Cognition has been identified as an area of priority in examining health impacts of COVID-19 infection, and evidence suggests the virus invades the brain, with potential for long-term cognitive impact. Studies utilizing screening measures have reported cognitive sequelae (e.g., attention disorder, executive dysfunction) of the post-COVID-19 condition (i.e., long-haulers). More extensive examination of cognitive difficulties via comprehensive neuropsychological assessment is critical to informing treatment for those experiencing cognitive or functional difficulties post-infection. We aimed to comprehensively evaluate cognitive resiliencies and vulnerabilities of acutely recovered COVID-19 patients, across key domains (i.e., attention, processing speed, language, visuospatial abilities, memory, executive functioning), compared to healthy controls.

Adults (N=103; aged 19-85; 69.2% female) who had COVID-19 at least three months prior (n=50) and those with no history of infection (n=53) completed demographic and health questionnaires via Qualtrics, along with measures of depressive (CES-D) and anxiety (GAD-7) symptoms, the Lawton-Brody Instrumental Activities of Daily Living (IADL) Scale, and a measure of subjective cognitive difficulties (SCD-Q). Participants (n=84) completed a teleneuropsychology assessment including a short interview and battery of neuropsychological tests assessing attention (BTA, Digit Span Forward), processing speed (DKEFS Colour Naming & Word Reading, SDMT), language (FAS, Animals, NAB Naming), visuospatial abilities (JLO, RCFT Copy), verbal and visual memory (HVLT-R, NAB Shape Learning, RCFT), and executive function (DKEFS Color-Word Interference & Switching, Digit Span Backward & Sequencing, BRIEF), and including multiple measures of cognitive effort/assessment validity (RFIT, RDS), and a self-report measure of symptom validity (SIMS). T-tests were used to examine demographic and health variables between COVID-19 and control groups. MANCOVA were used to examine group differences across each cognitive domain assessed, and across cognitive effort and symptom validity tasks, while controlling for English language status.

Group comparisons indicated that the COVID-19 group was slightly older (mean age = 40 vs. 34 yrs.; f=-2.101, p=0.04). Those who had COVID-19 reported more difficulties completing IADLs (f=2.204; p=0.03), more depressive symptoms (f=-2.299; p=0.02), and more subjective cognitive difficulties (f=-3.886; p<0.01). Examination of cognitive performance indicated a main effect of prior infection on executive function, controlling for language status (Wilks’ /\=0.817, F(6,73)=2.733, p=0.02). Specifically, having COVID-19 was associated with worse DKEFS Colour-Word Switching performance (p=0.01) and slightly higher selfreported difficulties on the BRIEF MI (p=0.04). No other significant group differences were seen across cognitive domains. There was also a main effect of COVID-19 infection on effort and symptom validity task performance (Wilks’ /\=0.705, F(10,70)=2.923, p<0.01). Specifically, prior infection was associated with higher SIMS Neurologic Impairment (p<0.01) and Amnestic Disorders (p<0.01) subscale scores, and paradoxically, slightly higher RFIT combined scores (p=0.02).

Interestingly, results indicate a significant role for subjective cognitive complaints and potential exaggeration of cognitive symptoms post-COVID-19 infection, in the absence of differences in objective performance in most cognitive domains. While subtle differences are seen on some executive function measures, mean group differences are small, and in the context of higher SIMS subscale scores, may not be readily interpretable. Studies employing similarly comprehensive neuropsychological assessments including validity measures in larger samples are needed to further disambiguate potential objective cognitive performance decrements from subjectively experienced difficulties.

To examine patterns of cognitive function among a clinical sample of patients seeking treatment for Post-Acute Sequelae of COVID-19 (PASC).

One hundred nineteen patients each completed a baseline neuropsychological evaluation, including clinical diagnostic interview, cognitive assessments, and a comprehensive battery of self-report questionnaires. Patients had a mean age of 50 years (range:18 to 74, SD=10.1) and a mean of 15.5 years (SD=2.54) of formal education. Patients were primarily female (74%) and of White/Caucasian race (75%). Hierarchical agglomerative clustering was used to partition the data into groups based on cognitive performance. Euclidean distance was used as the similarity measure for the continuous variables and within-cluster variance was minimized using Ward’s method. The optimal number of clusters was determined empirically by fitting models with 1 to 15 clusters, with the best number of clusters selected using the silhouette index. All analyses were conducted using the NbClust package, an R package for determining the relevant number of clusters in a data set.

Clustering yielded two distinct clusters of cognitive performance. Group 1 (n=57) performed worse than Group 2 (n=62) on most cognitive variables (including a brief cognitive screener and tests of attention/working memory, executive function, processing speed, learning and delayed recall). Of note, there were no significant differences between groups on an infection severity scale, hospitalizations/ICU admissions, initial or current COVID-19 symptoms, or prior comorbidities. Groups did not differ in age or gender, but Group 1 had a lower education level than Group 2 (M=14.7, SD=2.45 vs. M=16.2, SD=2.42; p=.001). Group 1 also had significantly more minorities than Group 2 (40% vs. 8%; p<.001). No other demographic differences (income, living arrangement, or marital status) were observed. In comparison to Group 2 patients, Group 1 patients self-reported significantly higher levels of anxiety and depression and functional impairment (Functional Activities Questionnaire: M=11.3, SD=8.33 vs. M=7.65, SD=7.97), perceived stress (Perceived Stress Scale: M=24.7, SD=7.90 vs. M=20.3, SD=7.89), insomnia (Insomnia Severity Index: M=16.0, SD=6.50 vs. M=13.1, SD=6.76), and subjective cognitive functioning (Cognitive Failures Questionnaire: M=58.8, SD=16.9 vs. M=50.3, SD=18.6; p’s<.05).

Findings indicate two predominant subtypes of patients seeking treatment for PASC, with one group presenting as more cognitively impaired and reporting greater levels of anxiety, depression, insomnia, perceived stress, functional limitations, and subjective cognitive impairment. Future directions include follow-up assessments with these patients to determine cognitive trajectories over time and tailoring treatment adjuncts to address mood symptoms, insomnia, functional ability, and lifestyle variables. Understanding mechanisms of differences in cognitive and affective symptoms is needed in future work. Limitations to the study were that patients were referred for evaluation based on the complaint of “brain fog” and the sample was a homogenous, highly educated, younger group of individuals who experienced generally mild COVID-19 course.

