Feasibility of Telecognitive Assessment

in Dementia
C. Munro Cullum
Myron F. Weiner
Helena R. Gehrmann
Linda S. Hynan
University of Texas Southwestern Medical Center at Dallas

Videoconferencing (VC) technology has been used successfully to provide psychiatric

services to patients in rural and otherwise underserved settings. VC-based diagnostic
interviewing has shown good agreement with conventional face-to-face diagnosis of
dementia in several investigations, but extension of this technology to neurocognitive
assessment has received little attention. To this end, the authors administered a brief bat-
tery of common neuropsychological tests via VC technology (telecognitive) and tradi-
tional face-to-face methods to 14 older persons with mild cognitive impairment (MCI)
and 19 persons with mild to moderate Alzheimer’s disease (AD). Highly similar test
scores were obtained when participants were tested in-person or via VC. Telecognitive
assessment appears to be a valid means to conduct neuropsychological evaluation of
older adults with cognitive impairment. Furthermore, continued development of VC tech-
nology has implications for expanding neuropsychological assessment options in under-
served populations.

Keywords: neuropsychological testing; cognition; dementia; videoconferencing; telemed-

icine; telecognitive assessment

Neuropsychological testing is used to detect, charac-
terize, and quantify cognitive impairment in elders and is
an integral component of dementia evaluations (Cullum,
Paulman, Koss, Chapman, & Lacritz, 2003). However,
the use of neuropsychological testing in some settings
has been limited by the need for face-to-face contact.
Significant advances have been made in telemedicine in
the first decade of its existence, and although still not
widely used, a growing number of studies suggest its
applicability and validity in psychiatry (Frueh et al.,
2000; Hilty, Luo, Morache, Marcelo, & Nesbitt, 2002)
and geropsychiatry in particular (Tang, Chiu, Woo,
Hjelm, & Hui, 2001). Good agreement between in-person
and VC-based clinical diagnosis of dementia has been
reported (Lee et al., 2000; Shores et al., 2004) and there
is high satisfaction with VC-based psychiatric interviews
(Hilty et al., 2002; Kobak, 2004). On the other hand, little
has been done to explore VC technology in the assess-
ment of elders’ cognitive functioning. A literature review
revealed only four publications that included elders, and
none included more than a few persons with adequately
diagnosed dementia.
Montani et al. (1997) administered the Mini-Mental
State Exam (MMSE; Folstein, Folstein, & McHugh, 1975)
and the Clock-Drawing Test (Tuokko, Hadjistavropolulos,
Miller, Horton, & Beattie, 1995) to 14 medical inpatients
(age 83 to 95) comparing face-to-face with VC examina-
tion. Tests were administered a week apart in random
order. Mean MMSE scores were similar, 23.7 (face-to-
face) versus 22.2 (VC), r = .95, p < .003. For Clock

This article was supported in part by NIA 2P30 AG12300. Please address correspondence to C. Munro Cullum, PhD, 5323 Harry
Hines Blvd., Dallas, TX 75390-9044; e-mail: munro.cullum@utsouthwestern.edu.
Assessment, Volume 13, No. 4, December 2006 385-390
DOI: 10.1177/1073191106289065
© 2006 Sage Publications

