For the Evaluation of Dementia and Age-Related Cognitive Change
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APA GUIDELINES
for the Evaluation of
Dementia and Age-Related
Cognitive Change
APA TASK FORCE ON THE EVALUATION OF DEMENTIA AND AGE-RELATED COGNITIVE CHANGE
APPROVED BY APA COUNCIL OF REPRESENTATIVES
FEBRUARY 2021
APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change ICopyright © 2021 by the American Psychological Association. This material may be reproduced and distributed without permission provided that acknowledgment is given to the American Psychological Association. This material may not be reprinted, translated, or distributed electronically without prior permission in writing from the publisher. For permission, contact APA, Rights and Permissions, 750 First Street, NE, Washington, DC 20002-4242. This document will expire as APA policy in 10 years (2031). Correspondence regarding the Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change should be addressed to the American Psychological Association, 750 First Street, NE, Washington, 20002-4242. Suggested Citation American Psychological Association, APA Task Force for the Evaluation of Dementia and Age-Related Cognitive Change. (2021). Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change. Retrieved from https://www.apa.org/practice/guidelines/ II APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change
APA GUIDELINES
for the Evaluation of
Dementia and Age-Related
Cognitive Change
APA TASK FORCE FOR THE EVALUATION OF DEMENTIA AND AGE-RELATED COGNITIVE CHANGE
APPROVED BY APA COUNCIL OF REPRESENTATIVES
FEBRUARY 2021
APA Task Force
Benjamin T. Mast, PhD, ABPP (Chair) Mary M. Machulda, PhD, ABPP, LP
University of Louisville Department of Psychiatry and Psychology
Mayo Clinic College of Medicine and Science
Andreana Benitez, PhD
Medical University of South Carolina Glenn E. Smith, PhD, ABPP
University of Florida
Shellie-Anne Levy, PhD
University of Florida Kelsey R. Thomas, PhD
University of California, San Diego and
Veterans Affairs San Diego Healthcare
SystemTAB L E O F C O NT ENTS Introduction3 The Guidelines 6 General Guidelines: Competence7 General Guidelines: Ethical Considerations8 Procedural Guidelines: Conducting Evaluations of Dementia and Age-Related Cognitive Change12 Conclusion 19 References29 APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change 1
2 APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change
IN TRO D UCTI ON
Dementia, or major neurocognitive disorder as it is termed in the and may be accompanied by an enforcement mechanism.
Diagnostic and Statistical Manual of Mental Disorders (DSM-5®) Guidelines are aspirational in intent. They are intended to facilitate
(American Psychiatric Association, 2013), is a leading cause of cog- the continued systematic development of the profession and to help
nitive and functional decline among older adults worldwide and will facilitate a high level of practice by psychologists. Guidelines are not
continue to ascend in global health importance as populations con- intended to be mandatory or exhaustive and may not be applicable
tinue to age and effective cures remain elusive (Mathers & Loncar, to every professional situation. They are not definitive, and they are
2006). By 2060, 13.9 million Americans age 65 and older are pro- not intended to take precedence over the judgment of psychologists.
jected to be diagnosed with Alzheimer’s disease and related demen- Further, professional practice guidelines are developed based on
tias (Matthews, et al, 2019), although the incidence of dementia may consensus within the field and thus differ from clinical practice
be decreasing (Knopman, 2020). The incidence for mild cognitive guidelines that rely on systematic reviews and strength of evidence
impairment (MCI) or mild neurocognitive disorder (DSM-5®) rules (APA, Professional Practice Guidelines, Guidance for Develop-
(American Psychiatric Association, 2013) may be twice as high as ers and Users, 2015b). These guidelines conform to the “Ethical
dementia (Plassman & Potter, 2018). African Americans and Latinx Principles of Psychologists and Code of Conduct” (APA, 2017a). The
have higher rates of dementia (Mehta et al., 2017) due in part to guidelines may not be applicable in certain circumstances, such as
historical, sociocultural, and healthcare inequities (Plassman & some experimental or clinical research projects or some forensic
Potter, 2018). evaluations. The guidelines are developed for use in the United
What follows are professional practice guidelines developed for States but may be appropriate for adaptation in other countries.
psychologists who perform evaluations of dementia, MCI, and Psychologists are uniquely equipped through training, exper-
age-related cognitive change. Although the DSM-5 uses the terms tise, and the use of specialized neuropsychological tests to assess
mild neurocognitive disorder and major neurocognitive disorder, the changes in cognitive and behavioral functioning and to distinguish
broader research and practice literature typically uses the terms typical changes from early signs of neuropathology. Neuropsycho-
mild cognitive impairment and dementia, and this document follows logical evaluation and cognitive testing remains the most effective
that convention. Their goal is to promote proficiency and expertise differential diagnostic methods for discriminating pathophysiologi-
in assessing dementia and age- related cognitive decline in clinical cal dementia from age-related cognitive decline, cognitive difficul-
practice. Although dementia and MCI occur in individuals under age ties that are depression related, and other related disorders. Although
65, the majority of cases occur in older adults, who are the popula- biomarkers are used broadly in research and in some clinical settings,
tion of focus in these Guidelines. neuropsychological evaluation and cognitive testing are necessary
Additionally, given the stark racial and cultural disparities in to determine the onset of dementia, the functional expression of the
dementia outcomes (Stokes et al. 2020), multicultural competence disease process, the rate of decline, the functional capacities of the
in all aspects of assessment of cognitive decline in older adults is individual, and eventually response to disease-modifying therapies.
applicable to all the guidelines and is their ideal aspiration. That is, while biomarkers can detect the underlying neuropathologic
Guidelines are statements that suggest or recommend specific changes, cognitive testing is necessary to determine how the disease
professional behavior, endeavors, or conduct for psychologists. is impacting one’s functioning (Block et al., 2017; Weissberger et al.).
