2013. Vol.4, No.10A, 23-28
Published Online October 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.410A005
Copyright © 2013 SciRes. 23
Conceptual Foundations of a Cognitive Health Program for
Hispanic Patients with Minor Neurocognitive Disorder
Jorge A. Herrera Pino1,2, Jose Arm as 1, Nora Dieguez1, Eduardo Alarcon1
1Medical Care Consortium, Inc. (MCCI), Miami, USA.
2Herbert Wertheim College o f Medicine, Flor ida International University, Miami, USA
Received July 27th, 2013; revised September 1st, 2013; accepted September 22nd, 2013
Copyright © 2013 Jorge A. Herrera Pino et al. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
The purpose of this paper is to present the conceptual foundations used in the development of a cognitive
health program for Hispanic patients who report memory concerns or complaints to their primary care
physicians. These models are drawn from the field of neuropsychology, both as a professional endeavor
and as a scientific discipline. This program has been developed based on prevailing models of higher
cerebral functions, addressing primarily attention, memory, and executive functions. The role of neuro-
psychologists as active participants in the improvement of the cognitive status of the patients referred to
them is not only emphasized in this article as going much beyond the diagnostic process, but also having
an active participation in the subsequent treatment process. The models of attention that have served as
the bases for the MCCI COGNITIVE HEALTH PROGRAM are those developed by Allan F. Mirsky and
Michael I. Posner, while the memory model used is authored by Alan Baddeley. The two models of ex-
ecutive functions that are employed in the development of this program are those of Russell Barkley and
Elkonon Goldberg. This program was also very much anchored on the concept of cognitive reserve and
the work of Yaakov Stern was incorporated into the models used for the development of the program. The
program is implemented in two phases. Patients referred by their primary care physicians undergo a func-
tional neuropsychological evaluation to determine the nature and extent of their memory impairments.
The results obtained in these evaluations are interpreted using the models referred to above. A treatment
plan is developed and the program is implemented through the use of computer assisted cognitive reha-
bilitation procedures. The advantages of using computer assisted procedures are discussed in this article.
Keywords: Mild Cognitive Impairment; Minor Neurocognitive Disorder; Cognitive Reserve; Cognitive
Rehabilitation; Attention; Memory; Executive Functions
The practice of neuropsychology in the United States has
seen a substantial increase in the past 20 years. However, by
and large, neuropsychologists have played a much more preva-
lent role in the diagnosis of disorders of brain-behavior rela-
tionship, as opposed to participating directly in the re mediation
or correction of identified deficits. The purpose of this paper is
to share with the professional community the foundations and
implementation of a program of direct intervention based on
solid neuropsychological principles and procedures, in which
the participation of neuropsychologists is at its core.
Cognitive decline often seen in elderly individuals has been a
focus of attention of scientific and medical literature for more
than two decades (Albert et al., 2013). In many instances, prior
to the identification of a definitive or at least probable dementia,
what has been described as cognitive slippage, and subsequent
cognitive decline, leading to mild cognitive impairment is iden-
tified. This is characterized by complaints made by patients
oftentimes to their primary care physicians. Unfortunately, in
many instances, these professionals are not available for their
patients any form of intervention that may delay, to a signifi-
cant degree, the onset of functional decline.
Cognizant of this situation, many healthcare institutions have
begun implementing measures aimed at assisting their patients
during these initial phases of what may eventually convert into
a dementing disorder, manifested through significant decline in
functions. For the past eight years, the MEDICAL CARE
CONSORTIUM, INC. (MCCI), has implemented the MCCI
COGNITIVE HEALTH PROGRAM, aimed at providing its
primary care physicians with an effective intervention tool de-
signed to alleviate and slow down the cognitive decline associ-
ated with mild cognitive impairment.
The term mild cognitive impairment, introduced initially by
Petersen (Petersen, 2004; Petersen et al., 2001; Petersen et al.,
1999) has been substituted recently by the term minor neuro-
cognitive disorder in the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders of the American Psy-
chiatric Association (DSM-5; APA, 2013). To this effect, this is
the term, which will be used to describe the patients that cur-
rently participate in the MCCI COGNITIVE HEALTH PRO-
GRAM discussed in this paper.
