Geriatric Neuropsychology Implications For

NeuroRehabilitation
381
IOS
Press
23
(2008)
381394
Geriatric neuropsychology: Implications for front line clinicians

Christina Weyer Jamoraa,, Ronald M. Ruffb and
Bonnie B. Connor c
a San Francisco Clinical Neurosciences, San Francisco General
Hospital, San Francisco, CA, USA
b San Francisco Clinical Neurosciences, University of California San
Francisco, San Francisco, CA, USA
c University of San Francisco, San
Francisco, CA, USA
Abstract. Consistent with the aging population, neuropsychologists are being

asked with increased frequency to evaluate older adults. These assessments are
often complicated by medical and psychiatric co-morbidities, polypharmacy, and
complex psychosocial and legal issues that are frequently encountered in this
population. The aim of this review article is to address the challenges
neuropsychologists and other frontline clinicians often confront when evaluating
older individuals. Specifically, we review psychiatric and medical co-morbidities,
testing accommodations, diagnostic versus descriptive testing approaches,
normative issues, polypharmacy, and reimbursement rates. Finally, future
implications are discussed for advancing the neuropsychologists role in
evaluating and treating older individuals.
Keywords:
Geriatric
neuropsychology,
assessment and treatment challenges
1. Introduction
In the United States, older
individuals are the fastest growing
segment of the population with 20% of
these older Americans experiencing
some type of mental disorder [25].
One in seven adults 70 years of age
and older have some type of dementia
[60].
As a result, psychological
services to older adults are rapidly
growing. To meet the increasing
needs of older individuals various
national and state agencies have

encouraged psychologists to deepen
and extend their exist- ing knowledge
base and clinical expertise to include
this population. The American
Psychological Associa- tion (APA) has
developed guidelines for psychological
practice with older adults that address
the psychologists attitudes, general
knowledge about adult development,
and special skills required for
assessment, intervention, and
consultation [7]. Many psychology internship programs now offer rotations

in geriatric psychiatry, and post
doctoral fellowships in geropsycholo-
Address for correspondence:

Christina Weyer Jamora, 909 Hyde
Street, Suite 620, San Francisco, CA
94109, USA. Tel.: +1 415 771
7833; Fax: +1 415 922 5849; E-mail:
cyweyer@aol.com.
ISSN 1053-8135/08/$17.00
reserved
gy have emerged. The importance of

geriatric specific education has also
been recognized by the California
Board of Psychology, which now
requires licensed psychologists to
complete training in aging and longterm care.
The aim of this review article is to
address many of the issues that
neuropsychologists and other frontline
clinicians face when evaluating older
individuals. The following questions
will be discussed: (a) Can psychiatric
illnesses, in particular depression,
exacerbate or cause cognitive deficits?
(b) What testing accommodations
can yield the most benefit for older
individuals?
(c) How should
neuropsychologists distinguish the
effects of brain damage in the context
of comorbid medical illnesses? (d)
What effects do medications or
polypharmacy have on patients
mental status? (e) Given that pain is
prevalent in this population, what effects
do
pain
have
on
neuropsychological assessments? (f)
What role should norms play in our
test selection? (g) What are the
strengths and weaknesses of descriptive versus diagnostic norms? (h) For
most referrals, is a juxtaposition of a
descriptive and diagnostic approach
called for? (i) What services are
reimbursable
for
clinical
neuropsychologists, and what ethical
issues
2008 IOS Press and the authors. All rights
126
C.W. Jamora et al. / Geriatric neuropsychology: Implications for front line clinicians
are
raised
by
reimbursement
limitations? and (j) How can we
advance our future services?
1.1. Can psychiatric illnesses, in
particular depression,
exacerbate or cause cognitive
deficits?
Almost one quarter of individuals
over the age of
55 meet the criteria for a psychiatric
disorder [39,
77]. Specifically, in older individuals
it has been estimated that 1035%
have significant depressive symptomatology, 1321% have significant
anxiety, and 3.6
4.5% experience psychosis secondary
to major depression [34,47,52].
Moreover, depression following an
acute medical crises, such as stroke
and traumatic brain injury (TBI), are
relatively common.
For example,
some studies estimate that one out of
four stroke survivors will experience
a major depressive episode within
one year [64], and 80% of older
individuals with a TBI meet criteria
for an Axis I disorder [70]. Giv- en
the prevalence of these psychiatric
disorders, most referral questions are
best addressed by adding a psychodiagnostic evaluation component
to the cognitive assessment.
A study by Feil and colleagues found
that older individuals with psychiatric diagnoses
have increased levels of apathy and
depression and demonstrate slowed
speed of cognitive processing and
diminished executive functioning [27].
High levels of depression were relat-
ed to cognitive inflexibility, decreased

word generation, and diminished
abstract reasoning [27]. These findings suggest that as the severity of the
psychiatric dis- turbance increases the
effect on cognition can become more
pronounced. Other research findings
suggest that the clusters of cognitive
deficits may differ depending upon the
nature of the psychiatric illness. For
example, after controlling for
medical burden, patients diag- nosed
with generalized anxiety disorder were
found to have deficits in attention, as
well as short and long term memory
[32]. In comparison, individuals with
major depression also demonstrated
deficits in attention and memory, with
compromised word finding ability,
speed of processing, and global
cognitive functioning also noted
[32,51].
In conclusion, neuropsychological
examinations should capture the
presence and severity of psychiatric
disorders, including anxiety and
depression.
Milder forms of
depression and adjustment disorders
can be caused by stressors including
retirement,
outliving loved ones,
limited social networks, and age
related physical and cognitive decline
[14]. Bereavement and
C.W. Jamora et al. / Geriatric neuropsychology: Implications for front line clinicians
the availability of psychosocial

