Psychological Assessment of Elderly Clients in Rehabilitation and Residential Care Settings Patrick Dulin, Ph.D. School of Psychology Massey University Presentation Overview 1. Brief discussion of a fundamental differential diagnoses of elderly patients within the geriatric rehab/nursing home context. 2. Discussion of contextual variables and the condition of patients in these settings. 3. Functional assessments of elderly individuals in this environment. 4. Process and content of competency evaluations of incapacitated elderly. Depression vs. Dementia Clarfield (1998) found that 26% of elderly thought to be demented were actually depressed. Age bias?? Symptoms in Common: Apathy, sleep and appetite changes, poor concentration, loss of interests, psychomotor slowing/retardation, self- neglect and irritability. Symptoms specific to depression in older adults: Guilt, depressed mood, suicidal ideation, thoughts of death, hopelessness, helplessness, worthlessness, refusal to eat, mood congruent delusions. Dementia vs. Depression Dementia Depression Widespread memory Memory dysfunction more dysfunction focal (vis.m. is poor) Recall and recognition Recognition memory is memory is impaired intact Intrusion errors common in Omission errors common memory tasks in memory task, not as Mood and behavior many intrusions fluctuate Mood consistently poor Not worried about Frequent complaining, high cognitive loss, may try to level of distress. conceal cog. problems, Very distressed about anosognosia. cognitive loss Consideration of the Setting Contextual Variables Admission of an elderly individual to a facility typically follows an injury or medical illness. Not unusual to be mentally compromised in this circumstance for numerous reasons: They are in a foreign environment and are stressed, frightened, and sometimes drugged or in pain. Contextual Factors Anxiety and reluctance about the interview and testing is common. 80% of elderly have at least one chronic medical condition….fatigue is common This combination of factors frequently leads to an UNDERESTIMATION of actual abilities. Process Factors The elderly individual typically has not encountered a “shrink” before and is frequently quite daunted at the opportunity for an “examination”. Process Factors Assure that you are not going to “analyse them”. It can help to make jokes, talk about everyday things, maybe share a bit about yourself (they are always curious). Slow the pace…take more time during the interview. Testing for more than one hour is not advisable. Cultural Awareness Ask if they would like family present. Simple familiarities (tea) are helpful. More Process Factors It is also very helpful to take time to discuss what a neuropsychologist does with particular emphasis on providing information that will HELP them. More time taken to build rapport yields more accurate test results. Before testing..check for sensory deficits (40% difficulty hearing and 90% require glasses) Check meds..always carry a geriatric drug guide Armour, D. (2002). Medicines in the Elderly. Burns (2002) Clinical Guidelines in old age psychiatry. Functional Assessment Fundamental Question: What is their level of independence? Multidisciplinary Decision (ideally): Requires input from M.D., Social Work, and OT. Info about health, ADL’s and IADL’s, supports (caring others?) and MONEY are crucial. Psychologist’s input: Mood and Cognitive functioning..either can inhibit functioning. Psychological Assessment and Functioning: Key Issues 1. Executive functioning abilities!! Very important for independent living. DRS-2 I/P, Trails A and B, DKEFS 2. Memory….mild to moderate difficulties are tolerable, but moderate to severe problems inhibit independence significantly. DRS-2 mem, WMS III LM. 3. Constructional and visual abilities: DRS-2 Const, line bisection, clock drawing. Psychological Assessment and Functioning: Key Issues Mood: Serious depression is an obvious impediment to I.F. In this context, mood is a bit tricky to assess as many times when they go home, mood improves. Important to assess when depression started. Psychometrics: GDS and BDI are useful. Anxiety: Another obvious impediment to I.F. Anxiety is underreported in this population…dx by interview, no helpful psychometrics, unfortunately. Ego Strength, independence, resilience are key personality factors. Functional Assessment: Key Issues Final Thoughts This is an integrational task. Not easy and requires judgement and experience. Always best to have multidisciplinary input, but not always available. Funding is frequently low, therefore testing is usually kept to a minimum. Social support, mood functioning, and personal “will” are key factors. Determining Competence Essential question: “Does the client possess the ability to make their own decisions?” Relevant Situations 1. Making decisions regarding current and future health care (living will, advance directives, informed consent to medical treatment). Of importance is the decisional capability regarding medical procedures. 2. Decisions pertaining to money. 3. Lifestyle decisions. Not a trivial undertaking. In one study of 150 referrals to a U.S. hospital ethics committee, 39% referred to patient’s decision making capability (Schenkenberg, 1997). Competence? In the U.S., Competence is defined as: 1. The patient is in possession of a set of values and goals. 2. The patient has the ability to communicate and understand information. 3. The patient has the ability to reason and deliberate about his or her choices. (President’s Commission on Making Health Care Decisions, 1982). Very tricky to assess competence. The most important tool is clinical judgment, particularly as no established instrument for assessing competence exists. A thorough clinical interview and information from collaterals is crucial. Competence Decisions and Psychometrics Research has shown that with regard to “rational reasons” for a choice of medical treatment among mildly to moderately demented elderly, the DRS I/P and A sub-scales were particularly useful in determining ability to reason. More so than many aspects of WAIS, BNT, and Trails. This study was particularly instructive in that measures of memory were not useful in the prediction of “rational decision making” among this population. Authors conclude that frontal lobe functioning is particularly important regarding “rational reasoning”. (Marson, et al., 1995. Neuropsychological predictors of competency in A.D. using a rational reasons standard. Archives of Neurology, 52, 955-959. Competence and Depression Does depression in this population influence competence? Research suggests that severely depressed elderly may not be making good decisions regarding health care. One study showed that 26% of severely depressed elderly preferred more life sustaining procedures following treatment of depression. Competence and ECF Context Rehab and ECF placement is very stressful and has been shown to impact performance on competency evals. One study (Fitten and Waite, 1990) indicated that 28% of recently admitted elders evidenced impaired performance on a vignette d.m. task despite no neuropsych deficits Case Study Mrs. Smith, 79 y.o. widowed female living in an ECF in Bountiful, UTAH (cultural factors??) Medical Conditions: DM II, COPD, “mild dementia”. Situation: Mrs. Smith has on multiple occasions been found by care staff having sexual contact with Mr. Jones, another elderly resident. Family distraught, staff confused. Referral Question: “Is Mrs. Smith competent to decide to have sex with Mr. Jones?” Competency Case Questions: “Is she a willing partner?” “Does she know that this is happening?” “Can she remember the incidents?” “Does she know the consequences?” “Is this behaviour due to disinhibition and therefore at variance with her values?” In general, is there a cognitive deficit interfering with her judgement? Competency Case Interview Results: Well presented, clean. No obvious problems with f.o.t. or c.o.t., low awareness of cog problems, affect mildly blunted, but not depressed, language functioning intact. Very reluctant to discuss “incidents”, but had awareness of them and indicated that Mr. Jones was a “friend” and that he never coerced her into anything. “My life is my business”. No evidence of other uninhibited behaviours during interview or by staff report. Competency Case History Widowed 4 yrs previously, 4 children, housewife, somewhat active in Mormon religion (“not a zealot”), placed in ECF due to combination of health needs and lack of support. Psychometrics: DRS: Total score of was mildly above cut-off for dementia, but not much. Mild to moderate impairment in memory sub- scales. Initiation and Perseveration scales w.n.l. Other scales unremarkable. Case Recommendations Overall, Mrs. Smith is functioning well. Mrs. Smith has some evidence of a dementing illness, but still mild. Recommendations???
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