Category: News

Those who are educated and trained in forensic (e.g., legal), neuropsychology are often called upon to provide expert neuropsychological testimony.  This frequently occurs in cases of personal injury (e.g., traumatic brain injury) and medical malpractice, and less frequently in cases involving criminal behavior (e.g., attempted murder).  Following a comprehensive, forensic-quality neuropsychological evaluation, the neuropsychologist may be requested by either the plaintiff or defense attorney to provide expert testimony either through a formal deposition or live testimony at trial.

Following the swearing-in process, the neuropsychologist will be asked questions regarding their credentials including their formal education, training, research, areas of specialization, and other aspects of professional development.  The neuropsychologist’s qualifications may be scrutinized by opposing counsel during cross examination.  In any event, this is an important initial part of formal testimony whereby the neuropsychologist has the opportunity to set the stage for being considered an expert and able to render a neuropsychological opinion with a reasonable degree of neuropsychological certainty.

As noted above, formal testimony will begin with direct questioning and examination with regard to the neuropsychological test results, consequences of the case at hand, formulation of clinical opinions, and possible recommendations.  It is imperative that one’s testimony makes sense to the jury and thus, formal discussion should be completed, as much as possible, in layman’s terms and refraining from complex and esoteric terminology.  Undoubtedly, cross examination will be an attempt to refute one’s opinions, often times asking redundant questions in an attempt to derail the neuropsychologists clinical focus and previously addressed conclusions and opinions.  While formal testimony can be an anxiety provoking and daunting task, these concerns can be tempered with excellent preparation including ongoing research and consultation with colleagues.  Below are a number of simple strategies that can be utilized during complex neuropsychological testimony:

• Dress appropriately and professionally; appearance is imperative!
• Remain consistent and persistent with your testimony; don’t allow opposing counsel to change your testimony.
• Remain as calm and cool as possible; never appear angry or hostile during even the most upsetting questioning.
• Prior to questioning, spend as much time as needed with the attorney who issued the subpoena to avoid any misinterpretation regarding your clinical understanding of the case, data interpretation, conclusions, and diagnostic opinions.
• Make sure you have obtained, reviewed, and analyzed ALL records pertinent to the case.
• NEVER testify on an issue or render an opinion without having full knowledge of that information and defense against the potential for hostile questioning during cross examination.
• During your testimony, make sure you make eye contact and address the jury, as opposed to the attorney when answering questions.
• Questions should always be answered in a complete, accurate, and truthful manner and without elaboration.
• Be aware and knowledgeable during the differences between legal and neuropsychological concepts.
• During the preparation phase, it is important that you understand the statistical aspects of the tests administered and data obtained including validity, reliability, and standard error of measurement.  Your knowledge and understanding will in all likelihood combat any potential embarrassing circumstances.
• Choose your words carefully during testimony and avoid irrelevant or prolonged explanations; an over explanation or elaboration of information often leads to unwarranted questioning by opposing counsel.
• Finally, and most importantly, NEVER deviate from the facts of the case or information that had been previously provided in a formal report.

The implementation of a few of these simple strategies during potentially complex neuropsychological testimony might prove beneficial in alleviating some pre-testimony anxiety, nervousness, or other concerns.  While there is no guarantee that the successful implementation of some of these strategies will prevent instances of frustration, they might prove beneficial; time will tell.  The more one testifies the more one feels comfortable; however, even the most experienced and seasoned neuropsychologist will and should experience pre-testimony “jitters.”

For additional information or to schedule a consultation, please contact our office at 732-988-3441.

Michael J. Raymond, Ph.D., ABN, FACPN
Board Certified Neuropsychologist #232
Licensed Psychologist #35S100252900

Tossing and turning in bed at 2 a.m. trying to fall asleep might seem like an impossible dream, but you have more control over a good night’s sleep than you might think.

Researchers have concluded that “healthy sleep” practices and habits – defined as “sleep hygiene” – can help maximize the hours you spend sleeping, despite disrupted sleep due to insomnia, sleep apnea, jet lag, shift work, or any other sleep disorders.

Sleep hygiene is defined as the recommended behavioral and environmental practices that are intended to promote better quality of sleep. They are habits that are essential for both physical and mental health necessary to promote overall quality of life and full daytime alertness.

