The Center for Aging Resources

1. The Center for Aging Resources www.centerforagingresources.org (626) 577-8480

2. Janet Anderson Yang, Ph.D. The Center for Aging Resources Pasadena, California Assessment of Older Adults

4. Purposes of assessment, general Special issues relevant to older adults Specific assessment needs: Older adults Domains to be assessed Techniques of assessment Tools to consider Possible protocol Resources & References Assessment of Older Adults Outline

5. Why are you assessing this client? What is your assessment expected to accomplish? Clarify who needs to know what. Purposes of Assessment

6. Determination of whether to accept as a client Diagnosis of psychopathology What type of treatment to offer Specific plan for mental health treatment Plan for quality of life improvement Evaluate client outcomes Other Purposes of Assessment

7. Reminder: Purpose of assessment is to discover and document facts, not to support previously reached conclusions. Purposes of Assessment

8. Medical conditions Cohort differences Cognitive changes Developmental issues Cultural & linguistic diversity Special issues relevant to assessing older adults

9. 80% of older adults have at least 1 chronic illness Most have multiple chronic illnesses Multiple medications (ave. =11) Physical disabilities impair mobility Vision impairment; hearing impairment Chronic pain Older adults fatigue more easily Physical illness is a risk factor for suicide 1. MEDICAL CONDITIONS

10. Stigma of mental health assessment & treatment Value on frugality Value on independence Tendency to somaticize 2. COHORT DIFFERENCES

11. Age consistent memory decline Mild Cognitive Impairment Dementia Delirium 3. COGNITIVE CHANGES

12. Normal age changes include decreased: Speed of thinking & remembering Ability to stay focused on a mental task Ability to attend to several tasks simultaneously Memory for names & words Memory when given little time to learn Mild Cognitive Impairment (MCI) Changes with dementia: More serious impairment Significant impact on functioning May or may not be progressive Delirium: alteration in attention and level of consciousness 3. COGNITIVE CHANGES

13. Retirement Social status changes Losses Family role changes Death & dying issues 4. DEVELOPMENTAL CHANGES

14. Older immigrants are more likely to be monolingual and less acculturated to the United States 5. Cultural/Linguistic Diversity

15. Often do not self-refer a. networking & case finding necessary b. multidisciplinary collaboration Often hesitant / need engagement a. more rapport building time b. slower pace often needed PRIMARY ADAPTATIONS NEEDED

16. Need education about process of assessment, including what, when, where, how long, cost, why Impaired mobility & stigma requires assessment in clients’ homes Health conditions require assessment of medical illnesses, medications & sensory acuity, and communication with primary care physician ADAPTATIONS (cont.)

17. Assessment for suicidality Use larger fonts; speak loudly & clearly; repeat instructions as needed Communicate in simpler sentence structure if needed Appropriate language & culture “broker” ADAPTATIONS (cont.)

18. Social workers / case mangers Physicians & nurses Home health aides (e.g., IHSS) Religious ministers Apartment managers Law enforcement Senior center staff Attorneys Multi-disciplinary Involvement

19. Assessment of depression Assessment of suicidality Presence and degree of anxiety Presence of impaired reality testing Assessment of substance abuse Presence or absence of cognitive impairment Type of cognitive impairment Is it pathological? What type of dementia? Is it treatable? Distinguishing between Dementia & Depression SPECIFIC ASSESSMENT NEEDS

20. Presence of Delirium Distinguishing between Delirium & Dementia Presence of elder abuse Comorbidity of mental illness with medical illness Ability to make informed consent Assessment of capacity/Conservatorship issues Functional assessment, living environment appropriateness Assessment of safety issues SPECIFIC ASSESSMENT NEEDS (cont.)

21. Referral information Client’s self-reported concerns and goals Presenting symptoms & history of symptoms Psychiatric history Medical history, medications Sensory acuity Developmental history Social network Living environment DOMAINS TO BE ASSESSED

22. Substance abuse, including prescription medication, over the counter, & supplement usage Cognition General level Memory Attention Language Visual-spatial ability Executive functioning Estimate of premorbid ability DOMAINS TO BE ASSESSED (cont.)

