Epilepsy & Behavior 7 (2005) 708–714

www.elsevier.com/locate/yebeh

EpiTrack: Tracking cognitive side effects of medication on attention

and executive functions in patients with epilepsy q
M.T. Lutz, C. Helmstaedter *
Department of Epileptology, University of Bonn, Bonn, Germany

Received 14 June 2005; revised 25 August 2005; accepted 26 August 2005

Available online 2 November 2005

Abstract

Rationale. Achievement of maximum seizure control with preservation or even improvement of patientÕs cognitive capabilities is the
major aim of epilepsy therapy. EpiTrack is a brief screening tool for the tracking of cognitive side effects of antiepileptic drugs. Test
selection was based on recent studies on the effects of topiramate on cognition and retrospective inspection of results from patients with
antiepileptic drug (AED) side effects.
Methods. The 15-minute screening tool comprises six subtests: the Trail-Making Test (parts A and B), a test of response inhibition,
digit span backward, written word fluency, and a maze test. These tests were standardized in 220 healthy subjects, 100 of whom were
reevaluated after 5.3 months to obtain information on reliability and practice effects. Criterion validity was determined by correlation
to other neuropsychological measures. For a first clinical evaluation, the impact of epilepsy (seizures) and medication on EpiTrack scores
was evaluated cross-sectionally in 184 consecutive inpatients with chronic epilepsy.
Results. According to the normative data, we developed an easy scoring scheme assigning test scores on a 7-point scale. The EpiTrack
is suitable for patients between 18 and 60 years of age. Age corrections were included for patients between 40 and 60 years. EpiTrack
scores on subtests for both controls and patients were submitted to principal component analysis. VARIMAX rotation yielded a two-
factor solution (verbal/visuo-spatial) that accounted for 63.8% of the total variance in controls. In the patient group, only one factor
emerged accounting for 54.7% of variance. EpiTrack correlates with global scores of attention (r = 0.85) and language (r = 0.67)
(PÕs < 0.001). At a cutoff score of 25, only 2.7% of the controls were classified as impaired, while impairment was indicated in 48.4%
of the patients. The score is sensitive to monthly frequency of complex partial seizures and to number of AEDs. It shows negative cog-
nitive effects of valproate and topiramate given in mono/polytherapy.
Conclusion. EpiTrack is a promising 15-minute screening tool for the detection and tracking of cognitive side effects of AEDs and adverse
effects of seizures in patients with epilepsy. Future application will show its value in prospective follow-up studies on AED side effects.

2005 Elsevier Inc. All rights reserved.

Keywords: Epilepsy; Neuropsychology; Screening; Antiepileptic drug; AED; Cognitive side effects; Attention; Executive function; Cognition

1. Introduction impairments may have negative effects on social life, work,

Clinicians often are confronted with attention, memory,
and language problems in patients with epilepsy. These
q
EpiTrack has been published and is distributed by UCB Pharma
(Europe). Test construction and development, as well as this study, have
not been supported.
*
Corresponding author. Fax: +49 0 228 287 4486.
E-mail address: Christoph.Helmstaedter@ukb.uni-bonn.de (C. Helm-
staedter).
or school achievement. Most cognitive problems have a
multifactorial origin. While some factors, like etiology
and lesions, may cause stable and persisting impairment,
other factors, such as seizures, epileptiform electroenceph-
alographic activity, and side effects of antiepileptic drug
(AED) treatment, may cause dynamic and principally
reversible changes [1–3]. Following this, achievement of
maximum seizure control while minimizing negative effects
of the treatment of epilepsy is essential. There are two com-
mon clinical situations in the management of patients with