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386 ASSESSMENT
Drawing, the mean scores were similar but the correla-
tion was nonsignificant (r = .55).
Ball and Puffett (1998) administered the cognitive
portion (CAMCOG) of the CAMDEX (Roth, Huppert,
Tym, & Mountjoy, 1988) comparing face-to-face with
VC administration to eight elders from an outpatient
psychogeriatric service tested 1 week apart. Ages ranged
from 65 to 84; diagnoses included depression, schizo-
phrenia, and dementia. It was noted that visual quality
of test stimuli was good using VC-based presentation,
and agreement rates were good for orientation (r = .83) and
memory (r = .84) but poor for calculation (r = .10) and
abstract thought tasks (r = 0.41). Menon et al. (2001)
used VC to administer the Short Portable Mental Status
Questionnaire (SPMSQ; Pfeiffer, 1975) to a convenience
sample of persons admitted to a VA Geriatric Evaluation
and Management Unit using videophones. Twelve partic-
ipants underwent both face-to-face and VC interviews.
There were similar cognitive and depression scores
across conditions, although few quantitative details were
provided. Ratings of participant satisfaction with the
interview procedures across conditions were similar.
More recently, Hildebrand, Chow, Williams, Nelson,
and Wass (2004) administered a battery of neurocognitive
tests to a group of 29 cognitively intact volunteers older
than age 60. Participants were tested face-to-face and by
VC. Two test batteries were assembled using nine stan-
dardized measures and alternate forms, including tests of
verbal learning, verbal fluency, vocabulary, visuospatial
reasoning, attention, and clock drawing. Similar mean test
scores (i.e., within 0.5-2.0 points) were obtained under each
condition on most measures, although a slight order effect
was seen on six of the nine tests, with greater variability in
scores found among the participants who underwent VC-
based testing first. A survey of participants revealed satis-
faction with VC testing, although a slight majority (44%)
indicated a preference for face-to-face testing.
Little is known about the efficacy of VC as a medium
for neuropsychological assessment of cognitively impaired
elders and no studies have systematically examined
VC-based neurocognitive assessment in patients with a
clinical diagnosis of Mild Cognitive Impairment (MCI;
Petersen et al., 1999) or Alzheimer’s disease (AD). With
the rapid growth of the elderly segment of our popula-
tion, there will be an increasing need for neuropsycho-
logical evaluations for both diagnosis and monitoring of
treatment. If telecognitive assessment is valid, reliable,
practical, and cost efficient, it may significantly advance
the diagnosis and treatment of underserved elders with
known or suspected cognitive impairment.
We hypothesized that VC and face-to-face testing would
yield consistent results across neurocognitive measures
using a brief battery of commonly used tests to evaluate
patients with MCI and AD.
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METHOD
Participants
During March and April 2005, we recruited 14
individuals with MCI (Petersen et al., 1999) and 19 indi-
viduals with possible (n = 1) or probable (n = 18) AD
(McKhann et al., 1984). Diagnosis was made via con-
sensus (involving psychiatry, neurology, and neuropsy-
chology) using standard criteria as noted and prior to
participation in the current study. Diagnostic evaluations
included neuropsychological testing with instruments
other than those used in this investigation. Participants
with AD were required to have an accompanying study
partner (in all cases, this was a spouse or an adult child)
who could be with them in the VC testing room to
decrease potential anxiety associated with the unfamiliar
environment and to assist the examiner if the patient
became confused or uncooperative. We excluded per-
sons who were illiterate, had profound hearing loss or
severe visual impairment, or whose cognitive incapacity
precluded informed consent. The MCI sample consisted
of nine men and five women. The AD sample was com-
posed of 18 participants with a diagnosis of probable AD
and 1 with possible AD and included 13 men and 6
women. All participants were fluent in English, and all
but 1 was Caucasian; 3 participants had mild hearing
impairment. Because the primary goal of this study was
to demonstrate the feasibility of VC-based neuropsycho-
logical testing in older participants with cognitive
impairment, and to keep other test conditions stable,
optimize patient compliance, and minimize anxiety in
the novel VC environment, the same examiner tested the
same participants in each condition. Test condition (in-
person or VC) and test forms were counterbalanced
across participants and tests were administered in the
same order.
Procedure
Approval for this study was obtained from the
Institutional Review Board at The University of Texas
Southwestern Medical Center and written consent was
obtained from all participants prior to participation.
Prospective participants were told that we were doing an
experiment to see if cognitive testing could be done by
television/video. The examiner gave each participant a
brief introduction about the VC testing procedure at the
outset and explained that the examiner would appear on
screen but would be readily available in person should
they require assistance. Participants were seated and
viewed the examiner and test materials on a 19-in. color
monitor. Study partners were asked to remain seated in
the background behind the patient to provide reassurance

