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Psychodiagnostic testing services: The elusive quest for clinicians
Assessment psychologists should be colocated in specialty practices
Imagine the clinical care consequences if patients seen in specialty or primary care practices did not have ready access to laboratory, other medical tests, and/or consultative services deemed critical to quickly establishing diagnostic status and the development of an appropriate treatment plan. For instance, what would be the implications if a dentistry practice did not employ a dental hygienist; an otolaryngology group was not staffed with an audiologist; or a gastroenterology practice had no one available for digestive/nutritional consultation support.
Consider a neurologist who suspects that a patient has a potentially life-threatening brain condition, but the patient has to wait months for brain imaging or – even worse – is tasked to find their own provider for this diagnostic test only to be told that the neuroimaging service does not take their insurance and/or there are no available appointments for several months.
Situations of this kind would not be – and should not be – tolerated by medical professionals or their patients.
A common “real-world” scenario: After evaluation, a psychiatrist needs clarification regarding a possible subtle psychotic process, or, in another instance, suspects that there is an early degenerative cognitive change underlying recent changes in mood and personality. However, the psychiatrist has no dependable access to an assessment psychologist to assist in cases of this kind.
Patients are frequently told by psychiatrists and other physicians that they should have psychodiagnostic testing to arrive at a clearer picture of their clinical status and treatment needs. However, most medical practices, in particular, psychiatry, pediatrics, neurology, and neurosurgery, who see substantial numbers of patients who could benefit from testing, do not employ psychologists. When they do, many do not possess the requisite assessment skills to address the reason(s) for referral.
If the patient needing testing services is fortunate enough, he/she is referred to a well-trained psychologist within commuting distance who takes the patient’s insurance and is able to set up a timely appointment – an unlikely set of circumstances in today’s health care environment.
Some state psychological associations allow for a “matching service” of sorts in the form of announcements in the organization’s listserv, which reviews the referral and includes a back channel for psychologists to contact the patient regarding their availability for testing.
Over the past 2 decades, significant advancements have been made in the integration of primary and mental health care. Those need to continue to include colocating assessment psychologists in medical specialty practices, such as psychiatry, which make frequent referrals for psychodiagnostic testing or would like to but have no place to turn.
Dr. Pollak is affiliated with the Seacoast Mental Health Center in Portsmouth, N.H.
Assessment psychologists should be colocated in specialty practices
Assessment psychologists should be colocated in specialty practices
Imagine the clinical care consequences if patients seen in specialty or primary care practices did not have ready access to laboratory, other medical tests, and/or consultative services deemed critical to quickly establishing diagnostic status and the development of an appropriate treatment plan. For instance, what would be the implications if a dentistry practice did not employ a dental hygienist; an otolaryngology group was not staffed with an audiologist; or a gastroenterology practice had no one available for digestive/nutritional consultation support.
Consider a neurologist who suspects that a patient has a potentially life-threatening brain condition, but the patient has to wait months for brain imaging or – even worse – is tasked to find their own provider for this diagnostic test only to be told that the neuroimaging service does not take their insurance and/or there are no available appointments for several months.
Situations of this kind would not be – and should not be – tolerated by medical professionals or their patients.
A common “real-world” scenario: After evaluation, a psychiatrist needs clarification regarding a possible subtle psychotic process, or, in another instance, suspects that there is an early degenerative cognitive change underlying recent changes in mood and personality. However, the psychiatrist has no dependable access to an assessment psychologist to assist in cases of this kind.
Patients are frequently told by psychiatrists and other physicians that they should have psychodiagnostic testing to arrive at a clearer picture of their clinical status and treatment needs. However, most medical practices, in particular, psychiatry, pediatrics, neurology, and neurosurgery, who see substantial numbers of patients who could benefit from testing, do not employ psychologists. When they do, many do not possess the requisite assessment skills to address the reason(s) for referral.
If the patient needing testing services is fortunate enough, he/she is referred to a well-trained psychologist within commuting distance who takes the patient’s insurance and is able to set up a timely appointment – an unlikely set of circumstances in today’s health care environment.
Some state psychological associations allow for a “matching service” of sorts in the form of announcements in the organization’s listserv, which reviews the referral and includes a back channel for psychologists to contact the patient regarding their availability for testing.
Over the past 2 decades, significant advancements have been made in the integration of primary and mental health care. Those need to continue to include colocating assessment psychologists in medical specialty practices, such as psychiatry, which make frequent referrals for psychodiagnostic testing or would like to but have no place to turn.
Dr. Pollak is affiliated with the Seacoast Mental Health Center in Portsmouth, N.H.
Imagine the clinical care consequences if patients seen in specialty or primary care practices did not have ready access to laboratory, other medical tests, and/or consultative services deemed critical to quickly establishing diagnostic status and the development of an appropriate treatment plan. For instance, what would be the implications if a dentistry practice did not employ a dental hygienist; an otolaryngology group was not staffed with an audiologist; or a gastroenterology practice had no one available for digestive/nutritional consultation support.
Consider a neurologist who suspects that a patient has a potentially life-threatening brain condition, but the patient has to wait months for brain imaging or – even worse – is tasked to find their own provider for this diagnostic test only to be told that the neuroimaging service does not take their insurance and/or there are no available appointments for several months.
Situations of this kind would not be – and should not be – tolerated by medical professionals or their patients.
A common “real-world” scenario: After evaluation, a psychiatrist needs clarification regarding a possible subtle psychotic process, or, in another instance, suspects that there is an early degenerative cognitive change underlying recent changes in mood and personality. However, the psychiatrist has no dependable access to an assessment psychologist to assist in cases of this kind.
Patients are frequently told by psychiatrists and other physicians that they should have psychodiagnostic testing to arrive at a clearer picture of their clinical status and treatment needs. However, most medical practices, in particular, psychiatry, pediatrics, neurology, and neurosurgery, who see substantial numbers of patients who could benefit from testing, do not employ psychologists. When they do, many do not possess the requisite assessment skills to address the reason(s) for referral.
If the patient needing testing services is fortunate enough, he/she is referred to a well-trained psychologist within commuting distance who takes the patient’s insurance and is able to set up a timely appointment – an unlikely set of circumstances in today’s health care environment.
Some state psychological associations allow for a “matching service” of sorts in the form of announcements in the organization’s listserv, which reviews the referral and includes a back channel for psychologists to contact the patient regarding their availability for testing.
Over the past 2 decades, significant advancements have been made in the integration of primary and mental health care. Those need to continue to include colocating assessment psychologists in medical specialty practices, such as psychiatry, which make frequent referrals for psychodiagnostic testing or would like to but have no place to turn.
Dr. Pollak is affiliated with the Seacoast Mental Health Center in Portsmouth, N.H.
How you can aid your patient’s claim for long-term disability
Neuropsychiatric disorders are associated with high rates of impaired work capacity despite the best efforts of treating clinicians to help their patients stay employed or resume working after symptoms improve.1
In the past, a note from the psychiatrist stating that the patient was unable to work because of a neuropsychiatric condition often was sufficient to approve a disability claim. This is no longer the case in today’s more restrictive climate, and what constitutes prima facie evidence of a patient’s inability to sustain competitive employment secondary to neuropsychiatric illness has significantly changed.
The following practices can help facilitate approval of your patient’s disability claim.
Document as you go. Progress notes should include the type, frequency, context, duration, and severity of symptoms supporting ≥1 psychiatric diagnoses which prevent your patient from holding a job. It also is important to document the parameters of treatment and the patient’s response, including compliance with treatment recommendations. Preferably, progress notes should include quantitative ratings over time that pertain to everyday functioning, highlighting how your patient is coping with the psychosocial, cognitive, and executive functioning demands of his (her) job.
When documented over time, ratings based on the Global Assessment of Functioning scale or a comparable scale are useful in quantifying the nature and degree of impaired functioning related to work capacity. Consider administering rating scales at periodic intervals to show changes over time. When feasible, scales should be based on a patient’s and informant’s report of symptomatic status and everyday functioning, and could include use of instruments such as the World Health Organization’s Disability Assessment Schedule.2,3
Include documentation specific to work capacity. Disability claims often are denied, in part, because the treating psychiatrist’s judgment regarding work capacity seems to “come out of the blue,” appears premature, or lacks discussion of the functional implications of the patient’s clinical status in regards to recent or current job expectations. Therefore, progress notes should include reference to long-standing, emerging, or worsening behaviors or symptoms that have clear implications for your patient’s ability to work.
Outline the functional implications of the patient’s preserved and impaired abilities and skills as they relate to work capacity, vocational history, and recent or current job situation. For example, work requirements that are highly dependent on interaction with the public, supervisors, or coworkers would be significantly affected by recurrent or persistent psychosis, even if the patient adheres to treatment and symptoms are relatively mild. Problems with working memory or anterograde memory could impair work that routinely involves learning and retention of new instructions and procedures.