1525-5050/$ - see front matter
2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.yebeh.2005.08.015
 M.T. Lutz, C. Helmstaedter / Epilepsy & Behavior 7 (2005) 708–714
epilepsy in which physicians need to know whether or not
medical treatment causes negative effects on patientsÕ men-
tal capability. First, with satisfactory seizure control,
patients are on one or more drugs and their mental status
is not satisfactory. Here, the clinician wants to know
whether the decision to withdraw or change medication is
or was the correct decision. Second, with unsatisfactory sei-
zure control, a new drug is chosen that may cause cognitive
impairment when administered alone or in combination
with other AEDs. Here, the clinician must monitor the
patient to see whether this is the case.
To achieve a favorable treatment, physicians not only
have to know potential side effects of AEDs but also have
to carefully observe cognitive changes in their patients.
Relying alone on patientsÕ reports is often not sufficient.
Patients may be unaware of impairment or cognitive
change or may misattribute their problems to epilepsy or
normal aging. It has been shown that subjective complaints
about cognitive impairment more reliably indicate depres-
sion than the actual degree of impairment [4]. Further-
more, patients may have different concepts of cognition
as do health care professionals, leading easily to misunder-
standings [5,6]. Reports from relatives on the patientsÕ
everyday cognitive function provide valuable information,
especially with regard to performance change, but even
their reports are not free from subjective distortions. The
situation is clear-cut when patients attract the attention
of caregivers or clinicians by obvious signs of intoxication
or by subtle slowing of speech, impaired concentration, or
forgetfulness. In every case the valid detection of cognitive
impairment and cognitive change requires repeated neuro-
psychological testing, including mood and personality.
Specialized epilepsy centers may offer this, but in primary
care settings, rapid detection of cognitive problems and
tracking of cognitive changes are needed. However,
paper-and-pencil cognitive screening tools designed for
patients with epilepsy are rare, and direct adoption of tools
designed for the detection of early signs of dementia is not
easily performed due to different psychometric demands
[7].
The present study describes the scaling and standardiza-
tion procedure for EpiTrack, a new 15-minute screening
tool developed to detect dysfunctions of attention and exec-
utive control caused by epileptic disorders or antiepileptic
drugs, and to track cognitive performance parallel to chang-
es in medical therapy. Reliability, factor structure, and con-
current validity with other neuropsychological measures are
examined, and preliminary data on the clinical validity and
utility are provided. EpiTrack was developed to avoid com-
mon shortcomings of screening instruments. The test was
developed as a brief portable paper-and-pencil measure
consisting of six tests suited for repeated assessment of a
highly constricted range of cognitive functions, namely,
attention and executive control. Attentional functions
include the ability to attend to stimuli, concentrate on task
demands, and self-monitor responses. Executive control
comprises such abilities as strategy formation, planning,
709
and motor programming that are involved in the organiza-
tion of complex behavior. Dysfunction in attention and
executive control often significantly impairs a patientÕs per-
formance in other cognitive domains. In addition, such def-
icits may interfere with everyday life activities and safety,
especially in the performance of time-dependent or complex
activities [8]. The rationale behind the test selection was that
the selected tests proved to have the highest sensitivity to
medication side effects among a comprehensive test battery
that has routinely been used in patients with epilepsy for the
last two decades. Medication side effects, if not recognized,
can distort the neuropsychological diagnosis and lead to
invalid statements about attention, memory, language, or
intelligence. In our own clinical practice, the EpiTrack sub-
tests are routinely performed at the beginning of each
neuropsychological evaluation, to decide whether or not
in-depth examination with a time-consuming comprehen-
sive neuropsychological test battery can be performed.
Validity of the tests was furthermore indicated by the fact
that four of the six EpiTrack subtests have been successfully
applied in two recently published studies on the negative
side effects of topiramate [9,10]. In another longitudinal
study of differential cognitive effects of topiramate versus
tiagabine, five of the six EpiTrack subtests were included
and proved to be useful [11].
2. Methods
2.1. Test description
The EpiTrack consists of six subtests requiring atten-
tion, cognitive tracking, and working memory. These tests
are versions of published tests found in traditional neuro-
psychological assessment. The procedure was explicitly
developed to enable repeated testing. The overall adminis-
tration of EpiTrack takes about 12 to 15 minutes, but may
take longer with more impaired patients. All test instruc-
tions follow the standard instructions of the respective
tests. There are no explicit discontinuation criteria; howev-
er, these can be easily deduced using the lowest categories
in the transformation table.
• The first subtest is an interference test, which is a varia-
tion of a German screening test for the assessment of
response inhibition or susceptibility for interference,
respectively [c.I.-test;] [12]. This test requires inverse
reading of three rows of ones and twos (11212 as
22121). Time needed to perform the tasks is the object
of the evaluation.
