7. Assessment of Older Adults Flashcards
What is the age range for children?
Birth - 12
What is the age range for adolescents?
12-18
what is the age range for young adults?
21-45
What is the age range for middle adult?
45-65
What is the age range for young-old?
65-75
What is the age range for middle-old?
75-84
What is the age range for old-old
85 +
Who tend to live longer?
females
What is the expected life expectancy for males in Australia?
79.7
What is the expected life expectancy for Females in Australia?
84.2
What are the major changes in older adult life?
Marriage/partnership Parenting Health Social relations Finances Work
What are the major changes in parenting for older adult life?
o empty nest syndrome;
o assuming grand parenting role;
o redefinition of parenting role
What are the major changes in health for older adult life?
o adjusting to decreasing physical strength and health;
o possibily cognitive decline;
o awareness of mortality
What are the major changes in social relations for older adult life?
o changing social networks following retirement/relocation
o loss of close friends
What are the major changes in Finances for older adult life?
o change in financial position following retirement
o going on welfare/receiving superannuation
o financial planning for remainder of lifetime
What are the major changes in work for older adult life?
o adjusting to retirement and reduce income
o physical injury/illness causing work disability
What are the major changes in marriage/partnership for older adult life?
o change in relationship due to retirement
o assuming caring role
o adjusting to illness/death of spouse
What are Erikson’s psychosocial stages?
trust v mistrust autonomy v shame/doubt initiative v guilt industry v inferiority identity v role confusion intimacy v isolation generosity v stagnation integrity v dispair
when does trust v mistrust occur?
infancy
when does autonomy v shame and doubt occur
early childhood (1-3)
When does initiative v guilt occur?
preschool age (3-6)
When does industry v inferiority occur?
school age (6-12)
When does identity v role confusion occur?
adolescence (12-18)
When does intimacy v isolation occur?
young adulthood (18-35)
when does generosity v stagnation occur?
35-60
when does integrity v despair occur?
60+
When will integrity result in integrity v despair?
if one looks back on life with few regrets and feels personally worthwile, ego integrity results
When does despair occur in integrity v despair?
failure to achieve ego integrity can lead to feelings of despair, hopelessness, guilt, resentment and self-rejection
What are Cohen’s developmental stages in the second half life?
Midlife evaluation
Liberation
Summing up
Encore
what age group does midlife evaluation occur?
40-50s
what occurs in the midlife evaluation?
quest to make life and work more gratifying and meaningful (the midlife crisis)
What age does liberation occur?
60s - early 70
what occurs in the liberation stage?
experience of new personal freedom (if not now, when?)
When does summing up occur?
70+
what occurs in summing up?
search for meaning in life through looking back, summing up and giving back
When does Encore occur?
80+
What occurs in encore?
desire to make a final statement or take care of unfinished business
What are the common themes in older adult assessment?
- Normal ageing versus dementia
- Neuropsychological assessment of dementia
- Assessment of mood & anxiety disorders
- Assessment of carer stress
What are the categories involved in normal ageing?
primary vs secondary ageing
What causes ageing in primary ageing in normal ageing?
due to the passage of time. Visual acuity and lung capacity affected
What cases ageing in secondary ageing in normal ageing?
due to the disease process. E.g. Alzheimer’s disease, depression
What mostly stays good with age?
General knowledge about things and people
The gist of long ago events
A strong sense of self and emotional maturity
using reminder strategies
Remembering given time
Skills acquired long ago (procedural memory)
What can worsen with age?
Tip-of-tongue occurrences Remembering cold turkey Future intentions without reminder cues juggling multiple things remembering under time pressure Where and when something was learnt
What are the myths of the ageing brain?
o dementia is to be expected as part of the normal ageing process
o it is too late to improve brain reserve in later life
o we have no control over the way our brains age
When do memory abilities peak and get lost?
memory ability peaks in the early 20s with some loss each decade from then on
When is it normal for memory to begin slipping?