Cognitive sequelae are reported in 20-25% of patients following SARS-CoV-2 infection. It remains unclear whether post-infection sequelae cluster into a uniform cognitive syndrome. In this cohort study, we characterized post-COVID neuropsychological outcome clusters, identified factors associated with cluster membership, and examined 6-month recovery trajectories by cluster.

The Mayo Clinic Institutional Review Board approved study protocols. Informed consent was obtained from all participants. Participants (> 18 years old) were recruited from a hospital-wide registry of Mayo Clinic Florida patients who tested positive for SARS-CoV-2 infection from July 2020 to Feb 2022. We abstracted participant health history and COVID-19 disease severity (NIAID score) from the electronic health record and retrieved Area Deprivation Index (ADI) scores as a measure of neighborhood socioeconomic disadvantage. We assessed objective cognitive performance with the CNS Vital-Signs (CNSVS) and subjective neuropsychological symptoms with the Neuropsych Questionnaire-45 (NPQ-45). Results were used as input features in a K-means clustering analysis to derive neurophenotypes. Chi-square and analysis of variance (AnOvA) tests were used to identify clinical and sociodemographic factors associated with cluster membership. Participants repeated the CNS Vital Signs, NPQ-45, as well as the Medical Outcomes Survey (MOS SF-36) and a posttraumatic stress disorder (PTSD) checklist (PCL-C 17) 6 months following initial testing. Repeated-measures ANOVA was used to assess change in neurocognitive performance over time by cluster. Significance was set at P < 0.05.

Our cohort consisted of 205 participants (171 ambulatory, 34 hospitalized) who completed post-acute outcome assessment a mean of 5.7 (± 3.8) weeks following testing positive for SARS-CoV-2. K-means clustering with elbow method fitting identified three subgroups (see figure). The first cluster (N = 31) is characterized by executive dysfunction, greater socioeconomic disadvantage, and higher rates of obesity. The second cluster (N = 32) is characterized by memory and speed impairment, higher COVID severity, prevalent anosmia (70%), and greater severity of memory complaints, depression, anxiety, and fatigue. The third and largest cluster (N = 142) is absent cognitive impairment. Approximately 39% of participants completed the 6-month outcome assessment (N=79). Regardless of cluster membership, verbal memory, psychomotor speed, and reaction time scores improved over time. Regardless of timepoint, cluster 1 (dysexecutive) showed lower scores on cognitive flexibility and complex attention and cluster 2 (memory-speed impaired) showed lower scores on verbal memory, psychomotor speed, and reaction time. Modeling of cluster by timepoint interactions showed a steeper slope of improvement in complex attention and cognitive flexibility in cluster 1 (dysexecutive). Cluster 3 (normal) showed significant improvement in fatigue while cluster 2 (memory-speed impaired) continued to report moderate-severe fatigue, worse medical outcomes, and higher PTSD symptom severity scores at six months.

Most participants were cognitively normal or experienced cognitive recovery following SARS-CoV-2 infection. The 25-30% of participants who showed cognitive impairment cluster into two different neurophenotypes. The dysexecutive phenotype was associated with socioeconomic factors and medical comorbidities that are non-specific to COVID-19, while the amnestic phenotype was associated with COVID-19 severity and anosmia. These results suggest that cognitive sequelae following SARS-CoV-2 infection are not uniform. Deficits may be influenced by distinct patient- and disease-specific factors, necessitating differentiated treatment approaches.

To effectively diagnose and treat cognitive post-COVID-19 symptoms, it is important to understand objective cognitive difficulties across the range of acute COVID-19 severity. The aim of this meta-analysis is to describe objective neuropsychological test performance in individuals with non-severe (mild/moderate) COVID-19 cases in the post-acute stage of infection (>28 days after initial infection).

This meta-analysis was pre-registered with Prospero (CRD42021293124) and utilized the PRISMA reporting guidelines, with screening conducted by at least two independent reviewers for all aspects of the screening and data extraction process. Inclusion criteria were established before the article search and were as follows: (1) Studies using adult participants with a probable or formal and documented diagnosis of COVID-19 in the post-acute stage of infection; (2) Studies comparing cognitive functioning using objective neuropsychological tests in one or more COVID-19 groups and a comparison group, or one group designs using tests with normative data; (3) Asymptomatic, mild, or moderate cases of COVID-19. Twenty-seven articles (n=18,202) with three types of study designs and three articles with additional longitudinal data met our full criteria.

Individuals with non-severe initial COVID-19 infection demonstrated worse cognitive performance compared to healthy comparison participants (d=-0.412 [95% CI, -0.718, -0.176)], p=0.001). We used metaregression to examine the relationship between both average age of the sample and time since initial COVID-19 infection (as covariates in two independent models) and effect size in studies with comparison groups. There was no significant effect for age (b=-0.027 [95% CI (0.091, 0.038)], p=0.42). There was a significant effect for time since diagnosis, with a small improvement in cognitive performance for every day following initial acute COVID-19 infection (b=0.011 [95% CI (0.0039, 0.0174)], p=0.002). However, those with mild (non-hospitalized) initial COVID-19 infections performed better than did those who were hospitalized for initial COVID-19 infections (d=0.253 [95% CI (0.372, 0.134)], p<0.001). For studies that used normative data comparisons, there was a small, non-significant effect compared to normative data (d=-0.165 [95% CI (-0.333, 0.003)], p=0.055).

Individuals who have recovered from non-severe cases of COVID-19 may be at risk for cognitive decline or impairment and may benefit from cognitive health interventions.

Previous research has explored the performance of working memory in children with ADHD and individual co-occurring disorders, finding that internalizing disorders such as depression and anxiety, both independently negatively impact working memory performance (Saarinen, Fontell, Vuontela, Carlson, & Aronen, 2015; Kofler, Rapport, Bolden, Sarver, Raiker, & Alderson, 2011; Skogan, Zeiner, Egeland, Rohrer-Baumgartner, Urnes, Reichborn-Kjennerud & Aase, 2013). However, there is limited research on the impact of co-occurring depression and anxiety on working memory, which are common in children with ADHD. When depression is present, parts of the prefrontal cortex regions are hypoactive and therefore lead to impairment in executive functioning abilities (Snyder, 2013). In regard to anxiety, previous literature (Moran, 2016) has found that anxious arousal competes with processes located in the prefrontal cortex leaving limited neural resources for executive functioning skills (Moran, 2016). The current study will evaluate the influences of depression and anxiety on working memory in children with ADHD.