TABLE 1
Demographics and MMSE Scores
MCI + AD Sample (N = 33)
M SD
Age (years) 73.3 6.9
Education (years) 15.1 2.7
MMSE (face-to-face) 26.1 3.3
MMSE (VC) 26.3 3.7
NOTE: MMSE = Mini-Mental State Exam; MCI = mild cognitive
impairment; AD = Alzheimer’s disease; VC = videoconferencing.
or assistance understanding test instructions if needed.
Testing took place in back-to-back sessions, each lasting
45 to 50 min, with a brief (i.e., 5 to 10 min) break in
between. Examiners were two trained psychometrists
who also operated the VC equipment during each testing
session.
Criteria for the selection of tests administered included
(a) brevity, (b) common use in the clinical evaluation of
older adults with cognitive impairment, (c) availability of
alternate forms (where possible), (d) adequate test-retest
reliability (Lezak, Howieson, & Loring, 2004), (e) suit-
ability for VC-based administration and response record-
ing, and (f) assessment of a variety of cognitive skills
important in dementia evaluations (global cognitive func-
tioning, verbal memory, attention, verbal fluency, and
naming). Measures included the MMSE, Hopkins Verbal
Learning Test–Revised (HVLT-R; Benedict, Schretlen,
Groninger, & Brandt, 1998), Clock Drawing Test
(Goodglass & Kaplan, 1983), Digit Span (Randolph,
1998), Category Fluency (fruits and vegetables; Spreen &
Strauss, 1991), letter fluency (FAS and CFL versions;
Benton, Hamsher, & Sivan, 1994), and 15-item versions of
the Boston Naming Test (BNT; Mack, Freed, Williams, &
Henderson, 1992). With the exception of the MMSE and
Clock Drawing, the other tests had an available alternate
form. We made the following modifications to adapt for
repeated testing and VC administration: The MMSE items
were the same in both testing conditions except for three-
word recall, which used different stimuli in each condition.
For the HVLT-R, Forms 1 and 4 were selected due to their
high correlation. Four primary HVLT-R scores were
obtained: total words learned throughout trials 1 to 3,
delayed recall, percentage retention (Delayed Recall / Trial
3 × 100), and a recognition discrimination index (True
Positives – False Positives). We used short form BNT ver-
sions 3 and 4, which show the highest correlation (Mack
et al., 1992). The visuospatial measures (MMSE pen-
tagons and Clock Drawing) were scored via the television
monitor by asking participants to hold up their paper in
front of the camera when they were finished.
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Cullum et al. / TELECOGNITIVE ASSESSMENT 387
Equipment
An H.323 PC-based Videoconferencing System was
set up in two nonadjacent rooms using a Polycom iPower
Range 680 Series videoconferencing system (2 units). The 680
51–84
provided high quality audio and full motion video. Visual
8–20 stimuli for testing were displayed by a flatbed graphics
15–30 camera with integrated lighting, 12X zoom, autofocus, and
15–30 iris (Canon Video Visualizer RE 650 MK II). Participants
viewed the examiner on a 19-in. color monitor and a
29-in. monitor was used to view the participant. Because
we were able to adjust the audio volume of the monitor,
hearing-impaired individuals did not report or appear to
have difficulty. The cost of this equipment, including
both stations, was approximately $12,000.
RESULTS
The MCI and AD groups were similar in age, t(31) =
.37, p = .72, and education, t(31) = 1.3, p = .21; they dif-
fered significantly on face-to-face MMSE, t(22.99) =
4.09, p < .001, and telecognitive MMSE, t(21.73) = 3.31,
p = .003. For the purpose of this study as a demonstration
of feasibility of telecognitive assessment, the MCI and
AD groups were combined and their general characteris-
tics are presented in Table 1.
Paired samples statistics were performed for each
of the tests comparing in-person with telecognitive test-
ing across both groups combined. Because the Clock
Drawing test (Goodglass & Kaplan, 1983) has a range of
1 to 3, Cohen’s Kappa and percentage of agreement were
used to examine reliability. For the other continuous
measures, reliability across the two testing formats was
determined by examining the results for the Intraclass
Correlation Coefficient, a measure of reliability agree-
ment, and the Bradley-Blackwood Procedure, a test that
simultaneously compares the means and variances of
the two measurements (Bartko, 1994). The pattern for
good reliability using these two statistics is a significant
Intraclass Correlation Coefficient (indicating high agree-
ment between measurements) greater than .60 and a non-
significant Bradley-Blackwood Procedure (the test-retest
measurements have similar means and variances). If
the Bradley-Blackwood Procedure was significant, the
paired t test and the Pitman test were used to evaluate
where the bias between the two measurements occurred
(inequality of means and variances). Analyses were per-
formed using Statistical Package for the Social Sciences
(SPSS) version 13 and due to the proof-of-concept
nature of the study design, the significance level for
reporting statistical results was set at .01 to adjust for
multiple comparisons. Table 2 presents a comparison of
388 ASSESSMENT