Following are some simple guidelines for making the sleep of your dreams a persistent reality:

• Avoid stimulants – alcohol, nicotine, caffeine, and other chemicals that interfere with sleep
  • Avoid for 4-6 hours before bedtime
  • Although alcohol may aid with sleep onset, within a few hours it acts as a stimulant causing increased awakening and a general decrease in the quality of sleep
• Turn your bedroom into a sleep-inducing environment
  • A quiet, dark, and cool environment can promote good sleep
  • Your mattress and pillows should be comfortable
  • The room temperature should be between 60 and 70 degrees
  • Keep the lights off!
• Bright light from the television and phone can make it difficult to fall asleep, resulting in a dysregulated sleep cycle
  • Consider using black out curtains, eyeshades, earplugs, or “white noise” machines to promote serenity
  • Keep computers, TVs, and other work materials out of the room to strengthen the mental association between your room and sleep
• Establish a Relaxing Pre-Sleep Routine
  • A smooth transition from wake time to sleep time with a period of soothing activities an hour or so before bed should be considered
  • Take a bath, read a book, or practice relaxation exercises.
  • Avoid stressful, stimulating activities – work, engaging in emotional discussions, and exercising.
• If you cannot fall asleep within 20 minutes, get up from your bed.
• Maintain a regular sleep routine
  • Go to bed at the same time
  • Wake up at the same time
  • Ideally, your schedule should remain the same (+/- 20 minutes) every night of the week including weekends
  • Regular sleep routine sets the body’s “internal clock” to expect sleep at a certain time at night consistently.
• Nap Early – or Not at All
  • Naps decrease the “sleep debt” that is so important for easy sleep onset
  • People, who nap, as a part of their day, find falling asleep or staying asleep though the night problematic
  • If you must nap, it’s best to keep it short and before 4 p.m.
• Exercise Early and Regularly
  • Exercise can assist you falling asleep and sleeping more soundly – if it’s done at the right time and on a consistent basis
  • Exercise before 2 p.m. can help initiate and maintain restful sleep.

Incorporating the tips above in your daily routine can majorly improve your ability to achieve optimal restful sleep. However, not all sleep problems are easily treated and may signify the presence of a sleep disorder.

If your sleep problems do not improve or you find it difficult to accommodate healthy sleep habits, you may want to consult our team at NRS|LS for a consultation and treatment plan.

Mihir J. Shah, Psy.D.
Clinical Neuropsychologist

A person suffering from different forms of dementia places significant pressure upon the spouse, children, and extended family members. Additionally, it becomes confusing when your loved one with dementia is better one day versus another in how they think and behave. What do you do when you are unsure of someone’s capabilities? How can you plan a schedule? How comfortable are you if your loved one with dementia is driving, cooking, handling money, credit cards, and obvious problems are noted?

The NPE is the “blueprint” explaining the patient’s ability to function with regard to activities of daily living, independent living skills, cognition, emotion, and behavior.

Below are some example areas that the NPE can answer:

•  Driving ability.
• Independent activities of daily living.
• Taking care of finances.
• Level of independence.
• Adjusting to unexpected changes.
• Taking care of personal hygiene.
• Remembering locations and work-like procedures.
• Detailed instructions.
• Maintaining a schedule and self-reliance.
• Interacting appropriately with general public.
• Overall summary of level of functioning.

Needless to say, there are many other areas of appraisal that maybe unique to your loved one.  We can answers those for you.

If we can be of help in answering any of your questions and plan a course of treatment for you, please give us a call and schedule a consultation.

Sincerely,

Robert B. Sica, Ph.D., ABN, FACPN
Board-Certified in Neuropsychology # 84, #255
Director, Principal, Neuropsychological Rehabilitation Services|LifeSpan
Fellowship/Residency Supervisor
Jersey Shore University Medical Center, Neuroscience Division
Clinical Assistant Professor, Rutgers-Robert Wood Johnson Medical School
Clinical Assistant Professor, Seton Hall – Hackensack Meridian School of Medicine

Mild Cognitive Impairment (MCI) occurs with a decline in memory and other thinking abilities that are more serious than in healthy aging, but not as severe as in dementia. Although people diagnosed with MCI can take care of their daily chores independently, they still see a decline in their quality of life. Quality of life has to do with physical and mental well-being, mood, and the ability to complete activities of daily living such a taking care of finances and have positive relationships.

MCI can also negatively affect the quality of life of family members, typically spouses and/or adult children who are involved in the care of their loved one with MCI. The most significant challenges for families include uncertainty about whether their loved one’s cognitive abilities (i.e. MCI) will progress to dementia and the potential for a long-term disease, causing anxiety and depression.

According to research, the quality of life in patients and their family members can improve. For instance, multiple patients with MCI and their family members reported that their quality of life improved after receiving counseling focused on adjustment strategies for memory, participating in support groups, receiving cognitive training and wellness education, and participating in yoga.