Guidelines differ from standards in that standards are mandatory
APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change 3Development Process
Professional practice guidelines on this topic were originally devel-
oped by an APA Presidential Task Force, approved as policy 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). The guidelines were
reviewed, updated and renamed the Guidelines for the Evaluation of
Dementia and Age-Related Cognitive Change in 2011 (APA, 2012c).
In 2019, the Board for the Advancement of Psychology in the
Public Interest (BAPPI) and the Committee on Aging (CONA)
received notification from the Policy and Planning Board that the
2011 guidelines were set to expire in 2021. After conferring with
BAPPI and Board of Professional Affairs (BPA) staff, CONA reached
out to its collaborators on the 2011 guidelines, Division 20
(Adult Development and Aging), Division 40 (Society of Clinical
Neuropsychology), and Division 12-Section II (Society for Clinical
Geropsychology). Together they reviewed the 2011 guidelines and
determined that there was a clear need to revise this policy. They
also prepared a slate of experts to serve as Task Force members for
BAPPI’s consideration. In November 2019, BAPPI appointed the Task
Force to Update the Guidelines for the Evaluation of Dementia and
Age- Related Cognitive Change. Its members are: Benjamin T. Mast,
PhD, ABPP (Chair), Andreana Benitez, PhD, Shellie-Anne Levy, PhD,
Mary M. Machulda, PhD, ABPP, Glenn E. Smith, PhD, ABPP and
Kelsey R. Thomas, PhD. The members selected represent multiple,
diverse, constituent groups – practice, science, multicultural diver-
sity, early career psychologists, and experience in APA guideline
development. The Task Force convened monthly via teleconference,
supplemented by small group discussions through December 2020
to complete the update.
A preliminary review of the 2011 guidelines commenced in
January 2020 with a 60-day public comment period during which 10
APA Boards and Committees provided input on issues for consider-
ation by the crafters of the guidelines’ revision. In addition, eight
subject matter experts provided extensive comments that informed
the revisions. The draft of the updated guidelines was reviewed by
the Office of General Counsel and posted online for the final, 60-day
public comment period in September, 2020. The Task Force made
its final revisions to the guidelines in response to comments received
and the final draft was reviewed by the Office of General Counsel
that found no issues of concern. There was no financial support for
this effort as all Task Force meetings were held remotely. Nor was
financial support received from any group or individual, and no finan-
cial benefit to the Task Force is anticipated from approval or imple-
mentation of these guidelines.
An update of the guidelines is warranted at this time as psycho-
logical science and practice in dementia and age-related cognitive
change have evolved rapidly. The current document serves to update
the 2011 guidelines based upon recent research and emerging
practice trends.
Each guideline includes a Rationale section that provides
content relevant to the guideline topic and an Application section
that provides recommendations for the clinician to follow when
enacting these guidelines in clinical practice.
4 APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive ChangeGuidelines for the Evaluation
of Dementia and Age-Related
Cognitive ChangeTH E GUI DEL I NES
Overview of the Guidelines
GENERAL GUIDELINES: COMPETENCE PROCEDURAL GUIDELINES: CONDUCTING EVALUATIONS
OF DEMENTIA AND AGE-RELATED COGNITIVE CHANGE
• Guideline 1: Psychologists gain specialized competence in
assessment and intervention with older adults. • Guideline 6: Psychologists strive to obtain all appropriate infor-
mation for conducting an evaluation of dementia and age-related
• Guideline 2: Psychologists performing evaluations of dementia
cognitive change, including pertinent medical history and com-
are familiar with the prevailing diagnostic nomenclature and
municating with relevant health care providers.
specific diagnostic criteria.
• Guideline 7: Psychologists conduct a clinical interview as part of
GENERAL GUIDELINES: ETHICAL CONSIDERATIONS the evaluation.
• Guideline 8: Psychologists are aware that standardized psycho-
• Guideline 3: Psychologists are aware of the special issues sur-
logical and neuropsychological tests are important tools in the
rounding informed consent in older people living with cognitive
assessment of dementia and age-related cognitive change.
impairment.
• Guideline 9: When evaluating for cognitive and behavioral
• Guideline 4: Psychologists seek and provide appropriate consul-
changes in individuals, psychologists attempt to estimate pre-
tation in the course of performing evaluations of dementia and
morbid abilities.
age-related cognitive changes.
• Guideline 10: Psychologists are sensitive to the limitations and
• Guideline 5: Psychologists are aware of cultural perspectives and
sources of variability and error in psychometric performance and
of personal and societal biases and engage in nondiscriminatory
to the sources of error in diagnostic decision-making.
practice.
• Guideline 11: Psychologists make appropriate use of longitudinal
data.
• Guideline 12: Psychologists recognize that dementia and cogni-
tive impairment are often accompanied by changes in mood,
behavior, personality and social relationships, and attend to these
in the assessment process.
• Guideline 13: Psychologists recognize the importance of assess-
ing family caregiver health and well- being.
• Guideline 14: Psychologists recognize that providing constructive
feedback, support, and education as well as maintaining a thera-
peutic alliance are important parts of the evaluation process.
• Guideline 15: As part of the evaluation process, psychologists
recommend appropriate, empirically-based interventions avail-
able to people living with cognitive impairment and their family
caregivers.
• Guideline 16: Psychologists are aware that full evaluation of pos-
sible dementia is an interprofessional, holistic process involving
other health care providers. Psychologists respect other profes-
sional perspectives and approaches. Psychologists communicate
fully and refer appropriately to support integration of the full
range of information for informing decisions about diagnosis,
level of severity, and elements of the treatment plan.
6 APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive ChangeGEN ERAL GUI DEL I NES: C O MP ET ENC E
GUIDELINE 1 GUIDELINE 2
Psychologists gain specialized competence in Psychologists performing evaluations of dementia are
assessment and intervention with older adults. familiar with the prevailing diagnostic nomenclature and
specific diagnostic criteria.
