Geriatric Neuropsychology Implications For

8/17/2019 Geriatric Neuropsychology Implications For

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NeuroRehabilitation 23 (2008) 381–394381IOS

Press

Geriatric neuros!cholo"!# I$lications %or %ront line clinicians

&hristina 'e!er a$oraa ,∗ Ronal* +, Ru%% b an*

-onnie -, &onnor ca San Francisco Clinical Neurosciences, San Francisco General

Hospital, San Francisco, CA, USA b San Francisco Clinical Neurosciences, University of California San Francisco, San Francisco, CA, USAc University of San Francisco, San

Francisco, CA, USA

Abstract, &onsistent .ith the a"in" oulation neuros!cholo"ists are bein"

as/e* .ith increase* %reuenc! to ealuate ol*er a*ults, hese assess$ents are

o%ten co$licate* b! $e*ical an* s!chiatric co$orbi*ities ol!har$ac! an*

co$le s! chosocial an* le"al issues that are %reuentl! encountere* in this

oulation, he ai$ o% this reie. article is to a**ress the chal len"esneuros!cholo"ists an* other %rontline clinicians o%ten con%ront .hen ealuatin"

ol*er in*ii*uals, Seci%icall!) .e reie. s!chiatric an* $e*ical co$orbi*ities

testin" acco$$o*ations *ia"nostic ersus *escritie testin" aroaches

nor$atie issues ol!har$ac! an* rei$burse$ent rates, 5inall! %uture

i$lications are *iscusse* %or a*ancin" the neuros!cholo"ist6s role in

ealuatin" an* treatin" ol*er in*ii*uals,

7e!.or*s# Geriatric neuros!cholo"!assess$ent an* treat$ent challen"es

1. Introduction

In the nite* States ol*er

in*ii*uals are the %astest "ro.in"se"$ent o% the oulation .ith 20 o% these ol*er :$ericans eeriencin"

so$e t!e o% $ental *is or*er ;20 !ears o% a"ean* ol*er hae so$e t!e o% *e$entia;?0= :s a result s!cholo"ical

national an* state a"encies haeencour a"e* s!cholo"ists to *eeenan* eten* their eist in" /no.le*"e

base an* clinical eertise to inclu*ethis oulation, he :$ericanPs!cholo"ical :ssocia tion (:P:) has

*eeloe* "ui*elines %or s!cholo"ical

ractice .ith ol*er a*ults that a**ressthe s!cholo "ist6s attitu*es "eneral/ l * b t * lt * l t


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consultation ;>=, +an! s!cholo"! in

ternshi ro"ra$s no. o%%er rotationsin "eriatric s! chiatr! an* ost*octoral %ello.shis in "eros!cholo

∗:**ress %or correson*ence#&hristina 'e!er a$ora 909 @!*e

Street Suite ?20 San 5rancisco &:94109 S:, el,# A1 41< >>1

>833B 5a# A1 41< 922


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12? C.W. Jamora et al. / Geriatric neuropsycholoy! "mplications for front line clinicians

are raise* b! rei$burse$ent

li$itationsF an* () @o. can .ea*ance our %uture sericesF

#.#. Can psychiatric illnesses, in

particular $epression,

e%acer&ate or cause conitive

$eficits'

:l$ost one uarter o% in*ii*uals

oer the a"e o% >=, Seci%icall! in ol*er in*ii*uals

it has been esti $ate* that 10–30=, Gi en

the realence o% these s!chiatric

*isor*ers $ost re%erral uestions are

best a**resse* b! a**in" a s!

cho*ia"nostic ealuation co$onent

to the co"nitie assess$ent,: stu*! b! 5eil an* collea"ues %oun*

that ol*er in*ii*uals .ith s!chiatric *ia"noses

hae increase* le els o% aath! an**eression an* *e$onstrate slo.e*

e* to co"nitie in%leibilit!) *ecrease*

.or* "eneration an* *i$inishe*abstract reasonin" ;2>=, hese %in*

in"s su""est that as the seerit! o% the

s!chiatric *is turbance increases the

e%%ect on co"nition can beco$e $ore

ronounce*, Other research %in*in"s

su""est that the clusters o% co"nitie

*e%icits $a! *i%%er *een*in" uon the

nature o% the s!chiatric illness, 5or

ea$ le a%ter controllin" %or $e*ical bur*en atients *ia" nose*

.ith "eneraliEe* aniet! *isor*er .ere

%oun* to hae *e%icits in attention as

.ell as short an* lon" ter$ $e$or!

;32=, In co$arison in*ii*uals .ith

$aor *eression also *e$onstrate*

*e%icits in attention an* $e$or!) .ith

co$ro$ise* .or* %in*in" abilit!

see* o% rocessin" an* "lobalco"nitie %unctionin" also note*

;32


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C.W. Jamora et al. / Geriatric neuropsycholoy! "mplications for front line clinicians 12>

the aailabilit! o% s!chosocial

suort are t.o seci% ic areas that

shoul* be %ull! elore* .hen

assessin" *eression in ol*er

in*ii*uals ;14=,

#.(. What testin accommo$ations

yiel$ the most &enefit for ol$er

in$ivi$uals'

&linical eerience coule* .ith an

aroriate a reciation o% e$er"in"literature roi*es an aenue %or

i*enti%!in" .a!s to a*at

neuros!cholo"ical tests to $eet the

nee*s o% ol*er a*ults, here are three

basic cate"ories that $a! reuire

a*atation o% testin" ro ce*ures# (a)

the atient6s h!sical status (b) co"ni

tie li$itations an* (c) s!cholo"ical

status, Seere $otor (e,", *!sarthriahe$ile"ia) an* sensor! li$ita tions

(e,", blin*ness *ea%ness) o%ten reuire

clinicians to a*$inister tests that rel!

on the atient6s resere* abilities,

Si$ilarl! so$e ol*er a*ults $a!

