Psychological Assessment of
Elderly Clients in Rehabilitation
and Residential Care Settings
Patrick Dulin, Ph.D.
School of Psychology
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
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.
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
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
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
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.
The elderly individual typically has not
encountered a “shrink” before and is frequently
quite daunted at the opportunity for an
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
Testing for more than one hour is not advisable.
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
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.
Fundamental Question: What is their level
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
Mood and Cognitive functioning..either can
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
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,
Ego Strength, independence, resilience are key
Functional Assessment: Key Issues
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.
Essential question: “Does the client possess the ability to
make their own decisions?”
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).
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
3. The patient has the ability to reason and deliberate about
his or her choices.
(President’s Commission on Making Health Care Decisions,
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
Competence Decisions and
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
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
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
Mrs. Smith, 79 y.o. widowed female living in an
ECF in Bountiful, UTAH (cultural factors??)
Medical Conditions: DM II, COPD, “mild
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?”
“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?
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.
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.
DRS: Total score of was mildly above cut-off for
dementia, but not much.
Mild to moderate impairment in memory sub-
Initiation and Perseveration scales w.n.l.
Other scales unremarkable.
Overall, Mrs. Smith is functioning well.
Mrs. Smith has some evidence of a
dementing illness, but still mild.