Last updated on January 6th, 2024 at 08:34 am
In search of a strategy to address Cognitive Impairment (Ci), a major health problem
The following article is directed to the attention of health benefits managers, HR professionals, psychologists and physicians.
Dr. Ruthven practiced as a Kansas Licensed Psychologist for 55 years, 15 years diagnosing and treating the full range of the mental disorders, 20 years specializing in clinical neuropsychology and 20 years the founder/developer of Preferred Mental Health Management, Inc., the company arranging and managing outpatient and inpatient mental health and addiction services for large self-insured corporations for their employees in all 50 states. PHHM’s preferred provider network included 750 contracted hospitals and 10,000 Ph.D. selected psychologists, clinical social workers and a lesser number of psychiatrists practicing cognitive psychotherapy. Covered members in the health plan accessing care had a telephonic assessment by a senior level psychologist who arranged appropriate treatment by a provider in the caller’s community. Over those years 65,000 callers complaining of depressive or anxiety symptoms were referred for behavioral treatment and none of these patients ever required psychiatric drugs, which saved the health plans additional sums of money. The average treatment episode for these 65,000 patients was 6 hours of therapy. All patients who used PMHM’s services and contracted providers were offered to fill out a satisfaction survey regarding PHMH and provider services. There was a 28% return rate of these surveys, which found typically a satisfaction rate of 90% or above in each of the health plans receiving services. Those returning the surveys believed the behavioral treatment substantially decreased their absenteeism from work and a substantial number believed the therapy improved their overall health. PMHM was unique in the industry in that it never authorized inpatient services for the addictions and psychologists, rather than nurses, managed and reviewed all inpatient services.
From his work in the practice of clinical neuropsychology for 20 years Dr. Ruthven found that the the diagnosis and treatment of brain disorders was grossly inefficient and much too costly as well. For example, for many Alzheimer’s Disease (AZ) patients it took 8 to 10 years for a number of patients to be finally correctly diagnosed. Many mentally impaired patients were inappropriately treated psychiatrically before it was determined the source of the impairment was due to brain damage of one kind or another. Dr. Ruthven saw that a systematic approach was needed for the early and cost efficient identification of cognitive impairment in many members of a health plan. The need was for the invention of an inexpensive but powerful screening test to identify the presence of CI in the members covered in the health plan; such a screening test would serve as a bridge by the reviewing psychologist/neuropsychologist to the final and correct diagnosis by referring the patient to the most appropriate professional for further assessment. There are several such screening tests available to primary care and other physicians that are in use today but these screening tests do not seem to help in decreasing the time and the cost of finally determining the correct impairing diagnosis. Most of the screening tests select items from neuropsychological test batteries, they are put together in a format that is administered to the patient by a nurse or other health professional in a 30 to 60 minute session. The most powerful means of determining brain pathology is a 5 to 6 hour neurocognitive assessment review of the patient’s performance on a large range of mental and behavioral functions mediated by the brain. The battery is administered one on one by a fully qualified neuropsychologist and in many cases by a technician trained to administer the battery by a neuropsychologist. In the technician administered battery the neuropsychologist reviews the data from the assessment and makes the diagnosis. However, such and an assessment can cost the benefit plan anywhere from one thousand to two thousand dollars and such evaluations are needed in many cases as are appropriate referrals for MRIs of the patient’s brain. However, the problem of mental or cognitive brain impairment is endemic in those using the healthcare system as well as those in the plan who never access health services. Most if not all of the mental disorders impair brain functions to some degree, there are 10 classes of prescription drugs that impair brain functions (most if not all psychiatric drugs), concussions impair the brain, strokes, head injuries, several progressive dementias, hypoxias of the brain from several sources and others as well. A distinction early in the diagnostic process is the need to separate impairing conditions that are reversible, as with many but not all prescription medications, from those that are irreversible such as in many head injuries (static brain damage) and those with irreversible and progressive brain disease. We simply cannot afford to give MRIs or comprehensive neuropsychological evaluations to several hundreds of thousands of patients yearly; costs and professional availability forces the health industry to come up with a powerful and cost effective screening devise to initiate and start the diagnostic process. The screening devices now in use simply do not meet the need for a number of reasons mentioned above and these screening tests are unable to detect if the impairment may arise from causes that are reversible or if the cause is one of structural brain damage.
