The discussion begins with Nora, who provides insights into the importance and execution of capacity assessments within the clinical framework. She clarifies that while neuropsychologists are typically associated with these assessments, other clinicians, including general practitioners (GPs), can conduct them if the case is straightforward. If a patient presents with early-stage dementia and seems to understand the implications of a specific decision, a GP can evaluate their capacity. However, for more complex cases where cognitive impairment or insight levels are unclear, referring the patient for a neuropsychological evaluation is advisable. The role of neurologists in making capacity assessments is also highlighted, noting that many referrals come from this specialty.

Continuing the conversation, the panel addresses practical aspects of neuropsychological assessments, such as their accessibility, duration of validity, and costs. It is emphasized that capacity is presumed until evidence suggests otherwise; hence re-assessment is not a regular requirement but rather situational. Nora mentions that private neuropsychological assessments can be expensive, costing around $2,000, which can vary based on the specifics of the evaluation. Accessibility in public health settings is also a topic of concern, as Nora elaborates on Medicare provisions allowing patients to receive neuropsychological services at no cost, albeit with limitations regarding medico-legal assessments and long waiting lists for public services.

The discussion shifts focus as Candice introduces the topic of migraine, particularly in patients with past migraine histories who develop new headache symptoms. She emphasizes the importance of reassessment when patients report different types of headaches, as this could indicate new underlying neurological conditions. In these situations, brain imaging may be warranted, typically starting with an MRI, although routine follow-ups may not be necessary unless new clinical indicators arise. The link between cognitive processing and headache is noted, especially in patients whose MRI results reveal white matter changes, leading to concerns about cognitive decline.

Nora enriches the discussion by exploring the neuropsychological testing process further, particularly regarding conditions like adult-onset ADHD, anxiety, and depression, providing insights into the distinct cognitive profiles associated with these disorders. This information proves crucial for clinicians assessing capacity and cognitive functionality in patients with such conditions, allowing for a nuanced interpretation of their capacity status.

Candice then transitions the conversation towards treatment options for chronic migraines, touching on criteria for accessing expensive therapies through PBS, the complexities surrounding prescriptions, and the importance of fitting patient needs within treatment guidelines. She discusses challenges in prescribing medications for individuals who may not fully meet the PBS criteria, as well as considerations for women in specific life stages when managing migraines.

The complexities of managing migraines in the context of pregnancy and perimenstrual headaches are discussed. Suggestions include the use of estrogen patches or anti-inflammatory medications timed with menstrual cycles to prevent migraine onset. Candice emphasizes the limited options available during pregnancy, thus presenting the need for careful management of migraine prophylaxis in this demographic.

In closing, the conversation returns to contraceptive considerations for women experiencing migraines, particularly those with auras. The panel outlines the risks of stroke associated with hormonal contraceptives in these patients and the need for thorough patient education and informed consent regarding treatment options. Alternatives such as low-dose oral contraceptives are discussed, emphasizing the importance of shared decision-making between the patient and physician to ensure both safety and relief from headaches.

Overall, the panel provides a comprehensive examination of the nuances in capacity assessments, neuropsychological evaluations, headache management, and their intersection with individual patient circumstances, delivering critical knowledge for improved clinical outcomes in these complex areas of patient care.

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So, Nora, if I could start with you, perhaps first of all, obviously,

you've given us a very clear rationale for capacity assessments.

We understand that they're important.

Is it only a neuropsychologist that can provide a capacity assessment or are

other clinicians able to do that as well?

Yeah, that's a good question. Other clinicians are able to do it and GPs are

able to do it if it is not complex.

So, if someone comes to you and they have an early stage dementia,

but you can talk to them about that specific decision and you feel they have

a good understanding of what the factors are involved,

if their reasoning is okay, if you feel like they can understand consequences, you can understand.

You can make that decision about capacity. But when it is complex,

when you're not sure about their level of cognitive impairment or their level

of insight, then I would recommend sending for a neuropsychology assessment.

