Defining Scope re: Assessment as a Geropsychologist

[IWillSurvive]

I was trained in internship and fellowship as a geropsychologist. I received training/supervision in graduate school, on internship, and on fellowship in neuropsychological assessment. It has always been ambiguous to me the boundary of what I am/am not able to do in terms of neuropsychological assessment as a geropsychologist. I hear a lot about cognitive assessment being in the geropsychologist wheelhouse, but I have to be honest, I am not clear on the difference between this and neuropsychological assessment. When I read the geropsychologist competencies, it says geropsychologists perform cognitive assessments and refer out for neuropsychological evaluations. I know geropsychologists who seem to be doing neuropsychological assessments for differential diagnosis of dementia and supervised me doing so. I'm wanting to put a battery together to perform dementia assessments in my VA position but need some feedback on what/if this would be appropriate. Thoughts appreciated--especially from gero and neuropsychologists.

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[PsyDr]

The FIRST edition of the Handbook of Rehabilitation Psychology had a chapter published by Erin Bigler about this matter.

He differentiated:

1) Different "levels" of training in neuropsych.

a. Rehab/geropsych - training in administration of neuropsych tests, training in some aspects of the different cognitive domains, focal training in neuroanatomy, limited training in pathology.

b. Neuropsych- training in neuroanatomy, neuropathology, training in test patterns associated with different pathologies, etc .

2) Associated different applications in the use of neuropsychological instruments.

a. Using tests to describe functional ability, track functional changes, and make DSM type diagnoses. (e.g., using an RBANS to track cognitive changes over time, determining if an intervention is having an effect on cognition, stating someone has Minor Neurocognitive Disorder).

b. Using tests data to deduce which neuropathological process is present (e.g., the test scores are consistent with an NCD secondary to an embolic shower with both an MCA and PCA distribution, potentially of a cardiac etiology, the which is unlikely to further improve).

 

[Sanman]

So, along the lines of what @PsyDr mentioned, I tend to focus on more functional assessment than differential dx if I am testing and I really think it comes down to the referral question. Questions, I feel comfortable answering:

1. Does the pt have dementia or MCI vs normal cog functioning?
2. Are they cognitively able to live independently?
3. Are they able to participate in rehab?
4. Cognitive impairment vs neg sx of depression
5. What activities are they likely to be able to engage in at their cognitive level.
6. Capacity for decision making
7. Functional declines/retesting

Things I would refer out:

1. AD vs VD vs mixed etiology
2. Any really oddball neuro presentation


I tend to feel that briefer evals are most appropriate ( more similar to inpt neuropsych), but that is also affected by my setting (HBPC and CLC/SNF).

 

[Justanothergrad]

does anyone know of studies of neuro assessment differentiating AD and VD dementia with post mortem confirmation? I'm curious the positive predictive power

 

[PsyDr]

does anyone know of studies of neuro assessment differentiating AD and VD dementia with post mortem confirmation? I'm curious the positive predictive power

Like a physical examination in medicine, neuropsychological assessment is not really a blind "test", nor is it a single test. This creates problems with sensitivity and specificity. Some of the batteries have sensitivity and specificity data for "neurological lesions". Determination of the etiology of those lesions is determined by the skill of the neuropsychologist and the history.

 

[Justanothergrad]

Like a physical examination in medicine, neuropsychological assessment is not really a blind "test", nor is it a single test. This creates problems with sensitivity and specificity. Some of the batteries have sensitivity and specificity data for "neurological lesions". Determination of the etiology of those lesions is determined by the skill of the neuropsychologist and the history.

ok.... but none of that answered what I asked.

 

[R. Matey]

ok.... but none of that answered what I asked.

Neuropsychological Profiles Differentiate Alzheimer Disease from Subcortical Ischemic Vascular Dementia in an Autopsy-Defined Cohort - PMC

The aim of this study was to assess the ability of neuropsychological tests to differentiate autopsy-defined Alzheimer disease (AD) from subcortical ischemic vascular dementia (SIVD). From a sample of 175 cases followed longitudinally that underwent ...

www.ncbi.nlm.nih.gov

 

[Fan_of_Meehl]

The FIRST edition of the Handbook of Rehabilitation Psychology had a chapter published by Erin Bigler about this matter.

He differentiated:

1) Different "levels" of training in neuropsych.

a. Rehab/geropsych - training in administration of neuropsych tests, training in some aspects of the different cognitive domains, focal training in neuroanatomy, limited training in pathology.

b. Neuropsych- training in neuroanatomy, neuropathology, training in test patterns associated with different pathologies, etc .

2) Associated different applications in the use of neuropsychological instruments.

a. Using tests to describe functional ability, track functional changes, and make DSM type diagnoses. (e.g., using an RBANS to track cognitive changes over time, determining if an intervention is having an effect on cognition, stating someone has Minor Neurocognitive Disorder).

b. Using tests data to deduce which neuropathological process is present (e.g., the test scores are consistent with an NCD secondary to an embolic shower with both an MCA and PCA distribution, potentially of a cardiac etiology, the which is unlikely to further improve).

Very useful summary of the issues involved. Thank you.

Under...

- - - b. Using tests data to deduce which neuropathological process is present (e.g., the test scores are consistent with an NCD secondary to an embolic shower with both an MCA and PCA distribution, potentially of a cardiac etiology, the which is unlikely to further improve).


It is really concerning to me how many (pseudo)neuropsychological reports I see on a routine basis that imply that something like process (b.) (above) is going on when they are sent someone with a 'history of concussion' that occurred 10+ years ago in the context of multiple severe mental health conditions (clinical depression, PTSD, substance abuse, etc.) and they note any variation around the mean (i.e., what I learned in grad school to conceptualize as 'subtest scatter') as somehow indicative of enduring 'brain damage' attributable to the history of a concussion. They go on to diagnose 'Mild Neurocognitive Disorder due to Traumatic Brain Injury' (or Unspecified Neurocognitive Disorder) and speak of the slight deviations under the mean score as being possible evidence of a deterioration of 'premorbid functioning' (when there is absolutely NO information on 'premorbid functioning' (which, implicitly, they are presuming premorbid functioning must have been at or above the population mean??? Why???). They ALWAYS conclude that--despite having this 'brain damage'--that they are fully capable of participating in any/all cognitively demanding psychotherapy treatment protocols (CPT, etc.) as long as (and here's the trademark phrase) 'appropriate accommodations are made' (by the clinician). These reports are worse than meaningless, I find. They basically 'confirm' for the patient that they 'have' 'brain damage' and therefore set up a ready-made reason for not engaging in the more demanding elements of these protocol therapies but--simultaneously--assert that any failure of the patient to successfully engage in the therapy or complete homework assignments is due to the fact that 'proper accommodations' haven't been made.