It is normal for memory to begin slipping around 60 YO
What is more affected with regard to memory and age?
Memory for recent events are affected more than long held memories
What is not necessarily a sign of dementia?
minor memory lapses are not necessarily a sign of dementia
What classification of abilities increase during the lifespan and are less affected by ageing?
Crystallised abilities
When do fluid abilities peak and decline?
peak at about mid 20s and then decline gradually until the 60s when more rapid decline occurs
What is the score range for vocabulary in crystallised intelligence?
0 - 66
What is the average score range for vocabulary in crystallised intelligence for 20 yo?
41
What is the average score range for vocabulary in crystallised intelligence for 40 yo?
44
What is the average score range for vocabulary in crystallised intelligence for 60 yo?
41
What is the average score range for vocabulary in crystallised intelligence for 80 yo?
36
What is a test for fluid intelligence?
Symbol digit modalities test
What is the average score for the symbol digit modalities test for people age 20?
55
What is the average score for the symbol digit modalities test for people age 40?
51
What is the average score for the symbol digit modalities test for people age 60?
42
What is the average score for the symbol digit modalities test for people age 80?
33
What is ageing that is not normal?
dementia
What is dementia?
Dementia is an impairment of memory and other intellectual functions which goes beyond that expected y the normal ageing process and is usually progressive
What is used to test dementia?
DSM-5 : Major Neurocognitive Disorder & Mild Neurocognitive Disorder
What evidences DSM-5 Major Neurocognitive Disorder?
evidence of significant cognitive decline from pervious levels of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perpetual-motor, or social cognitive based on:
a. Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive functions; and
b. A substantial impairment in cognitive performance, preferably documented by standardised neuropsycholigical testing or, in its absence another quantified clinical assessment
What must the cognitive deficit in DSM-5 major neurocognitive disorder interfere with?
The cognitive deficits interfere with independence in everyday activities (i.e. at a minimum requiring assistance with complex instruments activities of daily living such as paying bills or managing mediations)
What are other criteria for DSM-5 Major neurocognitive disorder?
The cognitive deficits do not occur extensively in the context of delirium
The cognitive deficits are not better explained by another mental disorder (e.g. major depressive disorder, schizophrenia)
How does the DSM-5 mild neurocognitive disorder criteria differ from the major neurocognitive disorder?
That The cognitive deficits do not interfere with capacity for independence in everyday activities (i.e. complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater efforts, compensatory strategies, or accommodation may be required).
How many people had dementia in 2000 in Australia?
171,220 people
How many people had dementia in 2004 in Australia?
197,900
How many people are predicted to have dementia by 2050?
731,030
How many Australian women are predicted to have dementia by 2050?
over 420 000 Australians women with dementia (3.2% of all women)
How many Australian men are predicted to have dementia by 2050?
over 310 000 Australian men with demetia (2.4% of men)
What percentage of the population are projected to have dementia by 2050?
2.8%
What did Brayne et al (2014) discover with his two surveys of dementia numbers done 20 years apart in the UK?
o the first (1994) concluded there were 650000 people with the condition
o The second should have found nearly 900000people with dementia, but the count came up over 200000short
o people were developing dementia later in life
What could be the cause of a decline in dementia?
Could be due to increased education, better health, and higher levels of cognitive activity
What are the common causes of dementia?
o Alzheimer’s disease (AD) o Mixed AD and VaD o Vascular dementia (VaD) o Frontotemporal dementia o dementia with Lewy Bodies
What are the potential reversible causes of dementia?
o Benign tumors o Normal pressure hydrocephalus o Vitamin deficiency states e.g. B13 o Endocrine disease e.g. hypothyroidism o Limbic encephalitis
Who discovered Alzheimer’s Disease?
Alois Alzheimer
What did Alios Alzheimer do?
1864-1915 German neuropathologist and psychiatrist
When did Alios Alzheimer first describe the disease?
in a 1906 lecture
Who was to first patient described to have Alzheimer’s disease?
