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

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

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

4. 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)

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

6. 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)

7. 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)

8. 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

9. 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

10. 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

11. 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)

12. 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)

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

14. Children
MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

15. 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

16. 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

17. 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

18. 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

19. 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)

20. 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

21. 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)

22. Adults
MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

23. 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

24. 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

25. 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

26. 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

27. 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)

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

29. 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

30. 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

31. Neuropsychology
MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY

32. 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

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

34. 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)

35. 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)

36. 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)

37. 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)

38. 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)

39. 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)

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

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

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

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

44. 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)

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

46. 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)

47. 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)

48. 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)

49. 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)

50. 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)

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

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

53. 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)

54. 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)

55. 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

56. 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)

57. 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

58. 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

59. 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

60. 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

61. 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)

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

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

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

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

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

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

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

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

70. 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)

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

72. Thank you and questions.
MEMORY AND CONCENTRATION PROBLEMS IN EPILEPSY