J. A. HERRERA PINO ET AL.
Medical Care Consortium, Inc. (MCCI)
MCCI is a full coverage multi-center organization that pro-
vides health care services to a variety of patients. MCCI
out-patient centers are staffed by both primary care physicians
and specialists. Patients who report difficulties or complaints
with memory and cognitive functions are referred to the MCCI
COGNITIVE HEALTH PROGRAM for diagnosis and treat-
ment of minor neurocognitive disorder. Patients seen in the
MCCI centers in Metropolitan Miami-Dade County, Florida,
are primarily Hispanic and their native and preferred language
Conceptual Models of Brain Functioning
The MCCI COGNITIVE HEALTH PROGRAM is based on
a number of conceptual models of brain functioning. Following
please find a description of the conceptual models of brain
functioning that have served as the foundations for this pro-
American neuropsychology, following initially the tradition
established by authors such as Ward C. Halstead, Ralph M.
Reitan, Philip M. Rennick, and others, followed what has been
described to be an actuarial model of interpretation, in contra
position to a heuristic model. However, as time has passed, a
number of very important theoretical positions have been de-
veloped by renowned authors in the field of brain-behavior
relationship. Salient among these are the contributions of Allan
F. Mirsky and colleagues of the National Institutes of Mental
Health in regards to the process of attention.
According to Mirsky et al. (Mirsky, 1987; Mirsky & Duncan,
2001; Mirsky et al., 1991), attention is not a unitary process,
but rather, it can be broken down into at least four sub-proc-
esses. The first of these is the ability to focus and execute effi-
ciently. According to these authors, this is the component of
attention which opens the door to cognitive processing. Being
able to attend to relevant stimuli or to relevant aspects of spe-
cific stimuli, is a necessary prerequisite, if attention is going to
be used effectively. The second function which Mirsky et al.
(Mirsky, 1987; Mirsky & Duncan, 2001; Mirsky et al., 1991)
include in their model of attention is being able to sustain it
over time. Again, if the focusing and executing efficiently
component is put into effect, it needs to remain active for the
time that is necessary for attention to actually be useful.
This model of attention includes a third component, which
has to do with coding information into working memory so that
the process of learning can take place. Once the individual has
attended to relevant stimuli or to relevant aspects of stimuli and
sustained attention sufficient time for learning or coding to take
place, the focus of attention has to be shifted to meet new envi-
ronmental demands which require the individual to adapt. Thus,
the fourth and final component of attention presented by Mir-
sky et al. (Mirsky, 1987; Mirsky & Duncan, 2001; Mirsky et al.,
1991) is that of shifting attention adaptively and resisting the
ever present tendency to perseverate, experienced by individu-
als who somehow have attentional impairment s .
Another model of attention, which goes beyond that pro-
posed by Mirsky et al. (Mirsky, 1987; Mirsky & Duncan, 2001;
Mirsky et al., 1991), has been described by Michael I. Posner
from the University of Oregon. This model introduces an “ex-
ecutive” component to the process of attention. According to
Posner et al. (Posner & Rothbart, 2007; Rueda, Posner, &
Rothbart, 2005), paying attention implies a decision making
process which directs attention adaptively to relevant stimuli or
relevant aspects of stimuli present in the environment. Michael
I. Posner has been reported as saying something to the effect
that “we see with our occipital lobes, but we look with our
frontal lobes” in reference to “executive attention” (Rothbart &
The implication is that attention is not only “vigilance”. That
is, being alert or awake. Attention implies being able to direct it
appropriately within the concept of “orientation”. According to
Posner et al. (Rothbart & Posner, 2005) there is often a conflict
between that which you habitually pay attention to and that
which you need to pay attention to, in order to function adap-
tively. Posner’s model of attention has been widely validated by
neuro-radiological studies (cf. Kübler, Dixon, & Garavan, 2006;
Talati & Hirsch, 2005).
Once attention has done its job and it has been used to further
adaptation to the demands of the environment, the process that
has been described as “working memory” needs to take place.
The model of working memory chosen for the MCCI COGNI-
TIVE HEALTH PROGRAM described in this article is the one
developed by Alan Baddeley, formerly of Bristol University
and currently of York University in the United Kingdom. Ac-
cording to Baddeley’s model (Baddeley, 2003, 2010, 2007),
information is usually processed through two different avenues
in order to become incorporated into memory. The first mecha-
nism described by Baddeley (2003) is the “phonological loop”.