Provide psychoeducation and support. Educate your patient and their family about the disability claims process, including the high rate that claims are initially denied. Consider retaining an advocate—clinical case manager, family member, or non-family third party—to assist your patient in navigating the disability application process, such as help completing paperwork, setting up appointments, and providing transportation.
Remain responsive to inquiries from disability examiners. Return forms and phone calls from disability examiners, psychiatrists, and other health care professionals reviewing your patient’s claim for long-term disability in a timely manner. Failure to do so can be used to support denial of the claim.
Consider referral for consultations and diagnostics to support the claim of impaired work capacity. Depending on the nature of the case, this could involve additional medical workup (including neuroimaging), a consultation from a vocational rehabilitation specialist, or referral for psychological or neuropsychological testing.
Psychometric assessment is becoming the preferred method for garnering support for impaired work capacity caused by neuropsychiatric factors. Findings from psychometric assessment hold up to scrutiny better if the evaluation includes symptom validity testing to rule out factitious disorder, malingering, or somatization, and results from self-report and informant-based measures of adaptive behavior and functioning.4
1. Gold LH, Shuman DW. Evaluating mental health disability in the workplace: models, process and analysis. New York, NY: Springer; 2009.
2. Traxler J. Mental health disability: a resident’s perspective of problems and solutions. Psychiatric Times. http://www.psychiatrictimes.com/residents-corner/mental-health-disability-residents-perspective-problems-and-solutions. Published November 26, 2014. Accessed August 31, 2016.
3. Zimmerman M. The importance of measuring outcomes in clinical practice. Psychiatric Times. http://www.psychiatrictimes.com/uspc2014/importance-measuring-outcomes-clinical-practice. Published October 1, 2014. Accessed August 31, 2016.
4. Schwarz L, Roskos PT, Grossberg GT. Answers to 7 questions about using neuropsychological testing in your practice. Current Psychiatry. 2014;13(3):34-39.
Neuropsychiatric disorders are associated with high rates of impaired work capacity despite the best efforts of treating clinicians to help their patients stay employed or resume working after symptoms improve.1
In the past, a note from the psychiatrist stating that the patient was unable to work because of a neuropsychiatric condition often was sufficient to approve a disability claim. This is no longer the case in today’s more restrictive climate, and what constitutes prima facie evidence of a patient’s inability to sustain competitive employment secondary to neuropsychiatric illness has significantly changed.
The following practices can help facilitate approval of your patient’s disability claim.
Document as you go. Progress notes should include the type, frequency, context, duration, and severity of symptoms supporting ≥1 psychiatric diagnoses which prevent your patient from holding a job. It also is important to document the parameters of treatment and the patient’s response, including compliance with treatment recommendations. Preferably, progress notes should include quantitative ratings over time that pertain to everyday functioning, highlighting how your patient is coping with the psychosocial, cognitive, and executive functioning demands of his (her) job.
When documented over time, ratings based on the Global Assessment of Functioning scale or a comparable scale are useful in quantifying the nature and degree of impaired functioning related to work capacity. Consider administering rating scales at periodic intervals to show changes over time. When feasible, scales should be based on a patient’s and informant’s report of symptomatic status and everyday functioning, and could include use of instruments such as the World Health Organization’s Disability Assessment Schedule.2,3
Include documentation specific to work capacity. Disability claims often are denied, in part, because the treating psychiatrist’s judgment regarding work capacity seems to “come out of the blue,” appears premature, or lacks discussion of the functional implications of the patient’s clinical status in regards to recent or current job expectations. Therefore, progress notes should include reference to long-standing, emerging, or worsening behaviors or symptoms that have clear implications for your patient’s ability to work.
Outline the functional implications of the patient’s preserved and impaired abilities and skills as they relate to work capacity, vocational history, and recent or current job situation. For example, work requirements that are highly dependent on interaction with the public, supervisors, or coworkers would be significantly affected by recurrent or persistent psychosis, even if the patient adheres to treatment and symptoms are relatively mild. Problems with working memory or anterograde memory could impair work that routinely involves learning and retention of new instructions and procedures.
Provide psychoeducation and support. Educate your patient and their family about the disability claims process, including the high rate that claims are initially denied. Consider retaining an advocate—clinical case manager, family member, or non-family third party—to assist your patient in navigating the disability application process, such as help completing paperwork, setting up appointments, and providing transportation.
Remain responsive to inquiries from disability examiners. Return forms and phone calls from disability examiners, psychiatrists, and other health care professionals reviewing your patient’s claim for long-term disability in a timely manner. Failure to do so can be used to support denial of the claim.
Consider referral for consultations and diagnostics to support the claim of impaired work capacity. Depending on the nature of the case, this could involve additional medical workup (including neuroimaging), a consultation from a vocational rehabilitation specialist, or referral for psychological or neuropsychological testing.
Psychometric assessment is becoming the preferred method for garnering support for impaired work capacity caused by neuropsychiatric factors. Findings from psychometric assessment hold up to scrutiny better if the evaluation includes symptom validity testing to rule out factitious disorder, malingering, or somatization, and results from self-report and informant-based measures of adaptive behavior and functioning.4
Neuropsychiatric disorders are associated with high rates of impaired work capacity despite the best efforts of treating clinicians to help their patients stay employed or resume working after symptoms improve.1
In the past, a note from the psychiatrist stating that the patient was unable to work because of a neuropsychiatric condition often was sufficient to approve a disability claim. This is no longer the case in today’s more restrictive climate, and what constitutes prima facie evidence of a patient’s inability to sustain competitive employment secondary to neuropsychiatric illness has significantly changed.
The following practices can help facilitate approval of your patient’s disability claim.
Document as you go. Progress notes should include the type, frequency, context, duration, and severity of symptoms supporting ≥1 psychiatric diagnoses which prevent your patient from holding a job. It also is important to document the parameters of treatment and the patient’s response, including compliance with treatment recommendations. Preferably, progress notes should include quantitative ratings over time that pertain to everyday functioning, highlighting how your patient is coping with the psychosocial, cognitive, and executive functioning demands of his (her) job.
When documented over time, ratings based on the Global Assessment of Functioning scale or a comparable scale are useful in quantifying the nature and degree of impaired functioning related to work capacity. Consider administering rating scales at periodic intervals to show changes over time. When feasible, scales should be based on a patient’s and informant’s report of symptomatic status and everyday functioning, and could include use of instruments such as the World Health Organization’s Disability Assessment Schedule.2,3
Include documentation specific to work capacity. Disability claims often are denied, in part, because the treating psychiatrist’s judgment regarding work capacity seems to “come out of the blue,” appears premature, or lacks discussion of the functional implications of the patient’s clinical status in regards to recent or current job expectations. Therefore, progress notes should include reference to long-standing, emerging, or worsening behaviors or symptoms that have clear implications for your patient’s ability to work.
Outline the functional implications of the patient’s preserved and impaired abilities and skills as they relate to work capacity, vocational history, and recent or current job situation. For example, work requirements that are highly dependent on interaction with the public, supervisors, or coworkers would be significantly affected by recurrent or persistent psychosis, even if the patient adheres to treatment and symptoms are relatively mild. Problems with working memory or anterograde memory could impair work that routinely involves learning and retention of new instructions and procedures.
Provide psychoeducation and support. Educate your patient and their family about the disability claims process, including the high rate that claims are initially denied. Consider retaining an advocate—clinical case manager, family member, or non-family third party—to assist your patient in navigating the disability application process, such as help completing paperwork, setting up appointments, and providing transportation.
Remain responsive to inquiries from disability examiners. Return forms and phone calls from disability examiners, psychiatrists, and other health care professionals reviewing your patient’s claim for long-term disability in a timely manner. Failure to do so can be used to support denial of the claim.
Consider referral for consultations and diagnostics to support the claim of impaired work capacity. Depending on the nature of the case, this could involve additional medical workup (including neuroimaging), a consultation from a vocational rehabilitation specialist, or referral for psychological or neuropsychological testing.
Psychometric assessment is becoming the preferred method for garnering support for impaired work capacity caused by neuropsychiatric factors. Findings from psychometric assessment hold up to scrutiny better if the evaluation includes symptom validity testing to rule out factitious disorder, malingering, or somatization, and results from self-report and informant-based measures of adaptive behavior and functioning.4
1. Gold LH, Shuman DW. Evaluating mental health disability in the workplace: models, process and analysis. New York, NY: Springer; 2009.
2. Traxler J. Mental health disability: a resident’s perspective of problems and solutions. Psychiatric Times. http://www.psychiatrictimes.com/residents-corner/mental-health-disability-residents-perspective-problems-and-solutions. Published November 26, 2014. Accessed August 31, 2016.
