Education as a Moderator of Help Seeking Behavior in Subjective Cognitive Decline.

OBJECTIVE: Disparities in Alzheimer disease (AD) and differences in help seeking (HS) across sociodemographic groups warrant public health concern. Research addressing such disparities must shift toward the earliest clinical manifestations of AD to optimize diagnosis, intervention and care planning. Subjective cognitive decline (SCD), a risk state for AD, provides an important context in which to examine sociodemographic-related disparities in HS. PARTICIPANTS AND METHODS: One hundred sixty-seven cognitively healthy older adults (M age =73, M education =16) (26.4% Black, Asian, or "Other") completed SCD questionnaire, HS questions, and mood measures (depression and anxiety). Binary logistic adjusted regressions examined: (a) the association between SCD and HS; and (b) the extent to which education moderated the relationship between SCD and HS. SCD [b = 0.06, SE=0.13, P <0.001, odds ratio=1.06, 95% CI (1.03, 1.08)] and education [b=0.32, SE=0.09, P <0.001, odds ratio=1.37, 95% CI (1.15, 1.64)] were independently associated with HS, with significant interaction between education and SCD on HS [b=0.2, SE=0.01, P =0.01, odds ratio=1.02, 95% CI (1.00, 1.03)]. CONCLUSIONS: Findings elucidate the importance of tailoring SCD-related psychoeducational resources depending on educational background as a preliminary stepping-stone in encouraging HS among older adults who may be at particular risk for developing dementia.

Financial decision-making and self-awareness for financial decision-making is associated with white matter integrity in older adults.

Financial decision-making (FDM) and awareness of the integrity of one's FDM abilities (or financial awareness) are both critical for preventing financial mistakes. We examined the white matter correlates of these constructs and hypothesized that the tracts connecting the temporal-frontal regions would be most strongly correlated with both FDM and financial awareness. Overall, 49 healthy older adults were included in the FDM analysis and 44 in the financial awareness analyses. The Objective Financial Competency Assessment Inventory was used to measure FDM. Financial awareness was measured by integrating metacognitive ratings into this inventory and was calculated as the degree of overconfidence or underconfidence. Diffusion tensor imaging data were processed with Tracts Constrained by Underlying Anatomy distributed as part of the FreeSurfer analytic suite, which produced average measures of fractional anisotropy and mean diffusivity in 18 white matter tracts along with the overall tract average. As expected, FDM showed the strongest negative associations with average mean diffusivity measure of the superior longitudinal fasciculus -temporal (SLFT; r = -.360, p = .011) and -parietal (r = -.351, p = .014) tracts. After adjusting for FDM, only the association between financial awareness and average mean diffusivity measure of the right SLFT (r = .310, p = .046) was significant. Overlapping white matter tracts were involved in both FDM and financial awareness. More importantly, these preliminary findings reinforce emerging literature on a unique role of right hemisphere temporal connections in supporting financial awareness.

Examining the Role of Aging Perceptions in Subjective Cognitive Decline.

OBJECTIVE: While subjective cognitive decline (SCD) is gaining ground as a "preclinical" risk state for Alzheimer disease, its utility depends on our understanding of the factors linked to SCD. Rarely examined sociocultural factors including perceptions of aging may relate to the subjective experience of cognitive aging. Identifying such associations will help to refine the utility of SCD as an early marker of AD while setting the stage for addressing modifiable factors contributing to SCD. METHODS: The study consisted of N=136 participants (68% female; 73% White; 22% Black race, age mean =74.72; education mean =16.01). Questionnaires assessed SCD, depressive symptoms, and age perceptions (essentialist aging beliefs, subjective age, age group identification, and explicit/implicit age stereotypes). Cognitive functioning was measured with a semantic interference and learning task. RESULTS: SCD was correlated with essentialist aging beliefs, age identification, and depressive symptoms [ rrange =0.18 to 0.22, Prange =0.009 to 0.02, confidence interval (CI) range =0.00-0.39]. Essentialist aging beliefs were correlated with subjective age and age group identification ( rrange =0.22 to 0.42, Prange <0.001 to 0.003, CI range =0.08-0.57). Both age group identification and essentialism were correlated with depressive symptoms ( rrange =0.22, Prange =0.009 to 0.01, CI range =0.04-0.39). In the adjusted regression model including depressive symptoms, age perceptions, and SCD, only SCD was associated with cognition ( b =-0.31, P <0.001). CONCLUSION: Although correlated with SCD, perceptions of aging do not explain the relationship between SCD and performance on a sensitive cognitive test among older adults.

