An Assessment Guide To Geriatric Neuropsychology

Holly Tuokko, Thomas Hadjistavropoulos

• Publisher: Psychology Press
• Year: 2014
• ISBN:
  9781135692384
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

At least half of all neuropsychological assessments are performed on elderly persons, but the information clinicians need to make appropriate judgment calls is widely scattered. Several books offering general descriptions of the cognitive functioning of the aged or of neuropsychological conditions affecting them are helpful to practitioners but do not provide reliable and valid normative information. Two books that do provide this information do not focus on geriatric populations. A concise, yet comprehensive summary of what we now know about those over 65--with an extensive bibliography-- An Assessment Guide to Geriatric Neuropsychology fills the gap. The neuropsychological assessment of elderly persons involves not only the performance-based measurement of various capacities but heavy reliance on reports from caregivers (both formal and informal) about the day to day functioning of the affected person. It also raises important, yet often neglected, ethical concerns. The authors discuss all the measures that detect and discriminate among cognitive disorders of elderly persons, including special measures relevant to caregiver reports, and provide useful tables to assist in differential diagnosis. They also reflect on the ethical issues that often confront the assessor of an elderly individual: informed consent, confidentiality, the right of bodily autonomy and self-determination, and appropriate feedback. This book will be an invaluable resource for all those called on to evaluate older clients.

Chapter 1
Issues in Psychogeriatric Assessment

The field of clinical neuropsychology is broad-ranging, covering diverse problems and populations. Although the field as a whole has experienced tremendous growth over the past two decades, one of the fastest growing areas within clinical neuropsychology is the assessment of persons over age 65, or geriatric assessment.

There are a number of reasons for this development. First, changes in the demographic structure of the North American population have been occurring over the last century such that larger and larger proportions of the population are living past age 65. A variety of factors, most related to improved health status, are contributing to this change. Improvements in public health (e.g., sanitation, sewage treatment, nutritional knowledge), the introduction of antibiotics and immunizations in the middle of this century, and the development of effective interventions for the leading causes of death (e.g., cardiac and cerebrovascular disorders and cancer) are all contributors to this demographic shift. Moreover, in the years following World War II, a record number of births were recorded in North America—the “baby boom.” These “baby boomers” are now moving toward age 65 and the consequences of the “graying of the baby boom” has been the source of much economic and political debate (e.g., Barer, Evans, & Hertzman, 1995; Denton & Spencer, 1995), particularly in the context of health and health-related issues.

Age-related changes have been documented in nervous system structure and function as well as other physical systems such as vision, hearing, gastrointestinal functions, and the musculoskeletal system (e.g., Birren, Sloane, & Cohen, 1992; Meneilly & Tuokko, 1994). These normal changes in biological, psychological, cognitive, and behavioral systems seem to occur at differing rates in different persons and result in increased variability on most measures of functioning with increasing age. Moreover, certain disorders or conditions appear correlated with age or occur commonly in older age groups. Comorbidity of physical illness and mental disorders (e.g., anxiety is often seen with cardiovascular, gastrointestinal, or pulmonary disease) is also more common in an aged population than in younger persons (Birren et al., 1992). Thus, distinguishing the anticipated effects of aging from the effects of diseases that are more prevalent with age within the context of comorbid processes is a very important and challenging task.

To fulfill their role, practitioners working with elderly persons require a comprehensive knowledge of processes associated with normal aging (gerontology), as well as a current understanding of the pathological processes associated with aging (geriatrics). Each of these areas has expanded rapidly, most notably since the early 1980s, and is continuing to grow with the realization of, and speculation as to, the impact of the demographic changes within the North American society. This book summarizes the areas of knowledge required to address issues specific to elderly persons. Although many of the principles of neuropsychological assessment presented elsewhere (e.g., Lezak, 1995) may be common to all client populations, the focus here is on the specific issues that may influence the choice of assessment techniques or interpretation of test findings for persons over age 65. Neuropsychological assessments are typically requested when brain dysfunction is suspected or known to exist. The assessment may focus primarily on concerns over diagnostic issues, documentation of change over time, or care planning and management of behavior.

