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  • 1 College 1 Cost Effectiveness



  • Dimensions of a clinical neuropsychological examination


    §Processing speed
    §Attention
    §Memory and learning
    §Executive functions
    §Visuo- spatial skills
    §Speech and language functions
    §Perceptual skills (auditory, visual and tactual)
    §Psychomotor speed and coordination of simple motor responses
    §Emotional and motivational characteristics
    §Social functioning and social cognition
    §Self-awareness of level of functioning and judgements regarding psychosocial implications
  • Markers of value
    Refers to money equivalent (e.g. cost saving) of the service received

    Comparison between costs of assessment and treatment with money saved by avoiding other health care costs and by returning an individual to work and social responsibility
  • Objective markers
    Reduce cost and liability
    Improve quality of life
    assess the effectiveness of treatment
    guide treatment procedures
    provide a continuum of care for patients
    Improve physician education and decision making
  • Subjective markers
    • Reduce patients sense of psychological aloneness with daily problems
    • Reduce patient's expectations, confusion and frustration about the nature of their disturbances.
    • Help family members feel less guilty in making decisions regarding brain-dysfunctional adults and children.
  • 2 Advancing the profession of clinical neuropsychology with appropriate outcome studies and demonstrated clinical skills.

  • For clinical neuropsychology to flourish as a profession, two types of 'data' or 'evidence' are needed. One type of data comes from well-designed, 'evidence-based' outcome studies that demonstrate the efficacy and the cost-effectiveness of our procedures and interventions. Another crucial type of 'data' needed is for individual practicing clinicians to demonstrate clearly to the referring physicians the value of their clinical judgment in patient care. Wanneer deze twee bronnen van bewijs voor ons beroep  niet serieus worden genomen zal het economisch fundament verliezen in de al moeilijke gezondheidszorg economie. Dat zal ertoe leiden dat alleen mensen die het zich kunnen permitteren gebruik kan maken van neuropsychologische diensten. En dat andere mensen door een tekort komen van de juiste zorg en behandeling een veel slechtere uitkomst hebben
  • Professional identity of npsych
    The value of our work is ultimately judged by four individuals
    1. patient
    2. familie
    3. referral source
    4. payor of the services

    Patient satisfaction is often directly related to the perception that the clinical neuropsychologist took adequate time to carefully listen to his or her concerns and then acted on those concerns in a way that helped the patient.
  • 1. Vind je professionele plek
    Dit betekent een plek die voldoet aan je professionele behoeftes en de behoeftes van anderen. 
    2. Zie in dat neuropsychologen geen ‘mini’ neurologen, psychiaters of radiologen zijn.
    Hou je identiteit als een psycholoog vast die geïnteresseerd is in de brein-gedrags relatie.
    3. Evalueer het concept van waarde in de gezondheidszorg economie
    De objectieve en subjectieve waarde van neuropsychologen. Streef altijd na om van toegevoegde waarde te zijn. En het belang van de patiënt voorop te stellen in plaats van het belang van veel geld.
  • 3 College 2 Fatigue

  • Fatigue

    Significant proportion of general population affected by excessive fatigue

    One of the most common complaints reported to primary care physicians
    --> Frequent and prolonged tiredness interfering with everyday life in about 27% of patients in primary care settings
  • Difference pathological and non-pathological fatigue
    - greater intensity
    - longer duration
    - more disabling effect on functional abilities
    - remains after rest as a severe condition
  • Fatigue as a symptom
    • Fatigue = Often reported as the most disabling symptom in many diseases by affecting the patient’s physical, psychological  and social well-being
    • Fatigue = Nonspecific symptom, because it can be indicative of many causes or conditions

    Neurological conditions/ psychiatric conditions / medical conditions / medications/ unhealty lifestyles
  • Fatigue as a disease
    • Fatigue = Often part of a group of “unexplained” illnesses (e.g. chronic fatigue syndrome, neurasthenia) with little understanding of its causes
    • Chronic fatigue syndrome (CFS) = Persistent debilitating fatigue lasting for at least 6 months not due to ongoing exertion, not substantially relieved by rest, and not caused by other medical conditions
    • Chronic fatigue = Estimated to occur in about 4% to 5% of general population (Jason et al., 1999)
  • Defining/ conceptualising fatigue
    No general consensus on a universal definition of the term “fatigue” --> Lack of a consensual definition remains a major obstacle to understanding the clinical manifestations of fatigue

    Fatigue can be conceptualized as…
    • a subjective feeling
    • a performance decrement
    • Clinical definitions of fatigue focus primarily on patients’ subjective feelings of fatigue 
  • Peripheral fatigue

    Is defined as failure to sustain force or power output because of neuromuscular dysfunction outside of the central nervous system
  • Central fatigue

    Is defined as resulting from failure to achieve and maintain the recruitment of high-threshold motor units, implicating dysfunction in the central nervous system
  • Fatigue comprises at least four components
    • Behaviour
    • Feeling
    • Mechanism
    • Context
  • Neurobiological correlates of Fatigue
    Fatigue has been suggested as general indicator of brain damage
    Primary mechanisms of fatigue include:
    • Basal ganglia
    • Frontal lobes
    • HPA- axis
    • Proinflammatory cytokines affecting neural metabolism
  • Primary fatigue

    Fatigue caused by its primary neural mechanisms (e.g. changes in basal ganglia activation during fatigue-producing activity)
  • Secondary fatigue