Through this process, information is “rehearsed” verbally to
facilitate it bec oming pa rt of memory.
The next mechanism of working memory posed by Baddeley
(2007) is the “visual scratch pad”. This is an eidetic memory
process through which information becomes part of working
memory by being able to be “visualized”.
It is quite interesting to note that the two mechanisms of ac-
quisition of working memory posed by Baddeley (2007) are
very consistent with the concepts proposed by authors like
Ralph M. Reitan and others regarding the “functional asymme-
try of the brain” (Reitan, 1955). One of the most important
early discoveries of the research conducted by Reitan (Reitan,
1966) in the Neuropsychology Laboratory of Indiana Univer-
sity, was the fact that there was a definite identifiable set of
cognitive impairments associated with right hemisphere dam-
Other contemporary authors (cf. Funka et al., 2010; Karnath,
Rorden, & Ticini, 2009) have identified the mechanisms un-
derlying a phenomenon seen frequently in neurologically im-
paired patients with right hemisphere damage. This is the pres-
ence of left visual field neglect. This symptom is seen very
frequently in patients who have sustained some form of cere-
brovascular accident affecting the right hemisphere.
Once the information is stored into memory, it serves as the
basis for planning, organizing, and carrying out action. This
process has been described abundantly in the neuropsychologi-
cal literature and given the name “executive functions”. Two
models of executive functions have served as the bases for the
MCCI COGNITIVE HEALTH PROGRAM described in this
article. These have been developed respectively by Russell
Barkley of the Medical University of South Carolina and Elk-
onon Goldberg of the New York University School of Medi-
The model developed by Barkley (1997, 2001) proposes that,
before action is implemented in response to a given situation
Copyright © 2013 SciRes.
J. A. HERRERA PINO ET AL.
that arises in the en v i r o n m e n t , an inhibitory process must be put
in place in order to allow sufficient time for executive functions
to modulate the response. This inhibitory process of the “pre-
potent behavior” allows the individual to produce a more adap-
The four executive functions proposed by Barkley (1997;
2001) are non-verbal working memory, which allows the indi-
vidual to recollect similar situations confronted in the past,
verbal working memory, which refers to guidance provided by
internalized language, self-regulation of affect, emotion, and
arousal, as well as what Barkley (1997, 2001) referred to as
reconstitution. All of these processes are brought to bear on the
decision the individual will make when confronted with a spe-
cific situation or problem.
Goldberg (2002, 2009), on the other hand, proposed a model
of executive functions very much in line with what Alexandr R.
Luria (1972) had referred to as Functional Unit III of the brain.
Included in these processes are the intention, the planning, and
the execution of behavior, as well as the process of monitoring
its consequences. Goldberg (2002, 2009) also makes emphasis
on higher level cognitive processes, such as concept formation
One final conceptual framework used as the basis for the
MCCI COGNITIVE HEALTH PROGRAM described in this
article, was developed by Yaakov Stern of the Columbia Uni-
versity Medical Center (Stern, 2002, 2006). The concept of
“cognitive reserve” has become increasingly popular and
widely accepted in the past decade. At the root of this concept
is the notion that there are many things that can be done
through an individual’s life in order to strengthen cognitive
abilities as a protective factor to cognitive decline in later life.
The concept of cognitive reserve is fundamental to the de-
velopment and implementation of the MCCI COGNITIVE
HEALTH PROGRAM. Cognitive reserve was initially seen
within the context of a “passive model”. This implied that con-
stitutional or genetic protective factors were responsible for
delaying the onset of functional deterioration in dementing
processes. Authors such as Alexander et al. (1997) studied
premorbid intellectual functioning as a strong contributor to
cognitive reserve, if not the most important one.
Other authors, such as Mori et al. (1997) posited that consti-
tutional factors, such as brain size, were responsible for “re-
serve capacity” against intellectual decline in dementing disor-
ders, such as Alzheimer’s disease.
