November 10, 2005 Older Adults: Assessment

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2005 Copyright The Center for Aging Resources

The Center for Aging Resources

www.centerforagingresources.org

(626) 577-8480

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Assessment of Older Adults

Janet Anderson Yang, Ph.D.

The Center for Aging Resources

Pasadena, California

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Assessment of Older Adults Outline

1. Purposes of assessment, general2. Special issues relevant to older adults3. Specific assessment needs: Older adults4. Domains to be assessed5. Techniques of assessment6. Tools to consider7. Possible protocol8. Resources & References

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Purposes of Assessment

• Why are you assessing this client?

• What is your assessment expected to accomplish?

• Clarify who needs to know what.

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1. Determination of whether to accept as a client

2. Diagnosis of psychopathology 3. What type of treatment to offer4. Specific plan for mental health treatment5. Plan for quality of life improvement6. Evaluate client outcomes7. Other

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Reminder:

• Purpose of assessment is to discover and document facts, not to support previously reached conclusions.

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Special issues relevant to assessing older adults

1. Medical conditions

2. Cohort differences

3. Cognitive changes

4. Developmental issues

5. Cultural & linguistic diversity

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1. MEDICAL CONDITIONS

1. 80% of older adults have at least 1 chronic illness

2. Most have multiple chronic illnesses3. Multiple medications (ave. =11)4. Physical disabilities impair mobility5. Vision impairment; hearing impairment6. Chronic pain7. Older adults fatigue more easily8. Physical illness is a risk factor for suicide

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2. COHORT DIFFERENCES

1. Stigma of mental health assessment & treatment

2. Value on frugality

3. Value on independence

4. Tendency to somaticize

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3. COGNITIVE CHANGES

1. Age consistent memory decline

2. Mild Cognitive Impairment

3. Dementia

4. Delirium

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3. COGNITIVE CHANGESNormal age changes include decreased:

a. Speed of thinking & rememberingb. Ability to stay focused on a mental taskc. Ability to attend to several tasks simultaneouslyd. Memory for names & wordse. Memory when given little time to learn

Mild Cognitive Impairment (MCI)Changes with dementia:

a. More serious impairmentb. Significant impact on functioningc. May or may not be progressive

Delirium: alteration in attention and level of consciousness

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4. DEVELOPMENTAL CHANGES

1. Retirement

2. Social status changes

3. Losses

4. Family role changes

5. Death & dying issues

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5. Cultural/Linguistic Diversity

Older immigrants are more likely to be monolingual and less acculturated to the United States

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PRIMARY ADAPTATIONS NEEDED

1. Often do not self-refer

a. networking & case finding necessary

b. multidisciplinary collaboration

2. Often hesitant / need engagement

a. more rapport building time

b. slower pace often needed

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ADAPTATIONS (cont.)

3. Need education about process of assessment, including what, when, where, how long, cost, why

4. Impaired mobility & stigma requires assessment in clients’ homes

5. Health conditions require assessment of medical illnesses, medications & sensory acuity, and communication with primary care physician

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ADAPTATIONS (cont.)

6. Assessment for suicidality

7. Use larger fonts; speak loudly & clearly; repeat instructions as needed

8. Communicate in simpler sentence structure if needed

9. Appropriate language & culture “broker”

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Multi-disciplinary Involvement

1. Social workers / case mangers2. Physicians & nurses3. Home health aides (e.g., IHSS)4. Religious ministers5. Apartment managers6. Law enforcement7. Senior center staff8. Attorneys

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SPECIFIC ASSESSMENT NEEDS

1. Assessment of depression2. Assessment of suicidality3. Presence and degree of anxiety 4. Presence of impaired reality testing5. Assessment of substance abuse6. Presence or absence of cognitive impairment7. Type of cognitive impairment

a. Is it pathological?b. What type of dementia?c. Is it treatable?

8. Distinguishing between Dementia & Depression

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SPECIFIC ASSESSMENT NEEDS (cont.)

9. Presence of Delirium10. Distinguishing between Delirium & Dementia11. Presence of elder abuse12. Comorbidity of mental illness with medical

illness13. Ability to make informed consent 14. Assessment of capacity/Conservatorship

issues15. Functional assessment, living environment

appropriateness16. Assessment of safety issues

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DOMAINS TO BE ASSESSED

1. Referral information2. Client’s self-reported concerns and goals3. Presenting symptoms & history of symptoms4. Psychiatric history5. Medical history, medications6. Sensory acuity7. Developmental history8. Social network9. Living environment

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DOMAINS TO BE ASSESSED (cont.)