Here at NRS|LS, we offer an opportunity to get tested for MCI and receive Medical Adjustment Counseling ® and Cognitive Rehabilitation Therapy. If you have any questions, call our office for more information.

_______________________
Eleonora Gallagher, Psy.D.
NJ Permit: TP# 213-079
Neuropsychology Post-Doctoral Fellow

Annually, children age 16 years and younger account for half a million emergency department visits for traumatic brain injuries (TBIs). Several factors such as the patient’s age at the time of the occurrence, severity, comorbidities, and timely access to quality care can drastically affect the short-term and long-term effects of pediatric TBIs and mild concussions. While prognoses can be highly variable, research published in the Journal of Head Trauma Rehabilitation shows that these key factors have been shown to help kids recover both medically and socially:

• Educating healthcare providers, parents, and teachers about the importance of prompt TBI care at the time of the injury.
• Parents should be encouraged to establish a positive family dynamic, attend all medical follow up, and communicate with schools.
• Medical professionals should provide parents with clear documentation of their child’s diagnosis that informs them of any recommendations as well as possible complications their child may experience. They should be instructed to report these documents to their child’s school.  Neuropsychologists are uniquely equipped to spearhead the child’s recovery.
• All children with mild to moderate TBI should receive an evaluation to determine if they would benefit from rehabilitation services, and if so, to what extent.
• Neuropsychological testing is encouraged to characterize the changes that may have occurred and describe how they will affect real world functioning. From here, more recommendations for treatment planning will be established with the child, family, and school.
• Bridging the gap between healthcare and educational care is often overlooked, but the transition back to school can be a very difficult experience for TBI patients. If needed, students should take advantage of specialized support services such as speech therapy, occupational therapy, vestibular therapy, cognitive rehabilitation, and medical adjustment counseling(MAC).
• Students should be gradually reintroduced into their school work and routine. 504 plan most likely will be needed.
• The utilization of child-validated symptom rating scales to target concerns and improve patient care.

Dr. Greco has been serving children in Monmouth and Ocean counties for nearly twenty years.  If your child incurred a concussion and assistance is needed, please call our office as soon as possible.  Timing is key after a concussion.

Sincerely,

Steven P. Greco, PhD, ABN
Board Certified Neuropsychology
Clinical Assistant Professor
Department of Neurology/Psychiatry
Rutgers Robert Wood Johnson Medical School
Seton Hall-Hackensack Medical School

Welcome to 2023, the era of switching gears from focusing on disease, illness, and pathology to wellness, optimization, and resilience. “Regenerative medicine,” “neuroplasticity,” “epigenetics,” “health span extension,” “longevity medicine,” and “cellular anti-aging” all represent pockets of research dedicated to looking at the body’s ability to regenerate, repair, and heal itself from external factors (environmental stressors, toxins, and things we eat and drink) as well as internal factors (inflammation, viruses, and simply getting older).

What researchers are finding is that your chronological age doesn’t necessarily match your “biological age”. Here’s an easy demonstration of this – think of someone you’ve met who is 70 years old but looks and functions like a 60 year old. On the flip side, you may have also met a 70 year old who looks and functions like an 80 year old. Scientists are uncovering the reasons behind that by looking at how cells age and, even, reverse age. For instance, telomeres are the caps on the end of your chromosomes, which protect your DNA. Similar to how an aglet on a shoelace keeps your shoelaces from fraying, telomeres keep your DNA from mutating into diseases, cancers, and chronic illnesses (example: researchers at the University of Utah found that people older than 60 with shorter telomeres are 3 times more likely to suffer from heart disease and 8 times more likely to suffer from infectious diseases).

Scientists study the length of telomeres within individuals to see what factors cause them to shorten faster or slower. It turns out that lifestyle factors such as sleep quantity and quality, smoking and alcohol use, nutrition, obesity, exercise habits, stress management, and meditation can play an important role in accelerating biological aging or reversing it. For instance, researchers at the University of California San Francisco found that men who adopted a mostly plant based diet, walked 30 minutes 6 days per week, and practiced stress reduction methods daily over the span of 5 years had a significant increase in telomere length by approximately 10%. Men who did not make any lifestyle changes were found to have nearly 3% shorter telomeres due to natural aging.

While these findings represent a genuine reason to be optimistic about the future, lifestyle adjustments are often very difficult to make and integrate into a daily routine that is realistic, sustainable, and enjoyable. Clinical health psychologists can assist you if you feel stuck implementing changes, overwhelmed by information, or want support and guidance in applying cutting edge science into your life. Contact our office at 732-988-3441 to schedule a consultation appointment with a clinical health psychologist today.