Neurology and clinical neuropsychology as well are designed to detect and diagnose structural brain damage/disease and they do it quite well but the technology of both health professions are not sufficient to detect significant cognitive impairment that has not damaged the brain structurally and permanently. .Also, some brain diseases, such as Alzheimer’s Disease (AZ), in the early stages may be below the impairment floor of the technology of both neurology and clinical psychology. If this is true we are in need of tests that can detect cognitive impairment that are below the floor of the present neurodiagnostic tools. Many prescription drugs, both psychiatric and non-psychiatric, impair the brain that is reversible but some of these drugs used chronically eventually may cause structural and permanent damage to the brain. At this point we do not know the answer to this question but we need research to determine the answer to this important question.
In attempting to serve such needs Dr. Ruthven set us certain parameters for such an assessment. The test, which can be taken on line or in house, must be self-administered for most adults and teens while some will require a monitor to assist the patient in test taking. In addition to the test itself the person tacking the test for the first time would fill out a medical and prescription drug history that can be modified by the person when and if health and drug changes occur. In addition to the test results and the medical and prescription drug history, Dr. Ruthven saw the need for the patient to respond to a brief (10 item) survey of behaviors/symptoms. If the patient’s current test pattern was in the normal range (the test results are available to the person right after completing the test) nothing would occur except providing the patient with information of their current and normal cognitive functioning. If the performance is in the impaired range a reviewing psychologist/neuropsychologist would analyze the results (medical history, RIA test results and the current behavioral screening) and make the recommendation of a specific referral for further assessment. If the reviewing clinician believed the test performance and related data pointed to reversible or irreversible structural damage the clinician would direct the patient to the appropriate health professional for further diagnosis.
The RIA was developed to be performed on a desktop computer and was designed to be taken by the health plan member 2 to 3 times a year or whenever the member became aware of any problems with mental impairment. It is very important that such a test would have little or no practice effects since repeated testing would be necessary over time. With little or no practice effects decreased performance from one test session to the next would imply the possible onset of CI. The test, having limited or no practice effects on repeated testing, could also be used for known stroke, head injury and other such patients during rehabilitation to measure over time improvement of CI. Because of the anticipated demand for such a screening test the procedure should be very inexpensive.
From the above assessment requirements, Dr. Ruthven created the Ruthven Impairment Assessment (RIA), which is described in the attachment in a publication describing the RIA which appeared in Applied Neuropsychology in March of 2017. The first author of the publication was Gerald Goldstein, Ph.D., an eminent clinical and research neuropsychologist and a past president of the National Academy of Neuropsychology (NAN). The RIA requires the patient to perform the test on a desktop computer. There are 5 brief performance tasks with 10 items on the first 4 tasks and 13 items on task #5. For each task on the computer screen task instructions appear on the left of the screen and on all five tasks on the right side of the screen appears a standard and numbered clock face. All tasks are performed on the numbered clock face. The first 3 tasks (simple, complex and conditional reaction time) are responded to by the subject pressing the space bar consistent with the task instructions. In task 1 the patient presses the space bar when any clock number is lighted, task 2 requires bar pressing to any even clock number and on task 3 the patient is directed to press the space bar to the number following two even numbers unless that number is either 1 of 2 numbers given in the task instructions. If the numbers given in the instructions (these 2 numbers change from test to test) were a 7 and 10, for example, the subject should not bar press if the numbers 7 or 10 followed two even numbers. Bar pressing to a number 7 or 10 would generate on the screen the word incorrect. Not responding to those number exceptions would give the subject a correct on the computer screen. If the subject fails to respond in the allowed time (this varies for each of the 5 tasks) the screen announces “timed out”, meaning an error.
Task # 4 is an assessment of attention/memory. From intelligence testing it is known that the average adult can retain and give back a series of 6 numbers. This task requires the subjects to respond with the computer mouse and left clicking on the numbers described in the instructions. When the subject has read and understands the instructions to task 4 the subject with the computer mouse left clicks on any part of the clock face and the test begins. On the clock face there appears two sequences of three lighted clock numbers (such as 3, 9,8) and here for a correct response the subject would left click when told to Go on the clock numbers 3, 9, and 8 in the time allowed . On any of the tasks the subject is given on the screen the feedback of correct, incorrect or timed out on the computer screen after the S makes the response. Again there are two sets of 3 numbers, two sets of 4 numbers, two sets of 5 numbers and 2 sets of 6 numbers. Here if the subject responds to this task without error the maximum score is 8 points.