3. Zimmerman M. The importance of measuring outcomes in clinical practice. Psychiatric Times. http://www.psychiatrictimes.com/uspc2014/importance-measuring-outcomes-clinical-practice. Published October 1, 2014. Accessed August 31, 2016.
4. Schwarz L, Roskos PT, Grossberg GT. Answers to 7 questions about using neuropsychological testing in your practice. Current Psychiatry. 2014;13(3):34-39.
1. Gold LH, Shuman DW. Evaluating mental health disability in the workplace: models, process and analysis. New York, NY: Springer; 2009.
2. Traxler J. Mental health disability: a resident’s perspective of problems and solutions. Psychiatric Times. http://www.psychiatrictimes.com/residents-corner/mental-health-disability-residents-perspective-problems-and-solutions. Published November 26, 2014. Accessed August 31, 2016.
3. Zimmerman M. The importance of measuring outcomes in clinical practice. Psychiatric Times. http://www.psychiatrictimes.com/uspc2014/importance-measuring-outcomes-clinical-practice. Published October 1, 2014. Accessed August 31, 2016.
4. Schwarz L, Roskos PT, Grossberg GT. Answers to 7 questions about using neuropsychological testing in your practice. Current Psychiatry. 2014;13(3):34-39.
How to assess the merits of psychological and neuropsychological test evaluations
Psychological and neuropsychological test evaluations, like all consultative diagnostic services, can vary in quality and clinical utility. Many of these examinations provide valuable insights and helpful recommendations; regrettably, some assessments are only marginally beneficial and can contribute to diagnostic confusion and uncertainty.
When weighing the pros and cons of evaluations, consider these best practices.
Gold-standard tests ought to be in-cluded in the assessment. These include (but are not limited to) the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV); Wechsler Memory Scale-Fourth Edition (WMS-IV); Delis-Kaplan Executive Function System (D-KEFS); Wechsler Individual Achievement Test-Third Edition (WIAT-III); and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). These tests have a strong evidence base that:
• demonstrates good reliability (ie, produce consistent and accurate scores across examiners and time intervals and are relatively free of measurement error)
• demonstrates good validity (ie, have been shown to measure aspects of psychological and neuropsychological functioning that they claim to measure).
Many gold-standard tests are normed on national samples and are stratified by age, sex, ethnicity or race, educational level, and geographic region. They also include normative data based on the performance of patients who have neuropsychiatric syndromes often seen by psychiatrists in practice.1
The test battery ought to comprise cognitive and neuropsychological measures as well as affective and behavioral measures. When feasible, these tests should be supplemented by informant-based measures of neuropsychiatric functioning to obtain a comprehensive assessment of the patient’s capacities and skills.
An estimated premorbid baseline should be established. This is done by taking a relevant history and administering tests, such as the National Adult Reading Test (NART), that can be used to compare against current test performance. This testing-in-context approach helps differentiate long-term limitations in information processing, which might be attributed to a DSM-5 intellectual disability, specific learning disorder, or other neurodevelopmental disorder, from a known or suspected recent neurobehavioral change.
Tests in the assessment should tap a broad set of neurobehavioral functions. Doing so ensures that, when a patient is referred with a change in cognition or other aspects of mental status, it will be easier to determine whether clinically significant score discrepancies exist across different ability and skill domains. Such dissociations in performance can have important implications for the differential diagnosis and everyday functioning.
Tests that are sensitive to a patient’s over-reporting of symptoms should be used as part of the evaluation in cases of suspected malingering—especially subtle simulation that might elude identification with brief screening-level measures.2 These tests can include the Test of Memory Malingering (TOMM) and the Structured Interview of Reported Symptoms, 2nd edition (SIRS-2).
Test recommendations ought to be grounded in findings; practical; and relatively easy to implement. They also should be consistent with the treatment setting and the patient’s lifestyle, values, and treatment preferences.3
Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Geisinger KF, Bracken BA, Carlson JF, et al, eds. APA handbook of testing and assessment in psychology. Washington, DC: American Psychological Association Press; 2013.
2. Brady MC, Scher LM, Newman W. “I just saw Big Bird. He was 100 feet tall!” Malingering in the emergency department. Current Psychiatry. 2013;12(10):33-38,40.
3. McHugh RK, Whitton SW, Peckham AD, et al. Patient p for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry. 2013;74(6):595-602.
Psychological and neuropsychological test evaluations, like all consultative diagnostic services, can vary in quality and clinical utility. Many of these examinations provide valuable insights and helpful recommendations; regrettably, some assessments are only marginally beneficial and can contribute to diagnostic confusion and uncertainty.
When weighing the pros and cons of evaluations, consider these best practices.
Gold-standard tests ought to be in-cluded in the assessment. These include (but are not limited to) the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV); Wechsler Memory Scale-Fourth Edition (WMS-IV); Delis-Kaplan Executive Function System (D-KEFS); Wechsler Individual Achievement Test-Third Edition (WIAT-III); and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). These tests have a strong evidence base that:
• demonstrates good reliability (ie, produce consistent and accurate scores across examiners and time intervals and are relatively free of measurement error)
• demonstrates good validity (ie, have been shown to measure aspects of psychological and neuropsychological functioning that they claim to measure).
Many gold-standard tests are normed on national samples and are stratified by age, sex, ethnicity or race, educational level, and geographic region. They also include normative data based on the performance of patients who have neuropsychiatric syndromes often seen by psychiatrists in practice.1
The test battery ought to comprise cognitive and neuropsychological measures as well as affective and behavioral measures. When feasible, these tests should be supplemented by informant-based measures of neuropsychiatric functioning to obtain a comprehensive assessment of the patient’s capacities and skills.
An estimated premorbid baseline should be established. This is done by taking a relevant history and administering tests, such as the National Adult Reading Test (NART), that can be used to compare against current test performance. This testing-in-context approach helps differentiate long-term limitations in information processing, which might be attributed to a DSM-5 intellectual disability, specific learning disorder, or other neurodevelopmental disorder, from a known or suspected recent neurobehavioral change.
Tests in the assessment should tap a broad set of neurobehavioral functions. Doing so ensures that, when a patient is referred with a change in cognition or other aspects of mental status, it will be easier to determine whether clinically significant score discrepancies exist across different ability and skill domains. Such dissociations in performance can have important implications for the differential diagnosis and everyday functioning.
Tests that are sensitive to a patient’s over-reporting of symptoms should be used as part of the evaluation in cases of suspected malingering—especially subtle simulation that might elude identification with brief screening-level measures.2 These tests can include the Test of Memory Malingering (TOMM) and the Structured Interview of Reported Symptoms, 2nd edition (SIRS-2).
Test recommendations ought to be grounded in findings; practical; and relatively easy to implement. They also should be consistent with the treatment setting and the patient’s lifestyle, values, and treatment preferences.3
Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Psychological and neuropsychological test evaluations, like all consultative diagnostic services, can vary in quality and clinical utility. Many of these examinations provide valuable insights and helpful recommendations; regrettably, some assessments are only marginally beneficial and can contribute to diagnostic confusion and uncertainty.
When weighing the pros and cons of evaluations, consider these best practices.
Gold-standard tests ought to be in-cluded in the assessment. These include (but are not limited to) the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV); Wechsler Memory Scale-Fourth Edition (WMS-IV); Delis-Kaplan Executive Function System (D-KEFS); Wechsler Individual Achievement Test-Third Edition (WIAT-III); and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). These tests have a strong evidence base that:
• demonstrates good reliability (ie, produce consistent and accurate scores across examiners and time intervals and are relatively free of measurement error)
• demonstrates good validity (ie, have been shown to measure aspects of psychological and neuropsychological functioning that they claim to measure).
Many gold-standard tests are normed on national samples and are stratified by age, sex, ethnicity or race, educational level, and geographic region. They also include normative data based on the performance of patients who have neuropsychiatric syndromes often seen by psychiatrists in practice.1
The test battery ought to comprise cognitive and neuropsychological measures as well as affective and behavioral measures. When feasible, these tests should be supplemented by informant-based measures of neuropsychiatric functioning to obtain a comprehensive assessment of the patient’s capacities and skills.
An estimated premorbid baseline should be established. This is done by taking a relevant history and administering tests, such as the National Adult Reading Test (NART), that can be used to compare against current test performance. This testing-in-context approach helps differentiate long-term limitations in information processing, which might be attributed to a DSM-5 intellectual disability, specific learning disorder, or other neurodevelopmental disorder, from a known or suspected recent neurobehavioral change.
Tests in the assessment should tap a broad set of neurobehavioral functions. Doing so ensures that, when a patient is referred with a change in cognition or other aspects of mental status, it will be easier to determine whether clinically significant score discrepancies exist across different ability and skill domains. Such dissociations in performance can have important implications for the differential diagnosis and everyday functioning.