Participants were from an archived data set, which included 849 individual children ages 7-15 years old and their biological parents, recruited between 2009 and 2015. The 849 children included 76 sibling pairs. Families were part of an ongoing longitudinal study. The children completed a computerized version of a spatial working memory task identical to the spatial span task from CANTAB (De Luca et al., 2003). In regard to verbal working memory, children completed Digit Span from the WISC-IV, including both forward and backward conditions. Depression was measured by the Children’s Depression Inventory, 2nd edition (Kovac, 2004) and anxiety was measured by the Multidimensional Anxiety Scale for Children, 2nd edition (MASC-2) (March, 2012). ADHD was measured by having the parents and teachers complete two questionnaires: the ADHD rating scale (ADHD-RS; DuPaul et al. 1998), the Connor’s Rating Scale, 3rd edition (CRS-R, Connors 2003), and an in person semi-structured diagnostic interview (Kiddie Schedule for Affective Disorders and Schizophrenia -KSADS, Kaufman et al. 1997). A best estimate DSM-IV ADHD (American Psychiatric Association [APA], 1994) diagnosis was established by a multidisciplinary diagnostic team (ADHD diagnosis agreement kappa = .88). On cases where consensus was not achieved, they were excluded from the participant pool, and this became the clinical referred control group for the study.

The results indicated that children with ADHD and a co-occurring diagnosis of depression experience more difficulties with working memory abilities than those who do not have a co-occurring diagnosis of depression. Additionally, depression has a greater impact on verbal working memory in children with ADHD than anxiety does alone. This study also found that there were no significant gender differences between children with ADHD who identify as males and females on verbal or visual working memory tasks.

The findings of this study indicate the importance of addressing depressive symptoms in children with ADHD. With a holistic understanding of working memory deficits in children with ADHD as well as potential gender differences, caretakers and providers can integrate more effective intervention plans to help mitigate significant working memory deficits.

We previously reported the impact of hormonal changes during menopause on ADHD and associated symptoms. Here we provide findings from an expanded sample limited to those 46 and older.

Information was obtained from a reader survey sponsored by ADDitude Magazine. Responses were received from 3117 women of whom 2653 were 46 or older. Analyses were limited to this older group, since mean age of perimenopause is around 47 in the general population. The final sample ranged in age from 46 to 94 (mean=53) and 85% had been diagnosed with diagnosed with ADHD. Respondents were asked to indicate their age at diagnosis and the impact of 11 different symptoms or associated problems of ADHD at each of 5-time intervals: 0-9 years, 1019 years, 20-39 years, 40-59 years and 60+years. Co-morbidities were also considered.

Changes in ADHD Symptoms: Sixty-one percent reported that ADHD had the greatest impact on their daily lives between 40 and 59 years of age. The largest group of respondents (43%) were first diagnosed between ages 41 and 50. The reported prevalence of inattention, disorganization, poor time-management, emotional dysregulation, procrastination, impulsivity and poor memory/brain fog increased over the life span. More than half indicated that a sense of overwhelm, brain fog & memory issues, procrastination, poor time-management, inattention/distractibility and disorganization had a 'life altering impact’ during the critical menopausal/perimenopausal window. By contrast, complaints about significant hyperactivity, impulsivity, social struggles and perfectionism remained fairly constant over the lifespan, and were not among the most common complaints (i.e., only endorsed by 25% to 35% of the sample). Interestingly, while 61% reported that ADHD had its greatest impact on daily life between 40-59, only 3% reported the same thing for age 60 and above. Thus, in this expanded sample the first diagnosis of ADHD was most common in adulthood and peaked in the perimenopausal years. ADHD was also again most disruptive during the perimenopausal/menopausal window of time. This shift was most pronounced for symptoms of poor memory/brain fog and 'feeling overwhelmed.' Symptoms either diminished or they adjusted as they moved out of the transition years.

Comorbid Symptoms: Anxiety and depression were most common (73% and 63%, respectively) consistent with the literature. Also elevated, but much less frequent here, were learning, eating and sensory processing disorders (i.e., 10%-13% each). Thus, depression and anxiety may be the most frequent correlates of an ADHD diagnosis, irrespective of age of onset.

Hormonal change during the climacteric often is associated with worsening of cognitive complaints. Such increased complaints can lead to a first diagnosis of ADHD during this period, as well as a worsening of symptoms in those previously diagnosed. Moreover, this hormonal shift may underlie this diagnosis in a subset of the individuals currently characterized as having adult-onset ADHD. Lessoning of complaints in those ages 60 and above raises questions regarding the underlying mechanisms for this change (e.g., physiologic adaptation, compensation or decreased life demands).

Accurately interpreting cognitive change is an essential aspect of clinical care for older adults. Several approaches to identifying 'true’ cognitive change in a single cognitive measure are available (e.g., reliable change methods, regression-based norms); however, neuropsychologists in clinical settings often rely on simple score differences rather than advanced statistics, especially since multiple scores compose a typical battery. This study sought to establish quick-reference normative criteria to help neuropsychologists identify how frequently significant change occurs across multiple measures in cognitively normal older adults.

Data were obtained from the National Alzheimer’s Coordinating Center (NACC). Participants were 845 older adults who were classified as cognitively normal at baseline and at 24-month follow-up. In NACC, these clinical classifications are made separately from the assessment of cognitive performance, including cognitive change. The sample was 34.9% female, 83.5% White, 13.1% Black 2.3% Asian, and 1.1% other race with a mean age of 70.7 years (SD=10.2). Of the sample, 95.5% identified as non-Hispanic. Mean education was 16.1 years (SD=2.8). The cognitive battery entailed: Craft Story Immediate and Delayed Recall, Benson Copy and Delayed Recall, Number Span (Forward & Backward), Category Fluency (Animals & Vegetables), Trails A&B, Multilingual Naming Test, and Verbal Fluency (F&L). Change scores between baseline performance and follow-up were calculated for each measure. The natural distribution of change scores was examined for each measure and cut points representing the 5th and 10th percentile were applied to each distribution to classify participants who exhibited substantial declines in performance on each measure. We then examined the multivariate frequency of statistically rare change scores for each individual.

As expected in a normal sample, overall cognitive performance was generally stable between baseline and 24-month follow-up. Across cognitive measures, 81.9% of participants had at least one change score fall below the 10th percentile in the distribution of change scores, and 55.7% had at least one score below the 5th percentile, 49.3% of participants had two or more change scores that fell below the 10th percentile and 21.1% with two or more below the 5th percentile. There were 26.7% participants that had three or more change scores below the 10th percentile, and 6.4% of participants had three change scores below the 5th percentile.

