APA Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia

Approved by the Council of Representatives
American Psychological Association

February 1998

Suggested citation: American Psychological Association, Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia (1998). Guidelines for the evaluation of dementia and age-related cognitive decline. Washington, DC: American Psychological Association.

APA Presidential Task Force on the Assessment of
Age-Consistent Memory Decline and Dementia
Thomas H. Crook, III, Ph.D., Chair
Glenn J. Larrabee, Ph.D.
Asenath LaRue, Ph.D.
Barry D. Lebowitz, Ph.D.
Martha Storandt, Ph.D.
James Youngjohn, Pd.D.

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

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. Although strenuous efforts are being exerted to identify the physiological causes of dementia, there are still no conclusive biological markers short of autopsy for the most common forms of dementia, including Alzheimer's disease. 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.

The following guidelines were developed for psychologists who perform evaluations of dementia and age-related cognitive decline. These guidelines conform to the American Psychological Association's Ethical Principles of Psychologists and Code of Conduct (APA, 1992).

Assessment of dementia and age-related cognitive decline in clinical practice is a core activity of the specialty of Clinical Neuropsychology. The recent Houston Conference on Specialty Education and Training in Clinical Neuropsychology (Hannay et al., 1998) has specified the appropriate integrated training model to attain that specialty. These guidelines, however, are intended to specify appropriate cautions and concerns for all clinicians which are specific to the assessment of dementia and age-related cognitive decline. These guidelines are aspirational in intent and are neither mandatory nor exhaustive. They are guidelines for practice and are not intended to represent standards for practice. 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 and/or some forensic evaluations.

A. Alzheimer's disease (AD) is the major cause for dementia in later life (Evans, Funkenstein, & Albert, 1989). The most widely accepted diagnostic criteria for probable AD are those offered by the National Institute of Neurological and Communicative Disorders and Stroke and by the Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA; McKhann et al., 1984). These criteria include the presence of dementia established by clinical examination and confirmed by neuropsychological testing. The dementia is described as involving multiple, progressive cognitive deficits in older persons in the absence of disturbances of consciousness, presence of psychoactive substances, or any other medical, neurological, or psychiatric conditions that might in and of themselves account for these progressive deficits. The Diagnostic and Statistical Manual of Mental Disorders: 4th Edition of the American Psychiatric Association (DSM-IV, 1994) also outlines diagnostic criteria for dementia of the Alzheimer's type that are generally consistent with the NINCDS-ADRDA criteria. DSM-IV also provides diagnostic criteria for vascular dementia, as well as dementia due to other general medical conditions including HIV disease, head trauma, Parkinson's disease, Huntington's disease, Pick's disease, Creutzfeldt-Jakob disease, and other general medical conditions and etiologies. New causes and varieties of dementia continue to be elucidated (e.g., dementia with Lewy bodies; McKeith et al., 1996) and diagnostic criteria for the dementing disorders continue to be refined (e.g., International Classification of Diseases-10 and subsequent revisions).

B. Some older persons have memory and cognitive difficulties identified by neuropsychological testing that are greater than those typical of normal aging, but not so severe as to warrant a diagnosis of dementia. Some of these persons go on to develop frank dementia and some do not. There is not yet a clear consensus regarding nosology for this middle group. Proposed nomenclature includes mild neurocognitive disorder, mild cognitive impairment, late-life forgetfulness, possible dementia, incipient dementia, benign senescent forgetfulness, senescent forgetfulness, and provisional dementia (see Table 1). Terms such as incipient dementia, provisional dementia, and mild cognitive impairment refer to persons who are somewhat more severely impaired and have a relatively greater likelihood of eventually becoming demented (Flicker, Ferris, & Reisberg, 1991). Terms such as benign senescent forgetfulness or late-life forgetfulness refer to persons with milder cognitive difficulties relative to their age peers who are less likely to go on to develop dementia.

C. Declines in memory and cognitive abilities are a normal consequence of aging in humans (e.g., Craik & Salthouse, 1992). This is true across cultures and, indeed, in virtually all mammalian species. The nosological category of Age-Associated Memory Impairment was proposed by a National Institute of Mental Health (NIMH) work group to describe older persons with objective memory declines relative to their younger years, but cognitive functioning that is normal relative to their age peers (Crook et al., 1986). The group's recommendations contained explicit operational definitions and psychometric criteria to assist in identifying these persons. The more recent term, Age-Consistent Memory Decline, has been proposed as being a less pejorative label and to emphasize that these are normal developmental changes (Crook, 1993; Larrabee, 1996), are not pathophysiological (Smith et al., 1991), and rarely progress to overt dementia (Youngjohn & Crook, 1993). The DSM-IV (1994) has codified the diagnostic classification of Age-Related Cognitive Decline, which will be used throughout the body of these Guidelines. This nomenclature has the advantage of not limiting the focus solely to memory, but lacks the operational definitions and explicit psychometric criteria of age-associated memory impairment.