Auguste Deter
What were Auguste Deter’s symptoms?
symptoms included memory impairment, poor judgement, language difficulties and hallucinations
When did Auguste Deter die?
1906 at age 55
What is Alzheimer’s disease?
AD is a gradual, progressive degenerative process defined by the presence of an extensive number of plaques and tangles in the brain
What do MRI studies show with regard to Alzheimer’s disease?
MRI studies show 2.8% loss of brain volume each year in patients with AD, compared to around 0.2 to 0.4% loss in older people without demetia.
What are the three stages of alzheimer’s disease?
- Stage 1: Mild Cognitive Impairment
- Stage 2: Mild-to-moderate dementia
- Stage 3: Advanced dementia
What occurs in stage 1: Mild Cognitive impairment, of dementia?
o Complaint of poor memory, often corroborated by informant
o Episodic memory impairment
o Largely intact general (non-memory) cognitive abilities
o Able to perform activities of daily living
o A prodromal stage of AD
How many people in Stage 1: mild cognitive impairment will covert to Alzheimerz disease within a year and within 5 years?
- 10 – 20% will convert to AD within a year
* Majority will convert to AD within 5 years
What occurs in stage 2: mild-to-moderate dementia of Alzheimer’s disease?
o Worsening memory and attention, patients retain very little new information
o Disorientation and confusion
o Breakdown of semantic memory results in word-finding difficulties and decreased vocabulary
o difficulty understanding complex sentences
o difficulty performing everyday activities e.g. dressing
o difficulty with complex tasks e.g. using the computer
o difficulty recognising people and objects
What occurs in stage 3: advanced dementia in Alzheimer’s disease?
o Marked, cglobal loss in all areas of intellectual function
o Progressive deterioration of personality
o Incontinence, poor social conduct, aggressive behaviour wandering
o Difficulties eating and walking
What percentage of people at age 65 have Alzheimer’s disease?
less than 5%
What percentage of people over 85 have Alzheimer’s disease?
Nearly 50%
How long does an Alzheimer’s disease course typically last?
8-12 years
What percentage of Alzheimer’s disease cases have an early onset?
5-10% of all cases of AD have an early onset (before age 65) and the typically has a rapid course
which sex has a greater risk of Alzheimer’s disease?
women
What can assist doctors in determining whether dementia is present and what the possible causes of dementia are?
Cognitive test results combined with careful history taking and observation can assist doctors in determining whether dementia is present and the possible causes
What is Neuropsychological assessment of dementia more sensitive to than CT or MRI?
Neuropsychological testing is more sensitive in detecting early changes characteristic of Alzheimer’s Disease than are CT or MRI
What do different dementia disorders produce result in?
Different dementing disorders tend to produce different “profiles” of test scores
Why is identifying the likely cause of dementia important?
Identifying the likely cause of dementia (e.g. Alzheimer’s disease or vascular dementia) is important in terms of management and informing family or likely course and prognosis
What is the first step to neuropsychological assessment of dementia?
Review of medical records and related documents
What is so crucial about the first step to neuropsychological assessment of dementia?
Crucial to understand health history and current treatment contexts (e.g. injuries, infections/illness, blood tests, cerebrovascular risk factors, medications)
How can nauroimaging results me useful in the first step to neuropsychological assessment of dementia?
to assess extent of any cerebrovascular disease and degree of brain shrinkage
What does completion of the first step to neuropsychological assessment of dementia aid?
Aids initial hypothesis formation
What is the second step to neuropsychological assessment of dementia?
Initial interview with patient
What questions are often asked and answered in the second step to neuropsychological assessment of dementia?
Symptom type and onset? time course of the symotoms?
What does the second step to neuropsychological assessment of dementia purport to discover?
• Full psychosocial history – FEWMAPS o Family o Education o Work o Medical o Alcohol & Drugs o Psychological o Social
What is the third step to neuropsychological assessment of dementia?
Interview with significant other
Why is it important to interview the significant other in neuropsychological assessment of dementia?