support are two specific areas that
should be fully explored when
assessing
depression
in
older
individuals [14].
1.2. What testing accommodations
yield the most benefit for older
individuals?
Clinical experience coupled with an
appropriate ap- preciation of emerging
literature provides an avenue for
identifying
ways
to
adapt
neuropsychological tests to meet the
needs of older adults. There are three
basic categories that may require
adaptation of testing pro- cedures: (a)
the patients physical status, (b) cognitive limitations, and (c) psychological
status. Severe motor (e.g. dysarthria,
hemiplegia) and sensory limitations
(e.g. blindness, deafness) often require
clinicians to administer tests that rely
on the patients preserved abilities.
Similarly, some older adults may
fatigue eas- ily and it is recommended
that rest breaks be provided during the
evaluation as needed. Also, it may be
beneficial to complete testing
sessions in the morning hours and/or
divide the testing up over several days.
Adapta- tions for cognitive limitations
may be most pronounced for
individuals with non-fluent aphasia
and in these instances adaptive
techniques such as picture books may
be useful. Accomodations may also
be beneficial to alleviate deficits in
comprehension, speed of cognitive
processing and behavioral responding,
and word finding difficulties. The
interested reader is referred to the
127
article by Caplan and Shechter in this

special issue of NeuroRehabilitation
for a thorough review of testing
accomodations for older adults.
In comparison to these physical and
cognitive adaptations, psychological accomodations
are frequently not considered during
the evaluation process. It is important to remember that many older
individuals may feel threatened by the
assessment process. Especially when
the intent of the referral is to address
their ability to drive, handle their
finances, live independently, and/or
determine their need for supportive
interventions. These types of referral
questions may cause patients to
refuse participation or prematurely
terminate
the
testing
session.
Informed consent is central to respecting a patients autonomy and
rights, and neuropsychologists are
encouraged to identify and address
any questions or patient concerns
upfront.
The therapeutic assessment model
from the psychodiagnostic assessment literature
provides an ef- fective approach to
assessing older individuals [28
30]. Therapeutic assessment is
complimentary
to
standard
assessment practices and proposes that
assessment
is more than just an information

gathering exercise. Rather it can be
viewed as an opportunity for patients
to come to a new understanding about
themselves
and
their
life
accomplishments. In particular, older
individuals frequently view their
lives on the basis of past accomplishments. This is understandable
since a forward looking perspective
may be marked with uncertainty, a
progressive decline in health, chronic
pain, and loss. The clinician must be
sensitive to the developmental state of
the older individual, which Erikson
describes as the stage of Integrity
versus Dispair [26]. Thus, the
neuropsychological evaluation should
allow for older individuals to review
their life accomplishments whilst
coming to terms with prominent
negative
events
they
have
experienced.
The
therapeutic
assessment
approach places strong emphasis on
integrating therapeutic skills such as
re- spect, trust, genuine enthusiastic
curiosity, and collab- oration into the
standard assesment. The major
components of the therapeutic
assessment model include (a) treating
the patient as a collaborator, (i.e. lets
find out these answers together); (b)
addressing the patients personal
concerns; (c) giving feedback that is
tied to the patients everyday
functioning and concerns; and (d)
following up with a letter outlining the
assessment findings using the patients
questions to guide the feedback [28].
The following case example
illustrates the benefit of
the therapeutic assessment approach.

An older individual was referred for a
neuropsychological evaluation of her
functional status. While the evaluation
suggested that the patient was unable
to live independently, she firmly
refused in-home nursing care. This
was particularly worrisome since her
children lived out of state and they
were unable to provide support or
supervi- sion to their mother. During
the feedback session, the patients
concerns
about
losing
her
independence were identified. It also
became clear that while she wanted to
please her family, she resolutely felt
that in-home care was unnecessary
because she believed she possessed no
cognitive impairments. The patients
concerns were reframed by focusing
on her lifetime achievement of having
been a good mother and that her
children were worried for her welfare.
The in-home support subsequently
was viewed as a gift of peace of mind
to her children which was congruent
with her long held value that the role
of a mother is to sacrifice for the sake
of her children.
Emotional accommodations can be
utilized to align
ourselves with our patients by
acknowledging their difficulties,
regardless of our ability to help, and
prais-
ing them for their own efforts to

enhance their sense of well-being and
control [53]. Indeed, research has
found that clinicians who utilize the
therapeutic assessment model had
fewer incomplete assessments due to
premature termination, and patients
were more likely to experience
decreased distress and increased hope,
even when the assessment findings
were negative [30,
57
].
1.3. How should neuropsychologists
distinguish the effect of brain
damage in the context of
comorbid medical illnesses?
As individuals grow older they tend
to have multiple co-morbid medical
diseases, many of which can have a
detrimental impact on cognitive
functioning. For example, medical
conditions common in older
individuals include congestive heart
failure, diabetes, pulmonary disorders,
cardiovascular disease, and renal
failure, with many of these conditions
being known to compromise
cognitive functioning [2,37,41,61].
Specifically, congestive heart failure
has been linked to deficits in global
cognitive functioning [2]; diabetes
with deficits in episodic memory
[61], processing speed, executive
functioning and verbal memory [37];
respiratory diseases with deficits in
attention, processing speed and
memory [41]; cardiovascular disease
with deficits in executive
functioning, attention, and
processing speed [43]; and renal
failure with declines in executive

functioning, verbal memory, and
processing speed [48]. While older
individuals often experience multiple
chronic medical conditions, research
studies typically focus on single
disease states, excluding those individuals with co-morbidities.
Accordingly these findings may bear
little resemblance to the older
individuals typically encountered in
clinical practice. Tightly controlled
studies may be the paragon of internal
validity; however, the questionable
generalizability of these results limits
their clinical utility. This is
particularly concerning since research
has indicated that there is a positive
relationship between disease burden
and cognitive impairment [22]. In
particular, older individuals who
have five or more comorbid medical
diseases were found to be prone to
deficits in selective, speed- ed, and
divided attention [22]. Moreover,
marginal- ized older individuals are
particularly at risk, due in part to
higher base rates of stress, unstable
housing, and chronic medical
conditions such as diabetes, and
hyperlipidemia
[75].
Understanding the interactions
between multiple medical comorbidities can be daunting for even
the
most experienced neuropsychologist.