%ati"ue eas il! an* it is reco$$en*e*

that rest brea/s be roi*e* *urin" the

ealuation as nee*e*, :lso it $a! be

bene %icial to co$lete testin"sessions in the $ornin" hours an*Hor

*ii*e the testin" u oer seeral *a!s,

:*ata tions %or co"nitie li$itations

$a! be $ost ronounce* %or

in*ii*uals .ith non%luent ahasia

an* in these in stances a*atie

techniues such as icture boo/s $a!

be use%ul, :cco$o*ations $a! also

be bene%icial to alleiate *e%icits inco$rehension see* o% co"nitie

article b! &alan an* Shechter in this

secial issue o% Neuro)eha&ilitation

%or a thorou"h reie. o% testin"

acco$o*ations %or ol*er a*ults,In co$arison to these h!sical an*

co"nitie a*atations s!cholo"ical acco$o*ations

are %reuentl! not consi*ere* *urin"

the ealuation rocess, It is i$

ortant to re$e$ber that $an! ol*er

in*ii*uals $a! %eel threatene* b! the

assess$ent rocess, Cseciall! .henthe intent o% the re%erral is to a**ress

their abil it! to *rie han*le their

%inances lie in*een*entl! an*Hor

*eter$ine their nee* %or suortie

interen tions, hese t!es o% re%erral

uestions $a! cause a tients to

re%use articiation or re$aturel!

ter$inate the testin" session,

In%or$e* consent is central to resectin" a atient6s autono$! an*

ri"hts) an* neuros! cholo"ists are

encoura"e* to i*enti%! an* a**ress

an! uestions or atient concerns

u%ront,he therapeutic assessment mo$el

%ro$ the s!cho*ia"nostic assess$ent literature

roi*es an e% %ectie aroach to

assessin" ol*er in*ii*uals ;28– 30=, heraeutic assess$ent is

co$li$entar! to stan *ar*

assess$ent ractices an* rooses that

assess$ent


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is $ore than ust an in%or$ation

"atherin" eercise, Rather it can be

ie.e* as an oortunit! %or atients

to co$e to a ne. un*erstan*in" about

the$seles an* their li%e

acco$lish$ents, In articular) ol*er

in*ii* uals %reuentl! ie. their

lies on the basis o% ast ac

co$lish$ents, his is un*erstan*able

since a %or.ar* loo/in" ersectie

$a! be $ar/e* .ith uncertaint! a

ro"ressie *ecline in health chronic

ain an* loss, he clinician $ust be

sensitie to the *eelo$ental state o%

the ol*er in*ii*ual .hich Cri/son

*escribes as the sta"e o% "nterity

versus *ispair ;2?=, hus the

neuros!cholo"ical ealuation shoul*

allo. %or ol*er in*ii*uals to reie.

their li%e acco$lish$ents .hilst

co$in" to ter$s .ith ro$inent

ne"atie eents the! hae

eerience*,

he theraeutic assess$ent

aroach laces stron" e$hasis on

inte"ratin" theraeutic s/ills such as

re sect trust "enuine enthusiastic

curiosit! an* collab oration into the

stan*ar* asses$ent, he $aor

co$o nents o% the theraeutic

assess$ent $o*el inclu*e (a) treatin"

the atient as a collaborator (i,e, Jlets

%in* out these ans.ers to"etherK)B (b)

a**ressin" the atient6s ersonal

concernsB (c) "iin" %ee*bac/ that is

tie* to the atient6s eer!*a!

%unctionin" an* concernsB an* (*)

%ollo.in" u .ith a letter outlinin" the

assess$ent %in*in"s usin" the atient6s

the theraeutic assess$ent aroach,

:n ol*er in*ii* ual .as re%erre* %or a

neuros!cholo"ical ealuation o% her

%unctional status, 'hile the ealuation

su""este* that the atient .as unable

to lie in*een*entl! she %ir$l!

re%use* inho$e nursin" care, his

.as artic ularl! .orriso$e since her

chil*ren lie* out o% state an* the!

.ere unable to roi*e suort or

sueri sion to their $other, Lurin"

the %ee*bac/ session the atient6s

concerns about losin" her

in*een*ence .ere i*enti%ie*, It also

beca$e clear that .hile she .ante* to

lease her %a$il! she resolutel! %elt

that inho$e care .as unnecessar!

because she beliee* she ossesse* no

co"nitie i$air$ents, he atient6s

concerns .ere re%ra$e* b! %ocusin"

on her li%eti$e achiee$ent o% hain"

been a "oo* $other an* that her

chil*ren .ere .orrie* %or her .el%are,

he inho$e suort subse uentl!

.as ie.e* as Ja "i%t o% eace o% $in*

to her chil*renK .hich .as con"ruent

.ith her lon" hel* al ue that the role

o% a $other is to sacri%ice %or the sa/e

o% her chil*ren,C$otional acco$$o*ations can be

utiliEe* to ali"nourseles .ith our atients b!

ac/no.le*"in" their *i% %iculties

re"ar*less o% our abilit! to hel an*

rais


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in" the$ %or their o.n e%%orts to

enhance their sense o% .ellbein" an*control ;


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$ost eerience* neuros!cholo"ist,

o re*uce *ia" nostic errorsclinicians shoul* strie to %in* .a!s to$easure the *!na$ic relationshi

bet.een co"nition an* $ultile*isease states, Since etensieneuros! cholo"ical testin" is o%tencontrain*icate* .ith these atients it

is i$ortant to hae a clear un*erstan*in" o% the si"ns associate*.ith reersible ersus nonre ersible

