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Evaluation and Consultation

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LOUISVILLE Neurologic events, such as traumatic brain injury, stroke, and dementia, require multi-faceted care. Frazier Rehab Institute, a part of KentuckyOne Health, is well-known for its inpatient and outpatient rehab services. At Frazier, rehabilitation is about recovering not just physical deficits, but also improving cognitive functioning and quality of life.

In addition to rehab therapists, Frazier employs psychologists and neuropsychologists whose services supplement inpatient and outpatient rehab. “Our focus is on adjustment to disability and facilitating recovery post-injury,” according to Brandon C. Dennis, PsyD, neuropsychologist with Frazier. He adds, “Neurologic injury often comes with psychological, behavioral, and cognitive changes. We work with the patient, family, physician, and treatment team to maximize recovery.” But how is that cognitive recovery measured? And when can a patient return to normal activities? That’s where neuropsychological evaluation can help.

A Unique Subspecialty

In contrast to typical psychologists, the neuropsychologist’s job is primarily assessment. Their services are sought out when, “There is a suspected or confirmed condition, and a physician has a question about diagnosis, severity, functioning, treatment, or whether other factors are contributing,” says Dennis. He adds, “Our job is focusing on neurologic function, the cognition, as opposed to the purely psychiatric.” Dennis, whose father is a clinical psychologist, says he initially resisted following in his father’s footsteps, but his aptitude led him into the field. “I always loved neuropsychology because it allowed me to see the complex brain-behavior relationships from both psychological and neurological perspectives,” he says. “Practicing in a physical rehab setting is especially rewarding because everything is focused on the positive and improving outcomes.”

Dennis’ primary focus is acquired brain injury, as in traumatic brain injury or stroke. Dementia and memory disorders are a close second, followed by movement disorders, epilepsy, and other conditions with a cognitive component.

In addition to rehab, Dennis sees patients in a variety of contexts. He does pre-and post-surgical assessment for patients undergoing deep brain stimulation surgery with U of L Physicians. He consults with Jewish Sports Medicine on sports-related concussion, and he works closely with KentuckyOne neurologists on a variety of conditions. Although many of his referrals are internal, Dennis is quick to note that the department is happy to accept outside referrals and, in fact, up to half of their current referrals come from outside the KentuckyOne network.

The Power of Pen and Paper

Most patients have never encountered a neuropsychologist, and thus do not know what to expect from an evaluation. The tools neuropsychologists use are mostly pencil and paper, Dennis says, adding, “All of what we do is individually administered. It’s one-on-one, face-to-face, and we don’t use any needles or electrodes. It’s answering questions and performing tasks to see how well they can remember new information, sustain attention, or solve problems.”

An analogy Dennis often uses is, “Neuropsychological assessment is kind of like radiology. The MRI scan will give you the structure of the brain, but our testing tells us how those areas are functioning. We look at scores compared to what we expect, and send our findings back to your physician for ongoing treatment.” He adds, “In addition, we are trained in cognitive intervention and have experience with learning/attention problems and psychiatric or behavioral issues, so we are in a unique position to help.”

The most common “treatment” Dennis provides is patient education. “Education goes a long way and that’s a lot of what we do. Studies have shown patients with brain injury have better outcomes when they understand their injury and know what to expect in recovery,” he says. Consistent with that idea, Dennis teaches a family and patient education group at Frazier, does regular lectures and support group talks, and is active with research efforts.

When making a referral, Dennis says the best thing a physician can do is communicate clearly what neurologic symptoms he/she is seeing that would necessitate evaluation. “What are yours or the patient’s concerns? Are there skills we can measure or questions we can answer? That’s where we can really be most helpful,” he concludes.

The Other Talk

Have your patients had “The Conversation”?

LOUISVILLE I would certainly count myself among the 90 percent of Americans that say it’s important to talk about their end-of-life care wishes, but like many others (70 percent, to be exact) I had not actually had “The Conversation” with my loved ones — until recently.

