1. Identifying and Tracking Changes in Cognition Related to NPH Sheldon Herring, Ph.D. Clinical Director Outpatient Brain Injury and Young Stroke Program

3. Identifying and Tracking Changes in Cognition Related to NPH OUTLINE Background Cognitive changes associated with NPH NPH- a distinct dementia (?) NPH- a reversible dementia (?) Role of Cognitive Assessment Timing of Assessments Benefits of testing

4. Stargazing 101

5. Stargazing 102

10. Cognitive changes associated with NPH Impairment of wakefulness or vigilance Psychomotor speed Attention and concentration Memory and learning Visual-perceptual, spatial, and constructive ability Calculus or arithmetic Reading and writing

11. Cognitive changes associated with NPH Problem-solving Conceptualization Abstract reasoning Executive functions Awareness of change and deficit (anosagnosia)

12. Cognitive changes associated with NPH Differences remain after exclusion of patients with more severe deficits. Pattern of associations between neuropsychological domains was consistent with multi-regional pathological changes and impaired connectivity. Severity of cognitive deficits not always associated with chronicity

13. Cognitive changes associated with NPH Cerebrovascular disorders or shown to add substantially to the neuropsychological impairment in a manner “aptly described as more of the same”. Hellstrom et al 2007

14. Hellstrom et all Neurosurgery 2007

15. NPH- a distinct dementia (?) Stargazing 201 NPH greater impairment on measures of frontal lobe functioning while AD worse on verbal memory ( Saito et al 2011) Cortical- subcortical debate

16. NPH- a reversible dementia (?) Cognitive area showing improvement after shunting include: Delayed verbal recall Memory for designs (visual memory) Visual constructional abilities Psychomotor speed Visual scanning

17. NPH- a reversible dementia (?) Cognitive area showing improvement after shunting include: Executive skills may be more variable. DeVito et al 2005 Physical symptoms (gait) greater change than cognition in many cases

18. NPH- a reversible dementia (?) There is no general agreement about which cognitive functions are more likely to be restored after shunt placement. Iddon et al showed that more demented patient showed significant improvement after surgery whereas nondemented patients remain unchanged.

19. NPH- a reversible dementia (?) Thomas (2005)showed verbal memory and psycho motor speed more likely to respond to shunt surgery with half of their patient showing changes as early as three months. If verbal and visual constructional functioning was impaired, less likely to see improvement. Some of these improvements parallel increase in corpus callosum size as noted on the MRI

20. NPH- a reversible dementia (?) Metabolic changes assumed related to improved cognition measurable within one week of shunt Statistically significant changes noted across groups at 1, 3 and 6 months Improvement after 12 months unlikely

21. NPH- a reversible dementia (?) Need to note that even with patients who show improvement there is increased risk of cognitive decline years down the road. At 4.8 years 80% showed cognitive decline and 46% showed clinical dementia. Picascia et al 2015

22. Role of Cognitive Assessment Group profiles do not predict individual patterns. Individualized neuropsychological profiles are required for clinically relevant conclusions Individualized testing converts the hypothetical into the real. Goes beyond the “what” to the “so what”.

23. Role of Cognitive Assessment Neuropsychological evaluation versus mental status testing Even patients with MMSE of greater than 26 can show neuropsychological deficits

24. Role of Cognitive Assessment Diagnostically: The inter-correlation of tests justifies some reduction in testing without jeopardizing sensitivity. (Hellstrom 2007) Minimally, diagnostic testing can be more focused and should include measures of executive skills, memory (verbal and visual*) and psychomotor abilities (Hellstrom 2012) Optimally, premorbid intelligence, apathy, depression, quality-of-life, dementia screen, memory, including verbal and visual learning, executive skills, attention, psychomotor speed, and visual construction skills. (DeVito 2005)

25. Role of Cognitive Assessment Other potential applications such as competence, return to work, etc. may require more broader testing. In cases where the hydrocephalus may be secondary to other prior medical events such as meningitis, subarachnoid hemorrhage, or trauma, screening may be less appropriate and a broader assessment required.

26. Timing of Assessments Pre- and post surgery benefits – There been two documented cases where post shunt testing revealing decreased neuropsychological performance after shunting compared to premorbid testing leading to discovery of subdural fluid collections

27. Benefits of testing Personal Family – Understanding of behaviors Intentional versus non-intentional – Significance of strengths and deficits (driving, financial decisions, other important decision making)