Reduced Awareness of Memory Deficit is Associated With Increased Medicare Home Health Care Use in Dementia.

OBJECTIVE: The objective of this study was to examine whether reduced awareness of memory deficits in individuals with dementia is associated with more frequent need for Medicare home health care services. METHODS: Cross-sectional analyses were conducted in a multicenter, clinic-based cohort. In total, 192 participants diagnosed with dementia and their informants were independently asked whether or not the participant demonstrated cognitive symptoms of dementia related to memory and word-finding. Participant self-awareness was measured as the discrepancy between participant and caregiver report of these symptoms. Annual Medicare home health benefit use data was obtained from Medicare claims matched by year to the Predictors study visit. RESULTS: Participants that used home health services had lower awareness scores than those who did not. Awareness remained independently associated with home health use in a logistic regression adjusted for age, gender, education, caregiver relationship, global cognition, dementia subtype, and medical comorbidities. IMPLICATIONS: Reduced self-awareness of memory deficits in individuals with dementia is associated with more frequent use of Medicare home health services. The disproportionate use of in-home assistance as a function of awareness level may reflect dangers faced by patients, and challenges faced by caregivers, when patients have limited awareness of their memory deficits. Current results have implications for clinical care, caregiver education, and models of health care utilization.

An examination of financial capacity and neuropsychological performance in chronic acquired brain injury (CABI).

PRIMARY OBJECTIVE: Financial Capacity (FC) is known to be impaired in the acute and subacute stages of brain injury. The current study sought to examine FC in the context of chronic, moderate to severe acquired brain injury (CABI). RESEARCH DESIGN: The Financial Competence Assessment Inventory (FCAI), developed in Australia, was adapted to examine the integrity of FC in an American sample. METHODS AND PROCEDURES: Healthy comparison (HC) participants were recruited from the community, whereas participants with CABI were recruited from a community-based rehabilitation center. Participants completed the FCAI and a neuropsychological battery. FCAI performance in the current study was compared against previously published Australian data. Multiple regression analyses examined group (CABI vs. HC) as a predictor of FC. Bivariate correlations examined the cognitive correlates of FCAI in the CABI group. MAIN OUTCOMES AND RESULTS: The HC group in the current study obtained similar mean scores as those in the Australian sample. CABI group membership predicted lower performance on each FCAI dimension. In the CABI group, attention, working memory, delayed verbal memory, abstract reasoning and impulsivity were uniquely associated with FCAI dimensions. CONCLUSIONS: Findings underscore the importance of continued monitoring of FC even after the subacute stage of injury, and identify cognitive impairments that may be particularly detrimental for specific dimensions of FC.

Informant Report of Financial Capacity for Individuals With Chronic Acquired Brain Injury: An Assessment of Informant Accuracy.

OBJECTIVE: Primarily, to investigate the association between informant report and objective performance on specific financial capacity (FC) tasks by adults with chronic, moderate to severe acquired brain injury, and to examine the nature of misestimates by the informants. DESIGN: Cross-sectional design. SETTING: A postacute, community-based rehabilitation center. PARTICIPANTS: Data were obtained from 22 chronic acquired brain injury (CABI) adults, mean age of 46.6 years (SD = 8.67), mean years of education of 13.45 years (SD = 2.15), with moderate to severe acquired brain injury (86% had traumatic brain injury), with a mean postinjury period of 17.14 years (SD = 9.5). Whereas the CABI adults completed the Financial Competence Assessment Inventory interview-a combination of self-report and performance-based assessment, 22 informants completed a specifically designed parallel version of the interview. RESULTS: Pearson correlations and 1-sample t tests based on the discrepancy scores between informant report and CABI group's performance were used. The CABI group's performance was not associated with its informant's perceptions. One-sample t tests revealed that informants both underestimated and overestimated CABI group's performance. CONCLUSIONS: Results indicate lack of correspondence between self- and informant ratings. Further investigation revealed that misestimations by informants occurred in contrary directions with CABI adults' performance being inaccurately rated. These findings raise critical issues related to assuming that the informant report can be used as a "gold standard" for collecting functional data related to financial management, and the idea that obtaining objective data on financial tasks may represent a more valid method of assessing financial competency in adults with brain injury.

