A major purpose of the Observations section in a report is to describe the patient’s appearance and effort put forth during the testing, and to comment on whether this, or anything else, affected the test results. A profoundly depressed person may show lack of attention/interest to the point where the test findings “underestimate” his or her potential. We aren’t seeing the patient to confirm and measure their deficits, we are there to estimate their true potential as to how well they can speak, write, think, process and function when not depressed. Remember, our goal (as outlined in the section on Testing Philosophy) is to find out what is right with the patient, not just what is wrong. Seeing a depressed patient with possible neurocognitive disorder (NCD) we want to get their best performance on testing, as that will set the target that treatments and interventions will aim for.

There is little we can correct or fix in someone with NCD, but we can build on strengths/interests to motivate them (a love for dancing can lead to recommendations for aerobic exercise aimed as reducing NCD progression). So we need to, first, estimate their “premorbid” (before depression, cognitive disorder, etc. began) abilities, then see what we can do to get the patient back, or as close as possible, to that point. Next we test for current capacity, and if it is lower (emotionally, cognitively, etc.) in any way we try to determine why, and what can be done about that. In order do this, we need to test the patient under ideal conditions, motivating them to perform as well as possible.

You can see why it makes no sense to say in Observations, something like
At this testing, the patient’s behavior appeared consistent with their typical functioning and mood, thus, these findings are believed valid. Valid regarding what? Everyone already knew the patient appeared depressed, and had reduced capacity for their basic ADLs; e.g., the problem statement indicates they are “not grooming or dressing every morning.” If you are trying to rule out pseudodementia in a profoundly depressed person, then you do not want to assess the patient’s typical lack of motivation/interest (i.e., how they have performed at home over the last six months) at your testing. You want to, first, try to rule out NCD and you do that by getting the patient’s best performance in testing (not by trying for their typical performance), to see if it calls within average expectations. Then you can say, in feedback, to the family and patient:

You described worry over dementia in Mr. Smith, given his flattened affect, reduced self care (e.g., not bathing regularly), social isolation and episodic forgetfulness. However, he seemed to brighten with the attention afforded him during testing and when challenged and praised for his successes, he scored within average expectations on all cognitive measures. So under ideal conditions he displays normal function, which means we need to look/test elsewhere for the cause of his apparent depression.

Results from a patient who displays behavior, effort and mood during the testing consistent with their condition that brought them to the evaluation, tell us nothing. You’ve just duplicated the problem. Boosting the patient’s effort, motivation and function during testing to rule out NCD tells you a lot about the problem. You may not be able to do this in every case (i.e., rule out NCD) but it will help you determine how bad the NCD is, if present, like distinguishing Mild from Major NCD.

The takeaway here, is that in Observations you should state the results of your efforts to maximize the patient’s effort, attention and motivation. You begin to see how important it is to establish a positive rapport and maintain the patient’s attention/motivation throughout a tiring test battery. The goal, in Observations, is to document how well the patient could do, when putting out their maximum effort, which will inform the diagnostic impressions and Treatment Plan.*

Informing the Diagnosis and Recommendations
What potential is concealed under the patient’s appearance? If you only confirm the inattentive, depressed lack of arousal reported by family than you’ve found nothing about their true potential. You just confirmed the problems, when they’re function in testing is consistent with, or the same, as it is at home. We need to try to observe under what circumstances the patient’s true, underlying ability blossoms, if even for just a moment, because we will want to reduplicate that process in the Treatment Plan or recommendations.

A better approach to writing Observations might be:
At this testing the patient’s behavior appeared inattentive and depressed (little eye contact and no initiated conversation); however, when discussing her grandchildren her interpersonal affect became more animated and alert. This statement is useful as it lends itself to a diagnostic implication (lack of social contact with her grandkids plays a role, R/O “pseudodementia”) and yields a recommendation that her mood disorder seems related to social isolation and more contact with her grandchildren could likely improve it.

This writer was once asked to classify degree of mental retardation in a 1st grader who came to Cape Cod when his military parents were transferred from Florida to the Otis Air Force Base. His prior school had reported subpar performance in all academic areas, yet my Stanford-Binet yielded an IQ of 150. I couldn’t even use my WISC-R results, as its norms did not go high enough to generate that IQ! Of course, the student “appeared” unable to learn, as he was bored and disengaged entirely in school. I had to work to get him to demonstrate his ability, but the inherent challenge of the IQ test motivated him to do his best, and demonstrate his hidden ability.

If I had accepted his “typical” disinterested behavior during my testing, my results would not have been valid, as they would have underestimated his true potential. I would have just confirmed the reports of how he functioned in Florida; a result of no value likely to perpetuate harm to the child (placement in a class for developmental disabled students). With a challenge and a bit of encouragement I was able to briefly see, and objectively confirm, his true potential leading to a Educational (Treatment) Plan involving tons of enrichment activities. Of course, the youngster’s life changed, as he perked up and became “normal” as soon as he was placed in a gifted classroom.

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