1. Competency in Older Adults: Clinical and Legal Perspectives The Role of Cognitive and Neuropsychological Evaluations John Crumlin, PhD Assistant Director, CU Aging Center

2. Neuropsychological Evaluations Purpose of the Evaluation – A clear and specific referral question is essential Assessment involves more than testing – Interview & observations – Social history & present life circumstances – Medical history & present status – Circumstances surrounding the examination – Relevant records

3. Guardianship In guardianship cases: Does the person meet criteria for an incapacitated person An incapacitated person is one who is unable to effectively receive or evaluate information or both or make or communicate decisions to such an extent that the individual lacks the ability to satisfy essential requirements for physical health, safety, or self-care, even with appropriate and reasonable available technological assistance. (CO Statue)

4. Neuropsychological Evaluations The basic assumption: performance on a series of brief tasks predicts everyday cognitive functioning and ability for adaptive behavior in the real world The best tests have good ecological validity, but no test is perfect

5. Test Selection Include the minimum amount of established standardized tests that will provide an answer to the referral question Tests should have “good” reliability & validity A test has good reliability if it gives similar results on repeated testing. A test has good validity if its results correlate with the construct of interest Even the very best tests have error rates

6. Interpreting Results No test result in isolation is particularly informative – Interpretation of results requires an analysis of error patterns, the abilities required for each test, and collateral information – Conceptualizing cognitive abilities in domains helps interpret the assessment results

7. Cognitive Domains Attention and Concentration – Attention: The ability to direct one’s awareness to the task at hand – Concentration : sustaining attention until a task is completed Information processing – speed, capacity, & control

8. Cognitive Domains Memory – Verbal – Visual – Immediate vs. delayed – Recall vs. recognition – Working memory The ability to keep information in consciousness while manipulating it

9. Cognitive Domains Language – Receptive and expressive language abilities Visuo-spatial abilities – The ability to understand how elements form wholes, and to appreciate the spatial layout of one’s surroundings Motor functions

10. Cognitive Domains Executive Functions – Captain of the Ship / Orchestra Conductor – Ability to organize, initiate, and follow through with goal-directed behavior, to evaluate problem solving efforts, and to adapt behavior based on feedback – Includes impulse control and higher order functions such as math skills, abstract and categorical reasoning, and concurrently considering divergent lines of thinking

11. The Nomothetic Approach Performance is scored on strict criteria to provide a numerical score Individual’s numerical score is compared to the appropriate “average person” providing a percentile rating and/or a qualitative descriptor – Typical descriptors: Average; Low-average; Borderline; and Mildly, Moderately, or Severely Impaired

12. Interpreting Results Tests are designed to assess specific domains, but performance is always multi-determined Task and error analysis – What abilities are required to perform well on a specific test? – What is the pattern of the person’s deficits/strengths across all tests? Conclusions about specific domains

13. Assessment Results versus Legal Criteria Able to effectively receive information – attention/concentration, information processing capacity and control, receptive language Able to effectively evaluate information – Information processing control, memory, executive functioning Able to effectively make decisions – Information processing control, memory, executive functioning Able to effectively communicate decisions – expressive language, executive functions

14. Confounding Factors Typically we are seeking an estimate of the person’s true cognitive functioning. Any influence of the following factors must be taken into consideration (partial list) Fatigue Distractions Pain Anxiety & distress Depression Motivation Medications Cooperation

15. Final Thoughts Be sure you provide a clear and specific question(s) that you want answered Not all neuropsychologists have experience in assessing capacity. In seeking an evaluation for guardianship purposes, be sure that cognitive abilities will be assessed against the legal criteria A psychologist cannot decide the ultimate issue (whether a guardian is required)

16. Resources A comprehensive neuropsychological referral form is available on the CU Aging Center website www.uccs.edu/agingcenterwww.uccs.edu/agingcenter The American Psychological Association and the American Bar Association collaboratively produced a series of handbooks on capacity assessment. These very informative works are available free in PDF format on the web at http://www.apa.org/pi/aging/homepage.html The Alzheimer’s Association published an excellent guide to help families cope with members who have diminished capacity and locate resources related to capacity issues