Because collateral information is very important
Where is the interview with the significant other best performed?
best done separately from the patient
What is the 4th step to neuropsychological assessment of dementia?
Behavioural and other quantitative observations
What does the 4th step to neuropsychological assessment of dementia aim to determine?
- Insight?
- Difficulties recalling important personal details?
- Affect?
- Psychosis?
What is the 5th and final stage of neuropsychological assessment of dementia?
Formal cognitive testing
What does the formal cognitive testing stage of neuropsychological assessment of dementia aim to determine?
- Is impairment present and, if so, in which cognitive domains?
- Does the profile of impairment, together with relevant history, appear consistent with dementing disorder? if so, which type(s)?
What are some general considerations of neuropsychological assessment of dementia?
- Possible impact of sensory impairments
- Ensure adequate time available
- Effects of pain? Fatigue?
- Ensure appropriate, age-based norms
- Likely premorbid intellectual ability
- Cultural factors
What cognitive functions should neuropsychological assessment of dementia test?
o General intellectual functioning
o Memory (verbal and visual)
o Language (particularly word-finding ability)
o Attention & concentration
o Speed of information process
o Visuospatial and constructional abilities
o Executive functioning (i.e. Higher-level abilities which enable effective behaviour e.g. planning, organising, self-awareness, reasoning, problem-solving, flexibility of thinking
o Mood and anxiety
How dod the RBWH Memory Clinic Test Battery test general intellectual functioning?
o Test of premorbid functioning
o Wechsler Adult Intelligence Test – 4th edition (WAIS-IV)
How dod the RBWH Memory Clinic Test Battery test memory?
o The weschler memory scale – Fourth Esition (WS-IV)
o The Rey Auditory Verbal Learning Test
o The Rey Complex Figure Test
How dod the RBWH Memory Clinic Test Battery test language?
o The Boston Naming test
o the Controlled Oral Word Association Test
o Supplementary tests of reading, comprehension, verbal production
How dod the RBWH Memory Clinic Test Battery test attention/concentration?
o Digit span & arithmetic (from WAIS-IV)
How dod the RBWH Memory Clinic Test Battery test speed of information processing?
o Trails A
o Coding & Symbol Search (from WAIS-IV)
o Stroop Tesst (word reading and colour naming trials)
How dod the RBWH Memory Clinic Test Battery test visuospatial and constructional abilities?
o Block Design, Matrix Reasoning, Visual Puzzles (from WAIS-IV)
o The judgement of line orientation
o Rey Complex Figure Test (Copy trial)
o The Clock Drawing Test
How dod the RBWH Memory Clinic Test Battery test executive functioning?
o Trails B o Similarities (From WAIS-IV) o Stroop test (Inference task) o The tower of London test o the Wisconsin card sorting test
How dod the RBWH Memory Clinic Test Battery test mood and anxiety?
o the geriatiric Depression Scale
o The Geriatric Anxiety Inventory
What will brief, screening tools be useful for in neuropsychological assessment of dementia?
Brief, screening tools may be useful in providing a gross assessment of current cognitive functioning (e.g. Mini Mental Status Examination, Dementia Rating Scale)
What are the possible limitations of using brief screening tools in neuropsychological assessment of dementia?
o They provide only limited assessment of important cognitive domains, therefore unable to establish a pattern of impairment
o Often they are too brief to help determine the specific cause of the dementia (e.g. Alzheimer’s vs vascular)
o The often fail to detect subject deficits in cognitive ability
o Many do not have age or education-based norms
What is the “Memory Clinic” approach for assessing for dementia?
o G.P. refers patient to hospital-based Memory Clinic
o Memory Climic team typically consists of geriatrician, neurologist, psychiatrist, neuropsychologist, social worker
o Patient reviewed by medical specialist in team, who refers patient for further assessment (e.g. neuropsychological testing, brain imaging) where necessary to assist in diagnosis
o Team meeting facilities discussion between the multiple disciplines to assist in reaching diagnosis
o Patient and G.P. informed of outcome. Patient assisted re medication, community support, practical advice
How can we control cognitive ageing?
