Mohammed T. Abou-Saleh

138 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYprocedure utilized should have reasonably adequate norms thattake age and educational level into consideration.Validity and ReliabilityValidity and reliability of the assessment procedure must beestablished and the relationship between the given dementingprocess and test scores well established within the scientificliterature.. Constructional abilities.. Motor functions.. Memory and learning.. Attention and concentration.. Judgment and problem-solving abilities.. Speed of processing.At times, these assessments may be as informal as just listening tothe patient, but are necessary descriptive parameters of theassessment.Depression and CognitionCognitive and affective diagnostic procedure should be utilizedwithin the same battery, whether formally or informally, since thetwo interact so powerfully. The diagnosis of dementia vs.depression often resolves itself down to the proportion of each.Depth/Breadth of AssessmentSufficient breadth and depth of assessment is required so thatpatients can be followed over time, in improving and deterioratingconditions, so that unsuspected conditions are not easily missed ina routine assessment.Desirable CharacteristicsShortRelative brevity, even in a multi-factorial assessment, is highlydesirable. Geriatric patients become impatient, threatened andexhausted when test batteries become too lengthy. The procedureat the end of the assessment process may be less valid than that atthe beginning of the assessment process.PracticalIdeally, along with reliability and validity, the assessmentencompasses those variables that are clinically important. Whilereaction time may be highly sensitive at the bedside, in day-to-dayclinical practice memory assessment or assessment of attention ismuch more likely to be broadly useful. The geriatric patient ismore likely to be uncooperative and sometimes appropriatelycontemptuous of ‘‘kid’’ games. If a patient can perceive therelevance of the procedure, whether or not he/she feels threatenedby it, the test results are more likely to be valid and reliable.NumbersQuantification of the test result is very desirable, since multiplesuccessive assessments may be done that trace the course of thesyndrome or the effects of medication.ModelsIt is highly desirable that the tests, in aggregate, fit together into arelatively coherent model of cognitive assessment and includeformal and informal assessment of at least the following:. General abilities.. Speech and language.NON-COMPUTERIZED ASSESSMENT OFCOGNITIVE FUNCTIONSelection of Assessment ToolsAs in all patient populations, neuropsychological assessment ofolder individuals begins with a thorough understanding of thereferral question and a clear goal as to the purposes of theevaluation. The specific functional areas of cognition to be tested,and therefore the format and comprehensiveness of the entireevaluation, should be based on the initial referral question andtargeted at achieving the specific goals of the referring healthcareprovider. Nowhere is it more important to tailor the assessmentbattery to the specific diagnostic concerns, while considering theunique abilities and limitations of the patient population, thanwith a geriatric population. Test selection must optimally allowfor an in-depth evaluation of the cognitive areas of concern, whilekeeping battery length and difficulty level manageable for theaging patient. Ultimately, the battery ‘‘should discriminatemaximally between normal aging and CNS disorders such asthe different dementias’’ 1 . As these authors state further, asuccessful test battery should also allow differentiation amongthe various common subtypes of dementia, as well as betweendementia and affective disturbance.Screening Evaluations vs. Full BatteriesEven when the referral question implies a broad assessment ofoverall cognitive abilities for the purpose of identifying thepresence or absence of neuropsychological deficits, the use of abrief but well-rounded neuropsychological screening measure canbe prudent. Such tools typically allow the examiner to quantifygross deficits against normative data in order to classify the testedindividual as ‘‘normal’’ or ‘‘abnormal’’ in particular cognitiveareas of functioning. Cut-off scores and the number of abnormalscores necessary for rating an individual’s performance on suchmeasures against target normative populations usually allow forqualitative classifications ranging from superior to severelyimpaired. Depending upon the psychometric soundness of thescreening instrument, the examiner may be able to drawconclusions with respect to specific cognitive abilities, or may belimited to a judgment of impaired or not impaired.The benefits of using a brief screening measure for cognitiveevaluation are obvious; they tend to require less administrationtime for both the patient and the examiner, and they are typicallyless labor-intensive and intimidating for the patient. Mostcommercially available cognitive screens are easily scored andprovide feedback for recommendations quickly, which is an assetin inpatient settings or other situations when the patient’streatment plan and disposition considerations may be urgent.As with most things in life, however, time-saving procedures maysacrifice quality. Even the most widely accepted brief cognitivescreens lack the diagnostic sensitivity and specificity of the morecomprehensive neuropsychological battery, particularly when