Psychological Assessment and Treatment of Older Adults E-Book

• Herausgeber: Hogrefe Publishing
• Kategorie: Geisteswissenschaft
• Sprache: Englisch
• Veröffentlichungsjahr: 2021

Seitenzahl: 698

Beschreibung

Learn about the key issues when assessing and treating older adults with mental health problems: - Expert guidance through the key topics - Highlights the best assessment and treatment practices - Addresses diversity, ethical, and health system issues - Full of real-life case examples - Resources in the appendix to test your knowledgeMore about the book Mental health practitioners are encountering an ever-growing number of older adults and so an up-to-date and comprehensive text addressing the special considerations that arise in the psychological assessment and treatment of this population is vital. This accessible handbook does just that by introducing the key topics that psychologists and other health professionals face when working with older adults. Each area is introduced and then the special considerations for older adults are explored, including specific ethical and healthcare system issues. The use of case examples brings the topics further to life. An important feature of the book is the interweaving of diversity issues (culture, race, sexuality, etc.) within the text to lend an inclusive, contemporary insight into these important practice components. The Pikes Peak Geropsychology Knowledge and Skill Assessment Tool is included in an appendix so readers can test their knowledge, which will be helpful for those aiming for board certification in geropsychology (ABGERO). This an ideal text for mental health professionals transitioning to work with older clients, for those wanting to improve their knowledge for their regular practice, and for trainees or young clinicians just starting out.

Leseprobe

Psychological Assessment and Treatment of Older Adults

Nancy A. Pachana, PhD

Victor Molinari, PhD, ABPP

Larry W. Thompson, PhD, ABPP

Dolores Gallagher-Thompson, PhD, ABPP

Library of Congress of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2021934339

Library and Archives Canada Cataloguing in Publication

Title: Psychological assessment and treatment of older adults / Nancy A. Pachana, PhD, Victor Molinari, PhD, ABPP, Larry W. Thompson, PhD, ABPP, Dolores Gallagher-Thompson, PhD, ABPP.

Names: Pachana, Nancy A., editor. | Molinari, Victor, 1952- editor. | Thompson, Larry W., editor. | Gallagher-Thompson, Dolores, editor.

Description: Edited by Nancy A. Pachana, Victor Molinari, Larry W. Thompson, and Dolores Gallagher-Thompson. | Includes bibliographical references.

Identifiers: Canadiana (print) 20210152192 | Canadiana (ebook) 20210152362 | ISBN 9780889375710 (softcover) | ISBN 9781616765712 (PDF) | ISBN 9781613345719 (EPUB)

Subjects: LCSH: Older people—Mental health. | LCSH: Older people—Psychology. | LCSH: Geriatric psychiatry.

Classification: LCC RC451.4.A5 P79 2021 | DDC 618.97/689—dc23

© 2021 by Hogrefe Publishing

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|v|Acknowledgments

Tell me with whom you associate, and I will tell you who you are.

Johann Wolfgang von Goethe

We would like to thank our colleagues, mentors, and friends, past, present, and future, in the Society of Clinical Geropsychology, for their passion for the profession and their commitment to early career clinicians and researchers.

|vii|Contributors

Rebecca S. Allen, PhD, ABPP

Department of Psychology

Alabama Research Institute on Aging

The University of Alabama

Tuscaloosa, AL, USA

Sherry A. Beaudreau, PhD, ABPP

Sierra Pacific Mental Illness Research and Clinical Center

VA Palo Alto Health Care System

Palo Alto, CA, USA

Department of Psychiatry and Behavioral Sciences

Stanford University School of Medicine Stanford, CA, USA

School of Psychology (honorary)

The University of Queensland

Brisbane, QLD Australia

Danielle N. Berkel, M.A.