Investing: the case for recognition as an independent capacity.

In this article, we provide support for the need to recognize investing as an independent capacity. A comparison of the definitions and models of financial and investing capacities revealed significant differences between them. A review of the status of investing capacity assessment revealed that there are currently no investing capacity specific assessment instruments (ICSAIs). Implications for researchers and clinicians resulting from the lack of recognition of investing as an independent capacity are discussed and used as a rational for the need to develop ICSAIs. The benefits of ICSAI development for financial, legal, and clinical professionals as well as for investors are discussed, and a direction for future investing capacity research is proposed.

Integrating the Constructs of Anosognosia and Metacognition: a Review of Recent Findings in Dementia.

The current review integrates recent findings regarding the construct of self-awareness in dementia from both clinical and cognitive perspectives. We present the predominant theoretical models of awareness and summarize both traditional and emerging approaches to assessing awareness from clinical and meta-cognitive perspectives. In this review, we focus primarily on findings from recent studies in anosognosia and meta-cognition in the context of neurodegenerative disease with special emphasis on Alzheimer's disease and frontotemporal dementia. Emerging trends in the study of awareness, including examination of the longitudinal course of anosognosia, and investigation of the neural substrates underlying meta-cognitive abilities are addressed. Finally, the practical importance of studying and assessing awareness from both theoretical and clinical angles is emphasized.

A scoping review of neuropsychological assessment for Asian Indians in the United States - research and clinical recommendations.

Objective: There is an increasing focus on understanding health disparities among various cultural groups in the United States. The need for heterogeneity in norms and test stimuli across ethnically diverse individuals are being increasingly recognized. However, to date it remains unknown whether and to what extent differences in cognitive norms and tests exist in Asian Indians, a fast-growing population in the U.S. It is essential to understand these differences to improve diagnostic accuracy and provide timely and appropriate clinical care. Method: In this study, we conducted a scoping review of available cognitive tests that were normed, developed, or adapted for Asian Indians living in the U.S. Results: The results suggested a paucity of norms and tests specifically examining cognition in this community. Conclusions: Based on the findings, we provide suggestions for research directions focusing on the development of culturally sensitive neuropsychological tools, normative data representative of this demographic, and interventions addressing healthcare access barriers. Overall, this review provides readers with relevant clinical information to immediately enhance patient care as well as provide actionable items in research to improve the future utility of neuropsychology for Asian Indians in the United States.

Design and Feasibility Analysis of a Smartphone-Based Digital Cognitive Assessment Study in the Framingham Heart Study.

BACKGROUND: Smartphone-based digital technology is increasingly being recognized as a cost-effective, scalable, and noninvasive method of collecting longitudinal cognitive and behavioral data. Accordingly, a state-of-the-art 3-year longitudinal project focused on collecting multimodal digital data for early detection of cognitive impairment was developed. METHODS AND RESULTS: A smartphone application collected 2 modalities of cognitive data, digital voice and screen-based behaviors, from the FHS (Framingham Heart Study) multigenerational Generation 2 (Gen 2) and Generation 3 (Gen 3) cohorts. To understand the feasibility of conducting a smartphone-based study, participants completed a series of questions about their smartphone and app use, as well as sensory and environmental factors that they encountered while completing the tasks on the app. Baseline data collected to date were from 537 participants (mean age=66.6 years, SD=7.0; 58.47% female). Across the younger participants from the Gen 3 cohort (n=455; mean age=60.8 years, SD=8.2; 59.12% female) and older participants from the Gen 2 cohort (n=82; mean age=74.2 years, SD=5.8; 54.88% female), an average of 76% participants agreed or strongly agreed that they felt confident about using the app, 77% on average agreed or strongly agreed that they were able to use the app on their own, and 81% on average rated the app as easy to use. CONCLUSIONS: Based on participant ratings, the study findings are promising. At baseline, the majority of participants are able to complete the app-related tasks, follow the instructions, and encounter minimal barriers to completing the tasks independently. These data provide evidence that designing and collecting smartphone application data in an unsupervised, remote, and naturalistic setting in a large, community-based population is feasible.

Shifting From Active to Passive Monitoring of Alzheimer Disease: The State of the Research.

