Teleneuropsychology refers to the use of audiovisual technologies for remote neuropsychological assessments and interventions [1]. Specialty psychological services, namely, neuropsychological assessments, seek to integrate digital tools into conventional practice, combining traditional in-person measures for rich clinical observations with novel digital or remote assessments that allow for more precise quantification of behavioral patterns [2]. Teleneuropsychology requires the use of various tests and tools to evaluate a person’s current cognitive and emotional status. This service usually requires patients to visit assessment sites and undergo clinical interviews and neuropsychological testing. Nevertheless, health emergencies such as the COVID-19 pandemic hindered in-person visits, prompting mental health professionals to adopt remote evaluations or teleneuropsychological assessments as an alternate method. The Inter Organizational Practice Committee created new guidelines for the practice of teleneuropsychology during the pandemic [3,4] to aid with some of the difficulties that are common in teleneuropsychology, such as uncontrolled conditions of in-home assessments [5]. In Latin America, recommendations on the use of teleneuropsychology emerged during the pandemic, with a lack of normative data for various countries [3]. However, teleneuropsychology did not arise solely as a response to health emergencies. Before the COVID-19 pandemic, guidelines for remote testing had been created by the American Psychological Association and Joint Task Force for the Development of Teleneuropsychology Guidelines for Psychologists [6]. These guidelines were developed to address ethical and methodological challenges associated with internet-based assessments, such as limited confidentiality and security risks when using the internet. One key recommendation was to incorporate ethical limitations into the informed consent process, providing participants with a clear and thorough explanation of the unique aspects of teleneuropsychology assessments [7]. Moreover, historically, studies have explored the validity and feasibility of remote care, initially through telephone and later through videoconferences.

Teleneuropsychology’s origins date back to the 1980s, when telephones were used for patient follow-up and cognitive health assessments. By then, widespread telephone use in US households facilitated telephonic data collection, particularly in primary care for consultations and surveys. In the 1990s, telephones were used for follow-ups with patients and screenings to detect dementia in older adults [8] as they function as a cost-effective alternative to in-person surveys [9]. In this period, there was an initial exploration of the feasibility of videoconferencing for cognitive evaluations in older adults [10,11] and an ongoing development and validation of remote tests [12-21]. Telephone screening tools, such as the modified Telephone Interview for Cognitive Status (TICS-M) and the Mini-Mental Status Examination, offer benefits such as rapid administration and cost-effectiveness, making them suitable for large-scale epidemiological studies [22]. These tools can also help minimize dropout rates in longitudinal studies and overcome geographical barriers [23]. Older adults, who may have mobility issues or reduced motivation, often respond well to telephone assessments, enabling “cognitive triage” and follow-ups in hard-to-reach populations [24]. However, the effectiveness of telephone assessments largely depends on the design of the screening instruments [25]. In this context, videoconferencing presents several limitations, including the inability to assess praxis or visuospatial abilities [26], limited use of visual stimuli, and the examiner’s restricted ability to directly observe behavior in an uncontrolled environment [27]. In addition, communication challenges arising from hearing loss or cognitive decline further complicate the assessment process [28].

Since the early 21st century, research has explored the feasibility of teleneuropsychological assessments. Studies have shown no significant performance differences between videoconference and face-to-face assessments, demonstrating its feasibility and potential utility [27-31]. Furthermore, teleneuropsychology has not hindered clinical intervention or rapport building [29,30]. Diagnostic agreement between on-site and videoconference screenings for neurocognitive disorders has also been confirmed [32,33]. Likewise, teleneuropsychological assessments have shown to be feasible in different clinical settings, such as assessment of survivors of stroke [34]. Acceptability [35] and satisfaction [36] with teleneuropsychology have been documented, including assessments designed for use in Latin populations [37] and other underrepresented populations [38].

Before the pandemic, a survey revealed that approximately one-fourth of professionals, primarily from the United States, used teleneuropsychology for clinical interviews and interventions [39]. This highlighted the underuse of teleneuropsychology, which was largely due to lack of reimbursement from Medicare and private insurance [40]. Challenges such as limited access to technology, inability to perform hands-on assessments, and reduced behavioral observation opportunities also hindered its adoption [41]. However, lockdowns increased the need for recommendations and research, leading to greater use of teleneuropsychology among practitioners [5,42-44]. Research during the COVID-19 pandemic underscored the necessity for further investigation into teleneuropsychology and its limitations. Individuals with lower incomes often lacked access to necessary technology [45,46]. In addition, participants’ computer literacy skills were frequently inadequate, and there was a scarcity of research on teleneuropsychology’s application in home health care [33,47-49].