The purpose of this book is to bring together the available normative information for persons over age 65 and to highlight the conceptual and methodological issues pertinent to the use of this information. For example, the variety of factors specific to the individual that may influence test performance or interpretation are raised in the remainder of this chapter. Definitions of what constitutes a normal sample and procedures for determining norms are discussed in chapter 2.

Factors Associated with the Aging Process

A number of issues specific to the population under investigation must be taken into consideration when selecting and interpreting psychological measures. These include the cognitive, physical, and social processes associated with normal aging.

Cognitive Processes

Cognitive and behavioral changes compatible with normal aging should not be misinterpreted as being indicative of abnormal or pathological change in functioning. Although this may seem obvious, it is extremely important that practitioners appreciate the complexity of this distinction. Diseases commonly manifested by elderly persons may be superimposed on normal age-related changes. Normal age-related changes influence not only the presentation of the disease, but the expectation of response to treatment and the likelihood of potential complications. Cognitive aging research has shed much light on the types of changes in functioning that occur with advancing age.

The introductions to chapters 4, 5, 6, and 7 address age-related expectations for various domains of cognitive functioning (i.e., intelligence, memory, attention, language, visuospatial, perceptual, and motor skills). Briefly, the most striking age-related changes observed in cognitive functioning include:

1. Measures dependent on motor speed (e.g., reaction time, tapping, etc.) are performed less well by older persons. Slowed mental processing appears as the most important component in the characteristic behavioral slowing associated with normal aging (Lezak, 1995). Hence, any task that contains decision points, initiation or redirection of movement may be slowed and will become particularly apparent when timed.
2. Measures of the ability to focus on a simple task and perform it without losing track of the task (e.g., Digit Span Forward) are performed well by most older adults (M. S. Albert, 1988).
3. Semantic knowledge changes significantly with age. Age-related declines have been shown on measures of naming (M. S. Albert, Heller, & Milberg, 1988; Borod, Goodglass, & Kaplan, 1980; Goodglass, 1980; La-Barge, Edwards, & Knesevich, 1986) and verbal fluency (i.e., generation of words within a time period; M. S. Albert et al., 1988; Obier & M. L. Albert, 1981; Spreen & Benton, 1969). These changes appear primarily after age 70 while other linguistic abilities appear to remain relatively intact (M. S. Albert, 1988).
4. Manifestations of changes in memory functioning are dependent on the type of memory task involved. The ability to retain small amounts of information over a brief period of time (once called short-term memory) shows hardly any loss with age (Talland, 1965). Secondary, or long-term, memory declines with age. The degree of loss is related to the type of material to be remembered and the assessment method. Large age-related declines are found in free recall (Botwinick & Storandt, 1974; Craik, 1977; Gilbert & Levee, 1971; Kausler & Lair, 1966). Decrements are larger for recall than for recognition of material (Erber, 1974; Harwood & Naylor, 1969; Howell, 1972).
5. Visuospatial ability, as assessed by complex visual reproduction and recognition tasks (e.g., Block Design, Figure Integration), declines as individuals age (Doppelt & Wallace, 1955; Wentworth-Rohr, Mackintosh, & Flalkoff, 1974). Similarly, drawing task performance (e.g., three-dimensional cube, clock face) also appear to decline with age (Plude, Milberg, & Cerella, 1986; Tuokko, Hadjistavropoulos, Miller, Horton, & Beattie, 1995). This seems to be true even when the speed components of the tasks are removed (Botwinick, 1977).
6. Abstraction and conceptualization have been assessed in a variety of ways many of which show age-related declines. Of particular interest is proverb interpretation, which shows substantial deterioration with age (M. S. Albert, 1988; Bromley, 1957).