Tests that are sensitive to a patient’s over-reporting of symptoms should be used as part of the evaluation in cases of suspected malingering—especially subtle simulation that might elude identification with brief screening-level measures.2 These tests can include the Test of Memory Malingering (TOMM) and the Structured Interview of Reported Symptoms, 2nd edition (SIRS-2).
Test recommendations ought to be grounded in findings; practical; and relatively easy to implement. They also should be consistent with the treatment setting and the patient’s lifestyle, values, and treatment preferences.3
Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Geisinger KF, Bracken BA, Carlson JF, et al, eds. APA handbook of testing and assessment in psychology. Washington, DC: American Psychological Association Press; 2013.
2. Brady MC, Scher LM, Newman W. “I just saw Big Bird. He was 100 feet tall!” Malingering in the emergency department. Current Psychiatry. 2013;12(10):33-38,40.
3. McHugh RK, Whitton SW, Peckham AD, et al. Patient p for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry. 2013;74(6):595-602.
1. Geisinger KF, Bracken BA, Carlson JF, et al, eds. APA handbook of testing and assessment in psychology. Washington, DC: American Psychological Association Press; 2013.
2. Brady MC, Scher LM, Newman W. “I just saw Big Bird. He was 100 feet tall!” Malingering in the emergency department. Current Psychiatry. 2013;12(10):33-38,40.
3. McHugh RK, Whitton SW, Peckham AD, et al. Patient p for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry. 2013;74(6):595-602.
How to talk to patients and their family after a diagnosis of mild cognitive impairment
Mild cognitive impairment (MCI) is a transitional clinical stage between normal aging and dementia. Together with aging, it is considered the most significant risk factor for developing dementia, often the Alzheimer’s type.1
MCI is a challenging neuropsychiatric diagnosis to discuss with patients and their family because it is characterized by overlapping features of normal aging and because of its heterogeneity of etiology, clinical presentation, and outcome.2,3 The evolution to dementia and the lack of effective treatments for preventing or forestalling this outcome can be difficult to address—particularly when the patient is in good health and has been leading a productive life.
Successful communication is key
You can take steps to communicate in a helpful way, build a strong treatment alliance, and reduce the potential for the iatrogenic effects of disclosing this diagnosis and its prognostic implications.
Clarify that your findings are consistent with the patient’s or family’s report of sustained and concerning change in cognition and, depending on the patient, concurrent alterations in affect, behavior, or both. Emphasize that these changes are disproportionately severe relative to expectations for the patient’s age and are not caused by psychiatric or clear-cut medical factors.
Highlight contexts in which the patient’s symptoms are likely to become more disruptive and impaired, and situations in which the patient can be expected to function more effectively.
Provide evidence-based support for the rate of progression of symptoms and functional impairment.3
Emphasize that major lifestyle adjustments usually are unnecessary in the absence of progression, especially for patients who are retired or not involved in endeavors that involve significant cognitive and executive functioning demands.
Discuss the role that cognition-enhancing medications might play in managing symptoms.4
Address indications for additional services, including formal psychiatric care for patients who have concomitant affective or behavioral symptoms and who are highly distressed by the diagnosis. Pair these services with longitudinal monitoring for possible exacerbation of symptoms.
Identify psychiatric, medical, and lifestyle factors that can increase the risk of dementia. Depending on the patient’s history, this might include diabetes, hypertension, elevated lipid levels, obesity, smoking, head trauma, depression, physical inactivity, and lack of intellectual stimulation.
Review compensatory strategies. In MCI predominantly amnestic type, for example, having the patient make systematic lists for shopping and other activities of daily living, as well as establishing routines for organizaton, can bolster successful coping.
If psychometric testing was not utilized to establish the diagnosis, discussion can include the value of performing such an assessment for a more finely tuned profile of preserved and impaired neurobehavioral functions. Such a profile can include test patterns that 1) have prognostic value with regard to the likelihood of progression to dementia and 2) establish a baseline against which you can assess stability or progression over time.5
Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Albert MS, DeKosky ST, Dickson D, et al. The diagnosis of mild cognitive impairment due to Alzheimer’s disease: recommendations from the National Institute on Aging- Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7(3):270-279.
2. Ellison JM, Harper DG, Berlow Y, et al. Beyond the “C” in MCI: noncognitive symptoms in amnestic and non-amnestic mild cognitive impairment. CNS Spectr. 2008;13(1):66-72.
3. Goveas JS, Dixon-Holbrook M, Kerwin D, et al. Mild cognitive impairment: how can you be sure? Current Psychiatry. 2008;7(4):36-40, 46-50.
4. Doody RS, Ferris SH, Salloway S, et al. Donepezil treatment of patients with MCI: a 48-week randomized, placebo-controlled trial. Neurology. 2009;72(18):1555-1561.
5. Summers MJ, Saunders NL. Neuropsychological measures predict decline to Alzheimer’s dementia from mild cognitive impairment. Neuropsychology. 2012;26(4):498-508.
Mild cognitive impairment (MCI) is a transitional clinical stage between normal aging and dementia. Together with aging, it is considered the most significant risk factor for developing dementia, often the Alzheimer’s type.1
MCI is a challenging neuropsychiatric diagnosis to discuss with patients and their family because it is characterized by overlapping features of normal aging and because of its heterogeneity of etiology, clinical presentation, and outcome.2,3 The evolution to dementia and the lack of effective treatments for preventing or forestalling this outcome can be difficult to address—particularly when the patient is in good health and has been leading a productive life.
Successful communication is key
You can take steps to communicate in a helpful way, build a strong treatment alliance, and reduce the potential for the iatrogenic effects of disclosing this diagnosis and its prognostic implications.
Clarify that your findings are consistent with the patient’s or family’s report of sustained and concerning change in cognition and, depending on the patient, concurrent alterations in affect, behavior, or both. Emphasize that these changes are disproportionately severe relative to expectations for the patient’s age and are not caused by psychiatric or clear-cut medical factors.
Highlight contexts in which the patient’s symptoms are likely to become more disruptive and impaired, and situations in which the patient can be expected to function more effectively.
Provide evidence-based support for the rate of progression of symptoms and functional impairment.3
Emphasize that major lifestyle adjustments usually are unnecessary in the absence of progression, especially for patients who are retired or not involved in endeavors that involve significant cognitive and executive functioning demands.
Discuss the role that cognition-enhancing medications might play in managing symptoms.4
Address indications for additional services, including formal psychiatric care for patients who have concomitant affective or behavioral symptoms and who are highly distressed by the diagnosis. Pair these services with longitudinal monitoring for possible exacerbation of symptoms.
Identify psychiatric, medical, and lifestyle factors that can increase the risk of dementia. Depending on the patient’s history, this might include diabetes, hypertension, elevated lipid levels, obesity, smoking, head trauma, depression, physical inactivity, and lack of intellectual stimulation.
Review compensatory strategies. In MCI predominantly amnestic type, for example, having the patient make systematic lists for shopping and other activities of daily living, as well as establishing routines for organizaton, can bolster successful coping.
If psychometric testing was not utilized to establish the diagnosis, discussion can include the value of performing such an assessment for a more finely tuned profile of preserved and impaired neurobehavioral functions. Such a profile can include test patterns that 1) have prognostic value with regard to the likelihood of progression to dementia and 2) establish a baseline against which you can assess stability or progression over time.5
Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
Mild cognitive impairment (MCI) is a transitional clinical stage between normal aging and dementia. Together with aging, it is considered the most significant risk factor for developing dementia, often the Alzheimer’s type.1
MCI is a challenging neuropsychiatric diagnosis to discuss with patients and their family because it is characterized by overlapping features of normal aging and because of its heterogeneity of etiology, clinical presentation, and outcome.2,3 The evolution to dementia and the lack of effective treatments for preventing or forestalling this outcome can be difficult to address—particularly when the patient is in good health and has been leading a productive life.
Successful communication is key
You can take steps to communicate in a helpful way, build a strong treatment alliance, and reduce the potential for the iatrogenic effects of disclosing this diagnosis and its prognostic implications.
Clarify that your findings are consistent with the patient’s or family’s report of sustained and concerning change in cognition and, depending on the patient, concurrent alterations in affect, behavior, or both. Emphasize that these changes are disproportionately severe relative to expectations for the patient’s age and are not caused by psychiatric or clear-cut medical factors.
Highlight contexts in which the patient’s symptoms are likely to become more disruptive and impaired, and situations in which the patient can be expected to function more effectively.
Provide evidence-based support for the rate of progression of symptoms and functional impairment.3
Emphasize that major lifestyle adjustments usually are unnecessary in the absence of progression, especially for patients who are retired or not involved in endeavors that involve significant cognitive and executive functioning demands.
Discuss the role that cognition-enhancing medications might play in managing symptoms.4
Address indications for additional services, including formal psychiatric care for patients who have concomitant affective or behavioral symptoms and who are highly distressed by the diagnosis. Pair these services with longitudinal monitoring for possible exacerbation of symptoms.