And the same obviously with other health professionals and neurologists can

obviously make that decision too.

But I should say we get a lot of referrals for capacity assessments from neurologists?

Yeah, I mean, I think it's a little bit like my comment before about clinical

neurophysiology. If it's not clear on the history and examination,

you can zap some nerves and get a bit more information.

It's the same sort of thing with neuropsychology.

We don't have access to the detailed neuropsychology that Nora and her colleagues do.

And that obviously can help support why you're saying somebody does or does not have capacity.

I guess, just following on from that, there are some questions about,

you know, how do we access neuropsychology?

How much does it cost?

If somebody has had an assessment and capacity is preserved, how long does that last?

You know, do we have to do it again next month or next year?

You know, those sorts of kind of practical aspects.

A few questions there. In terms of,

they need to come back and have another assessment. So, your last question first.

It will only be, so if they're determined to have capacity.

So, we always assume someone has capacity to start with.

And so, if they're determined to have capacity after a formal assessment,

then we would assume they have capacity until there's some reason that makes

you think they maybe no longer have it.

So, if something questionable happens in their behaviour, if they start making

certain decisions that the family are very worried about then.

But it's not, we wouldn't say, okay, they have capacity now.

They need to come back in 12 months and we'll check it again.

We don't work like that. We work based on what their capacity is like going

forward and whether people become worried about it again.

One of your other questions was the cost.

And it is an expensive assessment. So, if you see a neuropsychologist privately for an assessment,

the assessment will vary, but generally a clinical assessment that includes

capacity is somewhere around $2,000.

It's a long assessment and very detailed, and that is sort of the general cost.

In fact, that's probably at the lower end. You'll find there's quite a range.

So cheap doesn't always mean value. I guess we'd make that point.

You know, Nora, obviously you worked for a long time in the public system.

Correct. Is clinical neuropsychology accessible in the public system?

We heard earlier from Sally about a speech pathology clinic run by students.

Is that an option in neuropsychology as well? Yeah. So, certainly at Royal Prince

Alfred Hospital and most public hospitals.

So I worked at RPA, but other public hospitals too, they won't accept capacity assessments.

If you're in area, you can be referred for a neuropsychology assessment and you can have it,

for free under Medicare, but they won't see a medico-legal one because these assessments,

you have to understand, so we have to do a level of testing that can then stand up in court.

So these assessments often end up being evidence where the will is contested or various things.

So the level of assessment has to be of a legal standard that holds up in court.

And the neuropsychologist working in the public system won't do them as part of those assessments.

I mean, waiting lists are also a massive problem, right? Waiting lists are very

long in the public system. That's true. And often you can't get in unless you're in area.

Now, student clinics are another thing, so universities have student clinics,

including Macquarie University,

where you can get a neuropsychology assessment for a discounted fee and the

student is under supervision with a qualified neuropsychologist.

But not all student clinics will do capacity assessments for that reason,

that they need to be of a level that will hold up in court and they just don't offer them.

So it depends on the student clinic.

Thanks, Nora. I'll let you have a little break. There's some more questions coming your way.

Candice, just thinking about headache. So I think, you know,

you presented some terrific cases of, you know, classic migraine that we all

are familiar with, I guess.

But what happens if you've got someone that has a history of classic migraine,

and then they develop some other type of headache?

You know, when do you get worried about their new symptoms?

I mean, in general, I get worried when they start developing a different type of headache.

Especially if it's not like the headache I mentioned, like the headache related

to overuse of antialgics.

So if there is anything new or different, someone who has migraine can,

like any other patient, have a different type of headache.

Like someone could develop giant cell arthritis, for instance,

on the background of migraine.

So I think when something is different, we always have to reassess our initial diagnosis.

I mean, the patient can have headache and can have a completely different neurological

condition, which needs further assessment.