Most research using digital technologies builds on existing methods for staff-administered evaluation, requiring a large investment of time, effort, and resources. Widespread use of personal mobile devices provides opportunities for continuous health monitoring without active participant engagement. Home-based sensors show promise in evaluating behavioral features in near real time. Digital technologies across these methodologies can detect precise measures of cognition, mood, sleep, gait, speech, motor activity, behavior patterns, and additional features relevant to health. As a neurodegenerative condition with insidious onset, Alzheimer disease and other dementias (AD/D) represent a key target for advances in monitoring disease symptoms. Studies to date evaluating the predictive power of digital measures use inconsistent approaches to characterize these measures. Comparison between different digital collection methods supports the use of passive collection methods in settings in which active participant engagement approaches are not feasible. Additional studies that analyze how digital measures across multiple data streams can together improve prediction of cognitive impairment and early-stage AD are needed. Given the long timeline of progression from normal to diagnosis, digital monitoring will more easily make extended longitudinal follow-up possible. Through the American Heart Association-funded Strategically Focused Research Network, the Boston University investigative team deployed a platform involving a wide range of technologies to address these gaps in research practice. Much more research is needed to thoroughly evaluate limitations of passive monitoring. Multidisciplinary collaborations are needed to establish legal and ethical frameworks for ensuring passive monitoring can be conducted at scale while protecting privacy and security, especially in vulnerable populations.

Digital neuropsychological measures by defense automated neurocognitive assessment: reference values and clinical correlates.

Introduction: Although the growth of digital tools for cognitive health assessment, there's a lack of known reference values and clinical implications for these digital methods. This study aims to establish reference values for digital neuropsychological measures obtained through the smartphone-based cognitive assessment application, Defense Automated Neurocognitive Assessment (DANA), and to identify clinical risk factors associated with these measures. Methods: The sample included 932 cognitively intact participants from the Framingham Heart Study, who completed at least one DANA task. Participants were stratified into subgroups based on sex and three age groups. Reference values were established for digital cognitive assessments within each age group, divided by sex, at the 2.5th, 25th, 50th, 75th, and 97.5th percentile thresholds. To validate these values, 57 cognitively intact participants from Boston University Alzheimer's Disease Research Center were included. Associations between 19 clinical risk factors and these digital neuropsychological measures were examined by a backward elimination strategy. Results: Age- and sex-specific reference values were generated for three DANA tasks. Participants below 60 had median response times for the Go-No-Go task of 796 ms (men) and 823 ms (women), with age-related increases in both sexes. Validation cohort results mostly aligned with these references. Different tasks showed unique clinical correlations. For instance, response time in the Code Substitution task correlated positively with total cholesterol and diabetes, but negatively with high-density lipoprotein and low-density lipoprotein cholesterol levels, and triglycerides. Discussion: This study established and validated reference values for digital neuropsychological measures of DANA in cognitively intact white participants, potentially improving their use in future clinical studies and practice.

Corrigendum: Digital neuropsychological measures by defense automated neurocognitive assessment: reference values and clinical correlates.

[This corrects the article DOI: 10.3389/fneur.2024.1340710.].

Comparing Cognitive Tests and Smartphone-Based Assessment in 2 US Community-Based Cohorts.

BACKGROUND: Smartphone-based cognitive assessments have emerged as promising tools, bridging gaps in accessibility and reducing bias in Alzheimer disease and related dementia research. However, their congruence with traditional neuropsychological tests and usefulness in diverse cohorts remain underexplored. METHODS AND RESULTS: A total of 406 FHS (Framingham Heart Study) and 59 BHS (Bogalusa Heart Study) participants with traditional neuropsychological tests and digital assessments using the Defense Automated Neurocognitive Assessment (DANA) smartphone protocol were included. Regression models investigated associations between DANA task digital measures and a neuropsychological global cognitive Z score (Global Cognitive Score [GCS]), and neuropsychological domain-specific Z scores. FHS participants' mean age was 57 (SD, 9.75) years, and 44% (179) were men. BHS participants' mean age was 49 (4.4) years, and 28% (16) were men. Participants in both cohorts with the lowest neuropsychological performance (lowest quartile, GCS1) demonstrated lower DANA digital scores. In the FHS, GCS1 participants had slower average response times and decreased cognitive efficiency scores in all DANA tasks (P<0.05). In BHS, participants in GCS1 had slower average response times and decreased cognitive efficiency scores for DANA Code Substitution and Go/No-Go tasks, although this was not statistically significant. In both cohorts, GCS was significantly associated with DANA tasks, such that higher GCS correlated with faster average response times (P<0.05) and increased cognitive efficiency (all P<0.05) in the DANA Code Substitution task. CONCLUSIONS: Our findings demonstrate that smartphone-based cognitive assessments exhibit concurrent validity with a composite measure of traditional neuropsychological tests. This supports the potential of using smartphone-based assessments in cognitive screening across diverse populations and the scalability of digital assessments to community-dwelling individuals.