Research in teleneuropsychology, especially concerning culturally diverse populations, has progressed following the declaration of the end of the COVID-19 pandemic [50-52]. Notably, neuropsychologists have reported significant use of this work method [53]. In addition, new tools such as the Tele-Global Examination of Mental State [54] and Tele Executive Function for children [55] have shown promising results.

Studies on validity have shown that standardized cognitive tests used in teleneuropsychology retain their psychometric properties and yield results comparable to in-person administration [56]. Similarly, research shows that teleneuropsychology assessments are reliable, as they often show stable results when repeated over time, indicating reliability in tracking cognitive performance [57]. In addition, remote assessments allow for broader participation while maintaining standardized administration protocols through platforms such as Zoom (Zoom Video Communications), REDCap (Research Electronic Data Capture; Vanderbilt University), and other secure testing software [5].

Until 2021, no studies on teleneuropsychology had been reported in Latin America [41]. However, from 2021 to date, 8 studies have been documented regarding the use of teleneuropsychology in 4 countries in the region. Most of the studies are descriptive, and only 1 is a randomized controlled trial. In 38% of the studies, a satisfaction survey was included. In half of the studies, teleneuropsychology was used to evaluate participants, and in 1 study, telerehabilitation was performed. Results indicated good acceptance of teleneuropsychology as an assessment or rehabilitation modality by both participants and professionals [49,58,59]. Key benefits included reducing the stress of traveling to evaluation sites, increased accessibility to remote areas, increased comfort of home assessments [45,60], continued access during social distancing, and reduced COVID-19 risk [59]. Moreover, challenges noted by practitioners included patients’ unfamiliarity with technology; lack of environmental control; and insufficient access to technological resources, including internet connectivity [46].

These studies represent a significant initial progress in Latin America, revealing insights into the experiences of neuropsychology professionals in the region. Although Mexico and Argentina are middle-income countries, they face findings and challenges similar to those observed in high-income nations. Moreover, proposals for clinically applicable models are beginning to emerge in Latin America [61]. However, normative data in the region are scarce, a phenomenon not unique to the teleneuropsychology, and precedes the COVID-19 pandemic as a recurrent issue in Latin America clinical practice [62]. There is a pressing need for studies that test the feasibility of teleneuropsychology and contribute to the development of tools, models, and validations and the establishment of normative data for the diverse populations of the region.

The objective of this study is to conduct the first pilot study in Central America to assess the feasibility of a teleneuropsychology protocol and to generate normative data for a Panamanian sample. The specific objectives of the study are to (1) administer a teleneuropsychological assessment to a Panamanian sample of participants identified as having a low risk of developing dementia, (2) generate normative teleneuropsychological data from a Latin American sample in Panama to compare with a Hispanic sample in the United States, (3) compare performance on teleneuropsychological tests across different gender and age groups, and (4) assess the sample’s level of satisfaction with the administration of the teleneuropsychological evaluation battery using a standardized scale.

The protocol of this study is adapted from the Development and Validation of Teleneuropsychology Normative Data for Older Adults in Florida (FLOAT) [63], a study being conducted at the University of Florida with the aim of validating a battery in a healthy sample of older adults with low risk of developing Alzheimer disease and related dementias (ADRD). This study is cross-sectional, descriptive, and community based. As of November 11, 2024, we have recruited 67 (44%) out of 150 participants, all aged ≥50 years and residing in Panama. Details of participants invited to participate, recruited, and assessed are shown in Figure 1.

Participant eligibility criteria are presented in Textbox 1.

Potential participants are recruited from the community in Panama through social media advertisements, flyers in community centers, and newspaper announcements. Individuals living outside the city are also encouraged to participate due to the availability of remote testing. The research team, which includes the principal investigator, research assistants, and trained psychology students, supervised by senior scientists, assist in recruitment and data collection. Participant recruitment process is displayed in Figure 2.