Identify psychiatric, medical, and lifestyle factors that can increase the risk of dementia. Depending on the patient’s history, this might include diabetes, hypertension, elevated lipid levels, obesity, smoking, head trauma, depression, physical inactivity, and lack of intellectual stimulation.
Review compensatory strategies. In MCI predominantly amnestic type, for example, having the patient make systematic lists for shopping and other activities of daily living, as well as establishing routines for organizaton, can bolster successful coping.
If psychometric testing was not utilized to establish the diagnosis, discussion can include the value of performing such an assessment for a more finely tuned profile of preserved and impaired neurobehavioral functions. Such a profile can include test patterns that 1) have prognostic value with regard to the likelihood of progression to dementia and 2) establish a baseline against which you can assess stability or progression over time.5
Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Albert MS, DeKosky ST, Dickson D, et al. The diagnosis of mild cognitive impairment due to Alzheimer’s disease: recommendations from the National Institute on Aging- Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7(3):270-279.
2. Ellison JM, Harper DG, Berlow Y, et al. Beyond the “C” in MCI: noncognitive symptoms in amnestic and non-amnestic mild cognitive impairment. CNS Spectr. 2008;13(1):66-72.
3. Goveas JS, Dixon-Holbrook M, Kerwin D, et al. Mild cognitive impairment: how can you be sure? Current Psychiatry. 2008;7(4):36-40, 46-50.
4. Doody RS, Ferris SH, Salloway S, et al. Donepezil treatment of patients with MCI: a 48-week randomized, placebo-controlled trial. Neurology. 2009;72(18):1555-1561.
5. Summers MJ, Saunders NL. Neuropsychological measures predict decline to Alzheimer’s dementia from mild cognitive impairment. Neuropsychology. 2012;26(4):498-508.
1. Albert MS, DeKosky ST, Dickson D, et al. The diagnosis of mild cognitive impairment due to Alzheimer’s disease: recommendations from the National Institute on Aging- Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement. 2011;7(3):270-279.
2. Ellison JM, Harper DG, Berlow Y, et al. Beyond the “C” in MCI: noncognitive symptoms in amnestic and non-amnestic mild cognitive impairment. CNS Spectr. 2008;13(1):66-72.
3. Goveas JS, Dixon-Holbrook M, Kerwin D, et al. Mild cognitive impairment: how can you be sure? Current Psychiatry. 2008;7(4):36-40, 46-50.
4. Doody RS, Ferris SH, Salloway S, et al. Donepezil treatment of patients with MCI: a 48-week randomized, placebo-controlled trial. Neurology. 2009;72(18):1555-1561.
5. Summers MJ, Saunders NL. Neuropsychological measures predict decline to Alzheimer’s dementia from mild cognitive impairment. Neuropsychology. 2012;26(4):498-508.
Strategies to enhance patients’ acceptance of voluntary psychiatric admission
Voluntary psychiatric admission has become more problematic because of managed care authorization policies, restrictive inpatient entry criteria, uninsured
patients, and a decline in hospital beds.
In addition, patients often are ambivalent or resistant to hospitalization. It can be challenging to persuade a patient, as well as his (her) family, of the need for psychiatric admission, even when he acknowledges emotional suffering and impaired functioning.
The strategies offered here can enhance the probability that your patient, and his family, will agree to voluntary admission.
Provide a compelling rationale. Stress the need for immediate, specialized, and intensive services. If the patient is receiving outpatient mental health care, advise him that these services have been unsuccessful in achieving safety and clinical stability, and that it is not possible to quickly establish a modified outpatient plan or a day hospital placement that would meet his needs. For a patient who is not receiving outpatient care, explain that it is not feasible to implement a workable plan “from the ground up” in a timely manner.
Reset the clock. Redefine admission as a way to interrupt a downward spiral and offer a new start with a treatment team that has “fresh eyes.”
Use language of the medical model. Explain to the patient that a person who has a dangerously high, poorly controlled body temperature unquestionably needs to be hospitalized and that, by analogy, he—your patient—is running a “high emotional temperature” that warrants inpatient care.
Consider having the patient complete a brief, self-report rating scale, such as the Beck Depression Inventory-II or the Generalized Anxiety Disorder 7-item scale.1 Review findings with him and his family to show the frequency, duration, and severity of symptoms.
Dispel misconceptions and myths. These include catastrophic fears—often based on stereotypes—about coercive treatment and indefinite confinement. Clarifying what a patient can expect with voluntary admission with regard to probable length of stay, participation in the milieu, visitation, and discharge planning is helpful for allaying such fears.
Build bridges with significant others. Ally with parties who support voluntary admission, including the patient’s primary care or mental health provider, if appropriate. Getting family members and significant others on board; having them talk with the patient can go a long way toward reaching an agreement to proceed with hospitalization.
Maintain an empathic stance. For many patients, psychiatric admission evokes considerable distress. Remain sensitive to the situational concerns that typically arise, such as disruption to family and job responsibilities, insurance coverage, and whether there will be an outpatient plan in place at discharge.
A psychiatric admission often triggers long-standing psychological vulnerabilities— such as feelings of humiliation or failure, fear of separation and abandonment, worry about being a burden to family, stigma, and anxiety about having a serious mental illness—all of which might require exploration to allay upset and enhance compliance.
Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned with this article or with manufacturers of competing products.
Reference
1. Blais MA. A guide to applying rating scales in clinical psychiatry. Psychiatr Times. 2011;28:58-62.
Voluntary psychiatric admission has become more problematic because of managed care authorization policies, restrictive inpatient entry criteria, uninsured
patients, and a decline in hospital beds.
In addition, patients often are ambivalent or resistant to hospitalization. It can be challenging to persuade a patient, as well as his (her) family, of the need for psychiatric admission, even when he acknowledges emotional suffering and impaired functioning.
The strategies offered here can enhance the probability that your patient, and his family, will agree to voluntary admission.
Provide a compelling rationale. Stress the need for immediate, specialized, and intensive services. If the patient is receiving outpatient mental health care, advise him that these services have been unsuccessful in achieving safety and clinical stability, and that it is not possible to quickly establish a modified outpatient plan or a day hospital placement that would meet his needs. For a patient who is not receiving outpatient care, explain that it is not feasible to implement a workable plan “from the ground up” in a timely manner.
Reset the clock. Redefine admission as a way to interrupt a downward spiral and offer a new start with a treatment team that has “fresh eyes.”
Use language of the medical model. Explain to the patient that a person who has a dangerously high, poorly controlled body temperature unquestionably needs to be hospitalized and that, by analogy, he—your patient—is running a “high emotional temperature” that warrants inpatient care.
Consider having the patient complete a brief, self-report rating scale, such as the Beck Depression Inventory-II or the Generalized Anxiety Disorder 7-item scale.1 Review findings with him and his family to show the frequency, duration, and severity of symptoms.
Dispel misconceptions and myths. These include catastrophic fears—often based on stereotypes—about coercive treatment and indefinite confinement. Clarifying what a patient can expect with voluntary admission with regard to probable length of stay, participation in the milieu, visitation, and discharge planning is helpful for allaying such fears.
Build bridges with significant others. Ally with parties who support voluntary admission, including the patient’s primary care or mental health provider, if appropriate. Getting family members and significant others on board; having them talk with the patient can go a long way toward reaching an agreement to proceed with hospitalization.
Maintain an empathic stance. For many patients, psychiatric admission evokes considerable distress. Remain sensitive to the situational concerns that typically arise, such as disruption to family and job responsibilities, insurance coverage, and whether there will be an outpatient plan in place at discharge.
A psychiatric admission often triggers long-standing psychological vulnerabilities— such as feelings of humiliation or failure, fear of separation and abandonment, worry about being a burden to family, stigma, and anxiety about having a serious mental illness—all of which might require exploration to allay upset and enhance compliance.
Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned with this article or with manufacturers of competing products.
Voluntary psychiatric admission has become more problematic because of managed care authorization policies, restrictive inpatient entry criteria, uninsured
patients, and a decline in hospital beds.
In addition, patients often are ambivalent or resistant to hospitalization. It can be challenging to persuade a patient, as well as his (her) family, of the need for psychiatric admission, even when he acknowledges emotional suffering and impaired functioning.
The strategies offered here can enhance the probability that your patient, and his family, will agree to voluntary admission.
Provide a compelling rationale. Stress the need for immediate, specialized, and intensive services. If the patient is receiving outpatient mental health care, advise him that these services have been unsuccessful in achieving safety and clinical stability, and that it is not possible to quickly establish a modified outpatient plan or a day hospital placement that would meet his needs. For a patient who is not receiving outpatient care, explain that it is not feasible to implement a workable plan “from the ground up” in a timely manner.
Reset the clock. Redefine admission as a way to interrupt a downward spiral and offer a new start with a treatment team that has “fresh eyes.”