Among cognitively normal older adults assessed twice at a 24-month interval with a battery of 13 measures, it was not uncommon for an individual to have at least one score fall below the 10th percentile (82% of the sample) or even the 5th percentile (56%) in the natural distribution of change scores. There were 27% participants that had three or more declines in test performance below the 10th percentile; in comparison, only 6% of the sample had three or more change scores at the 5th percentile. This suggests that individuals who exhibit more multivariate changes in performance than these standards are likely experiencing an abnormal rate of cognitive decline. Our findings provide a preliminary quick-reference approach to identifying clinically significant cognitive change. Future studies will explore additional batteries and examine multivariate frequencies of change in clinical populations.

The Apolipoprotein E (APOE) gene has been established in the Alzheimer’s disease (AD) literature to impact brain structure and function and may also show congruent effects in healthy older adults, although findings in this population are much less consistent. Magnetic Resonance Imaging (MRI), Diffusion Tensor Imaging (DTI), and neuropsychological measures present as useful, non-invasive tools to investigate the impact of APOE-e allele status on grey matter structure, white matter integrity, and cognitive functioning, respectively. Nonetheless, studies to date have revealed mix findings and few studies have taken a multimodal approach to investigating APOE’s effects. Thus, the objective of the current study was to replicate and expand upon the multimodal neuroimaging study conducted by Honea et al. (2009), that examined the impact of APOE-e4 presence on brain structure and cognitive function in healthy older adults, with the addition of APOE-e2 carriers and cognitive composite measures. The aim of the current replication study was to identify reliable changes to grey matter volume and white matter integrity in healthy older adults as it relates to APOE-e allele presence and cognitive performance. This represents one of the first studies to investigate both the risk and protective effects of APOE-e alleles (e4 and e2 respectively) on measures of cognitive performance, GMV and white matter integrity in healthy older adults.

Data were obtained from the Alzheimer’s Disease Initiative phase 3 (ADNI3) database. Baseline MRI, DTI and cognitive composite scores for memory (ADNI-Mem) and executive function (ADNI-EF) were acquired from 116 healthy controls. Participants were grouped according to APOE allele presence (APOE-e2+ N= 17, APOE-e3e3 N= 64, APOE-e4+ N=35). Voxel-based morphometry (VBM) and tract based spatial statistics (TBSS) were used to compare grey matter volume (GMV) and white matter integrity respectively between APOE-e2+ and APOE-e3e3 controls, and again between APOE-e4+ and APOE-e3e3 controls. Multivariate analysis of covariance (MANCOVA) was used to examine the effects of APOE polymorphism on memory and EF across all APOE groups with covariates of age, sex, education, and cognitive scores were correlated with imaging metrics within groups (Pearson r) to examine associations between cognitive performance and brain structure.

Consistent with findings from Honea et al. (2009), no significant differences were seen across APOE groups, within-groups in MRI metrics, or cognitive performance (p>0.05, corrected for multiple comparisons). Taking a similar approach to Honea and company, nonsignificant, trend-level results were examined (p<0.2, corrected for multiple comparisons) and suggested: 1) Decreased GMV and increased mean diffusivity (MD) were present in APOE-e4+ compared to APOE-e3e3 and 2) Increased GMV and fractional anisotropy (FA) were present in APOE-e2+ compared to APOE-e3e3.

The current study replicated and extended previous findings. Trend-level findings across both the current and replicated study suggests there may be subtle neurostructural differences in healthy aging as a function of APOE-e4 status. The current study additionally found potential subtle differences in GMV and white matter integrity in APOE-e2 carriers at the trend-level, consistent with previous reports of APOE-e2 's protective effects against neurodegeneration. Although these findings should be interpreted with caution, trend-level effects seen in the current study are consistent with previous research and may hold important implications for APOE neuromechanisms.

The current study aimed to evaluate the psychometric properties and diagnostic accuracy of the 32-item version of the Multilingual Naming Test (MINT) in a sample of English and Spanish monolinguals and bilingual older adults from two ethnic groups (EA; European Americans and HA; Hispanic American) with typical and atypical aging. An IRT model was used to identify 24 MINT Items assessed across ethnicity and language testing groups (Spanish and English). We analyzed the discriminant and predictive validity of the 32-item and 24-item scales across diagnostic groups (cognitively normal [CN], mild cognitive impairment [MCI], and dementia [AD]). Diagnostic accuracy was then assessed with both versions applying ROC (Receiver Operating Characteristics) curve reporting using AUC (Area Under the Curve). We expected the MINT to distinguish between the CN and AD groups but not between CN and MCI and the MCI and AD. We conducted IRT analyses to evaluate the cross-language validity of the items from the 32-item MINT in English and Spanish through Rasch Analysis across our two ethnic groups. Finally, we tested the association between MINT scores and MRI volumetric measures of language-related areas in both cerebral hemispheres’ temporal and frontal lobes.

The sample comprised 281 participants (178 females) enrolled in the 1Florida Alzheimer’s Disease Research Center (ADRC), with 175 participants self-identified as HA (51 tested in English and 124 in Spanish) and 106 EA, all of them monolingual English speakers. The participants were classified into three diagnostic groups: 1. CN (n = 94); 2. MCI (n = 148); and 3. AD (n = 39). Participants are evaluated yearly through a comprehensive neuropsychological battery, including the MINT is a standard CN task that requires patients to retrieve words upon presentation of a line drawing.

We obtained a ceiling effect in four items (Butterfly, Glove, Watch, and Candle). Four items were easier in English (Blind, Gauge, Porthole, and Pestle) and four in Spanish (Dustpan, Funnel, Anvil, and Mortar). In the 32-item version of the MINT, EA scored significantly higher than HA, but when removing those eight items, the ethnic difference was attenuated and no longer statistically significant (controlling for education). The ROC curves showed that both versions of the MINT had poor accuracy when identifying CN participants and were acceptable in identifying dementia participants but unacceptable for classifying MCI participants. The 32-item MINT in English and Spanish and the 24-item MINT in Spanish were significantly correlated with the bilateral MTG. However, the 24-item MINT in English was only correlated with this area’s volume in the right hemisphere. The left FG correlated with MINT scores regardless of language and MINT version. We also found some differential correlations depending on the language of administration. The bilateral hippocampi, STG, MTG and FG, and right ITG were significantly correlated only with MINT Spanish scores, while the left ITG was significant only when either version of the MINT was administered in English.