Task #5 is the most difficult and challenging of the 5 tasks and might be described as anticipatory thinking and complex problem solving. This task reflects how the subject would respond to the more complex demands of a normal environment. In this task of 13 items, there appears on the clock face a lighted series and sequence of 5 clock numbers; the subject is instructed to try to detect a pattern or “theme” in each 5 number series and to left click on the two clock numbers that would either complete or continue the series. The first 3 items are very easy and more explanatory of the task requirements. One of the first 3 items is the lighted 5 number sequence of 1, 2,3,4,5. Of course the correct response is left clicking on the numbers 6 and 7, which would give a “correct” on the clock face. A 62 year old health professional responded incorrectly to this item and he was later diagnosed as having a progressive frontal lobe disease on comprehensive neuropsychological assessment. This person’s test pattern suggests the above diagnosis rather than Alzheimer’s Disease because on task 4 his memory was less impaired than on the more frontal lobe functions of task 5. It would be very rare for the RIA to come up with such a final diagnosis. What can be expected is that the RIA can identify those with impaired cognition of a non-specific origin, give a measure of the degree or severity of the impairment, and perhaps whether the impairment is likely to be reversible or irreversible. The latter test results of irreversible damage would give the reviewing clinician (along with the related patient information) solid information to determine the likely efficient path to obtain the correct diagnosis, in this case referral to a neuropsychologist.
What is known about the RIA and cognitive impairment (CI) from the Applied Neuropsychology article and pilot studies and clinical use of the RIA.
The RIA was standardized on 55 WSU college students taking the test 3 times in ten days and at least 24 hours between two test sessions. Forty students took the test with a test monitor and 15 students self-administered the test following the task instructions on the computer screen. There was no statistically significant differences in performance scores between the two groups and the performance scores of the two groups were combined. There were also no gender performance differences on any of the 5 tasks. Ages were from 18 to 58 and there was only a slight decrement on speed of mental processing (the RT tests) and memory with advancing age. Task 5 higher level adaptive abilities held up within the age range tested.
RIA WSU Student Norms RIA scores in the Impaired range*
Subtest #1 Mean correct 9.27 C. 8.00 or less
Mean RT 0.33 M RT 0.43 or slower
Subtest #2 Mean correct 8.63 C. 7.00 or less
Mean RT 0.50 M RT 0.60 or greater
Subtest #3 Mean correct 8.27 C. 5.68 or less
Mean RT 0.51 0.65 or greater
Number exception errors 0 2 of 2 possible errors
Subtest #4 7.31 out of 8 6.48 or less
Subtest #5
# correct out of 13 items 9.59 7.00 or less
- The impaired range is 1 standard deviation in the impaired direction
Above are the nine (9) major performance measures of the RIA. Note that the Mean RT of subtests 2 and 3 are of equal difficulty despite the more complex instructions of subtest 3 (Press the space bar to the number following two even numbers except if that number is a e.g.,7 or a 12 vs. the subtest 2 instructions (“Press the space bar to any even number”). Those two number exceptions are random and change on each administration of the test. In cognitively normal subjects RT on subtest 2 and 3 are each 50% slower than the score on simple RT, which is extremely important for diagnosing impairment. In impaired person’s complex RT on subtest 2 is substantially more than 50% slower than on subtest 1 and also in impaired persons RT on subtest 3 is substantially slower than RT on subtest 2. Score an additional impairment point if Subtest 3 RT is 0.14 seconds slower than the Subject’s Mean RT on subtest 2. The greater the degree of slowness in RT on complex and conditional RT vs. the RT on simple RT the greater the degree of CI in the subject. In addition to a subject’s performance on each task the results include the number of the 9 performance measures that were in the impaired range (0 to 9). In addition from the above data the results include the number of the 9 measures that were one standard deviation above the Mean in the impaired direction, which gives another ball park measure of the degree of the person’s impairment. The higher the number of measures in the impaired range the more likely the presence of structural brain damage/disease.
At this stage of RIA development it is speculated that persons of dull normal intelligence and above (not including those with some college) are expected to perform in the normal range on tasks 1 through 4 despite a poor performance on task 5. At this time it appears that if persons with some degree of college show impairment on the first four subtests—and task 5 performance is well within the norms—the subject’s brain dysfunction is likely to be reversible and due to a source or sources other than structural brain damage/disease! In such a case the reviewing clinician would direct attention to sources that induce reversible brain impairment such as many prescription drugs. For example, some impairing drugs may be reversible in the short term but research is needed to determine if structural brain damage occurs from some of these drugs in the long term!