Department of Psychology

University of Colorado at Colorado Springs

Colorado Springs, CO, USA

Shane S. Bush, PhD, ABPP

Long Island Neuropsychology, PC

Lake Ronkonkoma, NY, USA

University of Alabama

Tuscaloosa, AL, USA

Brian D. Carpenter, PhD

Department of Psychological and Brain Sciences

Washington University

St. Louis, MO, USA

Dolores Gallagher-Thompson, PhD, ABPP

Department of Psychiatry and Behavioral Sciences (Emeritus)

Stanford University School of Medicine Stanford, CA, USA

School of Psychology (honorary)

The University of Queensland

Brisbane, QLD Australia

Laura Gallego-Alberto, PhD

Universidad Autónoma de Madrid

Facultad de Psicología

Madrid, Spain

Alisa O’Riley Hannum, PhD, ABPP

PFC Floyd K. Lindstrom Outpatient Clinic

VA Eastern Colorado Healthcare System

Colorado Springs, CO, USA

Gregory A. Hinrichsen, PhD, ABPP

Icahn School of Medicine at Mount Sinai

New York, NY, USA

Lindsey Jacobs, PhD, MSPH, ABPP

Department of Psychiatry

Harvard Medical Center

VA Boston Healthcare System

Boston, MA, USA

Julia Kasl-Godley, PhD

Adjunct Faculty, Doctoral Program in Clinical Psychology Program, the Wright Institute

Berkeley Cognitive Behavioral Therapy Clinic, the Wright Institute

Berkeley, CA, USA

VA Hospice and Palliative Care Center,

VA Palo Alto Health Care System

Palo Alto, CA, USA

Andrés Losada, PhD

Universidad Rey Juan Carlos

Facultad de Ciencias de la Salud

Madrid, Spain

|viii|Julie Lutz, PhD

Center for the Study and Prevention of Suicide

University of Rochester Medical Center Rochester, NY, USA

María Márquez-González, PhD

Universidad Autónoma de Madrid

Facultad de Psicología

Madrid, Spain

Victor Molinari, PhD, ABPP

University of South Florida

Tampa, FL, USA

Nancy A. Pachana, PhD

School of Psychology

The University of Queensland

Brisbane, QLD, Australia

Kyle S. Page, PhD, ABPP

Edward Hines, Jr. VA Hospital

Hines, IL, USA

María S. Pedroso-Chaparro, MA

Universidad Autónoma de Madrid

Facultad de Psicología

Madrid, Spain

Matthew Picchiello, BA

Department of Psychological & Brain Sciences

Washington University

St. Louis, MO, USA

Candice D. Reel, MA

Department of Psychology

Alabama Research Institute on Aging

The University of Alabama

Tuscaloosa, AL, USA

Hillary J. Rouse, M.A.

University of South Florida

Tampa, FL, USA

Viktoriya Samarina, PhD

Sierra Pacific Mental Illness Research and Clinical Center

VA Palo Alto Health Care System

Palo Alto, CA, USA

Rachael Spalding, MS

Department of Psychology

West Virginia University

Morgantown, WV, USA

Ann M. Steffen, PhD, ABPP

Department of Psychological Sciences

University of Missouri – St. Louis

St. Louis, MO, USA

Madhuvanthi Suresh, MS

Palo Alto University

Palo Alto, CA, USA

Larry W. Thompson, PhD, ABPP

Department of Psychiatry and Behavioral Sciences (emeritus)

Stanford University School of Medicine Stanford, CA, USA

School of Psychology (honorary)

The University of Queensland

Brisbane, QLD, Australia

Stacey Wood, PhD, ABPP

Department of Psychology, Scripps College

Claremont, CA, USA

Nabeel T. Yehyawi, PsyD, ABPP

VA Central Iowa Health Care System

Des Moines, IA, USA

|ix|Preface

In this work, we have assembled experts in the field of clinical geropsychology to provide key theoretical constructs across a range of interventions and disorders. The chapters offer key readings on the topics covered, and copious case examples are offered. The text assumes a basic literacy with respect to psychological diagnosis, assessment, and intervention paradigms. Each chapter also addresses the cultural implications of the topic at hand, and how such considerations translate into practice.

