent services. Thanks, Eliot Brenner!



Consumer-focused psychological assessment.
By Brenner, Eliot
Professional Psychology: Research and Practice, Vol 34(3), Jun 2003, 240-247.
Abstract
To enhance the clinical utility of psychological assessments, the author recommends a consumer-focused approach to health care marketing--the "Four Rs": relevance, response, relationships, and results (J. English, 2000). Research suggests 5 responses psychologists can take to increase the relevance of psychological assessments: (a) eliminate jargon, (b) focus on referral questions, (c) individualize assessment reports, (d) emphasize client strengths, and (e) write concrete recommendations. To build relationships with consumers, psychologists should collaborate with them when formulating referral questions and providing feedback of assessment results. Finally, psychologists should use the results of consumer satisfaction studies to improve the clinical utility of psychological assessments. (PsycINFO Database Record (c) 2012 APA, all rights reserved)



Neuropsych practice resources I: Survival tips for neuropsychologists in inpatient rehab settings.


In the coming months, I hope to share some of my favourite practice articles. 
This first one is worth obtaining for those working in multidisciplinary teams, or for neuropsychologists setting up a new service in an existing health service - whether rehabilitation or not. It talks about the importance of developing relationships with the other team members, and for different ways to demonstrate what you can do as a neuropsychologist. Thanks to Kelly Blair and Patrick Gorman for writing this piece back in 2003. It's still relevant today!
Survival Tips for the Neuropsychologist in an Inpatient Rehabilitation Setting.
By Blair, Kelly L.; Gorman, Patrick W.
Rehabilitation Psychology, Vol 48(4), Nov 2003, 310-313.
Abstract
Objective: To assist neuropsychologists in adapting productively to the unique culture of the inpatient physical rehabilitation setting. Specific Aims: Identify potential problem areas in accommodating neuropsychological presence and practice in this environment, highlight steps to a more constructive adjustment to this unique clinical milieu, and identify predictable pitfalls if these adjustments are not made. Conclusion: Neuropsychologists who understand this culture and can speak the language of the physical rehabilitation setting have much to offer the patients, their families, and the other treating professionals. (PsycINFO Database Record (c) 2012 APA, all rights reserved)


If you're a member of the Australian Psychological Society, remember that you can use the  EBSCO host service to access articles. The link to the service is:




Wednesday 23 May 2012

Brain injury and sexuality

The North American Brain Injury Society publication, Brain Injury Professional, has a wonderful issue dedicated to brain injury and sexuality.

http://issuu.com/bipmagazine/docs/bip22

The articles in this publication go beyond the usual neuropsychological preoccupation with how to deal with sexually disinhibited behaviours. As Tina Trudel, guest editor of the issue writes,  "Sexuality is a life affirming gift that enriches all of us. How we share love, experience passion and engage in sexual activity are unique, vital aspects of who we are. Brain injury rehabilitation seeks to support and empower each individual to reach their full human potential, a potential that rests on the cornerstones of our capacity to work and to love (not necessarily in that order...)." (p. 6).

The five articles in the issue talk about integrating sexuality in rehabilitation; disability and sexual expression (including lots of practical hints for different forms of cognitive and motor disability); promoting sexual health in adolecents with brain injury; sexual intimacy after brain injury; and behavioural interventions for sexual disinhibition after brain injury. Being comfortable and informed in discussing these issues with patients and their partners is an important, but often neglected part of clinical care.

The publication is highly recommended reading for all neuropsychologists who are interested in providing informed patient-centered care for their clients, whatever their age or disability.

Sports Concussion readings

This is a controversial and very current topic.

Thanks to Arthur Shores for providing these links to guidelines and resources on sports concussion:

http://www.sportconcussions.com/html/Zurich%20Statement.pdf

http://www.aan.com/globals/axon/assets/7913.pdf

http://www.slideshare.net/andrewcannon/nh-sport-concussion-advisory-council-consensus-statement-version-21

http://theconcussionblog.com/


There are also a couple of statements by neuropsychological groups in the US:



And the National Academy of Neuropsychology had a recent NAN Bulletin article about the issue

and a video and other resources at: 


There will be a meeting in Zurich later this year, to update the Zurich guidelines - but there's plenty of reading to do in the meantime!  

