Cognitive assessment using digital tools — including computers, smartphones, tablets and wearable devices — could improve upon pencil-and-paper evaluations by allowing for more in-depth measurement and enhanced monitoring of neuropsychological functioning.
These opportunities, however, are not without challenges, according to Laura Germine, PhD, technical director of the McLean Institute for Technology in Psychiatry, and author of a paper recently published in The Clinical Neuropsychologist that offers a review of the current state of digital neuropsychology, with an emphasis on personal devices.
“Digital neuropsychology is not simply the substitution of paper and pencil for a computer screen and electronic response capture; rather, it is a shift in the way we conceptualize neuropsychological measurement that encapsulates both the challenges of digital assessment as well as the opportunities,” Germine and colleagues wrote. “This means, simultaneously, a shift towards developing and incorporating more sophisticated models of behavior that emphasize the sorts of moment-to-moment data that can be easily captured with digital devices as well as accounting for the potential confounds that come with digital assessment.”
In an interview with Healio Psychiatry, Germine pointed to some of the challenges of digital neuropsychology outlined in the paper. At the most basic level, variations in device types and models may cause variable results. For instance, a patient may take an assessment on an old Android device, then upgrade 1 year later to a brand-new iPhone that’s lighter in feel and more responsive to touch and show improved cognition. In this case, researchers must be able to distinguish between true cognitive improvement and differences in devices or software.
Germine likened this to administrator variation in the traditional pencil-and-paper assessments.
“A neuropsychologist in one area of the country and a neuropsychologist in another area of the country are going to do things a little differently, even if they received the same training,” Germine said. “Then, of course, there are variations in the administrators themselves, day to day. If they’re tired that day, or not feeling well or if they’ve had a really stressful week, you might not get as high a score as you would if you were assessed by someone who’s doing really well and has had their coffee and is totally focused.”
According to Germine, variation in digital devices is a trackable problem, though, and one that researchers can measure and adjust for. In their paper, they propose giving enough attention to norms and designing tests to reduce factors related to device variability when possible. Specifically, when it comes to test validation and establishing norms, they recommend testing a range of devices to determine whether a particular measure produces similar scores. At the test design stage, they suggest relying less on measurement characteristics or stimuli that are less sensitive to device-related differences.
Promise of technology
The paper also explains the benefits of digital neuropsychology, particularly the ability to test people in their every day environment, Germine explained. With traditional clinical neuropsychology, the goal is to ascertain a person’s optimal performance — when they’re fully engaged, they’re concentrating and when the conditions are ideal. With digital neuropsychology, researchers can determine a person’s actual performance, in real time and in real life. For some people, Germine said, those answers could be very similar and for others very different. Because psychiatric symptoms — particularly mood symptoms and anxiety symptoms — fluctuate on a daily, weekly or even hourly basis, it is nearly impossible to understand how positive changes are related to symptoms using traditional assessment.
“With digital neuropsychology, we’re opening the door to being able to understand cognitive information processing and brain functioning in many different environments, in many different contexts and in ways that will hopefully not only allow us to understand more about mental disorders, but also better inform treatment and interventions,” Germine said.
To this end, she and colleagues are currently working on a project with the National Institute on Aging to develop infrastructure to allow for digital neuropsychological testing via mobile devices.
“We’re bringing together the brightest minds and innovators to create a standard set of tools for mobile devices that will help move the needle in our understanding of brain health and how neuropsychological functioning contributes to physical and mental disorders,” she said in the press release. – by Stacey L. Adams
Germine L, et al. Clin Neuropsychol. 2019;doi:10.1080/13854046.2018.
Disclosure: Germine and colleagues report no relevant financial disclosures.