Digital Neuropsychology: Technological Approaches for the Assessment of Cognitive Functions in Older Adults
Elif YıldırımConsistent with the growth in aging population, the number of individuals with dementia is increasing. There is an agreement regarding the essential role of neuropsychological assessment in the early detection of cognitive decline, which is crucial in improving the course of dementia. Neuropsychological assessment that is usually applied with classical paper–pencil tests became digitalized with advancing technology. This digitalization spread rapidly, especially with the COVID-19 pandemic. This study aimed to investigate the digital approaches that are used in the neuropsychological assessment of older adults. In this context, a critical review of digital approaches, including teleneuropsychology, computerized neuropsychological assessment batteries, mobile technology or web-based assessment tools, and innovative technological methods, such as virtual and augmented reality has been conducted. The results of teleneuropsychology studies, which focused on remote administration of neuropsychological tests usually via videoconference, indicated that this method is reliable and valid. Computerized batteries and methods based on mobile technology provide an opportunity for self-testing in nonclinical settings and a background for follow-up studies with large samples. Although assessment methods using new technologies, such as virtual reality, are still in their infancy, they have great potential for more sensitive measurements. The majority of the methods involved in digital approaches, which have advantages such as increased accessibility and standardization of measurements, revealed consistent results with classical paper–pencil tests and patients’ diagnosis. However, a detailed psychometric analysis and best practice guidelines of the digital approaches are still lacking. Moreover, digital approaches can present a challenge in the clinician–patient relationship and have limitations in patient observation during testing. Despite the limitations due to digital neuropsychology applications, digital approaches have the potential to provide important benefits to patients, professionals in the area, and the health system. In this respect, academic and clinical studies that would benefit all parties are important.
Dijital Nöropsikoloji: Yaşlı Bireylerin Bilişsel İşlevlerinin Değerlendirilmesinde Kullanılan Teknolojik Yaklaşımlar
Elif YıldırımNüfusun yaşlanması ile paralel olarak demans tanılı kişilerin sayısı artmaktadır. Demans seyrinin iyileştirilmesi için kritik bir öneme sahip olan bilişsel bozuklukların erken saptanmasında nöropsikolojik değerlendirmenin büyük bir rolü olduğu kabul edilmektedir. Sıklıkla klasik kâğıt- kalem testleri ile uygulanan nöropsikolojik değerlendirme, günümüzde gelişen teknoloji ile birlikte dijitalleşmeye başlamıştır. Özellikle de Covid–19 pandemisi ile birlikle bu dijitalleşme ivme kazanmıştır. Bu çalışmada, yaşlı bireylerin nöropsikolojik değerlendirmelerinde kullanılan dijital yaklaşımların incelenmesi amaçlanmaktadır. Bu kapsamda, telenöropsikoloji, bilgisayarlı nöropsikolojik değerlendirme bataryaları, mobil teknoloji ya da web temelli değerlendirme araçları ve sanal gerçeklik, arttırılmış gerçeklik gibi yenilikçi teknolojik yöntemlere dayanan ölçümleri içeren dijital yaklaşımların eleştirel bir değerlendirmesi yapılmıştır. Sıklıkla videokonferans aracılığı ile nöropsikolojik testlerin uzaktan uygulanmasına odaklanan telenöropsikoloji çalışmaları ile ilgili sonuçlar bu yöntemin güvenilir ve geçerli olduğunu belirtmektedir. Bilgisayarlı bataryalar ve mobil teknolojiye dayanan yöntemler, klinik dışı bireysel uygulamaya olanak sağlamakta ve geniş örneklemli takip çalışmaları için altyapı hazırlamaktadır. Sanal gerçeklik gibi yeni teknolojilerin kullanıldığı değerlendirme yöntemler ise henüz emekleme aşamasında olsa da daha hassas ölçümlerin yapılması için büyük potansiyel taşımaktadır. Ulaşılabilirliğin artması ve ölçümlerin standartlaşması gibi avantajlar taşıyan dijital yaklaşımlar içinde sıklıkla kullanılan yöntemlerin büyük bir kısmının klasik kağıt-kalem testleri ve hastaların tanıları ile tutarlı olduğu gösterilmiştir. Fakat dijital yaklaşımların detaylı psikometrik analizlerinin yapılması ve iyi uygulama rehberlerinin geliştirmesi konusunda çeşitli eksiklikler bulunmaktadır. Buna ek olarak, dijital yaklaşımların uzman-hasta ilişkisinde zorluk yaratabileceği ve hastanın test sırasında gözlemlenmesi konusunda kısıtlılıklar taşıdığı belirtilmektedir. Her ne kadar dijital nöropsikoloji uygulamalarının yarattığı kısıtlılıklar mevcut olsa da, dijital yaklaşımlar hastalar, alandaki uzmanlar ve sağlık sistemi açısından önemli faydalar sağlama potansiyeline sahiptir. Bu nedenle, tüm taraflar açısından fayda sağlayacak akademik ve klinik çalışmaların yapılması önem taşımaktadır.
