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Advanced Automated Assessment of Cognitive Changes Associated with Brain Injury and Neurological Disease


OBJECTIVE: Develop a computerized cognitive assessment system that is primarily self-administering using video or avatar-based instructions and language recognition to assess language-based skills including verbal memory in addition to other core cognitive domains. DESCRIPTION: Automating the administration of neurocognitive tests is inevitable and has a number of advantages including: 1) improved standardization, 2) reduced administration and scoring errors, 3) increased access to care, and 4) reduction in cost and examination time. Currently, a number of computer tests can be administered with minimal input from a trained tester. However, the ability to develop a primarily self-administering core test battery has been limited by requiring patients to read instructions and by the need to include tests requiring verbal responses. Technology now exists to overcome these limitations. Programs have been developed using avatars as interactive counselors and voice recognition technology has improved to the point that the basic word recognition needed to assess skills such as list learning and confrontation naming are now possible. In addition, computerized tests themselves enhance cognitive testing by permitting accurate response timing important for the assessment of concussion and a variety of neurological disorders. Computers have also expanded the range of tasks that can be administered as part of a cognitive assessment. Extensive experience using computerized tests within clinical settings as demonstrated their utility and feasibility with various neurological populations. Voice recognition will enhance the clinical utility of computerized metrics by improving the process of presenting instructions (visually and verbally) and by permitting patients with upper extremity motor impairments to respond verbally. In addition to being cost effective and improving the reliability of the assessment process, having a core neurocognitive test battery that is self-administering with minimal to no tester input addresses Army operational needs and long-term health objectives. Such a system will enhance telemedicine based assessment for underserved and remote locations including in theater and has the potential to be used in the patient centered medical home as part of a more general health monitoring program. Experience has also taught that even when potentially available, neurocognitive assessments are underutilized for patient assessment due to wait times for appointments, the examination length, and the turn-around time for reports. Consequently, increasing the capabilities of computerized assessment methods will improve services in medical centers as well as in the home and in remote locations. For these benefits to occur, the required next phase is to integrate improved instruction delivery and voice recognition into automated test systems. Consistent with current best practices, this enhanced system is not intended to replace the essential role of the clinician in integrating information and developing a formal assessment. Rather, it is intended to substantially update and streamline the testing process. Hence, the focus of this announcement is to develop an automated test system that can be reliably self-administered with minimal supervision, potentially using video or avatar based instructions, that incorporates language recognition to assess language-based cognitive domains and to provide an alternate method of responding to test stimuli for individuals who have significant upper motor limitations. The methods employed should be adaptable for telemedicine based-assessment to extend this capability to remote locations and to the home. These objectives are achievable through the integration and enhancement of current technologies. PHASE I: Phase I will have two principal objectives. The first objective is to develop and demonstrate a system for administering a battery of neurocognitive tests that is potentially self-administering with clearly presented directions using both visual illustrations and verbal instructions. A number of methods for doing this are possible and may include video and avatar-based instructions. The second objective is to demonstrate the implementation of voice recognition that is sufficiently accurate to permit computer administration of verbally based tasks including word-list learning, confrontation naming, and aural comprehension. While current technology may not permit the direct assessment of word-list generation, contractors should consider the degree to which current capabilities would permit this type of assessment. The goal of Phase I is to produce a prototype test battery that is primarily self-administering and comprehensive with respect to core cognitive domains assessed including language-based skills. No studies involving human use can be conducted during Phase I in view of the 6-month period of performance. PHASE II: The contractor will further develop, optimize, and demonstrate their self-administering neurocognitive test system. The contractor will refine the technology needed to present test instructions clearly and to assess verbal skills on the computer without input from or real-time response recording by an examiner. At the completion of Phase II, the contractor will have produced a computerized test battery that: 1) is essentially self-administering, 2) assesses core cognitive domains, 3) assesses key verbal skills without the aid of an examiner, and 4) has a verbal response option for individuals with upper extremity impairment. A pilot study should be completed at the end of Phase II demonstrating that the test system can administered to a to a select group of neurological patients. PHASE III: The contractor will produce a self-administering computerized neurocognitive assessment system capable of meeting FDA standards which are expected to evolve over the next several years. Phase III will involve demonstrations of test reliability, the compilation of norms from relevant reference groups, and demonstrated utility for various clinical populations. The end product will be suitable for use in military and civilian medical clinics and deployable to remote locations. It will provide for a core neurocognitive assessment that is time efficient with respect to examination length and by providing immediate scoring of test results. Since the test system will be self-administered with minimal supervision, it will make maximum use of the limited number of trained neuropsychologists in the military and in a number of civilian clinical settings by focusing their efforts on providing clinical interpretation of test findings. This automated capability will have considerable commercial value in light of changes taking place in heal care delivery with respect to utilization and reimbursement. This system will result in timely service delivery reducing the time between the initial referral and the completion of the examination. It will also permit timely reporting of test results which currently can lag several weeks to a month post examination. The proposed system will both reduce the cost of individual examinations while making the service more accessible and more likely to be implemented when clinically indicated. In addition, it will be possible with further development to adopt this system for telemedicine applications such that service personnel and civilians will be able to undergo a detailed neurocognitive evaluation independent of their geographic location. Test development and validation is a continuing and ongoing process. However, at the end of Phase III, the contractor should produce an instrument that can be employed in military and civilian settings. REFERENCES: 1. Jacobsen SE, Sprenger T, Andersson S, Krogstad JM. Neuropsychological assessment and telemedicine: a preliminary study examining the reliability of neuropsychological services performed via telecommunication. Journal of the International Neuropsychological Society, 2003; 9(3): 472-8. 2. Kanauss K, Schztz P, Puente AE. Current trends in the reimbursement of professional neuropsychological services. Archives of Clinical Neuropsychology, 2005; 20(3): 341-53 3. Kane RL, Roebuck-Spenser T, Short P, Kabat MH, Wilken JA. 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