• Second, the popular Trail-Making test (TMT, parts A
and B) was incorporated [13]. In TMT A, the subject
has to track numbers from 1 to 25 in ascending order
with a pencil. In TMT B, numbers and letters of the
alphabet have to be tracked in alternating ascending
order (1-a-2-b-3-c, etc). This test requires cognitive
tracking, psychomotor speed, short-term memory, and
cognitive flexibility.
710 M.T. Lutz, C. Helmstaedter / Epilepsy & Behavior 7 (2005) 708–714
• The third test is a maze test. The maze was selected from
the maze test from Chapuis [14]. Patients are asked to
track the maze like driving a car, i.e., going back when
a dead end is entered. As in most of the EpiTrack sub-
tests, time score is subject to evaluation; errors are cor-
rected while time is running. For retesting, a rotated
version of this test is available. This test assesses visual
anticipation, planning, and psychomotor speed.
• The fourth task is a written phonematic verbal fluency
task. This task requires the subject to write down as
many words as possible in 60 seconds that begin with
a designated letter (P and L). In the retest version of this
subtest, two other letters are used (R and K). The num-
bers of valid words, irrespective of orthography, were
totaled.
• Finally, working memory is assessed by use of the digit
span backward task of the German adaptation of the
WAIS-R [15]. Subjects have to repeat digits in reverse
order until they fail two times at a given level.
Instructions for testing, scoring, and interpretation are
included in a test booklet that is now distributed by
UCB-Pharma [16]. In addition a video demonstration is
available on CD Rom.
3. Subjects and procedure
The healthy control group consisted of 220 subjects.
Subjects who manifested or had a history of significant
medical, neurological, or psychological conditions that
might significantly interfere with cognitive functioning
were excluded based on an anamnestic interview. This
group ranged in age from 17 to 64 years (mean = 41.4,
SD = 13.9) and had obtained 11.8 years of formal educa-
tion (SD = 1.7). Fifty-eight percent of subjects were wom-
en. One hundred (45%) of the normal control subjects
underwent repeated testing after an average interval of
5.3 months (range 2.9–9.7 months). The clinical sample
consisted of a series 184 consecutive patients in the age
range 16 to 65 years (mean = 36.0, SD = 12.0) and with
9.6 years of formal education (SD = 1.8). Forty-seven per-
cent of subjects were women. The average duration of epi-
lepsy was 20.8 years (SD = 12.5). All participants received
the EpiTrack subtests as part of a comprehensive neuro-
psychological test battery. Patients were candidates for epi-
lepsy surgery and had been examined in the context of
preoperative diagnostics; healthy controls took part in a
normative study.
4. Results
4.1. Scale development
4.1.1. Scaling procedure and age correction
Performance of the normal control sample on the Epi-
Track is summarized in Table 1. This table lists means
and standard deviations of the raw scores together with
Table 1
Means and SD of raw scores and EpiTrack subtest scores for the control
group
Raw scores EpiTrack scores
M SD M SD
Interference test 17.9 4.1 5.4 1.0
TMT A 28.3 10.4 5.5 1.0
TMT B 61.1 28.2 5.5 1.0
Maze test 34.8 16.1 5.4 1.0
Verbal fluency 28.4 6.8 4.5 1.0
Digits backward 5.4 1.3 4.0 0.9
the corresponding EpiTrack scores. EpiTrack scores were
derived by using a linear scaling strategy based on the stan-
dard deviations of the subtestsÕ raw scores. EpiTrack scores
range from 1 to 7 points, with 1 point indicating the
impaired end of the performance range. The Kolmogo-
rov–Smirnov procedure has shown that, with the exception
of the verbal fluency task, the null hypothesis, that the sam-
ples of subtest scores come from a normal distribution, had
to be rejected. Consequently, EpiTrack subtests scores are
simply ordinal indexes and should not be interpreted as
interval scaled scores.
To obtain the total score, the six EpiTrack subtest scores
are summed. The control subjects achieved a total EpiTrack
score of 30.3 (SD = 3.9). EpiTrack scores were significantly
correlated with age in the control group (r = 0.492,
P < 0.001) and within the patient group (r = 0.167,
P < 0.05). This is in line with the well-known findings of
age-related declines in processing speed and attention (see,
e.g., [17]). To prevent an age-related bias, an age correction
based on control group data was introduced. Accordingly,
subjects 40 years or older receive two correction points, sub-
jects 50 years or older receive 5 additional points. As a result
of this procedure, the correlations between age and age-cor-
rected EpiTrack scores diminished and were no longer signif-
icant (control group: r = 0.011, n.s.). The control group
achieved an age-corrected EpiTrack total score of 32.3
points (SD = 3.3). This score does not deviate significantly
form a normal distribution (Kolmogorov–Smirnov-
Z = 1.266, n.s.). Because of insufficient data under the age
of 18 and above 60 years, we suggest restricting the age range
for test application to 18–60 years.
4.1.2. Setting a cut-off
Based on the mean and SD of the age-corrected Epi-
Track distribution, the cutoff 28/29 represents the transi-
tion from unimpaired to borderline/mildly impaired
performance and an EpiTrack score of 25 or less indicates
clearly impaired performance. Table 2 is a frequency table
for the EpiTrack total scores together with corresponding
z-scores. The frequency distribution of the total score
shows that 11.9% of the normal controls achieved a score
of 28 or less, and only 2.7% (n = 6) scored 25 or less. Nor-
mative data for above-average performance are not provid-
ed in accordance with the aim of the EpiTrack, which is to
mainly detect clinically significant impairments.
 M.T. Lutz, C. Helmstaedter / Epilepsy & Behavior 7 (2005) 708–714 711