$e*ical *iseases, hus consultin".ith $e* ical sta%% as nee*e* an*reco"niEin" the li$itations o% our

co"nite assess$ents $a! be .a!s toincrease our *ia"nostic accurac!,'hile it is not .ithin our scoe o%

ractice to *ia"nose $e*ical *iseasessuch as car *ioascular *isease or

*iabetes .e shoul* asire to un*erstan* ho. $ultis!ste$ *iseases

in%luence the co" nitie an*e$otional %unctionin" o% our atients,&ol laboration an* consultation .ith

$e*ical ro%essionals can enhance our ealuations an* ro$ote accurate conclusions about atients .ho are

eeriencin" $ultile $e*ical

con*itions,'hen assessin" ol*er in*ii*uals

.ith $ultile $e* ical con*itions the%ollo.in" uestions shoul* be consi*ere*#

1, 'hat $e*ical *ia"noses areactie at this ointF

'hat are the atient6s chronic$e*ical *iseasesF 'hat is the

seerit! an* len"th o% these*iseasesF Is the atient

'hile is it not necessar! to $aster

the nuances o% $e*ical laborator!tests it is i$or tant to as/ $e*ical roi*ers the etent to

.hich our atients are$etabolicall! an* he$o*!na$icall! stable) an* the etent to

.hich these *iseases $a! bein%luencin" their *ail! %unctionin",

2, I% the atient is con%use* .hatis the *uration an* ualit! o% his

or her $entation (i,e, acute ersuschronic .ain" an* .anin".orse in the eenin")F Is the

onset recent or rolon"e*FLeliriu$ is co$$on in ol*er in*ii*uals, Prior to testin" it $a!

be necessar! to consult .ith there%errin" h!sician to rule out

$e*ical instabilit! in the%ollo.in" areas# $etabolic

o!"enation ascular en*ocrine)seiEures tu$or trau$a ure $ia

s!chiatric in%ection $e*ications

an* *e "eneratie *iseases,3, @as the atient recentl! %allen orha* a histor!

o% %alls in the ast an* i% so .as

brain i$a"in" or*ere*F Loes the atient hae a stea*! "aitF Is the

atient incontinent or hae urinar!ur"enc!F 5alls are co$$on inol*er a*ults an* are the $ost

%reuent $echanis$ o% trau$atic brain inur! in this oulation;10=, In articular the co$bina


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tion o% unstea*! "ait hi"h

anticholiner"ic bur*en an* urinar!ur"enc! can reciitate %alls ;1=, Itis i$ortant to note that $an! %allsin nursin" ho$es are not .itnesse* b! sta%% an* a"e associate* cere bral atroh! can allo. bloo* an*cerebrosinal %lui* to collect to asi"ni%icant *e"ree be%ore $asse%%ect causes neurolo"ical chan"es;39=, Si$i larl! nor$al ressureh!*rocehalus secon*ar! to asub*ural he$ato$a $i$ics*e$entia ;39=, 'hen atientseerience ersistent con%usionhea*aches) an* loss o% consciousness %ollo.in" a %all

brain i$a"in" $a! be nee*e* torule out the ossibilit! o% asub*ural he$ato$a,

:*$itte*l! obtainin" ans.ers to allo% the aboe uestions is o%tenunrealistic in settin"s .here sta%% ti$eis si"ni%icantl! li$ite* an* recor*s aresarse, :lter natiel! in*ii*uals%a$iliar .ith the atient such as%a$il! $e$bers) %rien*s) care"iers)an* sta%% $e$bers can o%ten be use%ulsources o% collateral in%or$ation, Ina**ition) the atient6s list o% $e*ications an* resec tie *osa"escan be inaluable in ter$s o% orientin"the clinician to the atient6s $aor $e*ical illnesses,

O%ten neuros!cholo"ists $a! %ocus ri$aril! on

co"nitie *e%icits) secon*aril! one$otion) an* to a less er etent on

h!sical %unctionin") .ith li$ite*inte"ra tion o% these three areas,Oerl! co$art$entaliEe* *i a"nostic

har$ the atient, 5or ea$le it

.oul* be short si"hte* o% aneuros!cholo"ist) on the basis o% seerl! i$aire* co"nitie *e%icits to*ia"nose an ol*er in*i i*ual .ith*e$entia .hen it is subseuentl!*isco ere* that the atient .as*eh!*rate* an* their con%usionsubsi*e* a%ter their .ater inta/eincrease*, his e a$le is articularl! co$$on in nursin"ho$es .here there is little aailablecollateral in%or$ation) %e. $e* ical

ro%essionals .ith .ho$ to consultan* hi"h sta%% to atient ratios as .ellas %reuent sta%% turnoer, he

atient6s $e*ical acuit! li$ite*$e*ical recor*s an* ti$e constraintsalso can li$it the accurac! brea*than* *eth o% our assess$ents,

:*$itte*l! it is *i%%i cult to achieea balance* aroach that "ies oiceto the atients6 h!sical co"nitiean* e$otional %unc tionin" relatie totheir social an* cultural %unctionin",@o.eer /eein" these issues in $in*can re*uce our ten*enc! to %all icti$to *ia"nostic it%alls,

#.-. What effects $o me$ications or polypharmacy have on the

patients mental status'

:s eole a"e the! ten* to be rescribe* $ore $e* ications ;4


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$e*ications ;19= an* eerience

$ore a*erse *ru" reactions an*hositaliEations secon*ar! to

ol!har $ac! ;31=, Leen*in" on

the settin" ol*er in*ii*u als onaera"e $a! ta/e an!.here %ro$ %our to 10 or $ore $e*ications *ail!;31>2=, :lso it is note.or th! that

$e*ication nona*herence rates inol*er a*ults ran"es %ro$ 2?–8= .hich can lea* to $e*i cal