TABLE 2
Means, Standard Deviations, and Correlations for Cognitive Tests
Administered Via VC and Face-to-face
Pearson Bradley-Blackwood
Telecognitive Face-to-Face Correlation* Procedure

Measure M SD M SD r Intraclass Correlation p**

MMSE 26.27 3.67 26.09 3.29 .89 .88 .36

HVLT-R total recall 18.91 7.66 19.00 7.58 .77 .77 .99
HVLT-R delayed recall 3.21 3.91 4.39 5.07 .63 .61 .10
HVLT-R retention % 33.39 36.46 41.85 40.92 .55 .54 .33
HVLT-R recognition 8.03 3.84 8.00 3.64 .68 .68 .92
Digit span total 10.30 2.64 10.30 2.02 .81 .78 .05
Category fluency 9.67 3.39 9.18 3.28 .58 .58 .65
Letter fluency 32.64 13.78 33.97 12.53 .83 .83 .40
BNT (15 item) 12.30 2.62 12.48 2.84 .88 .87 .49

NOTE: VC = videoconferencing; MMSE = Mini-Mental State Exam; HVLT-R = Hopkins Verbal Learning Test–Revised; BNT = Boston Naming Test.
*p < .001. **two-tailed p.

neurocognitive test results between the two testing
conditions.
There were similar mean scores on HVLT-R Total
Recall and Recognition, category and letter fluency, and
BNT. Slightly higher means in the face-to-face condition
were seen on HVLT-R Delayed Recall. One of the larger
(but statistically nonsignificant) differences was seen on
HVLT-R Retention, with in-person testing associated
with a higher mean score. Large standard deviations were
seen on this measure in both conditions, which was not
unexpected because the retention score is computed from
immediate and delayed recall scores, thereby inflating
measurement error beyond the individual scores alone
and making it more difficult to achieve high stability esti-
mates. Scores on Clock Drawing (which has a very lim-
ited range of scores) had equal medians and Digit Span
had identical mean scores for both testing groups.
The measures that showed significantly high (> .60)
ICC scores were MMSE, HVLT-R Total Recall, HVLT-R
Delayed Recall, HVLT-R Recognition, Digit Span Total,
Letter Fluency, and short form BNT. Although HVLT-R
Retention and Category Fluency scores were considered
significant, these measures did not meet the criterion of
.60 or higher. Kappa for the Clock Drawing scores was
moderate (κ = 0.48, p < .0001), with 75.8% (25/33)
agreement.
To examine the potential bias (unequal means and/or
variances) for these two testing methods, the Bradley-
Blackwood Procedure was used. All tests were found to
have simultaneously nonsignificant means and variances,
suggesting highly similar results across testing condi-
tions. Fully eight of the nine test scores (continuous mea-
sures) had high associations and little bias between VC
and face-to-face testing conditions. Thus, for most mea-
sures, similar results were obtained when participants
were tested in-person or by VC. Examiners also solicited
feedback from participants about their testing experiences
following testing sessions. No participant expressed any
difficulties or concerns regarding telecognitive testing,
although several indicated a preference for personal
contact.
DISCUSSION
Scores between VC-based and face-to-face testing
were highly similar across tests administered, supporting
our hypothesis of good agreement between testing
modalities in addition to good agreement between the
alternate test forms used. Overall, 9 of the 10 cognitive
test scores were found to have both high associations and
little bias between testing conditions. Measures of verbal
learning and memory, simple attention, letter and cate-
gory fluency, and confrontation naming showed excellent
agreement between telecognitive and face-to-face testing.
Despite a strong correlation, the verbal percentage reten-
tion score on the HVLT-R showed substantial variability
in each test session, suggesting that this score may not
be as reliable as the other memory indices. Additional
reminders for examinees to memorize the words for later
recall might help decrease the variability on this task in
future studies. The finding of somewhat higher mean ver-
bal retention scores in the face-to-face condition is inter-
esting and merits further investigation, although it is
possible that the personal support of having the examiner
present in the room may somehow have a beneficial effect

