Assessment of older adults

Question 1

Who are older adults?

Answer 1

Children – birth – 12 years
Adolescents: 12-18 years
Young adults: 18-21
Adults: 21-45 
Middle adulthood: 45-65
Young old: 65-74 (start of older adulthood)
Middle old: 75-84
Old-old: 85+

Question 2

Major changes in older adult life: Marriage/ Partnership –

Answer 2

• change in relationship due to retirement,
• assuming caring role;
• adjusting to illness/death of spouse

Question 3

Major changes in older adult life: Parenting

Answer 3

• “empty nest” syndrome;
• assuming grand parenting role;
• redefinition of parenting role

Question 4

Major changes in older adult life: Health

Answer 4

adjusting to decreasing physical strength and health;

• possible cognitive decline;
• awareness of mortality

Question 5

Major changes in older adult life: Social Relations

Answer 5

• change in social networks following retirement/relocation

- loss of close friends

Question 6

Major changes in older adult life: Finances

Answer 6

• change in financial position following retirement
• going on welfare/receiving superannuation
• financial planning for remainder of lifetime

Question 7

Major changes in older adult life: Work

Answer 7

• adjusting to retirement and reduced income

- physical injury/illness causing work disability

Question 8

Erikson’s psychosocial stages (8)

Answer 8

• infancy: trust v mistrust
• early childhood: autonomy v shame/doubt (1-3)
• preschool age: initiative v guilt (3-6)
• school age: industry v inferiority (6-12)
• adolescence: identity v role confusion (12-18)
• young adulthood: intimacy v isolation (18-35)
• middle age: generativity v stagnation (35-60)
• later life: integrity v despair (60+)
  o if one looks back on life with few regrets and feels personally worthwhile, ego integrity results. Failure to achieve ego integrity can lead to feelings of despair, hopelessness, guilt, resentment, and self-rejection

Question 9

Cohen’s developmental stages in the second half of life (4)

Answer 9

• midlife evaluation (40-50s)
  o quest to make life and work more gratifying and meaningful (the “mid life crisis”)
• liberation (60s to early 70s)
  o experience of new personal freedom (“if not now, when?”)
• summing up (70s & older)
  o search for meaning in life through looking back, summing up, and giving back
• encore (80s and older)
  o desire to make a final statement or take care of unfinished business

Question 10

Common themes in older adult assessment

Answer 10

• normal aging versus dementia
• neuropsychological assessment of dementia
• assessment of mood and anxiety disorders
• assessment of carer stress

Normal ageing versus “abnormal” ageing

Question 11

Normal ageing

Answer 11

-	primary vs secondary ageing
o	primary: due to the passage of time
•	visual acuity
•	lung capacity
o	secondary: due to the disease process
•	alzheimer’s disease
•	depression

Question 12

Normal Ageing: Mostly Stay good with age

Answer 12

1) General Knowledge about things and people
2) The gist of long ago events
3) A strong sense of self and emotional maturity
4) Using reminder strategies
5) Remembering given time
6) Skills acquired long ago (procedural memory)

Question 13

Normal Ageing: Can worsen with age

Answer 13

1) Tip-of-tongue occurrences
2) Remembering cold turkey
3) Future intentions without reminder cues
4) Juggling multiple things
5) Remembering under time pressure
6) Where and when something was learned

Question 14

Myths of the ageing brain

Answer 14

• dementia is to be expected as part of the normal ageing process
• is it too late to improve “brain reserve” in later life
• we have no control over the way our brains age

Question 15

Facts about the ageing brain

Answer 15

• memory ability peaks in the early 20s, with some loss each decade from then on
• it is normal for memory to begin slipping around 60 years of age
• memory for recent events are affected more than long held memories
• minor memory lapses are not necessarily a sign of dementia
• crystallised abilities increase during lifespan, less affected by ageing
• fluid abilities peak in mid-20s, decline gradually until the 60s when more rapid decline occurs

Question 16

• Crystallised intelligence:

Answer 16

o	Vocabulary
•	Score range = 0-66
•	Age 20: average score = 41
•	Age 40: average score = 44
•	Age 60: average score = 41
•	Age 80: average score = 36

Question 17

• Fluid intelligence:

Answer 17

o	Symbol digit modalities test
•	Age 20: 55 symbols
•	Age 40: 51 symbols
•	Age 60: 42 symbols
•	Age 80: 33 symbols