Participants undergo an initial screening to determine their eligibility. Those who meet the inclusion criteria and agree to participate will provide telephone-informed consent. Following this, participants complete 2 questionnaires: an adapted Spanish version of the modified TICS-M and the National Alzheimer’s Coordinating Center (NACC) Health Questionnaire. These assessments help identify any underlying neurological diseases or uncontrolled medical conditions that may impact cognition, such as depression or bipolar disorder. The screening aims to (1) confirm that the participant does not have cognitive impairment (eg, mild cognitive impairment or dementia) and (2) ensure that they have the cognitive capacity to provide informed consent. Participants scoring ≤31 points in TICS-M, indicating mild cognitive impairment or dementia, are excluded from the study. Those who do not meet the eligibility criteria are thanked for their time, and the assessment is discontinued.

Eligible participants receive a link to complete the questionnaires and surveys via email using the REDCap platform, an online platform designed for data collection and storage [64]. This process takes approximately 30 minutes. Later, a member of the research team schedules a 2-hour block for the teleneuropsychological assessment with ≥1 breaks if requested by the participants. A team member assists participants in setting up the videoconferencing technology. Before beginning the study, research staff reviews the informed consent document with the participant and addresses any questions.

REDCap is used to capture and store participant data, while Zoom facilitates the administration of neurocognitive tests. The screen-sharing feature is used to display test stimuli. For tasks requiring a scored motor component (eg, figure drawing), participants are asked to hold their drawings up to the camera, and a screenshot is taken for later scoring. These screenshots do not include any identifying information about the participants. Captured images are stored in the participant’s REDCap dataset for future analysis. During the assessment, 2 computers are used: a laptop and a touchscreen device, both of which project visual stimuli via the screen-sharing function. These stimuli are displayed in PowerPoint, and data collection is conducted in REDCap throughout the assessment.

Neuropsychological test results will be analyzed using multivariate statistical methods. We will perform initial data analyses with chi-square and ANOVA tests to observe distribution across age groups or other groups of interest. We will obtain raw scores of each test as well as composites of cognitive domains to conduct further analyses per test and per cognitive domain. Comparisons will be made regarding sex and age groups. Student t test will be applied to examine differences in performance between sexes and within age groups (the sample will be divided in 3 groups: aged 51-59 years, 60-69 years, and >70 years). Multivariable regression analyses will be performed to assess linear relationships between age, years of education, or other (ie, income) variables and cognition. Once we have assessed and ruled out potential interaction effects influencing participant performance, we will proceed with an in-depth analysis of normative data stratified by age, sex, and education level. Test scores will be standardized into z scores based on the mean and SD of the respective group, and these z scores will be subsequently converted into normative scores for each assessment. Cases with incomplete data will be excluded from analyses via listwise deletion.

The study protocol was approved by the Research Bioethics Committee of Universidad Santa María La Antigua (CBI-USMA; 2022-P004). Informed consent is read to participants via phone call. After verbal confirmation of acceptance to participate in the study, participants get a Google Forms link were they formally accept to be part of the study and attach an image of their personal sign. Once they finish filling the forms, they are assigned a unique code.

All data collected will be saved in a password-protected database. Only authorized research personnel will have access to this database. If a participant chooses to withdraw from the study, the data collected before their withdrawal will still be included in the analysis. Data collected on REDCap are identified with a specific number to protect the identity of the participant.

Some estimated harms that could be caused by this type of evaluations include fatigue, stress, or anxiety while either responding to the questionnaires or performing the neuropsychological tests. However, we expect minimal harm to our participants. If the participant needs it, the evaluation is rescheduled. Participants are informed that they are free to withdraw from the research study at any time. As exclusion criteria indicates eligibility for participating is based on participants not having a diagnosis of ADRD or other neurological disorders that affect cognitive functioning, all participants contacted and included in the study are cognitively healthy. Nevertheless, if a participant with a diagnosis of ADRD contacts the research team, researchers will refer them to a neurologist.

All data, including consent, will be added to a REDCap database that has all the measures obtained in this study. To ensure high-data quality collection, scoring of the tests is reviewed by 2 different evaluators at the end of the testing. This is done to improve interrater reliability in test scoring. All evaluators have been trained using the same tools and in a standardized environment to minimize variability in score interpretation. Test scoring instructions are followed precisely.

