- •TeleNP represents a medium through which clinical research and important clinical care can continue.
- •We discuss benefits, challenges, and practical considerations in the use of teleNP.
- •We describe how the Australian Epilepsy Project has adapted to the COVID-19 environment.
- •TeleNP data acquired to date reveals deficits typical of those observed in epilepsy.
- •TeleNP presents an opportunity to expand the reach and breadth of neuropsychological services.
Abbreviations:AEP (Australian Epilepsy Project), ASM (antiseizure medication), TeleNP (teleneuropsychology)
- Fowler G.
2. The Australian Epilepsy Project
3. TeleNP can enable research in the era of COVID-19
- •Recruitment occurs through neurologists during routine clinical practice. For the majority of patients this is now via telehealth consultation.
- •Information provision and the establishing of informed consent are conducted via email and telephone. Participant consent is confirmed verbally and documented electronically and in writing by the researcher.
- •Cognition: Neuropsychological assessment is performed entirely via TeleNP. This includes a combination of neuropsychologist-supervised oral and computer-assisted testing, in conjunction with purely computer-administered web-based testing. Further detail is provided in the main text.
- •MRI: MRI is performed in-person, at research-dedicated scanners. All participants are screened for COVID-19 symptoms or risk factors before they attend the premises. On-site, physical distancing strategies, appropriate personal protective equipment use, and cleaning procedures are all applied according to up-dated research facility protocols. Images are transmitted electronically to the hospital radiology departments for standard reporting and clinical use. This approach eliminates the need for participants to physically attend hospital premises for clinical scans and reduces the burden on hospital radiology at a time of increased strain on the hospital system.
- •While genetics and epilepsy follow-up (e.g. seizure diaries, medications, psychological and quality of life questionnaires, adverse events, health economic data) are not collected in the AEP Pilot Study, in the full project genetic samples will be obtained by blood-draw at a local community pathology provider (typically at the same time as routine clinical blood tests), and epilepsy follow-up will occur via smart device app/web survey and telephone call.
- •Data analysis and transfer is performed by research staff accessing secure server platforms remotely via encrypted network connections, enabling this work to be safely performed from home. Key team decision making activities are supported via teleconferencing.
4. Selecting epilepsy-relevant tools for TeleNP
|Test of Premorbid Functioning [|
]: an estimate of premorbid intellect based on irregular word reading, used here both as a measure of intellect, and due to the elevated incidence of reading disorders in epilepsy [
|WASI-II FSIQ 2 (Matrix Reasoning, Vocabulary) [|
]*: a short form intelligence measure with excellent psychometric properties.
|Oral Symbol Digit Modalities Test [|
]: the SDMT is a sensitive measure of processing speed and, in its written form, has been used widely in epilepsy trials [
|Oral Trail Making Test [|
]: a measure of divided attention and speed, sensitive (in its original written form) to dysfunction in epilepsy [
|Reverse Digit Span [|
]*: a measure of working memory, sensitive to dysfunction in epilepsy [
|Verbal Fluency [|
]*: letter and category based verbal fluency are sensitive markers of dysfunction in epilepsy, both in focal epilepsy [
] and as an effect of antiseizure medications [
], and also useful as a predictor of cognitive risk from surgery [
|Boston Naming Test [|
]*: a measure of confrontation naming, sensitive to lateralised dysfunction in focal epilepsy [
], and also useful as a predictor of cognitive risk from surgery [
|Rey Auditory Verbal Learning Test (learning and delayed recall trials)*: a word list learning task sensitive to memory dysfunction across a range of epilepsy syndromes [|
], to lateralisation in temporal lobe epilepsy [
], and predictive of post-operative cognitive outcome [
|CANTAB Connect (web-based testing) [|
]: a computerised assessment battery with an emphasis on executive functions. While the CANTAB does not have an extensive research base in epilepsy [
], it has been used widely in other neurological conditions and is sensitive to frontal and temporal lobe dysfunction [
]. We include the following measures from the CANTAB:
|The following psychological measures, administered via REDCap [|
] online surveys, are also reviewed by the neuropsychologist during the TeleNP testing session:
|Neurological Disorders Depressions Inventory for Epilepsy (NDDI-E) [|
]*: a widely used mood screening tool developed specifically for epilepsy, validated against psychiatric interview determined clinical diagnosis [
|Generalised Anxiety Disorder 7-item scale (GAD7) [|
]*: a brief generalised anxiety screening tool that has been validated in epilepsy against psychiatric interview determined clinical diagnosis [
|Epilepsy Anxiety Survey Instrument (EASI) [|
]: an anxiety screening tool designed specifically for use in epilepsy, validated against psychiatric interview determined clinical diagnosis.