Stern (2002) acknowledges the “passive model” of cognitive
reserve in his seminal paper. However, he presents a much
more “active model” of cognitive reserve, which, in turn, is
divided into two different approaches. The first approach fo-
cuses on the development of cognitive reserve in order to en-
hance cognition within a “normative” framework. That is, ac-
cording to this view, there are things that individuals can do to
enhance their cognition and to become more resistant to the
onset of functional deterioration.
There is no question that cognitive reserve can be built up
during the person’s developmental cycle. However, the ques-
tion arises regarding the possibility of improving cognitive
reserve if there already is brain pathology, as is definitely sus-
pected in minor neurocognitive disorder. To this effect, the
second approach proposed by Stern (2002) for the development
of cognitive reserve already presupposes the presence of brain
pathology. It seeks to “compensate” for cognitive decline by
stimulating and activating alternative circuits or neural net-
works, in order to perform the same function that is in peril of
becoming impaired. It also proposes that previously inactive
portions of the cortex can be recruited in order to improve brain
activity and functional efficiency. This point of view has been
subsequently expanded and clarified by Stern (Stern, 2006,
2009) and Stern et al. (2003).
There has recently been an accumulation of research and
studies found in contemporary neuropsychological literature
that strengthens the notion that cognitive intervention or reha-
bilitation implemented during the initial phases of a progressive
dementing disorder can delay the onset of functional deteriora-
tion. To this effect, Vasile (2013) very aptly described this
phenomenon: “Exercising the memory and the desire of under-
standing the environment, together with a proper relationship
with it, is probably one of the strongest factors generating cog-
nitive reserve” (2013: p. 604). This seems to be particularly
well suited for patients with minor neurocognitive disorder.
Patients that participate in the MCCI COGNITIVE HEALTH
PROGRAM are initially referred by their primary care physi-
cians, usually due to having reported memory difficulties. Upon
referral, an initial neuropsychological diagnostic interview is
conducted by a doctoral level neuropsychologist. In addition to
gathering pertinent information as to the nature and onset of the
memory complaint s, the pati ents’ pre sent medic ation re gime, as
well as the presence of any systemic or psychiatric condition,
the patients are administered the Mini-Mental Status Examina-
tion (Folstein, Folstein, & McHugh, 1975; Folstein et al. 2001,
Subsequent to that, a neuropsychological evaluation of the
patients is conducted, including the following instruments: Test
de Inteligencia No-Verbal 2 (Brown, Sherbenou, & Johnsen,
2000) or Test of Non-Verbal Intelligence 4 (Brown, Sherbenou,
& Johnsen,, 2010), Symbol Digit Modalities Test (Smith, 1973,
1982, 2002), Controlled Oral Word Association Test (Lezak,
Howieson, & Loring, 2004; Spreen & Strauss, 1998), Rey Os-
terrieth Complex Figure Test (Rey, 2003; Meyers & Meyers,
1995), Rey Auditory Verbal Learning Test (Schmidt, 1996),
Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1983,
1996), Benton Visual Retention Test (Benton, 1974, 2002;
Sivan, 1992), Grooved Pegboard Test (Lafayette Instrument
Company Model 32025), Beck Anxiety Inventory (Beck & Steer,
1993), and Geriatric Depression Scale (Yesavage et al., 1983).
If the patients’ primary language is Spanish, as is the case
with Hispanic patients, the authorized Spanish language edi-
tions of the neuropsychological instruments is used and admin-
istered by Spanish speaking neuropsychologists. The results
obtained by the patients in these instruments are analyzed fol-
lowing the parameters of double dissociation of function de-
veloped by Hans-LukasTeuber (Walsh, 1985) and the axes of
interpretation proposed by Manfred Meier (1974). These proc-
esses allow for the identification of impairments following the
conceptual models described above and the development of a
treatment plan within the framework of “restorative” cognitive
rehabilitation, as described in the paragraphs that follow.
Neuropsychologists have traditionally conducted evaluations
of brain-behavior relationships. These evaluations often result
Copyright © 2013 SciRes. 25
J. A. HERRERA PINO ET AL.
in recommendations for interventions for other disciplines, such
as occupational and speech and language therapy, as well as
different specialists in education. In the MCCI COGNITIVE
HEALTH PROGRAM, the role of the neuropsychologist has
been extended much beyond the process of evaluation. Based
on the knowledge of brain-behavior relationship, which is in-
herent to the training of the neuropsychologist, direct proce-
dures of intervention have been put in place stemming directly
from this knowledge and expertise, through the implementation
of an active “restorative” cognitive rehabilitation program.
