Guidelines for the Evaluation of Dementia and Age-Related Cognitive Decline

APA Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia Approved by the Council of Representatives American Psychological Association February 1998

Suggested citation: American Psychological Association Presidential !as" Force on the Assessment of Age#Consistent $emory %ecline and %ementia &1998'( Guidelines for the evaluation of dementia and age-related cognitive decline ( )ashington %C: American Psychological Association(

APA Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia !homas *( Croo" +++ Ph(%( Chair ,lenn -( .arrabee Ph(%( Asenath .aRue Ph(%( /arry %( .ebo0it1 Ph(%( $artha Storandt Ph(%( -ames 2oung3ohn Pd(%(

Guidelines for the Evaluation of Dementia and Age-Related Cognitive Decline Psychologists can play a leading role in the evaluation of the memory complaints and changes in cognitive functioning that fre4uently occur in the later decades of life( Although some healthy aging persons maintain very high cognitive performance levels throughout life most older people 0ill e5perience a decline in certain cognitive abilities( !his decline is usually not pathological but rather parallels a number of common decreases in physiological function that occur in con3unction 0ith normal developmental processes( For some older persons ho0ever declines go beyond 0hat may be considered 6normal6 and are relentlessly progressive robbing them of their memories intellect and eventually their abilities to recogni1e spouses or children maintain basic personal hygiene or even utter comprehensible speech( !hese more malignant forms of cognitive deterioration are caused by a variety of neuropathological conditions and dementing diseases( Psychologists are uni4uely e4uipped by training e5pertise and the use of speciali1ed neuropsychological tests to assess changes in memory and cognitive functioning and to distinguish normal changes from early signs of pathology( Although strenuous efforts are being e5erted to identify the physiological causes of dementia there are still no conclusive biological mar"ers short of autopsy for the most common forms of dementia including Al1heimer7s disease( 8europsychological evaluation and cognitive testing remain the most effective differential diagnostic methods in discriminating pathophysiological dementia from

age#related cognitive decline cognitive difficulties that are depression#related and other related disorders( 9ven after reliable biological mar"ers have been discovered neuropsychological evaluation and cognitive testing 0ill still be necessary to determine the onset of dementia the functional e5pression of the disease process the rate of decline the functional capacities of the individual and hopefully response to therapies( !he follo0ing guidelines 0ere developed for psychologists 0ho perform evaluations of dementia and age#related cognitive decline( !hese guidelines conform to the American Psychological Association7s Ethical Principles of Psychologists and Code of Conduct &APA 199:'( Assessment of dementia and age#related cognitive decline in clinical practice is a core activity of the specialty of Clinical 8europsychology( !he recent *ouston Conference on Specialty 9ducation and !raining in Clinical 8europsychology &*annay et al( 1998' has specified the appropriate integrated training model to attain that specialty( !hese guidelines ho0ever are intended to specify appropriate cautions and concerns for all clinicians 0hich are specific to the assessment of dementia and age#related cognitive decline( !hese guidelines are aspirational in intent and are neither mandatory nor e5haustive( !hey are guidelines for practice and are not intended to represent standards for practice( !he goal of the guidelines is to promote proficiency and e5pertise in asseierissing dementia and age#related cognitive decline in clinical practice( !hey may not be applicable in certain circumstances such as some e5perimental or clinical research pro3ects and;or some forensic evaluations(

Guidelines for the Evaluation of Dementia and Age-related Cognitive Decline

! General Guidelines" Familiarity #ith $omenclature and Diagnostic Criteria %. Psychologists performing evaluations of dementia and age-related cognitive decline should be familiar with the prevailing diagnostic nomenclature and specific diagnostic criteria. A. Alzheimer's disease (AD) is the ma3or cause for dementia in later life &9vans Fun"enstein < Albert 1989'( !he most 0idely accepted diagnostic criteria for probable A% are those offered by the 8ational +nstitute of 8eurological and Communicative %isorders and Stro"e and by the Al1heimer7s %isease and Related %isorders Association &8+8C%S#A%R%A= $c>hann et al( 198?'( !hese criteria include the presence of dementia established by clinical e5amination and confirmed by neuropsychological testing( !he dementia is described as involving multiple progressive cognitive deficits in older persons in the absence of disturbances of consciousness presence of psychoactive substances or any other medical neurological or psychiatric conditions that might in and of themselves account for these progressive deficits( !he Diagnostic and Statistical Manual of Mental Disorders: 4th Edition of the American Psychiatric Association & DSM-I 199?' also outlines diagnostic criteria for dementia of the Al1heimer7s type that are generally consistent 0ith the 8+8C%S#A%R%A criteria( DSM-I also provides diagnostic criteria for vascular dementia as 0ell as dementia due to other general medical conditions including *+@ disease head trauma Par"inson7s