Our results highlight the importance of analyzing cross-cultural samples when implementing neuropsychological tests.

Late-life depression is prevalent among older adults and the presence of depressive symptoms has been shown to be associated cross-sectionally with worse verbal fluency performance. There is limited and mixed evidence as to whether depressive symptoms impact change in verbal fluency performance over time, and whether gender impacts this relationship.

Participants were community-dwelling older adults who were dementia-free at baseline (N = 522; M age = 75.96, SD + 6.46 years). Baseline depressive symptoms were measured using the Geriatric Depression Scale. Category fluency and letter fluency performance, using the Controlled Oral Word Association Test (COWAT), were examined annually. Linear mixed effects models stratified by gender examined whether associations between baseline depressive symptoms and changes in fluency performance over five years were different in female (n = 289) as compared to male (n = 233) participants. Sensitivity analyses excluding participants with prevalent or incident mild cognitive impairment (MCI) (n = 141), excluding participants with incident dementia (n = 28), and excluding participants with prevalent or incident MCI or incident dementia (n = 169) were run. All analyses were adjusted for age, years of education, estimated premorbid functioning, and health comorbidities.

Depression was minimal across participants (m = 4.72, SD + 3.96). A subset of participants (n = 44) reported “possible depression,” namely levels suggestive of subclinical depression, according to clinical cutoffs. The “possible depression” group included 31 females (10.73% of females) and 13 males (5.58% of males), and the “no depression” group included 258 females (89.27% of females) and 220 males (94.42% of males). Baseline levels of depressive symptoms suggestive of subclinical depression were associated with worse decline in category fluency performance during longitudinal follow-up in females (estimate = -0.16, p = .002) but not males (estimate = -0.03, p = .658). Results remained the same when excluding prevalent and incident MCI cases (estimate = -0.19, p = .005), excluding incident dementia cases (estimate = -0.12, p = .017), and excluding prevalent and incident MCI and incident dementia cases (estimate = -0.20, p = .004). Letter fluency performance did not decline over time and was not influenced by levels of depressive symptoms in females (estimate = -0.03, p = .502) or males (estimate = 0.05, p = .452).

Baseline presence of depressive symptoms suggestive of subclinical depression was associated with worse decline in category fluency performance during longitudinal follow-up in female but not male participants. Letter fluency performance did not decline and was not impacted by levels of depressive symptoms. Results remained significant when accounting for covariates and potential confounders. The present study elucidated the combined influence of gender and depressive symptoms on change in fluency performance in older adults and can aid in identifying individuals who may be at a greater risk of cognitive decline.

White matter microstructure (WMM) potentially mediates the relation between APOE4 and memory performance. This study’s purpose was to understand whether p-tau effects this mediation model and whether education level differentially impacts the relations between these genetic and biological biomarkers’ influence on memory.

Participants included 161 older adults (M=74 years, 40.4% female, 92% White, 74 e4 non-carriers, 87 e4 carriers) with subjective and objective cognitive impairment from the Alzheimer’s Disease Neuroimaging Initiative (ADNI). A composite memory score created by ADNI was used as the outcome variable. Mean fractional anisotropy (FA) and radial diffusivity (RD) values of white matter tracts within regions of interest (i.e., fornix (FX), hippocampal cingulum (CGH)) were individually used as the measures of WMM. A moderated mediation was run to examine whether p-tau was a moderator of the mediation between APOE4, white matter microstructure, and memory. An exploratory dual moderated mediation analysis examined education as a moderator of the moderated mediation. Indirect effects were tested using bootstrapping procedures.

In the FA moderated mediation model, APOE4 was significantly related to FA of the fornix and memory performance. FA of the CGH and FX were also related to memory performance. With FA of the fornix as the mediator, the conditional indirect effect was not significant (95% CI[-.0009, .0070]). There was a trend suggesting at low (95% CI[-.2421, -.0140]) and average (95% CI[-.1658, -.0083]) levels of p-tau, FA of the fornix was a significant mediator but was non-significant at high levels of p-tau (95% CI [-.1322, .0341]). The RD moderated mediation model was non-significant. The FA and RD exploratory dual moderated mediation models were non-significant. However, the APOE4 x p-tau interaction with FA of the fornix as the mediator suggested a trend. At low levels of p-tau, increased education was related to a significant moderated mediation.

Results suggest that FA of the fornix is a significant mediator between the relation of APOE4 and memory, and this may be dependent upon p-tau levels. When p-tau burden load was high, the path by which APOE4 impacts memory performance was not through white matter microstructure degradation. Additionally, the potential buffering effects of education may be most robust at lower levels of p-tau burden.

The prevalence of memory complaints in older adults is between 25 and 50%, with poor memory associated with decreased quality of life and declines in daily functioning. Memory training programs are a method for training older adults on strategies and skills to improve memory performance. We conducted a feasibility study of a virtually-delivered adaptation of an Ecologically-Oriented Neurorehabilitation of Memory (EON-Mem) in improving memory for healthy older adults. The primary purposes of this study included: (1) determine the feasibility of conducting EON-Mem virtually with older adults, (2) determine whether a randomized control trial using EON-Mem in older adults is of value, and (3) determine whether electronic delivery of memory training programs with ecological validity is beneficial for older adults.

Twenty-five older adults 55 years of age and older were recruited for participation in a memory training program. All testing and intervention sessions were completed virtually through the Zoom platform. Measures of emotional functioning (Hospital Anxiety and Demographics Scale, health-related quality of life (Short Form-36) and cognitive functioning (Ecological Memory Simulations and Repeatable Battery for Neuropsychological Status; RBANS) were administered before and following the intervention. Participants attended one virtual treatment session per week, with sessions ranging between 60-90 minutes, for a total of six weeks. Between treatment sessions, participants were asked to complete daily homework assignments that allowed them to apply strategies to real-world situations. A priori, feasibility was set at an 80% completion rate and variables that influenced completion are reported.