Question 18

Dementia: ageing that is not normal

Answer 18

• Dementia is an impairment of memory and other intellectual functions which goes beyond that expected by the normal ageing process and is usually progressive
• DSM-5: major neurocognitive disorder and mild neurocognitive disorder

Question 19

DSM-5 Major Neurocognitive Disorder

Answer 19

A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:
a. Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function and
b. A substantial impairment in cognitive performance, preferably documented by standardised neuropsychological testing or, in its absence, another quantified clinical assessment
B. The cognitive deficits interfere with independence in everyday activities (i.e. at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications)
C. The cognitive deficits do not occur exclusively in the context of a delirium
D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia)

-	Specify whether due to
o	Alzheimer’s disease
o	Frontotemporal lobar degeneration
o	Lewy body disease
o	Vascular disease
o	Traumatic brain injury
o	Substance/medication use
o	Hiv infection
o	Prion disease
o	Huntington’s disease
o	Another medical condition
o	Multiple etiologies
o	Unspecified
-	Specify with or without behavioural disturbance
-	Specify current severity (mild, moderate, severe)

Question 20

DSM- 5 Mild Neurocognitive Disorder

Answer 20

A. Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:
a. Concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function and
b. A modest impairment in cognitive performance, preferably documented by standardised neuropsychological testing or, in its absence, another quantified clinical assessment
B. The cognitive deficits do not interfere with independence in everyday activities (i.e. at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required)
C. The cognitive deficits do not occur exclusively in the context of a delirium
D. The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia)

Question 21

Projected Dementia Growth

Answer 21

• In Australia, the data show that dementia prevalence increases from:
  o 171,220 people in 2000 to
  o 197,900 in 2004
  o to a predicted 731,030 by 2050
• by 2050 there are projected to be:
  o over 420,000 australian women with dementia (3.2% of all women)
  o over 310,000 Australian men with dementia (2.4% of men
• Overall, 2.8% of the population are projected to have dementia by 2050
• But could dementia be on the decline?
• Brayne et al. (2014) led two surveys of dementia numbers in the UK 20 years apart
  o The first (1994) concluded there were 650 000 people with the condition
  o The second should have found nearly 900 000 people with dementia, but the count came up over 200 000 short
  o People were developing dementia later in life
• Could be due to increased education, better health, and higher levels of cognitive activity

Question 22

Causes of dementia

Answer 22

-	Common causes
o	Alzheimer’s disease (AD)
o	Mixed AD and VaD
o	Vascular dementia (VaD)
o	Frontotemporal dementia
o	Dementia with Lewy Bodies

Question 23

Potentially reversible causes

Answer 23

• Benign tumours
• Normal pressure hydrocephalus
• Vitamin deficiency states e.g. B12
• Endocrine disease e.g. hypothyroidism
• Limbic encephalitis

Question 24

Alzheimer’s Disease – the most common form of dementia in Australia

Answer 24

• Alois Alzheimer
  o (1864 – 1915) German neuropathologist and psychiatrist
• in a 1906 lecture, he first described the disease which now carries his name
• Auguste Deter: the first patient with Alzheimer’s disease to be described
• Symptoms included memory impairment, poor judgement, language difficult and hallucinations
• Died 1906 – aged 55 years
• AD is a gradual, progressive degenerative process defined by the presence of an extensive number of plaques and tangles in the brain
• MRI studies show 2.8% loss of brain volume each year in patients with AD, compared to around .2 to .4% loss in older people without dementia
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Question 25

• Stage 2: mild cognitive impairment

Answer 25

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
• 10-20% will convert to AD within a year
• majority will convert to AD within 5 years

Question 26

• Stage 2: Mild to moderate dementia

Answer 26

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

Question 27

• Stage 3: advanced dementia

Answer 27

• • marked, global loss in all areas of intellectual function
• progressive deterioration of personality
• incontinence, poor social conduct, aggressive behaviour, wandering
• difficulties eating and walking
• less than 5% of people age 65 have AD
• nearly 50% of people who are > 85 years have AD
• Course typically lasts for 8-12 years
• Early onset AD (Before age 65) accounts for 5-12% of all cases of AD and typically has a rapid course
• Women are at greater risk of AD than men

