Measuring Thinking, Memory, and Speech in Epilepsy Robert W. Trobliger, Ph.D. Director Clinical Neuropsychology Northeast Regional Epilepsy Group October 20, 2018

Epilepsy and Cognition Cognitive Functioning Attention Processing Speed Executive Functioning Language Visuospatial/Visuomotor functions Memory NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Epilepsy and Cognition Significant variation: no impairment minimal impairment moderate impairment significant impairment MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Epilepsy and Cognition Complaints of mental slowness Attention/concentration difficulties 30-40% children with epilepsy (Lodhi & Agrawal, 2012; Westerveld, 2009, Rijckevorsel, 2006) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

High prevalence of memory problems (20%-50%) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Trouble remembering names Common complaints: Trouble remembering names Forgetting appointments or when to take medication Difficulty recalling recent events or conversations (Lodhi & Agrawal, 2012; Westerveld, 2009, Rijckevorsel, 2006) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Epilepsy and Cognition Problems with langauge also common. - Weak vocabulary - Word finding problems - Difficulty naming things (Busch et al., 2016; Oddo et al, 2003; Davey & Thompson, 1991) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Factors Affecting Cognition in Epilepsy Multiple factors contribute towards cognitive difficulties: Seizure etiology TBI, stroke, cortical malformations Epilepsy-related factors Location of epileptogenic/seizure focus (Blackburn et al., 2007.) MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Factors Affecting Cognition in Epilepsy Location of seizure onset: Frontal lobe: Mental flexibility, problem-solving, attention, memory, processing speed, initiation, judgment, inhibition, language Parietal lobe: Visual and spatial abilities Occipital lobe: Integration of visual information, reading Temporal lobe: Memory, language MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Factors Affecting Cognition in Epilepsy Seizure-related factors Type Age of onset/duration of epilepsy Frequency, duration, severity of seizures Occurrence of status epilepticus MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Factors Affecting Cognition in Epilepsy Treatment-related factors Impact of antiepileptic drugs (AEDs) slowed psychomotor speed, poor attention, and mild memory impairment (Loring, 2005; Park & Kwon, 2008) Epilepsy surgery NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Factors Affecting Cognition in Epilepsy Psychosocial factors Mood/emotional functioning (Park & Kwon, 2008; Lodhi & Agrawal, 2012; Loring et al., 2007; Saling et al, 1993; Jones-Gotman, 2000; Helmstaedter & Kurthen, 2001; Jokeit & Ebner, 2002: Aldenkamp & Arends, 2004; Dorill, 2004.) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

