Psychological Assessment of Elderly Clients in Rehabilitation and Residential Care Settings - PowerPoint PPT Presentation

1 / 22
About This Presentation
Title:

Psychological Assessment of Elderly Clients in Rehabilitation and Residential Care Settings

Description:

Psychological Assessment of Elderly Clients in Rehabilitation and ... evidenced impaired performance on a vignette d.m. task despite no neuropsych deficits ... – PowerPoint PPT presentation

Number of Views:106
Avg rating:3.0/5.0
Slides: 23
Provided by: PDub
Category:

less

Transcript and Presenter's Notes

Title: Psychological Assessment of Elderly Clients in Rehabilitation and Residential Care Settings


1
Psychological Assessment of Elderly Clients in
Rehabilitation and Residential Care Settings
  • Patrick Dulin, Ph.D.
  • School of Psychology
  • Massey University

2
Presentation Overview
  • 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 this environment.
  • 4. Process and content of competency evaluations
    of incapacitated elderly.

3
Depression vs. Dementia
  • Clarfield (1998) found that 26 of elderly
    thought to be demented were actually depressed.
  • Age bias??
  • 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.

4
Dementia vs. Depression
  • Dementia
  • Widespread memory dysfunction
  • Recall and recognition memory is impaired
  • Intrusion errors common in memory tasks
  • Mood and behavior fluctuate
  • Not worried about cognitive loss, may try to
    conceal cog. problems, anosognosia.
  • Depression
  • Memory dysfunction more focal (vis.m. is poor)
  • Recognition memory is intact
  • Omission errors common in memory task, not as
    many intrusions
  • Mood consistently poor
  • Frequent complaining, high level of distress.
  • Very distressed about cognitive loss

5
Consideration of the Setting
  • Contextual Variables
  • 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 in pain.

6
Contextual Factors
  • 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.
  • Process Factors
  • The elderly individual typically has not
    encountered a shrink before and is frequently
    quite daunted at the opportunity for an
    examination.

7
Process Factors
  • 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 pacetake more time during the
    interview.
  • Testing for more than one hour is not advisable.
  • Cultural Awareness
  • Ask if they would like family present.
  • Simple familiarities (tea) are helpful.

8
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
    them.
  • 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.

9
Functional Assessment
  • Fundamental Question What is their level of
    independence?
  • Multidisciplinary Decision (ideally)
  • Requires input from M.D., Social Work, and OT.
    Info about health, ADLs and IADLs, supports
    (caring others?) and MONEY are crucial.
  • Psychologists input
  • Mood and Cognitive functioning..either can
    inhibit functioning.

10
Psychological Assessment and Functioning Key
Issues
  • Executive functioning abilities!! Very important
    for independent living. DRS-2 I/P, Trails A and
    B, DKEFS
  • Memory.mild to moderate difficulties are
    tolerable, but moderate to severe problems
    inhibit independence significantly. DRS-2 mem,
    WMS III LM.
  • Constructional and visual abilities
  • DRS-2 Const, line bisection, clock drawing.

11
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 populationdx by
    interview, no helpful psychometrics,
    unfortunately.
  • Ego Strength, independence, resilience are key
    personality factors.

12
Functional Assessment Key Issues
  • Final Thoughts
  • 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.

13
Determining Competence
  • Essential question Does the client possess the
    ability to make their own decisions?
  • Relevant Situations
  • 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 patients decision
    making capability (Schenkenberg, 1997).

14
Competence?
  • In the U.S., Competence is defined as
  • The patient is in possession of a set of values
    and goals.
  • The patient has the ability to communicate and
    understand information.
  • The patient has the ability to reason and
    deliberate about his or her choices.
  • (Presidents Commission on Making Health
    Care Decisions, 1982).
  • 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 is crucial.

15
Competence Decisions and Psychometrics
  • 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.

16
Competence and Depression
  • Does depression in this population influence
    competence?
  • 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 of depression.

17
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 neuropsych deficits

18
Case Study
  • Mrs. Smith, 79 y.o. widowed female living in an
    ECF in Bountiful, UTAH (cultural factors??)
  • Medical Conditions DM II, COPD, mild
    dementia.
  • 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?

19
Competency Case
  • Questions
  • 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?

20
Competency Case
  • Interview Results
  • 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.

21
Competency Case
  • History
  • 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.
  • Psychometrics
  • DRS Total score of was mildly above cut-off for
    dementia, but not much.
  • Mild to moderate impairment in memory sub-scales.
  • Initiation and Perseveration scales w.n.l.
  • Other scales unremarkable.

22
Case Recommendations
  • Overall, Mrs. Smith is functioning well.
  • Mrs. Smith has some evidence of a dementing
    illness, but still mild.
  • Recommendations???
Write a Comment
User Comments (0)
About PowerShow.com