Table 2 4.2. Validation and clinical utility

Frequency table of the age-corrected EpiTrack total scores together with
corresponding z-scores
4.2.1. Classification and group differences
EpiTrack total score Percent Cumulative percent z score Comparison of the patient and control groups yielded a
P29 88.1 100 P 1.0 highly significant difference for the age-corrected EpiTrack
28 3.2 11.9 1.3 score (t = 16.1, P < 0.001), with patients (M = 24.9,
27 4.1 8.7 1.6
26 1.8 4.6 1.9
SD = 5.8) performing more poorly than controls
25 0.5 2.7 2.2 (M = 32.3, SD = 3.3). This difference holds even when
24 0.9 2.3 2.5 effects of education and premorbid IQ are parceled out
23 0.5 1.4 2.8 (analysis of covariance, ANCOVA; F = 54.6, P < 0.001).
22 0.5 0.9 3.1 Significant differences were also evident in all subtest scores
21 0.5 0.5 3.4
[tÕs between 5.4 and 18.6; all PÕs < 0.001] (Fig. 2).
Table 3 summarizes the classification of controls and
4.1.3. Reliability and change analysis patients to the unimpaired, borderline, and impaired rang-
Test–retest reliability, which measures stability over es of EpiTrack performance. Among the patients, 48.4%
time, was obtained from 100 (45%) of the normal control manifested definite cognitive impairment.
subjects at an average intertest interval of 5.3 months
(range 2.9–9.7 months). The coefficient (Pearson) obtained 4.2.2. Principal component analysis
was 0.79. As a lower bound for the true reliability of the EpiTrack scores on subtests were submitted to principal
scale, we calculated CronbachÕs a, which was 0.750 in the component analysis (Table 4) with VARIMAX rotation. In
normal controls, suggesting good internal consistency. controls, this procedure yields a two-factor solution (with
EpiTrack is supposed to be a change-sensitive screening eigenvalues >1.0) that accounted for 63.8% of the total var-
instrument. Hermann et al. [18] suggested the use of reliable iance. Factors can be easily interpreted as verbally based
change indexes (RCIs [19]) to identify and characterize and visuospatially based attention. Among patients only
meaningful and reliable changes in cognitive performance. one factor emerged that accounted for 54.7% of variance.
RCIs take into account not only the measurement error in
the test–retest setting, but also practice effects. In specifying 4.2.3. Convergent and discriminant validity
the degree of test–retest change required to exceed sources of Validity was assessed by correlating the EpiTrack scores
measurement errors, RCIs determine whether a patientÕs test with concurrently administered neuropsychological tests.
performance has changed relative to baseline performance. Analysis was performed within the total sample (controls
Parameters used to calculate RCI were a SD of 3.3, a retest and patients). To prevent contamination of the criterion,
reliability of 0.79 and a mean change (practice effect) of 0.9 convergent validity was tested by the correlation between
with a 90% confidence interval. According to this, differences
(retest minus baseline performance) between 3 and +4 can
be seen as normal. RCIs indicate statistically reliable chang- 6