*eco$ensation) unnecessar!hositaliEations an* *eath ;31=,

Phar$aco*!na$ics re%ers to Jthe

e%%ects o% a *ru"K .hile har$aco/inetics re%ers to Jthe$oe$ent o% a *ru" throu"h the

bo*!K ;42 , ?30=, :s an in*ii*uala"es %actors such as *ecrease*

"astrointestinal bloo* %lo. increase* orosit! o% the bloo* brain barrier re

*uce* bloo* circulation increase* bo*! %at co$osi tion altere* cell bin*in" re*uce* heatic an* renal e%

%icienc! an* en*o"enousneurotrans$itter *ecline can lea* toalterations in the $etaboliEation

*istribution absortion an* ecretion

o% *ru"s ;?42=, :s outline* in able1 benEo*iaEeines *iuretics

narcotics non steroi*al antiin%la$$ator! an* anticholiner"ic$e*i cations $a! be articularl!

*etri$ental to the co"nitie%unctionin" o% ol*er a*ults,

nnecessar! ol!har$ac!

co$$onl! occurs in the ol*er a*ult

oulation, One stu*! %oun* that 44o% ol*er in*ii*uals .ere rescribe* at

use o% unnecessar! $e*ications is

articularl! roble$atic in ol*er in*ii*uals, :ccor*in" to the:$erican +e*ical :ssociation &ouncil

on Scienti%ic :%%airs JPol!har $ac!is roble$atic %or ol*er ersons

because it is the "reatest ris/ %actor %or :LRs (a*erse *ru" reactions) *ru"

interactions re*uce* co$liance an*increase* e$er"enc! roo$ isitshositaliEations an* nursin" ho$e

a*$issionsK (ara, 0 o% ol*er in*ii*uals *o not in%or$their h!sicians .hen usin" *ietar!

sule$ents .hich can ne"atiel!inter act .ith $e*ications, heintereste* rea*er is re%erre* to

GonEaleE an* collea"ues %or a *etaile**iscussion o% the i$lications

associate* .ith *ietar! suli$ent usea$on" the el*erl! ;3


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:brut $e*ication chan"es an*

$e*ication non a*herence canlea* to *eliriu$ in ol*er in*ii*

uals, 5or atients .ith $ultile

an* s!chiatric roi*ers the

neuros!cholo"ical reort can be

a central *ocu$ent hi"hli"htin"

.ho is rescrib in" .hat, It $a!

be hel%ul to consult .ith er

tinent $e*ical roi*ers to see i%

the nu$ber o% $e*ications can bestrea$line*,

2, 'hat $e*ications *i* the atient

ta/e rior to the assess$entF

I*eall! clinicians shoul* be

a.are o% .hat $e*ications the

atient too/ rior to the

assess$ent an* .or/ .ith a

har$acist or h!si cian to

ascertain the *e"ree to .hich$e*ica tion e%%ects coul*

in%luence testin" er%or$ance,

Phar$aco/inetic in*icators such

as $e*ication hal%li%e an* ea/

absortion ti$e can be hel%ul in

this re"ar*,

#.. What effect $oes pain

have onneuropsycholoical

performance'

:roi$atel! 80 o% nursin" ho$e atients an*


11/33

abl

e 1+e*ications that $a! hae co"nitie

e%%ects in ol*er in*ii*uals

Lru" class +e*ications In*ication Si*e e%%ects :*erse behaioral$ani%estations

:nticholinerics Litroan Letrol Incontinence:nticholiner"ic e%%ects &on%usion

:ntihista$ines -ena*r!l istaril SleeSe*ation anticholiner"ic &on%usion a"itation e%%ects

urine retention *eliriu$

:ntis!chotics @al*ol !rea :"itation Ps!chosis:/athisia h!otension Increase* %all ris/

*ue h!otension Riser*al Serouel orthostatic

anticholiner"ic con%usion restlessness 5L: has asi*e e%%ects heart arrh!th$ias blac/

bo .arnin" on the use o% antis!chotics .ith

ol*er in*ii*uals *ueto increase* ris/ o%stro/e an* car*iac

arrh!th$ias

-enEo*iaEeines :tian Sera :niet! +otor slo.in"Increase* %alls *eliriu$ $a! haealiu$ ana *i$inishe* $otor .ith*ra. s!$to$s

i% *iscontinue* coor*ination se*ationabrutl! lon" actin"

are articularl!inaroriate

Liuretics Masi :l*actone @!ertension %lui* loa* inClectrol!te i$balance &on%usion an* %alls secon*ar! to@!*rochlorothiaEi*e &on"estie @eart 5ailure *eh!*ration

*eh!*ration %lui* olu$e loss hiaEi*e

Narcotics +orhine ico*in Pain Se*ation&on%usion

%allsMoritab Le$erol


12/33

In%la$$ator!

*iseasesSelectie Serotonin Pail Leression @i"h anticholiner"ic

ro%ile &on%usionReuta/e Inhibitors

ric!clic Clail o%ranil Leression Pain @i"h anticholiner"ic ro%ile Increase* %alls relate* to orthostatic:nti*eressants Nortrit!line

h!otension &on%usion

:*ate* .ith er$ission %ro$ (@unter Q &!r 200?),

*ii*uals has ne"li"ible e%%ects on

neuros!cholo"ical test er%or$ance

;1149=,It can be *i%%icult to assess ain in

atients .ithneuros!cholo"ical i$air$ent, 5or

ea$le atients .ith co"nitie

i$air$ents such as *e$entia or

aha sia $a! be unable to articulatethe seerit! o% their ain, he! also

$a! hae re*uce* ain *etection *ue

to slo.e* cortical rocessin" ;?2=,

Neuros!cholo"ists $a! nee* to

e*ucate %a$il! care"iers) an* sta%%

$e$ bers .ho .or/ .ith ol*er a*ults

.ho are eeriencin" co"nitie

*!s%unction or eressie lan"ua"e

*i%%icul ties about nonerbalin*icators o% ain, : listin" o%

co$$on ain behaiors in ol*er a*ults

.ith co"nitie i$air$ents is

roi*e* in able 2,In ter$s o% clinical issues it isi$ortant to assess

the location %reuenc! *uration

ualit! intensit! as .ell as reliein"