Use language of the medical model. Explain to the patient that a person who has a dangerously high, poorly controlled body temperature unquestionably needs to be hospitalized and that, by analogy, he—your patient—is running a “high emotional temperature” that warrants inpatient care.
Consider having the patient complete a brief, self-report rating scale, such as the Beck Depression Inventory-II or the Generalized Anxiety Disorder 7-item scale.1 Review findings with him and his family to show the frequency, duration, and severity of symptoms.
Dispel misconceptions and myths. These include catastrophic fears—often based on stereotypes—about coercive treatment and indefinite confinement. Clarifying what a patient can expect with voluntary admission with regard to probable length of stay, participation in the milieu, visitation, and discharge planning is helpful for allaying such fears.
Build bridges with significant others. Ally with parties who support voluntary admission, including the patient’s primary care or mental health provider, if appropriate. Getting family members and significant others on board; having them talk with the patient can go a long way toward reaching an agreement to proceed with hospitalization.
Maintain an empathic stance. For many patients, psychiatric admission evokes considerable distress. Remain sensitive to the situational concerns that typically arise, such as disruption to family and job responsibilities, insurance coverage, and whether there will be an outpatient plan in place at discharge.
A psychiatric admission often triggers long-standing psychological vulnerabilities— such as feelings of humiliation or failure, fear of separation and abandonment, worry about being a burden to family, stigma, and anxiety about having a serious mental illness—all of which might require exploration to allay upset and enhance compliance.
Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned with this article or with manufacturers of competing products.
Reference
1. Blais MA. A guide to applying rating scales in clinical psychiatry. Psychiatr Times. 2011;28:58-62.
Reference
1. Blais MA. A guide to applying rating scales in clinical psychiatry. Psychiatr Times. 2011;28:58-62.
Is your patient’s poor recall more than just a ‘senior moment’?
Memory and other cognitive complaints are common among the general population and become more prevalent with age.1 People who have significant emotional investment in their cognitive competence, mood disturbance, somatic symptoms, and anxiety or related disorders are likely to worry more about their cognitive functioning as they age.
Common complaints
Age-related complaints, typically beginning by age 50, often include problems retaining or retrieving names, difficulty recalling details of conversations and written materials, and hazy recollection of remote events and the time frame of recent life events. Common complaints involve difficulties with mental calculations, multi-tasking (including vulnerability to distraction), and problems keeping track of and organizing information. The most common complaint is difficulty with remembering the reason for entering a room.
More concerning are complaints involving recurrent lapses in judgment or forgetfulness with significant implications for everyday living (eg, physical safety, job performance, travel, and finances), especially when validated by friends or family members and coupled with decline in at least 1 activity of daily living, and poor insight.
Helping your forgetful patient
Office evaluation with brief cognitive screening instruments—namely, the Montreal Cognitive Assessment and the recent revision of the Mini-Mental State Examination—might help clarify the clinical presentation. Proceed with caution: Screening tests tap a limited number of neurocognitive functions and can generate a false-negative result among brighter and better educated patients and a false-positive result among the less intelligent and less educated.2 Applying age- and education-corrected norms can reduce misclassification but does not eliminate it.
Screening measures can facilitate decision-making regarding the need for more comprehensive psychometric assessment. Such evaluations sample a broader range of neurobehavioral domains, in greater depth, and provide a more nuanced picture of a patient’s neurocognition.
Findings on a battery of psychological and neuropsychological tests that might evoke concern include problems with incidental, anterograde, and recent memory that are not satisfactorily explained by: age and education or vocational training; estimated premorbid intelligence; residual neurodevelopmental disorders (attention, learning, and autistic-spectrum disorders); situational, sociocultural, and psychiatric factors; and motivational influences—notably, malingering.
Some difficulties with memory are highly associated with mild cognitive impairment or early dementia:
• anterograde memory (involving a reduced rate of verbal and nonverbal learning over repeated trials)
• poor retention
• accelerated forgetting of newly learned information
• failure to benefit from recognition and other mnemonic cues
• so-called source error confusion—a misattribution that involves difficulty differentiating target information from competing information, as reflected in confabulation errors and an elevated rate of intrusion errors.
Disclosure
Dr. Pollak reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Weiner MF, Garrett R, Bret ME. Neuropsychiatric assessment and diagnosis. In: Weiner MF, Lipton AM, eds. Clinical manual of Alzheimer disease and other dementias. Arlington, VA: American Psychiatric Publishing, Inc.; 2012: 3-46.
2. Strauss E, Sherman EMS, Spreen O. A compendium of neuropsychological tests: administration, norms and commentary: third edition. New York, NY: Oxford University Press; 2006.
Memory and other cognitive complaints are common among the general population and become more prevalent with age.1 People who have significant emotional investment in their cognitive competence, mood disturbance, somatic symptoms, and anxiety or related disorders are likely to worry more about their cognitive functioning as they age.
Common complaints
Age-related complaints, typically beginning by age 50, often include problems retaining or retrieving names, difficulty recalling details of conversations and written materials, and hazy recollection of remote events and the time frame of recent life events. Common complaints involve difficulties with mental calculations, multi-tasking (including vulnerability to distraction), and problems keeping track of and organizing information. The most common complaint is difficulty with remembering the reason for entering a room.
More concerning are complaints involving recurrent lapses in judgment or forgetfulness with significant implications for everyday living (eg, physical safety, job performance, travel, and finances), especially when validated by friends or family members and coupled with decline in at least 1 activity of daily living, and poor insight.
Helping your forgetful patient
Office evaluation with brief cognitive screening instruments—namely, the Montreal Cognitive Assessment and the recent revision of the Mini-Mental State Examination—might help clarify the clinical presentation. Proceed with caution: Screening tests tap a limited number of neurocognitive functions and can generate a false-negative result among brighter and better educated patients and a false-positive result among the less intelligent and less educated.2 Applying age- and education-corrected norms can reduce misclassification but does not eliminate it.
Screening measures can facilitate decision-making regarding the need for more comprehensive psychometric assessment. Such evaluations sample a broader range of neurobehavioral domains, in greater depth, and provide a more nuanced picture of a patient’s neurocognition.
Findings on a battery of psychological and neuropsychological tests that might evoke concern include problems with incidental, anterograde, and recent memory that are not satisfactorily explained by: age and education or vocational training; estimated premorbid intelligence; residual neurodevelopmental disorders (attention, learning, and autistic-spectrum disorders); situational, sociocultural, and psychiatric factors; and motivational influences—notably, malingering.
Some difficulties with memory are highly associated with mild cognitive impairment or early dementia:
• anterograde memory (involving a reduced rate of verbal and nonverbal learning over repeated trials)
• poor retention
• accelerated forgetting of newly learned information
• failure to benefit from recognition and other mnemonic cues
• so-called source error confusion—a misattribution that involves difficulty differentiating target information from competing information, as reflected in confabulation errors and an elevated rate of intrusion errors.
Disclosure
Dr. Pollak reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Memory and other cognitive complaints are common among the general population and become more prevalent with age.1 People who have significant emotional investment in their cognitive competence, mood disturbance, somatic symptoms, and anxiety or related disorders are likely to worry more about their cognitive functioning as they age.
Common complaints
Age-related complaints, typically beginning by age 50, often include problems retaining or retrieving names, difficulty recalling details of conversations and written materials, and hazy recollection of remote events and the time frame of recent life events. Common complaints involve difficulties with mental calculations, multi-tasking (including vulnerability to distraction), and problems keeping track of and organizing information. The most common complaint is difficulty with remembering the reason for entering a room.
More concerning are complaints involving recurrent lapses in judgment or forgetfulness with significant implications for everyday living (eg, physical safety, job performance, travel, and finances), especially when validated by friends or family members and coupled with decline in at least 1 activity of daily living, and poor insight.
Helping your forgetful patient
Office evaluation with brief cognitive screening instruments—namely, the Montreal Cognitive Assessment and the recent revision of the Mini-Mental State Examination—might help clarify the clinical presentation. Proceed with caution: Screening tests tap a limited number of neurocognitive functions and can generate a false-negative result among brighter and better educated patients and a false-positive result among the less intelligent and less educated.2 Applying age- and education-corrected norms can reduce misclassification but does not eliminate it.
Screening measures can facilitate decision-making regarding the need for more comprehensive psychometric assessment. Such evaluations sample a broader range of neurobehavioral domains, in greater depth, and provide a more nuanced picture of a patient’s neurocognition.
Findings on a battery of psychological and neuropsychological tests that might evoke concern include problems with incidental, anterograde, and recent memory that are not satisfactorily explained by: age and education or vocational training; estimated premorbid intelligence; residual neurodevelopmental disorders (attention, learning, and autistic-spectrum disorders); situational, sociocultural, and psychiatric factors; and motivational influences—notably, malingering.