23. Perceptual motor deficits Suicidality/homocidality Elder abuse, including self-neglect Diversity issues, e.g., acculturation, language, family dynamics, etc. Preexisting abilities Services and agencies involved Note strengths as well as deficits DOMAINS TO BE ASSESSED (cont.)

24. Clinical interview Self report measures Cognitive performance testing Informant data Behavioral observation ASSESSMENT TECHNIQUES:Multimodal assessment

25. Client Referral source Primary care physician Case manager Conservator/Power of Attorney Family/Caregiver Confidentiality: release of information Ca. Welfare & Institutions Code 10850.1 Possible Informants

26. Geriatric medical assessment Multidisciplinary geriatric assessment: geriatrician, nursing, neurologist, psychologist, physical therapy, social work, speech, occupational therapy, et al Neuropsychological assessment Gero-pharmacology consult Nutritional consult Neurological consult Occupational therapy consult Additional referrals to consider

27. Tests need to be appropriate for age: Valid: does it measure what it claims to? Reliable: over time & between administrators Standardization sample/norms Developed specifically for older adults Public vs. privately owned (cost) Time to administer Skill required & ease of administration Appropriate for culture, language & education Clinical utility vs. research Factors to consider when choosing tools

28. 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 TOOLS TO CONSIDER

29. Education relevant comparisons: Average normal score for persons with 0-4 years education: 22 Average normal score for persons with 5-8 years education: 26 Average normal score for persons with 9-12 years education: 28 Average normal score for persons with college years education: 29 Folstein Mini Mental State Exam

30. 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 TOOLS TO CONSIDER

31. Orientation Attention Language Comprehension Repetition Naming Constructions Memory Calculations Reasoning Similarities Judgment Neurobehavioral Cognitive Status Exam: Subtests

32. 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 TOOLS TO CONSIDER

33. Acute onset or fluctuating course? Inattention Disorganized thinking Altered level of consciousness Presence of 1 & 2 and either 3 or 4 indicates delirium CAM: Confusion Assessment Method

34. Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)? CAGE

35. Life skills functioning Lawton & 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 TOOLS TO CONSIDER

36. Toileting Feeding Dressing Grooming Physical ambulation Bathing Activities of Daily Living (ADL) Index

37. Ability to use telephone Shopping Food preparation Housekeeping Laundry Mode of transportation Responsibility for own medications Ability to handle finances Instrumental Activities of Daily Living Scale (IADL)

38. 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 TOOLS TO CONSIDER

39. 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) TOOLS TO CONSIDER

40. Physical Health: Clinical Interview Sensory deficits Medications, incl. over the counter meds. Medical conditions & symptoms Call Primary Care Physician Nutrition Self-rated health SF 12 TOOLS TO CONSIDER

41. Anxiety Beck Anxiety Inventory Short Anxiety Screening Test Sinoff et al, 1999 Personality characteristics MMPI-II MCMI-II Thought Disorder Rorschach TOOLS TO CONSIDER

42. 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 TOOLS TO CONSIDER

43. Anxious/Depressed Worries Somatic Complaints Thought Problems Functional Impairment Memory/Cognition Problems Irritable/Disinhibited OASR & OABCL: subtests

44. 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 TOOLS TO CONSIDER

45. 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 TOOLS TO CONSIDER

46. 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 TOOLS TO CONSIDER

47. Clinician rates 6 areas: Memory Orientation Judgment & Problem solving Community affairs Home & Hobbies Personal Care As to 5 levels of impairment: None(0), Questionable(0.5), Mild(1), Moderate(2) or Severe(3) Clinical Dementia Rating Scale (CDR ; Hughes et al, 1982)

48. Standard Clinical Interview Geriatric Depression Scale + somatic symptoms Mini Mental State Exam Clock Drawing MAST-G short form or CAGE CAM Medication review Medical conditions list ADL & IADL Client satisfaction questionnaire Possible Protocol

49. 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 Assessment Follow-Up

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