Rationale
A central ethical tenet for psychologists is that they practice only Rationale
within their area of competence (APA, 2017a). In addition to meeting A clear understanding of how cognitive disorders are defined and diag-
general competency benchmarks for the practice of professional nosed is important for developing assessment plans, providing feed-
psychology (APA Competency Benchmarks in Professional back to individuals and their family members, and communicating
Psychology, 2012a), psychologists who conduct evaluations of effectively with other professionals involved in an individual’s care.
dementia and age-related cognitive changes are encouraged to Differential diagnosis requires knowledge of a broad range of psy-
obtain special competencies required for this activity. Specialized chological and medical conditions that can affect an individual’s
training in geropsychology and/or neuropsychology and/or rehabil- cognitive and behavioral functioning and an appreciation of both the
itation psychology provide conceptual and clinical foundations for general trends and individual differences that characterize typical
practice in this area. cognitive aging. Because diagnostic nomenclature and criteria
evolve in response to clinical and scientific advances, updating of
Application knowledge is important to sustain a high level of proficiency in
Psychologists engaged in evaluation of dementia and age-related assessing cognitive disorders.
cognitive change have a solid foundation in clinical psychology. In
addition, they are encouraged to obtain and maintain fundamental Application
education, training, and supervised experience in specialties and Psychologists are encouraged to obtain training and continuing educa-
subfields including but not limited to geropsychology, neuropsychol- tion to enhance and maintain their expertise and to utilize current
ogy, rehabilitation psychology, psychopharmacology, neuropathol- diagnostic methods, concepts, criteria, and nomenclature in their
ogy, and psychopathology. Competence in gathering clinical history; evaluations of older adults.
conducting clinical interviews; administering, scoring, and interpret- The Diagnostic and Statistical Manual of Mental Disorders (5th ed.;
ing psychological and neuropsychological tests; and delivering inter- DSM–5; American Psychiatric Association, 2013) outlines diagnostic
ventions to people living with dementia or age-related cognitive criteria for the clinical syndromes of major neurocognitive disorder
impairment and their families is necessary but may not be sufficient. and mild neurocognitive disorder. Although the nomenclature of the
Psychologists obtain training in cultural psychology and strive for DSM-5 is different from ongoing research definitions and prior DSM
multicultural competence in clinical practice with older adults. diagnoses, in general, a major neurocognitive disorder that is thought
Psychotherapy and other intervention training, as well as training in to be due to a likely neurodegenerative etiology is consistent with a
interprofessional consultation is beneficial for psychologists work- classification of dementia and mild neurocognitive disorder is
ing with older adults and their families as they navigate the chal- consistent with the concept of mild cognitive impairment (MCI; note
lenges that dementia and cognitive impairment have on daily living, it is also possible to have a major or mild neurocognitive disorder due
particularly interventions designed to help individuals to adjust to to non-degenerative etiologies such as Traumatic Brain Injury (TBI),
diagnosis and its implications, assist family caregivers, reduce unmet infection, or other disease processes). The DSM-5 now includes
needs, and address behavioral and psychological symptoms that additional criteria for determining the likely etiologies of a neurocog-
occur in the context of dementia. Psychologists also strive to stay nitive disorder due to Alzheimer’s disease (AD), (e.g. frontotemporal
abreast of state laws pertinent to dementia evaluations and lobar degeneration, vascular disease, dementia with Lewy bodies).
diagnosis. Separate from the DSM-5, familiarity with other diagnostic
schemes for dementia and MCI such as the International
Classification of Diseases (ICD) codes and disease-specific task
forces is encouraged. For example, for Alzheimer’s disease, slightly
different classification guidelines for dementia and MCI due to AD,
as well as preclinical AD, have also been provided by task forces
jointly established by the National Institute on Aging (NIA) and the
Alzheimer’s Association (AA; Albert et al., 2011; Jack et al., 2018;
McKhann et al., 2011; Sperling et al., 2011). The NIA-AA guidelines
APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change 7provide criteria for identifying cognitive of cognitive domains impacted that may be
impairment (dementia, MCI) of probable useful in determining etiology and brain
and possible AD etiologies, with greater regions/systems affected, likelihood of
certainty in etiology when biomarker infor- reversion to cognitively unimpaired, or risk
mation is available. Neuropsychological of future progression to dementia (e.g.,
testing to confirm the presence and nature Edmonds et al., 2020; Yaffe et al., 2006).
of cognitive decline is an important part of The use of biomarkers in both research
the NIA-AA criteria for AD, particularly in and clinical settings has drastically
questionable cases. Indeed, the use of increased in recent years. In research, the
comprehensive neuropsychological testing concept of preclinical AD has garnered
has been shown to improve diagnostic increasing attention and is thought torepre-
accuracy and improve the prognostic value sent a stage when AD pathologies are
of an MCI classification relative to methods accumulating, but frank cognitive impair-
that rely more heavily on brief cognitive ment consistent with MCI or dementia is
screening measures and/or clinical ratings not yet observed. The NIA-AA has put forth
(Bondi et al., 2014; Edmonds et al., 2015). a research schema for the biological classi-
Neuropsychological testing also fication of preclinical AD that focuses on
figures prominently in the consensus panel amyloid (A), tau (T), and neurodegenera-
guidelines for assessing other forms of tion (N) such that individuals are character-
dementia. Consensus groups have offered ized as positive or negative for each
detailed and clinically useful diagnostic biomarker and are given an A/T/N profile
criteria for several other major causes of (Jack et al., 2018). However, this framework
late-life dementia, including vascular cogni- has yet to be implemented into clinical
tive impairment (Gorelick et al., 2011; practice. Research evaluating its utility for
Sachdev et al., 2014), behavioral variant clinical use across populations as well as
frontotemporal dementia (Rascovsky et al., the nature of the subtle cognitive changes
2011), and dementia with Lewy bodies that likely occur during this preclinical
(McKeith et al., 2017). All diagnostic criteria phase of AD is ongoing. Practitioners are
require confirmation of dementia by a clini- encouraged to maintain up-to-date knowl-
cal evaluation to exclude other explanations edge of the status of the research and
for the cognitive impairment that may be recommendations for use of biomarkers in
determined by history, clinical examination, clinical practice.
