Cognitive Assessment Ethics and Methods

Ethical Formal Cognitive Assessment

• Formal cognitive assessments involve administering, scoring, and interpreting standardized scales to evaluate cognition.
• Assessments are typically standardized and use a bottom-up approach, focusing on performance skills and client factors.
• Sample assessments include the MoCA and COPM.
• A bottom-up approach focuses on performance skills and client factors. It often prioritizes impairments.
• A top-down approach considers participation in meaningful activities, examines occupational dysfunction, and pays careful attention to the context of the occupation.

Standardized Testing

• Standardized testing ensures defined and controlled administration and scoring parameters.
• Standardized tests often use scripts or written procedures to improve reliability and validity.
• Examples include simple screens (e.g., MoCA) and comprehensive tests (e.g., NOTCE).

Considerations

• Factors to consider before administering a cognitive assessment include:
  • Purpose for testing
  • Appropriateness of testing for the client
  • Client characteristics (e.g., education, language, sensory abilities)
  • Testing environment (e.g., noise level, lighting)
  • Timing
  • Clinician competency
  • Consequences of results

Triggers for Testing

• Triggers for cognitive assessments can include:
  • Doctor's order
  • Client or family concerns
  • Court order
  • Insurance/WCB request
  • Employer requirement

Doctor's Order

• When a doctor orders a cognitive assessment, carefully assess:
  • The information the doctor is seeking.
  • If formal testing is the best and/or only way to obtain that information.
  • If the referral is within your scope of practice.
  • The appropriateness of the referral.
  • How the results will be utilized by the doctor.

Example – Inappropriate Referral

• Example: An Occupational Therapist being asked to administer the MoCA for a client taking Donepezil. This shows incorrect reasoning and rationale.

Judging Appropriateness

• Key questions to consider when evaluating the appropriateness of testing:
  • Will the results make a difference?
  • Is the potential risk for harm outweighed by the potential benefits?
  • Is the testing related to occupational therapy services?
  • Will you act on the results with the client?

Example – Appropriate Referral

• Example: OT for cognitive concerns related to driving. This aligns with client wishes, public safety, and holistic assessment.

Client or Family Concerns

• Properly address client or family concerns.
  • Define concerns explicitly, including the context and potential consequences.
  • Speak openly with both the client and family.
  • Recognize collateral information, which may be forthcoming during a separate conversation.
  • Receive and do not provide information

Client Considerations

• Consider relevant client factors for cognitive assessments like:
  • Educational profile
  • Language
  • Sensory abilities/limitations
  • Handedness
  • Previous testing and results/experience
  • Current health, diagnoses, and social considerations

Testing Environment & Timing

• Ideal testing conditions include a private space with appropriate noise and lighting levels, ensuring the setting is familiar or novel as needed. Adequate time for a debrief should also be planned.

Competence: Qualification Levels

• Level A: Requires no special qualifications.
• Level B: Requires a Master's degree in a relevant field and formal training in ethical administration, scoring, and assessment.
• Level C: Requires a doctorate and significant expertise, including formal training in assessing and interpreting cognitive performance.
• Different testing levels require varying competency and training experience.

Competence: Training

• Comprehensive training in testing administration, scoring, interpretation of CSSTs is essential.
• Specific training in the chosen assessment tool is needed (e.g., MoCA training).
• Practicing administering the tool, with feedback, is crucial.
  • Accuracy in scoring and interpretation of results.
• Regular updates on testing tools and maintenance of competency are required.

Competence

• Maintain the test's fidelity.
• Recognize that a single measure doesn't define cognitive status completely.
• Integrate test results with other assessments and clinical findings.
• Interpreting scores within a range and understanding their conceptual meaning
• Report results clearly and clinically.
  • Explain recommendations clearly to clients and other stakeholders.
  • Adhere to established practice standards.

Competence – Continued

• Practice with cultural competency, awareness of bias, and respect for client individual differences.
• Guard against misusing test results.

Selecting a CSST

• Consider factors like:
  • Measurable outcome
  • Client acceptance
  • Psychometric properties (reliability, validity)
  • Cost

Knowledge of Psychometric Properties

• Gain a thorough understanding of descriptive statistics.
• Master the psychometric properties of assessment tools, including validity, reliability, and measures of central tendency and dispersion.
• Interpretation of test scores using scaling and the meaning of scores within a given test's established range.

Outcomes of Testing

• Potential negative impacts on clients, employees, general public, and other professionals need careful consideration.
• Recognize ethical and/or legal obligations related to proper application of tests.
• Be aware that the tests can reveal information detrimental to the client.

Final Considerations

• Tests are often developed within a specific regional or cultural context.
• Testing can take place in a variety of settings.
• Acknowledge that it's impossible to be an expert in all relevant areas related to cognitive testing.
• Expertise in fields like pediatrics, school, geriatrics, and neurology are pertinent in addressing the complexities of cognitive assessment.

Try It – MoCA

• Administering the MoCA requires:
  • Client consent
  • Client's educational profile
  • Administration of the assessment
  • Scoring
  • Interpretation with debriefing.

Explore the ethical considerations and methodologies involved in administering formal cognitive assessments. This quiz covers both standardized testing approaches and the differences between bottom-up and top-down assessment strategies. Test your understanding of key assessments like MoCA and COPM.