5. Practical considerations for TeleNP
- Haralambous B.
- Subramaniam S.
- Hwang K.
- Dow B.
- LoGiudice D.
- •Screened to check that they have adequate technology to support TeleNP, defined at minimum as:
- oComputer or iPad with web cam, microphone and internet connection (smartphones and non-iPad tablets are not suitable, given software requirements of the web-delivered computer-administered testing used in the AEP, see below).
- oQuiet, distraction free room in which to complete the TeleNP assessment
- •Emailed a link to a set of electronically-hosted surveys tapping elements of psychosocial functioning germane to epilepsy (e.g. Neurological Disorders Depression in Epilepsy []; Patient Health Questionnaire GAD-7 []; Epilepsy Anxiety Survey Instrument []; QoLiE-31 []; Liverpool Adverse Events Profile [66,67,68]; ABNAS []). The surveys are hosted on a REDCap [,] database server at our institution.
- •Emailed a telehealth information sheet, along with text describing an ‘agreement to telehealth’ whereby participant and researcher agree that they will not “record, reproduce, publish or make copies of the materials used during the neuropsychology telehealth session” []. Participants are advised that their TeleNP session cannot proceed until they confirm acceptance of this agreement.
- •Verifies the participant’s identity
- •Checks the participant’s telehealth technology setup (e.g. microphone and webcam setup and testing; quality of connection; disabling of other apps and notifications; suitability of environment)
- •Explains what will happen in the event of lost connection (attempt to reconnect; if unable to, will call mobile phone; if no contact within 10 min, session considered aborted and will be rescheduled)
- •Confirms the participant’s current location and obtains additional contact information in event of emergency (e.g. seizure). We explain that in the event of a seizure, if we cannot reach one of the contacts provided, or if we feel a more urgent response is appropriate, that we will call an ambulance. This information is summarised in a teleNP information sheet provided to all participants in advance of their session. We are yet to have a participant experience a seizure during testing.
- •Re-iterates terms of agreement to participate in telehealth (e.g. participant will not record or reproduce any materials)
- 1via ScreenShare linked to a high resolution document camera: Test of Premorbid Function []; Matrix Reasoning from WASI-II []; Boston Naming Test []; oral Symbol Digit Modalities Test [].
- 2via oral stimulus delivery: letter and category verbal fluency, reverse digit span, oral Trail Making Test [], Rey Auditory Verbal Learning Test [], Vocabulary from WASI-II [].
- 3via web-delivered computer-administered testing: using the CANTAB [] web platform. While testing via this platform can be completed by the participant in a standalone manner, we have the examiner remain on the videocall throughout, to handle any unanticipated problems that might arise and also to monitor behaviour during the testing.