Results from this research will be published, shared, and presented at national and international conferences, science events, and high-impact journals. At the end of the study, participants will be given a summary of their results that will give them an insight of their cognitive status. The report will be divided in different cognitive domains, including “below average,” “average,” and “above average” to identify the participant’s cognitive level when compared with other peers of the same age range, sex, and education.

The demographic and clinical characteristics of the sample are summarized in Tables 1 and 2. Participants were mostly female (53/67, 79%) and were on average aged 62.2 (SD 7.6) years. Participants on average had 16.7 (SD 1.9) years of formal education. Most participants have a partner (44/67, 66%). Participants reported few cardiovascular, cerebrovascular, and psychiatric illnesses. Nevertheless, the most common chronic illness is hypertension (22/67, 33%), followed by hypercholesterolemia (19/67, 28%). Most participants identify as White (31/67, 46%) or other (20/67, 30%). Participants showed a high degree of functional independence in performing basic and instrumental activities of daily living. On average, participants had 1.5 (SD 1.8) symptoms of depression.

Feasibility will be assessed based on an analysis of the tools, funding, expertise, and resources needed to conduct neuropsychological assessments. Likewise, the Teleneuropsychological Assessment Satisfaction Scale will assess feasibility through the satisfaction of the sample with the teleneuropsychology assessment. The Teleneuropsychological Assessment Satisfaction Scale provides participants with an opportunity to give feedback on various aspects of the assessment, including satisfaction, the use of Zoom and REDCap, instructions, advantages, difficulties, recommendations, and overall time.

So far, the Teleneuropsychological Assessment Satisfaction Scale (Multimedia Appendix 1) has shown that most participants (39/67, 58%) were very satisfied with the teleneuropsychological assessment, while high levels of satisfaction were found with other elements of the assessment, such as the use of the Zoom platform (47/67, 70%), the evaluator (57/67, 85%), or the REDCap platform (33/67, 49%). All participants reported instructions were clear. Most participants (49/67, 73%) were satisfied with being able to do the evaluation from home. Two-thirds of participants (44/67, 66%) reported that they were able to use electronic equipment, such as computers, phones, or tablets. Most participants (37/67, 55%) would recommend a teleneuropsychological assessment to others.

Although most of the sample (53/67, 79%) reported no difficulties at all, main limitations that were stated by participants were internet connection (8/67, 12%), space in which the assessment took place (8/67, 12%), and electronic equipment used (5/67, 7%). Other barriers (12/67, 18%) included the long duration of the assessment, confusing wording in questionnaires, problems with sound, interruptions, difficulties with the assessment materials, problems with the Zoom platform, availability for the assessment, lack of light, and complaints regarding their own abilities.

In line with the FLOAT study [63], percentile ranks for each test’s raw scores will be calculated from cumulative frequency distributions and then normalized to a distribution with a mean of 10 and an SD of 3 (ie, scaled scores). These normalized scores will then be entered into a stepwise regression, including sex (male and female), education, and different age groups. Predictors contributing <5% of additional variance in the normalized scores will be retained for further regression-based adjustments.

This paper describes the protocol of a pilot study designed to assess the feasibility of conducting teleneuropsychological cognitive assessments in adults aged ≥50 years. Teleneuropsychology is a technology-based practice that includes collecting patient data using multiple assessment modalities. So far, we have successfully assessed 67 participants with a complete teleneuropsychology evaluation. Our results indicate that our sample is comparable to those in other studies in terms of age [34,38], education level [80,81], and the distribution of men and women [40], characteristics that might contribute to the validity of our design in future analyses.

Moreover, feasibility could also be demonstrated through the successful use of various technological platforms in the assessments, including REDCap and Zoom. This approach to teleneuropsychological assessments has been recommended in other studies [5] and aligns with guidelines established before and during the COVID-19 pandemic [1,7]. To date, very few studies in Panama have used REDCap to capture and store clinical data; nevertheless, this is the first time it is used for neuropsychological assessments, making this an unprecedented study. REDCap has been widely used and recommended for teleneuropsychology studies across various regions worldwide [3,82], as data can only be accessed with a password and server administrator permissions, making the platform ideal for securely storing the collected information [83]. REDCap stands as a viable platform that could be part of the regular clinical practice, ensuring the security, conservation, and confidentiality of gathered data. Likewise, using Zoom as the platform for the assessment is a notable strength, as it has been effectively used in other similar studies [48,84].