an* eacerbatin" %actors associate*.ith the atient6s ain eerience

;40= It is also hel %ul to elore

an* .hat their /no.le*"e eec

tations an* belie%s are re"ar*in" ain

$ana"e$ent an* control ;40=,

:ssess$ents o% e$otional %unction

such as *eression an* aniet! shoul*

be incororate* as


13/33

.ell, Mastl! there are o%ten tra*eo%%s

.hen testin" ol* er in*ii*uals .hoare in seere ain, 5or ea$le a

reoccuation .ith ain $a!

co$ro$ise attention an* sta$ina, In

these instances it $a! be ru*ent to

ostone testin" until their ain is

better controlle*, O% course i% a

atient6s ain is bein" ina*euatel!

treate* or oerloo/e* the

neuros!cholo"ist shoul* collabo rate.ith $e*ical roi*ers to ensure that

the atient6s ain is aroriatel!

assesse* an* treate*,

#.0. What role shoul$ norms

play in our test selection'

he utilit! o% neuros!cholo"ical

assess$ent lar"el! *een*s on

nor$atie *ata, It is essential that

clini cians are aroriatel!

acuainte* .ith the ualit! an*

uantit! o% aailable nor$s, :s

*ia"nosticians a *is tinction shoul* be

$a*e bet.een re%erral uestions that

are $ianostic in nature an* those that

are $escriptive. Lescritie re%erral

uestions %ocus on ho. an in*i i*ual

is %unctionin" co"nitiel! relatie to

the aro riate re%erence "rou,

hus nor$s %or this urose usuall!

rel! on the "eneral oulation as the

re%erence stan*ar*, hat is the

in*ii*ual6s test er%or$ance is


14/33

abl

e 2&o$$on ain behaiors in ol*er a*ults .ith co"nitie i$air$ent

5acialeression

s

– Sli"ht %ro.nB sa*%ri"htene* %ace

– Gri$acin" .rin/le*

%orehea* close* orti"htene* e!es

– :n! *istorte*eression – Rai* blin/in"

-o*!$oe$ent

s

– Ri"i* tense bo*! osture "uar*in"

–

5i*"etin"

– Increase* acin"roc/in"

– Restricte* $oe$ent – Gait or $obilit!

chan"es

+ental status chan"es

– &r!in"or tears

– Increase* con%usion –

Irritabilit!

ocaliEationsHerbaliEations

– Si"hin" $oanin" "roanin" – Gruntin" chantin" callin" out – Nois! breathin" – :s/in" %or hel – erball! abusie

&han"es in interersonal interactions

– :""ressie co$batie resistin" care – Lecrease* social interactions – Sociall! inaroriate *isrutie – 'ith*ra.n

&han"es in actiit! atternsHroutines

– Re%usin" %oo* aetite chan"e –

Increase* erio*s o% restin" – Increase* slee – Su**en cessation o% co$$on routines – Increase* .an*erin"

:*ate* .ith er$ission %ro$ :$erican Geriatric :ssociation(200>)


15/33

$e$or! score o%

8< neither rules in nor rules out the*ia"nosis o% brain i$air$ent,In contrast to the *escritie

aroach the *ia"nos tic re%erralraises the uestion o% .hether or not

an in *ii*ual is i$aire*, In*ee**ia"nostic assess$ents %ollo. the

atho"no$onic si"n aroach ;20=,

hus re$orbi* %unctionin" beco$esthe re%erence stan*ar* .ith theneuros!cholo"ist char"e* to

*eter$ine i% the atient6s testin" er%or$ance *eiates %ro$ eecte* re$orbi* leels o% %unctionin", In

this contet test er%or$ance ischaracteriEe* as JIntactK ersus J+il*l! I$aire*K) J+o*eratel! I$aire*K)

or JSeerel! I$ aire*,K @o.eerthese scores or labels b! the$seles*o not i*enti%! abnor$al er%or$ance,: score in the

10th or een


16/33

o% such $easures inclu*e the

:lEhei$er6s Lisease :s sess$entScale ;?


17/33

#.2. What are the strenths an$

ea3nesses of $escriptive

norms'

he ractice o% clinicalneuros!cholo"! is stron"l! roote* in

s!cho$etric assess$ent, Gien that

.e re l! heail! on nor$s it is*isaointin" that nor$atie sa$les%or ol*er in*ii*uals hae historicall!

been in su%%icient, Si$ilarl! -ushan* collea"ues hae note* that $an!nor$atie sa$les hae been stitche*to "ether %ro$ control "rous that