Chapter 2 tackles the important subject of clinical assessment of older adults, including the clinical interview and a variety of common validated assessment tools for use with frequently presented syndromes such as depression and cognitive syndromes. The chapter emphasizes careful consideration of the unique circumstances and context of the older person, as variables such as having English as a second language, an earlier history of head trauma, or a recent loss may all affect the way a person presents and reacts to testing. It is easy to say this in a textbook; much harder to ferret out useful background information from a client who lacks any relatives or friends, or whose medical chart is complex and contradictory. But the effort to understand the person as fully as possible leads to the most useful and complete clinical picture.

Cognitive behavioral therapy (CBT), the most common and widely researched intervention in older populations, is discussed regarding its application to depression, again one of the most common presentations of older adults to mental health services, in Chapter 3. Conceptualizing depression in older adults and working through the therapeutic process are reviewed. Chapter 3 also discusses how positive psychology principles and strategies of change can be integrated into existing CBT interventions with older adults.

Chapter 4 brings together Case-Based Approaches With Older Adults: Acceptance and Commitment Therapy, Interpersonal Psychotherapy, and Dialectical Behavior Therapy with older adults. For each type of intervention, its condensed background theory and basic principles of its application are given, and illustrated with an expanded case example. Modifications of approaches with older adults are highlighted.

Anxiety symptoms and disorders, although highly prevalent among older populations, are often not given as much attention across clinical settings. In Chapter 5, diagnosis, assessment, and treatment approaches for anxiety disorders are described. Key issues to keep in mind to avoid diagnostic and assessment misdirections are given. Posttraumatic stress disorder is also discussed in this chapter, with a detailed case discussion presented.

Working with older persons living with dementia and those who care for them is the topic of Chapter 6. A brief overview of dementia is followed by recommendations. Finally, lifestyle interventions to reduce the likelihood of dementia are discussed. The last are an |x|important growth area in research as well as in practical applications when working with older persons.

Long-term care (LTC) settings are one of the richest and most fulfilling environments for psychologists to work in. Why is this? LTC interventions (and often assessments) must take a systems perspective, and often a systems approach to implementation, if they are to be successful. While demanding, such an approach can also yield gains across the entire facility. Chapter 7 covers theoretical models of care, as well as practical intervention strategies, in LTC settings.

Especially for early career psychologists, determining decisional capacity in older adults can be daunting. Chapter 8 discussed key issues in determining capacity, including issues of culture and family dynamics. Ethical and legal considerations are detailed, and the process of undertaking capacity assessments is laid out in detail, with a complex medicolegal case example presented to highlight key issues in practice.

Chapter 9 addresses the underresearched but incredibly clinically important topic of elder abuse, with particular emphasis on identifying and acting on risk. Culturally specific conceptualizations of abuse are offered. Strategies for screening for elder abuse are described, and issues arising in the reporting of abuse are detailed.

Psychological interventions developed for use in palliative care contexts are described in Chapter 10. Palliative care practice guidelines are discussed; the interventions are informed by developmental theory. Advance care planning and common issues arising in the last phase of life are also covered here.

The psychological sequelae of grief and loss, as well as death and dying, are covered in Chapter 11. A variety of interventions are described, including the use of acceptance and commitment therapy and mindfulness interventions in palliative care contexts. Factors affecting bereavement in care partners, and appropriate interventions in these circumstances, are also discussed. The case examples in Chapters 10 and 11 are linked to illustrate end-of-life complexities.

