There are 3 ways to assess a patient’s cognitive status: an easy way that is fast but unreliable; a formal approach that is definitive but expensive; and a number of alternatives in between. The first is based on a psychiatrist’s observations of a patient’s memory, attention, and thought processes during the mental status examination, complemented sometimes by symptom checklists for the patient or knowledgeable observers. The second is a gold standard formal neuropsychological evaluation. It is hard to get sometimes and is not always well covered by insurance, including Medicaid and Medicare.
The alternatives include an array of “mini-mental state” measures, from the ubiquitous Mini-Mental State Evaluation (MMSE), the Montreal Cognitive Assessment (MoCA), and the Saint Louis University Mental Status used by physicians to the Wechsler Abbreviated Scale of Intelligence, the Repeatable Battery for the Assessment of Neuropsychological Status, and the Neurobehavioral Cognitive Status Examination, primarily used by psychologists.
Theoretically at least, computerized neurocognitive tests (CNTs) have the advantage of all 3 approaches: they can be administered relatively quickly and do not require a physician’s time; they can be tailored to a specific clinical issue (eg, ADHD), concussion, or mild cognitive impairment, or they can be broad-spectrum and comprehensive; and they are self-scoring and generate a report as soon as the test is done. They are accurate to the millisecond and data can be stored for serial comparison of a patient’s results. When such tests are reported in the medical literature, the developers assure us of their reliability and validity.
Discriminant validity, however, may not be a meaningful standard for a clinician. Test A, for example, can distinguish between patients with ADHD and normal controls. However, can it distinguish among the conditions in the differential diagnosis of ADHD (eg, anxiety, depression, OCD)? Similar questions arise when CNTs are used for dementia screening or concussion management. Such questions are rarely addressed, although that is really what the clinician needs.
There are many CNTs available for clinical assessment. Most are commercial products, with costs ranging from $7.50 per test to several hundred dollars for a license with per-test costs on top of that. Several are research instruments that are not available to clinicians but are used in academic centers or in clinical trials. At least one is free and available on the Internet for qualified users. There is even a CNT code that covers “computerized tests” (99120), but reimbursement is never ensured.
Cognitive assessment by computer might solve many of the problems physicians have in accurately appraising a patient’s cognitive abilities if, in fact, the tests are reliable and valid in the clinical setting. The first CNT used in the North Carolina Neuropsychiatry Clinics was the neurobehavioral evaluation system (NES)-II, developed by the late Richard Letz in the early 1980s for measuring the cognitive effects of industrial neurotoxins.1 We found it useful for evaluating patients with ADHD and mild brain injury, but because it was a DOS-based program, it is only a fossil now. A number of specific ADHD tests—the Conners Continuous Performance Test (CPT) and the Test of Variables of Attention as well as computerized versions of single tests such as Categories, the Stroop Test, and the Computerized Assessment of Response Bias (CARB)—were useful for detecting malingerers but are now also extinct.
Another CNT we used was MicroCog. It was developed at the behest of the Risk Management Foundation of the Harvard Medical Institutions, which insured about 5000 physicians at the time. The purpose of the test was to improve malpractice underwriting by identifying impaired physicians. A CNT would be less threatening to physicians, it was thought, than a battery administered by one of their colleagues.
Since the early days, when CNTs ran on Commodores or Apple 2e’s, dozens of computerized tests and test batteries have been developed—1 or 2 new ones every year. Physicians and psychologists in research settings like CNTs it seems, but they have been slow to catch on in clinical practice. In 2001, my colleagues and I developed our own test battery—CNS Vital Signs.
Dr Gualtieri is Medical Director of the North Carolina Neuropsychiatry Clinics in Chapel Hill, Charlotte, and Raleigh. He reports no conflicts concerning the subject matter of this article.
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