Question 28

Neuropsychological Assessment of Dementia

Answer 28

• Cognitive test results combined with careful history taking and observation can assist doctors in determining whether dementia is present and the possible causes
  o Neuropsychological testing is more sensitive in detecting early changes characteristic of Alzheimer’s Disease than are CT or MRI
• Different dementing disorders tend to produce different “profiles” of test scores
• Identifying the likely cause of dementia (e.g. Alzheimer’s disease or vascular dementia) is important in terms of management and informing family of likely course and prognosis

Question 29

Assessment of Dementia

Answer 29

1. Review of medical records and related documents:
   a. Crucial to understand health history and current treatment contexts (e.g. injuries, infections/illnesses, blood tests, cerebrovascular risk factors, medications)
   b. Neuroimaging results: CT or MRI (to assess extent of any cerebrovascular disease and degree of brain shrinkage)
   c. Aids initial hypothesis formation
2. Initial interview with patient
   a. Symptom type and onset? Time course of the symptoms?
   b. Full psychosocial history – FEWMAPS
   i. Family
   ii. Education
   iii. Work
   iv. Medical
   v. Alcohol and drug
   vi. Psychological
   vii. Social
3. Interview significant other
   a. Collateral information very important
   b. Best done separately from the patient
4. Behavioural and other qualitative observations
   a. Insight?
   b. Difficulties recalling important personal details?
   c. Affect?
   d. Psychosis?
5. Formal cognitive testing
   a. Is impairment present, and if so, in which cognitive domains?
   b. Does the profile of impairment together with relevant history, appear consistent with a dementing disorder? If so, which type(s)?

Question 30

• General considerations

Answer 30

o	Possible impact of sensory impairments
o	Ensure adequate time available
o	Effects of pain? Fatigue?
o	Ensure appropriate, age-based norms
o	Likely premorbid intellectual ability
o	Cultural factors

Question 31

• Test selected should assess a range of important cognitive functions including

Answer 31

o	General intellectual functioning
o	Memory (verbal and visual)
o	Language (particularly word finding ability)
o	Attention and concentration 
o	Speed of information processing
o	Visuospatial and constructional abilities
o	Executive functioning 
o	Mood and anxiety

Question 32

The RBWH Memory Clinic Test Battery-

Answer 32

• General intellectual functioning
  o Test of Premorbid functioning
  o Wechsler Adult Intelligence Test – Fourth Edition (WAIS-IV)
• Memory (verbal and visual)
  o The Wechsler Memory Scales – Fourth Edition (WMS-IV)
  o The Rey Auditory Verbal Learning Test
  o The Rey Complex Figure Test
• Language
  o The Boston Naming Test
  o The controlled oral word association test
  o Supplementary tests of reading, comprehension, verbal production
• Attention/Concentration
  o Digit span and arithmetic (from WAIS-IV)
• Speed of Information Processing
  o Trails A
  o Coding & symbol search (from WAIS-IV)
  o Stroop test (word reading and colour naming trials)
• 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
• Executive Functioning
  o Trails B
  o Similarities (from WAIS-IV)
  o Stroop test (interference task)
  o The tower of London test
  o The Wisconsin card sorting test
• Mood and anxiety
  o The geriatric depression scale
  o The geriatric anxiety inventory

Question 33

Assessing for Dementia

Answer 33

• The “memory clinic” approach
  o GP refers patient to hospital-based memory clinic
  o Memory clinic 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. neurpsychological testing, brain imaging) where necessary, to assist in diagnosis
  o Team meeting facilitates discussion between the multiple disciplines to assist in reaching diagnosis
  o Patient and GP informed of outcome. Patient assisted re medication, community support, practical advice

Question 34

Can we control cognitive ageing?

Answer 34

Can we control cognitive ageing?

1. Ensure you are well educated to boost cognitive reserve
2. Ensure adequate intake of omega 3 fatty acids (at least one meal of fatty fish per week or omega 3 supplements)
3. Ensure a diet rich in antioxidants (vitamins B, C, E and folate)
4. Maintain a socially active lifestyle
5. Maintain a physicaly active lifestyle (walking for at least 30 minutes, 3 times a week)
6. Continuing to engage in activities that are cognitively challenging (including at work)
7. Develop and hold positive attitudes towards the ageing process

Question 35

Depression in older adults

Answer 35

• Prevalence of MDD in community-residing older adults is lower than in younger adults (around 1%- 5%)
• Prevalence of milder depressive symptoms in older adults is much higher (10%-25%)
• Prevalence of major depression higher for those hospitalised or in residential facilities (around 30% have MDD)