A. Psychologists recognize that there are special considerations regarding informed consent and competency, given the nature of these evaluations with some patients who may be suffering from advanced stages of dementia. Psychologists attempt when possible to educate patients regarding the nature of their services, financial arrangements, potential risks inherent in their services, and limits of confidentiality. When patients are clearly not competent to give their informed consent, psychologists attempt to discuss these issues with family members and/or legal guardians, as appropriate.

B. There may also be special considerations regarding the limits of confidentiality in these circumstances. Family members, other professionals, and state agencies may have to be involved under circumstances of potential harm to the patients or others, without patients' consent. In potential cases of abuse or neglect, there may be mandated reporting responsibilities for psychologists consistent with state statutes and/or other applicable laws.

A. Psychologists who propose to perform evaluations for dementia and age-related cognitive decline are aware that special competencies and knowledge are required for such evaluations. Competence in conducting clinical interviews and administering, scoring, and interpreting psychological and neuropsychological tests is necessary, but may not be sufficient. Education, training, experience, and/or supervision in the areas of gerontology, neuropsychology, rehabilitation psychology, neuropathology, psychopharmacology, and psychopathology in older adults may help to prepare the psychologist for performing evaluations of age-related cognitive decline and dementia.

B. Psychologists use current knowledge of scientific and professional developments, consistent with accepted clinical and scientific standards, in selecting data collection methods and procedures. The Standards for Educational and Psychological Testing (APA, 1985) are adhered to in the use of psychological tests and other assessment tools.

A. Psychologists performing dementia and age-related cognitive decline evaluations communicate their findings to primary care physicians and/or other referring physicians, with sensitivity to issues of informed consent. When the psychologist is the first professional contact, the client is referred, when appropriate, for a thorough medical evaluation to discover any underlying medical disorder or any potentially reversible medical causes for dementia or cognitive decline. Given the prevalence of health problems in the elderly it is recommended that psychologists providing services to this population be particularly sensitive to these issues. A thorough dementia work-up is a multidisciplinary effort (Small et al., in press).

B. Psychologists help to educate health care professionals who may be administering mental status examinations or psychological screening tools regarding the psychometric properties of these instruments and their clinical utility for particular applications. Education is also provided about the differences between brief screening examinations and more comprehensive psychological or neuropsychological evaluation.

C. In the course of conducting evaluations for dementia and age-related cognitive decline, allegations of abuse, neglect, or family violence, issues regarding legal competence or guardianship, indications of other medical, neurological, or psychiatric conditions, or other issues may arise that are not necessarily within the scope of a particular evaluator's expertise. If this is so, the psychologist seeks additional consultation, supervision, and/or specialized knowledge, training, or experience to address these issues.

Psychologists are aware of how biases regarding age, gender, race, ethnicity, national origin, religion, sexual orientation, disability, language, culture, and socioeconomic status may interfere with an objective evaluation and recommendations. The psychologist strives to overcome any such biases or withdraws from the evaluation. Psychologists are alert and sensitive to differing roles, expectations, and normative standards within a sociocultural context.

A. Psychologists obtain the client's self-report and subjective impressions regarding changes in memory and cognitive functioning. This information can be obtained through informal interview or through formal memory complaint questionnaires (Crook & Larrabee, 1990; Dixon, Hultsch, & Hertzog, 1988; Gilewski, Zelinski, & Schaie, 1990). Advantages of formal scales include the quantification of memory complaints and the ability to measure subsequent changes in perception of memory loss.

B. Psychologists are aware that self-reported memory problems often do not correspond to actual decreases in memory performance (Bolla, Lindgren, Bonaccorsy, & Bleecker, 1991). Frequently, persons with significant cognitive dysfunction are not aware of the problem. This lack of awareness of genuine impairment can be a component of the neurobehavioral syndrome or it can be the result of denial or other psychological defenses. Conversely, some persons who report severe memory deficits actually have normal, or even above average performance. Depression and other psychological factors can lead to over-reporting of cognitive disturbance. Additionally, clients performing in the average range may actually have experienced significant decreases in performance, relative to their premorbid functioning (Rubin et al., in press).