10. Substance abuse, including prescription medication, over the counter, & supplement usage

11. Cognition1. General level2. Memory3. Attention4. Language5. Visual-spatial ability6. Executive functioning7. Estimate of premorbid ability

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DOMAINS TO BE ASSESSED (cont.)

12. Perceptual motor deficits13. Suicidality/homocidality14. Elder abuse, including self-neglect15. Diversity issues, e.g., acculturation, language,

family dynamics, etc.16. Preexisting abilities17. Services and agencies involved

Note strengths as well as deficits

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ASSESSMENT TECHNIQUES:Multimodal assessment

1. Clinical interview

2. Self report measures

3. Cognitive performance testing

4. Informant data

5. Behavioral observation

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Possible Informants

1. Client

2. Referral source

3. Primary care physician

4. Case manager

5. Conservator/Power of Attorney

6. Family/Caregiver

Confidentiality: release of informationCa. Welfare & Institutions Code 10850.1

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Additional referrals to consider

Geriatric medical assessmentMultidisciplinary geriatric assessment:

geriatrician, nursing, neurologist, psychologist, physical therapy, social work, speech, occupational therapy, et al

Neuropsychological assessmentGero-pharmacology consultNutritional consultNeurological consultOccupational therapy consult

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Factors to consider when choosing tools

1. Tests need to be appropriate for age:a. Valid: does it measure what it claims to?b. Reliable: over time & between administrators c. Standardization sample/normsd. Developed specifically for older adults

2. Public vs. privately owned (cost)3. Time to administer4. Skill required & ease of administration5. Appropriate for culture, language & education6. Clinical utility vs. research

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TOOLS TO CONSIDER

Overall mental status :• Folstein Mini Mental State Exam (MMSE)

Folstein et al 1975

• Short Portable Mental Status Questionnaire (SPMSQ) Pfeiffer, 1975

• Short Mental Status Questionnaire Robertson et al, 1982

• Clock Drawing Brodaty & Moore, 1997

• Neurobehavioral Cognitive Status Exam Kiernan et al, 1998

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Folstein Mini Mental State Exam

Education relevant comparisons:Average normal score for persons with

0-4 years education: 22Average normal score for persons with



college years education: 29

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TOOLS TO CONSIDER

Overall mental status :

• Folstein Mini Mental State Exam (MMSE)

• Short Portable Mental Status Questionnaire (SPMSQ)

• Short Mental Status Questionnaire

• Clock Drawing

• Neurobehavioral Cognitive Status Exam

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Neurobehavioral Cognitive Status Exam: Subtests

OrientationAttentionLanguage

ComprehensionRepetitionNaming

ConstructionsMemoryCalculationsReasoning

SimilaritiesJudgment

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TOOLS TO CONSIDER

Delirium:• Confusion Assessment Method (CAM) Inouye

et al, 1990

Substance Abuse:• Michigan Alcohol Screening Test-Geriatric

version: MAST-G, 10 & 24 item versionsBlow

• CAGE: 4 direct questions Ewing, 1984

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CAM: Confusion Assessment Method

1. Acute onset or fluctuating course?

2. Inattention

3. Disorganized thinking

4. Altered level of consciousness

Presence of 1 & 2 and either 3 or 4 indicates delirium

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CAGE

1. Have you ever felt you should Cut down on your drinking?

2. Have people Annoyed you by criticizing your drinking?

3. Have you ever felt bad or Guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?

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TOOLS TO CONSIDER

Life skills functioningLawton & Brody, 1969

• Activities of Daily Living (ADL) Index

• Instrumental Activities of Daily Living Scale (IADL)

Each activity is compared with 3,4 or 5 criterion and rated as independent vs. not

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Activities of Daily Living (ADL) Index

• Toileting

• Feeding

• Dressing

• Grooming

• Physical ambulation

• Bathing

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Instrumental Activities of Daily Living Scale (IADL)

• Ability to use telephone• Shopping• Food preparation• Housekeeping• Laundry• Mode of transportation• Responsibility for own medications• Ability to handle finances

