Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change

Introduction

Dementia1 in its many forms is a leading cause of functional limitation among older adults worldwide and will continue to ascend in global health importance as populations continue to age and effective cures remain elusive (Mathers & Loncar, 2006). Plassman et al. (2007) estimated that over 2.5 million Americans suffered from Alzheimer's disease (AD) and that nearly 4 million had that and other forms of dementia in 2002. Given expected increases in the size of the older adult population, those numbers are expected to increase strikingly by 2050 (Alzheimer's Association, 2009).

The following guidelines were developed for psychologists who perform evaluations of dementia and agerelated cognitive change. These guidelines conform to the American Psychological Association's (APA's) "Ethical Principles of Psychologists and Code of Conduct" (APA, 2002). The term guidelines refers to statements that suggest or recommend specific professional behavior, endeavors, or conduct for psychologists. Guidelines differ from standards in that standards are mandatory and may be accompanied by an enforcement mechanism. Guidelines are aspirational in intent. They are intended to facilitate the continued systematic development of the profession and to help facilitate a high level of practice by psychologists. Guidelines are not intended to be mandatory or exhaustive and may not be applicable to every professional situation. They are not definitive, and they are not intended to take precedence over the judgment of psychologists.

Guidelines on this topic were originally developed by an APA Presidential Task Force, approved as policy of APA by the APA Council of Representatives, and published in 1998 (APA Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia, 1998). Consistent with APA standards, these guidelines were subject to sunset or review in 2008. The Board of Professional Affairs and the Committee on Professional Practice and Standards conducted an initial review and determined that the guidelines should not be sunset and that revision was appropriate. The APA Committee on Aging empanelled a group of experts who reviewed and deemed appropriate the maintenance of these guidelines with appropriate revision and updating. The introduction to the original guidelines remains pertinent today:

"Psychologists can play a leading role in the evaluation of the memory complaints and changes in cognitive functioning that frequently occur in the later decades of life. Although some healthy aging persons maintain very high cognitive performance levels throughout life, most older people will experience a decline in certain cognitive abilities. This decline is usually not pathological, but rather parallels a number of common decreases in physiological function that occur in conjunction with normal developmental processes. For some older persons, however, declines go beyond what may be considered normal and are relentlessly progressive, robbing them of their memories, intellect, and eventually their abilities to recognize spouses or children, maintain basic personal hygiene, or even utter comprehensible speech. These more malignant forms of cognitive deterioration are caused by a variety of neuropathological conditions and dementing diseases.

Psychologists are uniquely equipped by training, expertise, and the use of specialized neuropsychological tests to assess changes in memory and cognitive functioning and to distinguish normal changes from early signs of pathology. . . . Neuropsychological evaluation and cognitive testing remain the most effective differential diagnostic methods in discriminating pathophysiological dementia from age-related cognitive decline, cognitive difficulties that are depression related, and other related disorders. Even after reliable biological markers have been discovered, neuropsychological evaluation and cognitive testing will still be necessary to determine the onset of dementia, the functional expression of the disease process, the rate of decline, the functional capacities of the individual, and hopefully, response to therapies. . . .

These guidelines, however, are intended to specify for all clinicians the appropriate cautions and concerns that are specific to the assessment of dementia and age-related cognitive decline. These guidelines are aspirational in intent and are neither mandatory nor exhaustive. . . . The goal of the guidelines is to promote proficiency and expertise in assessing dementia and age-related cognitive decline in clinical practice. They may not be applicable in certain circumstances, such as some experimental or clinical research projects or some forensic evaluations." (APA Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia, 1998, p. 1298)

1 The DSM-5 Neurocognitive Disorders Work Group has proposed that a new category, neurocognitive disorders, replace the DSM-IV category of delirium, dementia, amnestic, and other geriatric cognitive disorders.
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