To reduce diagnostic errors
clinicians should strive to find ways to
measure the dynamic relationship
between cognition and multiple
disease states. Since extensive
neuropsychological testing is often
contraindicated with these patients, it
is important to have a clear
understanding of the signs associated
with reversible versus nonre- versible
medical diseases. Thus consulting
with medical staff as needed, and
recognizing the limitations of our
cognitve assessments may be ways to
increase our diagnostic accuracy.
While it is not within our scope of
practice to diagnose medical diseases
such as cardiovascular disease or
diabetes, we should aspire to understand how multi-system diseases
influence the cognitive and
emotional functioning of our patients.
Col- laboration and consultation with
medical professionals can enhance our
evaluations and promote accurate conclusions about patients who are
experiencing
multiple
medical
conditions.
When assessing older individuals
with multiple medical conditions the
following questions should be considered:
1. What medical diagnoses are
active at this point?
What are the patients chronic
medical diseases? What is the
severity and length of these
diseases?
Is
the
patient
metabolically stable based on
recent laboratory results, vital
signs, oxygenation, and hydration?
While is it not necessary to master

the nuances of medical laboratory
tests, it is important to ask
medical providers the extent to
which
our
patients
are
metabolically and hemodynamically stable, and the extent to
which these diseases may be
influencing their daily functioning.
2. If the patient is confused, what
is the duration and quality of his
or her mentation (i.e. acute versus
chronic, waxing and waning,
worse in the evening)? Is the
onset recent or prolonged?
Delirium is common in older
individuals. Prior to testing it may
be necessary to consult with the
referring physician to rule out
medical
instability
in
the
following areas:
metabolic,
oxygenation, vascular, endocrine,
seizures, tumor, trauma, ure- mia,
psychiatric, infection, medications
and de- generative diseases.
3. Has the patient recently fallen or
had a history
of falls in the past, and if so was
brain imaging ordered? Does the
patient have a steady gait? Is the
patient incontinent or have urinary
urgency? Falls are common in
older adults and are the most
frequent mechanism of traumatic
brain injury in this population
[10]. In particular, the combina-
tion of unsteady gait, high

anticholinergic burden, and urinary
urgency can precipitate falls [1]. It
is important to note that many falls
in nursing homes are not witnessed
by staff and age associated cerebral atrophy can allow blood and
cerebrospinal fluid to collect to a
significant degree before mass
effect causes neurological changes
[39]. Simi- larly, normal pressure
hydrocephalus secondary to a
subdural
hematoma
mimics
dementia [39]. When patients
experience persistent confusion,
headaches,
and
loss
of
consciousness following a fall,
brain imaging may be needed to
rule out the possibility of a
subdural hematoma.
Admittedly, obtaining answers to all
of the above questions is often
unrealistic in settings where staff time
is significantly limited and records are
sparse. Alter- natively, individuals
familiar with the patient such as
family members, friends, caregivers,
and staff members can often be useful
sources of collateral information. In
addition, the patients list of
medications and respec- tive dosages
can be invaluable in terms of orienting
the clinician to the patients major
medical illnesses.
Often, neuropsychologists may focus
primarily on
cognitive deficits, secondarily on
emotion, and to a lesser extent on
physical functioning, with limited
integra- tion of these three areas.
Overly compartmentalized diagnostic
formulations can lead to diagnostic
errors, inappropriate treatment
recommendations, and ultimate- ly
harm the patient. For example, it

would be short- sighted of a
neuropsychologist, on the basis of
severly impaired cognitive deficits, to
diagnose an older individual with
dementia, when it is subsequently
discov- ered that the patient was
dehydrated and their confusion
subsided after their water intake
increased.
This example is
particularly common in nursing
homes, where there is little available
collateral information, few medical
professionals with whom to consult,
and high staff to patient ratios, as well
as, frequent staff turnover. The
patients medical acuity, limited
medical records, and time constraints
also can limit the accuracy, breadth,
and depth of our assessments.
Admittedly, it is difficult to achieve
a balanced approach that gives voice
to the patients physical, cognitive,
and emotional functioning relative to
their social and cultural functioning.
However, keeping these issues in mind
can reduce our tendency to fall victim
to diagnostic pitfalls.
1.4. What effects do medications or
polypharmacy have on the
patients mental status?
As people age they tend to be
prescribed more medications [45]
have greater difficulty managing
multiple
medications [19], and experience

more adverse drug reactions and
hospitalizations
secondary
to
polypharmacy [31]. Depending on
the setting, older individuals on
average may take anywhere from four
to 10 or more medications daily
[31,72]. Also, it is notewor- thy that
medication nonadherence rates in
older adults ranges from 26%59%
[78], which can lead to medical
decompensation,
unnecessary
hospitalizations, and death [31].
Pharmacodynamics refers to the
effects
of
a
drug,
while
pharmacokinetics refers to the
movement of a drug through the
body [42, p. 630]. As an individual
ages, factors such as decreased
gastrointestinal blood flow, increased
porosity of the blood brain barrier, reduced blood circulation, increased
body fat composi- tion, altered cell
binding, reduced hepatic and renal efficiency,
and
endogenous
neurotransmitter decline can lead to
alterations in the metabolization,
distribution, absorption, and excretion
of drugs [6,42]. As outlined in Table
1,
benzodiazepines,
diuretics,
narcotics,
nonsteroidal
antiinflammatory, and anticholinergic
medications may be particularly
detrimental
to
the
cognitive
functioning of older adults.
Unnecessary
polypharmacy
commonly occurs in the older adult
population. One study found that 44%
of older individuals were prescribed at
least one medication unnecessarily
[36]. While co-morbid disease states
often require multiple medications, the
use of unnecessary medications is