And I mean, obviously that's clinical assessment, but brain imaging,

I mean, would you Would you do some form of brain imaging, CT or MRI at the

initial diagnosis, and then would you repeat that?

Yes, I would do a brain imaging, and I usually use brain MRIs if someone has

a different type of headache.

Whether I would repeat it...

It's a very good question. Probably not. I mean, as some of you might know,

we often see little things when we do brain MRIs, especially in patients with migraines.

Like we see some mild changes in the white matter, usually more anteriorly.

Whether we need to follow this up, I don't think, I don't do it at this stage.

I would repeat the MRI if I have a clinical reason to do it.

Yeah, I think just to comment on the white matter changes, that's often the

overlap between cognition and headache.

So somebody has an MRI, they've got a history of migraine, there's some white

matter changes, they'd start Googling and they say, oh my God,

I'm going to get dementia.

So that's a common reason for

us to see patients is the MRI kind of report showing white matter changes.

Just coming back to you, Nora, obviously the main bulk of your talk was about capacity and so on.

But I guess there are a few questions coming through about, you know,

how do we interpret neuropsychological testing in the context of,

say, adult onset ADHD, depression, anxiety?

You know, do we have a specific sort of pattern of deficits in these conditions

or, you know, are they more confounders, you know, when we're trying to assess patients?

There's very specific cognitive profiles that go with those different conditions,

so neuropsychology is very useful to diagnose those other conditions, yes.

So that's often a supportive investigation if we're not sure what's going on. Definitely.

And so obviously, I guess just to draw you out on that,

if somebody does have ADHD but you need to know if they've got capacity,

so you're kind of stacking two indications on top of each other,

you're able to interpret the capacity

in the context of their pre-existing condition. Correct. That's right.

Um, and, um, Candice, just coming back to you.

Um, so you mentioned a little bit about some of the more expensive treatments in chronic migraine.

And I think, uh, just to kind of, uh, repeat what you said, more than 15 headache

days per month, um, failing at least three conventional therapies.

Um, and for more than six months, I guess is the requirement for the PBS is that's right, isn't it?

So you know that how often

do you find that that patients actually meet those

criteria and I guess I'm just thinking about PBS and

how accessible these therapies are if patients don't meet the criteria that

we've outlined yeah I mean it's a very tricky question because because these

drugs are so effective that it would be very nice if we could give it to many

more patients but obviously they are very expensive.

I mean, we try to fit as well as we can with the PBS criteria before we prescribe them.

I mean, I sometimes find myself still prescribing it, for instance,

because someone is already on an antidepressant, so I can't really prescribe another one.

So, I might hit that box as saying one, but then I would still try two other

medications before I go ahead with one of the expensive medications.

Yeah. I find it particularly difficult if patients have bad migraine,

but maybe they're 12 headaches a month or 10 headaches a month,

which is still bad, but they don't quite meet the PBS criteria.

What about pregnancy and perimenstrual headache?

Any suggestions on how migraine should be managed in that context?

So perimenstrual headaches, usually we would, there are different alternatives, I guess, we could in,

We could use an estrogen patch because it's usually when the estrogen drops

that the migraines will happen. So that's one of the options.

Or suggest that the woman takes a pill without stopping would be a possibility.

And so that definitely helps some patients.

Or planning for her to take a big dose of anti-inflammatory on the days that she would usually have.

The headaches. So kind of prophylactically, we know these two days before I

have my periods, I'm going to have a migraine.

Okay, let's take 800 milligrams of ibuprofen on these two days.

Tricky if the menstrual cycle is not regular though, isn't it?

Yeah, it is sometimes tricky. That's right. And pregnancy?

Pregnancy is a very difficult one. I mean, usually migraines get better during

pregnancy, but obviously the amount of medications we can use is very limited, so it's tricky.