Question 36

DSM-5 major depressive disorder

Answer 36

• Five or more of the following symptoms
  o Depressed mood most of the day, nearly every day
  o Markedly diminished interest/pleasure in activities
  o Significant weight loss/weight gain or decrease/increase in appetite
  o Insomnia or hypersomnia
  o Psychomotor agitation or retardation
  o Fatigue or loss of energy
  o Feelings of worthlessness or guilt
  o Diminished concentration or indecisiveness
  o Recurrent thoughts of death or suicide

Question 37

Depression in Older adults

Answer 37

-	Increased risk of depression associated with
o	Females
o	Unmarried (particularly widowed)
o	Stressful life events
o	Low social support
o	Coexisting medical conditions
•	Thyroid disorders
•	Cancer
•	Cerebrovascular disease
•	Parkinsons disease
•	Chronic obstructive pulmonary disease
o	Medications
•	Beta blockers
o	Limited education

• Depression under-diagnosed and under-treated in older adults
• BUT depression in this cohort may be more difficult to 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
• Reports of depressed mood, guilt, low self-esteem less prominent
• Loss of pleasure, problems with concentration and vegetative symptoms (poor appetite, insomnia, poor energy) more indicative
• BUT changes in appetite, sleep, and energy may reflect side effects of medication or physical illnesses

Question 38

Assessing Depression – Interview

Answer 38

• Many do not describe themselves as ‘depressed’
• Often spontaneously report memory/concentration problems and concerns with physical health
  o Careful questioning is key. Ask about
  • Experience of daily life
  • Interest in and 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
• Question need to be appropriate to the individual
  o E.g. for patient with limited mobility “do you feel tired when resting” is better than “have you no energy”
  o E.g. for patient with pain and early morning waking “do you wake up with pain or worrying thoughts?”
• Complaint of loneliness should also raise suspicions
• Collateral information is often very useful
• Observations during interview also important. Is the patient
  o Withdrawn?
  o Lacking in energy?
  o Easily tearful?
  o Irritable or disinterested?
  o Having difficulty sustaining effort on questioning?

Question 39

Assessing Depression – Screening Instruments

Answer 39

• Cornell scale for depression
• Hamilton rating scale for depression
• Back depression inventory – second edition (BDI-II)
• Geriatric Depression Scale (GDS)
• BDI-II not ideal for older adults
  o Multiple choice format confusing
  o patients may have difficult remembering the alternate responses and thus become frustrated
  o Many items assess somatic complaints which may be related to medical conditions or even normal age related changes

Question 40

Geriatric Depression Scale

Answer 40

• Recommended
• Advantages
  o Yes/no format easy to understand
  o Places more emphasis on cognitive rather than somatic complaints
  o Relatively quick to complete
• Comes in 30 item, 15 item and 5 item version
• For 30 item version
  o Scores 10-19 indicate mild depression
  o Scores 20-30 indicates severe depression
• For 15 item scale
  o Scores 5-9 indicate possible depression
  o Scores 10-15 indicate probabl depression
• Good psychometric properties

Question 41

Suicide

Answer 41

• More frequent in older adults than any other population
  o Rates similar for women across all age groups, but highest age-specific rate in 70-74 age group (6.1 per 100 000)
  o Much more variation for males, but highest in 85+ years age group (34.5 per 100 000)
• Up to 75% of older adults who commit suicide visited a GP within a month of their suicide

Question 42

Treatment for depression

Answer 42

• Older adults do not seek treatment readily
• Meta-analyses suggest treatment for depression in older adults produces very good outcomes (70-80% recovery rates)
• Evidence for effectiveness of CBT and IPT
• Particular support for combination of antidepressant medication and psychological approaches

Question 43

Anxiety disorders in older adults

Answer 43

• Anxiety disorders include panic disorder, agoraphobia, social anxiety disorder, specific phobia, generalised anxiety disorder (GAD)
• Prevalence of anxiety disorders is around 5% in Australia over age 65
• More prevalent in older adults with chronic health conditions
• More common in females than males
• Unusual for an anxiety disorder to begin in late life
• Specific phobia and GAD most prevalent anxiety disorders in older adults
• Panic disorders is least common in older adults
• Risk factors: co morbid depression, lack of social support, poor physical health, functional and/or cognitive impairment
• Anxiety can be difficult to diagnose in older adults due to
  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
• The association between anxiety and medical symptoms can occur in several ways
  o Anxiety can increase one’s vulnerability to physical disease
  o Physical disease can cause psychological changes
  o Disease and medication side-effects can imitate psychological symptoms