Understanding the context and application of assessment and intervention strategies with older persons is useful both for established practitioners encountering increasing numbers of older adults in their practice and for young professionals entering a field where the likelihood of seeing older adults professionally is ever-increasing. For practitioners who have not seen a large number of older clients, irrespective of their maturity within general professional practice, treating older clients can be daunting. Medical illnesses, unfamiliar medications and their side effects, and complex sociodemographic histories can seem bewildering. We have pitched the text to make sense of these complexities and contextualize them without diminishing the importance of a thorough understanding of older persons themselves.

The importance of understanding specific ethical and systemic issues in working with older persons is highlighted across chapters. Case examples or vignettes are given in each chapter to bring the work to life. Please note that significant details about all cases described in this work have been changed to maintain confidentiality and privacy. Recommended readings are provided at the end of each chapter.

Where to go for further information on working with older adults? A great place to start is the Council of Professional Geropsychology Training Programs (CoPGTP) [https://copgtp.org/] and GeroCentral [https://gerocentral.org/], both excellent online |xi|resources. The top professional organizations such as the Society of Clinical Geropsychology (APA Division 12/ii), Psychologists in Long-Term Care (PLTC), the International Psychogeriatric Association (IPA), and the Gerontological Society of America are well worth exploring for the value of their networking and informational resources; all are easily findable online.

If this volume inspires interest in readers who may desire to gain advanced expertise in clinical geropsychology, the authors hope that they will consider becoming certified as specialists. The American Board of Professional Psychology (ABPP) is the major credentialing organization in the US that certifies specialists, and since 2014 there has been a specialty board in geropsychology (American Board of Geropsychology; ABGERO). Certification requires not only specialized education and supervised training, but also demonstration of competence in assessment, intervention, and consultation with older adults, by oral examination. Such a process allows the public and other health care professionals to identify those who have been designated to be competent in professional geropsychology. For more information, please go to the ABGERO website (https://abgero.org/).

Nancy A. Pachana

Victor Molinari

Larry W. Thompson

Dolores Gallagher-Thompson

Contents

Acknowledgments

Contributors

Preface

Chapter 1 Introduction to Working With Older Adults

Chapter 2 Assessment Approaches for Psychiatric and Cognitive Syndromes

Chapter 3 Theoretical Support and Practical Strategies for CBT With Depressed Older Adults

Chapter 4 Case-Based Approaches With Older Adults: ACT, IPT, and DBT

Chapter 5 Therapeutic Approaches for Anxiety and PTSD in Late Life

Chapter 6 Working Successfully With Older Persons on the Dementia Continuum, and Their Informal Caregivers

Chapter 7 Working With Older Adults in Long-Term Care Settings

Chapter 8 Determining Decisional Capacity Across Settings and Clinical Presentations: A Systematic Approach

Chapter 9 Elder Abuse: Navigating Ethical and Legal Responsibilities

Chapter 10 Psychological Interventions Developed Specifically for Use in Palliative Care: A Lifespan Developmental Perspective

Chapter 11 Psychological Palliative Care and Bereavement Interventions: Psychopathology and Family Contexts

Appendix

Peer Commentaries

|1|Chapter 1Introduction to Working With Older Adults

Nancy A. Pachana, Larry W. Thompson

Introduction

Working with people from a psychological perspective increasingly focuses on the individual and their needs. The field of psychology is becoming less concerned with testing the dogmas of schools of thought and more focused on what interventions work for which people, under which circumstances. One group for whom the focus of psychological enquiry has increased is older adults, who represent an increasing proportion of the population across the globe (see Figure 1.1).

Figure 1.1 is worth keeping in mind for psychologists, as demographics play an important part in government and private sector planning, innovation, and spending for health care. As clinicians, we also find that demographics play a key role in how we envision the clinical populations we serve, and how these populations are changing over time. Changing demographics around age are not a temporary state of affairs, but rather represent the state of the globe for the foreseeable future. And it is also not simply the number of older adults that is increasing worldwide; lifespan is also increasing around the globe (see Figure 1.2).

