Tele-Neurobehavior and Computerized Cognitive Tests

Tele-Neurobehavior

Telemedicine allows access to health care at a distance, including for people who live in remote places or who cannot easily travel to medical centers. Clinical visits via telephone or computer-based videoconferencing allow greater availability not only to routine medical care but also to neurological, psychiatric, neuropsychological, and other specialty evaluations. Patients need not travel to clinics only to linger in waiting rooms for brief in-person encounters with specialists or other clinicians. Moreover, with COVID-19 and other similar situations, telemedicine facilitates the maintenance of social distancing and, when necessary, isolation from others. In addition to direct communication via telephone, e-mail, or real-time “synchronous” videoconferencing, telemedicine includes “asynchronous” (store-and-forward) transmission of the patient’s prior medical information, laboratory findings, and neuroimaging. This section focuses on telephone and synchronous videoconferencing for mental status assessment before going on to discuss computerized cognitive testing.

Tele-neurobehavior involves the telephone or videoconferencing administration of the mental status tasks and mental status scales described in prior chapters. Some aspects of the mental status examination are more amenable to testing via telecommunications than others. Using telephone or videoconferencing, the mental status examiner can easily test mental control/attention, orientation, spoken language and speech, verbal memory and semantic knowledge, and visual stimuli recognition. The examination of constructional and spatial abilities, written calculations and related functions, and some executive operations require more planning and effort. Tele-neurobehavior also relies heavily on verbal responses from the patient, whereas, assessing visual, motor, or behavioral responses requires some modification of test administration. In summary, with some training and preparation, the examiner can perform a complete mental status examination via videoconferencing and much of it via telephone.

Despite its benefits, clinicians must first consider whether tele-neurobehavior for mental status assessment is appropriate for each patient. Most patients are comfortable with telephone encounters, and this continues to be an important choice, particularly for those who have visual or physical limitations that preclude videoconferencing. In addition, the elderly and those from lower educational and socioeconomic backgrounds may prefer telephone encounters because of a lack of familiarity, experience, comfort, or access to computers. Patients who are too cognitively impaired or disturbed may not be able to participate in either telephone encounters or videoconferencing.

After concluding a patient’s eligibility for tele-neurobehavior there are several preliminary recommendations before testing. The examiner should have an initial routine that includes an introduction of himself/herself (identity, credentials, institution) and a request for verification of the patient’s identity and location. The examiner needs to verify the patient’s telephone number, should they get disconnected or it is needed during either a videoconferencing or a telephone session. Explain the purpose of the encounter and that it is private, confidential, and not being recorded without permission. The examiner then obtains informed consent from the patient or the caregiver if the patient is unable to give proper consent. The consent can be electronic but should be included in the clinical note. Determine who else, if anyone, will be participating in the session, either on the examiner’s side, for example, other clinicians, trainees, therapists, or on the patient’s side, for example, caregivers, facilitators. The examiner must assure that the patient is comfortable with this. If caregivers participate, determine if speakerphone, conference call, or, if video, a linked-in participation is indicated. The examiner then administers the mental status tests and tasks simulating, as much as possible, a traditional in-person session. Beyond the application of mental status tasks and the neurobehavioral status examination, there are specific considerations involved in the use of individual mental status scales by telephone or videoconferencing.