C. It is important, when possible, to obtain behavioral descriptions and subjective estimations of cognitive performance from collateral sources such as family and friends. This information can be obtained either through clinical interview or through memory complaint questionnaires. It is important to be particularly alert to discordance between self and family reports. When formal scales are used, discrepancies between self and family reports can be quantified (Feher, Larrabee, Sudilovsky, & Crook, 1994; Zelinski, Gilewski, & Anthony-Bergstone, 1990).

D. It is important to take a careful history. The time of onset and nature and rate of the course of the difficulties provide information important to differential diagnosis. The clinical interview provides an opportunity to assess for the presence of deleterious side effects of medication, substance abuse, previous head injury, or other medical, neurological, or psychiatric history relevant to diagnosis. Obtaining a family history of dementia is also important.

E. Depression in elderly persons can mimic the effects of dementia (Kaszniak & Christenson, 1994). Psychomotor retardation and decreased motivation can result in nondemented persons appearing to have pathophysiologically determined cognitive disturbances in both day-to-day functioning and on formal neuropsychological testing. Depression can also cause nondemented persons to over-report the severity of cognitive disturbance. Consequently, it is important to perform a careful assessment for depression when evaluating for dementia and age-related cognitive decline. Depression is best assessed during an interview, so that the clinician can obtain information regarding the client's body language and affective display. Formal mood scales (e.g., Beck et al., 1961; Yesavage et al., 1983) can also play an important role in assessing for depression and have the advantages of quantifying and facilitating the assessment of changes in mood over time. Psychologists are sensitive to sociocultural factors that might cause some older persons to underreport depressive symptoms. Psychologists are also aware that depression and dementia are not mutually exclusive. Depression and dementia and/or age-related cognitive decline frequently coexist in the same person. Depression can also be a feature of certain subcortical dementing conditions, such as Parkinson's disease (Cummings & Benson, 1983; Youngjohn, Beck, Jogerst, & Cain, 1992).

A. The use of psychometric instruments may represent the most important and unique contribution of psychologists to the assessment of dementia and age-related cognitive decline. Tests used by psychologists should be standardized, reliable, valid, and have normative data directly referable to the older population. Discriminant, convergent, and/or ecological validity should all be considered in selecting tests. There are many tests and approaches that are useful for these evaluations, including but not limited to the Wechsler scales of intelligence and memory, tests from the Halstead-Reitan battery, and the Benton tests. Psychologists seeking more comprehensive compendiums of appropriate tests are referred to The Buros Yearbooks of Mental Measurement, Neuropsychological Assessment (3rd ed.) (Lezak, 1995), and A Compendium of Neuropsychological Tests (Spreen & Strauss, 1991). Many other excellent texts also provide lists of valuable neuropsychological instruments for use in these evaluations. For example, La Rue (Aging and Neuropsychological Assessment, 1992), Nussbaum (Handbook of Neuropsychology and Aging, 1997), and Storandt and VandenBos (Neuropsychological Assessment of Dementia and Depression in Older Adults: A Clinician's Guide, 1994) present a variety of useful psychological and neuropsychological methods and issues relevant to assessing older adults.

B. Brief mental status examinations and screening instruments are not adequate for diagnosis in most cases. Comprehensive neuropsychological evaluations for dementia and age- related cognitive decline include tests or assessments of a range of multiple cognitive domains, typically including memory, attention, perceptual and motor skills, language, visuospatial abilities, problem solving, and executive functions. It is recognized, however, that detection of profound dementia may not require a comprehensive neuropsychological test battery.

A. Ideally, psychologists assessing for cognitive declines in older persons would have baseline test data from earlier years against which current performance could be compared. Unfortunately, this information rarely exists, so psychologists must try to estimate premorbid abilities by taking into consideration socioeconomic status, educational level, occupational history, and client and family reports. Clinical judgement can be an important part of this process. There are a number of systematic biases in human judgement that may lead to inaccurate clinical estimates of premorbid function (Kareken, 1997). Various techniques have been used to estimate cognitive abilities in earlier years (e.g., Barona, Reynolds, & Chastain, 1984; Blair & Spreen, 1989). Psychologists are aware, however, that any measure of current cognitive functioning can be affected by dementia (Larrabee, Largen, & Levin, 1985; Storandt, Stone, & LaBarge, 1995).

