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Taking cognitive assessment out of the Dark Ages and into the Digital Era

(Image credit: Image source: Shutterstock/everything possible)

The phrase neurocognitive assessment doesn’t exactly roll off the tongue, I know. 

But as digital health becomes more sophisticated and pervasive, there’s a vast opportunity for this paper-and-pencil-driven field to help countless people. Affordable, digital cognitive tests have the potential to improve human health and well-being dramatically through prevention and personalized treatment plans. These personalized treatment plans, informed by digital health tools, can in turn indeed improve outcomes in many diseases. 

Still, the challenge remains that neuroscience and cognitive science are today at the point where our knowledge of the heart and heart disease was about 50 years ago. It was around then that doctors began to measure vitals such as blood pressure regularly. And, of course, it seems that just about everyone in the industrialized world knows his or her cholesterol levels. 

But the brain is the “motherboard” of the body -- it is the driver, regulator and operator of all our bodily systems, from pain feedback loops, to our beating hearts, to the respiration of our lungs. Yet most of us, and our doctors, know more about our liver function than about the health or ill health of our cognitive functions. 

Why is this? 

Because to this day the knowledge of how to assess cognitive function with tasks has been locked inside analog processes (including the paper, forms and pencils I wrote about above) that require a neuropsychologist to administer, score and report. As you might imagine, this makes cognitive screens prohibitively expensive and time consuming for the vast majority of us in developed countries. This entire process is still very much task-based – and a lot of it has been around since, wait for it, the 1940s. But today, cognitive screens can now be measured  less expensively and more quickly by a computer and a virtual technician. 

Already, some patient assessment functions have moved to mobile. While not smartphones, these devices are indeed mobile and allow individuals to measure their blood pressure and blood sugar levels at home or on the road. We already have pregnancy tests and HIV tests available through updated and more accessible means – you can buy them over-the-counter at the drugstore. With these shifts and more to come, a move to the digitization of healthcare is both continuing and inevitable. 

For example, in her annual and widely followed Internet Trends report, Mary Meeker of VC firm Kleiner Perkins Caufield & Byers noted recently that a good deal of the most widely used medical technology is now digital. Dental X-rays that were analog and 2D have given way to digital, 3D images. Electrocardiograms (ECGs), formerly with paper-based readouts, are now both wearable and digital. And hospital monitoring, which used to be analog and in room, is now both remote and digital. Digital cognitive assessment will soon follow in the mobile space. 

In fact, in my opinion, cognitive status really is the fifth vital sign (in addition to body temperature, blood pressure, heart rate and respiration) and it should be widely, professionally, easily and affordably available to all as a key barometer of overall human health. For instance, cognition is a top predictor of treatment outcome in many conditions, ranging from diabetes to postoperative recovery. For instance, cognitive impairment is commonly associated with pain and is a considerable obstacle to rehabilitation and recovery. 

From a physiological point of view, because neural systems overlap in both cognitive and pain-processing parts of the brain, being able to capture impairment could help uncover targeted treatment strategies to manage chronic conditions. By modernizing these 80-year-old standards, the delivery and cost structures for cognitive tests have the potential to improve the lives of many who live with chronic diseases and disorders such as diabetes, ADHD and Alzheimer’s. 

Already, there’s been some attention given in the last decade or so to brain health and, as a result and in my view, some suspect technologies have come to market promising rapid gains in cognition by playing a game or ingesting a questionable pill. Controlled studies have actually shown that many of these techniques make no difference whatsoever. 

What we know of today about cognitive neuroscience is that if you want to protect and improve cognitive health, the methods to do so are very much the same that you would do for physical health -- what have been called “the big four” of diet, exercise, sleep and social engagement. We must exercise every day, adhere to a Mediterranean diet, get good, un-medicated sleep with proper sleep hygiene, and enjoy daily face-to-face social interaction (not the Facebook kind). 

Why is cognitive data as critical in managing health as other metrics like blood glucose or blood pressure? First, we know that cognition plays a major role in being able to remember and complete daily tasks. In fact, a recent opinion piece posted by the National Institute of Health (opens in new tab) called for cognitive assessment and ongoing monitoring of cognition in a variety of chronic diseases such as COPD, heart disease and diabetes. 

Deficits in attention and mental flexibility predict non-adherence to taking a daily medication. These findings have been replicated across many clinical populations: patients taking once daily lipid-lowering medications, diabetic patients on multiple medications, and breast cancer patients on hormonal therapy. 

Let’s look at one high-impact example, diabetes. Today, standard protocol provides that diabetes be largely self-managed through diet, exercise, and medications. However, cognitive changes throughout the diabetes course are common, particularly to verbal memory and psychomotor function, studies have shown. 

A review of 12 studies looking at the relationship between cognitive traits and diabetes self-management found that cognitive measures of executive function, memory, and low scores on tests of global cognitive functioning showed significant correlations with multiple areas of diabetes self-management. Patients with lower cognitive function demonstrated poor diabetes knowledge, insulin dose adjustment skills, and the ability to learn to perform insulin injections. 

Even more alarmingly, cognitively impaired patients were less likely to manage low blood sugar events when sick. In comparison with cognitively healthy diabetics, patients with cognitive impairment were less likely to follow diet and exercise plans or be involved in diabetes self-care and monitoring.

Unfortunately, as it stands today, generally, only patients with high income or extreme cases have access to cognitive tests and comprehensive reports that provide valuable details about their condition. This insight enables physicians to prescribe treatments tailored specifically to the individual. Not only is it expensive and labor intensive, the status quo in cognitive assessment also means that these resulting treatment plans take far too long to prepare. 

But mobile, digitally powered neurocognitive assessment can be -- and will be -- a key pillar of overall health in the very near future. The research substantiating it is here, so is the technology, and so is the mobile connectivity (through cellular and WiFi). If we don’t harness this opportunity, there’s a great deal at stake: in the form of lost lives, weakened social bonds, decreased productivity, and unrealized human potential. 

Already far too much suffering comes from lack of access to healthcare and sound, trusted information. But digital tools can be the great levelers -- particularly in cognitive health -- making clinically valid and evidence-based care more affordable and accessible. 

Mylea Charvat, Ph.D. CEO & Founder,  Savonix (opens in new tab)

Image Credit: Everything Possible / Shutterstock

A trained clinical psychologist with a neuro specialty, Dr. Charvat is a recognized thought leader. She completed her fellowship in clinical neuroscience at Stanford School of Medicine and has been a lecturer at Stanford, the University of San Francisco and San Francisco State University.