es, without accounting for the effective frequency of test–re- controls

EpiTrack subtest score (points)

5 patients
test differences in the normative sample. Fig. 1 shows
differences (retest score minus baseline score) in the stan-
4
dardization sample. It can be seen that difference scores
smaller than 4 or larger than 5 are highly infrequent. 3

30 2

25 1
number of subjects

20 0
Interference TMT A TMT B Maze Fluency Digits

15 Fig. 2. EpiTrack subtest performance of the patient and control groups.

Significant differences in all subtest scores (all PÕs < 0.001).
10

Table 3
5
Classification of controls and patients according to age-corrected Epi-
Track total scores
0
-4 -3 -2 -1 0 1 2 3 4 5 6 7 8 Controls Patients
difference score Unimpaired (P29 points) 88.1% 29.3%
Fig. 1. Frequencies of difference scores (retest score minus baseline score). Borderline (26–28 points) 9.1% 22.3%
Bars indicate reliable changes. Impaired (625 points) 2.7% 48.4%
712 M.T. Lutz, C. Helmstaedter / Epilepsy & Behavior 7 (2005) 708–714

Table 4 the fact that epilepsy-related variables gain a stronger influ-

Results of principal component analysis with VARIMAX rotation of ence. The correlation between age-corrected EpiTrack
EpiTrack subtest scores within control and patients group
score and onset of epilepsy was 0.175 (P < 0.05), the corre-
Controls Patients lation with duration of epilepsy was not significant. The
Factor I visuospatial Factor II verbal Factor I age-corrected EpiTrack score correlated with the frequency
TMT A 0.824a 0.785 of complex partial seizures (CPS; r = 0.186, P < 0.05)
Maze test 0.802 0.634 and as a trend with tonic–clonic seizures (P = 0.06).
TMT B 0.770 0.798 As the next step in the analysis, we explored whether
Digits backward 0.800 0.716
Verbal fluency 0.761 0.676
EpiTrack scores reflect differences in AED treatment in
Interference test 0.619 0.809 the 184 patients. First, the age-corrected EpiTrack score
Variance explained 35.3% 28.5% 54.7% turned out to be sensitive to polytherapy (i.e., number of
a
Loadings <0.4 suppressed. antiepileptic drugs; r = 0.187, P < 0.05). To evaluate the
sensitivity of EpiTrack to specific AEDs, we performed a
multiple regression analysis predicting EpiTrack scores
EpiTrack score and a factor score consisting of eight non- from AED use (while controlling for age and number of
redundant tests assessing attention and executive control. AEDs). Frequency of complex partial seizures and treat-
Tests were motor sequences (Luria), letter cancelation, ment were entered into the regression model. Treatment
block design, error score of an extended maze test, mental with AEDs was coded as eight dichotomous independent
rotation, symbol counting, digit forward, Corsi block tap- variables (e.g., topiramate (TPM) yes/no), representing
ping, and semantic word fluency. A significant correlation the eight AEDs with the highest frequency in the patient
(r = 0.85, P < 0.001) indicated convergent validity. sample. Fig. 3 shows the predictive relevance of the inde-
Discriminate validity was examined by the correlations pendent variables. With regard to the EpiTrack total score,
between EpiTrack and a verbal factor consisting of token it can be seen that topiramate and valproate are associated
test, Boston naming test, similarities, vocabulary with worse performance. Fig. 3 also shows the impact of
(r = 0.67, P < 0.001) and a memory factor consisting of different AEDs on EpiTrack subtest scores. TPM and
verbal and nonverbal list learning (r = 0.71, P < 0.001). VPA have negative effects on three of the six subtests,
These correlations are comparably lower but still very high. CBZ negatively affects one subtest, and LEV and LTG
The correlation between EpiTrack and the delayed verbal are associated with better performance in individual sub-
memory recall (number of words lost) was -0.33 tests. Clobazam, oxcarbazepine, and gabapentin were also
(P < 0.001), correlation with a vocabulary intelligence included in the analysis, but these AEDs had no predictive
score was 0.49 (P < 0.001). All correlation coefficients can value for EpiTrack performance in a multivariate model.
be found in Table 5 together with the respective coefficients
broken down for controls and patients separately. With 4.2.5. The impact of depression