Task demand influences relationships among sex, clustering strategy, and recall: 16-word versus 9-word list learning tests.

OBJECTIVE: We compared the relationships among sex, clustering strategy, and recall across different task demands using the 16-word California Verbal Learning Test-Second Edition (CVLT-II) and the 9-word Philadelphia (repeatable) Verbal Learning Test (PrVLT). BACKGROUND: Women generally score higher than men on verbal memory tasks, possibly because women tend to use semantic clustering. This sex difference has been established via word-list learning tests such as the CVLT-II. METHODS: In a retrospective between-group study, we compared how 2 separate groups of cognitively healthy older adults performed on a longer and a shorter verbal learning test. The group completing the CVLT-II had 36 women and 26 men; the group completing the PrVLT had 27 women and 21 men. RESULTS: Overall, multiple regression analyses revealed that semantic clustering was significantly associated with total recall on both tests' lists (P<0.001). Sex differences in recall and semantic clustering diminished with the shorter PrVLT word list. CONCLUSIONS: Semantic clustering uniquely influenced recall on both the longer and shorter word lists. However, serial clustering and sex influenced recall depending on the length of the word list (ie, the task demand). These findings suggest a complex nonlinear relationship among verbal memory, clustering strategies, and task demand.

A narrative review of the biopsychosocial and health characteristics of Asian Indians in the United States: Clinical and research implications for neuropsychological functioning.

Objective: The prevailing scientific literature aggregates Asians living in America into one omnibus category and thus can problematically result in a subpar and at times inaccurate understanding of health, social and cultural factors necessary for competent and informed medical care. Method: A literature search was conducted by cultural experts familiar with Asian Indian culture with a focus on immigrants from this community living in the US. Database using search engines was sought in the following domains: immigration patterns, prevalence for key medical and neurological conditions commonly associated with cognitive dysfunction, psychiatric/psychological needs in the community, some preliminary neuropsychological testing considerations while working with this community, and treatment considerations that could affect adherence and efficacy of outcomes. Articles were selected from 2000 to the most recent date, with emphasis on compiling information from review papers and meta-analysis from the past decade. Conclusions: Asian Indians living in the US are distinct from the larger Asian American community. Immigration trends underscore that Asian Indians have a bimodal distribution of wealth. Regarding medical conditions, a key and highly concerning finding is the higher prevalence of cardiovascular risk factors, especially in young males. The lack of non-existent cognitive data in this community is glaring and should serve as an impetus for conducting high-priority research in this community. Preliminary neuropsychological testing considerations are discussed from a practical perspective with emphasis on multilingualism and region of origin. Finally, treatment considerations include understanding attitudes and beliefs regarding traditional medicine.

Adherence type impacts completion rates of frequent mobile cognitive assessments among older adults with and without cognitive impairment.

Background: Prior to a diagnosis of Alzheimer's disease, many individuals experience cognitive and behavioral fluctuations that are not detected during a single session of traditional neuropsychological assessment. Mobile applications now enable high-frequency cognitive data to be collected remotely, introducing new opportunities and challenges. Emerging evidence suggests cognitively impaired older adults are capable of completing mobile assessments frequently, but no study has observed whether completion rates vary by assessment frequency or adherence type. Methods: Thirty-three older adults were recruited from the Boston University Alzheimer's Disease Research Center (mean age = 73.5 years; 27.3% cognitively impaired; 57.6% female; 81.8% White, 18.2% Black). Participants remotely downloaded and completed the DANA Brain Vital application on their own mobile devices throughout the study. The study schedule included seventeen assessments to be completed over the course of a year. Specific periods during which assessments were expected to be completed were defined as subsegments, while segments consisted of multiple subsegments. The first segment included three subsegments to be completed within one week, the second segment included weekly subsegments and spanned three weeks, and the third and fourth segments included monthly subsegments spanning five and six months, respectively. Three distinct adherence types - subsegment adherence, segment adherence, and cumulative adherence - were examined to determine how completion rates varied depending on assessment frequency and adherence type. Results: Adherence type significantly impacted whether the completion rates declined. When utilizing subsegment adherence, the completion rate significantly declined (p = 0.05) during the fourth segment. However, when considering completion rates from the perspective of segment adherence, a decline in completion rate was not observed. Overall adherence rates increased as adherence parameters were broadened from subsegment adherence (60.6%) to segment adherence (78.8%), to cumulative adherence (90.9%). Conclusions: Older adults, including those with cognitive impairment, are able to complete remote cognitive assessments at a high-frequency, but may not necessarily adhere to prescribed schedules.