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TOOLS TO CONSIDER

Depression• Geriatric Depression Scale (GDS) 15 & 30

item versions Yesavage et al, 1983

• Beck Depression Inventory (BDI) Beck et al, 1961

• Patient Health Questionnaire (PHQ)• Center for Epidemiological Studies –

Depression Scale (CES-D) Radloff & Teri, 1966

• Hamilton Depression Rating Scale Hamilton, 1960

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TOOLS TO CONSIDER

Suicidality

• Interview• Paykel Scale for Suicidality Paykel, 1974

– Life not worth living– Wishing you were dead– Thought of taking own life– Seriously considered taking own life– Past attempt(s)

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TOOLS TO CONSIDER

Physical Health:• Clinical Interview

a. Sensory deficitsb. Medications, incl. over the counter meds.c. Medical conditions & symptomsd. Call Primary Care Physiciane. Nutrition

• Self-rated health• SF 12

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TOOLS TO CONSIDERAnxiety• Beck Anxiety Inventory• Short Anxiety Screening Test Sinoff et al, 1999

Personality characteristics• MMPI-II• MCMI-II

Thought Disorder• Rorschach

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TOOLS TO CONSIDER

Symptom Inventories• MMPI-II• MCMI-II• Survey Psychiatric Assessment Schedule (SPAS) Bund et al,

1980

• Brief Symptom Inventory (BSI) Derogatis, 1975

• SCL-90• Brief Psychiatric Rating Scale (BPRS) Overall & Gorham, 1962

• Older Adult Self-Report (OASR) & Older Adult Behavior Checklist (OABCL), Achenbach & Newhouse

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OASR & OABCL: subtests

Anxious/DepressedWorriesSomatic ComplaintsThought ProblemsFunctional ImpairmentMemory/Cognition ProblemsIrritable/Disinhibited

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TOOLS TO CONSIDER

Interview Schedules

• Humboldt County Older Adults System of Care

• Orange County Older Adult Services Geriatric Field Assessment Tool

• LA County Adult Initial Assessment

Client Satisfaction

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TOOLS TO CONSIDER

Dementia Progression

• MMSE

• Clinical Dementia Rating Scale (CDR)

• Global Deterioration Scale (GDS)

(Reisburg, et al.)

• Ability to:– Understand and respond meaningfully in the

therapeutic encounter

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TOOLS TO CONSIDER

Elder Abuse

• California State Department of Social Services guidelines

• County Community and Senior Services guideline, e.g., Elder and Dependent Adult Abuse: A guide for the mandated reporter, Community and Senior Services, County of Los Angeles, 2003

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Clinical Dementia Rating Scale (CDR ; Hughes et al, 1982)

Clinician rates 6 areas:• Memory• Orientation• Judgment & Problem solving• Community affairs• Home & Hobbies• Personal CareAs to 5 levels of impairment:None(0), Questionable(0.5), Mild(1), Moderate(2)

or Severe(3)

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Possible Protocol

1. Standard Clinical Interview2. Geriatric Depression Scale + somatic symptoms3. Mini Mental State Exam4. Clock Drawing5. MAST-G short form or CAGE6. CAM7. Medication review8. Medical conditions list9. ADL & IADL10. Client satisfaction questionnaire

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Assessment Follow-Up

Appropriate feedback to appropriate parties: client, family, treating professionals, referring party

• Who needs to get feedback

• How to give feedback

• What permissions do you need to release information

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RESOURCES

1. Assessment Scales in Old Age Psychiatry 2nd Ed. By A. Burns, B. Lawlor & S. Craig. 2004. A very comprehensive book briefly describing approximately 200 assessment tools.

2. Psychotherapy and Older Adults Resource Guide: www.apa.org/pi/aging/psychotherapy. An extensive list of resources relevant to assessment and treatment of older adults.

3. American Psychological Association: Guidelines for Psychological Practice with Older Adults. 2004. American Psychologist, 59 (1) 236-260.

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RESOURCES

4. American Psychological Association: Assessment of Older Adults, 2004. http://www.apa.org/pi/aging/practitioners/assessment.html.

5. Assessment of Older Adults with Diminished Capacity. Reference appendix lists numerous tests useful with older adults.

6. Mental Health: A report of the Surgeon General. Chapter 5: Older Adults and Mental Health. http://www.surgeongeneral.gov/library/mentalhealth/chapter5/sec1.html.

7. The Dementias. National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health, Bethesda, MD. NIH Publication No. 04-2252.