Australian House of Representatives Inquiry into Dementia: early diagnosis and detection

There are a number of fascinating submissions to this recent inquiry, viewable at:

http://www.aph.gov.au/Parliamentary_Business/Committees/House_of_Representatives_Committees?url=haa/dementia/subs.htm

It is interesting to see the number of submissions that promote a particular service or service model.
I haven't read all of them yet, but the model described by Professor Philip Morris (#4) sounds excellent, taking a rehabilitation approach to dementia care. The submission made by my colleagues at the community dementia team (#14) describes an initiative that has been beneficial in a community setting. The Tasmanian DHHS submission (#41) has some very sobering statistics for my home state, and the federal department of health submission (#89) is also sobering.

I like the practical recommendations made by the Victorian CDAMS submission (#39). The Victorian Office of the Public Advocate (#3) wrote an interesting submission in terms of decision-making capacity and dementia, and Professor Jillian Krill (#6) argued about the vital importance of correct diagnosis of dementia, if targeted treatments are going to become available. The practicalities of getting postmortem examinations on people with dementia are challenging, but we need to have the postmortem gold standard available to clarify the relationship between clinical symptoms and pathology if targeted pharmacological therapies are going to be developed.

The Australian Psychological Society wrote a good submission with the assistance of members of the College of Clinical Neuropsychologists (#50), and I contributed my own submission in the hope that there would be at least one neuropsychologist's voice heard by the enquiry (#46). My submission isn't perfect, but hopefully it will back up the poignant voices of the various consumers and carers who talked about the difficult time between development of symptoms and diagnosis.

In case I'm called to give evidence to the Inquiry, Any suggestions on succinct things I can say to demonstrate the efficacy of neuropsychologists in early diagnosis and interventions for dementia would be appreciated.

Tuesday 15 May 2012

Neuropsychologist self-care

I found a touching and useful article today.

It's by John O'Brien and is called Wounded Healer: Psychotherapist Grief Over a Client's Death
You'll find a link to the abstract and citation at http://psycnet.apa.org/journals/pro/42/3/236/

O'Brien concludes that "A psychologist's grief over a client's death can be especially difficult if the psychotherapy has triggered the psychologists' past and/or present grief. If these reactions are not appropriately managed, they can hamper and ultimately impair present and future clinical practice. If, on the other hand, we learn to manage our wounds, we can use these wounds to better serve our clients. Appropriate self-care and consultation with colleagues are essential components of providing ethical and effective care to those who are critically or terminally ill." (O'Brien, 2011, p. 242).

The Australian Psychological Society says that "As a profession we need to support ourselves and our colleagues to seek out preventative and early interventions and to de-stigmatize help-seeking behaviour." http://www.psychology.org.au/practitioner/resources/self-care/

I've had a look on the web for neuropsychologist self-care resources, and have only found articles about neuropsychologists assessing self-care abilities in others!!!

I suspect that self-care for neuropsychologists is somewhat different compared to psychologists engaged in psychotherapy. We deal with patients with devastating acquired injuries or incurable progressive diseases. The majority of us don't follow patients through with regular therapy sessions. We help provide answers to their questions, hopefully provide therapeutic feedback and recommendations, and then send them on their way, with a sense of satisfaction of having helped shed light and knowledge where there was uncertainty and anxiety.

But sometimes our personal lives raise issues that intersect with our professional roles, or we see patients who break through our defences, who affect us emotionally. So what are the strategies neuropsychologists use to care for themselves? Please use the comments box below!

Wednesday 2 May 2012

Why is neuropsychology important? A personal view.

I wrote the following words in 2009, but never shared them with more than a few friends. I'd like to post them here now.


My elder son’s Year One class is looking at occupations this term. On a big sheet of butcher’s paper on the wall of their room is a list of occupations generated by his class – nurse, doctor, builder, truck driver, farmer, princess, architect, soldier, celebrity – the usual, and not-so-usual interests of 6 and 7-year olds. Throughout the term, they’ll be adding as many occupations as they can, and my son has already added ‘neuropsychologist’. He had to get his teacher to write it out so that he could trace over top, but he has the definition down pat. “It’s someone who helps people with brain problems, Mum”.

I’m going to have a neuropsychology stand at my son’s school science night, and talk to the Year Ones about being a neuropsychologist, because I think it is incredibly important. In his insatiable appetite for bedtime stories, he’s begun to soak up stories about Broca and Tan, Karl Wernicke, and Phineas Gage and his tamping iron. He can even sing some neuroanatomy with the first verse of Pinky and the Brain’s brain song, (to the tune of ‘Campdown races’):

Neocortex, frontal lobe
brain stem, brain stem
hippocampus, neural node,
temporal lobe
cerebellum left
cerebellum right
synapse, hypothalamus,
striate and dendrite’


Though he still tends to sing ‘try and get it right’ for the last line.
(for the full animation, see http://www.youtube.com/watch?v=Li5nMsXg1Lk ).