or specialized tests. Cognitive decline or complaints often
The diagnosis of MCI and/or mild co-occur with mental health conditions,
neurocognitive disorder has increased over such as depression and anxiety. Declines in
the last two decades and is thought to occur attention, concentration, or increased
in a period prior to dementia in which one indecisiveness and slowed thinking are
exhibits cognitive difficulties that are included in the DSM–5 diagnostic criteria
greater than expected based on demograph- for generalized anxiety disorder and a major
ically appropriate normative data, but not depressive episode. Given the complex
so severe as to warrant a diagnosis of relationship between mood/psychiatric
dementia given relative sparing of everyday symptoms and cognitive changes, familiar-
functioning. Although individuals with MCI ity with the cognitive impact of common
often remain stable or revert to cognitively psychiatric disorders is essential for differ-
typical ranges, MCI classification does entiating between psychiatrically-related
generally confer a greater risk for progres- cognitive impairments, mood and behav-
sion to dementia (Manly et al., 2008; ioral changes that may sometimes signal
Roberts et al., 2014; Smith & Bondi, 2013). early stages of a neurodegenerative process,
Separate from the DSM-5 mild neurocogni- and late-life mood and behavior changes
tive disorder criteria, specific criteria for that may develop in response to experienc-
defining MCI in clinical and research ing declining cognition (Geda et al., 2013;
settings vary (Albert et al., 2011; Jak et al., Krell- Roesch et al., 2019).
2009; Petersen, 2004, 2010; Winblad et al.,
2004). However, subtypes of MCI (e.g.,
amnestic vs. non-amnestic; single vs. multi-
ple domains) may provide additional infor-
mation about disease severity and breadth
8 APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive ChangeGEN ERAL GUI DEL I NES: ET HICAL C O NSIDER AT IO N S
GUIDELINE 3 to lack the capacity to refuse the evaluation. When describing the purpose, nature,
Psychologists are aware of the In some situations, the capacity evaluation and procedures of the evaluation with the
special issues surrounding informed stops there. In other situations, where a older adult, the psychologist uses terms in
capacity evaluation is court ordered, the a manner that will foster optimal under-
consent in older people living with
psychologist may be asked to provide an standing. To do this, psychologists consider
cognitive impairment. opinion based on his or her observations of the many factors that may impact
the person (ABA & APA, 2008, p.35).” decision-making (e.g., educational
The presence of dementia alone does background, culture, experience in health-
Rationale not imply that the person lacks decision-mak- care settings) and tailor their language
ing capacity. accordingly. In securing informed consent,
Psychologists recognize that informed con- Questions of capacity are addressed psychologists explain to individuals and
sent can be a special challenge in dementia with focused capacity evaluations that their legal proxies the following issues,
evaluations. Informed consent requires that address specific capacity domains (e.g., including but not limited to:
one’s agreement to assessment and treat- medical and financial decision making • what to expect in the evaluation (e.g.,
ment be competent, voluntary, and informed capacity) through assessment procedures the length of the appointment, how and
(American Bar Association [ABA] & APA, described by the ABA and APA (2008). to whom feedback will be provided, the
2008; Moye & Wood, 2020). Informed These include not only assessment of cogni- absence of invasive or painful proce-
consent implies the person has the capacity tive change, but also functional elements dures, the challenging nature of cogni-
to understand the significant benefits, risks, relevant to the capacity domain, other tive testing),
and alternatives of the proposed assess- psychological disorders, value and prefer-
ences, as well as steps that can enhance • the financial costs of an evaluation (e.g.,
ment and to make and communicate a
capacity including supported decision-mak- what insurance will and will not pay for,
health care decision (Uniform Health-Care
ing (ABA & APA, 2008; Moye, 2020). who is ultimately responsible for paying
Decisions Act, 1994). Yet cognitive impair-
Supportive decision-making enables older costs),
ment in the context of dementia may limit
one’s capacity to make healthcare decisions adults with cognitive impairment to make • the benefits and risks for the person
without support. This dilemma creates the decisions about their life and care, while
being assessed,
appearance of a double bind regarding receiving help and guidance from a trusted
obtaining informed consent for dementia network of people (Moye & Wood, 2020). • limitations to confidentiality (including
evaluations. Psychologists also recognize that exploita- reporting suspected elder abuse),
tion of older adults does occur and evaluate
• constraints on release of raw test data,
Application the possibility that an assessment may be
and
requested for reasons that may not be in the
The ABA and APA’s (2008) Assessment of Older best interest of the client (e.g., a family • mandatory reporting requirements.
