Identifying and Tracking Changes in Cognition Related to NP - PowerPoint Presentation

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Identifying and Tracking Changes in Cognition Related to NPH

Sheldon Herring, Ph.D.

Clinical Director

Outpatient Brain Injury and

Young Stroke ProgramSlide2
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Identifying and Tracking Changes in Cognition Related to NPH

OUTLINE

Background

Cognitive changes associated with NPH

NPH- a distinct dementia (?)

NPH- a reversible dementia (?)

Role of Cognitive Assessment

Timing of Assessments

Benefits of testingSlide4

Stargazing 101Slide5

Stargazing 102Slide6
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Cognitive changes associated with NPH

Impairment of wakefulness or vigilance Psychomotor speed

Attention and concentration

Memory and learning

Visual-perceptual, spatial, and constructive ability

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alculus or arithmetic

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eading and writingSlide11

Cognitive changes associated with NPH

Problem-solving

ConceptualizationAbstract reasoning

Executive functions

Awareness of change and deficit (anosagnosia)Slide12

Cognitive changes associated with NPH

Differences remain after exclusion of patients with more severe deficits.

Pattern of associations between neuropsychological domains was consistent with multi-regional pathological changes and impaired connectivity.

Severity of cognitive deficits not always associated with chronicitySlide13

Cognitive changes associated with NPH

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erebrovascular disorders or shown to add substantially to the neuropsychological impairment in a manner “aptly described as more of the same”.

Hellstrom

et al 2007Slide14

Hellstrom et all Neurosurgery 2007Slide15

NPH- a distinct dementia (?)

Stargazing 201

NPH greater impairment on measures of frontal lobe functioning while AD worse on verbal memory ( Saito et al 2011)

Cortical- subcortical debateSlide16

NPH- a reversible dementia (?)

Cognitive area showing improvement after shunting include:

Delayed verbal recall

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emory for designs (visual memory)

Visual constructional abilities

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sychomotor speed

V

isual scanningSlide17

NPH- a reversible dementia (?)

Cognitive area showing improvement after shunting include:

Executive skills may be more variable. DeVito et al 2005

Physical symptoms (gait) greater change than cognition in many casesSlide18

NPH- a reversible dementia (?)

There is no general agreement about which cognitive functions are

more likely to be restored after shunt placement.

Iddon

et al showed that more demented patient showed significant improvement after surgery whereas

nondemented

patients remain unchanged.Slide19

NPH- a reversible dementia (?)

Thomas (2005)showed verbal memory and psycho motor speed more likely to respond to shunt surgery with half of their patient showing changes as early as three months.

If verbal

and

visual constructional functioning was impaired, less likely to see improvement.

Some of these improvements parallel increase in corpus callosum size as noted on the MRISlide20

NPH- a reversible dementia (?)

Metabolic changes assumed related to improved cognition measurable within one week of shunt

Statistically significant changes noted across groups at 1, 3 and 6 months

Improvement after 12 months unlikelySlide21

NPH- a reversible dementia (?)

Need to note that even with patients who show improvement there is increased risk of cognitive decline years down the road.

At 4.8 years 80% showed cognitive decline and 46% showed clinical dementia.

Picascia

et al 2015Slide22

Role of Cognitive Assessment

Group profiles do not predict individual patterns.

Individualized neuropsychological profiles are required for clinically relevant conclusions

Individualized testing converts the hypothetical into the real.

Goes beyond the “what” to the “so what”.Slide23

Role of Cognitive Assessment

Neuropsychological evaluation versus mental status testing

Even patients with MMSE of greater than 26 can show neuropsychological deficitsSlide24

Role of Cognitive Assessment

Diagnostically:

The inter-correlation of tests justifies some reduction in testing without jeopardizing sensitivity. (

Hellstrom

2007)

Minimally, diagnostic

testing can be more focused and should include measures of executive skills, memory (verbal and visual*) and psychomotor abilities (

Hellstrom

2012)

Optimally, premorbid intelligence, apathy, depression, quality-of-life, dementia screen, memory, including verbal and visual learning, executive skills, attention, psychomotor speed, and visual construction skills. (DeVito 2005)Slide25

Role of Cognitive Assessment

Other potential applications such as competence, return to work, etc. may require more broader testing.

In cases where the hydrocephalus may be secondary to other prior medical events such as meningitis, subarachnoid hemorrhage, or trauma, screening may be less appropriate and a broader assessment required.Slide26

Timing of Assessments

Pre- and post surgery benefits

There been two documented cases where post shunt

testing revealing decreased neuropsychological performance after shunting compared to premorbid testing

leading to

discovery of subdural fluid collections Slide27

Benefits of testing

Personal

FamilyUnderstanding of behaviors

Intentional versus non-intentional

Significance of strengths and deficits (driving, financial decisions, other important decision making)Slide28
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