Why is clinical neuropsychology so important in this time of global financial crises and climate change? And why am I talking about it to my son, and his class, and maybe some of their parents? It’s because neuropsychologists help people from all ages and walks of life, and because we have specialised knowledge and skills that help us to help others understand what is happening when someone’s brain isn’t “working properly.”

My recent personal experience has shown me just how important neuropsychological knowledge is, and how we can’t assume that our medical colleagues will necessarily understand things the way we do.

My father has only recently become well enough to return home from Victoria to Tasmania, after a planned 3-week stay in hospital for some checkups and reconditioning became a 3-month admission. Dad has a history of normal pressure hydrocephalus (first diagnosed and shunted in 2004, followed by a shunt revision in 2005), TIAs, and angina in 2007. He became increasingly irritable and lethargic over the last few months of 2008, often falling asleep in his armchair after breakfast, and his gait fluctuated widely. We brought him to Melbourne to be reviewed by his neurosurgeon, who felt that his NPH wasn’t contributing to the clinical deterioration. Then we had him seen by a cardiologist, who did an angiogram and discovered extensive coronary artery disease, which required 6 stents, inserted over two sessions.

Dad developed a delirium after the first angiogram, and declined further after transfer to a geriatric unit. He became disoriented to place and time, and developed mildly paranoid delusions, nocturnal agitation, and occasional visual hallucinations. I was struck by how distressing this was to my parents, and also to me, even though I knew what delirium was. Perhaps it was even more distressing to me because I was reading about management and prognosis in delirium, and because no-one could tell me why he’d declined, other than speculating on toxicity from the dye used in the angiography. While cognitive decline after CABG is well-known, especially in patients with compromised cerebral functioning beforehand, I couldn’t find much through my distressed search of the literature to suggest that a toxic reaction to angiography dye was a common reaction, and even his cardiologist was surprised. I felt that we had to fight to convince the staff that he’d suffered an acute decline in functioning from being independent, albeit mildly impaired, in January to needing maximal assistance with transfers and ADLs in February. It wasn’t until I found him staring and unresponsive in his chair one day that I felt they were beginning to take us seriously. His mobility declined to the point that a hoist was needed for transfers, his bed was lowered to the floor, and we had him returned to the private hospital under the care of neurologist. The neurologist changed some of Dad’s medications, to remove any that might lower his sodium, and restricted his fluid intake in order to address the hyponatremia that a registrar had thought was not serious enough to be treated. While sodium levels <120 with cerebral impairment is considered to be severe hyponatremia, the neurologist explained that levels below 130 in an elderly person can cause problems. Over the weeks, with an increase in sodium levels from 125 to 134 (just below the normal range), Dad improved enough to be transferred back to hospital in Tasmania, where he is getting regular visits from family and friends. Unfortunately, his sodium levels have continued to fluctuate, and it looks like it will take a long time for him to be well enough to return home.

Having been through all this has given me a concerning insight into how difficult it must be for lay people to negotiate the health system, and how a neuropsychological perspective can make a difference to a patient’s care and outcome, even without doing any formal testing. If I, as a neuropsychologist, felt that I struggled to be heard, and to have my father’s changed status recognised, how difficult must it be for people without my knowledge? Even the backup of my husband, a member of the medical fraternity, didn’t help me overcome the feeling that I was perceived by some members of Dad’s treatment team to be making an inordinate fuss about my father’s condition. I found myself wishing I could slip into the “grateful relative of patient” role, where it is comfortable and comforting to accept the wise advice of the medical staff, but I just couldn’t understand why he’d declined like that, and I couldn’t accept that it was a normal thing to happen to an elderly man. Just because delirium is common in elderly people doesn’t mean that it’s “normal.” I wanted someone to give me reasons for the changes that made sense, and I felt that I had to fight to have them understand that in three weeks, this wonderful, loving, kind man had gone from being oriented to place and independent in ADLs to being disoriented, visually hallucinating, somnolent, distressed, agitated, catherterized, occasionally inappropriate, impulsive, and needing assistance with everything. My father-in-law died last year, 3 years after a stroke that saw him put prematurely into a nursing home, because we trusted the medical opinion that he wouldn’t benefit from rehab. He wasn’t even given the chance to try. He languished, with increasing contractures, even on his unaffected side, because the physio thought he was a “lost cause.” Passive mobilization exercises from a private physio improved his contractures to the point that he was able to sit comfortably in the few weeks before he finally passed away. I wasn’t going to let that happen to Dad.