MENTAL STATUS SCALES BY TELEPHONE ENCOUNTERS

Examiners have introduced a number of modifications of the Mini-Mental State Examination (MMSE) for administration over the telephone. A 22-item version of the MMSE administered as part of the Adult Lifestyles and Function Interview (ALFI) omits eight items of the original MMSE that require visual cues or assessment. The ALFI-MMSE specifically omits the three-step command, reading and written samples, the intersecting pentagons, the floor orientation, and one of the two naming items (changing the other to asking for the name of the object they are speaking into). A 26-item version, the Telephone MMSE (TMMSE), modifies the ALFI-MMSE, adding back a three-step command and including recall of the patient’s telephone number ( Fig. 18.1 ). The TMMSE, which takes 5 to 10 minutes to administer, appears valid and comparable to the traditional MMSE with a cut-off score for dementia of ≤20. Another widely used MMSE-based scale is the Telephone Interview for Cognitive Status (TICS), an 11‐item screening test (maximum score of 41 points) developed for assessing cognitive function in patients with Alzheimer disease. The TICS is longer than the MMSE as it includes a 10 word list learning task, responsive naming, and other items, yet it only takes approximately 10 minutes to administer on the telephone. The TICS has several variants itself (TICS-M, TICS-30, TICS-40), which include delayed word recall or other changes ( Table 18.1 ). Two additional telephone scales derived from the MMSE are the 34-item Telephone Modified Mini-Mental Status Exam (T3MS), and the 4-item Telephone Assessed Mental State (TAMS).

TABLE 18.1

The Telephone Interview for Cognitive Status (TICS) and Versions: Standard TICS, 41 items; TICS-M, 50 items; TICS-30, 30 items; TICS-40, 40 items

Instructions for Standard TICS [brackets indicate scoring]

To Proctor: In a couple of minutes, I am going to be asking [patient] a number of different questions to test his/her thinking and memory. Before we start, I need to ask you whether the address I have for your current location is correct. Please don’t repeat it out loud if [patient] is in the room with you since I will be asking him/her the same question in a few minutes. Is your current address [patient’s address]? Please be sure that all papers, pencils, books, calendars, newspapers, and everything else that might provide distraction or visual cues are removed from [patient’s] sight. Also, please be sure that the room is quiet; there should be no television, radio, or music playing. Some of the questions may be difficult for [patient] to answer. He/She may ask you for help. If he/she does, just encourage him/her to do as well as he/she can. He/She should guess if necessary. Please do not give him/her any answers or hints. O.K.? If you are [patient] ready, please put him/her on the phone.

To Patient: I am going to ask you some questions to test your memory. Some of these are likely to be easy for you, but some may be difficult. Please bear with me and try to answer all the questions as best you can. If you can’t answer a question, don’t worry. Just try your best. Are you ready?

1. Please tell me your full name. [2] (Not in TICS-30 or TICS-40 [0])

2. What is today’s date? What day of the week is it? or What season is it? [5]

3. Where are you right now? What number is that? What is your zip code? [5] (TICS-M has age and phone number [2]; TICS-30 and TICS-40 has address [3])

4. Please count backward from 20 to 1. [2]

5. I am going to read you a list of words. Please listen carefully and try to remember them. When I am done, tell me as many of the words as you can, in any order. Ready? The words are… cabin, pipe, elephant, chest, silk, theater, watch, whip, pillow, giant…. Now tell me all the words you can remember. [10]

6. I would like you to take the number 100 and subtract 7…. Now keep subtracting 7 from the answer until I tell you to stop. [5]

7. What do people usually use to cut paper? How many things are in a dozen? What do you call the prickly green plant that lives in the desert? What animal does wool come from? [4] (TICS-30 and TICS-40 only have two [2])

8. Please repeat after me: “No ifs, ands, or buts.” Now, please repeat this after me: “Methodist Episcopal.” [2] (TICS-30 and TICS-40 only have one [1])

9. Who is the president of the United States right now? Who is the vice-president? [2] (TICS-M includes first and last names [4])

10. With your finger, tap five times on the part of the phone you speak into. [2] (Not in TICS-30 or TICS-40 [0])

11. I am going to say a word and I want you to give me its opposite. For example, if I said “hot,” you would say “cold.” What is the opposite of “west”? What is the opposite of “generous”? [2] (Not in TICS-30 or TICS-40 [0])

12. Delay Word Recall—(Not in TICS [0]; Present in TICS-M and TICS-40 [10])

For Standard TICS: Total Possible Score 41 Suggested qualitative interpretive ranges 33–41 nonimpaired, 26–32 ambiguous, 21–25 mildly impaired; ≤20 moderately to severely impaired

Brandt J, Spencer M, Folstein M. The telephone interview for cognitive status. Neuropsychiatry Neuropsychol Behav Neurol . 1988;1:111–117.