However, perhaps the key to clinical gerontology is the ability to recognize the individuality of the patient, and hence the wide varieties of thinking and behaviors that this age group can demonstrate. As people age, they become more and more heterogeneous (Pachana, 2016). This is due to the accumulation of everything from life experiences, positive and negative, to life choices, including lifestyle choices as they relate to health. This then means that a person in later life is a unique combination of past medical, social, physical and psychological health and well-being, as well as a complex amalgamation of beliefs, preferences, and goals. This complexity presents itself daily in clinical practice. Cohort effects are important here, as the formative experiences of older persons earlier in life will have lasting impacts on all aspects of functioning, as well as approaches to their own problem solving and belief systems (including views on self-efficacy and buying into ageist stereotypes). This is another important issue in clinical practice, where the therapist and the client often come from different cohorts, and will have to work together to come to a |3|mutual understanding. Recognition of this multifactorial presentation is required of clinicians not just to get a good clinical history, but also to develop real rapport and a solid working relationship with their clients.

|2|

Figure 1.1 Demographic changes in aging: 1950-2050

Note. Reprinted with permission from World Population Prospects: The 2004 Revision, by United Nations, 2005. © 2005 by United Nations.

Figure 1.2 Increasing lifespan worldwide

Note. From World Population Prospects 2019, by DESA, Population Division, United Nations, (http://population.un.org/wpp/). © 2019 Population Division, DESA, United Nations. Licensed under Creative Commons license CC BY 3.0 IGO.

In an era of precision medicine, with its promise of molecularly tailored solutions to diseases, informed by genetics, psychology may look distinctly “old school” in its reliance on paper and pencil tests and face-to-face conversations to deliver person centered care. Yet a strength of psychology is its adaptation to current technological and measurement advances (e.g., telehealth and functional magnetic resonance imaging) in continuing to pursue the quest for the relief of symptoms of distress, and the fostering of skills to assist coping and flourishing with respect to mental well-being. The forward direction of psychology appears to be in entertaining less concern for particular assessment and intervention techniques that are effective across all populations, and more emphasis on discovering which approaches are most effective for persons from particular age cohorts, cultural backgrounds, and individual contexts. The field is also increasingly interested in the most effective procedures which can translate into real-world health care systems and communities of practice. Implementation science is still in many ways in its infancy, but in terms of building best practice models, such approaches are extremely important.

Changes in health globally also demonstrate that in most countries, increased lifespan has been matched with increasing health span. The US has seen some sliding on mortality and morbidity, mainly due to uninsured persons and the opioid crisis. However, globally, many countries are experiencing real gains in active health span, as well as in older adults working longer. It is important for clinical geropsychologists, particularly those in training or early in their professional careers, to recognize the changes across cohorts in terms of health, employment, and social and financial expectations, so that connections with older clients are not clouded by stereotypes or outmoded expectations (Laidlaw & Pachana, 2009). It is also increasingly clear that health solutions, particularly for older adults, will often have to occur in a multidisciplinary context. Many of the chapters in this book speak to the need to understand and work with other disciplines to achieve optimal outcomes.

As a field, clinical geropsychology has been sensitive to the training implications of demographic imperatives worldwide. All of the chapters in this work reference the Pikes Peak geropsychology competencies for trainees and psychologists (Knight et al., 2009). These competencies (which can be found listed in Appendix 1) include attitudinal, knowledge, and skills competencies for practice in professional geropsychology. Additionally, the Pikes Peak model requires familiarity with the importance of using a multimethod and interdisciplinary approach, and of clinical work that is sensitive to cultural differences and diversity. The Pikes Peak Knowledge and Skills Assessment Tool (Appendix 2; Karel et al., 2012) should be considered an important tool for informing clinical geropsychology practice; ratings as novice, intermediate, advanced, proficient, and expert, based on anchor items reflecting the various competencies can help guide continuing education as well as matching current skill levels to changing clinical demands in the workplace. The Pikes Peak competencies speak to a desire both to inform early career psychologists about the breadth and depth of knowledge required for competence in the field, and to provide a similar service to more mature practitioners wishing to shift their practices to serve more older adults. Increasingly, clinicians will wish to increase their skills in treating older adults, and we are hoping this text helps to meet those needs.

|4|Age-Related Changes – The Big Picture

The following represents a brief overview of common age-related changes that one can expect to encounter when assessing and treating an older adult. The interested reader seeking further information is referred to any of the more comprehensive texts listed at the end of this chapter in the section Suggested General Resources for Clinical Gerontology.

