Mohammed T. Abou-Saleh

134 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYcomputer-assisted technology for governing the conduct ofinterviews should facilitate the management of elaborate contingenciesfor driving the interview.A certain line of questioning or testing may hinge upon a largebody of information already gathered, rather than a single item orshort set of items. A classic example is the use of an interview as ascreen to select subjects for further investigation. Typically thelatter investigation is at a separate time and venue, but it couldfollow straight on the heels of the screening interview at the samesession. In either event it is essential to have immediate analysis ofthe information determining the contingency. Simple additivescoring systems are mainly invoked in these circumstances.Computer methods now allow much more elaborate analyses todetermine the flow of sequential interviews or even sequenceswithin a single session interview.The capacity for rapid retrieval of assessment information ondemand greatly enhances the value of mental assessment forsupporting clinical decisions. Yet the potential in this respectcannot be fully realized until clinical goals of assessment assumepriority over research goals in shaping the form and content of theassessment. Notwithstanding that mental assessment emergedfrom clinical experience, the current state or nature of mentalassessment owes much more to research than clinical interests. Areturn to the origins of its development is called for, in order tobring assessment into line with clinical as well as researchneeds 27,28 .Clinical activities, for reasons of practice organization and fiscalconsiderations, generally take place under pressure of time. Thecollection and even analysis of information for the review cliniciancan be delegated to personnel under less time pressure than thephysician/psychiatrist. In that arrangement, it becomes essentialthat the transfer of crucial information to the physician bemanaged expeditiously. This entails highly discriminating summarization,display and communication of mental assessmentinformation. It also assumes that the physician learns to assimilatethe type and form of information and to incorporate it in theplanning and monitoring of clinical management. This learningprocess, like other clinical skills, must be continuously honedthrough experience assisted by consultation. There are fewguidelines as yet as to the assignment, conduct and necessarytraining for the professional role of marshalling the mentalassessment information and communicating it to clinicians.Much of mental assessment is aimed at documenting thesubjective experience or inner states of a patient 29 . The bestreporter for this material should be the patient, but the latter maybe uncommunicative or give misleading information. An informantmay not do much better. Under these circumstances, itwould be desirable to turn to objective testing and observation ofbehaviour 30–32 and laboratory results if these can be obtained. Asmatters stand, laboratory findings in themselves are at bestambiguous 33 as mental assessment information in the elderly,although there is hope that eventually laboratory tests will play alarger part in mental assessment. In any event, whether intendedor not, many subjects in epidemiological studies will not undergolaboratory testing. In the meantime, other ways of achievingobjectivity are more likely to be productive. Testing organicmental status is objective in the sense that the task performance ofthe person is observable and errors can be quantified. Programmingis the presentation of the tests through computer softwareand adds to the objectivity 13,34 . Testing of an objective nature hasalso evolved for functional performance for tasks involvingeveryday activities, or simulations of the skill demands entailed insuch activities 14,15 . Inefficiencies in carrying out these tasks provideinformation on the diagnosis of certain mental conditions (e.g.dementia) and the outcomes of a wide range of mental illnesses.Structuring of testing procedures (backed up by suitabletraining) allows the results of assessment to be compared withdata collected on the same instruments in different studies. It alsopermits data to be interpreted in the light of accumulatedexperience on the normal distribution and longitudinal course oflevels or patterns of test results in the general population and inspecific clinically defined groups. Thus, the value of assessmentinformation is enhanced in diagnoses, prediction of outcomes,selection of treatment and evaluating the significance of changesin levels or patterns of test scores. This full psychometricdevelopment warrants the use of the term ‘‘standardized’’ todescribe a method (although the term is used to mean structured).However, there are several cautions that must be addressed inattempting to draw upon the potential value of standardization.Unless an assessment technique is administered in identicalfashion in two or more studies, the results of those studies cannotbe directly compared and information cannot be transferred fromone study to another. Not only must the structure and proceduresof the assessment protocol be kept constant, but also the methodsof training. Furthermore, adjustments must be made for differencesin the characteristics (e.g. age, education and culture) of twopopulations that might alter the meaning and confound thecomparison of results from the same assessment technique 35 .These adjustments may be difficult to make unless standardizationhas been accomplished on appropriate populations and formulaefor interpreting scores have been worked out 36,37 . Attempts arebeing made to construct culture-free assessments which, in effect,would obviate the need to adjust scores with reference todemographic characteristics.Most assessment techniques devoted to the classification ofmental disorders still rely heavily upon information gathered atone point in time 38 , cross-sectional status with or withoutretrospective historical information. Longitudinal or prospectiveinformation is principally regarded as measuring change, courseand outcomes. Yet the longitudinal picture of mental healthproblems offers crucial clues to diagnosis and needs to beincorporated into assessment techniques for classification. Inorder to meet the demands of longitudinal measurements,assessment techniques must deal with practice effects, ceilingand floor limits to the range of measurement, and the minimizationof attrition by maintaining the interest of the subject.Certain domains of mental ill-health appear well-represented,even over-represented, in current assessment techniques. Forinstance, there are probably more measures of cognitive impairment19,25,39–47 and of depressed mood 16,17,48–56 than are strictlyneeded. Conversely, there are neglected domains. Innovationswould be welcome in the measurement of positive mental health,either as a global concept or as applied to specific mental healthareas, such as affect 57 and cognition. There is a need to understandthe contribution of the measurements of positive states todiagnosis and prognosis.More generally, the scope of assessment techniques should beexpanded and explored so as to fill in gaps in the domains relevantto describing mental health and its associations. Moreover,assessments need to encompass the various perspectives ofsubject, family member 11,12,58,59 , health professional and otherparties with a legitimate interest in the subject’s mental health.When a complete inventory of domains and perspectives has beencaptured by assessment techniques, it may become possible todescribe a reasonable approximation to the plight of the wholeperson.A note on quality of life assessment. The concept andmeasurement of quality of life has come to fill a prominentplace in geriatric health care. Since about 1970 the relevantprofessional literature on measurement and its applications hassteadily increased in volume. Instruments have proliferated andsome have assumed ascendancy in terms of widespread use. Thereis no better indication of the need for measurement of this conceptthan the many applications to which it has been turned. These