Cognitive rehabilitation has become part and parcel of the
treatment options now available to patients with minor neuro-
cognitive disorders and its conceptual and practical dimensions
are the focus of on-going research (cf. Huckans et al., 2013).
Among the success obtained using cognitive rehabilitation pro-
cedures is the reduction of “conversion” of patients with mild
cognitive impairment (now minor neurocognitive disorder) to
dementia (Rojas et al., 2013) and the improvement of recall in
patients with dementia (Smith, 2013).
There are two primary models of cognitive rehabilitation,
which are widely implemented currently. There is “compensa-
tory” cognitive rehabilitation, which seeks to provide the patients
with alternative means to put into practice a particular cognitive
function. For instance, providing patients with a notebook to
write down information, to avoid forgetting it, is a common
way of implementing “compensatory” cognitive rehabilitation.
Other examples of this approach would be the establishment
of a fixed schedule of activities to be carried out as part of well
established routines, or making sure that objects are placed
always in the same place to facilitate later retrieval. Formulat-
ing verbally an intention before carrying out an action and to be
able to remember what the patients have come to do or get
when they arrive somewhere, is another example of “compen-
satory” cognitive rehabilitation.
The other model of cognitive rehabilitation has been de-
scribed as “restorative” in nature. It is essentially a neuropsy-
chological model, which proposes to identify where in a par-
ticular function the process has become impaired and subse-
quently to implement a series of well thought out and planned
exercises to, in effect, restore the function. The approach cho-
sen for the MCCI COGNITIVE HEALTH PROGRAM de-
scribed in this article is restorative in nature. This approach to
cognitive rehabilitation favors the use of computerized tech-
In this regard, there have been for many years now a number
of computer software suites specifically designed to improve
cognitive functioning. However, within the conceptual frame-
work of the MCCI COGNITIVE HEALTH PROGRAM de-
scribed in this article, rather than favoring one or another of
these suites, certain criteria have been established for their in-
clusion in it.
In the first place, any computerized suite of cognitive reha-
bilitation exercises included in this program must provide the
clinicians a wide range of exercises to choose from, addressing
the different functions covered by the models upon which the
MCCI COGNITVE HEALTH PROGRAM is based, as de-
scribed above. Exercises included in the suite must go from
being able to help the patients develop a quicker and more ac-
curate response to stimuli, being able to focus attention and
executing more efficiently, all the way to the development of
the ability to abstract, form concepts, and regulate behavior.
Evidently, if anyone suite of programs cannot cover this wide
range of cognitive abilities, exercises from different suites are
integrated into the overall MCCI COGNITIVE HEALTH
Another important feature of the exercises found in anyone
computerized or software suite is the ability to present them
with high-frequency. Restorative cognitive rehabilitation has
been predicated on the need for abundant repetition (León-
Carrión, 2010). This was nearly impossible to do at the rate that
exercises can be presented now, prior to the advent of the per-
sonal computer. Restorative cognitive rehabilitation requires
high-frequency presentation of stimuli within relatively short
periods of time.
Being able to provide patients with accurate and immediate
feedback regarding the appropriateness of their responses, both
in terms of correct and incorrect responses is another key fea-
ture necessary for a suite of computerized cognitive exercises.
It is also important that the patients involved in the program
maintain their motivation. In this regard, the clinicians in
charge should make sure that 60% of the responses made by the
patients are correct, and that appropriate feedback is given. The
other 40% of the exercises should present a challenge for the
patients and feedback on correct and incorrect responses is
Any suite of software exercises used in restorative cognitive
rehabilitation should also provide very accurate information on
a number of parameters that indicate if indeed there is progress
or not. For instance, the very basic attentional process of fo-
cusing and executing, described by Mirsky et al. (Mirsky, 1987;
Mirsky & Duncan, 2001; Mirsky et al., 1991) depends very
much on the length of the reaction time of the patients. It is
very important that any suite of computerized exercises that is
employed in a program is capable of providing the clinicians
with adequate and accurate information regarding the reaction
time of the patients and if, indeed, it is shortened as a result of
the procedures implemented in the program.