The World Health Organization (WHO) definition of health states that health goes beyond simple physical health to embrace “a complete state of physical, mental, and social well-being, and not merely the absence of disease or infirmity” (WHO, 1948). Thus, when considering age-related changes, such physical, mental, and social changes should be considered together, with the understanding, as stated above, that older adults are heterogeneous and are not all aging in the same way (Pachana, 2016). Indeed, various parts of the brain and body within a single person do not all age at the same rate; likewise, aspects of psychological and social functioning may be more or less well-preserved. Finally, acute illnesses such as delirium may diminish functioning, particularly cognitive functioning, for a short time, but treatment can (and very often does) restore functioning. This is particularly important to note in determining capacity. Similarly, changes in lifestyle can improve health and well-being. Aging should not be thought of as linear decline; it is a dynamic, responsive process. For example, for many years, personality was seen to be set in stone quite early in adulthood; now we know that personality shifts occur over the entire lifespan (Schwaba & Bleidorn, 2018) and are also linked with culture and ethnicity (Chopik & Kitayama, 2018).

Important health conditions associated with increasing age include chronic obstructive pulmonary disease, cancer, osteoarthritis, macular degeneration, type 2 diabetes, hypertension, and Alzheimer’s and Parkinson’s diseases; these conditions often share underlying basic biological mechanisms (such as inflammation) but are also greatly impacted by sociodemographic and lifestyle factors (Franceschi et al., 2018). Older adults over age 65 generally have at least one chronic illness for which they are taking a regular medication. All of the diseases listed here, along with others that may be encountered by clinicians, have the potential to negatively impact cognition and mental health, as well as to cause functional limitations (e.g., instrumental activities of daily living, or IADLs). Understanding the impact both of common medical conditions as well as medication side effects, on cognitive and emotional function is very important, as polypharmacy is also an issue among older persons. Between 1988 and 2010, the median number of prescription medications used among adults aged 65 and older in the US doubled from two to four, while the proportion taking five or more medications tripled from 12.8% to 39.0% (Charlesworth et al., 2015). Medication side effects may often underpin changes in cognition or affect. Here again, the point should be underlined about the importance of collaborative work and good communication channels with other health care professionals.

Cognitive changes with aging involve the interplay between changes in the brain and physical and psychological health, as well as lifestyle behaviors (O’Hara, 2020; Pachana, 2016). Important brain changes with increasing age include declines in production of neurotransmitters and of the sensitivity of neuroreceptors, which can influence mood and behavior, as well as cognitive functioning. Cumulative small changes in brain structures, such as minor vascular events which can negatively impact the white matter connective fibers in the brain, may contribute to slower speeds of physical reaction times and of cognitive |5|processing speed, and slower word or memory retrieval. Age-related changes, as mentioned, can vary across individuals, particularly impacted by prior levels of education, occupational history, and social factors such as isolation. Older adults can also compensate for decrements in cognitive functioning by recruiting more intact portions of the brain, a process Park and colleagues call scaffolding (Reuter-Lorenz & Park, 2014).