disease *untington7s disease Pic"7s disease Creut1feldt#-a"ob disease and other general medical conditions and etiologies( 8e0 causes and varieties of dementia continue to be elucidated &e(g( dementia 0ith .e0y bodies= $c>eith et al( 199A' and diagnostic criteria for the dementing disorders continue to be refined &e(g( International Classification of Diseases-!" and subse4uent revisions'( /( Some older persons have memory and cognitive difficulties identified by neuropsychological testing that are greater than those typical of normal aging but not so severe as to 0arrant a diagnosis of dementia( Some of these persons go on to develop fran" dementia and some do not( !here is not yet a clear consensus regarding nosology for this middle group( Proposed nomenclature includes mild neurocognitive disorder mild cognitive impairment late#life forgetfulness possible dementia incipient dementia benign senescent forgetfulness senescent forgetfulness and provisional dementia &see !able 1'( !erms such as incipient dementia provisional dementia and mild cognitive impairment refer to persons 0ho are some0hat more severely impaired and have a relatively greater li"elihood of eventually becoming demented &Flic"er Ferris < Reisberg 1991'( !erms such as benign senescent forgetfulness or late#life forgetfulness refer to persons 0ith milder cognitive difficulties relative to their age peers 0ho are less li"ely to go on to develop dementia( . Declines in memory and cognitive abilities are a normal conse4uence of aging in humans &e(g( Crai" < Salthouse 199:'( !his is true across cultures and indeed in virtually all mammalian species( !he nosological category of Age#Associated $emory +mpairment 0as proposed by a 8ational +nstitute of $ental *ealth &8+$*' 0or" group to describe older persons 0ith ob3ective memory declines relative to their younger years but cognitive functioning that is normal relative to their age peers &Croo" et al( 198A'( !he group7s recommendations contained e5plicit operational definitions and psychometric criteria to assist in identifying these persons( !he more recent term Age#Consistent $emory %ecline has been proposed as being a less pe3orative label and to emphasi1e that these are normal developmental changes &Croo" 199B= .arrabee 199A' are not pathophysiological &Smith et al( 1991' and rarely progress to overt dementia &2oung3ohn < Croo" 199B'( !he DSMI &199?' has codified the diagnostic classification of Age#Related Cognitive %ecline 0hich 0ill be used throughout the body of these ,uidelines( !his nomenclature has the advantage of not limiting the focus solely to memory but lac"s the operational definitions and e5plicit psychometric criteria of age#associated memory impairment(

! General Guidelines" Ethical Considerations &. Psychologists attempt to obtain informed consent. A( Psychologists recogni1e that there are special considerations regarding informed consent and competency given the nature of these evaluations 0ith some patients 0ho may be suffering from advanced stages of dementia( Psychologists attempt 0hen possible to educate patients regarding the nature of their services financial arrangements potential ris"s inherent in their services and limits of confidentiality( )hen patients are clearly not competent to give their informed consent psychologists attempt to discuss these issues 0ith family members and;or legal guardians as appropriate( /( !here may also be special considerations regarding the limits of confidentiality in these circumstances( Family members other professionals and state agencies may have to be involved under circumstances of potential harm to the patients or others 0ithout patients7