- Ensure you are well educated to boost cognitive reserve
- Ensure adequate intake of Omega 3 fatty acids (at least one meal of fatty fish per week or Omega 3 supplements)
- Ensure a diet rich in antioxidants (Vitamin B, C, E and folate)
- Maintain a socially active lifestyle
- Maintain a physically active lifestyle (walking for at least 30 minutes, 3 times per week)
- Continuing to engage in activities that are cognitively challenging (including work)
- Develop and hold positive attitudes towards the ageing process
What is increased risk of depression associated with?
o Female sex o unmarried (particularly widowed) o stressful life events o low social support o Coexisting medical conditions o Medications o Limited education
What is the prevalence of Mental Depression Disorder in older adults than in younger adults?
lower
what is the prevalence of milder depressive symptoms in older c/f to younger adults?
higher
Why might it be more difficult to diagnose depression in older adults than in younger adults?
diagnose due to different presentation to younger adults.
o Older generations may attribute psychological symptoms differently
o Frequent overlap between depressive symptoms and medical illnesses
o Symptoms may be thought to be attributable to dementia
In assessing depression through interview, what might people spontaneously report?
Many do not describe themselves as “depressed”. Often spontaneously report memory/concentration problems with physical health
What are the key things to remember when using interviews to assess depression?
Careful questioning is key
Questions need to be appropriate to the individual
observations during interview also important
What should you ask about when assessing depression through interview?
- Experience of daily life
- Interest in frequency of pleasurable activities
- Nature and quality of social interactions
- Nature and frequency of sad or worrying thoughts and thoughts about the future
- Insomnia accompanied by worry
- Apathy, agitation, anxiety, preoccupation with physical complaints
- Increased irritability, anger, impatience
- Suicidal ideation and plans
What are examples of scales used for assessing depression?
- Cornell Scale for depression
- Hamilton Rating scale for depression
- Beck depression inventory – 2nd edition (BDI-II)
- Geriatric Depression Scale (GDS)
Why is the Beck depression inventory- 2nd edition not ideal for older adults?
- multiple choice format confusing
- patients may have difficulty remembering the alternate responses and thus become frustrated
- many items assess somatic complaints which may be related to medical conditions or even normal age-related changes
Which scale is the most recommended for assessing depression in older adults?
Geriatric Depression Scale (GDS)
What are the advantages of the Geriatric Depression Scale (GDS)?
- Yes/No format easy to understand
- places more emphasis on cognitive rather than somatic complaints
- relatively quick to complete
which population is suicide more frequent in?
older adults. highest rate being in 70-74 for females and 85+ for males
What percentage of adults who commit suicide visit GP within a month of their suicide?
75%
What is the recovery rate for older adults who are treated with depression?
70-80%
What is the support for that treats depression in older adults?
Particular support for combination of antidepressant medication and psychological approaches
What do anxiety disorders include?
Anxiety disorders include panic disorder, agoraphobia, social anxiety disorder, specific phobia, generalised anxiety disorder (GAD)
What is the prevalence of anxiety disorders for Australians over 65?
5% but more prevalent in older adults with chronic health conditions
Which sex is more likely to have an anxiety disorder?
females
What are risk factors of anxiety disorders in older adults?
co morbid depression, lack of social support, poor physical health, functional and/or cognitive impairment
Why is anxiety more difficult to diagnose in older adults?
o high comorbidity with depressive disorders
o symptoms can mirror the neurocognitive changes associated with dementia
o Somatic rather than cognitive symptoms are typically reported which overlap with medical illnesses
How can association between anxiety and medical symptoms occur?
o Anxiety can increase one’s vulnerability to physical disease
o Physical disease can cause psychological symptoms
o Disease and medication side-effects can imitate psychological symptoms
In using interviews for assessing anxiety what is it important to distinguish between?