6. TeleNP reveals a typical pattern of impairments in epilepsy
|TEST||μ||SD||p (t/T)||n||n: z<-1.5 (%)||μ(home)||μ(onsite)||μ(f2f)||p (F/H)|
|ToPF||0.34||0.75||0.99||29||0 (0.0)||0.59 (18)||−0.19 (6)||0.11 (5)||0.07|
|FSIQ-2||−0.11||0.82||0.23||28||1 (3.6)||0.06 (17)||−0.57 (6)||−0.16 (5)||0.36|
|RVP: a’||−0.25||0.89||0.07||28||2 (7.1)||−0.08 (18)||−0.97 (5)||−0.16 (5)||0.47|
|Oral SDMT||−1.13||1.18||0.01||9||3 (33.3)||−0.93 (8)||−2.73 (1)||NaN (0)||0.16|
|^DSB||−0.10||0.97||0.07||24||0 (0.0)||−0.15 (18)||0.06 (6)||NaN (0)||0.71|
|^SWM: be468||−0.21||1.45||0.15||28||3 (10.7)||−0.35 (18)||0.04 (5)||0.02 (5)||0.68|
|^SWM: Strategy||−0.16||1.12||0.08||28||2 (7.1)||−0.15 (18)||0.02 (5)||−0.41 (5)||0.78|
|^Oral TMT B||−0.93||0.91||0.00||24||7 (29.2)||−0.75 (18)||−1.45 (6)||NaN (0)||0.11|
|OTS: 1st Try||0.24||0.99||0.89||28||0 (0.0)||0.31 (18)||0.27 (5)||−0.04 (5)||0.53|
|^IED: yerta||−0.14||0.94||0.29||28||2 (7.1)||−0.04 (18)||−0.27 (5)||−0.40 (5)||0.67|
|COWAT||−1.30||0.87||0.00||24||11 (45.8)||−1.11 (18)||−1.86 (6)||NaN (0)||0.07|
|Animals||−0.37||1.40||0.09||29||5 (17.2)||−0.26 (18)||−0.56 (6)||−0.52 (5)||0.65|
|^BNT||−1.77||1.65||0.00||28||13 (46.4)||−1.90 (18)||−1.76 (6)||−1.18 (4)||0.89|
|RAVLT: sum(A1-A3)||−0.92||1.05||0.00||29||8 (27.6)||−0.77 (18)||−1.22 (6)||−1.10 (5)||0.42|
|RAVLT: delay||−1.27||1.28||0.00||29||14 (48.3)||−1.02 (18)||−1.69 (6)||−1.66 (5)||0.23|
|RAVLT: loss||−1.07||1.27||0.00||29||12 (41.4)||−0.97 (18)||−1.29 (6)||−1.18 (5)||0.66|
|PAL: tea28||−0.12||1.17||0.29||28||3 (10.7)||−0.06 (18)||−0.54 (2)||0.05 (5)||0.95|
|PAL: fams28||−0.24||1.24||0.15||28||4 (14.3)||−0.18 (18)||−0.72 (2)||0.01 (5)||0.97|
7. The future of TeleNP in epilepsy research and clinical trials
- •Anterograde memory: the most common cognitive complaint in epilepsy []; the majority of focal epilepsies affect the temporal lobe [].
- •Executive functions/fluid intelligence: sensitive to ASM effects []; the frontal lobes are frequently involved in focal [] and genetic [] epilepsies.
- •Crystallized intelligence: considered less susceptible to ASM effects []; can be affected by age of epilepsy onset []; provides a measure of cognitive reserve [
Predicting cognitive impairment in epilepsy: findings from the bozeman epilepsy consortium.J Clin Exp Neuropsychol. 1995; 17: 909-917https://doi.org/10.1080/01688639508402439].
- Strauss E.
- Loring D.
- Chelune G.
- Hunter M.
- Hermann B.
- Perrine K.
- et al.