particularly problematic in older
individuals.
According
to
the
American Medical Association Council
on Scientific Affairs, Polyphar- macy
is problematic for older persons
because it is the greatest risk factor for
ADRs (adverse drug reactions), drug
interactions, reduced compliance, and
increased emergency room visits,
hospitalizations, and nursing home
admissions (para. 5) [6]. Also, up to
70% of older individuals do not inform
their physicians when using dietary
supplements which can negatively
inter- act with medications. The
interested reader is referred to
Gonzalez and colleagues for a detailed
discussion
of
the
implications
associated with dietary suppliment use
among the elderly [35]. Polypharmacy
can poten- tially lead to cognitive
impairment, delirium, falls, and
decreased functional status in older
individuals [6].
When assessing an older individual
with multiple
medications the following questions
should be considered:
1.
What
are
their
current
medications/supplements,
the
dosages, and indications for use?
Are there any recent changes to
their medication regime? Are they
taking
their
medications
regularly?
Abrupt medication changes and

medication nonadherence can
lead to delirium in older individuals. For patients with multiple
and psychiatric providers, the
neuropsychological report can be
a central document highlighting
who is prescrib- ing what. It may
be helpful to consult with pertinent medical providers to see if
the number of medications can be
streamlined.
2. What medications did the patient
take prior to the assessment?
Ideally, clinicians should be
aware of what medications the
patient took prior to the
assessment and work with a
pharmacist or physician to
ascertain the degree to which
medication effects could
influence testing performance.
Pharmacokinetic indicators such
as medication half-life and peak
absorption time can be helpful in
this regard.
1.5. What effect does pain
have on
neuropsychological
performance?
Approximately 80% of nursing home
patients and
50% of home dwelling older
individuals have significant pain
issues [69]. Common sources of pain
in older individuals include arthritis
and orthopedic issues, improper
positioning, postherpetic neuralgia,
vitamin deficiencies, constipation,
pressure ulcers, post-stroke syndrome,
contractures, and cancer [69]. Pain can

have psychosocial implications such
as increased isolation, depression,
anxiety, fatigue, learned helplessness,
reduced independence, and substance
abuse and depen- dence. While pain
is common in older individuals, it
often goes under-treated and underdiagnosed, especially in those
patients who are cognitively impaired.
For example, Cohen-Mansfield and
Lipson
found
that
physicians
consistently rated pain levels as lower
for patients with severe cognitive
impairments, regardless of their
medical diagnosis [18]. Alternatively,
many patients believe that pain is part
of growing older and subsequently
may under-report their symptoms to
practitioners.
On
neuropsychological
tests
uncontrolled pain has been linked with
cognitive inflexibility, distractibility,
and poor memory scores [38].
Eccleston found that attention and
concentration
were
negatively
influenced by severe pain [24]. Heyer
and colleagues found older individuals
with active pain after spinal surgery
showed diminished scores on the Rey
Complex Figure Test and Trail
Making Test-Part A [38]. Contrarily,
others have opined that mild to
moderate levels of pain in older in-
Tabl
e1
Medications that may have cognitive
effects in older individuals
Drug class Medications Indication
manifestations
Side effects
Adverse behavioral
Anticholinerics
Ditropan, Detrol
Incontinence
Anticholinergic effects
Confusion
Antihistamines
Benadryl, Vistaril
Sleep
Sedation, anticholinergic
Confusion, agitation, effects,
urine retention delirium
Antipsychotics
Haldol, Zyprexa,
Agitation, Psychosis
Akathisia hypotension,
Increased fall risk
due hypotension, Risperdal, Seroquel
orthostatic
anticholinergic
confusion, restlessness, FDA has a
side, effects heart arrhythmias black
box warning on the use of
antipsychotics with
older individuals due
to increased risk of
stroke and cardiac
arrhythmias
Benzodiazepines
Ativan, Serax, Anxiety
Motor slowing,
Increased falls, delirium, may have
Valium, Xanax
diminished motor withdraw symptoms
if discontinued coordination, sedation
abruptly, long acting
are particularly
inappropriate
Diuretics Lasix, Aldactone,
Hypertension, fluid load in
Electrolyte imbalance,
Confusion and falls secondary to
Hydrochlorothiazide, Congestive Heart Failure dehydration
dehydration, fluid volume loss Thiazide
Narcotics Morphine, Vicodin,
Pain
Sedation Confusion,
falls
Loritab, Demerol
Steroids
Prednisone Autoimmune diseases,
Confusion
Confusion, falls, psychosis, mania
Myeloma,
Inflammatory
diseases
Selective Serotonin Paxil
Depression
High anticholinergic
profile
Confusion
Reuptake Inhibitors
Tricyclic Elavil, Tofranil,
Depression Pain High anticholinergic
profile
Increased falls related to orthostatic
Antidepressants
Nortriptyline
hypotension, Confusion
Adapted with permission from (Hunter & Cyr, 2006).
dividuals has negligible effects on
neuropsychological test performance
[11,49].
It can be difficult to assess pain in
patients with
neuropsychological impairment. For
example, patients with cognitive
impairments such as dementia or
aphasia may be unable to articulate
the severity of their pain. They also
may have reduced pain detection due
to slowed cortical processing [62].
Neuropsychologists may need to
educate family, caregivers, and staff
members who work with older adults
who are experiencing cognitive
dysfunction or expressive language
difficulties
about non-verbal
indicators of pain.
A listing of
common pain behaviors in older adults
with cognitive impairments is
provided in Table 2.
In terms of clinical issues it is
important to assess
the location, frequency, duration,
quality, intensity, as well as, relieving
and exacerbating factors associated
with the patients pain experience
[40]. It is also helpful to explore
whether patients feel their pain is adequately controlled, what the impact of
pain is on their functional abilities,
and what their knowledge, expectations, and beliefs are regarding pain
management and control [40].
Assessments of emotional function
such as depression and anxiety should
be incorporated as
well. Lastly, there are often tradeoffs