.ere recruite* to $atch seci%icresearch roect ara$eters ;10 or 80,2, Since $ost tests roi*e $ultilescores) .hich o%

these test scores are nor$all!*istribute*F Note that $an! error

scores or ratio scores are not nor$all! *istribute*,

3, Is the test base* on a census$atche* sa$leF

I% not is the sa$le *erie* %ro$

one or $ulti le "eo"rahicre"ionsF 'hat *e$o"rahic %eatures are un*erreresente* an*.hat e%%ect $i"ht this haeF 5or

ea$le is the atient6s ethnicit!a*euatel! reresente*F

4, 'hat *e$o"rahic strati%ications

.ere use* %or e*ucation "en*eran* a"eF


18/33


19/33

the R-:NS has accetable testretest

reliabilit! %or the "lobal score this

reliabilit! is uestionable %or arious

subtests or in*e scores ;?3=,

Si$ilarl! research has sho.n that the

&o"nistat can lea* to hi"h $isclassi

%ication rates i% one relies on the

subtests rather than the total score ;?=,

5actor anal!tic research .ith ol*er

a*ults !iel*e* a unitar! %actor structure an* this sin"le co$osite

score .as sho.n to be $ore caable

o% *e tectin" co"nitie *e%icits in

ol*er in*ii*uals in reha bilitation

"rous ;?=, hus clinicians shoul* be

cau tious .hen ren*erin" conclusions

on arious subtests o% these batteries,

'hen interretin" *ia"nostic test

nor$s the %ollo. in" uestionsshoul* be consi*ere*#

1, On .hich clinical oulations

.as the *ia"nostic test ali*ate*F

('as the test *esi"ne* to *ia"nose

:lEhei$er *isease or *i%%erentiate

a$on" *i%%er ent *e$entias such

as :lEhei$er6s) @untin"ton6s or

Par/inson6s *iseaseF)2, 'hat stan*alone subtests .ithinthe batter! hae

accetable testretest reliabilit!F

(+ost o%ten these subtests hae

too %e. ite$s to !iel* accet able

testretest reliabilit!B ho.eer

the "lobal scores $a! be $ore

use%ul in ter$s o% *ia"nostic

ali*it!,)3, I% the *ia"nosis is /no.n base*

on neurolo"i cal or $e*ical

to allo. %or re liable assess$ent

"ra*ations to cature co"nitie

chan"es oer ti$eF

#.5. For most referrals is a

6u%taposition of a $escriptive an$

$ianostic approach calle$ for'

Generall!) .hile re%erral sources are

intereste* in *i a"nostic issues ;>?=their concerns usuall! eten* .ell

be!on* that ;23


20/33

he *ia"nostic an* *escritie

aroaches are not $utuall!eclusie but rather can be blen*e*

%or cer tain re%erral uestions, I% the

re%erral source .ants the

neuros!cholo"ist to *eter$ine i% the

atient6s co"ni tie *ecline $eets the

criteria o% $il* co"nitie i$air $ent

ersus *e$entia then a *ia"nostic test

shoul* be selecte*, @o.eer %or

$ost other etiolo"ies such as cerebralascular acci*ent trau$atic brain

inur! $ul tile sclerosis

Par/inson6s *isease $enin"itis or

other brain in%ections an* intracranial

tu$ors a *escritie aroach shoul*

be use*, In other .or*s i% the *ia"

nosis o% the neurolo"ical illness is not

in uestion but the re%erral is ai$e* at

un*erstan*in" the *e"ree o% i$ air$ent then a *escritie test

$easure is re%erable to cature the

"ra*ations o% *ecline, he latter is

es eciall! i$ortant .hen

establishin" a baseline a"ainst .hich

chan"e can be $onitore* oer ti$e as

.ell as ascertainin" co"nitie

stren"ths an* .ea/nesses that la! a

role in care lannin",Selectin" the $ost %ittin"neuros!cholo"ical test

batter! is *rien b! the re%erral

uestion an* the a tient6s

s!$to$atolo"! .ith neurolo"ists

bein" our $ost ro$inent re%erral

source ;>3=, In or*er %or neu

rolo"ists to continue to alue our

uniue contribu tion .e $ust

un*erstan* an* ta/e into account their nee*s, he :$erican :ca*e$! o%

cate"oriEe* these seen re%erral

uestions into either *escritie*ia"nostic or a co$bination o% both,:s *eicte* in able 3 ure*ia"nostic re%errals to

neuros!cholo"ists are relatiel! rare

ho.eer) our *e scritie nor$s %or

ol*er in*ii*uals re$ain ina*euate

co$ro$isin" our abilit! to ans.er

re%erral uestions in a soli* $anner,

Ph!sicians *o not usuall! *een* on

neuros!cholo"ists to *ia"nose acerebroascular acci*ent or trau$atic

brain inur!B instea* the! utiliEe

clinical histor!) labs an* neuroi$a"in"

to buttress their *ia"nostic

i$ressions, Neuros!cholo"ists can

be the $ost hel%ul in *eter$inin" an

in*ii*ual6s co"nitie status .hether

a"eaccelerate* *ecline $eets the cri

teria o% a $il* co"nitie i$air$ent or *e$entia an* .hen co"nition

ne"atiel! in%luences a atient6s *eci

sional caacit!, @o.eer our

*escritie tests lac/ soli* ol*er a*ult

nor$s to %ir$l! ans.er $an! o% these

uestions, :lso .hile re%erral

uestions co$$onl! reuire attention

to a articular co"nitie *o$ain it is

i$ortant to select assess$ent$easures .ith a co$ rehensie

aroach in $in*, here%ore

co$binin" *ia"nostic an* *escritie

testin" aroaches are rec o$$en*e*

to o%%set the shortco$in"s o% each,


21/33

abl

e 3Lia"nostic an* *escritie

neuros!cholo"ical re%errals

Re%erral uestions %or neuros!cholo"ical consultations accor*in" to the:$er Lia"nostic Lescritie Lia"nostic an* *escritie ican :ca*e$!o% Neurolo"! (199?)