B. Once a person has been tested, these data can serve as a baseline against which to measure future changes in cognitive functions. Magnitudes and rates of cognitive change, as well as response to treatment, can also be determined by follow-up testing. In most cases a one year follow-up interval is adequate for monitoring changes in cognitive performance, unless the client, family, or other health care professional report a more rapid decline, emergence of new symptoms, or changes in life circumstances. Psychologists try to be knowledgeable of the test-retest reliability of tests that are used so that patterns and extent of change can be interpreted appropriately. Interim follow-up not involving formal testing may also be useful in many cases.

C. Because declines in average levels of performance with age are observed on some tests, it is important that tests selected for use in the evaluation of dementia and age-related cognitive decline have adequate age-adjusted norms. Until recently, the relative lack of older adult norms posed a problem for clinicians, but better and larger older adult standardization samples are now available for many commonly used clinical tests. Gaps still remain in the normative data for very old persons and for diverse linguistic and ethnic populations. Comparison of an individual's test performance against even age-adjusted norms can be misleading if the individual's earlier abilities fell outside of the population curve.

A. Psychologists are aware that practice effects can result when tests are readministered in close temporal proximity. Such effects are more likely to be observed in normally aging older persons than in patients with dementia or amnestic conditions. In cases of questionable cognitive decline, the presence of robust practice effects can help to establish that cognitive functions are intact. Repeated, closely spaced testings, however, can obscure cognitive changes or intervention effects. The use of alternate test forms of equivalent difficulty can help to attenuate practice effect artifact, but such forms may not be available for many otherwise appropriate tests.

B. Psychologists realize that persons can have significant declines in day-to-day functional abilities that are not demonstrated on psychometric instruments because of a relative lack of sensitivity of the tests used. Psychometric instruments are effective, but still imperfect, measures of real-life abilities.

C. Reasons why people may do poorly on tests when the ability being assessed is intact include, but are not limited to, sensory deficits, fatigue, medication side effects, physical illness and frailness, discomfort or disability, poor motivation, financial disincentives, depression, anxiety, not understanding the test instructions, and lack of interest. Psychologists attempt to assess these sources of error and to limit and control them to the extent that they are able.

A. In many instances, patients may benefit from feedback regarding the evaluation in language that they can understand. Psychologists should exercise clinical judgement and take into consideration the needs and capabilities of the particular client when feedback is provided.

B. Providing feedback, education, and support to the family, with clients' informed consent, are also important aspects of evaluations and enhance their value and applicability. Knowledge regarding levels of impairment, the expected course, and expected outcomes can help families to make adequate preparations. Working with families can provide them with effective and humane methods for managing persons with problematic behaviors. Appropriately counseling families regarding known genetic components and the heritability of the various disorders can address their concerns, and in many cases, allay needless fears. Healthy older adults who have had concerns about their cognitive functions can benefit from reassurance based on results of testing (Youngjohn, Larrabee, & Crook, 1992) and from suggestions as to how they may enhance their everyday cognitive function.

C. Psychologists attempt to educate themselves regarding currently approved somatic and nonsomatic treatments of dementia and age-related cognitive decline. This is a rapidly evolving area and both families and healthcare professionals can benefit from education.

D. Psychologists offer or recommend appropriate treatment to persons with dementia and age-related cognitive decline for coexisting emotional and behavioral disturbances. Cognitive rehabilitation and memory training have limited effectiveness for persons with dementia, although environmental restructuring may be useful. By contrast, training in cognitive strategies, use of memory aids, and mnemonic techniques have proven effectiveness with nondemented persons, including those with age-related cognitive decline or those with focal brain disorders (Lapp, 1996; West & Crook, 1991). Clients and families can be educated about these treatments, which can be offered to clients as appropriate.

Summary

Assessment of cognitive function among older adults requires specialized training and refined psychometric tools. Psychologists conducting such assessments must learn current diagnostic nomenclature and criteria, gain specialized competence in the selection and use of psychological tests, and understand both the limitations of these tests and the context in which they may be used and interpreted. Assessment of cognitive issues in dementia and age-related cognitive decline is a core focus of the specialty of Clinical Neuropsychology. Therefore, these guidelines are not intended to suggest the development of an independent proficiency. Rather, they are intended to state explicitly some appropriate cautions and concerns for all psychologists who wish to assess cognitive abilities among older adults, particularly in distinguishing between normal and pathological processes.

References

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychological Association (1985). Standards for educational and psychological testing. Washington DC: Author.

American Psychological Association (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597-1611.