Some difficulties with memory are highly associated with mild cognitive impairment or early dementia:
• anterograde memory (involving a reduced rate of verbal and nonverbal learning over repeated trials)
• poor retention
• accelerated forgetting of newly learned information
• failure to benefit from recognition and other mnemonic cues
• so-called source error confusion—a misattribution that involves difficulty differentiating target information from competing information, as reflected in confabulation errors and an elevated rate of intrusion errors.
Disclosure
Dr. Pollak reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Weiner MF, Garrett R, Bret ME. Neuropsychiatric assessment and diagnosis. In: Weiner MF, Lipton AM, eds. Clinical manual of Alzheimer disease and other dementias. Arlington, VA: American Psychiatric Publishing, Inc.; 2012: 3-46.
2. Strauss E, Sherman EMS, Spreen O. A compendium of neuropsychological tests: administration, norms and commentary: third edition. New York, NY: Oxford University Press; 2006.
1. Weiner MF, Garrett R, Bret ME. Neuropsychiatric assessment and diagnosis. In: Weiner MF, Lipton AM, eds. Clinical manual of Alzheimer disease and other dementias. Arlington, VA: American Psychiatric Publishing, Inc.; 2012: 3-46.
2. Strauss E, Sherman EMS, Spreen O. A compendium of neuropsychological tests: administration, norms and commentary: third edition. New York, NY: Oxford University Press; 2006.
Distinguishing between adult ADHD and mild cognitive impairment
There is considerable overlap between symptoms of adult attention-deficit/hyperactivity disorder (ADHD) and mild cognitive impairment (MCI), including problems with sustained attention or concentration, anterograde memory, and executive functioning. Differentiating these clinical syndromes based on symptomatic presentation alone can be difficult, but considering the following factors can help you make a more informed diagnosis:
Neurodevelopmental disorder history. DSM-IV-TR stipulates onset for some ADHD symptoms by age 7, although a DSM-5 Work Group is considering symptom onset as late as age 12.1 Initial onset or a dramatic worsening of longstanding ADHD symptoms in middle-age or older adults is atypical for this neurodevelopmental disorder.
Detailed self-diagnosed symptoms. Patients with ADHD usually can give a satisfactory history of their symptoms. Patients with MCI often are less able to provide a useful history because they have prominent difficulties with anterograde memory, which may be associated with emerging anosognosia.
Educational learning difficulties. Patients with ADHD frequently have comorbid learning difficulties and substance abuse disorders, which are uncommon in MCI.
Rating scales. When in doubt, use rating scales to assess for ADHD.2 Ask your patient to complete the rating scale based on how he or she remembers behaving in elementary through middle school, most of their adult life after age 20, and since symptom onset. Obtain collateral ratings from a reliable informant based on his or her knowledge of the patient’s long-term behavioral functioning.
Worsening symptoms. The typical ADHD patient will have a “positive” screen for symptoms, but will report fewer and less severe symptoms from childhood or adolescence through young adulthood and into middle and older age. Suspect MCI when your patient or an informant reports a clear worsening of symptoms in recent months or years despite a lack of evidence of a significant intervening psychiatric disorder.
Psychopharmacotherapy. Patients with MCI usually do not benefit from medications for ADHD. Patients with ADHD often report improvement in at least some of their symptoms with psychopharmacologic treatment.
When your patient’s history, rating scale assessment, and medication trials do not allow you to make a confident differential diagnosis, consider referring him or her for psychological or neuropsychological testing.
There can be overlap in psychometric test findings of middle-age and older adults with a history of ADHD and those who may have MCI. Still, MCI patients’ cognitive difficulties usually are more concerning and dramatic, including problems with spontaneous recall as well as “recognition memory.”
When findings from psychometric testing are equivocal because of possible co-occurrence, retesting in 12 to 18 months usually will help you make a reliable differential diagnosis. Specifically, progression of cognitive dysfunction—including evidence of worsening anterograde memory—is common in MCI but not in ADHD.
Current symptoms of major depressive disorder may further “muddy the waters.” However, parameters such as response to adequate medication trials, progression of cognitive dysfunction, and worsening of test-based cognitive or neuropsychological deficits over time can be useful in reaching a satisfactory differential diagnosis.
Disclosure
Dr. Pollak reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
There is considerable overlap between symptoms of adult attention-deficit/hyperactivity disorder (ADHD) and mild cognitive impairment (MCI), including problems with sustained attention or concentration, anterograde memory, and executive functioning. Differentiating these clinical syndromes based on symptomatic presentation alone can be difficult, but considering the following factors can help you make a more informed diagnosis:
Neurodevelopmental disorder history. DSM-IV-TR stipulates onset for some ADHD symptoms by age 7, although a DSM-5 Work Group is considering symptom onset as late as age 12.1 Initial onset or a dramatic worsening of longstanding ADHD symptoms in middle-age or older adults is atypical for this neurodevelopmental disorder.
Detailed self-diagnosed symptoms. Patients with ADHD usually can give a satisfactory history of their symptoms. Patients with MCI often are less able to provide a useful history because they have prominent difficulties with anterograde memory, which may be associated with emerging anosognosia.
Educational learning difficulties. Patients with ADHD frequently have comorbid learning difficulties and substance abuse disorders, which are uncommon in MCI.
Rating scales. When in doubt, use rating scales to assess for ADHD.2 Ask your patient to complete the rating scale based on how he or she remembers behaving in elementary through middle school, most of their adult life after age 20, and since symptom onset. Obtain collateral ratings from a reliable informant based on his or her knowledge of the patient’s long-term behavioral functioning.
Worsening symptoms. The typical ADHD patient will have a “positive” screen for symptoms, but will report fewer and less severe symptoms from childhood or adolescence through young adulthood and into middle and older age. Suspect MCI when your patient or an informant reports a clear worsening of symptoms in recent months or years despite a lack of evidence of a significant intervening psychiatric disorder.
Psychopharmacotherapy. Patients with MCI usually do not benefit from medications for ADHD. Patients with ADHD often report improvement in at least some of their symptoms with psychopharmacologic treatment.
When your patient’s history, rating scale assessment, and medication trials do not allow you to make a confident differential diagnosis, consider referring him or her for psychological or neuropsychological testing.
There can be overlap in psychometric test findings of middle-age and older adults with a history of ADHD and those who may have MCI. Still, MCI patients’ cognitive difficulties usually are more concerning and dramatic, including problems with spontaneous recall as well as “recognition memory.”
When findings from psychometric testing are equivocal because of possible co-occurrence, retesting in 12 to 18 months usually will help you make a reliable differential diagnosis. Specifically, progression of cognitive dysfunction—including evidence of worsening anterograde memory—is common in MCI but not in ADHD.
Current symptoms of major depressive disorder may further “muddy the waters.” However, parameters such as response to adequate medication trials, progression of cognitive dysfunction, and worsening of test-based cognitive or neuropsychological deficits over time can be useful in reaching a satisfactory differential diagnosis.
Disclosure
Dr. Pollak reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
There is considerable overlap between symptoms of adult attention-deficit/hyperactivity disorder (ADHD) and mild cognitive impairment (MCI), including problems with sustained attention or concentration, anterograde memory, and executive functioning. Differentiating these clinical syndromes based on symptomatic presentation alone can be difficult, but considering the following factors can help you make a more informed diagnosis:
Neurodevelopmental disorder history. DSM-IV-TR stipulates onset for some ADHD symptoms by age 7, although a DSM-5 Work Group is considering symptom onset as late as age 12.1 Initial onset or a dramatic worsening of longstanding ADHD symptoms in middle-age or older adults is atypical for this neurodevelopmental disorder.
Detailed self-diagnosed symptoms. Patients with ADHD usually can give a satisfactory history of their symptoms. Patients with MCI often are less able to provide a useful history because they have prominent difficulties with anterograde memory, which may be associated with emerging anosognosia.
Educational learning difficulties. Patients with ADHD frequently have comorbid learning difficulties and substance abuse disorders, which are uncommon in MCI.
Rating scales. When in doubt, use rating scales to assess for ADHD.2 Ask your patient to complete the rating scale based on how he or she remembers behaving in elementary through middle school, most of their adult life after age 20, and since symptom onset. Obtain collateral ratings from a reliable informant based on his or her knowledge of the patient’s long-term behavioral functioning.
Worsening symptoms. The typical ADHD patient will have a “positive” screen for symptoms, but will report fewer and less severe symptoms from childhood or adolescence through young adulthood and into middle and older age. Suspect MCI when your patient or an informant reports a clear worsening of symptoms in recent months or years despite a lack of evidence of a significant intervening psychiatric disorder.
Psychopharmacotherapy. Patients with MCI usually do not benefit from medications for ADHD. Patients with ADHD often report improvement in at least some of their symptoms with psychopharmacologic treatment.
When your patient’s history, rating scale assessment, and medication trials do not allow you to make a confident differential diagnosis, consider referring him or her for psychological or neuropsychological testing.