1, 'hen $ental status ea$ination reeals $il* or uestionable co"nitie*e%icits

such as $il* co"nitie i$air$ent,2, 'hen %ollo.in" the course o% a *isor*er is either in recoer! or *eclinesuch

as *e$entia an* stro/e,3, 'hen co"nitie stren"ths an* .ea/ness are consi*ere* %or liin"in*een*entl!, 4, In the contet o% roi*in" seci%ic rehabilitation or other theraeuticserices

such as stro/e rehabilitation,, 'hen liti"ation issues arise uestionin" the atient6s co"nitie status suchas

caacit! %or *ecision$a/in",

#.#7. What levels of reim&ursements

are availa&le'

-e"innin" ul! 1 1990 non

h!sician roi*ers o% $ental health

serices (s!cholo"ists an* license*

clin ical social .or/ers) .ere "rante*

in*een*ent billin" authorit! un*er

+e*icare ;??=, Obtainin" these billin"

riile"es %or "eriatric

neuros!cholo"ists has been both a

but in "reat nee* o% s!cholo"ical

serices, he curse continues to be the

restrictions +e*icare an* other

$ana"e* care s!ste$s lace on .hich

serices can be rei$burse*) an* the

rate at .hich rei$burse$ent can be

$a*e, Ps!cholo"ists in riate

ractice hae been a$on" the har*est

hit,: 1993 Penns!lania stu*! ;13= o%

1>4 h l i t i i t ti


22/33

*ecrease* %ees in crease* aer.or/

an* *i%%icult! obtainin" authoriEa tion%or lon"er treat$ent, Lesite the %act

that s!chol o"ists ha* been "rante*

in*een*ent billin" authorit! un*er

+e*icare three !ears earlier t.o

thir*s o% the re son*ents reorte*

bein" eclu*e* %ro$ +e*icare eli

"ibilit! to articiate as Jclinical

s!cholo"ists,K Per has because

s!cholo"ists in riate ractice in%reuentl! initiate research the issue o%

ho. +e*icare an* $ana"e* care

rei$burse$ents i$act the ethical

roision o% neuros!cholo"ical

serices is o%ten not a**resse* in the

literature, 5or ea$le t.o o% the

$ost recentl! ublishe* boo/s on the

toic o% "eriatric neuros!cholo"!

Geriatric Neuros!cholo"! :ssess$ent an* Interention ;9= an*

Geriatric Neuros!chol o"!# Practice

Cssentials ;1?= *o not *iscuss ho. to

a* euatel! a**ress re%erral uestions

an* roi*e co$ etent an* ethical

serices %ro$ a neuros!cholo"ical

ersectie, his is eseciall!

roble$atic since +e*i

care rei$burse$ent sche*ules are

substantiall! lo.er than $eanneuros!cholo"ical billin" rates,

he nee* %or neuros!cholo"ical

serices in the ol* er a*ult oulation

is increasin" as are the costs o% *oin"

business, :"ainst this bac/*ro

$ana"e* care rei$burse$ents rates

are at best hol*in" stea*! an* in

so$e cases *eclinin", :s reorte* b!

the :P: Practice Or"aniEation the&enters %or +e*icare an* +e*icai*

Serices (&+S) roose* a rate

increase %or +e*icare h!sician

ealuation an* $ana"e$ent

rei$burse$ent rates lea*in" to an

a**itional 4,< billion in +e*icare

costs ;8=, o o%%set these costs &+S

cut the rei$ burse$ent rates %or

serices roi*e* re*o$inantl! b! s!cholo"ists an* social .or/ers,

Seci%icall! $en tal health an*

testin" serices .ere cut 9 in

a**ition to a


23/33

%ro$ 200? to 2011 h!sician

+e*icare a!$ents are eecte* to*ro b!

2?, @o.eer .hile +e*icare

a!$ents .ill be *e creasin" the

costs associate* .ith racticin"

$e*icine are eecte* to increase b!

1


24/33

In the resence o% an ean*in" role

%or neuros! cholo"! in "eriatric

s!chiatr! ;


25/33

&o"nitie ea$inations re$ain as

challen"in" as *i a"nosin" h!sicalillnesses, In our role as the ea$

iner .e $ust be inte"rate our

/no.le*"e about co" nition test

instru$ents s!choatholo"!) an* the

con seuence o% h!sical illness on

co"nition, et our re%erral strea$ is

also *een*ant on a hi"h *e"ree o%

interersonal s/ill ;


26/33

$ent care"ier suort an* e*ucation)an* as arori ate eniron$entalen"ineerin", :ccor*in"l! our ro%ession shoul* continue to a*ocate%or the allocation o% %un*s to researchinnoatie in*ii*ualiEe* treat $entaroaches an* roi*e serices %or

atients .ho are co"nitiel! i$aire*an* their care"iers, Priate

ractitioner6s aluable /no.le*"e an*

eertise .ith ol*er in*ii*uals isre"rettabl! bein" lost since their ti$eis o%ten %ille* .ith the *e$an*s o% clinical .or/, @o.eer to increasethe alicabilit! o% our "eriatricresearch riate ractitioners shoul*strie to increase their inole$ent inresearch,

Referen

ces

;1= L, :iEenber" +, Si"ler :,'eiE$an an* , -ara/ :nti

choliner"ic bur*en an* the ris/ o% %alls a$on" el*erl! s! chiatricinatients# : 4!ear casecontrol

stu*! "nternational

8sychoeriatrics 14 (2002) 30>– 310,

;2= :, :/o$ola%e :, uarshie P,

ac/son , ho$as O, Le% %er :,O*u.ole et al, he realence o% co"nitie i$air $ent a$on"

:%rican :$erican atients .ithcon"estie heart %ailure J Natl

9e$ Assoc 97 (200 %ro$htt#HH.. . ,a$aassn,o r "Ha$aHubHca t e" or! H 13= :$erican Ps!cholo"ical:ssociation Gui*elines %or theeal uation o% *e$entia an* a"e

relate* co"nitie *ecline Amer 8sycholoist 53 (1998) 1298– 1303,

;8= :$erican Ps!cholo"ical

:ssociation Practice Or"aniEation&+S a!$ent rule "rael!i$acts +e*icare $ental health

serices 200? 'ashin"ton LGoern$ent Relations O% %iceRetriee* Noe$ber 4 200> %ro$htt#HH"eros!ch,o r "H