Barona, A., Reynolds, C.R., & Chastain, R. (1984). A demographically based index of premorbid intelligence for the WAIS-R. Journal of Consulting and Clinical Psychology, 5, 885-887.

Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., & Erbaugh, J.K. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571.

Blackford, R.C., & La Rue, A. (1989). Criteria for diagnosing age-associated memory impairment: Proposed improvements from the field. Developmental Neuropsychology, 5, 295-306.

Blair, J.R., & Spreen, V. (1989). Predicting premorbid IQ: A revision of the National Adult Reading Test. The Clinical Neuropsychologist, 3, 129-136.

Bolla, K.I., Lindgren, K.N., Bonaccorsy, C., & Bleecker, M.L. (1991). Memory complaints in older adults: Fact or fiction? Archives of Neurology, 48, 61-64.

Buros Institute of Mental Measurements. The mental measurements yearbooks. Lincoln, NE: The University of Nebraska Press.

Craik, F.I.M., & Salthouse, T.A. (1992). Handbook of aging and cognition. Hillsdale, NJ: Erlbaum.

Crook, T.H. (1993). Diagnosis and treatment of memory loss in older patients who are not demented. In R. Levy, R. Howard, & A. Burns (Eds.) Treatment and care in old age psychiatry (pp. 95-111). London: Wrightson Biomedical Publishing.

Crook, T.H., Bartus, R.T., Ferris, S.H., Whitehouse, P., Cohen, G.D., & Gershon, S. (1986). Age-associated memory impairment: Proposed diagnostic criteria and measures of clinical change-Report of a National Institute of Mental Health workgroup. Developmental Neuropsychology, 2, 261-276.

Crook, T.H., & Larrabee, G.J. (1990). A self-rating scale for evaluating memory in everyday life. Psychology and Aging, 5, 48-57.

Cummings, J.L., & Benson, D.F. (1992). Dementia: A clinical approach. Stoneham, MA: Butterworth-Heineman.

Dixon, R.A., Hultsch, D.F., & Hertzog, C. (1988). The Metamemory in Adulthood (MIA) Questionnaire. Psychopharmacology Bulletin, 24, 67-688.

Evans, D.A., Funkenstein, H.H., & Albert, M.S. (1989). Prevalence of Alzheimer's disease in a community population of older persons. Journal of the American Medical Association, 262, 2551-2556.

Feher, E.P., Larrabee, G.J., Sudilovsky, A., & Crook, T.H. (1994). Memory self-report in Alzheimer's disease and in age-associated memory impairment. Journal of Geriatric Psychiatry and Neurology, 7, 58-65.

Ferris, S.H., & Kluger, A. (1996). Commentary on age-associated memory impairment, age- related cognitive decline and mild cognitive impairment. Aging, Neuropsychology, and Cognition, 3, 148-153.

Flicker, C., Ferris, S.H., & Reisberg, B. (1991). Mild cognitive impairment in the elderly: Predictors of dementia. Neurology, 41, 1006-1009.

Gilewski, M.J., Zelinski, E.M., & Schaie, K.W. (1990). The memory functioning questionnaire for assessment of memory complaints in adulthood and old age. Psychology and Aging, 5, 482-490.

Hannay, H.J., Bieliauskas, L., Crosson, B.A., Hammeke, T.A., Hamsher, K.deS., & Koffler, S. (Eds.: 1998). Proceedings of the Houston Conference on Specialty Education and Training in Clinical Neuropsychology. Archives of Clinical Neuropsychology, 13, 157-249.

Kareken, D.A. (1997). Judgment pitfalls in estimating premorbid intellectual function. Archives of Clinical Neuropsychology, 12, 701-709.

Kaszniak, A.W., & Christenson, G.D. (1994). Differential diagnosis of dementia and depression. In M. Storandt & G.R. VandenBos (Eds.), Neuropsychological assessment of dementia and depression in older adults: A clinician's guide (pp. 81-118). Washington, DC: American Psychological Association.

Kral, V.A. (1962). Senescent forgetfulness: Benign and malignant. Journal of the Canadian Medical Association, 86, 257-260.

Lapp, D.C. (1996). Don't forget! Easy exercises for a better memory. Reading, M.A.: Addison, Wesley, Longman Publishing Co.

Larrabee, G.J. (1996). Age-Associated Memory Impairment: Definition and psychometric characteristics. Aging, Neuropsychology, and Cognition, 3, 118-131.

Larrabee, G.J., Largen, J.W., & Levin, H.S. (1985). Sensitivity of age-decline resistant ("Hold") WAIS subtests to Alzheimer's disease. Journal of Clinical and Experimental Neuropsychology, 7, 497-504.