To address questions regarding feasibility (e.g., adherence, attrition, etc.), we calculated descriptive statistics (i.e., count statistics, means, standard deviations, and range) on sample information. Of the 25 participants enrolled in the study, 21 participants completed all steps of the study (84% completion rate) showing the delivery format is feasible. The average age of our sample was 61.7 (SD = 5.9) years and average years of education was 17.06 (SD=2.36). Excluding those who dropped, average completion was 72.76 days (SD=18.65, range=47-124). Across all six weeks, homework completion averaged 66.4% (33/49). There were varying effects of the EON-Mem for the EMS memory outcomes with the greatest proportion showing reliable improvement on the ability to recall names (10 participants [42%]). Regarding the RBANS, the greatest proportion of participants showed reliable improvement on the Story Memory task (i.e., four participants [17%]), but only two (9%) showing reliable change on the total Memory Index score.

Overall, a virtual administration of EON-Mem in older adults was feasible.

Regarding memory changes, the majority of the sample did not demonstrate reliable improvement in memory which might have been due to a variety of reasons including the fact that our sample had a high level of education and low level of memory impairment. Notably, however, this was a feasibility study, not an intervention study. Therefore, future directions should focus on randomized controlled trials to determine efficacy.

Heart failure occurs when the heart is unable to support a flow of blood that meets the body’s needs, ultimately resulting in decreased oxygenation throughout the body— including the brain. Results of previous research suggest that individuals with heart failure exhibit both localized and diffuse neuropsychological deficits. The aims of this study are to meta-analytically examine a) the performance of participants with heart-failure and healthy controls on the Mini Mental State Examination (MMSE), a neuropsychological test of general cognition, and b) the role of depressive mood as a potential moderator of performance on the MMSE in these participants.

Two researchers independently searched eight databases for articles that examined the neuropsychological functioning of patients with heart failure.

Inclusion criteria identified studies that had a heart failure group with a comparable control group and reported on neuropsychological assessment for both groups. Studies were excluded if a heart failure group had any other type of major organ failure or if the comparison was between different classes of heart failure rather than between a heart failure group and healthy controls.

A meta-analysis using a random-effects model revealed a statistically significant and large effect size estimate (g= 0.727, p <.001) CI [.331, 1.123]. The heterogeneity was found to be statistically significant and in the large range, I2 = 83.027%, tau2 = .155, p < .001. A meta-regression analyzing the relationship between depressive mood and MMSE effect size estimates was statistically significant, Q residual = 8.715, df = 3, p = .03.

This study is the first to examine the relationship between depressive mood and general cognitive status (as measured by the MMSE) in participants with heart failure. The strong relationship between cognitive status and heart failure, and the role of depression in explaining a statistically significant portion of the heterogeneity in the relationship seen in primary studies, highlights the importance of accurately assessing depression when studying the effect of heart failure on cognition. Further research needs to examine the impact of depression on quality of life in patients with heart failure as potentially mediated by difficulties in cognition.

The COVID-19 pandemic has been a catalyst for a shift towards virtual forms of working, and specific support for the provision of virtual therapy (BPS, 2020). Remotely delivered therapy has known potential benefits, such as improving access to people living in underserved areas and for those who struggle to attend face-to-face appointments due to psychosocial, physical or geographical constraints. Those with neurological conditions frequently fall in these groups.

Acceptance and Commitment Therapy (ACT) is an evidence-based psychological intervention which aims to improve the physical and mental health of people living with neurological conditions. However, there are several considerations to translating this into a virtual therapy for this clinical group that have not yet been thoroughly empirically evaluated. Such considerations include: fatigue, cognitive difficulties in the context of virtual communication, adaptations within the therapeutic alliance, and translation of dynamic and interactive therapeutic exercises within a virtual medium.

This study aimed to describe the experiences of Clinical Psychologists delivering ACT remotely in the context of two randomised controlled feasibility and acceptability clinical trials for young people (aged 11 to 24) who have experienced a brain tumour or Tuberous Sclerosis Complex. Exploring therapist perceptions and experiences provides valuable insights into potential barriers and facilitators to engagement with remote ACT delivery.

Clinical Psychologists who were trained to deliver ACT via videoconferencing were invited to take part in virtual interviews. The semi-structured interview guide aimed to draw on their experience of ACT training, supervision, remote delivery, and perceived impact of ACT. Interviews were audio-recorded, transcribed verbatim and analysed using inductive thematic analysis.

Five Clinical Psychologists were interviewed. Interview data were coded into broad themes around the experience of delivering ACT, engaging with remote systems, the wider perceived impact of ACT and the adaptability of ACT. ACT training was reported to be an effective, positive experience and the opportunity for regular peer and group supervision worked to solidify the training and support fidelity to the ACT processes. It was largely acknowledged that while remote delivery of the intervention did create some initial challenges to the therapeutic process, this approach created opportunity for the young people to access psychological support that they might not have been able to engage with due to logistical considerations. Clinical Psychologists also shared that training in and experience of delivering ACT had a positive and meaningful impact on their clinical practice and personal conduct. They also reported that ACT was adaptable to the needs of the young people in the clinical trials and felt appropriate to deliver in this context.

This in-depth, qualitative study demonstrated the clinical promise of remotely delivered ACT. Clinical Psychologists viewed remotely delivered ACT as an appropriate, acceptable and feasible intervention for young people with experience of brain tumour and Tuberous Sclerosis Complex within the context of research, that would be generalisable to everyday clinical practice.

The CCoSI is a brief screening instrument that is designed to detect cognitive impairment in children aged 5y0m-16y11m shortly after acquired brain injury (ABI) by evaluating language, fluency, attention, memory, and visuospatial domains. Each domain translates to a CCoSI index and is composed of a series of brief subtests. This study assessed the feasibility of modifying the Children’s Cognitive Screening Instrument (CCoSI) into an electronic version (eCCoSI) and administering it using video teleconferencing (VTC).

Tasks and stimuli were modified for online administration. Typically developing children aged 5y0m-16y11 m were tested using the modified eCCoSI via VTC. The eCCoSI was administered using Skype for Business and Microsoft Teams. Participants attended one 25-minute video assessment session over either platform. Results of VTC-assessed healthy controls were compared to age-matched peers ([25] Female: [19] Male; mean age = [11.54], SD = [3.01], age range =5.00-15.75) who had been previously tested face-to-face (FTF) with the original CCoSI at the Bristol Royal Hospital for Children (BRHC).

Age-related trends in performance were also examined across FTF and VTC for comparability.

44 typically developing children were virtually assessed ([25] Female: [19] Male; mean age = [11.79], SD = [3.03], age range =5.05-16.92). Results from a 2x2 ANOVA with age-group and modality as independent factors showed no significant difference in performance between participants tested FTF and VTC over the CCoSI Attention, Fluency, Language, Memory, and Visuospatial indices. No significant result of interaction between age and modality was found; however, there was a significant result of age-group.