Adults with Diminished Capacity: A Handbook for member hoping to take control over
Psychologists provides guidance to help the Benefits of the assessment may
finances for their own gain).
clinician when assessing persons who may include gathering of helpful clinical infor-
Consistent with the APA Code of
have diminished capacity. This handbook mation to be used in diagnosis and treat-
Ethics, when conducting evaluations of
notes, ment planning including ways to develop
dementia and cognitive change, psycholo-
“The person may have capacity to supports that would optimize their auton-
gists seek to balance the person’s autonomy
consent to the evaluation, and either agrees omy, while potential risks may include the
and protection (Bush, Allen, & Molinari,
or refuses. In this case, the person has loss of decision-making rights, preclusion
2017). The development of dementia may
provided a valid agreement or refusal, and from certain services or nursing home
threaten one’s autonomy and increase the
this can be documented. Alternatively the placement, potential lack of confidentiality,
need for greater protections to enhance
person may not have the capacity to consent and the possible need for a guardian or
safety such as supported decision-making;
to the evaluation, and either agrees or conservator. Psychologists recognize these
however, psychologists also seek to
refuses. If the person agrees, [they are] potential risks and inform the patient/client
promote as much autonomy as possible,
generally said to have “assented” and the what documentation will arise from an
recognizing that overprotection and
assessment process goes forward. If the evaluation (e.g., written report, verbal
inappropriate removal of one’s rights also
person disagrees, and refuses to comply communication, note in chart) and ways the
carries risks to the well-being of people
with an interview, then the psychologist information from the evaluation may be
living with dementia.
must document why the person is believed used by a recipient of that information
APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change 9(even if the use is unknown). In some situa- GUIDELINE 4 access to services that are highly valued by
tions, supported decision-making with a Psychologists seek and provide referring professionals (Mahoney et al,
trusted family member, friend, or profes- appropriate consultation in the 2017).
sional may provide people living with If issues of abuse or neglect arise,
course of performing evaluations of
dementia the opportunity to better under- psychologists notify appropriate authorities
stand the options and communicate with dementia and age-related cognitive and make referrals for appropriate services.
their providers while also supporting their changes. To do so, psychologists remain abreast of
autonomy. In certain situations, psycholo- local legal reporting requirements and
gists may need to offer an expert opinion Rationale processes (Mosqueda & Olsen, 2015).
regarding capacities regardless of whether Complex issues arise during the evaluation Psychologists seek to be attentive to issues
or not the person consents to a full evalua- of suspected cognitive decline or dementia. of financial exploitation, undue influence,
tion (Moye & Wood, 2020). In these situa- These issues may include multiple medical and loss of financial capacity (Lichtenberg,
tions, psychologists are encouraged to comorbidities or medication side effects, 2016; Marson, 2016; Wood & Lichtenberg,
inform the individual that the evaluation sociohistorical background and cultural 2017) and use well-validated tools to assess
must be conducted whether or not they are origins, genetic and heritability factors, these issues (Lichtenberg et al, 2015; 2016;
willing participants and that a refusal to abuse or neglect, questions of legal compe- 2017; Marson et al, 2009). In addition,
participate will result in the evaluation tence or guardianship, conflicting or unclear psychologists are encouraged to inform the
being compiled from other sources. assessment results, and families over- individual of the reporting requirement prior
The laws for determining capacity as whelmed or divided by the potential diagno- to services being rendered. In matters of
well as the rules and requirements of legally sis. For these reasons, integrated health care legal capacity and guardianship, psycholo-
authorized persons vary from state to state. approaches are particularly well-suited for gists seek additional legal consultation,
If the individual does not have legal capacity cognitive decline and dementia care (Galvin, supervision, and/or specialized knowledge,
to provide consent, the psychologist must Valois, & Zweig, 2014). training, or experience as appropriate to
obtain consent from a legally authorized address these issues (Moye & Wood,
person (see Section 3.10 of the APA’s Application 2020). Psychologists communicate their
“Ethical Principles of Psychologists and Code findings to other health care professionals
of Conduct”; APA, 2017a) to carry out the Psychologists providing services to this pop- with sensitivity to issues of informed written
evaluation and to gather information from ulation strive to be particularly sensitive to consent that is compliant with the guide-
other health professionals and family the multiple health conditions that impact lines of the Health Insurance Portability and
members. Psychologists understand that cognitive function. In all of these areas, the Accountability Act of 1996 (U.S. Depart-
legally authorized persons can take several clinician, individual, and/or family may ben- ment of Health and Human Services, Office
forms (i.e., power of attorney, medical efit from and contribute to the expertise or for Civil Rights, 1996). In addition to engag-
power of attorney, guardian), with each services of other professionals, including ing in nondiscriminatory practice (as
form having different levels of control; but not limited to a range of health profes- described in Guideline 5), psychologists
psychologists understand the permissible sionals such as physicians (e.g. neurologists, seek consultation from colleagues with
actions and timeframe of the representative geriatricians, psychiatrists, primary care multicultural competence, when possible,
as outlined in the documentation granting providers), speech therapists, occupational to appropriately contextualize results and
authority (and may ask for a copy when therapists, genetic counselors, adult pro- recommendations to all recipients of the
appropriate). Psychologists document the tective and social service workers, attorneys, information obtained from the assessment.
consent, assent, or refusal of the individual and other psychologists (ABA & APA, Psychologists are encouraged to help
as appropriate. Psychologists also document 2008). educate other health care professionals
evidence regarding the person’s capacity or When the psychologist is the first who administer mental status examina-
lack thereof to consent to the assessment. professional the individual contacts, the tions or other brief psychological tools
psychologist seeks to gather existing regarding the benefits and limitations of
medical records to complement and inform these instruments and their clinical utility
the assessment. Generally, the individual for particular applications as well as appro-
will have had or will be referred for a priate referrals, and the importance of
thorough medical evaluation to discover well-articulated referral questions. Educa-
any underlying medical disorder or any tion can also be provided about the utility
potentially reversible medical conditions and limitations of more comprehensive
associated with dementia or cognitive psychological or neuropsychological
decline. When the psychologist is a consul- assessment in dementia evaluations.
tant to other providers, the psychologist
seeks to contribute unique and high-value
information provided by psychological
methods in a thorough, integrated, and
efficient manner. Psychologists recognize
the need for efficient practice to improve
10 APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive ChangeGUIDELINE 5 neuropsychological tests and most diverse clients. If the psychologist is
Psychologists are aware of cultural appropriate norms. For example, the unable to conduct the evaluation fairly,
perspectives and of personal and most appropriate norms may be from the ethical psychologist seeks to refer
Mayo’s Older African American the individual to other psychologists
societal biases and engage in
Normative Studies (MOAANS) instead capable of providing services.
nondiscriminatory practice. of the more familiar Heaton norms.