With population aging, many social and clinical problems arise, and one of these problems is the increase in the incidence of dementia and cognitive disorders among elderly individuals (Corrada et al., 2010). Early detection of dementia and timely interventions are crucial in disease management (Geldmacher et al., 2014). Therefore, cognitive assessment of the elderly population should include reliable, valid, and appropriate methods to detect, prevent, or intervene early in cognitive functions and/or disorders (Eyre et al., 2015). Although standardized neuropsychological assessment is one of the most common methods used for this purpose, this method has many limitations due to its face-to-face application (Germine et al., 2019; Miller & Barr, 2017).
The age-related physical difficulties in the elderly population could lead to problems in terms of transportation to the hospital. Particularly, the requirement for patients with dementia to reach the hospital can impose a burden on caregivers. Moreover, the accessibility of the cognitive evaluations for individuals living in rural areas decreases because neuropsychologists are often designated in metropolitan cities and central hospitals (Miller & Barr, 2017). In this context, it is essential to develop methods that can be an alternative to face-to-face applications (Germine et al., 2019). In addition to these factors, introducing alternative practices has been increasingly necessary with the suggestion of reducing unnecessary medical interactions due to the COVID-19 pandemic, which carries fatal risks for elderly individuals (Roy et al., 2020). This review aimed to make a general evaluation of digital approaches, including the remote application of cognitive tests via video conference (teleneuropsychology), methods using technologies such as computerized assessment, mobile application, or virtual reality.
Studies on teleneuropsychology (for a meta-analysis: Brearly et al., 2017; Marra et al., 2020a) have shown that tests based on verbal application have strong reliability for remote applications. However, factors such as connection speed, physical characteristics of the place where the application is conducted, and test security are essential for the method (Cullum and Grosch, 2012). For this reason, taking precautions related to environmental factors that may affect test performance determine the success of videoconferencing applications. Moreover, if the patient has special needs or requires assistance, it is necessary to take precautions regarding these. At this point, it should be kept in mind that not every patient is suitable for videoconferencing.
The digital application of neuropsychological assessment via computer–tablet or mobile technologies allows the applicability of the tests to extended segments and provides richness in terms of measurement and standardization (Germine et al., 2019). Many batteries and applications evaluate core cognitive areas, such as attention, processing speed, memory, executive functions, and visuospatial functions via different tests and tasks (Zygouris & Tsolaki, 2015). Thus, the selection of a battery or specific test in the battery should depend on the intention of use and possibilities. It should be also noted that these batteries and applications are not intended to replace classical neuropsychological evaluation (Aslam et al., 2018; García-Casal et al., 2017). These methods could be use only to identify individuals with cognitive impairment because it is not possible to diagnose dementia with these tests. In addition to computerized batteries and applications, some studies also investigated webbased assessment approaches and digital versions of classical paper–pencil tests, such as Clock Drawing Test (Cohen et al., 2014), Trail Making Test (Fellows et al., 2017), and Montreal Cognitive Assessment (Berg et al., 2018). In addition to these methods, some studies focusing on the possibility of the cognitive assessment with virtual reality provided promising results (e.g., Cabinio et al., 2020; Eraslan Boz et al., 2020).
Discussion
Digital approaches for neuropsychological assessment have some advantages, including increased accessibility for patients, decreased costs of medical care for patients and healthcare system, and potential of more sensitive, standardized, and unbiased cognitive assessment (Germine et al., 2019). Thus, it can be thought that neuropsychology will be digitalized in the near future. However, digital approaches also have significant limitations (Miller & Barr, 2017). The first and foremost disadvantage of both remote and computerized cognitive assessment is the limited observation of behaviors and strategies of patients (Cullum & Grosch, 2012). Other disadvantages include the lack of normative and psychometric data of these methods, and factors adversely affecting test performance, such as lack of knowledge and experience of computer use and concerns about computer use (Bilder et al., 2020). Moreover, digital approaches are sensitive to technical specifications of the computer and internet connection speed. Therefore, a critical review of the digital approaches for neuropsychological assessment would benefit future research and clinical studies.