when testing older individuals who
are in severe pain. For example, a
preoccupation
with
pain
may
compromise attention and stamina. In
these instances, it may be prudent to
postpone testing until their pain is
better controlled. Of course, if a
patients pain is being inadequately
treated
or
overlooked,
the
neuropsychologist should collaborate
with medical providers to ensure that
the patients pain is appropriately
assessed and treated.
1.6. What role should norms
play in our test selection?
The utility of neuropsychological
assessment largely depends on
normative data. It is essential that
clinicians
are
appropriately
acquainted with the quality and
quantity of available norms.
As
diagnosticians a dis- tinction should be
made between referral questions that
are diagnostic in nature and those that
are descriptive. Descriptive referral
questions focus on how an individual
is functioning cognitively relative to
the appropriate reference group.
Thus, norms for this purpose usually
rely on the general population as the
reference standard. That is, the
individuals test performance is
Tabl
e2
Common pain behaviors in older
adults with cognitive impairment
Facial
Vocalizations/verbalizations
expression
Sighing, moaning, groaning
s
Grunting, chanting, calling out
Slight frown; sad,
frightened face
Grimacing, wrinkled
forehead, closed or
tightened eyes
Any distorted
expression
Rapid
blinking
Body
movement
s
Rigid, tense body
posture, guarding
Fidgeti
ng
Increased pacing,
rocking
Restricted movement
Gait or mobility
changes
Mental status changes
Noisy breathing
Asking for help
Verbally abusive
Changes in interpersonal interactions
Aggressive, combative, resisting care

Decreased social interactions
Socially inappropriate, disruptive
Withdrawn
Changes in activity patterns/routines
Refusing food, appetite change

Increased periods of resting
Increased sleep
Sudden cessation of common routines
Increased wandering
Crying
or tears
Increased confusion
Irritabil
ity
Adapted with permission from American Geriatric Association
(2007)
referenced to norms that allow for
characterizations as Below Average,
Average, Above Average and so

on. Yet, an intelligence quotient or
memory score of
85 neither rules in, nor rules out, the
diagnosis of brain impairment.
In contrast to the descriptive
approach, the diagnostic referral
raises the question of whether or not
an individual is impaired. Indeed,
diagnostic assessments follow the
pathognomonic sign approach [20].
Thus, premorbid functioning becomes
the reference standard, with the
neuropsychologist
charged
to
determine if the patients testing
performance deviates from expected
premorbid levels of functioning. In
this context, test performance is
characterized as Intact versus Mildly Impaired, Moderately Impaired,
or Severely Im- paired. However,
these scores or labels by themselves
do not identify abnormal performance.
A score in the
10th or even 5th percentile does not
necessarily indicate an abnormal
performance, unless the clinician
infers that this score deviates
significantly from the patients
premorbid level of functioning.
Therefore, population norms serve
only as points of reference and
premorbid estimates must be taken
into consideration.
Various
neuropsychological
screening batteries used in the
assessment of older individuals are
patterned after the pathognomonic
model, and thus can be characterized as diagnostic or deficitoriented rather than descriptive or
population-based. Indeed, near errorless performances becomes the
comparison standard against which
deviations from this expectation are
clas- sified according to degrees of

abnormality. Examples
of such measures include the

Alzheimers Disease As- sessment
Scale [65] with an estimated
administration time of 45 minutes, the
Blessed Dementia Scale [12] (<10
min), the Consortium for the
Establishment of a Registry for
Alzheimers Disease Battery [55]
(CER- AD; 2040 min), Cognistat
[46] (520 min), Demen- tia Rating
Scale-2 [44] (3045 min), Folstein
Mini- Mental State Exam [33] (510
min),
Montreal
Cognitive
Assessment [56] (10 min), the
Repeatable
Battery
for
the
Assessment of Neuropsychological
Status [63] (2030 min), St. Louis
University Mental Status [74] (7 min),
and the 7 Minute Screen [71].
In addition to diagnostic screening
batteries that were developed for
older individuals, neuropsychologists commonly rely on descriptive
tests (e.g. Wiscon- sin Card Sorting
Test, Trail Making Test) that were not
specifically designed for older
individuals. The geriatric clinician
must be mindful of the population
char- acteristics from which the
normative data is based. For example,
small cell sizes in the upper age
ranges may limit the utility of a
particular test with older adults.
Moreover, psychometrically sound
tests may rely on norms that are
grounded in the principles of a normal
curve and central tendency and small
cell sizes may increase the likelihood
of diminished reliability and validity
[54] with older adults. Therefore, it
is important that clinicians who rely

on descriptive norms understand the
inherent strengths and weakness of the
psychometric measures they employ.
1.7. What are the strengths and

weaknesses of descriptive
norms?
The
practice
of
clinical
neuropsychology is strongly rooted in
psychometric assessment. Given that
we rely heavily on norms, it is
disappointing that normative samples
for older individuals have historically
been in- sufficient. Similarly, Bush
and colleagues have noted that many
normative samples have been stitched
together from control groups that
were recruited to match specific
research project parameters [15].
This raises questions of whether
older individuals with mild cognitive
impairment were included versus
excluded from normative samples.
Indeed, norms based solely on the
most cognitively intact individuals
may not comprise a representative age
matched normal distribution since
some degree of cognitive decline is
part of normal aging. When age
and geographic stratifications vary
across tests, the comparability of
these reference groups is called into
question.
Indeed, for older
individuals, this heterogeneity among
norms is even more pronounced. Thus,
the application of norms for older
adults requires a familiarity with the
specific inclusion criteria of the
normative sample.
Questions that
should be considered when reviewing
descriptive
norms
include
the
following:
1. What is the age range of the
normative sample? A majority of
the neuropsychological tests are
not normed for individuals above