• Strive for continued growth in cultural
When appropriate norms are unavail-
Rationale competence. In their seminal work, Sue
able for a particular client, the psycholo-
and colleagues (1992) describe cultural
The population of the United States is becom- gist clearly documents the limitations of
competence as 1) awareness of one’s
ing increasingly older and heterogeneous, their assessment and diagnoses in this
own assumptions and biases, 2) under-
with the growth of racial and ethnic minori- regard. Research to establish norms on
standing the worldview of culturally
ties outpacing that of Whites (US Census commonly used clinical tests for specific
dissimilar clients, and 3) the ability to
Bureau, 2017). The trend for increased ethnic and racial populations is growing
develop culturally appropriate assess-
neuropsychological referrals for racially and (e.g., advances in norms for Spanish-
ments or interventions. This can be
ethnically diverse older adults has been Speaking individuals from several South
facilitated through educational opportu-
known for approximately 15 years (Byrd & American countries (Arango-Lasprilla,
nities and/or self-directed study through
Manly, 2005); the racial diversity of client 2015, Sayegh & Piersol, 2020), but rep-
published books and articles (Rabin, et
referrals is even greater today. There is resentative norms are still lacking in
al., 2020). Performing culturally sensi-
some evidence to suggest that dementia many cases. Psychologists assessing
tive assessments requires a life-long
prevalence is higher in ethnic minorities (i.e., older adults from racial and ethnic
process of self-reflection and analysis,
African Americans and Hispanic/Latinx) minority groups use the best available
checking one’s biases and assumptions
relative to Whites, in part due to genetic risk tests with norms appropriate for each
when interacting with diverse clients
factors and disproportionate rates of car- individual’s background and consult
(Chang, et al. 2020; Dugbartey, 2014).
diovascular disease, but also in part due to with expert colleagues as needed
sociocultural factors that may influence regarding battery construction and • Psychologists are advised to carefully
diagnosis and treatment (Chin et al., 2011; interpretation (Fujii, 2017; Robbins et al., evaluate test quality and appropriate-
Fernandez & Johnson, 2020). Therefore, it 2016). The neuropsychological report ness for individual circumstances, espe-
is paramount that psychologists engage in contains caveats related to cultural con- cially when the test is being administered
culturally sensitive assessment of cognitive siderations and limitations of measures to individuals with different cultural and
changes and dementia for their diverse cli- used, standardization of administration, linguistic backgrounds (American
ents. Despite the current sense of urgency, normative data available, and if an inter- Educational Research Association
culturally competent provision of services preter was used which raises many eth- [AERA], APA, & National Council on
and nondiscriminatory practice is already ical considerations that need to be Measurement in Education [NCME],
an established ethical mandate for all psy- considered (Pedraza, 2018; Rabin, et al., 2014). For example, the noose item in
chologists who work with diverse popula- 2020). For cultural considerations in the the Boston Naming Test (BNT) may be
tions (APA 2017a; Boundaries of evaluation process including test selec- culturally inflammatory for African
Competence). tion and interpretation, see Fujii (2017) Americans, who have a history of gener-
and Robbins et al., (2016). ational trauma related to slavery, vio-
Application lence, and discrimination. Because this
• Strive to contextualize neuropsycholog-
item may assess different constructs in
APA’s 2017 Multicultural Guidelines: An Ecological ical findings and recommendations with
African Americans vs. Whites and lacks
Approach to Context, Identity, and Intersectionality as much sociocultural information as
cultural sensitivity, the noose item has
recommend psychologists practice within possible (e.g., quality of education,
been suggested as inappropriate for
their boundary of competence, which degree of acculturation and immigration
continued inclusion in the BNT (Horwitz
includes assessment of culturally and lin- history, language proficiency/fluency,
& McCaffey, 2010). Notably, a replace-
guistically diverse groups. The psychologist and perspectives on caregiving and use
ment item can now be obtained free of
is alert and sensitive to differing roles, of support resources).
charge from the test publisher.
expectations, and normative standards • Strive to control biases through review-
within a sociocultural context. In practice ing relevant research, relying on evi- Ageism towards older adults is perva-
and when appropriate, the psychologist dence-based practice guidelines, and by sive in society and is also prevalent in
discusses and counters potential biases to seeking additional consultation or, in healthcare practice, of which psychologists
ensure optimal client performance is some cases, withdrawing from the eval- and other mental health care professionals
achieved for the assessment. Adapted from uation. The psychologist is encouraged are not immune (APA, 2020b). These
Mindt et al.’s (2010) “call to action”, the to be aware of their own personal biases, negative biases include assumptions that
following practices may be useful to con- acknowledge them, and work to mini- older adults are dependent, depressed,
sider when evaluating diverse older clients: mize their impact while working with socially isolated, and will inevitably become
• Strive to use the best available
APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change 11cognitively impaired (APA, 2014, 2020b). sociocultural factors that influence demen- practice with transgender and gender nonconform-
With regard to clinical practice, older adults tia rates and outcomes. For example, with ing people (2015a), and Guidelines for psycholog-
are screened less for functional abilities and regard to cultural beliefs, African American, ical practice for people with low-income and
cognitive changes, and late life depression Hispanic/Latinx, and Chinese Americans economic marginalization (2019a).