Improtant to distinguish anxiety from underlying medical conditions
What processes are involved in using interviews for assessing anxiety?
Review patient’s records and speak to GP
What should questions focus on when using interviews for assessing anxiety?
o Recent history of presenting symptoms o Past history of anxiety o current medical conditions and medications o history of substance use o Family history o Depressive symptoms
What should interviews for assessing anxiety focus predominantly on?
Focus primarily on feelings of fear and worry as opposed to somatic symptoms
What are examples of screening instruments used to assess anxiety?
- Bech Anxiety Inventory
- Stait-Trait Anxiety inventory
- Short anxiety screening test
- Geriatric anxiety inventory
Why is Generiatric anxiety inventory preferred for assessing anxiety in older adults?
o (Pachana et al., 2007) effective for detecting anxiety particularly GAD, in dults over age 60
o Overcomes shorcomings of other inventories
o Advantages over the other anxiety measures
o Good psychometric properties
What are the advantages of the Generiatric anxiety inventory for assessing anxiety in older adults over other anxiety measures?
- relative brevity (20 items) to minimise fatigue
- Dichotomous response format
- Minimal inclusion of somatic symptoms
what are the shortcomings of the other anxiety measures?
- Poor detecting anxiety symptoms in older adults
- Wording of items/response sets too long/Complex
- Somatic items in some inventories fail to reflect the somatic nature of older adults’ experience of anxiety
What are effective treatments of anxiety?
CBT (has been demonstrated for panic disorder, GAD)
What percentage of individuals with dementia are cared for at home?
70-80%
what are signs of caregiver burnout?
signs of caregiver burnout include exhaustion, guilt, anger, anxiety, social withdrawals and isolation, impaired sleep and concentration, increased health problems, and a decline in caregiving
What are the profound impacts of caregiving?
o practical – helping patients with cooking, cleaning, feeding, bathing
o Behavioural – dealing with incontinence, abusiveness, repitition, wandering, loss of own sleep and self-care time
o interpersonal – sadness, grief at change in patient, loss of closeness and intimacy
o Social – restrictions on getting out times constraints, resentment toward relatives and friends
What are the challenges faced by the caregiver in the early stages of dementia?
- anger/frustration at the patient’s confusion and vagueness
- strong sense of grief or anxiety
- depression due to loss of normal interaction
What are the challenges faced by the caregiver in the middle stages of dementia?
- physical demands become more evident
- distress due to more rapid progress of intellectual and personality deterioration
- challenges / frustration associated with wandering and aggression
What are the challenges faced by the caregiver in the later stages of dementia?
- difficult for carer to observe gross neurological disability (e.g. rigidity, tremor, body wasting)
- sense of guilt and stress associated with finding appropriate nursing home care, when required
What is the degree of stress of a caregiver related to?
o the degree of behavioural difficulty exhibited by the patient
o The severity of depression in the patient
• Characteristics of the caregiver’s skills are directly related to caregiver burden
What is associated with lower levels of caregiver burden?
active copign skills and management strategies are associated with lower levels of caregiver burden
Compared to non-caregivers, what do caregivers of persons with AD or related disorders require?
o 46% more visits to the doctors
o 71% more prescribed medications
What medical issues do caregivers tend to possess more than non-caregivers?
o higher blood pressure
o increased tendency to clit
o higher noradrenaline levels
What are ways to assess carer stress?
- Interview carer and obtain collateral where there is suspicion of denial
- Formal questionnaires of carer burden available
What is the most widely used scale of caregiver burden?
The Zarit Buden Interview
What are the 6 Es used by the psychologist when assisting carers?
o Educate caregivers re the diagnosis, disease course and available resources
o empower the strengths of the caregiver and abilities of the patient with dementia
o environemtnal comfort and protection of patient
o engage both caregiver and patents in stimulating, comfortable and structured activities
o energise the ability to be a caregiver by taking care of his/her needs and providing respite time
o end points should be discussed where appropriate. foster realistic attitudes and be proactive toward long-term placement options