There can be overlap in psychometric test findings of middle-age and older adults with a history of ADHD and those who may have MCI. Still, MCI patients’ cognitive difficulties usually are more concerning and dramatic, including problems with spontaneous recall as well as “recognition memory.”
When findings from psychometric testing are equivocal because of possible co-occurrence, retesting in 12 to 18 months usually will help you make a reliable differential diagnosis. Specifically, progression of cognitive dysfunction—including evidence of worsening anterograde memory—is common in MCI but not in ADHD.
Current symptoms of major depressive disorder may further “muddy the waters.” However, parameters such as response to adequate medication trials, progression of cognitive dysfunction, and worsening of test-based cognitive or neuropsychological deficits over time can be useful in reaching a satisfactory differential diagnosis.
Disclosure
Dr. Pollak reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Does your patient have a residual neurodevelopmental disorder?
Neurodevelopmental disorders are “life span” clinical syndromes1 that may contribute to development of axis I and axis II disorders and are associated with high rates of psychiatric comorbidity. Behaviors and symptoms of neurodevelopmental disorders are enduring and difficult to recognize—particularly in their milder and attenuated forms—because patients often “age out” of obvious manifestations. High rates of comorbidity with other DSM-IV-TR disorders also can contribute to substantial underdiagnosis and under-recognition. Failure to accurately identify a residual neurodevelopmental disorder can cause problems establishing and maintaining a working alliance and may lead to poor treatment outcomes.
Clues to help identify patients with residual neurodevelopmental symptoms include:
- repeating grade levels, requiring special education services, and/or failing to graduate high school
- academic and/or career underachievement
- developing uneven sensory, motor, cognitive, and/or academic skills
- chronically distressed “high achiever”
- long-term social ostracism and/or peculiarity.
Classification and typology
Patients within the dyslexic spectrum typically have a history of difficulty reading, spelling, and writing. These problems cannot be explained adequately by socio-cultural factors and/or general limitations in cognition.
Nonverbal learning disability patients have selective deficits in math reasoning and visuospatial processing, motor planning problems, and, at times, weak social interaction skills.
Signs of suspected residual attention-deficit/hyperactivity disorder include a history—usually dating back to elementary school—of poor concentration and weak retention abilities. These patients also have difficulty organizing, planning, and completing activities, particularly those requiring multiple steps and/or sustained mental effort.
Socially ostracized patients with social peculiarity, especially if coupled with ≥1 specific information processing and learning problems, frequently have mild residual difficulties that fall within the pervasive developmental disorder (autistic) spectrum.
Patients with histories of “across-the-board” problems acquiring academic skills and a lack of compensatory success in at least some non-academic pursuits may have generalized intellectual disability. This may be so-called “borderline” intellectual functioning or, in a much smaller number of cases, mild mental retardation/ mild intellectual disability.
Making an accurate diagnosis
To more easily identify patients with a residual developmental disorder, take a more detailed academic/educational history that includes Scholastic Aptitude Test scores, previous “coding” for ≥1 special needs psychoeducational conditions, and/or a childhood/adolescent history of psychometric testing. Also, obtain your patient’s educational/psychoeducational records.
Complete a detailed developmental history that includes exploring subtle anomalies in acquiring language pragmatics, motor coordination/planning, and social interaction skills.
Interview parents, spouses, and friends who are familiar with your patient’s longitudinal neurodevelopmental functioning.
Review recent texts on residual neurodevelopmental disorders.2 Consider referring your patient for psychometric testing to firm up diagnostic impressions and assist in treatment planning.
Neurodevelopmental disorders are “life span” clinical syndromes1 that may contribute to development of axis I and axis II disorders and are associated with high rates of psychiatric comorbidity. Behaviors and symptoms of neurodevelopmental disorders are enduring and difficult to recognize—particularly in their milder and attenuated forms—because patients often “age out” of obvious manifestations. High rates of comorbidity with other DSM-IV-TR disorders also can contribute to substantial underdiagnosis and under-recognition. Failure to accurately identify a residual neurodevelopmental disorder can cause problems establishing and maintaining a working alliance and may lead to poor treatment outcomes.
Clues to help identify patients with residual neurodevelopmental symptoms include:
- repeating grade levels, requiring special education services, and/or failing to graduate high school
- academic and/or career underachievement
- developing uneven sensory, motor, cognitive, and/or academic skills
- chronically distressed “high achiever”
- long-term social ostracism and/or peculiarity.
Classification and typology
Patients within the dyslexic spectrum typically have a history of difficulty reading, spelling, and writing. These problems cannot be explained adequately by socio-cultural factors and/or general limitations in cognition.
Nonverbal learning disability patients have selective deficits in math reasoning and visuospatial processing, motor planning problems, and, at times, weak social interaction skills.
Signs of suspected residual attention-deficit/hyperactivity disorder include a history—usually dating back to elementary school—of poor concentration and weak retention abilities. These patients also have difficulty organizing, planning, and completing activities, particularly those requiring multiple steps and/or sustained mental effort.
Socially ostracized patients with social peculiarity, especially if coupled with ≥1 specific information processing and learning problems, frequently have mild residual difficulties that fall within the pervasive developmental disorder (autistic) spectrum.
Patients with histories of “across-the-board” problems acquiring academic skills and a lack of compensatory success in at least some non-academic pursuits may have generalized intellectual disability. This may be so-called “borderline” intellectual functioning or, in a much smaller number of cases, mild mental retardation/ mild intellectual disability.
Making an accurate diagnosis
To more easily identify patients with a residual developmental disorder, take a more detailed academic/educational history that includes Scholastic Aptitude Test scores, previous “coding” for ≥1 special needs psychoeducational conditions, and/or a childhood/adolescent history of psychometric testing. Also, obtain your patient’s educational/psychoeducational records.
Complete a detailed developmental history that includes exploring subtle anomalies in acquiring language pragmatics, motor coordination/planning, and social interaction skills.
Interview parents, spouses, and friends who are familiar with your patient’s longitudinal neurodevelopmental functioning.
Review recent texts on residual neurodevelopmental disorders.2 Consider referring your patient for psychometric testing to firm up diagnostic impressions and assist in treatment planning.
Neurodevelopmental disorders are “life span” clinical syndromes1 that may contribute to development of axis I and axis II disorders and are associated with high rates of psychiatric comorbidity. Behaviors and symptoms of neurodevelopmental disorders are enduring and difficult to recognize—particularly in their milder and attenuated forms—because patients often “age out” of obvious manifestations. High rates of comorbidity with other DSM-IV-TR disorders also can contribute to substantial underdiagnosis and under-recognition. Failure to accurately identify a residual neurodevelopmental disorder can cause problems establishing and maintaining a working alliance and may lead to poor treatment outcomes.
Clues to help identify patients with residual neurodevelopmental symptoms include:
- repeating grade levels, requiring special education services, and/or failing to graduate high school
- academic and/or career underachievement
- developing uneven sensory, motor, cognitive, and/or academic skills
- chronically distressed “high achiever”
- long-term social ostracism and/or peculiarity.
Classification and typology
Patients within the dyslexic spectrum typically have a history of difficulty reading, spelling, and writing. These problems cannot be explained adequately by socio-cultural factors and/or general limitations in cognition.
Nonverbal learning disability patients have selective deficits in math reasoning and visuospatial processing, motor planning problems, and, at times, weak social interaction skills.
Signs of suspected residual attention-deficit/hyperactivity disorder include a history—usually dating back to elementary school—of poor concentration and weak retention abilities. These patients also have difficulty organizing, planning, and completing activities, particularly those requiring multiple steps and/or sustained mental effort.
Socially ostracized patients with social peculiarity, especially if coupled with ≥1 specific information processing and learning problems, frequently have mild residual difficulties that fall within the pervasive developmental disorder (autistic) spectrum.
Patients with histories of “across-the-board” problems acquiring academic skills and a lack of compensatory success in at least some non-academic pursuits may have generalized intellectual disability. This may be so-called “borderline” intellectual functioning or, in a much smaller number of cases, mild mental retardation/ mild intellectual disability.
Making an accurate diagnosis
To more easily identify patients with a residual developmental disorder, take a more detailed academic/educational history that includes Scholastic Aptitude Test scores, previous “coding” for ≥1 special needs psychoeducational conditions, and/or a childhood/adolescent history of psychometric testing. Also, obtain your patient’s educational/psychoeducational records.
Complete a detailed developmental history that includes exploring subtle anomalies in acquiring language pragmatics, motor coordination/planning, and social interaction skills.
Interview parents, spouses, and friends who are familiar with your patient’s longitudinal neurodevelopmental functioning.
Review recent texts on residual neurodevelopmental disorders.2 Consider referring your patient for psychometric testing to firm up diagnostic impressions and assist in treatment planning.