Unfortunately reversible brain impairment is largely under the radar by physicians, neurologists and clinical and research neuropsychologists.
If one goes without sleep for 24 hours or more one has significant but reversible brain impairment that is completely reversible with a good night’s sleep. Three martinis in a four hour period will also impair one’s brain functions temporarily as there are 10 classes of prescription drugs that injure brain cells including most psychiatric drugs. We know that with alcohol, as with other chemicals and pollutants, if alcohol consumption increases in quantity and frequency over time the once reversible impairment results in structural damage to the brain! What we don’t know, and we must find out, do prescription drugs that impair the brain temporarily in prolonged use result eventually in structural and permanent damage to the brain! In my review of the literature on the long time use of antidepressant and antipsychotic drugs the literature is quite convincing that these drugs do result in permanent damage to the brain when used over extended periods of time. Even some research psychiatrists have accepted the research that the long term use of antidepressants to treat depression and antipsychotic drugs to treat schizophrenia are associated with brain damage in these patients! However, these same psychiatrists have accepted these findings but do not accept that fact that it is the drugs that cause the damage to the brain. What these psychiatrists have done in a sense is to redefine depression and schizophrenia as neurodegenerative diseases! For these psychiatrists the putative cause of the brain damage in these patients is the mental disorders themselves and not the drugs!
Currently we have RIA performance norms on college students which means the RIA is only strictly applicable to adults over 18 who had some exposure to college. RIA norms are needed for non-college trained persons age 12 and above who have some experience with computers, at least the ability to operate a computer mouse. Even without additional norms task 5 is the only task that is highly correlated with general intelligence and even now the first 4 tasks can be applied to those outside current norms as long as there is evidence (schooling and other life experiences) that the person is of average intelligence or above. Since the RIA instructions are now only in English it is estimated that the person tested must have an 8th grade or above reading level (presently this is only a guess) to come up with a valid performance. If the person tested meets many but not all necessary criteria for a valid performance the reviewer should only consider results on the first 4 tasks in the analysis and not consider the performance on task 5. However, if the clinician has evidence that the S has intellectual ability comparable to college students task 5 performance should enter the analysis.
Use of the RIA by non-psychologists. Some cautions.
Three or more RIA scores in the impaired range (this depends on which scores are in the impaired range) should result in a referral to a neuropsychologist for further assessment but a non-psychologist should have access to a psychologist for consultation on some RIA cases. For a valid performance on all psychological and neuropsychological tests the person taking the test must be motivated to give their best performance. Most psychologists are pretty good in reviewing the inter and intra test patterns to determine when and if the Subject is faking bad. An “invalid” set of scores would be one in which the performance neither reflected normal nor abnormal functioning in a consistent way. The author tested a cheerleader with two diagnosed concussions and continuing migraine headaches and poor school performance for which she had a tutor. Her three reaction times did not reflect that of either a non-impaired or an impaired person. A later neuropsychological evaluation found no evidence of impaired cognitions from the concussions and her performance on the tests reflected low average intelligence and the same variable motivation as noted in performing the RIA.
Clinical pilot studies needed on the following groups:
Previously well diagnose cases with dementia, treated cancer patients complaining of “brain fog”, any CT scan patients who had 4 or more CT brain scans (there is research indicating induced cancer from brain scans), any patient who had one or more brain MRIs with the enhancer Gadolinium, any patient who had opioids off-label for pain, one who is on or been on psychiatric drugs (check the length of drug treatment), steroid injections for back pain, patients who were prescribed antidepressants off-label for any type of pain, any patients with Tardive Dyskinesia, depressed patients who were prescribed antipsychotic drugs when only responding partially to the antidepressant, demented patients on Aricept, and dozens of others should be assessed for CI.
When health professionals obtain permission to employ the RIA procedures in testing clinical patients and research subjects, the RIA principals automatically receive the test results and the health history and the symptom and behavior survey. The RIA principals do not need nor want any identifying information on the person being tested. The RIA user should assign a case number (and not the person’s name) which would allow communication about the case between the user and the RIA principals about the patient tested.
As the RIA principals and our “partnering” health professionals gather expanded norms and test patterns of various clinical groups, the RIA principals will collate the data on these clinical groups and forward the information to our collaborating RIA health professionals.
If you are a licensed psychologist, neuropsychologist, health benefits manager or general physician and have any questions on the above or would consider becoming involved in clinical or research with the RIA please contact Dr. Les Ruthven at: lruthven.mafinearts@gmail.com
