Report Interpretation
Clinicians routinely use the CNS Vital Signs VSX Neurocognitive and Behavioral Assessment testing platforms to evaluate a subject’s neurocognitive status, establish a neurocognitive baseline, and assess symptoms, behaviors, and comorbidities. The testing results are autoscored into a user-friendly, easy-to-interpret formats so clinicians can utilize the results to evaluate and manage a patient’s condition. Both the CNS Vital Signs Neurocognitive Assessment and the Rating Scales Reports were designed to present the testing results in a SUMMARY DASHBOARD and DETAILED REPORT format immediately following the testing session. Serial administered neurocognitive tests can also be presented in a LONGITUDINAL REPORT format to track disease progression, outcomes, or treatment effects. The CNS Vital Signs reports are logical and intuitive making the reports interpretation by a qualified health professional relatively straightforward. All assessment results should be considered with other relevant clinical information such as history, physical examination, other psychological or neuropsychological tests, lab results, imaging studies, etc., in accordance with good clinical practice standards.
Assessing Behavior:
CNS Vital Signs uses well known, evidence-based medical and health rating scales to help clinicians identify, assess, and track a patient’s symptoms, behaviors, and comorbidities.
Evaluating CNS Vital Signs Evidence-Based Rating Scales:
Over 50 evidence-based behavioral, medical, and health rating scales to help clinicians identify, assess, and track a patient’s symptoms, behaviors, and comorbidities have been added to the CNS Vital Signs assessment platforms. The rating scales are auto-scored according to scale developers guideline with most have either cutoff or severity scores. Access to additional interpretation information can be accessed by going to the SAMPLE CLINICAL REPORTS button on the homepage.
Assessing Brain Function:
CNS Vital Signs is a clinical testing procedure used by clinicians to evaluate and manage the neurocognitive state of a patient. Across the lifetime, serial testing allows ongoing assessments of a patient’s condition, disease progression, or clinical outcome.
HOW? CNS Vital Signs begins with…
A: Conducting a Valid Assessment (Refer to the Test Administration Guide.) To begin the staff should collect information about the CHIEF or REFERRAL COMPLAINT. This will be a primary driver for the selection of tests and rating scales. For initial evaluations or in complex presentations, a broad spectrum battery is always an appropriate starting point.
B: Review the immediately auto-scored report to (1) validate testing effort, (2) evaluate the Domain Dashboard to quickly assess the level of impairment or grade the deficit, and (3) Evaluate the Domain Pattern to help rule-in, rule-out, or confirm certain clinical conditions. Feedback to the patient on the testing results may be presented at the clinical encounter or at a subsequent patient visit.
C: If invalid test results were noted then consider re-testing the patient to confirm clinical results. If the test results were valid, then, as part a continuum of care, reschedule testing to track disease progression and measure ongoing status or outcomes.
NOTE: The Validity Indicator denotes a guideline for representing the possibility of an invalid test or domain score. “No” means a clinician should evaluate whether or not the test subject understood the test, put forth their best effort, or has a clinical condition requiring further evaluation.
1. Validity Indicator: Evaluate Credible Effort
WHY? When analyzing test data, either in research, or in clinical practice, it is important to know whether a test result is valid or not. Clinicians need to know if testing subjects are generating “dubious results” or a “non-credible response pattern.” CNS Vital Signs has developed “validity indicators” for its tests and domains that indicate whether the patient gave poor effort or generated invalid results (feigning, malingering, etc.) Across the span of neurological and psychiatric disorders, it is important to have “valid” tests to get a true evaluation of a patient.
