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12 Measuring effort on a continuum provides improved insight into concussion baseline cognitive assessments
- Heather C. Bouchard, Kate L. Higgins, Julia E. Maietta, Julia M. Laing, Douglas H. Schultz
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 889-890
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Objective:
Baseline assessment of cognitive performance is common practice under many concussion management protocols and is required for collegiate athletes by the NCAA. The purpose of baseline cognitive assessment is to understand an athlete’s individual uninjured cognitive performance, as opposed to using population normative data. This baseline can then serve as a reference point for recovery after concussion and can inform return-to-play decisions. However, multiple factors, including lack of effort, can contribute to misrepresentation of baseline results which raises concern for reliability during return-to-play decision-making. Measuring effort across a continuum, rather than as a dichotomous variable (good versus poor effort) may provide informative insight related to cognitive performance at baseline.
Participants and Methods:Collegiate athletes (n = 231) completed the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) as part of their baseline pre-participation concussion evaluation. ImPACT creates composite scores of Verbal Memory, Visual Memory, Visual-Motor Speed, and Reaction Time. Baseline self-reported symptoms and total hours of sleep the night prior to testing are also collected through ImPACT. ImPACT has one embedded indicator within the program to assess effort, and research has identified an additional three embedded indicators. Athletes were also administered one stand-alone performance validity test, either the Medical Symptom Validity Test (n = 130) or the Rey Dot Counting Test (n = 101), to independently measure effort. Effort was estimated across a continuum (zero, one, two, or three or more failed effort indicators) with both stand-alone and embedded effort indicators. We evaluated the relationship between effort, symptoms, self-reported sleep, Reaction Time composite score and Visual-Motor Speed composite score using a linear regression model.
Results:We found that 121 athletes passed all effort indicators, while 39 athletes failed only one effort indicator, 40 athletes failed two effort indicators, and 31 athletes failed three or four (three+) effort indicators. Self-reported symptoms and total hours of sleep were not related to effort, but Reaction Time and VisualMotor Speed composites were. Specifically, performance on the Visual-Motor Speed composite was significantly worse for athletes who failed two or three+ effort indicators compared to athletes who did not fail any, and performance on the Reaction Time composite was significantly worse only for athletes who failed three+ effort indicators. Additionally, athletes who failed one or more effort indicators and reported less sleep performed worse on both the Visual-Motor Speed and Reaction Time composites, compared to those who reported less sleep and did not fail any effort indicators.
Conclusions:Athletes who failed one effort indicator did not perform significantly worse on Reaction Time and Visual-Motor Speed composites compared to those who passed all effort indicators. However, 31% of athletes failed two or more effort indicators and these athletes performed worse on cognitive tests, likely due to factors impacting their ability to put forth good effort. These results suggest that effort is more complex than a previously used dichotomous variable and highlights the importance of using several indicators of effort throughout baseline assessments. In addition, the importance of sleep should be emphasized during baseline assessments, especially when effort is questionable.
64 Comparison of Post-Concussion Symptom Network Structure at Baseline and Post-Concussion
- Christine Salva, Grace J Goodwin, Hana Kuwabara, Jessica Woodyatt, Julia E Maietta, Thomas Kinsora, Staci Ross, Daniel N Allen
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 169-170
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Objective:
Recent conceptualizations of concussion symptoms have begun to shift from a latent perspective (which suggests a common cause; i.e., head injury), to a network perspective (where symptoms influence and interact with each other throughout injury and recovery). Recent research has examined the network structure of the Post-Concussion Symptom Scale (PCSS) cross-sectionally at pre-and post-concussion, with the most important symptoms including dizziness, sadness, and feeling more emotional. However, within-subject comparisons between network structures at pre-and post-concussion have yet to be made. These analyses can provide invaluable information on whether concussion alters symptom interactions. This study examined within-athlete changes in PCSS network connectivity and centrality (the importance of different symptoms within the networks) from baseline to post-concussion.
Participants and Methods:Participants were selected from a larger longitudinal database of high school athletes who completed the PCSS in English as part of their standard athletic training protocol (N=1,561). The PCSS is a 22-item self-report measure of common concussion symptoms (i.e., headache, vomiting, dizziness, etc.) in which individuals rate symptom severity on a 7-point Likert scale. Participants were excluded if they endorsed history of brain surgery, neurodevelopmental disorder, or treatment history for epilepsy, migraines, psychiatric disorders, or alcohol/substance use. Network analysis was conducted on PCSS ratings from a baseline and acute post-concussion (within 72-hours post-injury) assessment. In each network, the nodes represented individual symptoms, and the edges connecting them their partial correlations. Estimations of the regularized partial correlation networks were completed using the Gaussian graphical model, and the GLASSO algorithm was used for regularization. Each symptom’s expected influence (the sum of its partial correlations with other symptoms) was calculated to identify the most central symptoms in each network. Recommended techniques from Epskamp et al. (2018) were completed for assessing the accuracy of the estimated symptom importance and relationships. Network Comparison Tests were conducted to observe changes in network connectivity, structure, and node influence.
Results:Both baseline and acute post-concussion networks contained negative and positive relationships. The expected influence of symptoms was stable in both networks, with difficulty concentrating having the greatest expected influence in both. The strongest edges in the networks were between symptoms within similar domains of functioning (e.g., sleeping less was associated with trouble falling asleep). Network connectivity was not significantly different between networks (S=0.43), suggesting the overall degree to which symptoms are related was not different at acute post-concussion. Network structure significantly differed at acute post-concussion (M=0.305), suggesting specific relationships in the acute post-concussion network were different than they were at baseline. In the acute post concussion network, vomiting was less central and sensitivity to noise and mentally foggy more central.