All these inter-related factors make complex contributions to cognitive deficits. MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Children MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Attention/Concentration Problems Very common (30-40%) in children regardless of seizure type/syndrome High co-morbidity with ADHD (esp. ADHD-I) Different from ADHD in general population: boys and girls equally affected. (Dunn et al., 2003; Stucky et al., 2014; Westerveld, 2010) MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Attention/Concentration Problems Mechanism of attention/concentration problems varies depending on nature of seizures and underlying pathology Absence seizures more highly associated with attention problems Nocturnal seizures impact attention by altered sleep patterns (Stucky et al., 2014; Westerveld, 2010) MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Attention/Concentration Problems Treatment with some AEDs may produce attention problems – (side effect - doesn’t fully account for attention/problems). (Hermann et al., 2007; Stucky et al., 2014) MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Memory Problems Early-onset seizures (<5 yrs) global nonspecific learning/memory deficits Later seizure onset (>10 yrs) specific deficits in material-dependent learning/memory MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Memory Problems Particular role of temporal lobes in learning/memory e.g., LTLE associated with worse performance on verbal vs. visual memory tasks But findings mixed; face recognition only lateralizing measure Perhaps location of lesion within temporal lobe? mesial vs. lateral (Cohen, 1992; Lespinet et al., 2002; Gonzalez et al., 2007; Westerveld, 2010) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Memory Problems Childhood Absence Epilepsy Most common epilepsy syndrome of childhood (~15% of childhood seizures) Attention problems adversely affect encoding and storage of new information, with relatively greater impact on nonverbal memory Frontal lobe epilepsy Memory deficits related to poor organization of metacognitive strategies for learning and remembering (Pavone et al., 2001; Stucky, 2014) MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Language Problems Difficulties with receptive vocabulary, expressive vocabulary, naming, reading, and spelling (Oostrom et al., 2003; Fastenau et al., 2004; Cohen & Le Normand, 1998; Tuchman, 1994; De Koning et al., 2009) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Adults MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Attention/Concentration Problems 1 in 5 adults with epilepsy have symptoms of ADHD Rarely only attention/concentration difficulties in isolation Widespread neural underpinnings of attentional system Intact attention required to adequately perform variety of cognitive tasks Often seen with other cognitive difficulties (word-finding difficulty, forgetfulness, etc.) (Ettinger, 2015; Lee, 2010; Stucky et al., 2014, Westerveld, 2010) MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Attention/Concentration Problems Worsening attention/concentration (along with visuomotor speed) associated with: Early age of onset Long epilepsy duration History of more GTCs (Lee, 2010) MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Memory Problems Very frequent in patients with TLE but patients with other epilepsy syndromes also exhibit memory deficits Medial temporal structures crucial for long-term encoding but also network e.g., frontal lobe epilepsy and interconnectivity between frontal and temporal lobes Role of specific areas within the frontal cortex for encoding and retrieval (Centeno et al., 2010; Stucky, 2014) MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Memory Problems Memory deficits may be “material specific” depending on side of seizure onset Verbal memory for LTLE (left hemisphere dominance) and visual memory for RTLE - not as robust for visual learning/memory Patients with TLE and HS: degree of memory impairment directly related to degree of cell loss in hippocampus (Centeno et al., 2010; Stucky, 2014). MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Language Problems Problems with langauge also common. - Limited vocabulary - Word finding problems - Difficulty naming things (Busch et al., 2016; Oddo et al, 2003; Davey & Thompson, 1991) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Other Factors Contributing to Cognitive Difficulties MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Mood and Cognitive Functioning 50-60% of patients with chronic epilepsy have depression or anxiety disorders Increased risk of depression (x2) in patients with epilepsy compared with controls (impact on cognition, work, academics, social functioning) Perceived cognitive functioning strongly correlated with mood Memory performance scores weakly correlated with perceived cognitive functioning (Elixhauser et al., 1999). MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Medication and Cognition All AEDs have potential for adverse effects on cognition AEDs decrease neuronal excitability  slowed psychomotor speed, attention and memory problems Significant individual variability Some studies have found that carbamazepine (CBZ) and valproate (VPA) have fewest adverse effects in children and adults Individual variability - balance between treating seizures and minimizing side effects Keep doctor updated about any cognitive changes you notice (Devinsky, 1995; Loring, 2005; Park & Kwon, 2008). MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Neuropsychology MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Neuropsychological Assessment Standardized paper-and-pencil measures that assess variety of cognitive functions Cognitive strengths/weaknesses Assesses mood/emotional functioning Assists with treatment planning Plays a role in lateralizing/localizing seizure focus Pre-surgical baseline; serial assessments to track cognitive and emotional functioning over time MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Neuropsychological Assessment Typically last for several hours NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Review of records Medical records CT MRI EEG/VEEG Academic records IEP 504 plan Report cards NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Interview Developmental History Medical History including seizure information Educational and work history Social history (birth, where raised, languages, family, social relationships) Complaints regarding cognitive functioning (what and for how long, worsening?) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Comprehensive measures of attention Digit Span, Arithmetic, Comprehension of Instructions processing speed Coding, Symbol Search,DKEFS Trails NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

executive functioning DKEFS Switching & Tower, WAIS-IV reasoning/pattern recognition tasks - memory CVLT-II, WMS-IV Logical Memory, CVMT, RCFT, WRAML-2 NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