- •Adverse treatment side effects
8. TeleNP in the clinical management of epilepsy
Declaration of Competing Interest
- Smartphone data reveal which Americans are social distancing (and not).Washington Post, 2020 (accessed April 21, 2020)
- Where have all the heart attacks gone?.The New York Times, 2020
- Concern as heart attack and stroke patients delay seeking help.The Guardian, 2020
- Inter organizational practice committee Recommendations/Guidance for teleneuropsychology in response to the COVID-19 pandemic.Arch Clin Neuropsychol. 2020;
- Artificial intelligence for clinical decision support in neurology.Brain Communications. 2020;
- Test of premorbid functioning. UK version (TOPF UK).Pearson Corporation, UK2011
- Associations of dyslexia with epilepsy, handedness, and gender.Annals-New York Academy of Sciences. 1993; 682 (402–402)
- Reading difficulty is associated with failure to lateralize temporooccipital function.Epilepsia. 2014; 55: 746-753https://doi.org/10.1111/epi.12607
- Manual for the Wechsler abbreviated intelligence scale (WASI).The Psychological Corporation, San Antonio, TX1999
- Comparability, reliability, and practice effects on alternate forms of the Digit Symbol Substitution and Symbol Digit Modalities tests.Psychol Assess. 2005; 17: 237
- A neuropsychological battery for epilepsy.Epilepsia. 1978; 19: 611-623
- Army individual test battery. Manual of Directions and Scoring.1944
- EpiTrack: tracking cognitive side effects of medication on attention and executive functions in patients with epilepsy.Epilepsy Behav. 2005; 7: 708-714
- WAIS-IV technical and interpretive manual.Pearson, San Antonio, TX2008
- Controlled oral word association test.Multilingual aphasia examination. 1994
- Verbal fluency in focal epilepsy: a systematic review and meta-analysis.Neuropsychol Rev. 2014; 24: 200-218
- Predictors of decline in verbal fluency after frontal lobe epilepsy surgery.Epilepsy Behav. 2013; 27: 326-329https://doi.org/10.1016/j.yebeh.2013.02.015
- The Boston naming test.Lea & Febiger, Philadelphia, PA1983
- Differential neuropsychological test sensitivity to left temporal lobe epilepsy.J Int Neuropsychol Soc. 2008; 14: 394-400
- Sensitivity and specificity of memory and naming tests for identifying left temporal-lobe epilepsy.Appl Neuropsychol Adult. 2015; 22: 189-196
- Visual confrontation naming outcome after standard left anterior temporal lobectomy with sparing versus resection of the superior temporal gyrus: a randomized prospective clinical trial.Epilepsia. 1999; 40: 1070-1076
- Should cognition be screened in new-onset epilepsies? A study in 247 untreated patients.J Neurol. 2012; 259: 1727-1731
- Verbal memory in mesial temporal lobe epilepsy: beyond material specificity.Brain. 2009; (awp012)
- Predicting memory decline following epilepsy surgery: a multivariate approach.Epilepsia. 2006; 47: 1887-1894
- Cognitive assessment software.Cambridge Cognition, 2019
- Computerized neuropsychological testing in epilepsy: overview of available tools.Seizure. 2013; 22: 416-423
- A compendium of neuropsychological tests: administration, norms and commentary.3rd ed. Oxford University Press, New York2006
- Frontal lobe dysfunction as a predictor of depression and anxiety following temporal lobe epilepsy surgery.Epilepsy Res. 2019; 152: 59-66
- Cognitive and behavioural assessments in clinical trials: what type of measure?.Epilepsy Res. 2001; 45: 163-167
- Common data elements in epilepsy research: development and implementation of the NINDS epilepsy CDE project.Epilepsia. 2011; 52: 1186-1191
- The use of figural reproduction tests as measures of nonverbal memory in epilepsy surgery candidates.J Int Neuropsychol Soc. 1997; 3: 435-443
- Use of the Brief Visuospatial Memory Test—revised (BVMT-R) in neuropsychological evaluation of epilepsy surgery candidates.Epilepsy Behav. 2004; 5: 175-179
- Lateralization of verbal memory and unilateral hippocampal sclerosis - evidence of task-specific effects.J Clin Exp Neuropsychol. 1993; 15: 608-618https://doi.org/10.1080/01688639308402582