Lauren Gashlin, PsyD
Clinical-Health Psychologist

Sundowning syndrome, or sundowning effect, primarily results in neurocognitive and behavioral changes occurring later in the day.  This is frequently observed in patients with brain-related neurological conditions such as dementia, traumatic brain injury, brain tumors, metabolic disturbances, or other neurological conditions.  Not only is this condition stressful for patients, but it also affects caregivers and healthcare professionals.

While sundowning is not totally understood, a number of factors may influence the onset and persistent nature of this syndrome.  It is considered a multifactorial syndrome based on physiological, neurobiological, pharmacological, environmental, and medical components.  For example, specific elements considered to be a contributing factor to sundowning include medications, a patient’s history of a sleep disorder, brain-related physical changes (e.g., changes in melatonin, neurotransmitters, glucose, circadian rhythms) as well as environmental considerations (e.g., change in environment, overstimulation, reduced sunlight).  Individuals are particularly prone for developing sundowning when they are overstimulated and experience both physical and neurocognitive exhaustion.  At that time, individuals have difficulty and a lack of tolerance when placed in an unfamiliar, ever-changing, and often misperceived threatening environment.

Sundowning syndrome is generally considered, and eventually diagnosed, through patient observation.  As previously discussed, these individuals have a tendency toward increased confusion and behavioral changes (e.g., restlessness, agitation, disorientation) later in the day or when the sun goes down, hence the term sundowning.  Sundowning may also occur in individuals with other coexisting conditions such as depression, anxiety, urinary tract infections, pain symptoms, and documented sleep disturbances such as chronic obstructive sleep apnea.

Once sundowning is formally and clinically diagnosed, treatment strategies can be enforced.  First and foremost, an individuals prescribed an over-the-counter medication regimen needs to be identified and assessed.  It is imperative that specific medications be avoided to minimize an adverse medication interaction effect which often heightens an individual’s level of confusion and behavioral decompensation.  Despite this, some medications may prove beneficial in ameliorating some of the adverse symptoms.  Environmental changes can also prove beneficial, which may include keeping individuals in a familiar and non-threatening environment, minimize over-stimulation, increase light exposure, including fluorescent bulbs, and aromatherapy (e.g., in particular, lavender oils have proved to be both calming and relaxing).

From a preventive perspective, preventing or minimizing sundowning syndrome or sundowning effect is imperative.  The successful implementation of the following strategies often proves beneficial:

• Doctors’ appointments or daily therapeutic interventions should be scheduled in the morning or early afternoon.
• Maintain a regular morning and bedtime routine.
• Expose the individual to as much natural lightening as possible throughout the day.
• Provide the individual with a larger meal in the afternoon and a smaller meal at night.
• Keep a daily log as to what activities may increase confusion or adverse behavioral changes and those activities which appear beneficial in reducing sundowning.

In summary, while sundowning syndrome or sundowning effect often occurs in individuals with a host of neurological conditions, understanding the symptoms, causes, and preventive measures is paramount.   While sundowning is stressful to the patient, caregivers, and healthcare professionals, utilizing some of the aforementioned information and treatment strategies will undoubtedly be helpful.  If you or other individuals are exposed to this challenging situation and in need of additional information or clinical consultation, please do not hesitate to contact us at 732-988-3441.

Michael J. Raymond, Ph.D., ABN, FACPN
Board Certified Neuropsychologist #232
Licensed Psychologist #35S100252900

The fight-or-flight response is our body’s natural reaction to danger. It starts whenever we face a stressful, life threatening situation. This response helps us survive by preparing us to either fight the threat off or flee to safety. Unfortunately, this stress response is often triggered by events/situations that are non-life-threatening (e.g., traffic jams, work pressure, relationship difficulties), therefore affecting our mental and physical health.

Common Symptoms of Fight-or Flight Response:

• rapid heart rate
• faster, shallower breathing
• increased blood pressure
• high alertness
• muscle tension
• shaking or trembling
• dizziness/lightheadedness
• cold hands
• sweaty palms
• tunnel vision
• agitation
• focus on negative memories
• high anxiety/panic attack

Coping Strategies:

1. Moving to a quiet place
2. Deep breathing
3. Engaging in activity (e.g., going for a walk)
4. Seeking social support
5. Seeking professional support

Professional guidance can help with specific coping strategies. Feel free to contact our office to schedule a consultation and learn optimal ways to regain control and manage the fight-or-flight response.