These experiences have taught me the vital importance of listening carefully to the patient and their families, and of not accepting glib explanations from overworked medical staff who do not necessarily have the time to listen, and then think, about what they are being told. If we hadn’t had Dad reviewed by the neurologist, he’d probably be in a nursing home, or worse, right now, and my heart would be broken. Being a neuropsychologist doesn’t save you from that, it seems.

Being a neuropsychologist does help you to step back and look at the big picture for each person you see – what is their background, their highest level of functioning, their most recent level of functioning? What was the onset and course of their condition? How are they now? What is their medical history, what are their medications, how are all these factors interacting to produce the current clinical issue?

Even without access to our tests, we are able to make a meaningful contribution to the care of patients, because of the way we’re trained to think, and to formulate an understanding of how medical, neurological, psychological, and social factors are contributing to a person’s condition. We may not directly “save” lives, but we can have a huge impact on quality of life. We can also help their families and caregivers understand and deal with their condition, and I know my recent experience is going to make me even more sensitive to how carers feel and are coping.

Disorientation and lack of insight are things encountered regularly in practice with elderly people, but I’d never really felt how distressing it can be to patients or family members since becoming a neuropsychologist. But if I remember way, way back, I remember being awed and bewildered as a child when a dear, elderly family friend spent her last few months in a hospital bed, asking for her Father to come back from the top paddock, wondering if Mother had cooked the scones yet, and only recognizing those she had known for more than 40 years. It was that sense of powerlessness and not understanding that drew me to neuropsychology, because I wanted to help people understand these incomprehensible tricks of the mind.

The contribution of clinical neuropsychologists to healthcare is unique – our training in neurological and psychiatric disorders, in neuroanatomy and cognitive psychology, in normal and abnormal cognitive development across the lifespan, in psychometrics and behavioural observation, and psychology in general, give us an ability to understand a person’s presentation that is not held by any other healthcare professional. There aren’t enough of us to meet the current demand, but there is a role for us in every aspect of acute and chronic healthcare, in prevention and diagnosis and treatment, in admission and discharge planning. We need more training programs and clinical placements in each state of Australia, we need more publicly funded services so that we can help the public. We need to educate the public, and politicians, about what we do. Clinical neuropsychology is important.

Fiona

PS Dad finally returned home after 6 months in hospital. It took 9 months of fluid restriction for his sodium levels to return to normal, and he was able to move around the home and participate in a quiet but fulfilling family and social life. He accompanied Mum to choir practice and started sharing his beautiful voice at choir functions - his renditions of 'As Time Goes By' and 'Night and Day' were gentle and relaxed, and music gave him pleasure up to the end. We moved back to Tasmania to be closer to him at the start of 2010, but I'll save that story for another time.

Saturday 21 April 2012

Neuropsychological Controversies

We're going to have a session on controversies in neuropsychology at our CCN conference this year - it's intended to give students and recent graduates who are immersed in contemporary neuropsychological literature the chance to talk about any contentious issues or important new information that they've identified (see http://ccn2012.blogspot.com for conference details).

So I was delighted to find this online publication this morning - with an issue titled Controversies in Neuropsychology

http://issuu.com/bipmagazine/docs/bip02/1

There's some wonderful reading there, for the neuropsychologist looking for something different from the usual peer-reviewed articles. I really enjoyed Lloyd Cripe's thoughtful article on the biases operating in the practice of medicolegal neuropsychology; and I'm looking forward to reading Paul Lees-Haley and David Fox on why forensic neuropsychology is controversial (some good recommendations in their final section); Graeme Senior and Lucille Douglas on the MMPI-2, Michael Martelli and colleagues on rehabilitation neuropsychology; D. Corydon Hammond on Neurofeedback; and Scott Howard's account of neuropsychology from the perspective of someone studying clinical psychology after a severe brain injury.

If you look through the other issues of Brain Injury Professional, there are some wonderful offerings. I'll save my next post for the issue on sexuality after brain injury.

PS my apologies for blog silence this year, my father passed away at 87 after a long struggle with normal pressure hydrocephalus, and while I haven't stopped reading, sharing has just taken a little more effort than before.

Saturday 21 January 2012

Neurogastroenterology?

Happy new year!
This is a fascinating article, about a field of study that I knew nothing about.

http://www.sott.net/articles/show/240405-The-Real-Butterfly-in-Your-Stomach-Scientists-Explore-the-Possibility-of-a-Second-Brain-in-Our-Gut"

It reminds me of an article I read about good nutrition improving behaviour in prison inmates in the UK http://bjp.rcpsych.org/content/181/1/22.full

All the more motivating to maintain those new year resolutions about a healthy diet for self and family...