WHAT? The CNS Vital Signs Validity Indicator (VI) is a guideline identifying the possibility of an invalid test or domain score. When reviewing a report, a “No” in the VI column suggests the clinician should evaluate whether or not the test subject understood the test, put forth their best effort, or has a clinical condition requiring further evaluation. The CLINICAL DOMAIN validity indicators are based on summary data from multiple tests. NOTE: The CNS Vital Signs batteries can be successfully completed, without assistance, by a normal child with a 4th grade reading level. Likewise, elderly with MMSE scores above 22 can complete the battery. Keep in mind, it is not uncommon for patients to generate an invalid result on one test in the battery due to misreading the instructions or giving-up on the test. Proper pretest instruction leads to a better testing experience.
HOW? The Validity Indicator alerts the clinician to the possibility of an invalid test allowing the clinician, examiner or testing technician to question the testing subject: Do the testing results reflect an understanding of the test and the instructions? Did the testing subject put forth their best effort? Did they get a good night’s sleep? Does the subject have poor vision and need their glasses? Do the results suggest willful exaggeration, e.g., malingering?
Should a subject test abnormally low triggering an “invalid” test (NO as displayed in the Validity Indicator section of the report) then that would be a reason for retesting the individual, unless your clinical judgment makes you believe that is the best score the patient can achieve. Like any suspicious lab, the test should be re-administered, and it can be done with CNS Vital Signs through the RETEST function. Before Retesting, the test examiner or technician should reinforce the need for the subject to give a good testing effort and use the “Validity Indicator” as a tool to help with the reinforcement. To RETEST a subject go to MENU > RETEST SUBJECT > and select the appropriate subject and retest the subject. Upon retest, should a subject test abnormally low again triggering yet another “invalid” test (NO as displayed in the Validity Indicator section of the report) and the clinician believes it was the patient’s best effort further evaluation or referrals should be considered.
CNS Vital Signs Embedded Indicators of Valid Testing Effort
The “Validity Indicator” scoring algorithm is based on research presented (Detecting Invalidity In Neurocognitive Tests) at International Society for CNS Clinical Trials and Methodology (ISCTM) in 2009. The poster is available on the CNS Vital Signs website.
2. Evaluate Severity – Impairment Status
CNS Vital Signs grades severity of impairment based on an age-matched normative comparison database. Most neuropsychiatric and neurodegenerative conditions are multifactorial in nature. Effective evaluation of neurocognitive and behavioral issues can provide a standardized and efficient method of collecting valid and important neuropsychiatric clinical endpoints. These neuropsychiatric clinical endpoints can systematically document a patient’s clinical course. Altogether, CNS Vital Signs computerized testing can facilitate a more complete assessment and provide a basis for patient and family feedback.
The CNS Vital Signs STANDARD SCORES and PERCENTILE RANKS are auto-scored using an algorithm based on a normative data set of 1900+ subjects, ranging from Ages 8 – 90. In the age-matched normative sample subjects were: (1) in good health, (2) had no past or present psychiatric or neurological disorders, head injury, or learning disabilities, and the (3) Sample subjects were free of any centrally acting medications. The CNS Vital Signs normative data is presented in ten age groups: less than 10 years old, 10–14, 15–19; in deciles to 79, and finally, 80 years or older. NORMAL AGING affects performance on all CNS Vital Signs tests. A patient’s standard scores are based on data from normal controls that are the same age EDUCATION and SPECIAL SKILLS may also affect test performance; therefore, concern should be taken for patients that are very intelligent or well educated yet their scores are below average. Like any laboratory test, an abnormal result should be the occasion for further evaluation. As with any neuropsychological tests, results can be affected by motivation or effort level and the Validity Indicator will help identify those patients.
Psychometric and Normative Comparison
CNS Vital Signs advantages include consistency in administration and scoring, the ability to generate almost unlimited alternative forms suitable for repeated testing and millisecond precision responses. The ability to track various components of subject responses and develop large databases easily using the CNS Vital Signs platform provides a clinical robustness to clinicians interested in following groups of patients in registries for outcomes, research, and surveillance purposes.