This research emphasizes the need for normative information based on age. Norms can help determine what constitutes a change in functioning above and beyond age-related change. M. S. Albert (1981) noted “age-appropriate norms based on a systematic comparison between elderly normal and pathological populations do not exist for most behavioral tests of brain damage” (pp. 385-386). This situation has changed with the increasing demand for this information.

From the literature on age-related cognitive changes, issues concerning the appropriateness of various measures for use with older persons have been raised. The utility of many standard psychological measures for relating to the performance of everyday behaviors by older persons has been challenged and a need for more “ecologically valid” measures was identified. Moreover, it has been observed that elderly persons may perceive the measures as “meaningless” within the context of their lives and may be unwilling to take part in an assessment. This controversy has resulted in the recent development of measures incorporating real-life situations into the context of the assessment process (e.g., shopping list learning as part of a memory battery), thereby expanding the types of assessment tools available for this population.

Physical Processes

In addition to these age-related cognitive changes, there are a number of physical factors that might interact with, influence, or distort the clinical picture. Most notably, changes in sensory processes (i.e., vision and hearing) are common with increasing age and may significantly interfere with a person’s performance on measures of cognitive functioning. Most persons over age 60 experience some form of visual compromise (Fozard, 1990). Declines in hearing parallel those of vision and approximately 70% of persons in the 71- to 80-year-old age range suffer some hearing loss (Fozard, 1990). It should be noted, however, that even persons who are legally blind can perform well on many neuropsychological measures containing visual stimuli, because these stimuli are often large and clearly defined. Despite this, the clinician must be cognizant of the possible effects of vision and hearing loss on test performance and ensure that these influences have been controlled (e.g., ensure individuals wear their glasses or hearing aid; use of pockettalker to assist in communicating with hearing impaired) or compensated for by use of measures not dependent on the impaired sensory modality (e.g., use of a verbal measure of memory with a visually impaired person).

Another potential complication to test performance and interpretation when working with this population is the higher prevalence of medical problems than seen in younger individuals. Thus, in addition to normal changes in physiological functioning associated with age, the prevalence of a variety of medical conditions increases with age (e.g., diabetes, heart disease, arthritis). Many of these disorders may be related to observed cognitive impairment in older persons and become important within the context of differential diagnosis. For example, poor metabolic control in diabetics may greatly increase the risk of vascular complications, including retinopathy, nephropathy, and neuropathy (C. M. Ryan, 1988). Observed cognitive deficits may be a function of these micro- and macrovascular changes rather than suggestive of an additional disease process (e.g., Alzheimer’s disease). Too often, the role of existing medical disease in disrupting cerebral functioning is overlooked and deficits are attributed to other sources of cognitive impairment. Other disorders, such as arthritis, may limit performance on tasks requiring graphomotor skill or speed of performance, thereby complicating test interpretation.

A related issue is the potential effect of medications on test performance. It is not uncommon for elderly persons to be taking a variety of medications for comorbid disorders. Moreover, older persons have increased sensitivity to medications due to altered abilities to metabolize and excrete medications (e.g., Birren et al., 1992). As drug sensitivity and interactions are often specific to individuals, the potential complicating role of medications must be kept in mind. Thus, it is extremely important to determine the medications a person is taking at the time of the assessment, as well as the dosages. The most effective way to accomplish this is to have the person or a family member bring in all medications for review. It may be necessary to count the tablets to ensure that medications are being taken as prescribed. Inappropriate use of prescription (and nonprescription) medications may contribute to the clinical presentation and needs to be addressed. Noncompliance with medication regimes may result from an inability to monitor the medications due to memory deficits rather than unwillingness to comply. To ensure optimal functioning, it may be necessary to monitor the individual’s performance as medications are introduced or withdrawn.