consent( +n potential cases of abuse or neglect there may be mandated reporting responsibilities for psychologists consistent 0ith state statutes and;or other applicable la0s( '! Psychologists gain specialized competence. A( Psychologists 0ho propose to perform evaluations for dementia and age#related cognitive decline are a0are that special competencies and "no0ledge are re4uired for such evaluations( Competence in conducting clinical intervie0s and administering scoring and interpreting psychological and neuropsychological tests is necessary but may not be sufficient( 9ducation training e5perience and;or supervision in the areas of gerontology neuropsychology rehabilitation psychology neuropathology psychopharmacology and psychopathology in older adults may help to prepare the psychologist for performing evaluations of age#related cognitive decline and dementia( /( Psychologists use current "no0ledge of scientific and professional developments consistent 0ith accepted clinical and scientific standards in selecting data collection methods and procedures( !he Standards for Educational and Psychological #esting &APA 198C' are adhered to in the use of psychological tests and other assessment tools( (. Psychologists see! and provide appropriate consultation. A( Psychologists performing dementia and age#related cognitive decline evaluations communicate their findings to primary care physicians and;or other referring physicians 0ith sensitivity to issues of informed consent( )hen the psychologist is the first professional contact the client is referred 0hen appropriate for a thorough medical evaluation to discover any underlying medical disorder or any potentially reversible medical causes for dementia or cognitive decline( ,iven the prevalence of health problems in the elderly it is recommended that psychologists providing services to this population be particularly sensitive to these issues( A thorough dementia 0or"#up is a multidisciplinary effort &Small et al( in press'( /( Psychologists help to educate health care professionals 0ho may be administering mental status e5aminations or psychological screening tools regarding the psychometric properties of these instruments and their clinical utility for particular applications( 9ducation is also provided about the differences bet0een brief screening e5aminations and more comprehensive psychological or neuropsychological evaluation( C( +n the course of conducting evaluations for dementia and age#related cognitive decline allegations of abuse neglect or family violence issues regarding legal competence or guardianship indications of other medical neurological or psychiatric conditions or other issues may arise that are not necessarily 0ithin the scope of a particular evaluator7s e5pertise( +f this is so the psychologist see"s additional consultation supervision and;or speciali1ed "no0ledge training or e5perience to address these issues(

)! Psychologists are aware of personal and societal biases and engage in nondiscriminatory practice.

Psychologists are a0are of ho0 biases regarding age gender race ethnicity national origin religion se5ual orientation disability language culture and socioeconomic status may interfere 0ith an ob3ective evaluation and recommendations( !he psychologist strives to overcome any such biases or 0ithdra0s from the evaluation( Psychologists are alert and sensitive to differing roles e5pectations and normative standards 0ithin a sociocultural conte5t(

! Procedural Guidelines" Conducting Evaluations of Dementia and Age-Related Cognitive Decline *! Psychologists conduct a clinical interview as part of the evaluation. A( Psychologists obtain the client7s self#report and sub3ective impressions regarding changes in memory and cognitive functioning( !his information can be obtained through informal intervie0 or through formal memory complaint 4uestionnaires &Croo" < .arrabee 199D= %i5on *ultsch < *ert1og 1988= ,ile0s"i Eelins"i < Schaie 199D'( Advantages of formal scales include the 4uantification of memory complaints and the ability to measure subse4uent changes in perception of memory loss( /( Psychologists are a0are that self#reported memory problems often do not correspond to actual decreases in memory performance &/olla .indgren /onaccorsy < /leec"er 1991'( Fre4uently persons 0ith significant cognitive dysfunction are not a0are of the problem( !his lac" of a0areness of genuine impairment can be a component of the neurobehavioral syndrome or it can be the result of denial or other psychological defenses( Conversely some persons 0ho report severe memory deficits actually have normal or even above average performance( %epression and other psychological factors can lead to over#reporting of cognitive disturbance( Additionally clients performing in the average range may actually have e5perienced significant decreases in performance relative to their premorbid functioning &Rubin et al( in press'( C( +t is important 0hen possible to obtain behavioral descriptions and sub3ective estimations of cognitive performance from collateral sources such as family and friends( !his information can be obtained either through clinical intervie0 or through memory complaint 4uestionnaires( +t is important to be particularly alert to discordance bet0een self and family reports( )hen formal scales are used discrepancies bet0een self and family reports can be 4uantified &Feher .arrabee Sudilovs"y < Croo" 199?= Eelins"i ,ile0s"i < Anthony#/ergstone 199D'( %( +t is important to ta"e a careful history( !he time of onset and nature and rate of the course of the difficulties provide information important to differential diagnosis( !he clinical intervie0 provides an opportunity to assess for the presence of deleterious side effects of medication substance abuse previous head in3ury or other medical neurological or psychiatric history relevant to diagnosis( Fbtaining a family history of dementia is also important( E! De+ression in elderly +ersons can mimic the effects of dementia &>as1nia" < Christenson 199?'( Psychomotor retardation and decreased motivation can result in nondemented persons appearing to have pathophysiologically determined cognitive disturbances in both day#to#day functioning and on formal neuropsychological testing( %epression can also cause nondemented persons to over#report the severity of cognitive