respect to the factor scores, there were only small differenc- In a subgroup of 153 patients to whom the Beck Depres-
es between the total and subgroup correlations. The corre- sion Scale (BDI) was also administered [20], there was a
lation between EpiTrack score and delayed verbal recall negative correlation between a higher depression score
was substantially higher in the controls than in the patients (BDI) and performance on EpiTrack ( 0.258, P < 0.01),
(r = 0.31 vs. r = 0.17), whereas the correlation between
EpiTrack and verbal intelligence was higher in patients
(r = 0.30) than in controls (r = 0.15).
CPS TPM VPA CBZ LEV LTG
4.2.4. Criterion validity Interference test
As noted above, there was a strong correlation between TMT A
EpiTrack score and age. The influence of age on the Epi-
TMT B
Track was much smaller in patients than in controls
(r = 0.492 vs. r = 0.167). This may be explained by Maze test
Verbal fluency
Table 5
Correlations between EpiTrack scores and factor scores indicating Digits backward
convergent and discriminant validity EpiTrack total score
Total sample Controls Patients
Fig. 3. Effects of AEDs on EpiTrack performance (multiple regression
Attention/executive function factor 0.852a 0.782a 0.792a
analysis). Direction of arrows indicates the quality of the impact of
Speech factor 0.673a 0.503a 0.513a
respective AED (upward:positive impact, downward:negative impact).
Global memory factor 0.710a 0.664a 0.564a
Color of arrows indicates the significance level of this finding (white:
Delayed verbal recall 0.328a 0.307a 0.171b
P < 0.05; black: P < 0.01). For further details, see text. CPS, complex
Verbal intelligence 0.493a 0.154b 0.304a
partial seizures; LEV, levetiracetam (n = 77); LTG, lamotrigine (n = 65);
a
P < 0.001. CBZ, carbamazepine (n = 51); VPA, valproate (n = 26); TPM, topiramate
b
P < 0.05. (n = 8).
 M.T. Lutz, C. Helmstaedter / Epilepsy & Behavior 7 (2005) 708–714
indicating worse performance in more depressed patients.
Forty percent of the patients with a BDI score falling into
the clinically normal range attained an EpiTrack score
indicating impaired cognitive performance. The number
of impaired patients increases from 40, to 51.7, and
66.5% for the patients with borderline BDI scores and
BDI scores indicating severely depressed mood.
5. Conclusion
EpiTrack was developed as a brief and easily adminis-
tered screening tool for the detection of dysfunctions of
attention, psychomotor performance, and executive con-
trol caused by epileptic disorders or antiepileptic drugs,
and to track cognitive performance parallel to changes in
medical therapy.
Of key interest in this regard are the capability for
repeated administrations in longitudinal assessment and
the clinical utility of the test measure. EpiTrack comprises
standard concepts and measures within a long neuropsy-
chological tradition. Test selection was guided by theoreti-
cal, empirical, and clinical aspects. EpiTrack relies solely
on measures of attention and executive control. By this,
it differs explicitly from the rationale adopted by common
screening measures providing a global score of a broad
selection of cognitive domains. This parsimonious
approach was chosen because recent reviews on AEDs
and cognitive side effects show that they involve mainly
attention and psychomotor performance. If other impair-
ments, like memory dysfunctions, are found as a conse-
quence of AED use, they usually appear in association
with attentional dysfunctions. However, with the introduc-
tion of new AEDs in the future, it cannot be ruled out that
there will be a drug that selectively impairs long-term mem-
ory consolidation without affecting short-term or working
memory and attention. Such an effect would be missed by
EpiTrack. Regarding the clinical validity of EpiTrack, with
the exception of the maze test, all subtests had been demon-
strated to be useful for the monitoring of cognitive side
effects in previous studies, which addressed the impact of
topiramate on cognition [9–11]. Topiramate frequently
leads to cognitive impairment and requires monitoring,
particularly in a preoperative setting. The subtests chosen
furthermore proved to be useful in our center in deciding
whether the conditions exist for running comprehensive
testing.
The present study chose different approaches to demon-
strate the suitability of this particular test selection. Crite-