Assessing numerical reasoning provides insight into financial literacy.

Financial literacy is linked to financial well-being and decision making. While financial literacy and numeracy skills are strongly related, the relevance of different aspects of numeracy (mental arithmetic, math achievement, and numerical reasoning) for financial literacy has not yet been examined. Data were collected from 88 cognitively healthy adults, mean age = 50 years (SD = 15); mean education = 15 years (SD = 2); 61% females; with 56% Caucasian, 36% Black, and 90% non-Hispanic. Financial literacy was measured with the widely used Big Three scale, and numeracy was measured with the Wechsler Adult Intelligence Scale-III, Arithmetic subtest; the Wide Range Achievement Test-IV, Math Computation subtest; and the Weller's Abbreviated Numeracy Scale (WANS). Regressions analyses were conducted with financial literacy as the outcome variable and each numeracy measure along with demographics (age, sex, and education) as the predictors. In all the models, only the numeracy measures were significant as individual predictors, with numerical reasoning holding the strongest association with financial literacy, followed by mental arithmetic and math achievement. The current study supports the existing literature that numeracy is important for financial literacy, and provides empirical evidence for the specific contributions of individual numeracy measures that clinicians may use to garner impressions about financial skills.

Survey Findings About the Experiences, Challenges, and Practical Advice/Solutions Regarding Teleneuropsychological Assessment in Adults.

OBJECTIVE: In the wake of the coronavirus pandemic, teleneuropsychology utilization has increased. There is a need to characterize the first-hand experiences of individuals using teleneuropsychology, identify the common teleneuropsychology challenges, and devise practical strategies for mitigating/resolving these challenges. METHOD: Survey data were collected from U.S. based neuropsychologists and other individuals (e.g., graduate students and research assistants) who were engaged in remote cognitive assessment with adults (n = 87). Frequency analyses were conducted to examine: how respondents used teleneuropsychology (e.g., duration of use, types of measures and devices/technology platforms used); challenges that were encountered with different technology platforms and teleneuropsychology use; and advice for navigating these challenges. RESULTS: Most respondents began using teleneuropsychology relatively recently in the context of the coronavirus pandemic, with home-to-home or clinic-to-home settings being the most frequently reported teleneuropsychology settings. Zoom®, Doxy.Me®, and MyChart® were the most frequently used platforms, largely due to workplace mandates and/or Health Insurance Portability and Accountability Act-compliant features. Common challenges with teleneuropsychology included internet connection issues and environmental distractions in examinees' homes, and examinees having limited-to-no access to technologies requisite for teleneuropsychology. Providing clear instructions to the examinee prior to the teleneuropsychology visit was the most common advice for ensuring a successful teleneuropsychology evaluation. Similar response patterns were generally noted for those who used TeleNP for clinical or research purposes. CONCLUSIONS: These survey results reflect common experiences and challenges with teleneuropsychology and identify priority targets for increasing its feasibility, reliability, and validity. Findings provide context for the development of formal teleneuropsychology competencies.

Language and Acculturation: Neuropsychological Sequalae of COVID-19 in Indian Americans.

Coronavirus 2019 (SARS-CoV-2; COVID-19) has significant mental health and neuropsychological consequences, but data are insufficient on these specific implications of COVID-19, especially for Indian American patients. Few studies have critically explored risk factors and neuropsychological assessment considerations from a cultural and linguistic perspective, including how they impact the evaluation process for Indian Americans. The present paper focuses on cultural and linguistic considerations for case conceptualization, ethical challenges for best practices, and a specific example with a middle-aged Indian American woman. The need for a greater contextual understanding is emphasized as a step forward in establishing methodological and procedural guidelines for working with patients of Indian descent in the United States.