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on effort/performance on this arguably more challenging
task. The lack of statistical agreement between VC and
face-to-face administration of the Clock Drawing task is
also noteworthy but likely due to the limited variance in
the present sample.
This study is limited by its inclusion of well-educated
patients who were familiar with neuropsychological testing.
None had profound receptive or expressive aphasia, as
might be found in stroke patients, and all participants but
one were Caucasian. As noted, participants were tested by
the same examiner in both conditions, which may have
inflated test-retest correlations. As a pilot study, however,
the primary goal was to demonstrate the feasibility of VC-
based cognitive testing, and we wanted to keep as many
testing conditions as stable as possible. Our concern about
the potential effect of novelty of the VC environment on
cognitively impaired participants led us to have a study part-
ner sit in with them during testing. In practice, all partici-
pants seemed to adapt readily to the VC-based interactions
after initial introduction, and it is probably not necessary to
have a caregiver present during VC testing for most partici-
pants with mild to moderate AD. The use of VC technology
has previously been limited by the quality of sound and pic-
ture, but we did not find this to be an issue with the equip-
ment we employed. We do not know what effect
long-distance transmission of VC technology might have on
sound and picture, but we are currently investigating this. It
also should be noted that telecognitive assessment is limited
to tasks that do not require direct participant/examiner
interaction with test materials (e.g. Wechsler Adult
Intelligence Scale–Third Edition [WAIS-III] Block Design,
Wisconsin Card Sorting Test), although administration of a
number of other popular measures should be feasible (e.g.
Raven’s Matrices, WAIS-III Matrix Reasoning, Judgment
of Line Orientation). Future incorporation of computer-
based assessment procedures in conjunction with VC inter-
action also is promising, particularly as this technology
becomes less expensive and more widely available.
CONCLUSIONS
Neuropsychological tests administered by VC tech-
nology were successfully completed in all cases, and
there was close agreement with test findings when admin-
istered face-to-face in persons with MCI and mild to
moderate AD. In addition, telecognitive testing was well
tolerated by all participants. This suggests that telecognitive
assessment of persons with suspected or diagnosed
dementia is feasible, reliable, and merits further develop-
ment because it holds particular promise in rural and oth-
erwise underserved populations.
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Cullum et al. / TELECOGNITIVE ASSESSMENT 389
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C. Munro Cullum is a neuropsychologist and professor of psy-
chiatry and neurology at The University of Texas Southwestern
Medical Center at Dallas. His primary research interests include
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neurocognitive assessment and differential diagnosis of demen-
tia, memory dysfunction, and neuropsychiatric disorders.
Myron F. Weiner is a geriatric psychiatrist. He is professor of
psychiatry and neurology at The University of Texas
Southwestern Medical Center at Dallas. His clinical and
research interests are in improving the diagnosis, management,
and treatment of persons with dementing illness.
Helena R. Gehrmann is a psychological assistant in the
Alzheimer's Disease Center at The University of Texas
Southwestern Medical Center at Dallas. Her research interests
include dementia and neuropsychological assessment.
Linda S. Hynan is associate professor of biostatistics and psy-
chiatry at The University of Texas Southwestern Medical
Center at Dallas. Her primary research interests include assess-
ing psychometric properties of tests, modeling behavioral and
biological processes, and medical decision making.