rion validity was assessed by the correlation of EpiTrack
score with other cognitive measures. The EpiTrack score
is highly correlated with a broad range of cognitive abilities
assessed by a comprehensive neuropsychological battery.
There was even a significant correlation between EpiTrack
and verbal intelligence, assessed by a written vocabulary
test. However, we do not think that EpiTrack should be
interpreted as an indicator of global cognitive perfor-
mance. Rather, we interpret these correlations as reflecting
713
that EpiTrack is a measure of basic executive functions,
necessary for adequate performance in other domains,
including higher-order cognitive abilities.
Cross-sectional application of EpiTrack in consecutive
patients with epilepsy indicated that EpiTrack is sensitive
to the effects of seizures, polytherapy, and specific drugs
on cognition. The results resemble broadly the order of
negative and positive effects reported in the literature for
individual AEDs [2,21–23]. However, one must keep in
mind that these results did not consider important factors
like dosing, plasma concentration, duration of use of med-
ication, or neuropsychological baseline performance.
Future studies must provide these data together with longi-
tudinal design in which patients are screened using this
instrument and testing is repeated after the medications
are adjusted when necessary. Consequently, the present
results on individual AEDs must be taken as preliminary.
With respect to clinical utility, it first should be noted
that EpiTrack does not and cannot replace comprehensive
neuropsychological testing. The quality of screening tools
always lags that of neuropsychological tests, especially in
terms of standardization, reliability, and scale properties.
The decision to administer a screening measure originates
mostly from a cost–benefit analysis, and in this respect,
the advantage of EpiTrack is its brevity and easy adminis-
tration. As time needed for administration and scoring was
reduced to its minimum, cognitive functions other than
attention and executive functions are disregarded. More
general questions about the cognitive status or profiles in
patients with epilepsy would require additional neuropsy-
chological evaluation.
Beside the common limitations inherent to screening
measures, there are concerns that clinicians not specializing
in epilepsy would sufficiently understand the results to
make clinically important modifications to treatment. In
contrast to the easy administration and scoring, the inter-
pretation and conclusions for treatment schedule need to
be highly individualized, knowledge, training, and experi-
ence of clinicians. In the distributed German version, Epi-
Track test material is delivered together with an
introduction and instructions for application, scoring,
and interpretation. Training is currently provided by the
distributing company (UCB), and in addition, a video dem-
onstration is available for training purposes.
The test booklet also warns against errors that may arise
from mood disorders. In the present study a significant cor-
relation between depression and EpiTrack total score was
obtained. This must be expected with measures assessing
executive functions and speed [24] and needs to be con-
trolled by those who administer EpiTrack in epilepsy
patients. This is critical because depression is so common
in people with epilepsy and because depression is often
underdiagnosed [25]. In the presence of depression, the
instrument has limited value in assessing adverse effects
of AEDs.
Taken together, we believe that, with a clear-cut ques-
tion in mind and awareness of the limitations of screening
714 M.T. Lutz, C. Helmstaedter / Epilepsy & Behavior 7 (2005) 708–714
measures, EpiTrack facilitates the diagnostic process and
leads to prompt results. As EpiTrack assesses functions
not necessarily affected only in epilepsy, it can be expected
to be useful for monitoring cognitive drug effects in a more
general neurological or psychiatric setting. EpiTrack has
been designed for use in Germany. However, because only
the verbal fluency task is language dependent, adaptation
to other languages should be straightforward. An English
version will follow to enhance international application.
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