is often overdiagnosed. Diagnoses and may perceive memory loss and dementia as
recommendations may not be clearly typical parts of aging; without overgeneral-
communicated (Hinrichsen, 2020), which ization, some African Americans, in partic-
may be related to an assumption of low ular, may believe in spiritual causes for
competence. Psychologists are advised to illness with reliance on spirituality or
be vigilant for stereotype threats which may religion for health and well-being (Connell
activate internalized ageism and to work et al., 2009; Mahoney et al., 2005). Psychol-
with older individuals to better understand ogists aim to clarify possible cultural factors
the evaluation procedures and purposes to that may influence their client’s under-
ensure accurate and optimal performance. standing and perceptions of dementia and
For example, older clients may underper- cognitive impairment (e.g., normalizing
form on memory tests and other cognitive cognitive loss; viewing illness as retribution
measures due to age-based stereotype for past sins).
threat (APA, 2020b; Lamont, Swift, & Outreach and psychoeducation in
Abrams, 2015). Lastly, ageism may at-risk communities can improve their
compound the deleterious effects of other clients’ knowledge base; however, mistrust
biases related to one’s level of education of healthcare providers, including fears that
attainment, racial/ethnic background, their concerns may not be acknowledged or
disability, or other aspects of diversity fear of institutionalization when family-cen-
(Chang et al., 2020). Psychologists strive to tered care is preferred, may play a large role
consider how the interaction of their own in whether ethnic minority clients seek care
actual/perceived identities and that of their or even report symptoms of cognitive
clients may affect performance. Further- changes (Mahoney, 2005). In this vein,
more, psychologists strive to consider how trust and rapport with their clinicians,
the family histories and intersectional including psychologists who aim to be
identities of their older clients may affect culturally aware and sensitive, is vitally
their health status, risk factors, and access important. While there may be multiple
to services. cultural and institutional barriers to care
Ethnically diverse older adults experi- that require time and nuanced approaches
ence disparities in aging and dementia for remediation, financial barriers may be
outcomes that are influenced by a variety of more readily amenable for speedier resolu-
sociocultural factors including disparate tion. Ethnic minority populations are often
rates of poverty, lower educational attain- un- or underinsured at greater rates than
ment, cultural beliefs in the understanding Whites (Fiscella et al., 2000), having poorer
of dementia and caregiving that may limit access to health insurance that covers
service utilization, bias and discrimination neuropsychological services. Psychologists
based on race, religion, age, sex, disability, may wish to offer reduced fees or pro bono
sexual orientation, or gender identity, and services for individuals who are un- or
limited healthcare access and/or inade- underinsured.
quate provision of healthcare services (Chin For additional guidance on culturally
et al., 2011; Connell et al., 2009; Hernandez informed psychological practice, see the APA
et al., 2010; Mahoney et al., 2005; Mehta et Guidelines for psychological practice with older
al., 2005; Roberts et al., 2003; Wallace, adults (2014), Multicultural Guidelines: An ecolog-
2012; Yeo et al., 2019; Zuckerman et al., ical approach to context, identity, and intersection-
2008). Indeed, there are significant differ- ality (2017), Guidelines for psychological practice
ences in knowledge and awareness of with boys and men (2018a), Guidelines for psycho-
dementia, specifically Alzheimer’s disease, logical practice with girls and women (2018b),
in ethnically diverse older adults (Cahill et Guidelines on race and ethnicity in psychology
al., 2015; Ayalon, 2013; Milani et al., 2020). (2019b), Assessment of and intervention with
Psychologists are encouraged to work for persons with disabilities (2012b), Guidelines for
health equity in diverse populations, and psychological practice with lesbian, gay, and bisex-
strive to increase awareness of ual clients (2012d), Guidelines for psychological
12 APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive ChangeP RO CE DU RAL GUI DEL INES: C O NDUCT ING
E VA LUATI ONS OF DEMENT IA AND AG E - R EL AT ED
CO GN ITI V E CHANGE
GUIDELINE 6 Psychologists strive to utilize dementia (ABA & APA, 2008; Mackinnon &
Psychologists strive to obtain all supported decision making approaches Mulligan, 1998). Obtaining contextual and
appropriate information for when the person’s ability to recall and historical information from interviewing the
communicate personal and medical infor- client and knowledgeable informants
conducting an evaluation of
mation is limited by cognitive impairment. improves diagnostic accuracy and, ideally,
dementia and age-related cognitive When an individual is able to give only considered in combination with perfor-
change, including pertinent medical limited self-report, psychologists seek mance-based measures and self-report
history and communicating with consent or assent from the individual to (Edmonds et al., 2014; Galvin et al., 2005;
relevant health care providers. gather corroborative information from Mast & Yochim, 2018; Monnot, et al., 2005).
other informants including family members Interview data from a corroborative source,
Rationale and care providers. Psychologists inform such as a caregiver or knowledgeable family
these sources of the potential uses of the member, can provide information on every-
Cognitive function and change are associ- information and the limits to confidentiality. day cognitive functioning (Waite et al.,
ated with several medical and psychosocial In obtaining collateral information, the 1998). A potential advantage of informant
conditions that must be considered in any psychologist considers the interpersonal/ history is the ability to assess change in
evaluation of current cognitive performance. family dynamics and cultural contexts as functioning from earlier in life, which also
However, individuals and even knowledge- well as the potential motivations of infor- provides an important context from which
able informants may be imperfect histori- mants. For example, depression can influ- to interpret the objective test scores (Jorm,
ans or lack information regarding the ence the reports of both the person referred 1996). Finally, obtaining data from infor-
individual’s past and current medical status, for assessment and their family caregivers. mant interviews can add greater precision
neuroimaging findings, medication use, and Utilization of multiple sources of data helps in the design of appropriate behavioral,
daily function. Medical, occupational, and offset these issues. environmental and pharmacological treat-
educational records and family history doc- In practice, the amount of reliable ments of dementia (Hartman-Stein et al.,
uments can provide important contextual information available to the psychologist for 2002; Mast, 2011; Waite et al., 1998).
and functional information pertinent to the the evaluation may be highly variable,
evaluation (ABA & APA, 2008). depending in part on the availability of Application
relevant records as well as knowledgeable
Application Clinical interviews with the client and knowl-
family, friends, and other professionals.
