Psychological Assessment of Elderly Clients in Residential Care

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					 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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