the age of 70 or 80.
2. Since most tests provide multiple
scores, which of
these test scores are normally
distributed? Note that many error
scores or ratio scores are not normally distributed.
3. Is the test based on a censusmatched sample?
If not, is the sample derived from
one or multiple geographic
regions? What demographic features are underrepresented and
what effect might this have? For
example, is the patients ethnicity
adequately represented?
4. What demographic stratifications
were used for education, gender,
and age?
5. Are the older age stratifications of
equal cell size? (Some tests have
but a few individuals that are over
70 years old, thus the older age
sample
may
be
underrepresented.)
6. What age break downs were used
and are these sufficiently sensitive
for this particular patient? (Age
break down in decades for adults
between
3040, 4050, 5160 are typically
more stable than those for adults
between 6170, and especially
for the 7180, 8190, 91100 age
groups.)
7.
What inclusion or exclusion

criteria were used, that may have
resulted in a skewed representation
for the older samples?
Why has advancing the quality and

quantity of norms for older individuals
not been a priority?
Bush and
colleagues opined that financial
interests are one of the main reasons
for this paradox [15]. Specifically, the
development of norms is not
considered scientific enough to
secure research funding. In academic
settings, the publication of tests is not
viewed as being commensurate with
peer-reviewed research publications.
Consequently,
test
development
activities typically fall to publishing
companies, whose existence is
dependent on a broad market base and
instruments in the public domain
typically are not attractive to test
publishers.
One of the authors (Ruff), normed a
flexible test battery that was
originally designed for a National
Insti- tutes of Mental Health
multicenter study of patients with
moderate to severe brain injury. While
selecting this test battery, our team
(Arthur Benton, Neil Brooks, Harvey
Levin, Igor Grant, Jeff Barth, and Ron
Ruff) selected tests based on their
merit without considering what
company owned the publishing rights.
This project produced a flexible battery
normed on 360 individuals stratified
according to gender, age, and education. When we approached test
publishers to consider publishing the
normative data, they congratulated us
on the quality of the normative study,
but none were will- ing to publish the

test battery, since many of the tests
were owned by competing test
publishers. This example highlights
one reason why test batteries
comprised of tests that were developed
by
different
publishers
face
tremendous obstacles.
1.8. What are the strengths and
weaknesses of diagnostic
norms?
Many screening batteries developed
specifically for older adults were
designed to diagnose dementia with
many of these measures utilizing cutoff scores. While screening batteries
can be quite useful, it is important to
remember that these tests are best
applied to those cases where the
referral question is soliciting a diagnosis, rather than a psychometric
description of the individuals
cognitive abilities.
It is important for neuropsychologists
to be aware of
the reliability and validity of the
various indices and subtest scores they
use to guide clinical decisions before
interpreting the test findings. For
example, while
the RBANS has acceptable test-retest

reliability for the global score, this
reliability is questionable for various
subtests or index scores [63].
Similarly, research has shown that the
Cognistat can lead to high misclassification rates if one relies on the
subtests rather than the total score [6].
Factor analytic research with older
adults yielded a unitary factor
structure, and this single composite
score was shown to be more capable
of de- tecting cognitive deficits in
older individuals in rehabilitation
groups [6]. Thus, clinicians should be
cau- tious when rendering conclusions
on various subtests of these batteries.
When interpreting diagnostic test
norms, the following questions
should be considered:
1. On which clinical populations
was the diagnostic test validated?
(Was the test designed to diagnose
Alzheimer disease or differentiate
among different dementias such
as Alzheimers, Huntingtons, or
Parkinsons disease?)
2. What stand-alone subtests within
the battery have
acceptable test-retest reliability?
(Most often, these subtests have
too few items to yield acceptable
test-retest reliability; however,
the global scores may be more
useful in terms of diagnostic
validity.)
3. If the diagnosis is known, based
on neurological or medical
evidence (e.g. severe TBI, CVA,
MS), are the test norms sufficient
to allow for re- liable assessment

gradations to capture cognitive
changes over time?
1.9. For most referrals is a
juxtaposition of a descriptive and
diagnostic approach called for?
Generally, while referral sources are
interested in diagnostic issues [76]
their concerns usually extend well
beyond that [23,50]. According to
research, three primary referral
questions emerge [59]: evaluation of
capacity for independent living
(95%), the etiology of the observed
cognitive deficits (e.g. is it depression
or dementia) (31%), and driving
capacity (15%). Inter- estingly, 66%
of all referral questions include all
three of these questions [59].
Moreover,
the
geriatric
neuropsychologist often assumes the role
of a behavioral consultant. Most often
what referral sources want is for
clinicians to create and implement
interventions
that
enhance
the
capabilities of the patient while
reducing the patients problematic
behaviors [50].
The diagnostic and descriptive

approaches
are
not
mutually
exclusive, but rather can be blended
for cer- tain referral questions. If the
referral
source
wants
the
neuropsychologist to determine if the
patients cognitive decline meets the
criteria of mild cognitive impairment
versus dementia, then a diagnostic test
should be selected. However, for
most other etiologies, such as cerebral
vascular accident, traumatic brain
injury,
multiple
sclerosis,
Parkinsons disease, meningitis or
other brain infections, and intracranial
tumors a descriptive approach should
be used. In other words, if the diagnosis of the neurological illness is not
in question, but the referral is aimed at
understanding the degree of impairment, then a descriptive test
measure is preferable to capture the
gradations of decline. The latter is
especially
important
when
establishing a baseline against which
change can be monitored over time as
well as ascertaining cognitive
strengths and weaknesses that play a
role in care planning.
Selecting the most fitting
neuropsychological test
battery is driven by the referral
question and the patients
symptomatology with neurologists
being our most prominent referral
source [73]. In order for neurologists to continue to value our
unique contribu- tion we must
understand and take into account their
needs. The American Academy of
Neurology has recommended seven
reasons for neuropsychological consultations [3].
In Table 3, we
categorized these seven referral