disturbance( Conse4uently it is important to perform a careful assessment for depression 0hen evaluating for dementia and age#related cognitive decline( %epression is best assessed during an intervie0 so that the clinician can obtain information regarding the client7s body language and affective display( Formal mood scales &e(g( /ec" et al( 19A1= 2esavage et al( 198B' can also play an important role in assessing for depression and have the advantages of 4uantifying and facilitating the assessment of changes in mood over time( Psychologists are sensitive to sociocultural factors that might cause some older persons to underreport depressive symptoms( Psychologists are also a0are that depression and dementia are not mutually e5clusive( %epression and dementia and;or age#related cognitive decline fre4uently coe5ist in the same person( %epression can also be a feature of certain subcortical dementing conditions such as Par"inson7s disease &Cummings < /enson 198B= 2oung3ohn /ec" -ogerst < Cain 199:'( ,! Psychologists are aware that standardized psychological and neuropsychological tests are important tools in the assessment of dementia and age-related cognitive decline. A! The use of +sychometric instruments may re+resent the most im+ortant and uni-ue contri.ution of +sychologists to the assessment of dementia and agerelated cognitive decline! !ests used by psychologists should be standardi1ed reliable valid and have normative data directly referable to the older population( %iscriminant convergent and;or ecological validity should all be considered in selecting tests( !here are many tests and approaches that are useful for these evaluations including but not limited to the )echsler scales of intelligence and memory tests from the *alstead#Reitan battery and the /enton tests( Psychologists see"ing more comprehensive compendiums of appropriate tests are referred to #he $uros %ear&oo's of Mental Measurement( )europsychological *ssessment +,rd ed-. &.e1a" 199C' and * Compendium of )europsychological #ests &Spreen < Strauss 1991'( $any other e5cellent te5ts also provide lists of valuable neuropsychological instruments for use in these evaluations( For e5ample .a Rue &*ging and )europsychological *ssessment 199:' 8ussbaum &/and&oo' of )europsychology and *ging 199G' and Storandt and @anden/os &)europsychological *ssessment of Dementia and Depression in 0lder *dults: * Clinician1s Guide 199?' present a variety of useful psychological and neuropsychological methods and issues relevant to assessing older adults( /( /rief mental status e5aminations and screening instruments are not ade4uate for diagnosis in most cases( Comprehensive neuropsychological evaluations for dementia and age# related cognitive decline include tests or assessments of a range of multiple cognitive domains typically including memory attention perceptual and motor s"ills language visuospatial abilities problem solving and e5ecutive functions( +t is recogni1ed ho0ever that detection of profound dementia may not re4uire a comprehensive neuropsychological test battery(

/! "hen measuring cognitive changes in individuals# psychologists attempt to estimate premorbid abilities. A( +deally psychologists assessing for cognitive declines in older persons 0ould have baseline test data from earlier years against 0hich current performance could be compared(

