Assessment Of Older Adults

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Older adults are the fastest growing sector of the population

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High increases of those 85 years plus

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In 2012 14% of the population were

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Aged plus 65 years

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In 2061 the projected data will involved 15% of the population

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< 16 years

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In 2012 19% of the population

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Were < 15 years

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In 2061 the projected population will involved 24.5% of the population

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65 plus years

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Definition of an older adult

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65+ (retirement) > 100+ years

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Demographers have propised subgrouping

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Young old: 65-75 years, old old 75-84years, oldest old: 85 +

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Chronological age may have little value to a psychologist..

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Need to look at physical, cognitive and social functioning

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Older adults are less likely

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To experience low mood, better emotional regulation?, increased crystalised intelligence

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Expected aging physical changes

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Poor vision, hearing difficulty writing, medical illness, medications, fatigue

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Expected aging cognitive changes

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Normal age related: attentional and working memory problems, slowed processing speed and reaction time

Pathalogical: dementia

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Expected aging biological changes

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Circadian phase

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Expected aging cohort effects

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Different experiences and expectations, unfamiliarity with psychological testing or psychological concepts, reduced literacy, education

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Assessment with older adults what to ask?

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Early developmental milestones, specofic learning difficulties, illicit substance use, transition after retirement, social supports/changes, activities for enjoyment, living arrangements

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Clinical interview: cognitive changes

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Changes in memory, attention, proecessing speed? Changes in functioning?, how long, graduaal or rapid deline, precipitating event, functional impact, cooccuring changes in mood?

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Diagnostic considerations: insight

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Unable to give reliable reports od their psychological symptoms and history, multiple strategies are used to elicit the most comprehensive and meaningful description, suppliment the interview with a informant report (fmaily member, gp, community based services etc)

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Diagnostic considerations DSM 5

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No specific section for older adults (does have sections for childhood and adult), issues with including sysmtpoms that are due to a medical.condition or effects of medication (issue is difficult in older adults with multiple medications or conditions)

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Common assessmemt tools for older adults

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Cognitive assessment, depression, anxiety, capacity assessments

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Example depression scales that may bias older adult assessment: Beck depression inventory

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'I wake up several hours earlier than i used to and cannot get back to sleep (circadian phase?), 'i have no appetitie anymore' (medication?), 'i am.worries about my physical problems that i cannot think of anything else' (medical illness)

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Geriatric depression scale (Yesavage, 1998)

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Self report, 10 min, 30 items, does not include somatic symptoms, focuses on affective symptoms. Strong valodity for older adults without cog impairment. 'Do you feel that your life is empty', do you often get bored?' 'Do you feel helpless'

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Cornell scale for depression in dementia

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Interview with older person and informant, reports are integrated with clinical obs, validated, assesses depression in those with dementia, used commonly in aged care

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Psychotherapy for older adults

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Is effective, with similar effect sizes to medication trials and stuides with younger adults

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Cognitive behvaioural therapy

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Particularly helpful, >9 sessions reccomened for older adults, sessions may be shorter to manage fatigue and changes in sustained attention, therapist should have specialist training

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Socialisation to therapy

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Allow more time for orientation, explore attitudes to therapy, challenge ageist views, therapeutic not a social encounter, story telling is common may need to redicret, timelimited, deal with here and now

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Treatment issues

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Coordinate a treatment approach withother professionals, involving family or carers may aid maintenance and generalisability (ie dementia), family and carers may also need targeted interventions (due to stress of caring), develop concrete realistic goals, address medical issues, themes may be age related (illness, grief, cog decline etc), explore past successful coping methods, encourage and educate

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Psychotherapy with people with cognitive impairment?

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Simplify skills, focus on 1-2 skills, ask client to repeat info, provide summaries thoughout session, ask family/nurses to facilitate learning and memory, phone contact between sessions to remind of tasks/strategies, memory aids (repition, visual aids etc), integrate skills into normal routine

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Disorders of old age

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Mild cog impairment, alzheimers disease, parkinsons disease, dementia with lewy bodies, frontotemporal dementia, vascular dementia, delirium

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Manjor neurocognitive disorder DSM 5

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Cog decline from previous level or in one or more cog domains, cognitive problems that interfere with functioning, do not occur in the context of delirium, not explaine dny other disorder

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Cognitive domains

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Attention, processing speed, working memort, memory and new learning, visuospatial functioning, executive functioning

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Alzheimers disease cognitive profile: verbal memory decline (rapid forgetting, reduced recall, LTM initially, preserved

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Assessment tool: HVLT. Clinical presentation: forgetting convos, losing items, missing appointments

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Alzheimers disease cognitive profile: language

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Assessment tool: boston naming test. Clinical presentation: word finding difficulties

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Alzheimers disease cognitive profile: impaired spatial memory

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Assessment tool: WMS Visual repoductions. Clinical presentation: confusing locations, getting lost in public places

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Alzheimers disease cognitive profile: executive skills

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Assessment tool: verbal fluency. Clinical presentation: impaored reasoning difficulty planning/organising self/idea generation

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Dementia with lewy bodies cognitive profile: impaired attention and concentration

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Assessment tool: TMT, digit span, HVLT. Clinical prsesntation: confusion, disorientation

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Dementia with lewy bodies cognitive profile: resuced processing speed/psychomotor speed

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Assessment tool: coding, SDMT, qualitatively via other timed task. Clinical presentation: slow to respond, slowed movement

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Dementia with lewy bodies cognitive profile visuospatial abilities

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Assessment tool: rey complex figure. Clinical presentation: misjudging space, locating

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Dementia with lewy bodies cognitive profile executive dysfunction

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Assessment tool: verbal fluency. Clinical presentation: rigid thoughts, difficulty generating ideas, poor planning

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Additional features of dementia with lewy bodies

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Hallucinations (clinical presentation: detailed visual hallucinations), Autonomic dysfunction (clinical presentation: incontinence, falls, impotence), fluctuating attention and alertness (clinical presentation: can appear like delirium)

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Excretion of drugs by the kidneys decreases with age

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Leads to increase time medications in the body

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In older adults bodies water content decreases, fat content increases

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Water soluble drugs will have larger conentration, fat soluble drugs will have lower concentration

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Polypharmacy can lead to delirium, agitation, confusion

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Increases risk of mortality/morbidity

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Need ti be aware of what medications a patient is on

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What effects this may have on behvaiour, mood, cognition, function

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Difference between dementia and depression

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Depressive episode secondary to dementing illness or cognitive deficit secondary to mood disorder. What appears to be depressive symptoms can reflect cog/behav changes associated with dementing illness, neuropsych profiles are likely to differ.

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Neuropsychological profiles for depression

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Free recall (stronger primacy effect), weakness in processing speed, verbal fluency (reductions, slow responding), coping deficit often exaggerated, poor neuropsych profile incogruent with functional capacity

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Alzheimer's disease/dementia neuropsych profiles

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Free recall (stronger recency effect), semantic fluency (category) impaired eariler than phonemic, poor neuropsych profile mapped to functional difficulties

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Dementia with lewy bodies can be confused with

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Delerium at times

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Delerium vs dementia

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Alertness (disturbance in attention and awareness), time course (develops over short period, fluctuates throughout day), cognitive function (change in memory, language, perception, visuospatial abilities), previous diagnosis (not result of preexisting condition or development of neurocog disorder), medical condition(evidence to suggest phyiological consquence of medical condition?)

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Recognition trials can

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Help with discovering memory problems (thise with depression can seem a bit flat on this)