- Impaired verbal associative learning after resection of left perirhinal cortex.Brain. 2007; 130: 1423-1431
- Verbal memory in left temporal lobe epilepsy: evidence for task-related localization.Ann Neurol. 2002; 51: 442-447
- Paired associate performance in the early detection of DAT.J Int Neuropsychol Soc. 2002; 8: 58
- Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.J Biomed Inform. 2009; 42: 377-381
- The REDCap consortium: building an international community of software platform partners.J Biomed Inform. 2019; 95103208
- Rapid detection of major depression in epilepsy: a multicentre study.Lancet Neurol. 2006; 5: 399-405
- A brief measure for assessing generalized anxiety disorder: the GAD-7.Arch Intern Med. 2006; 166: 1092-1097
- Validation of the generalized anxiety disorder-7 in people with epilepsy: a MEPSY study.Epilepsy Behav. 2014; 35: 59-63
- Rapid detection of generalized anxiety disorder and major depression in epilepsy: validation of the GAD-7 as a complementary tool to the NDDI-E in a French sample.Epilepsy Behav. 2016; 57: 211-216
- Design and validation of two measures to detect anxiety disorders in epilepsy: the Epilepsy Anxiety Survey Instrument and its brief counterpart.Epilepsia. 2019; 60: 2068-2077
- The oral trail making test: effects of age and concurrent validity.Arch Clin Neuropsychol. 2010; 25: 236-243
- Aging and response inhibition: normative data for the Victoria stroop Test.Aging Neuropsychol Cogn. 2006; 13: 20-35
- A narrative review of the evidence regarding the use of telemedicine to deliver video-interpreting during dementia assessments for older people.Asia-pacific Psychiatry. 2019; 11e12355https://doi.org/10.1111/appy.12355
- Neuropsychological test administration by videoconference: a systematic review and meta-analysis.Neuropsychol Rev. 2017; 27: 174-186
- Initial practice recommendations for teleneuropsychology.Clin Neuropsychol. 2011; 25: 1119-1133
- Validity of teleneuropsychological assessment in older patients with cognitive disorders.Arch Clin Neuropsychol. 2018; 33: 1040-1045
- Recommendations/Guidance for teleneuropsychology (TeleNP) in response to the COVID-19 pandemic.2020
- Emory university telehealth neuropsychology development and implementation in response to the COVID-19 pandemic.Clin Neuropsychol. 2020; : 1-15
- Validity of teleneuropsychology for older adults in response to COVID-19: a systematic and critical review.Clin Neuropsychol. 2020; : 1-42
British Psychological Society D of N. Division of Neuropsychology Professional Standards Unit Guidelines to colleagues on the use of Tele-neuropsychology 2020.
- Teleneuropsychology: evidence for video teleconference-based neuropsychological assessment.J Int Neuropsychol Soc. 2014; 20: 1028-1033
- Cognitive assessment using face-to-face and videoconferencing methods.Nurs Older People. 2019; 31
- The feasibility of videoconferencing for neuropsychological assessments of rural youth experiencing early psychosis.J Telemed Telecare. 2011; 17: 328-331
- Neuropsychological assessment and telemedicine: a preliminary study examining the reliability of neuropsychology services performed via telecommunication.J Int Neuropsychol Soc. 2003; 9: 472-478
- Feasibility of neuropsychological testing of older adults via videoconference: implications for assessing the capacity for independent living.J Telemed Telecare. 2004; 10: 130-134
- The consistency of neuropsychological assessments performed via telecommunication and face to face.J Telemed Telecare. 2000; 6: 147-151
- Validation of a novel telehealth administration protocol for the NIH toolbox-cognition battery.Telemed E-health. 2019; 25: 237-242
- Remote cognitive assessments for patients with multiple sclerosis: a feasibility study.Mult Scler. 2015; 21: 1072-1079
- Video teleconference administration of the repeatable battery for the assessment of neuropsychological status.Arch Clin Neuropsychol. 2016; 31: 8-11