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RESOURCES

8. California State Older Adult System of Care; http://www.dmh.cahwnet.gov/

9. County Older Adult Systems of Care10. American Society on Aging;

http://www.asaging.org/index.cfm11. Gerontological Society of America;

http://www.geron.org/12. National Council on Aging; http://www.ncoa.org/13. American Psychological Association, Section 12,

Division II; http://www.apa.org/about/division/div12.html

14. Substance Abuse and Mental Health Services Administration (SAMHSA); http://www.health.org/

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RESOURCES

14. Geriatric Social Work Education Consortium; http://www.geriatricsocialwork.org/

15. Veterans Administration Hospitals

16. Stephen Bartels, M.D. M.S., consultant. Director, Aging Services Research. NH–Dartmouth Psychiatric Resources Center.

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References

Achenbach, T. & Newhouse, P. www.ASEBA.org.Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J. (1961).

An inventory for measuring depression. Archives of General Psychiatry 4:53-63.

Blow, F. Michigan Alcoholism Screening Test – Geriatric Version (MAST-G). Ann Arbour University: University of Michigan Alcohol Research Centre.

Bond, J. Brooks, P. Carstairs, V. Giles L. (1980). The reliability of a Survey Psychiatric Assessment Schedule for the elderly. British Journal of Psychiatry 137:148-62.

Brodaty, H., Moore, C.M. (1997). The Clock Drawing Test for dementia of the Alzheimer’s type: a comparison of three scoring methods in a memory disorders clinic. International Journal of Geriatric Psychiatry 12:619-27.

www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/questionnaire

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References

Derogatis, L.R. 1975. Brief Symptom InventoryEwing, J. 1984. Detecting alcoholism: the CAGE questionnaire.

Journal of the American Medical Association 252: 1905-7.Folstein M.F., Folstein S.E., McHugh P.R. (1975). Mini-Mental State: a

practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 12:189-98.

Hamilton, M. (1960) A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23:56-62. Hughes, C.P., Berg, L., Danziger, W.L., Coben, L.A., Martin, R.L. 1982. A new clinical scale for the staging of dementia. British Journal of Psychiatry, 140:566-72; updated by Morris, J. 1993. The CDR: current version and scoring rules. Neurology 43:2412-3.

Inouye, S.K., van Dyck C.H., Alessi, C.A., Balkin S., Siegal, A.P., Horwitz R.I. (1990). Clarifying confusion: the Confusion Assessment Method. Annals of Internal Medicine 113:941-8.

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References

Kiernan, R., Mueller, J. & Langston, W. 1998. The Neurobehavioral Cognitive Status Examination. The Northern California Neurobehavioral Group, Inc.

Lawton M.P., Brody, E.M. (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. The Gerontologist 9:179-86.

Lipman et al. 1979. Overall, J.E., Gorham, D.R. (1962). The Brief Psychiatric Rating Scale.

Psychological Reports 10: 799-812.Paykel et. Al., 1974. Pfeiffer, E. 1975. Short Portable Mental Status Questionnaire for the

assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society, 23(10), 433-41.

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References

Radloff, L.S., Teri, L. (1986). Use of the Center for Epidemiological Studies – depression scale with older adults. Clinical Gerontologist 5:119-37.

Reisburg, B., et al. (1982). The Global Deterioration Scale for Assessment of Primary Degenerative Dementia 139 American Journal of Psychiatry 1136

Robertson D., Rockwood, K., Stolee, P. (1982). A Short Mental Status Questionnaire. Canadian Journal of Aging 1:16-20.

Sheikh, K., Smith D.S., Meade, T.W., Goldenberg, E., Brennan, P.J., Kinsella, G. (1979). Repeatability and validity of a modified Activities of Daily Living (ADL) Index in studies of chronic disability. International Rehabilitation Medicine 1: 51-8.

Sinoff, G., Ore, L., Zlotogorsky,D., Tamir, A. (1999) Short Anxiety Screening Test: a brief instrument for detecting anxiety in the elderly. International Journal of Geriatric Psychiatry 14:1062-71.

Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M., Leirer, O. (1983). Development and validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric Research 17: 37-49.

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Assessment of Older Adults

Janet Anderson Yang, Ph.D.

Center for Aging Resources

Pasadena, California

November 10, 2005 Older Adults: Assessment

Health & Medicine

Transcript of November 10, 2005 Older Adults: Assessment