Question 44

Assessing anxiety – interview

Answer 44

• Important to distinguish anxiety from underlying medical conditions. Review patient’s records and speak to GP
• Questions should focus on
  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
• Focus primarily on feelings of fear and worry as opposed to somatic symptoms
  o E.g. during the past week, have you felt fearful? Unable to relax? Worried?

Question 45

Assessing Anxiety – Screening Instruments

Answer 45

• Beck Anxiety Inventory (BAI)
• Stait-Trait anxiety inventory
• Short anxiety screening test
• Geriatric anxiety inventory

Question 46

Geriatric anxiety inventory

Answer 46

• Geriatric anxiety inventory (Pachana et al., 2007) effective for detecting anxiety, particularly GAD, in adults over age 60
• Overcomes shortcomings of other inventories
  o Poor at detecting anxiety symptoms in older adults
  o Wording of items/responses sets too long/complex
  o Somatic items in some inventories fail to reflect the somatic nature of older adults’ experience of anxiety
• Advantages over other anxiety measures
  o Relative brevity (20 items) to minimise fatigue
  o Dichotomous response format
  o Minimal inclusion of somatic symptoms

Question 47

Treatment of anxiety

Answer 47

ess of CBT in older adults has been demonstrated for panic disorder, GAD

• Adjustments to psychological therapies may be necessary
• Efficacy of a range of medications have been demonstrated to be useful

Question 48

Assessment of Carer Stress

Answer 48

• Around 70 to 80% of all individual with dementia are cared for at home
• Psychological distress and ‘burnout’ are common amongst carers of people with dementia
• Signs of caregiver burnout include exhaustion, guilt, anger, anxiety, social withdrawal and isolation, impaired sleep and concentration, increased health problems, and ad ecline in caregiving
• Important to maintain a high index of suspicion for carer depression and anxiety

Question 49

Carer Stress

Answer 49

• Caregiving has profound impacts
  o Practical: helping patient with cooking, cleaning, feeding, bathing
  o Behavioural: dealing with incontinence, abusiveness, repetition, 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 towards relatives and friends
• Challenges faced by the carer may vary according to the stage of dementia at which the person is in
• In early stages
  o Anger/frustration at the patient’s confusion and vagueness
  o Strong sense of grief/anxiety
  o Depression due to loss of normal interaction
• In middle stages
  o Physical demands become more evident
  o Distress due to more rapid progress of intellectual and personality deterioration
  o Challenges/frustration associated with wandering and aggression
• In later stages
  o Difficult for carer to observe gross neurological disability (e.g. rigidity, tremor, body wasting)
  o Sense of guilt and stress associated with finding appropriate nursing home care, when required
• The level of perceived burden does not correlate with the duration of time spent as a caregiver, the degree of memory loss, or the level of functional impairment of the patient
• Degree of stress is 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
• Active coping skills and management strategies are associated with lower levels of caregiver burden
• Active strategies include “constructing a larger sense of the illness” and being firm in directing a relative’s behaviours
• Family and other social support correspond with lower levels of caregiver burden

Question 50

Assessment of carer stress

Answer 50

• Interview carer and obtain collateral where there is suspicion of denial
  o Collect detailed family and social history
  o Ask re respite and other home services, time away from caring role
  o Assess for depression and anxiety
• Formal questionnaires of carer burden available
• Important to monitor carer stress over time
• Institutionalisation does not totally relieve carer strain
• Zarit Burden interview
  o Most widely used scale of caregiver burden
  o 22 items, rated on 5 points scale
  o maximum score = 88. Higher scores indicate higher levels of carer burden

Question 51

Role of the psychologist in assisting carers: 6 E’s

Answer 51

• the six Es
  o Educate caregivers re the diagnosis, disease course, and available resources
  o Empower the strengths of the caregiver and the abilities of the patient with dementia
  o Environmental comfort and protection of patient
  o Engage both caregivers and patients 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, when appropriate, foster realistic attitudes and be proactive towards long-term placement options