- Remote neuropsychological assessment in rural American Indians with and without cognitive impairment.Arch Clin Neuropsychol. 2016; 31: 420-425
- Symbol digit modalities test: a valid clinical trial endpoint for measuring cognition in multiple sclerosis.Mult Scler. 2019; 25: 1781-1790
- Development and cross-cultural translations of a 31-item quality of life in epilepsy inventory.Epilepsia. 1998; 39: 81-88
- Development of a patient-based symptom check list to quantify adverse effects in persons receiving antiepileptic drugs.Epilepsia. 1993; 34: 18
- Initial development, reliability and validity of a patient-based adverse drug event scale.Epilepsia. 1994; 35: S20
- The Liverpool adverse drug events profile.Epilepsia. 1995; 36: S59
- The A–B neuropsychological assessment schedule (ABNAS): the further refinement of a patient-based scale of patient-perceived cognitive functioning.Epilepsy Res. 2001; 43: 227-237
- Pearson telepractice no objection letter.Pearson, 2020
- A comparison of intellectual assessments over video conferencing and in-person for individuals with ID: preliminary data.J Intellect Disabil Res. 2010; 54: 573-577
- Best practices for remote psychological assessment via telehealth technologies.Prof Psychol Res Pr. 2014; 45: 27
- Current standards of neuropsychological assessment in epilepsy surgery centers across Europe.Epilepsia. 2017; 58: 343-355
- Memory complaints in epilepsy: an accurate reflection of memory impairment or an indicator of poor adjustment? A review of the literature.Clin Psychol Rev. 2009; 29: 354-367
- Is the underlying cause of epilepsy a major prognostic factor for recurrence?.Neurology. 1998; 51: 1256-1262
- Genetics advances in autosomal dominant focal epilepsies: focus on DEPDC5. Progress in brain research, vol. 213.Elsevier, 2014: 123-139
- Evaluating the mediating role of executive functions for antiepileptic drugs’ effects on IQ in children and adolescents with epilepsy.Epilepsy Behav. 2019; 96: 98-103
- Predicting cognitive impairment in epilepsy: findings from the bozeman epilepsy consortium.J Clin Exp Neuropsychol. 1995; 17: 909-917https://doi.org/10.1080/01688639508402439
- Chronic epilepsy and cognition: a longitudinal study in temporal lobe epilepsy.Ann Neurol. 2003; 54: 425-432
- Depression in epilepsy: prevalence, clinical semiology, pathogenic mechanisms, and treatment.Biol Psychiatry. 2003; 54: 388-398https://doi.org/10.1016/S0006-3223(03)00469-4
International League Against Epilepsy Neuropsycholoigcal assessments for epilepsy surgery during COVID-19 Restrictions n.d.
- Videoconferencing psychotherapy: a systematic review.Psychol Serv. 2012; 9: 111
- Effects of an epilepsy-specific Internet intervention (Emyna) on depression: results of the ENCODE randomized controlled trial.Epilepsia. 2019; 60: 656-668
- Telephonic review for outpatients with epilepsy—a prospective randomized, parallel group study.Seizure. 2017; 53: 55-61
- A comparison of epilepsy patients in a traditional ambulatory clinic and a telemedicine clinic.Epilepsia. 2005; 46: 767-770
- Feasibility of epilepsy follow-up care through telemedicine: a pilot study on the patient’s perspective.Epilepsia. 2008; 49: 573-585
- Keeping people with epilepsy safe during the Covid-19 pandemic.Neurology. 2020; 94: 1032-1037
- Patient readmission and support utilization following anterior temporal lobectomy.Seizure. 1999; 8: 20-25
- Counseling of people with epilepsy via telemedicine: experiences at a German tertiary epilepsy center during the COVID-19 pandemic.Epilepsy Behav. 2020; 112107298https://doi.org/10.1016/j.yebeh.2020.107298
User LicenseCreative Commons Attribution – NonCommercial – NoDerivs (CC BY-NC-ND 4.0) |
For non-commercial purposes:
- Read, print & download
- Redistribute or republish the final article
- Text & data mine
- Translate the article (private use only, not for distribution)
- Reuse portions or extracts from the article in other works
- Sell or re-use for commercial purposes
- Distribute translations or adaptations of the article
Elsevier's open access license policy