Competency in Older Adults:
Clinical and Legal Perspectives
The Role of Cognitive and
Neuropsychological Evaluations
John Crumlin, PhD
Assistant Director, CU Aging Center
Neuropsychological Evaluations
• Purpose of the Evaluation
– A clear and specific referral question is essential
• Assessment involves more than testing
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Interview & observations
Social history & present life circumstances
Medical history & present status
Circumstances surrounding the examination
Relevant records
Guardianship
• In guardianship cases: Does the person meet
criteria for an incapacitated person
An incapacitated person is one who is unable to
effectively receive or evaluate information or both or
make or communicate decisions to such an extent that
the individual lacks the ability to satisfy essential
requirements for physical health, safety, or self-care,
even with appropriate and reasonable available
technological assistance. (CO Statue)
Neuropsychological Evaluations
• The basic assumption:
performance on a series of brief tasks
predicts everyday cognitive functioning and
ability for adaptive behavior in the real world
• The best tests have good ecological validity,
but no test is perfect
Test Selection
• Include the minimum amount of established
standardized tests that will provide an answer
to the referral question
• Tests should have “good” reliability & validity
A test has good reliability if it gives similar results
on repeated testing.
A test has good validity if its results correlate
with the construct of interest
• Even the very best tests have error rates
Interpreting Results
• No test result in isolation is particularly
informative
– Interpretation of results requires an analysis
of error patterns, the abilities required for
each test, and collateral information
– Conceptualizing cognitive abilities in domains
helps interpret the assessment results
Cognitive Domains
• Attention and Concentration
– Attention: The ability to direct one’s
awareness to the task at hand
– Concentration : sustaining attention until a
task is completed
• Information processing
– speed, capacity, & control
Cognitive Domains
• Memory
– Verbal
– Visual
– Immediate vs. delayed
– Recall vs. recognition
– Working memory
The ability to keep information in
consciousness while manipulating it
Cognitive Domains
• Language
– Receptive and expressive language abilities
• Visuo-spatial abilities
– The ability to understand how elements form
wholes, and to appreciate the spatial layout of
one’s surroundings
• Motor functions
Cognitive Domains
• Executive Functions
– Captain of the Ship / Orchestra Conductor
– Ability to organize, initiate, and follow through
with goal-directed behavior, to evaluate
problem solving efforts, and to adapt behavior
based on feedback
– Includes impulse control and higher order
functions such as math skills, abstract and
categorical reasoning, and concurrently
considering divergent lines of thinking
The Nomothetic Approach
• Performance is scored on strict criteria to
provide a numerical score
• Individual’s numerical score is compared to
the appropriate “average person” providing a
percentile rating and/or a qualitative
descriptor
– Typical descriptors:
Average; Low-average; Borderline; and
Mildly, Moderately, or Severely Impaired
Interpreting Results
• Tests are designed to assess specific
domains, but performance is always
multi-determined
• Task and error analysis
– What abilities are required to perform
well on a specific test?
– What is the pattern of the person’s
deficits/strengths across all tests?
• Conclusions about specific domains
Assessment Results versus
Legal Criteria
• Able to effectively receive information
– attention/concentration, information processing
capacity and control, receptive language
• Able to effectively evaluate information
– Information processing control, memory, executive
functioning
• Able to effectively make decisions
– Information processing control, memory, executive
functioning
• Able to effectively communicate decisions
– expressive language, executive functions
Confounding Factors
• Typically we are seeking an estimate of the
person’s true cognitive functioning.
• Any influence of the following factors must be
taken into consideration (partial list)
Fatigue
Distractions
Pain
Anxiety & distress
Depression
Motivation
Medications
Cooperation
Final Thoughts
• Be sure you provide a clear and specific
question(s) that you want answered
• Not all neuropsychologists have experience in
assessing capacity. In seeking an evaluation
for guardianship purposes, be sure that
cognitive abilities will be assessed against the
legal criteria
• A psychologist cannot decide the ultimate
issue (whether a guardian is required)
Resources
• A comprehensive neuropsychological referral form is available
on the CU Aging Center website www.uccs.edu/agingcenter
• The American Psychological Association and the American Bar
Association collaboratively produced a series of handbooks on
capacity assessment. These very informative works are
available free in PDF format on the web at
http://www.apa.org/pi/aging/homepage.html
• The Alzheimer’s Association published an excellent guide to
help families cope with members who have diminished
capacity and locate resources related to capacity issues