VTC assessment is a feasible alternative to FTF administration of the CCoSI within healthy controls. Results from the present study are promising for the use of the eCCoSI in clinical practice. Further research should attempt to replicate these results within clinical populations.

Baseline assessment of cognitive performance is common practice under many concussion management protocols and is required for collegiate athletes by the NCAA. The purpose of baseline cognitive assessment is to understand an athlete’s individual uninjured cognitive performance, as opposed to using population normative data. This baseline can then serve as a reference point for recovery after concussion and can inform return-to-play decisions. However, multiple factors, including lack of effort, can contribute to misrepresentation of baseline results which raises concern for reliability during return-to-play decision-making. Measuring effort across a continuum, rather than as a dichotomous variable (good versus poor effort) may provide informative insight related to cognitive performance at baseline.

Collegiate athletes (n = 231) completed the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) as part of their baseline pre-participation concussion evaluation. ImPACT creates composite scores of Verbal Memory, Visual Memory, Visual-Motor Speed, and Reaction Time. Baseline self-reported symptoms and total hours of sleep the night prior to testing are also collected through ImPACT. ImPACT has one embedded indicator within the program to assess effort, and research has identified an additional three embedded indicators. Athletes were also administered one stand-alone performance validity test, either the Medical Symptom Validity Test (n = 130) or the Rey Dot Counting Test (n = 101), to independently measure effort. Effort was estimated across a continuum (zero, one, two, or three or more failed effort indicators) with both stand-alone and embedded effort indicators. We evaluated the relationship between effort, symptoms, self-reported sleep, Reaction Time composite score and Visual-Motor Speed composite score using a linear regression model.

We found that 121 athletes passed all effort indicators, while 39 athletes failed only one effort indicator, 40 athletes failed two effort indicators, and 31 athletes failed three or four (three+) effort indicators. Self-reported symptoms and total hours of sleep were not related to effort, but Reaction Time and VisualMotor Speed composites were. Specifically, performance on the Visual-Motor Speed composite was significantly worse for athletes who failed two or three+ effort indicators compared to athletes who did not fail any, and performance on the Reaction Time composite was significantly worse only for athletes who failed three+ effort indicators. Additionally, athletes who failed one or more effort indicators and reported less sleep performed worse on both the Visual-Motor Speed and Reaction Time composites, compared to those who reported less sleep and did not fail any effort indicators.

Athletes who failed one effort indicator did not perform significantly worse on Reaction Time and Visual-Motor Speed composites compared to those who passed all effort indicators. However, 31% of athletes failed two or more effort indicators and these athletes performed worse on cognitive tests, likely due to factors impacting their ability to put forth good effort. These results suggest that effort is more complex than a previously used dichotomous variable and highlights the importance of using several indicators of effort throughout baseline assessments. In addition, the importance of sleep should be emphasized during baseline assessments, especially when effort is questionable.

Neuropsychological measures of verbal fluency help detect cognitive decline and neuropathology. The discrepancy between semantic verbal fluency and phonemic verbal fluency is commonly utilized to differentiate between cortical and subcortical processes. Understanding how other factors influence a patient’s verbal fluency scores is vital in informing clinical interpretation of neuropsychological test data. This study aimed to investigate how educational attainment and crystalized verbal skills (i.e., word reading and vocabulary) influence verbal fluency performance among a clinical sample of patients seen for neuropsychological evaluation services at a community-based outpatient neurology clinic.

We utilized data from N=26 patients [mean age = 50.5 (SD = 22.0), 31% female, mean education = 13.5 (SD = 2.3)] who completed neuropsychological evaluations as part of their clinical care at an outpatient neurology clinic. Participants were included in this study if they had complete data for all variables of interest. We used Pearson correlation analyses to investigate associations between each predictor variable of interest (years of education, WRAT-5 Reading, WASI-2 Vocabulary) and age-norm corrected D-KEFS Verbal Fluency scores. Prior to analysis, all variables were converted to z-scores.

We found that years of education (r = 0.49, p = 0.01) and vocabulary (r = 0.41, p = 0.04) were significantly positively correlated with category fluency performance. Reading was also positively correlated with category fluency at trend level, but this association was not statistically significant (r = 0.36, p = 0.07). We found that vocabulary (r = 0.47, p = 0.02) and reading (r = 0.51, p = 0.007) were significantly positively correlated with phonemic fluency performance, while the association between education and phonemic verbal fluency performance was not significant (r = 0.27, p = 0.18).

Our results suggest that educational attainment and crystalized verbal skills are positively associated with verbal fluency performance, though the degree of influence of these individual factors may differ for category fluency vs phonemic fluency performance. Our results have implications for the clinical practice of neuropsychology. Namely, appreciating a patient’s educational attainment and crystalized verbal skills can help guide clinical interpretation of whether or not a patient’s verbal fluency test scores reflect a decline from their baseline. This may be particularly important to consider among patients with high educational attainment or high premorbid verbal skills, as a subtle decline in their verbal fluency abilities may not be appreciated if relying only on age-based norms for interpretation. This is clinically relevant including when assessing for the early stages of neurodegenerative disorders (e.g., Alzheimer’s disease, Primary Progressive Aphasia) or for subtle changes associated with stroke or brain injury.

Even though the severity of HIV-associated neurocognitive disorders (HAND) has decreased with the introduction of combination antiretroviral therapy, mild forms of HAND remain prevalent. Many HIV-infected individuals live alone, so mild cognitive impairments are easily missed. It is important to check their neurocognitive and everyday functions during hospital visits; however, it is challenging for Japanese clinicians because many hospitals do not have enough clinical psychologists or neuropsychologists. Additionally, neuropsychological (NP) test results may not detect those mild cognitive impairments. A micro error has been given more attention as a new behavioral sign of the early stages of cognitive decline, especially among people with Mild Cognitive Impairment (MCI). The current study aimed to 1) develop a touch-panel HAND screening battery and 2) evaluate if the micro errors could differentiate individuals with HAND from their counterpart healthy individuals.

Forty HIV-infected men (age: 49.0±8.51 years old, education: 18.5±2.17 years) and 44 healthy men (age: 45.4±8.49 years old, education: 14.4±2.27 years) completed the touch-panel HAND screening battery which assessed six NP domains by seven subtests, everyday functions, and depression. A micro error is defined as a subtle action disruption or hesitation occurring immediately before making final actions. We evaluated the micro errors in short-term memory (STM) and long-term memory (LTM) of verbal learning tests (VLT).