Fong TG, Fearing MA, Jones RN, et al. Telephone interview for cognitive status: creating a crosswalk with the Mini-Mental State Examination. Alzheimers Dement . 2009;5(6):492–497.

Telephone-administered mental status scales that are not derived from the MMSE similarly omit visual items and other comparable modifications to traditional scales. These scales include the Structured Telephone Interview for Dementia Assessment (STIDA), Six-Item Screener, Telephone Screening Protocol (TELE), Telephone Cognitive Assessment Battery (TCAB), Hopkins Verbal Learning Test (HVLT), Memory Impairment Screen by Telephone (MIS-T), Category Fluency Test (CF-T), Blessed Telephone Information-Memory-Concentration Test (Blessed TIMC), Cognitive Assessment for Later Life Status (CALLS) instrument, and others ( Table 18.2 ). Of particular interest is the Telephone Montreal Cognitive Assessment (MoCA), or the “MoCA-Blind,” which is the MoCA stripped of its visual elements ( Fig. 18.2 ). This version has 22 items with a cutoff for cognitive impairment of 19.

TABLE 18.2

Mental Status Scales for Telephone Administration

Based Primarily or Originally Derived from MMSE

1. Telephone version of the MMSE (ALFI-MMSE)

2. The 26-point telephone version of the Mini-Mental Status Examination (TMMSE)

3. Telephone Interview for Cognitive Status (TICS)

4. Modified Telephone Interview for Cognitive Status (TICS-M) (also not TICS-30 and TICS-40 versions)

5. Telephone adaptation of the Modified Mini-Mental State Exam (T3MS)

6. Telephone Assessed Mental State (TAMS)

Not Based Primarily or Originally Derived from MMSE

7. Blessed Telephone Information—memory—concentration test (TIMC)

8. Brief Screen for Cognitive Impairement (BSCI)

9. Brief Test of Adult Cognition by Telephone (BTACT)

10. Cognitive Assessment for Later Life Status (CALLS)

11. Cognitive Telephone Screening Instrument (COGTEL)

12. Hopkins Verbal Learning Test (HVLT)

13. Memory and Aging Telephone Screen (MATS)

14. Memory Impairment Screen Telephone (MIS-T)

15. Minnesota Cognitive Acuity Screen (MCAS)

16. Short Portable Mental Status Questionnaire (SPMSQ-T)

17. Six-Item Screener (SIS)

18. Structured Telephone Interview for Dementia Assessment (STIDA)

19. Telephone Cognitive Assessment Battery (TCAB)

20. Telephone Montreal Cognitive Assessent (T-MoCA or MoCA-BLIND) and Short version of Telephone Montreal Cognitive Assessment (T-MoCA-Short)

21. Telephone Screening Protocol (TELE)

Castanho TC, Amorim L, Zihl J, Palha JA, Sousa N, Santos NC. Telephone-based screening tools for mild cognitive impairment and dementia in aging studies: a review of validated instruments. Front Aging Neurosci . 2014;6:16.

Advantages and Disadvantages. Telephone screening tools appear to have sufficient sensitivity and specificity to screen for dementia. These tools, particularly those that are derived from the MMSE, have adequate validity and reliability when compared with the in-person MMSE, but must be further validated with the NBSE or with neuropsychological testing. Telephone mental status scales are of particular value for follow-up assessments and monitoring the course of patients with dementia, but, like most mental status scales, they cannot accurately detect mild cognitive impairments. Contributing to this is that they are limited to verbal responses and are not good for assessing visuospatial or sensorimotor impairments. Their administration can be very difficult for patients with severe dementia and for those who are hearing impaired. In addition, the examiner must assure that patients do not take notes, write words down, consult external aids such as calendars, or ask for help during testing.