    Includes factors perpetuating or exacerbating its effects (e.g. deconditioning, sleep habits, medication). Secondary mechanisms are likely associated with the feeling fatigue.
  • Despite failures in proofing a relation between fatigue and performance decrement, patients’ subjective complaints about fatigue have to be taken serious
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Verschil tussen mensen met amnesie en confabulatie
Amnestische patienten maken errors of omission (kunnen dingen niet herinneren) en confabulerende patienten maken errors of commission (vervormde of geheel verzonnen herinneringen). Zij hebben dus niet alleen een gediscontinueerde identiteit na de hersenschade, ze hebben een valse identiteit en zijn daarmee een extreem voorbeeld van gereconstructueerd geheugen.
When is assent sufficient (no informed consent necessary)
  • Testing is mandate by law or governmental regulations
  • Informed consent is implied because testing is conducted as a routine educational, institutional, or organizational activity
  • Where the purpose of testing is to evaluate decisional capacity
But Psychologist must still:

  • Provide appropriate explanation
  • Consider such persons preferences and best interests
  • Obtain appropriate permission by a legally authorized person if permitted or required by law
  • Seek patients assent
Also patients can or should be informed of their right to revoke consent without penalty or prejudice.
Modifications in the APA ethics code and current standards for informed consent
he revised code specifies the need for informed consent for ´´assessment, evaluations, or diagnostic services,´´ albeit with several notable exceptions in which patient assent represents the appropiate standard of care,  addressing these issues in three sections (a) section 3.10 in Human relations, Section 4.2 discussing the Limits of Confidentiality, and Section 9.03 on Informed Consent in assessment.
What constitutes full disclosure in informed consent is less ambiguous than in previous versions of the APA Ethics Code.

Section 9.03 states that consent should include
  • An explanation of the nature and purpose of the assessment
  • Fees
  • Involvement of third parties
  • Limits of confidentiality
  • Patient should have sufficient opportunity to ask questions
Psychosis
is a constellation of symptoms including delusional beliefs and ideas and hallucinatory experiences that can manifest with or without insight. Psychosis is more common in global deterioration in patients with diffuse cerebrovascular disease where the symptoms may follow an episodic, stepwise occurrence, or in patients with degenerative white-matter disease. There is evidence of psychotic symptoms in AD-patients (34%) and in vascular dementia (54%), and are a common feature in Lewy Bodies dementia. In LBD visual hallucinations are a primary diagnostic criterion and therefore present at the earliest stage. Among patients with epilepsy, particularly those with partial seizures arising from mesial temporal structures, schizophrenia-like psychosis has been found in 3-7% of cases.

psychotic symptoms are well covered by standard psychiatric interviews such as the SCID, SANS and BPRS. The NPI in its various forms permits a brief assessment although the MOUSEPAD offers a more thorough evalutation.
Apathy
refers to a constellation of behavioural, emotional and motivational features including reduced interest an participation in normal purposeful behaviour.
Apathy follows often after TBI (46%) and hypoxic brain damage (79%), and noted higher rates in patients with right hemisphere damage or subcortical involvement. After stroke prevalence rate of 20-25% is found. Apathy is common in all dementia syndromes, regardless of whether the primary pathology is cortical or subcortical. In frontotemporal it can be an early feature. No reports of apathy in epilepsy.
The Apathy Evaluation Scale (AES)  & SANS-AD/ Dementia apathy rating scale
GAD
is one of the most common anxiety disorders in patients with neurological conditions, frequently comorbid with depression. In TBI patients the prevalence is 9-25%. After stroke almost 30% has an GAD.
Panic is complexly associated with epilepsy. Fear is a common feature of partial seizures arising from temporal lobe damage. Some patients with primary panic disorder experience non-epileptic seizures, while in other cases a seizure disorder may present in such a way that is misdiagnosed as a psychiatric condition. Panic disorders has received relatively less attention in other conditions.
Social avoidance (social phobia or agoraphobia) is significant following TBI (7%). Agoraphobia may also occur following stroke.
Brain injury can be associated with acute stress disorder and later PTSD. Although some authors suggest that post traumatic amnesia protect against PTSD, prevalence is 19-26%. Also after stroke persistent PTSD-like symptoms are common.

HAM-A (Hamilton Anxiety Rating Scale)
Depression
Is one of the most common problems in patients with brain disorders. One month after TBI 26% has a major depression, while 42% had depression at some point in the following year. Even after mild TBI the prevalence is high of MD. MD is also found after stroke (22%), mostly in people with right-hemisphere lesions. Depression is commonly reported in Alzheimer (30%) and Parkinson disease (17%) patients. In epilepsy depressive symptoms as well as anxiety and fear may be found. The study of depression in epilepsy is further complicated by the interaction between symptoms and medication.
BDI and HADS
Self-report instrument
provide an economical means of assessing specific psychological problems, particularly for screening and to assess change.
Informant-based assessment
can provide a valuable alternative or supplement to self-report and clinician based assessment (carers rating). Most widely used is the Neuropsychiatric Inventory (NPI), semi-structured interview. A questionnaire-based version is also available (NPIQ). The MOUSEPEAD and BEHAVE-AD have been developed to assess the ‘non-cognitive’ symptoms in AD
Psychological needs of patients in low awareness states
Relatives of patients in low awareness states have been reported to experience a range of emtional reactions including shock, anxiety, guilt, denial, depression and hostility towards staff caring for the patient. Many factors may contribute to these reactions including loss of the person they care about, changes in roles and/or social circumstances and the complex medical and ethical desicions in which they may become involved. All these factors can in turn impact on their relationships with staff caring for the patient.