$e*icare,ht$l,;9= L, :tti an* 7, 'elsh-oh$er

Geriatric Neuropsycholo; y Assessment an$ "ntervention Ne.

http://www.americangeriatrics.org/products/positionpapers/http://www.americangeriatrics.org/products/positionpapers/http://www.americangeriatrics.org/products/positionpapers/http://www.ama.org/http://www.ama.org/http://www.amaassn.org/ama/pub/category/13592.htmlhttp://www.amaassn.org/ama/pub/category/13592.htmlhttp://www.amaassn.org/ama/pub/category/13592.htmlhttp://geropsych.org/http://www.americangeriatrics.org/products/positionpapers/http://www.americangeriatrics.org/products/positionpapers/http://www.americangeriatrics.org/products/positionpapers/http://www.ama.org/http://www.amaassn.org/ama/pub/category/13592.htmlhttp://www.amaassn.org/ama/pub/category/13592.htmlhttp://www.amaassn.org/ama/pub/category/13592.htmlhttp://geropsych.org/


27/33

Shah , &hen" ', 5lesher an*

, 7raus, +il* trau$atic braininur! in the nite* States1998–2000 >rain "n6ury 19(2000!earol* $en an* .o$en J

8ain Sympt 9anae 26 (2003)903–912,

;12= G, -lesse* -, o$linson an*+, Roth he association be

t.een uantitatie $easures o% *e$entia an* o% senile chan"e inthe cerebral "re! $atter o% el*erl!

subects >rit J 8sych114 (19?8) >9>–811,

;13= , -o.ers an* S, 7na

Rei$burse$ent issues %or s!cholo "ists in in*een*ent ractice 8sychothera 8rivate 8ract 12(3) (1993) >3–8>,

;14= @, -ro*at! :, 'ithall :,:lten*or% an* P, Sach*e Rates o%

*eression at 3 an* 1< $onths oststro/e an* their relationshi.ith co"nitie *ecline# he

S!*ne! stro/e stu*! Amer J Geri 8sychtry 15 (200>) 4>>–48?,

;1


28/33

;20= M, Laison &urrent status o%

clinical neuros!cholo"! Clin;ical Neuropsycholoy! Current Status an$ Applications O %or*Cn"lan*# , @, 'inston Q Sons19>4,

;21= Leart$ent o% @ealth an*@u$an Serices 9ental Health! Areport of the Sureon General;

?%ecutive Summary Roc/ille+L# S Leart$ent o% @ealth an*@u$an Serices Sub stance

:buse an* +ental @ealth Serices:*$inistration &enter %or +ental@ealth Serices National Institutes

o% @ealth National Institutes o% +ental @ealth 1999,

;22= 7, Lu%% , +ol* +, Roberts

an* S, +c7a! +e*ical bur*en an*co"nition in ol*er atients in

ri$ar! care# Selectie *e%icits inattention Arch Clin Neuropsych22 (200>)


29/33

;32= :, 5lint :niet! *isor*ers inlater li%e# 5ro$ ei*e$iolo"! totreat$ent Amer J Geri 8sychtry 15

(200>) ?3) ?,;38= C, @e!er R, Shar$a &,'in%ree , +occo L, +c+ahon P,

+c&or$ic/ et al, Seere aincon%oun*s neuros!cholo"ical test

er%or$ance J Clini ?%peri Neuropsych 22 (2000) ?33– ?39,

;39= +, @ibbar* S, -ree* ,

:sh$an an* , 'illia$s &ooccurrin" s!chiatric an*neurolo"ical i$air$ents in ol*er

a*ults in# Geriatric Neuropsycholoy! 8ractice

?ssentials S, -ush an* , +artin

e*s Ne. or/# a!lor Q5rancis200–3?2,

;40= 5, @ill-ri""s , 7ir/ an* S,'e"ener Geriatric ain an*

neuros!cholo"ical assess$ent in#Geriatric Neuropsychol; oy!

8ractice ?ssentials Ne. or/#

a!lor Q 5rancis 200


30/33


31/33

?99,

;= +, Ne.$an an* P, Green.a!heraeutic e%%ects o% roi*in"++PI2 test %ee*bac/ to clients ata uniersit! counselin" serice# :

collaboratie aroach 8sych

Asses 9 (199>) 122–

131,

;iol 8sychtry 54 (2003)3>?– 38>,

;?


32/33

;>0= , Siler R, 7ra$er S,Green.oo* an* +, 'eiss$an heassociation bet.een hea* inuries

an* s!chiatric *isor*ers# 5in*in"s%ro$ the Ne. @aen NI+@ei*e$iolo"ic catch $ent area

stu*! >rain "n6ury 15 (2001)93?= @, uo//o an* ,

@a*istarooulos An Assessment Gui$e to Geriatric

Neuropsycholoy +ah.ah NS# Ma.rence Crlbau$ :ssociates

Publishers 1998,;>>= ,S, Leart$ent o% @ealth an*

@u$an Serices Ol*er a*ults an*$ental health in +ental @ealth# :

Reort o% the Sur"eon GeneralCecutie Su$$ar! Roc/ille+L# S Leart$ent o% @ealth an*

@u$an Serices Substance :busean* +en tal @ealth Serices:*$inistration &enter %or +ental

@ealth Serices National Instituteso% @ealth National Institute o% +ental @ealth 1999,

;>8= +, an Ci/en S, san" +,'ensin" P, *e S$et an* R,

Grol Interentions to i$roe$e*ication co$liance in ol*er

atients liin" in the co$$unit! *rus Aein 20 (2003)229–240,


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Documents

Geriatric Neuropsychology Implications For