questions into either descriptive,
diagnostic or a combination of both.
As depicted in Table 3 pure
diagnostic referrals to
neuropsychologists are relatively rare,
however, our descriptive norms for
older individuals remain inadequate
compromising our ability to answer
referral questions in a solid manner.
Physicians do not usually depend on
neuropsychologists to diagnose a
cerebrovascular accident or traumatic
brain injury; instead they utilize
clinical history, labs, and neuroimaging
to
buttress
their
diagnostic
impressions. Neuropsychologists can
be the most helpful in determining an
individuals cognitive status, whether
age-accelerated decline meets the criteria of a mild cognitive impairment or
dementia, and when cognition
negatively influences a patients decisional capacity.
However, our
descriptive tests lack solid older adult
norms to firmly answer many of these
questions.
Also, while referral
questions commonly require attention
to a particular cognitive domain, it is
important to select assessment
measures with a comprehensive
approach in mind.
Therefore,
combining diagnostic and descriptive
testing approaches are recommended
to offset the shortcomings of each.
Tabl
e3
Diagnostic and descriptive
neuropsychological referrals
Referral questions for neuropsychological consultations according to the
Amer- Diagnostic Descriptive Diagnostic and descriptive ican Academy
of Neurology (1996)
1. When mental status examination reveals mild or questionable cognitive
deficits
X
such as mild cognitive impairment.
2. When following the course of a disorder is either in recovery or decline
such
X
as dementia and stroke.
3. When cognitive strengths and weakness are considered for living
independently.
X
4. In the context of providing specific rehabilitation or other therapeutic
services
X
such as stroke rehabilitation.
5. When a comprehensive profile buttressed with
clinical, laboratory and imaging
X data may assist in diagnosis such as
differentiating subcortical dementia from
frontotemporal dementia.
6. When considering epilepsy surgery.
X
7. When litigation issues arise questioning the patients cognitive status such
as
X
capacity for decision-making.
1.10. What levels of reimbursements
are available?
Beginning July 1, 1990 nonphysician providers of mental health
services (psychologists and licensed
clinical social workers) were granted
independent billing authority under
Medicare [66]. Obtaining these billing
privileges
for
geriatric
neuropsychologists has been both a
blessing and a curse. The blessing is
the opportunity to provide services to
a population that is not only growing,
but in great need of psychological

services. The curse continues to be the
restrictions Medicare and other
managed care systems place on which
services can be reimbursed, and the
rate at which reimbursement can be
made.
Psychologists in private
practice have been among the hardest
hit.
A 1993 Pennsylvania study [13] of
174 psychologists in private practice
found respondents reported prob- lems
with
insurance
reimbursement,
decreased fees, increased paperwork,

and difficulty obtaining authoriza- tion
for longer treatment. Despite the fact
that psychologists had been granted
independent billing authority under
Medicare three years earlier, twothirds of the respondents reported
being excluded from Medicare eligibility to participate as clinical
psychologists. Per- haps because
psychologists in private practice infrequently initiate research, the issue of
how Medicare and managed care
reimbursements impact the ethical
provision
of
neuropsychological
services is often not addressed in the
literature. For example, two of the
most recently published books on the
topic of geriatric neuropsychology,
Geriatric Neuropsychology Assessment and Intervention [9] and
Geriatric Neuropsychol- ogy: Practice
Essentials [16] do not discuss how to
adequately address referral questions
and provide com- petent and ethical
services from a neuropsychological
perspective. This is especially
problematic since Medi-
care reimbursement schedules are

substantially lower than mean
neuropsychological billing rates.
The need for neuropsychological
services in the older adult population
is increasing, as are the costs of doing
business. Against this backdrop,
managed care reimbursements rates
are, at best, holding steady and in
some cases declining. As reported by
the APA Practice Organization the
Centers for Medicare and Medicaid
Services (CMS) proposed a rate
increase for Medicare physician
evaluation
and
management
reimbursement rates leading to an
additional $4.5 billion in Medicare
costs [8]. To offset these costs, CMS
cut the reimbursement rates for
services provided predominantly by
psychologists and social workers.
Specifically, mental health and
testing services were cut 9% in
addition to a 5.1% reduction in the
rate at which fees increase over time
[8]. APA, in response, has encouraged
psychologists to be persistent with
trying to negotiate with managed care
companies, and offers a Managed
Care Reimbursement Toolkit to assist
in their negotiations. Interestingly,
APA suggests that if psychologists are
unable to negotiate an acceptable rate
then they are encouraged to look to
other sources of income.
Not surprisingly, despite the
increased reimbursement rates by
CMS for physicians, psychologists
and physicians who work with
Medicare patients are facing the same
issues. Based on a report prepared by
the American Medical Association [5],
from 2006 to 2011, physician

Medicare payments are expected to
drop by
26%. However, while Medicare
payments will be de- creasing the
costs associated with practicing
medicine are expected to increase by
15%. The question for any health care
provider inevitably becomes: How
can I ethically provide appropriate
services to Medicare patients when I
cannot sustain my practice on the low
Medicare reimbursement rates?
In the presence of an expanding role

for neuropsychology in geriatric
psychiatry [58] reimbursement for
services
is
shrinking.
Neuropsychology, as a professional
practice, places a strong emphasis on
psychometric
evaluation
of
neurocognitive functions, as well as
interventions based on information
provided
by
psychometric
evaluations
[58].
In
contrast,
neuropsychologists in private
practice working in skilled nursing
facilities anecdotally report resorting
to clinical interviews of the patient,
family and staff, as an alterna- tive to
standardized
neuropsychological
testing due to reimbursement related
time constraints. While such methods
may provide sufficient information to
make treatment recommendations,
these clinical interviews are not
standardized,
normed,
or
psychometrically cor- related with
standardized neuropsychological tests
to establish their validity or reliability.
In essence, clinical interviews alone
are neither evidence based, nor the
standard of care for diagnosing
cognitive impairment in older adults.
What then is the impact, on the patient and on the profession of
Neuropsychology when we abandon
standardized assessment measures in
favor of more brief, but less thorough
services? If clinical interviews are
replacing standardized assessments,
research needs to be carried out to
establish the content and concordant
validity, as well as reliability, of this
approach to addressing referral
questions in the older adult population.