edgeable informants (e.g., family, close
Prior to conducting the evaluation, psychol- Conclusions and recommendations from
friends) provide a more complete picture of
ogists seek to clarify the referral question by the evaluation may be constrained by the
the person’s history, daily functioning, sup-
reaching out to the referral source. need for further information or a follow-up
port systems, and other social and psycho-
Psychologists strive to fully understand all evaluation.
logical resources. Directly interviewing the
facets of the referred individual’s context, person being evaluated for dementia com-
including the perspective of the person municates respect for the person’s perspec-
who has been referred for evaluation. tive and life history, while evaluating
Psychologists are encouraged to consult firsthand the level of cognitive function and
with other health care providers and seek GUIDELINE 7 the individual’s awareness of any cognitive
relevant records, particularly concerning Psychologists conduct a clinical and behavioral changes (Mast, 2011). It also
the individual’s health status, medical his-
interview as part of the evaluation. enables the psychologist to discern psycho-
tory, dementia-related biomarkers such as social stressors or other mental health
neuroimaging or cerebrospinal fluid infor- problemsthat may be contributing to cogni-
Rationale
mation, and current medications. Recent tive change. Such data obtained from direct
medical evaluations provide critical data Although objective testing provides valu-
interviews are invaluable for both diagnos-
concerning the onset and course of cogni- able data for diagnostic purposes, the clini-
tic and intervention planning purposes, and
tive changes. cal interview remains one of the central
enables the psychologist to tailor
elements of an in-depth assessment for
APA | Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change 13person- centered care recommendations to interprofessional team. Additionally, GUIDELINE 8
the individual. psychologists may consider a referral for a Psychologists are aware that
In order to accurately diagnose condi- neuropsychological evaluation, particularly standardized psychological and
tions that are associated with cognitive when results from brief mental status evalu-
neuropsychological tests are
decline and functional disability, psycholo- ations are unclear, that includes compre-
gists also strive to obtain corroboration hensive testing alongside a full clinical important tools in the assessment
from knowledgeable informants whenever interview as a way to integrate multiple of dementia and age-related
possible. Psychologists consider the pros sources of information when determining a cognitive change.
and cons of interviewing the individual and diagnosis or etiology for cognitive decline
collateral sources separately versus inter- and to best understand cognitive strengths Rationale
viewing them together at the same time. (see Guideline 8).
The use of psychometric instruments may
Psychologists also carefully consider the In order to design practical, person-cen-
represent the most important and unique
reliability of information obtained from tered recommendations for treatment
contribution of psychologists to the assess-
interviews and how client and informant planning purposes, during the clinical inter-
ment of dementia and cognitive change
characteristics influence what is reported view the psychologist strives to obtain,
(AERA, APA, & NCME,2017). Psychometric
(e.g., family caregiver burden, client memory whenever possible, an assessment of the
assessment provides objective information
or communication impairment). Key infor- person’s remaining strengths, unmet needs,
on cognitive strengths and weaknesses
mation obtained during the interview quality of life, psychological well-being,
necessary for diagnosis. Testing provides
includes but is not limited to the following: social resources, employment, and
reliable information for tracking cognitive
• the onset and course of changes in cog- functional information regarding the
change over time or in response to
nitive functioning, individual’s ability to manage the important
interventions.
aspects of self-care and the potential utility
• response to prior or current of compensatory techniques (Molony et al.,
interventions, Application
2018; ABA & APA, 2008; Mast, 2011). In
• level of functioning in instrumental and evaluating suspected dementia, psycholo- Psychologists select appropriate measures
basic activities of daily living, gists are encouraged to: to address the referral question and are
• be sensitive to families’ and individuals’ encouraged to use standardized, reliable,
• pre-existing disabilities, and valid tests. Whether traditional, tech-
understanding of the potential diagnosis
of dementia and its ramifications, nology assisted, or teleneuropsychology,
• educational and cultural background
appropriate tests have normative data for
that could affect testing, • attend to and seek to assess a person’s the age range of the person being assessed
goals, values and preferences regarding and are suitable for the individual’s gender,
• general medical and psychiatric history,
care, daily activity, habits, and aware- ethnicity, culture, language, and educa-
• past neurological history including prior ness of resources for care and advance tional background.
head injuries or other central nervous planning (Allen et al., 2019; Jennings et Psychologists strive to understand the
system insults (e.g. strokes, tumors, al., 2018; Van Haitsma et al., 2013; differences between cognitive screening,
infections), Whitlatch, 2010), cognitive testing, and neuropsychological
• current psychiatric symptoms and sig- • assess the individual’s past and current testing and to carefully evaluate if they have
nificant life stressors, coping skills as well as resources from the requisite competency to complete each
which the individual can receive support, type of evaluation through their training and
• current prescription and over-the- education prior to performing cognitive
including cultural, racial/ethnic, and reli-
counter medication and supplement evaluations (Block et al, 2017; Roebuck-Spen-
gious communities.
use, as well as home remedies, cer et al, 2017). This information is available
• current and past use and abuse of alco- in the education and training taxonomies
hol and drugs, and standards established by each recog-
nized specialty (APA, 2020a).
• family history of dementia (including Brief mental status examinations are
type and source of diagnosis). used to screen for dementia and other
Psychologists may choose to incorpo- cognitive impairments and track cognitive
rate structured, evidence-based clinical change in individuals with more severe
dementia rating tools, brief mental status levels of impairment (e.g., Mini- Mental
examinations, and formal measures of State Examination (MMSE), Montreal
functional status and capacity in their clini- Cognitive Assessment (MoCA). Brief
cal interviews. Some clinical information cognitive screening tools should be
may be gathered from interviews conducted standardized and have good positive predic-
by other professionals as part of an tive values for identifying possible cognitive
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