Sorry. A lot of young women with the question of fertility, and potentially

they want to fall pregnant but they're not called Shuwen,

they are very unlikely to take any of these prophylactic medications because

except for beta blockers, in my mind, and tricyclic antidepressants,

the rest of them are kind of indicated during pregnancy.

So that makes it very difficult to use any of those in young, fertile women.

Yes. I guess the mainstay of migraine prophylaxis is tricyclic antidepressants, so that's helpful.

And the second most common class that's used would be a beta blocker. So that's helpful.

I guess the one we worry about as neurologists, not so much in the migraine

space, more in the epilepsy space is epilim or sodium valproate.

That can be used as a migraine prophylaxis, but it causes weight gain and hair thinning.

So you're often not using it in a young woman anyway, but certainly wouldn't

want to use it if they're potentially going to get pregnant.

I guess the other thing just to, I'm not sure you mentioned,

but there are some nerve blocks that can be used either as a kind of a bit of

a once-off treatment in somebody with chronic,

headache or, you know, if other therapies are not available to you.

So greater occipital nerve blocks, for example, are pretty safe, pretty simple.

It's just a bit of local anesthetic and steroid given locally around the greater

occipital nerve, that can sometimes give people, you know, eight to 12 weeks

of relief without a lot of systemic side effects or interaction.

So that's worth considering when you're stuck.

But, you know, you're right, these are very difficult situations for us to deal with.

Yes, yes, so for, yeah, you could use Botox, that's right, actually.

You could use Botox during pregnancy.

That's one of the most attractive things about these injected therapies.

I mean, unlike the newer injected therapies, the locally available ones,

Botox really doesn't go very far.

It doesn't, it shouldn't, I should say, get absorbed into the bloodstream.

It's really a local therapy.

So that's helpful.

Oh, we've got one last question. Please go ahead. Thank you for your talk.

I want to ask about the migraines and very classical picture in my GP practice

when I see a young woman with a migraine, particularly oral migraine and premenstrual,

but she can't be on the pill because of the contradiction.

What's your take on it?

I think taking anti-inflammatory at the time of the headaches,

like a big dose of anti-inflammatory.

I mean, she would like to be on the contraceptive pill as well.

So you're asking about what contraceptive methods are available to her?

Right. So rather than migraine part, you're thinking, is there a contraceptive

therapy that we can use in migraine? Is that what you mean?

I mean, as a contradiction, like for a young woman who has got migraines with

aura, how do you assess this sort of clinical scenario?

I see a lot of young women coming with migraines and being on the pill,

but neurologists would say, oh, this is a migraine without aura.

She can have this pill. She can have this medication.

What would you come into? I guess I'm just trying to understand your question.

You're asking, should you be stopping the oral contraceptive pill in somebody

like that? Is that what you mean?

Yeah, because migraine with aura is unfair and deficient. Yeah,

so we've got migraine without aura.

Should we be stopping the contraceptive pill or can we continue? Is that the question?

Yeah, okay. So, I mean, the thing we worry about when we say in this discussion is risk of stroke.

And we know that it's higher in migraine with aura in women who also smoke.

And I forgot the third one now. Are overweight. Yeah.

So these three factors combined, obviously, is a big worry, but I wouldn't stop

the pill in someone who has migraine with no aura.

I guess we're talking about an increase in relative risk of stroke.

So the absolute risk of stroke in a reproductive age woman is relatively low,

but obviously this is increasing the risk over that.

So I think certainly education and counselling and, you know,

informed consent, all of those things are very important.

You know, sometimes a low dose, a presto and only pill, if that's an option

that, you know, you could think about that.

And other forms of contraceptive, you know, I mean, And I think part of the

discussion has to involve all of those things with the patient.

But often the patients will say, look, this is the pill that works best for

me. It's got the lowest side effects.

You know, I don't want to come off it. So that's okay too, so long as they understand

all of the kind of bits and pieces around it, I guess.

All right. So thank you very much. We'll thank our panelists once again. Fantastic session.