2021 MBHR Measure: Cognitive Assessment with Counseling on Safety and Potential Risk

QCDR Name: MBHR Mental and Behavioral Health Registry

Measure Justification

Numerous organizations and researchers have issued guidelines and statements asserting the importance of detection of cognitive impairment in at-risk individuals as well as the use of cognitive assessment results to address safety risks and health outcomes. Although the majority of guidelines focus on older adults at risk for dementia, there is broad support for the importance of identifying cognitive impairment to improve outcomes across a wide range of medical conditions that occur across the lifespan. See list of examples below:
National Institute on Aging: Cognitive assessment is valuable in identifying emerging cognitive disorders, initiating treatments, and preparing for the future [1].

• Family Medicine: Cognitive assessment assists with averting or addressing potential safety issues and allows for long term planning and presence of caregiver to help with medical, legal and financial concerns [2].
• Sports Concussion: Cognitive evaluations allow for safely managing recovery and treatment planning in athletes recovering from concussion by identifying when it is safe to return to physical activities and identifying those at risk for long-term adverse effects [3-5].
• Traumatic Brain Injury: Position statement supporting the importance of cognitive assessment in military-related traumatic brain injury was approved by the American Academy of Clinical Neuropsychology (AACN), American Psychological Association Division 40 (Neuropsychology), American Psychological Association Division 22 (Rehabilitation Psychology), and the National Academy of Neuropsychology (NAN) [6].
• Multiple Sclerosis: Researchers have highlighted the importance of neuropsychological evaluations for patients with multiple sclerosis with a proposal of a specific cognitive testing battery [7][8].
• Epilepsy: Guidelines and consensus statements assert the importance of cognitive and specifically, neuropsychological assessment in the treatment of epilepsy [9, 10].
• Oncology: Neurocognitive testing is highly valued in treatment planning for patients with brain tumors and is predictive of functional independence [11, 12].

Furthermore, existing Local Coverage Determinations issued by the Centers for Medicare and Medicaid Services provide support that cognitive testing is deemed medically necessary across a broad range of medical diagnoses (for example see ).

1. Aging, N.I.o. Assessing Cognitive Impairment in Older Patients. 2020 6/14/2020]; Available from: https://www.nia.nih.gov/health/assessing-cognitive-impairment-older-patients.
2.  Galvin, J.E., C.H. Sadowsky, and NINCDS-ADRDA, Practical guidelines for the recognition and diagnosis of dementia. J Am Board Fam Med, 2012. 25(3): p. 367-82.
3. Echemendia, R.J., et al., Role of neuropsychologists in the evaluation and management of sport-related concussion: an inter-organization position statement. Arch Clin Neuropsychol, 2012. 27(1): p. 119-22.
4. McCrory, P., et al., Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, Zurich, November 2012. J Athl Train, 2013. 48(4): p. 554-75.
5. Moser, R.S., et al., Neuropsychological evaluation in the diagnosis and management of sports-related concussion. Arch Clin Neuropsychol, 2007. 22(8): p. 909-16.
6. McCrea, M., et al., Official position of the military TBI task force on the role of neuropsychology and rehabilitation psychology in the evaluation, management, and research of military veterans with traumatic brain injury. Clin Neuropsychol, 2008. 22(1): p. 10-26.
7. enedict, R.H., et al., Minimal neuropsychological assessment of MS patients: a consensus approach. Clin Neuropsychol, 2002. 16(3): p. 381-97.
8. Kalb, R., et al., Recommendations for cognitive screening and management in multiple sclerosis care. Mult Scler, 2018. 24(13): p. 1665-1680.
9. Jones-Gotman, M., et al., The contribution of neuropsychology to diagnostic assessment in epilepsy. Epilepsy Behav, 2010. 18(1-2): p. 3-12.
10. Labiner, D.M., et al., Essential services, personnel, and facilities in specialized epilepsy centers–revised 2010 guidelines. Epilepsia, 2010. 51(11): p. 2322-33.
11. Noll, K.R., et al., Neurocognitive functioning is associated with functional independence in newly diagnosed patients with temporal lobe glioma. Neurooncol Pract, 2018. 5(3): p. 184-193.
12. Noll, K.R., et al., Neuropsychological Practice in the Oncology Setting. Arch Clin Neuropsychol, 2018. 33(3): p. 344-353.