Conclusions:PCSS network structure at acute post-concussion is altered, suggesting concussion may disrupt symptom networks and certain symptoms’ associations with the experience of others after sustaining a concussive injury. Future research should compare PCSS networks later in recovery to examine if similar structural changes remain or return to baseline structure, with the potential that observing PCSS network structure changes post-concussion could inform symptom resolution trajectories.
58 Highly Educated Professionals with Dementia: More than just Physicians
- John F Linck, Julia E Maietta, Christopher T Copeland
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, p. 569
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Objective:
Findings from cognitive screenings have resulted in lower-than-expected scores amongst late-career physicians (Moutier et al., 2013). Similar to healthy aging samples and those with mild cognitive impairment, inconsistencies in self-report and objective neuropsychological functioning have been noted in physicians (Nasreddine et al., 2005). Little research has focused on neuropsychological functioning of other highly educated groups, including PhD and JD degrees. We addressed a lack of normative cognitive performance data for populations with advanced degrees by exploring cognitive test scores in a mixed clinical sample of adults.
Participants and Methods:Archival data are from 208 neuropsychology clinic outpatients with 20 years of education (Mage=67.7, SDage=12.3; 25% female; 95% White). Academic degrees were PhD (35.6%), JD (28.4%), MD/DO (21.6%), and 6% other. Referrals sources were physicians (93.8%), licensing boards/employers (3.8%), self-referrals (1.4%), and attorneys (1.0%). Employment status was 55.3% employed and 44.7% not employed. Final DSM-5 neurocognitive diagnosis (NCD) status was: no NCD (45.2%), mild NCD (35.6%), and major NCD (19.2%). Etiologies were: possible Alzheimer’s disease (41.2%), unspecified (13.2%), and possible vascular (12.3%). Chi-square tests denoted diagnostic status differences between degree type and employment status. ANOVAs denoted differences in global cognitive and intellectual functioning (on the Repeatable Battery for Neuropsychological Status [RBANS] Total Index, Weschler Adult Intelligence Scale-IV (WAIS-IV), Weschler Abbreviated Scale of Intelligence-II [WASI-II] FSIQ-4 and FSIQ-2) between degree types. Cumulative frequency rates for low scores in the entire sample on normally distributed tests of general intellectual and cognitive functioning were computed for -1.0, -1.5, -2.0, and -2.5 standard deviations (SDs) at or below the population mean.
Results:NCD diagnosis did not differ by degree (X2[14]=8.73, p=.848) but did differ by employment status (x2[2]=40.98, p<.001, cp=0.44). Employment rate was highest for the no NCD group (66.0%), followed by mild NCD (37.8%), and major NCD (7.5%). For cases below retirement age (<65 years), employment status did not significantly differ between NCD diagnostic groups (x2[2]=5.97, p=.050). Low scores on an FSIQ measure were: -1 SD (7.0%), -1.5 SD (2.6%), -2.0 SD (0.9%), and -2.5 SD (0.0%) compared to general cognitive test scores which demonstrated 42.5% at -1 SD, 30.5% at -1.5 SD, 19.0% at -2.0 SD, and 9.2% at -2.5 SD below the population mean.
Conclusions:The high-education literature is limited to medical degree samples. This sample included multiple degree types. Unsurprisingly, employment rates were higher for healthy versus impaired samples; however, employment rates were similar across these groups for people below retirement age. Our findings suggest that cognitively impaired people with 20 years of education often perform at or near the general population average on tests of general intellectual functioning but below the general population average on tests of general cognitive functioning. Future work should include base rates of low scores on a broader array of cognitive tests across diagnostic groups.
Influence of Special Education, ADHD, Autism, and Learning Disorders on ImPACT Validity Scores in High School Athletes
- Julia E. Maietta, Kimberly A. Barchard, Hana C. Kuwabara, Bradley D. Donohue, Staci R. Ross, Thomas F. Kinsora, Daniel N. Allen
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- Journal:
- Journal of the International Neuropsychological Society / Volume 27 / Issue 5 / May 2021
- Published online by Cambridge University Press:
- 09 December 2020, pp. 461-471
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Objective:
The Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is commonly used to assist with post-concussion return-to-play decisions for athletes. Additional investigation is needed to determine whether embedded indicators used to determine the validity of scores are influenced by the presence of neurodevelopmental disorders (NDs).
Method:This study examined standard and novel ImPACT validity indicators in a large sample of high school athletes (n = 33,772) with or without self-reported ND.
Results:Overall, 7.1% of athletes’ baselines were judged invalid based on standard ImPACT validity criteria. When analyzed by group (healthy, ND), there were significantly more invalid ImPACT baselines for athletes with an ND diagnosis or special education history (between 9.7% and 54.3% for standard and novel embedded validity criteria) when compared to athletes without NDs. ND history was a significant predictor of invalid baseline performance above and beyond other demographic characteristics (i.e., age, sex, and sport), although it accounted for only a small percentage of variance. Multivariate base rates are presented stratified for age, sex, and ND.
Conclusions:These data provide evidence of higher than normal rates of invalid baselines in athletes who report ND (based on both the standard and novel embedded validity indicators). Although ND accounted for a small percentage of variance in the prediction of invalid performance, negative consequences (e.g., extended time out of sports) of incorrect decision-making should be considered for those with neurodevelopmental conditions. Also, reasons for the overall increase noted here, such as decreased motivation, “sandbagging”, or disability-related cognitive deficit, require additional investigation.