Another measure that has been found to be very informative
regarding the progress of the patients is the difficulty level of
the exercises. As the patients progress through their treatment,
their performance within a certain level of difficulty improves.
To this effect, an initial ratio of success of 60/40% should pro-
gress to 70/30%, and subsequently to 80/20%. The experience
gathered in the implementation of the MCCI COGNITIVE
HEALTH PROGRAM described in this article has shown that,
if the success to challenge ratio goes beyond 80/20%, motiva-
tion decreases, as the exercise becomes more a matter of rou-
tine. On the other hand, if this ratio is 50/50% or below, pa-
tients run the risk of losing motivation. This highlights the need
for the suite of computerized exercises used to have clearly
demarcated difficulty levels, so that patients can be moved from
easier to more difficult levels as the treatment progresses.
Although in the MCCI COGNITIVE HEALTH PROGRAM
a number of different suites of computerized cognitive exer-
cises are used, as noted earlier, the one suite of programs that
has been found to best meet the criteria mentioned above is
PSSCogRehab (Bracy, 1994). This suite of programs has a
recently developed new version (Bracy, 2012), which is also
available in Span is h .
Implementation of the MCCI Cognitive
Subsequent to the neuropsychological evaluation, a treatment
Copyright © 2013 SciRes.
J. A. HERRERA PINO ET AL.
plan is designed individually for each patient following the
framework of the conceptual models of brain functioning de-
scribed above. It is important to note that the diagnostic process
implemented in the MCCI COGNITIVE HEALTH PRO-
GRAM is not nosological in nature. That is, it does not neces-
sarily focus on the etiology of the condition presented by the
patients. As a matter of fact, mild cognitive impairment until
recently, and only after becoming minor neurocognitive disor-
der, was not considered a diagnosis as such.
The diagnostic process followed in the MCCI COGNITIVE
HEALTH PROGRAM is “functional” in nature. For instance, if
it is determined that the patients showed impairment in the
basic attentional process of focusing and executing, a very fre-
quent finding in elderly individuals who report difficulties with
memory processes, an assessment is made of their reaction time,
which may by now be increased, not allowing information to be
stored into memory for later retrieval. The experience obtained
throughout these eight years shows that reaction time is suscep-
tible to training, and once it is reduced, memory difficulties
reported by the patients are substantially decreased.
There are patients who present specific difficulties with other
cognitive functions, such as incorporating information through
the “phonological loop” described above. The use of computer-
ized exercises allows the clinicians working with these patients
to set up conditions under which abundant rehearsal and a con-
certed effort at developing the patients’ metacognitions regard-
ing this process has a restorative effect and the memory com-
Restorative cognitive rehabilitation in the MCCI COGNI-
TIVE HEALTH PROGRAM is delivered on a one to one basis
in which each patient works directly with a clinician. Given the
intensive nature of this procedure, it has been found that 45
minutes sessions conducted twice per week yield the most
benefit for the patients. Sessions are programmed in multiples
of 12, with reassessment at the end of each 12 session cycle.
Outcome measures obtained during the implementation of
the program with specific patients usually include reaction time,
ratio of correct to incorrect responses, difficulty level of the
exercises presented, as well as progress up and down the ladder
of cognitive functions, beginning with basic attentional proc-
esses and moving to executive functions, again, within the
framework of the conceptual models the program is based on.
Reduction of symptoms of memory impairment is assessed
every session using an ascending subjective rating scale ranging
from 0 to 10. Overall average reduction of symptoms obtained
in this scale is 8 points in this scale..
The purpose of this paper is to show that neuropsychology,
as a science and as a profession, can have a definite role, not
only in the diagnosis of neurological disorders, but also in their
management and treatment. This practice is theoretically sup-
ported by the emerging concepts of cognitive reserve and cog-
nitive rehabilitation. Clinicians and researchers in this field of
professional and scientific endeavor are encouraged to pursue
the role of the neuropsychologist in the restoration of cognitive
functions, in addition to furthering the knowledge of the effi-
cacy of restorative cognitive rehabilitation procedures and in-
terventions through research focusing on out-come measures
and neuro-radiological evidence of change. The decrease of the
rate of conversion from minor neurocognitive disorder to de-
mentia is another important research avenue to be pursued.
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