Impact. As with ADHD in children and adolescents there is a robust and extensive literature on the prevalence and impact of ADHD in adults. ADHD is conceptualized as a neurodevelopment disorder in the DSM 5 (APA, 2013) with prevalence estimated to be between 5 and 10% (e.g. Rowland, Skipper, & Umbach, 2015; Thomas, Sanders, Doust, Beller, & Glousiou, 2015). Current estimates are that between 4 and 5% of adults have ADHD (Kessler, et. al 2006) in the United States. ADHD in adults is also related to difficulties in school, occupational functioning, relationships, health, and various adaptive and psychological problems (see Barkley, 2015 as an example). Once thought to be a disorder of childhood, ADHD is now understood to be a disorder that continues well into adulthood including older adulthood.

Assessment and Treatment. Given the now well understood importance of ADHD in adults there are has been significant advancement in identifying how to assess and treat ADHD. The literature is voluminous. As with impact there are now a significant number of reviews of how to screen and diagnosis ADHD in adulthood (see Goodman, 2009; Ramsay, 2017; Ramsay & Rostain, 2016 in addition to the general reviews cited above as well as the CADDRA and NICE Guidelines). Given that attentional issues saturate multiple clinical presentations it is important that clinicians complete a thorough assessment using multiple methods to arrive at a proper diagnosis of ADHD. There are effective medications for ADHD as well as effective psychosocial treatments for this disorder. The issues in the current literature focus on relative efficacy and effectiveness of individual and combined treatments (see Ramsay & Rostain, 2016 as an example).

Underlying Mechanisms and Measuring Outcomes. Even though the word attention is prominent in the very diagnostic label (ADHD), the problems reflected in this diagnosis actually reflect deficits in more central cognitive processes, especially executive functioning (EF or on the deficit side, ED referring to executive dysfunction). Effective EF is needed for success in most tasks of adulthood in this society – planning, organization, execution, prioritizing, social skill, delay of gratification, and impulse control. Individuals with ADHD as defined in the DSM have difficulty with these tasks, and the issue in much of the literature has focused on whether ED is a correlate of ADHD or a criterial feature of ADHD much like the other symptoms in the DSM. There is uniform agreement that individuals with ADHD have difficulty with EF when it is assessed in addition to assessing the diagnostic symptoms of ADHD. Executive Dysfunction (ED) is the mechanism that translates the diagnosis of ADHD in the life difficulties experienced by adults who have this disorder. Therefore, any assessment or formal tracking of treatment outcomes must also address ED.

Specific Rationale for the Proposed Measurement Process. For the purpose of the proposed measure in this document the work of Adler and his colleagues provides the rationale and justification for the selection of the ASRS as the outcome assessment tool. The ASRS developed by the WHO Workgroup on Adult ADHD, is a patient report rating scale based on DSM ADHD symptoms that has been extensively used in clinical work and in research. (Adler, Kessler & Spencer, 2003; Kessler, et. al., 2005). The ASRS is publicly available and is easy to use in clinical settings. Given that ED central to addressing the impact of treatment it needs to be part of the assessment of outcome. In a series of important papers on this topic Adler and his associates have investigated the relation between ADHD/ED relationship and have demonstrated that independent measures of ED are highly correlated with ADHD symptoms in multiple samples (Adler, Faraone, Spencer, Berglund, Alperine, & Kessler, 2017; Silverstein, Faraone, Alperin, Biederman, Spencer, & Adler, 2018; Silverstein, Faraone, Leon, Biederman, Spencer, & Adler, 2018). In Adler et al. (2017), the intercorrelations between symptoms and ED are so substantial that the argument is made that ED is a core feature of ADHD and not simply a correlate of it. For the purpose of the measure proposed in the current document this work means that using the ASRS serves not only as a symptom measure but also serves as a proxy for the measurement of ED. Therefore, there is substantial empirical support for using only a symptom measure to track outcomes of care because this assessment also measures the mechanism that underlies the surface symptoms that are both reported by patients and observed by researchers.

The use of the ASRS in the current project is iterative step in developing a robust set of metrics and measures for assessing and monitoring the process and outcomes of care for adult ADHD. Also related to ADHD in adults are other emotional issues and quality of life difficulties (Agarwal, Goldenberg, Perry, & Ishak, 2012; Barkley, 2015).While these topics are important, and can be addressed either in metric refinement or new measures, they are excluded from this initial measure in this important area. The identification and development of this measure is consistent with the measure development model developed by the American Psychological Association (APA, see Wright, Goodheart, Bard, Bobbitt, Butt, Lysell, McKay, & Stephens, 2019 for overview of the APA project). Also excluded from this metric is proscription about the type of treatment that patients receive. It is expected that clinicians from different professional backgrounds will draw upon the above referenced Guidelines and also on the extant published literature on clinical best practices.