2. Future considerations
In our everyday clinical practice we
are often faced with patients who have
multiple medical illnesses. While our
training and experiences allow us to be
experts
in
brain-behavior
relationships, frequently we fall short
of
understanding
brain-body
relationships. In- deed, most studies
continue to focus on the neuropsychological effects of one medical
disease state at a time rather than comorbid disorders which are more common in older individuals. To improve
our diagnostic accuracy we must have
a better grasp of the influence that
multi-system disease has on brain
behavior relationships. Similarly,
neuropsychologists must become more
medically savvy and be more aware of
how medical decompensation
detrimentally influences cognition.
While we are not physicians we should
continue to ex- pand our understanding
of physical illness, polypharmacy,
and pain, as well as actively
collaborate
with
our
physician
counterparts.
Cognitive examinations remain as

challenging as diagnosing physical
illnesses. In our role as the examiner, we must be integrate our
knowledge about cognition, test
instruments, psychopathology, and the
con- sequence of physical illness on
cognition. Yet, our referral stream is
also dependant on a high degree of
interpersonal skill [53]. In the future,
neuropsychologists should consider,
when appropriate, implementing
aspects of the therapeutic assessment
model into their practice.
By
collaborating with our patients and
acknowledging their difficulties,
regardless of our ability to help, we
can facilitate a process by which the
patient leaves feeling validated,
helped, and understood.
Clinical evaluations depend on the
quality of the normative data;
however, our older adult norms
remain quite poor.
Instead,
neuropsychological
research
remains focused on localizing cognitive
components to specific regions of the
brain. While localization is academically interesting, it has limited
clinical application in the older adult
population. Indeed, we receive few if
any referrals for localization per se
[68]. However, we do receive
referrals to capture gradual declines,
mild cognitive deficits that are not
captured
in
neurological
examinations, and delineating both
strengths and weaknesses for
purposes of rehabilitation. To more
effec- tively answer these referral
questions, we must continue to
improve our normative data for older
individuals.
Ideally,
our
neuropsychological tests should have
more representative sample sized for
older individuals that are stratified by
age and education, as well as include
those
individuals
who
have
diminished cognition related to
normal aging. That said, test
companies have begun to recognize
the lack of appropriate norms for
older adults and have made greater
efforts to design tests with older adults
in mind and include older adults in
their normative samples (e.g. WAISIV, WMS-IV, Independent Living
Scales, and expanded norms for the
RBANS). Our neuropsychological
tests should also be based on our
theoretical understanding of cognitive functions. Finally, more effort
is called for to establish evidencebased links between tests and daily
functioning (i.e. ecological validity).
As we look to the future, we must
begin to devel- op our role in
promoting cognitive health, increasing
the applicability of our research, and
appropriate reimbursement for
services. Despite the expanding role
of neuropsychology in older adult
populations, it is concerning that
reimbursement for services are
shrinking. Rather than solely focusing
on neuropsychopatholo- gy, we should
work toward developing evidencebased treatment approaches that
incorporate case manage-
ment, caregiver support and education,

and as appropriate environmental
engineering. Accordingly, our profession should continue to advocate
for the allocation of funds to research
innovative, individualized treatment
approaches and provide services for
patients who are cognitively impaired
and
their
caregivers.
Private
practitioners valuable knowledge and
expertise with older individuals is
regrettably being lost since their time
is often filled with the demands of
clinical work. However, to increase
the applicability of our geriatric
research, private practitioners should
strive to increase their involvement in
research.
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NeuroRehabilitation

Geriatric neuropsychology: Implications for front line clinicians

Abstract. Consistent with the aging population, neuropsychologists are being

national and state agencies have

consultation [7]. Many psychology internship programs now offer rotations

Address for correspondence:

gy have emerged. The importance of

2008 IOS Press and the authors. All rights

ed to cognitive inflexibility, decreased

the availability of psychosocial

article by Caplan and Shechter in this

is more than just an information

the therapeutic assessment approach.

ing them for their own efforts to

failure with declines in executive

most experienced neuropsychologist.

While is it not necessary to master

tion of unsteady gait, high

harm the patient. For example, it

medications [19], and experience

use of unnecessary medications is

Abrupt medication changes and

contractures, and cancer [69]. Pain can

well. Lastly, there are often tradeoffs

Aggressive, combative, resisting care

Changes in activity patterns/routines

Refusing food, appetite change

Average, Above Average and so

clas- sified according to degrees of

of such measures include the

is impor- tant that clinicians who rely

1.7. What are the strengths and

not normed for individuals above

What inclusion or exclusion

Why has advancing the quality and

but none were will- ing to publish the

the RBANS has acceptable test-retest

to allow for re- liable assessment

The diagnostic and descriptive

categorized these seven referral

but in great need of psychological

decreased fees, in- creased paperwork,

care reimbursement schedules are

from 2006 to 2011, physician

In the presence of an expanding role

questions in the older adult population.

Cognitive examinations remain as

ment, caregiver support and education,

Shah, Y. Cheng, W. Flesher and

[32] A. Flint, Anxiety disorders in

[44] P. Jurica, C. Leitten and S.

[50] P. Lichtenberg, A Guide to

logical Status, San Antonio, TX:

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