Neurocognitive Domain Dashboard
CNS Vital Signs presents testing results in Subject (raw), Standard Scores, and Percentile Ranks. Results obtained from a CNS Vital Signs assessment can be used to evaluate or monitor a patient’s condition and the subsequent treatment and management of that patient. Below, is a description of each domain category:
- Subject Scores are computed from raw score calculations using the data values of individual subtests and are simply the number of correct responses, incorrect responses, and reaction times. Reaction times are in milliseconds. An ASTERISK (*) denotes that "lower score is better” e.g. timing, otherwise higher scores are better.
- Standard Scores are normalized from raw scores and present an age matched score relative to other people in a normative sample. CNS Vital Signs standardized have a mean of 100 and a standard deviation is 15. Higher scores are always better. The schema where the mean is 100 and the standard deviation is 15 is similar to the presentation of IQ scores where the mean for normal is 100.
- Percentile Scores is a mathematical transformation of the standard score and an index of how the subject scored compared to other subjects of the same age on a scale of 1 to 99. If an individual obtained a score at the 52nd percentile (50th percentile is average), this would mean that their performance would be equal to 52% of his same-aged peers in the general population. Higher scores are always better.
- See Psychometric - Normative Comparison above.
3. Evaluate Pattern – Suggestive Pathology
Like most psychological tests, clinicians will recognize, over time, which domains reveal the clinical conditions of their patients. The profiles below may help clinicians evaluate test results. The profiles are based on thousands of well-characterized patients, as well as a review of published literature and data.
Variation in neurocognitive scores can be multifactorial in nature. Genetic, maternal health issues, environmental, developmental, other disease processes e.g., diabetes or comorbidities can affect neurocognition. Patients may experience global deficits or domain specific deficits across a variety of neurological and psychiatric disease states which may differ from what is displayed below. CNS Vital Signs is sensitive to medication effects. Attention should be paid to the nature and response pattern as well as errors. Patient's scoring well below average in one domain or below average in two domain areas, might well be impaired and should be evaluated further. The first step in evaluating such a patient is to repeat the test under more favorable circumstances. Like any laboratory test, repetitive results outside of normal should be investigated. If the scores are low the second time, a targeted work-up may be necessary.
Neurocognitive Complexity Example:
“Over the past century, the syndrome currently referred to as attention-deficit/hyperactivity disorder (ADHD) has been conceptualized in relation to varying cognitive problems including attention, reward response, executive functioning, and other cognitive processes. More recently, it has become clear that whereas ADHD is associated at the group level with a range of cognitive impairments, no single cognitive dysfunction characterizes all children with ADHD. In other words, ADHD is not a one-size-fits-all phenomenon. Patients with this syndrome do not fit into any one category and present with widely differing co-occurring disorders—including varying cognitive profiles.” Source: Cognitive Impairments With ADHD, Psychiatric Times. Vol. 26 No. 3, 2009
Domain Score Calculations
The CNS Vital Signs domain scores initially established through a factor analysis of the raw data (Gualtieri & Johnson, 2006), are derived by summing multiple primary raw scores. Domain scores are presented as Subject (raw) Scores, Standard Scores, and Percentile Ranks. Subject Scores are computed from raw score calculations using the data values of individual subtests and are simply the number of correct responses, incorrect responses, and reaction times. The standard scores are normalized with a mean of 100 and standard deviation of 15. Percentile Ranks is a mathematical transformation of the standard score and an index of how the subject scored compared to other subjects of the same age on a scale of 1 to 99.
Formulas for Calculating the Neurocognitive Domain Scores:
Abbreviations Defined:
VBM – Verbal Memory Test; VIM – Visual Memory Test; SDC – Symbol Digit Coding Test; SAT – Shifting Attention Test; FTT - Finger Tapping Test; ST – Stroop Test; CPT – Continuous Performance Test; 4PCPT – Four Part CPT; POET – Perception of Emotions Test; NVR – Non-verbal Reasoning Test.
CNS Vital Signs VSX Report