BNT-2, DKEFS Verbal Fluency, Vocabulary, PPVT-4 language BNT-2, DKEFS Verbal Fluency, Vocabulary, PPVT-4 visuospatial/visuomotor abilities JOLO, Visual Puzzles, Beery VMI, RCFT Copy NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Results based on norms by gender, age, education Extremely low Borderline Low Average Average High Average Superior Very Superior NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Questionnaires self-report measures observer report measures NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment also measures of mood anxiety perceived cognitive functioning coping skills NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Observations NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Results in a comprehensive report for both the referring doctor(s) and the patient Results also used for research studies (identifying information not used) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Feedback Session NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Results of evaluations helpful to the referring doctor in determining the potential impact of seizures, underlying activity, and AEDs on cognitive functioning, which can affect treatment planning. NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Results of evaluations helpful in determining if clinically significant levels of mood and anxiety symptoms may be contributing, warranting referrals for therapy or psychiatric evaluation. NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Results of evaluations can demonstrate areas of strength and weakness and document patient's complaints, which can be used to generate recommendations for addressing such in daily life. NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment What about when patients do better than they thought they would - the findings and the complaints don't match up? NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Aspects of testing situation (low stress, regular shifting between tasks, regular breaks, few distractions) Normal effects of aging Sleep Psychological/Emotional Factors NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Neuropsychological Assessment Improving patient functioning through recommendations of compensatory strategies NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Adverse impact on daily functioning due to memory and concentration difficulties Losing things MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Adverse impact on daily functioning due to memory and concentration difficulties “I hate to lose anything. I don't like to lose anything because... Where is it?“ A Place for My Stuff (released 11/1981) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Addressed with: Organization strategies: “Put your stuff back where it belongs, when you’re done with it. Then, you can find your stuff later because you put it where it belongs.” NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Use of Compensatory Strategies to Improve Cognitive Functioning Compensatory strategies: patient learns alternative ways to cope with the daily flow of information. MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Compensatory Strategies Goal: use an individual’s strengths to enhance their ability to complete daily tasks and offset specific deficits in cognitive functioning External (e.g., environmental modification, calendar, timer, etc.) Internal (e.g., mnemonics, face-name associations, etc.) NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Common Complaints I ask my child/husband/wife/partner/roommate to do something and s/he doesn’t do it. I ask her later, and s/he says, “I forgot.” MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Strategies to Implement External: have person repeat request back to you use of dry erase board/notebook in central, prominent location to mark down tasks to be completed and timelines for completion. use notes to aid with recall Internal: get into the habit of doing task while still thinking of it use rehearsal to assist with recall. MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Common Complaints My child can’t keep track of upcoming tests or assignments or can't remember to turn things in on time. MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Strategies to Implement External: Utilize weekly/monthly planner to keep track of when tests/assignments due, which will help with preparation. Have daily checklist of things to do. Set-aside “organization time” at beginning/end of each day (i.e., check book bag to ensure all assignments are there). MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Highlight tasks/assignments Engage/complete the work Internal: mnemonics Check planner Highlight tasks/assignments Engage/complete the work Check/cross off tasks completed Return folder to book bag NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Common Complaints I go to the store and forget what I was supposed to buy. MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Strategies to Implement Use mnemonics Note-taking, use of lists Cell phone apps, voice memos MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

Common Complaints I walk into a room and forget why I went in there NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Return to original room - surroundings should cue original thought processes NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Common Complaints I keep losing my phone and keys NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Keep things in the same place Put away things - don't just drop them NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Common Complaints I can't learn people's names. NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Associations - rhyming, songs, famous people NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Repeat key pieces of information Other strategies Repeat key pieces of information Decide what is important (can’t remember everything) Testing your memory when studying Avoiding cramming and spreading out learning NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Don’t be too harsh on yourself. Give yourself a break at times. NAME OF PRESENTATION IN ALL CAPS (INSERT IN FOOTER)

Thank you and questions. MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY