Some General Thoughts on Geropsychological Assessment

Even prior to my entrée into Geropsychology practice, I have long regarded psychological assessment as a critical area for me to attain expertise – I consider assessment to be an indispensable aspect of psychology professional practice.  I think the context of practicing assessment in a research context served me very, well later in my career when it came to learning psychological test administration.

My internship year (University Behavioral Healthcare at the University of Medicine and Dentistry of New Jersey – UBHC at UMDNJ) was when my training and experience in psychological assessment was taken to another level, particularly as regards applications of neuropsychological testing to Geropsychological practice. In my year at the UBHC Dementia Diagnostic Clinic (DDC) in Piscataway, New Jersey, I performed easily 60-70 neuropsychological screening batteries on older adult patients with memory complaints in my year as Geropsychology intern. Typically, clinic patients were seen for suspected primary progressive dementia issues (e.g., Alzheimer’s disease, cerebrovascular dementia), however, on occasion we saw other, more challenging diagnostic issues present, such as cognitive deficits secondary to chronic alcoholism, dementia syndrome of depression, and reversible dementias due to medication issues (one issue I recall was due to probable lithium toxicity in a bipolar patient we assessed).

I performed at least an additional 30 or so batteries on adult and older adult clientele in my year at the UBHC Psychological Assessment clinic – it was there that I became competent on more involved neuropsychological assessment batteries, and doing more complex referral questions (e.g., ruling out various forms of dementia), capacity and disability assessments, and doing integrated assessment batteries as a means of assisting in treatment planning. In both cases (e.g., working for the DDC and the Assessment Clinic) I was able to learn valuable initial skills in that I continue to take with me today – in terms of test selection, report writing, and most importantly, in terms of providing feedback to clientele, caregivers, and other providers. This is where I really began to learn the value of Geropsychological assessment practice; the value is difficult to overestimate in terms of how it informs the work of paid and unpaid caregivers with our patients, and how it informs intervention approaches. Speaking of which, as I later progressed in my work and my practice began to coalesce around working in long term care Geropsychological practice, I feel that my approach to providing psychological assessment for primarily geriatric clientele within an integrated healthcare setting has gone from competent / proficient (as a practicum student and intern) to expert-level. I am extremely comfortable in performing a seamless blend of assessment with a therapeutic / consultative approach in my LTC practice where necessary. It is my practice identity, as it were.

As a geropsychologist, assessments are no good as isolated, academic exercises. My colleagues (nursing, medicine, social work) need specific questions efficiently answered on issues such as cognitive functioning (both as a snapshot and across time), personality functioning, psychiatric status, and capacity status. They need to know these things as they are critical to insuring patient safety, physical, psychological, and financial well-being, and in optimizing medications, and in finding the best way to approach patients in general. Assessment can be critical in alerting staff how they should approach patients. For example, personality testing may indicate whether the patient tends to prefer direction and structure from their caregivers, or whether they prefer nondirective approaches and more emphasis of independence and choice (e.g., whether trait resistance is an issue). Does a patient have memory problems? If so, how can we best assist the patient compensate and optimize for their deficits? If they have short-term memory loss, is cueing helpful? If so, do they have strengths and weaknesses in receptive language that would guide nursing approaches (e.g., written, spoken, pictorial and/or gestural cueing / reminders, etc.)? And so on.

A special category of geropsychological assessment are capacity assessments. A particularly valuable resource which I acquired in 2008 is the “Assessment of Older Adults with Diminished Capacity,” which I acquired around the same time. I made careful use of this resource, which covers areas I was previously barely familiar with as an early-career geropsychologist (e.g., such as undue influence, sexual consent capacity, etc). Since I have been licensed in 2006, I have performed scores of capacity assessments on my geriatric patients for the VA system – primarily regarding issues regarding medical decisionmaking capacity and capacity to live independently. In other roles (such as assessment consultant with the Institute on Aging), I have performed assessments of testamentary and fiduciary capacity as well (e.g., capacity to manage funds, finances, change wills, name durable power of attorney, etc). I tend to use a fixed-flexible battery approach where I combine standardized neuropsychological screening batteries (e.g., Cognitive Testing Battery, RBANS, etc.) with additional instruments added to do some limits-testing, and also to assess function (e.g., Independent Living Scales, etc). I also have several forms of semi-structured capacity assessment instruments which I have made use of over the years which supplement my interviews (e.g., the Hopemont Capacity Assessment Inventory, the Hopkins, etc).

I have found that a competent capacity assessment on my part is often written in a qualitatively different form than my other reports. The level of subjective detail is often much denser and my conclusions are based often on considerably more painstaking justification. In part this is due to the fact that in many areas of capacity that I am asked to assess that are rather murky in terms of relevant standards (such as sexual consent capacity) or where there is simply just not much relevant research and guidelines to light the way (such as undue influence).  This may also have to do with attention paid to my audience – frequently capacity assessment reports are more often consumed by case managers and lawyers as opposed to medical professionals, and really – a patients liberty often hinges on my assessment in this case. I take that responsibility very seriously.

I find psychological assessment with my geriatric patients to be one of the most professionally satisfying activities I engage in as a Geropsychologist. It’s for several reasons – I thoroughly enjoy the intellectual exercise of crafting a well-written report with concise conclusions based on systematic data. I also find the intellectual exercise of differential diagnosis (particularly as regards different types of dementia syndromes) to be quite engaging and satisfying as well. Finally, there is the personal gratification I receive when a paid or family caregiver or medical professional gains a new and useful understanding of the patient based on my report, sometimes with profound consequences.