Hnfortunately this information rarely e5ists so psychologists must try to estimate premorbid abilities by ta"ing into consideration socioeconomic status educational level occupational history and client and family reports( Clinical 3udgement can be an important part of this process( $here are a number of systematic biases in human %udgement that may lead to inaccurate clinical estimates of premorbid function &>are"en 199G'( @arious techni4ues have been used to estimate cognitive abilities in earlier years &e(g( /arona Reynolds < Chastain 198?= /lair < Spreen 1989'( Psychologists are a0are ho0ever that any measure of current cognitive functioning can be affected by dementia &.arrabee .argen < .evin 198C= Storandt Stone < .a/arge 199C'( /( Fnce a person has been tested these data can serve as a baseline against 0hich to measure future changes in cognitive functions( $agnitudes and rates of cognitive change as 0ell as response to treatment can also be determined by follo0#up testing( +n most cases a one year follo0#up interval is ade4uate for monitoring changes in cognitive performance unless the client family or other health care professional report a more rapid decline emergence of ne0 symptoms or changes in life circumstances( Psychologists try to be "no0ledgeable of the test#retest reliability of tests that are used so that patterns and e5tent of change can be interpreted appropriately( +nterim follo0#up not involving formal testing may also be useful in many cases( C( /ecause declines in average levels of performance 0ith age are observed on some tests it is important that tests selected for use in the evaluation of dementia and age#related cognitive decline have ade4uate age#ad3usted norms( Hntil recently the relative lac" of older adult norms posed a problem for clinicians but better and larger older adult standardi1ation samples are no0 available for many commonly used clinical tests( ,aps still remain in the normative data for very old persons and for diverse linguistic and ethnic populations( Comparison of an individual7s test performance against even age#ad3usted norms can be misleading if the individual7s earlier abilities fell outside of the population curve( 0! Psychologists are sensitive to the limitations and sources of variability and error in psychometric performance. A( Psychologists are a0are that practice effects can result 0hen tests are readministered in close temporal pro5imity( Such effects are more li"ely to be observed in normally aging older persons than in patients 0ith dementia or amnestic conditions( +n cases of 4uestionable cognitive decline the presence of robust practice effects can help to establish that cognitive functions are intact( Repeated closely spaced testings ho0ever can obscure cognitive changes or intervention effects( !he use of alternate test forms of e4uivalent difficulty can help to attenuate practice effect artifact but such forms may not be available for many other0ise appropriate tests( /( Psychologists reali1e that persons can have significant declines in day#to#day functional abilities that are not demonstrated on psychometric instruments because of a relative lac" of sensitivity of the tests used( Psychometric instruments are effective but still imperfect measures of real#life abilities( C( Reasons 0hy people may do poorly on tests 0hen the ability being assessed is intact include but are not limited to sensory deficits fatigue medication side effects physical illness and frailness discomfort or disability poor motivation financial disincentives depression an5iety not understanding the test instructions and lac" of interest(

Psychologists attempt to assess these sources of error and to limit and control them to the e5tent that they are able( %1! Psychologists recognize that providing constructive feedbac!# support# and education# as well as maintaining a therapeutic alliance# can be important parts of the evaluation process. A( +n many instances patients may benefit from feedbac" regarding the evaluation in language that they can understand( Psychologists should e5ercise clinical 3udgement and ta"e into consideration the needs and capabilities of the particular client 0hen feedbac" is provided( /( Providing feedbac" education and support to the family 0ith clients7 informed consent are also important aspects of evaluations and enhance their value and applicability( >no0ledge regarding levels of impairment the e5pected course and e5pected outcomes can help families to ma"e ade4uate preparations( )or"ing 0ith families can provide them 0ith effective and humane methods for managing persons 0ith problematic behaviors( Appropriately counseling families regarding "no0n genetic components and the heritability of the various disorders can address their concerns and in many cases allay needless fears( *ealthy older adults 0ho have had concerns about their cognitive functions can benefit from reassurance based on results of testing &2oung3ohn .arrabee < Croo" 199:' and from suggestions as to ho0 they may enhance their everyday cognitive function( C( Psychologists attempt to educate themselves regarding currently approved somatic and nonsomatic treatments of dementia and age#related cognitive decline( !his is a rapidly evolving area and both families and healthcare professionals can benefit from education( %( Psychologists offer or recommend appropriate treatment to persons 0ith dementia and age#related cognitive decline for coe5isting emotional and behavioral disturbances( Cognitive rehabilitation and memory training have limited effectiveness for persons 0ith dementia although environmental restructuring may be useful( /y contrast training in cognitive strategies use of memory aids and mnemonic techni4ues have proven effectiveness 0ith nondemented persons including those 0ith age#related cognitive decline or those 0ith focal brain disorders &.app 199A= )est < Croo" 1991'( Clients and families can be educated about these treatments 0hich can be offered to clients as appropriate( 2ummary Assessment of cognitive function among older adults re4uires speciali1ed training and refined psychometric tools( Psychologists conducting such assessments must learn current diagnostic nomenclature and criteria gain speciali1ed competence in the selection and use of psychological tests and understand both the limitations of these tests and the conte5t in 0hich they may be used and interpreted( Assessment of cognitive issues in dementia and age#related cognitive decline is a core focus of the specialty of Clinical 8europsychology( !herefore these guidelines are not intended to suggest the development of an independent proficiency( Rather they are intended to state e5plicitly some appropriate cautions and concerns for all psychologists 0ho 0ish to assess cognitive abilities among older adults particularly in distinguishing bet0een normal and pathological processes( References

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