In addition, current participant satisfaction has been assessed, revealing that most respondents (39/67, 58%) were highly satisfied with the remote assessment. This aligns with findings from previous studies on participant satisfaction [35,36,42,85]. Key positive aspects highlighted by participants included the use of electronic equipment, the convenience of conducting assessments from home, and the quality of interaction and communication with evaluators. These findings reinforce the strengths of teleneuropsychology identified in another research [41].

So far, participants reported difficulties primarily related to electronic equipment, internet connectivity, and the environment in which the assessment took place. These limitations are common challenges associated with teleneuropsychology [86,87], and as participants completed the assessment at home, these factors were beyond the assessor’s control. We expect other participants assessed to encounter technological difficulties. The use of REDCap presents both strengths and limitations. On the one hand, this platform ensures secure and confidential storage of test and questionnaire data, as it is only accessible to those connected to the research institution’s server. On the other hand, because the server hosting REDCap is owned by the institution, both the researcher and the participant must have access to the server to use the platform.

Other limitations include the use of convenience sampling for recruitment, which hinders the inclusion of a diverse sample. This resulted in participants with a high level of education and a medium to high socioeconomic level that are not representative of the population. We will actively aim to recruit participants that come from different backgrounds and diverse socioeconomic levels.

The study’s strengths include the innovative teleneuropsychology assessment format, which involved both the participant and assessor being at home, creating a teleneuropsychology “home-to-home” format, an approach that has been validated but not extensively studied [33,42,60,88,89]. This is of particular interest given that the use of teleneuropsychology home-to-home neuropsychological testing by mental health professionals has been reported in the Latin American region; however, no specific studies documenting this modality have been published to date [59], making this study one of the few to explore this method.

The application of the assessment battery enabled the collection of specific data from the Panamanian population, paving the way for the development of normative data for tests conducted remotely. This aims to address a significant limitation in the region, where standardized tests have not been adapted to the populations of these countries [90-93].

While some participants reported challenges related to connection issues, the assessment environment, and the equipment used, it is important to note that these difficulties were experienced by only a minority of the sample. In addition, specific issues related to the questionnaires emerged; participants noted that the wording and timing of the questions were not favorable. In contrast, the overall timing of the evaluation itself was well received by participants.

Teleneuropsychology has gained ground in the field of psychology, offering new spaces and opportunities for professionals, patients, and participants. Ongoing research is essential to bring clarity to the clinical practice of those using these alternatives. Drawing on lessons learned before, during, and after the pandemic, many professionals have adopted models that combine elements of remote and traditional face-to-face care, giving rise to hybrid neuropsychology [94]. In Latin America, further research is essential, particularly studies aimed at developing instruments, models, and validations and establishing normative data for diverse populations in the region.

This study represents the first pilot investigation in Central America aimed at assessing the feasibility of a teleneuropsychology protocol and establishing normative data for a Panamanian sample. By administering cognitive assessments to individuals at low risk of developing dementia, we aim to generate data that can be compared with Hispanic samples from the United States, contributing to a broader understanding of cognitive performance across diverse populations. In addition, evaluating participant satisfaction with the teleneuropsychological evaluation process provides valuable insights into its acceptability and usability. Furthermore, analyzing performance differences across gender and age groups will help identify potential demographic influences on test outcomes. Ultimately, this research will contribute to the validation of remote cognitive assessments in Latin America, supporting their use as reliable and accessible tools for neuropsychological evaluation.

We recommend expanding the sample to establish normative data for older adults in Panama. This will require strengthening participant recruitment efforts across diverse regions of the country to maximize the accessibility and advantages of teleneuropsychology. Likewise, this study can be replicated to use teleneuropsychology assessments with other age ranges and populations, such as children, adolescents, and middle-aged adults. In addition, it is imperative to conduct a similar study with individuals with mild cognitive impairment to explore applications in neurodegenerative conditions such as Alzheimer and Parkinson disease. Finally, in studies such as ours, we recommend incorporating medical records in future studies to confirm participants’ health status, aligning with best practices used in research worldwide.