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«WHAT PRACTITIONERS SHOULD KNOW ABOUT WORKING WITH OLDER ADULTS NORMAN ABELES, PHD President, American Psychological Association APA Working Group on ...»

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ASSESSMENT OF ACUTE AND REVERSIBLE CHANGES

Sometimes persons present with a rapid change in mental abilities as evidenced in a delirium (acute confusional state). A wide variety of factors may affect cognitive abilities in older adults. Family members or residential staff are often important sources of information regarding premorbid and current cognitive functioning.

A review of the medical record and drug regime (prescribed, nonprescribed) and consultation with a physician or other primary health care provider is usually a first step in evaluating acute cognitive changes.

Repeat testing in the acute phases may be necessary to help monitor improvement or deterioration in cognitive functioning.

ASSESSMENT OF DEMENTIA

Dementia is a global and often progressive loss of mental ability. Assessment of dementia should include tests of attention/concentration, short- and long-term memory and delayed recall, reasoning ability, language, executive functions (e.g., planning, organizing, sequencing, abstracting), and visual-motor skills.

Determination of the degree of impairment in these areas can be crucial for disposition planning.

No single accepted battery of tests exists. The Mattis Dementia Rating Scale and CogniStat (formerly known as Neurobehavioral Cognitive Status Examination; both tests are listed in the Geropsychology Assessment Resource Guide) are easily administered, well-validated tests of general cognitive functioning that can be useful in the assessment of dementia. Findings of cognitive deficits may need to be followed up with referral to neuropsychology/neurology colleagues to determine etiology and appropriate treatment.

ASSESSMENT OF DEPRESSION VERSUS DEMENTIA

Psychologists are often called upon to assist in the evaluation of the psychological status of patients with overlapping symptoms of depression and dementia (which can coexist). Depressed individuals are more likely to have an abrupt onset of symptoms, a history of psychiatric problems, decreased motivation, variability in mental status, and conspicuous complaints about their memory problems. Testing can be useful in identifying to what degree the cognitive deterioration is secondary to depression.

COMPETENCY Competency is a legal determination. Therefore, the psychologist must be knowledgeable of state laws governing determination of competency. Psychological assessment provides useful information in making this determination.

The examiners must be clear which competencies they are being asked to assess. Typical referral questions include competency to drive an automobile or to make medical, legal, or financial decisions.

Competency is a match between an individual’s abilities and environmental demands. Therefore, traditional neuropsychological tests of specific cognitive abilities must be supplemented by ecologically valid functional capacity measures (e.g., Lawton’s Instrumental Activities of Daily Living Scale).

Awareness of cognitive deficits is often an important factor in determining competency and can be gauged by the use of specific interview questions, prior behavior, and observations of current behavior.

HOW IS A BEHAVIORAL ASSESSMENT CONDUCTED?

Behavior disorders are frequent precipitants for admission to a psychogeriatric inpatient unit and may cause significant difficulties for family members or staff in acute medical units and nursing homes. Behavior disorders can take the form of physical aggression, motor overactivity (e.g., wandering), and disruptive vocalizations. Common causes of behavior disorders are delirium, dementia, depression, psychosis, and premorbid personality traits. Interpersonal and environmental factors may be antecedent to behavioral episodes, and an assessment of these is central to developing a treatment plan. While outwardly expressed behavioral problems are easily identifiable, behavior deficits (e.g., social withdrawal) can be more easily overlooked.

Agitation may be the result of an underlying physical condition, and referral for a medical workup may be needed.

Agitation in older adults is often attributable to chronic cognitive impairment and/or overstimulation in the environment. Changes in the milieu and in the response of staff, family, or other caregivers may reduce disruptive behavior.

Treatment plans that are supported by detailed behavioral analyses may increase staff receptivity to necessary systemic change. For example, careful observation may determine that the wandering problem of a nursing home resident can be reduced if the administrator of the institution designates a safe place for ambulation.

In institutions or residences, agitation may only occur at certain times of the day or evening, or only with particular caregivers, or only during specific activities (e.g., feeding, bathing). In such cases, the possibility of modifying existing caregiver behavior or routines should be assessed.

Family members may more closely attend to the older adult when he or she becomes agitated. Evaluation of family members’ ability or motivation to change their own behavior should be conducted.

Positive reinforcement of appropriate behavior in the agitated individual may increase its occurrence and reduce disruptive behavior.

HOW IS PSYCHOPATHOLOGY ASSESSED IN OLDER ADULTS?





Since geriatric and subclinical variants of some of the major psychological disorders exist, comparing the individual’s particular scores on a continuum with the relative performance of the older age group (e.g., dimensional analysis) is preferable to the use of strict cutoffs (e.g., categorical analysis).

No widely used self-report measures of anxiety have been specifically developed for older adults. The Beck Anxiety Scale is brief and easily administered, but results should be viewed with caution in the assessment of frail and less educated older adults.

A variety of good screening measures exists for depression (e.g., Hamilton Depression Rating Scale, Beck Depression Inventory). The Geriatric Depression Scale (GDS) was specifically developed for older adults.

The GDS is useful because it (1) has age-related norms; (2) can be administered in oral and written form, thus allowing for more accurate assessment of persons with mild cognitive impairment; and (3) omits somatic items that can elevate depression scores for clients who may be manifesting somatic symptoms associated with medical problems and not depression.

The CAGE and Michigan Alcoholism Screening Test-Geriatric Version are instruments that have demonstrated potential as alcohol screening tools with older adults.

Broad-based measures of psychopathology that have been normed on older people are available. The MMPI-2 is a widely used self-report instrument that was normed on persons up to 84 years of age.