Larrabee, G.J., Levin, H.S., & High, W.M. (1986). Senescent forgetfulness: A quantitative study. Developmental Neuropsychology, 2, 373-385.

La Rue, A. (1992). Aging and neuropsychological assessment. New York: Plenum.

Lezak, M. (1995). Neuropsychological assessment (3rd ed.). New York: Oxford.

McKeith, G., Galasko, D., Kosaka, K., Perry, E., Dickson, D., Hansen, L., Salmon, D., Lowe, J., Mirra, S., Byrne, E., Lennox, G., Quinn, N., Edwardson, J., Ince, P., Bergeron, C., Burns, A., Miller, B., Lovestone, S., Collerton, D., Jansen, E., Ballard, C., de Vos, R., Wilcock, G., Jellinger, K., & Perry, R. (1996). Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): Report of the consortium on DLB international workshop. Neurology, 47, 1113-1124.

McKhann, G., Drachman, D., Folstein, M., Katzman, R., Price, D., & Stadlan, E.M. (1984). Clinical diagnosis of Alzheimer's disease: Report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer's disease. Neurology, 34, 939-944.

Nussbaum, P.D. (Ed.). (1997). Handbook of neuropsychology and aging. New York: Plenum.

Rediess, S., & Caine, E.D. (1996). Aging, cognition, and DSM-IV. Aging, Neuropsychology, and Cognition, 3, 105-117.

Rubin, E.H., Storandt, M., Miller, J.P., Kincherf, D.A., Grant, E.A., Morris, J.C., & Berg, L. (in press). A prospective study of cognitive function and onset of dementia in cognitively healthy elders. Archives of Neurology.

Small, G.W., Rabins, P.V., Barry, P.P., Buckholtz, N.S., DeKosky, S.T., Ferris, S.H., Finkel, S.I., Gwyther, L.P., Khachaturian, Z.S., Lebowitz, B.D., McRae, T.D., Morris, J.C., Oakley, F., Schneider, L.S., Streim, J.E., Sunderland, T., Teri, L.A., Tune, L.E. (in press). Diagnosis and treatment of Alzheimer's disease and related disorders: Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society. Journal of the American Medical Association.

Smith, G., Ivnik, R.J., Peterson, R.C., Malec, J.F., Kokmen, E., & Tangalos, E. (1991). Age-Associated Memory Impairment diagnoses: Problems of reliability and concerns for terminology. Psychology and Aging, 6, 551-558.

Smith, G.E., Petersen, R.C., Parisi, J.E., Ivnik, R.J., Kokmem, E., Tangalos, E.G., Waring, S. (1996). Definition, course, and outcome of mild cognitive impairment. Aging, Neuropsychology, and Cognition, 3, 141-147.

Spreen, O., & Strauss, E. (1991). A compendium of neuropsychological tests: Administration, norms, and commentary. New York: Oxford.

Storandt, M., Stone, K., & LaBarge, E. (1995). Deficits in reading performance in very mild dementia of the Alzheimer type. Neuropsychology, 9, 174-176.

Storandt, M., & VandenBos, G.R. (Eds.). (1994). Neuropsychological assessment of dementia and depression in older adults: A clinician's guide. Washington, DC: American Psychological Association.

West, R.L., & Crook, T.H. (1991). Video training of imagery for mature adults. Applied Cognitive Psychology, 6, 307-320.

Yesavage, J., Brink, T., Rose, T., Lum, O., Huang, O., Adey, V., & Leier, V. (1983). Development and validation of a geriatric depression scale: A preliminary report. Journal of Psychiatric Research, 17, 37-49.

Youngjohn, J.R., Beck, J., Jogerst, J., & Cain, C. (1992). Neuropsychological impairment, depression, and Parkinson's disease. Neuropsychology, 6, 123-136.

Youngjohn, J.R., & Crook, T.H. (1993). Stability of everyday memory in age-associated memory impairment: A longitudinal study. Neuropsychology, 7, 406-416.

Youngjohn, J.R., Larrabee, G.J., & Crook, T.H. (1992). Discriminating age-associated memory impairment and Alzheimer's disease. Psychological Assessment, 4, 54-59.

Zelinski, E.M., Gilewski, M.J., & Anthony-Bergstone, C.R. (1990). Memory functioning questionnaire: Concurrent validity with memory performance and self-reported memory failures. Psychology and Aging, 5, 388-399.