Basia Andrejko-Gworek, Ph.D.
Clinical Psychology, Post-Doctoral Fellow
Permit# TP #213-03

What are Seizure “Triggers”?

Before listing common seizure triggers and ways to avoid them, lets briefly review what is Epilepsy or commonly known as seizure disorder.

Epilepsy is a disorder in which nerve cell activity in the brain is disturbed resulting in seizures.  It is basically a result of abnormal electrical brain activity causing seizures or periods of unusual behavior, sensations, and sometimes loss of awareness. Epilepsy is defined as having two or more unprovoked seizures. One seizure does not signify epilepsy (up to 10% of people worldwide have one seizure during their lifetime). Epilepsy may occur as a result of a genetic disorder or an acquired brain injury, such as trauma or stroke. But in 50% of cases, there’s no known cause.

Depending on the area of the brain impacted by these abnormal activities, seizures can cause:

•  Shaking
• Twitches
• Confusion
• Blank Stares
• Pain
• Changes in sensation (hearing, vision, taste)
• Feelings of fear, anxiety, dread, or even pleasure
• Changes in heart rate or breathing
• Stiffness throughout the body
• Repeated or automatic movements

That said, no two cases of epilepsy are the same.  An individual’s trigger can be completely different than someone else’s triggers.

Some of the most common known seizure triggers include:

• Missed dosage of anti-epileptic drug (AED)
• Stress
• Lack of sleep
• Alcohol
• Caffeine
• Flashing lights or patterns
• Withdrawal from narcotics and/or barbiturates
• Low blood sugar
• Time of the day
• Hormonal changes
• Fever
• Infection or other illness

Increased awareness and understanding of what causes one’s seizures can help with diagnostics, treatment planning, and symptoms management.

Journal entry (information about seizures and factors associated with epilepsy) coupled with structured routine can help with identification of specific triggers as well as pathways to avoid the known trigger.

Once a patient understands and knows their specific trigger(s), the following can help avoid them or reduce its impact.

• Take medications as prescribed (right dosage at the right time)
• Limit stress
• Getting adequate amount of sleep
• Avoiding alcohol
• Avoiding caffeine, nicotine, and/or other substances
• Avoid flashing lights or patterns
• Modifying eating habits
• Planning around hormonal changes
• Treating at the first sign of illness
• Talking with others who understand (outreach group, medical professional, mental health provider)

Neurology should always be consulted first.  Once you have established  yourself with a neurologist, neuropsychology can help with the treatment of seizure disorder.

Please contact our staff or schedule an appointment with our providers for diagnostic clarification and treatment planning including identifications of triggers and help with managing them.  Our doctors can help you manage symptoms associated with epilepsy with evidenced based approaches including Medical Adjustment Counseling ®, Biofeedback, and Cognitive Rehabilitation Therapy

Mihir J. Shah, Psy.D.
Clinical Neuropsychologist

Cognitive Rehabilitation Therapy (CRT) focuses on improving thinking abilities related to everyday functioning and strengthening independent living skills.  Typically, CRT focuses on patients with various neurological conditions, including but not limited to strokes, TBI, epilepsy, multiple sclerosis, and mild neurodegenerative disorders such as mild cognitive impairment and early stages of dementia.

Thinking abilities related to everyday functioning include attention, the ability to process information coming into the brain via sight, hearing, touch, or other senses, as well as memory, language, and problem-solving.

Examples of daily activities affected by problems in thinking may involve basic skills: preparing meals, taking care of personal hygiene and appearance, maintaining a daily schedule, etc. Other, more complex, negatively impacted abilities may include taking care of finances, managing medications, driving, making decisions, and solving problems related to work and life at home.

The neuropsychological examination (NPE) helps determine which thinking processes are impaired, the significance of their impact on daily functioning and whether the person would be a good candidate for CRT.

CRT is based on research demonstrating that thinking abilities can improve with practice. The treatment usually starts with simple tasks that become increasingly more difficult. A doctor or therapist decides on the tasks’ order and complexity.  In addition to retraining the brain, another treatment component included in CRT is based on learning compensatory strategies to compensate for thinking deficits. For instance, one of the strategies to improve memory learned during CRT may include using alarms and calendars. Techniques to strengthen attention may focus on minimizing distractions and taking breaks.

If you have any questions regarding CRT, please contact our office for more information.

Eleonora Gallagher, Psy.D.
Neuropsychology Post-Doctoral Fellow
NJ Permit: TP# 213-079