Mann Whitney U tests revealed that the HIV+ group made significantly more micro errors on both STM (HIV+: 1.45±0.90 times, Healthy: 0.52±0.84 times) and LTM (HIV+: 1.85±0.73 times, Healthy: 1.29±0.71 times) than the healthy group (STM: W=1362, p< .001, Effect Size (EF)= .548; LTM: W=1199.5, p= .002, EF= .363). An independent samples T-test showed that the HAND group made significantly more micro errors than the non-HAND group (t=1.822, p= .038, ES= .595) on STM; moreover, the Asymptomatic Neurocognitive Impairment (ANI) group made significantly more micro errors than the healthy group (W=446, p< .001, ES= .689). On LTM, no significant micro error differences between HAND and non-HAND (W=184.5, p= .539, ES= -.189) nor between ANI and healthy group (W=327.5, p= .103, ES= .241) were found.

The present study suggests that a novel behavioral measure, micro errors, may be able to help detect even the mildest form of HAND, ANI. Given that the touch-panel HAND screening battery consists of NP and IADL tests, it is important to evaluate micro errors on these various measures. Additionally, the touch-panel screening battery requires minimal administrative staff involvement, which could be beneficial for busy HIV clinicians.

Previous literature has studied the cognitive processes that contribute to performance on the Stroop interference condition in adults and found that the Stroop task performance (i.e., color-word interference) is comprised of multiple cognitive skills, including speed of visual search, working memory, and conflict monitoring (Perianez et al. 2020). However, the relationship of these cognitive processes to Stroop interference in youth remains understudied. Moreover, no studies have examined the contribution of effort measurement to the interference condition in healthy youth.

Golden Stroop Test interference performance was examined in healthy youth athletes (n=174) aged 8-16 years (mean age=12.07) who participated in a baseline neuropsychological evaluation as part of a clinical research program on sports concussion. Predictor variables included speed of visual search, working memory, processing speed, verbal fluency effort (i.e., validity tests), visuospatial abilities, visual processing, and executive functioning skills such as cognitive flexibility and reasoning.

Speed of visual search as measured by Trail Making Test visual scanning time (p<0.00), and effort as measured by Reliable Digit Span and Trail Making Test ratio (p=0.03; p<0.00, respectively) significantly contributed to Stroop interference performance in healthy youth. We provided three validity measures; however, only those requiring higher-order cognitive processes predicted Stroop performance: Reliable Digit Span (p=0.03) and the Trail Making Test ratio (p<0.00). The standalone validity measure (TOMM) was not a significant predictor of Stroop performance (p>0.05).

In contrast to adults, working memory and processing speed did not significantly predict Stroop performance, while visual search speed did predict Stroop interference. Furthermore, two embedded validity indicator (EVI) measures predicted Stroop interference, in contrast to a standalone validity measure requiring lower cognitive processes, which did not predict Stroop performance. Therefore, EVI’s that include an executive functioning component may not accurately represent effort in youth, perhaps due to their less developed executive functioning relative to adults (Lezak et al., 2012; Shanmugan & Satterthwaite, 2017). Overall, understanding the cognitive processes contributing to Stroop performance in healthy youth will allow clinicians to better detect deficits in those cognitive processes and understand how they may impact Stroop performance. This would lead to a better understanding of executive functioning and the accurate measurement of effort in healthy youth.

It has been established that capturing how an individual draws the Rey Complex Figure Task (RCF) is as important as assessing what is drawn (Rey, 1941, Osterrieth, 1944). Despite the development of multiple systems that have been designed to measure these qualitative characteristics there are still no systematic means to measure adherence to the temporal-spatial heuristic that represents a typical drawing practice in healthy, neurotypical adults (Visser, 1973; Hamby et al, 1993).This study sought to develop a system for scoring temporal-spatial adherence when drawing the figure to provide objective, continuous data.

Fifty-three English-speaking adults (mean age 44.61 yrs, SD 12.48; 44 female) were recruited. Exclusion criteria included vision and hearing impairment not corrected by aids; neurodivergent, neurological or psychiatric diagnosis, cancer or brain injury history. Participants completed the RCF copy phase as part of an extended neuropsychological battery. The RCF drawing process was recorded via video and a ball-point pen that digitally recorded drawing. Order data for the 18 RCF elements (Osterrieth, 1944,Taylor, 1959) was recorded by two scorers and analysed via Principal Component Analysis (PCA) with an equimax rotation to identify elements typically drawn together by a healthy, neurotypical adult. Using scoring methodology adapted from Geary et al (2011), the extent to which participants drew consecutively the member elements of each factor or 'strategy cluster’ was calculated and recorded. Strategy Cluster Scores across the population sample were examined to understand normative performance.

Order data was examined for interrater reliability via Pearson’s correlation coefficient and was considered good (r2 = 0.78, p < 0.001). PCA identified four factors or 'strategy clusters’ that were statistically robust and accounted for 67.34% of total variation. The strategy clusters were Core Structure (rectangle, diagonal, horizontal, vertical); Triangular Structure (triangle, horizontal in triangle, vertical in triangle, diamond); Internal Left-Hand Side (four horizontal lines, smaller rectangle, horizontal in top-left quad); and Internal Right-Hand Side (five lines, circle, vertical top-right quad, small triangle). The mean RCF Strategy Cluster Score was 6.23 (SD 1.94; possible range: 2.75 to 10). Population data spread indicated that healthy neurotypical adults only partially observed a temporal-spatial heuristic, rather than strict, absolute adherence.

Four strategy clusters were identified where cluster members were typically drawn consecutively. RCF Cluster Strategy scoring was shown to measure the temporal-spatial heuristic objectively, providing continuous data that lends itself to clinical standardisation. Further, the study demonstrated that whilst healthy, neurotypical adults copy the RCF using a temporal-spatial heuristic, it is only partially adhered to. Traditionally deviation from strict adherence to the four strategy clusters during drawing was deemed to be indicative of cognitive dysregulation, however our findings demonstrate a normal distribution of typical population performance. These findings have important implications for interpreting how RCF drawing strategy informs clinical assessment and diagnosis as both very strict and very weak adherence to a temporal-spatial heuristic can be indicative of atypical function. The study supports this novel scoring system as a fast and reliable means to systematically measure RCF Cluster Strategy that with further validation could be adopted within clinical practice.