There are a million reasons to avoid or put off having the conversation, but you and I already know the primary reason: Whether you’re doing the asking or the telling, it’s hard.

The Conversation Project, co-founded by Pulitzer-Prize-winning syndicated columnist Ellen Goodman, can make it a whole lot easier for your patients to talk with their loved ones about the rest of their lives. It offers the tools, guidance, and resources — as well as motivation — needed for patients to get their thoughts together, gather around the kitchen table, and have one of the most important conversations they’ll ever have.

There’s also a patient’s guide for how to talk to their doctor – and there’s even a guide for doctors about how to talk to patients and their families about end-of-life care wishes.

The conversation isn’t so much about filling out advance directives or other medical forms. According to author Tim Prosch, it’s more about navigating how and when to give up the car keys, where patients want (and where they’ll be able) to live, and how patients want their loved ones to start taking over decision-making when they no longer can — including their preference for cure versus comfort and who will advocate for their medical needs.

According to Goodman, “Elderly parents and adult children often enter into a conspiracy of silence. Parents don’t want to worry their children. Children… worry their parents will think they’re expecting or waiting for them to die. We often comfort ourselves with the notion that doctors are ‘in charge’ and will make the right decisions. And we all think it’s too soon to speak of death. Until it’s too late.

In the last years of my mom’s life, I started talking with other people I knew who had been through similar experiences… The difference between a good death and a difficult death seemed to be whether the dying person had shared his or her wishes. So a group of my friends and colleagues—about a dozen of us in medicine, media, and the clergy—decided to come together and try to get people talking about this subject.”

BY Jan Anderson, PsyD, LPCC

Like Goodman, Prosch’s motivation for writing The Other Talk: A Guide to Talking with Your Adult Children About the Rest of Your Life, came from his personal experience of caring for his parents during the last part of their lives. “Certainly the most challenging was the role reversal that I found myself in … becoming my parents’ parent … with no planning, no expertise, inadequate resources and, most significantly, no direction and no ‘buy-in’ from my parents. It brought me to the same conclusion as all those Boomers that I’ve interviewed over the last decade: I’ll never put my kids through what just happened to me!“

I didn’t expect the conversation to be very hard for me — I have a living will, an advance directive, and a health care proxy. One of the electives I chose in my doctoral program was Death and Dying. For 15 years I co-facilitated the Hosparus Living Through Grief program.

But I wasn’t prepared for the emotional wallop I encountered as I wrestled with questions like the ones in the Conversation Starter Kit as illustrated in the chart below.

Or pondering questions like:

Are there any circumstances you would consider worse than death? (Long-term need of a breathing machine or feeding tube, not being able to recognize your loved ones, etc.)
When would it be okay to shift from a focus on curative care to a focus on comfort care alone?

It’s a lot to think about.

And then there’s how to bring the subject up, whether you want to tell someone your wishes or ask someone about theirs.

Goodman suggests some ways patients or their loved ones can break the ice:

“I was thinking about what happened to ___, and it made me realize.”
“Even though I’m okay right now, I’m worried that ___, and I want to be prepared.”
“I just answered some questions about how I want the end of my life to be. I want you to see my answers. And I’m wondering what your answers would be.”

She emphasizes, “Whether you’re sharing your wishes or need to hear from your parents, start by bringing up a memory, a statistic, an article (like this one). Try to remember these are not Grim Reaper talks. They’re not discussions about what’s the matter with you. They are about what matters to you. How you want the end of your life to reflect the whole of it. As many people have told us, these conversations produce rich moments of emotional connection. They bring us closer together. What’s more, people who have had them tend to choose less aggressive care and leave their survivors less regretful and depressed. What a gift!”

Or as Tim Prosch says, “That’s why your kids will love you for it!”

Dr. Jan Anderson is a licensed professional clinical counselor with a doctorate in clinical psychology. Her private practice includes over 15 years of experience counseling individuals, couples, and families.