NFL Settlement Testing May Miss Cognitive Decline in Players With Advanced CTE

A study of former NFL players with chronic traumatic encephalopathy confirmed at autopsy suggests that the NFL Concussion Settlement’s cognitive testing program may fail to identify some players with measurable impairment, particularly those with more advanced disease.

Published in JAMA Network Open, the Boston University study examined 33 NFL players who had completed the settlement’s baseline assessment program, or BAP, while alive and later received an autopsy-confirmed CTE diagnosis. The participants had an average age of 63 when tested and 65 at death. Their families provided records from the standardized paper-and-pencil neuropsychological testing battery used in the program.

The researchers described the work as the largest study to date directly connecting cognitive performance during life with CTE pathology identified after death. Because CTE cannot currently be diagnosed accurately during life and can be definitively diagnosed only after death, the study focused on identifying cognitive patterns associated with the disease.

Memory impairment was the most common finding. It affected 63% of participants, with short-term memory particularly affected, and more advanced CTE was associated with poorer memory performance. The researchers also identified impairments in executive function in 52% of participants, language in 41%, and attention in 26%.

The findings also raised questions about how the settlement program classifies cognitive decline. The BAP can help former players qualify for financial compensation, but its scoring system may differ from clinical standards commonly used to identify cognitive disorders.

Seven participants had advanced CTE, classified as stage 3 or 4. Six of those seven showed measurable cognitive impairment on the standardized tests. Nevertheless, all seven received the BAP’s lowest impairment rating, Level 0.

The researchers said the difference between the settlement’s scoring rules and clinical diagnostic approaches could contribute to some former players being overlooked for support. The study’s findings do not establish that every player receiving a low BAP rating has cognitive impairment, but they indicate that the program’s criteria may not capture all measurable decline associated with confirmed CTE pathology.

The authors described the cognitive profile as potentially useful for improving recognition of CTE in living patients. However, the disease remains one that can be definitively confirmed only through examination after death, leaving diagnosis during life unresolved.