However, in view of its length and required reading level, it may not be practical for very old, less educated, or visually or cognitively impaired adults. The Brief Psychiatric Rating Scale is a clinician-rated scale encompassing primary domains of psychopathology and has been found to be useful with older adults.

Assessment of personality features can be important in planning treatment strategies. Unfortunately, there are no measures of personality disorder (PD) specifically developed for use with older adults. Current structured PD scales are lengthy, and their routine use with older adults is impractical.

The Rorschach Inkblot Test should only be used with caution in assessing the personality or disordered thinking of older adults. Age-related norms have not been established for the widely used Exner system,

THE GERIATRIC DEPRESSION SCALE (GDS) WAS SPECIFICALLY

DEVELOPED FOR OLDER ADULTS. THE GDS IS USEFUL BECAUSE IT…

Has age-related norms Can be administered in oral and written form, thus allowing for more accurate assessment of persons with mild cognitive impairment Omits somatic items that can elevate depression scores for clients who may be manifesting somatic symptoms associated with medical problems and not depression and psychopathology can easily be overdiagnosed by inexperienced examiners testing older adults who are not comfortable with unstructured tasks.

The Thematic Apperception Test has been used extensively with older adults in research studies and clinical settings. It yields geriatric themes with the same frequency as the Senior Apperception Test and Gerontological Apperception Test. Information from these measures is sometimes useful in identifying life issues that need to be addressed in psychotherapeutic interventions.

WHAT ARE THE ESSENTIALS OF A GOOD PSYCHOLOGICAL TESTING REPORT ON AN OLDER ADULT?

The psychologist should integrate psychological findings with relevant social and medical variables. The report should document both weaknesses and strengths.

The report should include the aging/cohort/cultural variables that may have affected test scores, including language barriers, low educational attainment, sensory/physical limitations, and the client’s values.

Recommendations should be geared to enhance or maintain the older client’s cognitive and psychological well-being and independence.

Referrals should be made to other professionals as needed, for example, to neuropsychologists for specialized cognitive testing; to mental health professionals for individual/family/group psychotherapeutic interventions; to psychiatrists for consultation on psychotropic medication; to medical internists, geriatricians, or other health care providers for assessment of physical health problems; and to social service workers for assistance with financial and community resources.

Re-testing may be recommended for older adults, particularly if there is variability in test scores or when an acute medical condition is suspected of affecting test results.

The assessment of psychological problems of older adults requires attention to a variety of complex biopsychosocial factors. Clear and timely communication of test findings and recommendations to all treatment team members, family caregivers, and especially to the older person is essential.

VI. APPROPRIATE PSYCHOLOGICAL INTERVENTIONS FOR OLDER ADULTS

Research indicates that psychological interventions that historically have been provided to younger and middle-aged adults are also effective for older adults. Many psychologists, therefore, possess therapeutic skills that could be beneficial to older adults with psychological difficulties. However, knowledge of the unique problems of late life and of the needed adaptation of psychological interventions for older adults will maximize the effectiveness of those therapeutic skills in this age group. Below are discussed general principles for conducting psychological interventions, the more common and appropriate interventions, and other useful interventions.

WHAT ARE GENERAL PRINCIPLES FOR CONDUCTING PSYCHOLOGICAL INTERVENTIONS WITH

OLDER ADULTS?

Many older adults are referred for psychological services at the behest of a third party, most typically a spouse, adult child, or service provider. The psychologist needs to ascertain older adults’ understanding of why they are meeting with the psychologist, their possible expectations for treatment, and motivation for treatment.

This cohort or generation of older adults’ perceptions of mental health care have been shaped by historical experiences in which mental illness was much more stigmatized than today. Embarrassment or shame about receiving mental health services or concerns about psychiatric institutionalization need to be addressed more frequently among older than younger adults.

Older adults may require more education with regard to the rationale, structure, and goals of psychological interventions than younger persons for whom there may be greater familiarity with psychotherapy.

The psychologist needs to be attuned to sensory deficits, particularly hearing and vision loss, that may make communication more difficult. Attention to the environment in which services are provided, such as privacy, adequate lighting, temperature, ambient noise, and ease of access for persons with physical limitations, is required.

Because older adults referred for psychological treatment often have concurrent physical or social problems, coordination with other service providers is essential. It is particularly critical to ascertain whether psychological symptoms (e.g., depression, anxiety) are caused or exacerbated by underlying medical problems or medications. When needed, psychologists should obtain permission from older adults or their legal guardians to contact other service providers.

Although recent evidence indicates that psychologists are interested in providing psychological services to older adults, many psychologists need to be attentive to their own negative biases or stereotypes about older people, including their suitability for psychological treatment.

WHAT PSYCHOLOGICAL INTERVENTIONS ARE APPROPRIATE FOR OLDER ADULTS?

No single psychological intervention is preferred for older adults. The treatment of choice is guided by the nature of the problem, therapeutic goals, preferences of the older adult, and practical considerations.

Although older people share similar generational experiences, there is considerable diversity among them.

As with younger individuals, differences in race, culture, gender, sexual orientation, and social class need to be taken into account in understanding problems of older adults and in making interventions.

Both individual and group psychotherapy appear to be effective in the treatment of older adults’ psychological problems.

Existing psychological interventions are likely beneficial to adults regardless of age. Cognitive-behavioral, brief psychodynamic, and Klerman and Weissman’s interpersonal psychotherapy have been shown to be effective in the treatment of one or more late-life mental disorders. These include depression, anxiety, sleep disturbance, and other psychological difficulties.



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