It is common knowledge that older persons, particularly those with medical problems, may tire easily. Hence, to obtain an estimate of maximal functioning, it may be necessary to limit the length of testing sessions or provide frequent breaks during the testing. This may be done by making it clear to the person that rest breaks are available as needed, or checking with the person at intervals during the assessment as to the need for a break. Increasing agitation or withdrawal from responding may signal that a rest break, or redirection to casual conversation, is warranted. For persons who are very frail, such as those in care facilities, it may be necessary to schedule several sessions to obtain a person’s optimal performance. Examination of test results in the context of the order of administration may be of assistance, if there is any concern that the person was fatigued by the assessment process. If there appears to be marked variability between the first and last measures administered, then it may prove beneficial to readminister the latter ones on another occasion to ensure fatigue was not the source of the difficulties. It is also important to view the tendency toward fatigue within the context of the person’s activities of daily living. An individual who cannot sustain enough focused attention to complete a 30-minute assessment procedure may have great difficulty performing daily activities when living alone in the community. Similarly, individuals living in a care facility cannot be expected to successfully take part in group recreational activities if they are unable to complete a simple mental status examination without becoming unduly fatigued.

Social Processes

When assessing older persons, the social context of the individual must be kept in mind. Although this is true when conducting neuropsychological assessments at any age, issues specific to older persons center around social change, loss, and the context of the psychological assessment. Retirement may be a major adjustment for some persons and can result in profound feelings of loss and isolation. Change of residence may result in loss of friends and family, social supports, or a sense of belonging. It is common for older persons to have friends and family members who have recently died or are ill. Certainly grieving and bereavement are processes with pervasive effects on a person’s functioning. Alternatively, the death of a spouse or caregiver may bring to light the poor cognitive functioning of the remaining partner, which, in the context of the struggle to assume new roles, comes to the attention of others.

Financial limitations and/or sociocultural issues may also complicate the clinical picture and need to be considered in the context of differential diagnosis and planning care. Many persons of this age cohort may lack familiarity with the types of assessment procedures conducted by neuro-psychologists, and fear of loss of ability or independence may complicate the assessment process. Careful explanations as to the intent and purpose of the assessment may be required to ensure maximal performance.

Purpose of the Assessment

Diagnosis

A neuropsychological assessment may be requested for a variety of reasons. Often, diagnostic issues are of primary concern. Identification of dementia is perhaps the most common referral issue in this age group. Dementia may be defined as an overall decline in mental capacity (one or more cognitive domains) that renders the individual unfit to meet the diverse intellectual demands associated with the obligations of everyday life. Within this diagnostic category, there may be a wide variety of individual patterns of cognitive disability. Dementia has been subclassified in a variety of ways: according to most prominent cognitive features (e.g., amnesic, aphasie, visuoperceptive, global), according to anatomical location (e.g., cortical, subcortical, axial; Joynt & Shoulson, 1979), according to reversibility of the underlying etiologic condition (reversible conditions may include Normal Pressure Hydrocephalus, drug toxicity, thyroid dysfunction, neurosyphilis, B12 deficiency, liver failure; irreversible conditions may include Alzheimer’s disease, vascular disorders, alcohol-related dementia, Huntington’s disease, Parkinson’s disease, Amyotrophic Lateral Sclerosis), and severity of functional deficits (i.e., mild, moderate, severe).

In addition to identifying cognitive impairment (i.e., greater than normal age-related decline), it is necessary to differentiate possible dementia from other common disorders affecting older persons. These include depression, acute confusional state, and cognitive changes associated with a variety of remediable medical conditions. Moreover, it is possible that there may be more than one condition present. For example, it has been noted that depress...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Preface
• 1 Issues in Psychogeriatric Assessment
• 2 Psychometric Issues
• 3 Screening Instruments for Cognitive Impairment
• 4 The Wechsler Adult Intelligence Scales
• 5 Measures of Intellectual Functioning and Neuropsychological Batteries
• 6 Memory Assessment
• 7 Attention and Executive Functioning
• 8 Language, Visuospatial, Perceptual, and Motor Functioning
• 9 Assessing Psychopathology
• 10 Age-Associated Conditions Affecting Cognition
• 11 The Role of the Caregiver in Neuropsychological Assessment
• 12 Ethics in the Assessment of Elderly Persons
• References
• Author Index
• Subject Index