Typically, normal, expected age-related changes in cognition include declines in memory and executive functioning; these changes are commonly of a magnitude that might be characterized as annoying without significantly affecting daily functioning. There are several types of memory: short-term and working memory (information we are currently using, like remembering a telephone number in order to dial it), episodic memory (memory for past events, i.e., autobiographical memories as well as more recent experiences), semantic memory (memory for facts), and procedural memory (memory for skills and tasks, such as how to ride a bike or swing a tennis racquet). The greatest declines in later life are seen in episodic memory, followed by short-term memory, while procedural memory is relatively preserved.

Similarly, executive functioning encompasses a broad suite of skills including planning, emotional regulation, and goal directed activities. Again, older adults may find declines in their abilities to plan or in goal-directed activities, while because of changes in neurotransmitter functioning, emotional regulation is actually better later than earlier in life (Lantrip & Huang, 2017).

Thus, multiple factors can influence the cognitive changes seen in later life, and clinicians need to be inclusive in their formulations and strategies for intervention when faced with such changes. While many of these are due to physiological changes in the brain, many may be minimized or even corrected with proper attention and healthy lifestyle change. Moreover, and critically, involvement of the older adult in understanding their goals for both assessment and intervention is critical, and their views should directly inform interventions (Pachana et al., 2010).

Older adults value their independence, which is why functional limitations may cause more distress than physical or even psychiatric symptoms. Functional declines such as muscle weakness, gait instability, and limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are not only tied to medical conditions but are also related to lifestyle behaviors such as excessive alcohol consumption (León-Muñoz et al., 2017) and sleep difficulties (Stone et al., 2018), and have been shown in some studies to differ between ethnic groups (McGrath et al., 2017).

An understanding of dementia is crucial for clinicians working with older persons. Alzheimer’s disease and vascular dementia are among the most common forms of dementia, all of which include family history of the illness as a nonmodifiable risk factor (Pachana, 2016). Potentially modifiable risk factors for increased risk of dementia of these types include high blood pressure and high serum cholesterol, presence of diabetes and stroke, and incidence of head injury; protective factors include a diet low in fat and regular consumption of fish, and a nonsedentary lifestyle, with avoidance of smoking particularly associated with lower risk of Alzheimer’s disease (Patterson et al., 2007). The impact of sleep disturbance on both risk of dementia as well as its symptoms, particularly memory and behavioral sequelae, is a growing area of research, which also holds some promise for symptom amelioration (Shi et al., 2018). Thus, positive lifestyle interventions should be |6|considered, along with more specific psychological and behavioral interventions when treating persons living with dementia.

Culture plays an important role in beliefs and attitudes toward dementia, risk factors for dementia, and the impact of dementia upon caregivers of those living with the disease. In both assessment and treatment, it is best practice for psychologists to be aware of the impact of culture and ethnicity on tests, assessment results, intervention strategies, and available collateral and community support for both persons living with dementia and those who care for them (American Psychological Association [APA], 2012). An often-overlooked cultural population with respect to dementia is Indigenous peoples. Dementia is the most common age-related cognitive condition among Aboriginal peoples (Bennett, 2008). Culture-based public health system approaches have produced positive health outcomes in American Indian, Alaska Native, and Native Hawaiian populations and have implications for research and practice in the dementia context, but this remains an underresearched area (Browne et al., 2017).

The topics covered above are expanded on and linked with case examples in the following chapters; the above is just a brief overview. Whenever one is writing a text, one is conscious of how research and practice may be evolving, and there is a recent development that bears mentioning here. It is impossible for us not to mention the significant global impact of the disease caused by a novel coronavirus, referred to as COVID-19, on both the global human population in general, and older adults specifically. In the course of writing this text, there have occurred epic shifts in medical and psychological service delivery (via telehealth), the rise of awareness of ageism in framing the impact of the virus, and an understanding of how social distancing has impacted care, particularly for those in nursing homes and palliative care settings. We believe that the material covered in this text is relevant in guiding a professional and empathic response to the mental health aspects of this crisis. Social distancing may have profound effects on older populations for whom it is known that social isolation negatively impacts health and well-being. Gaps in the availability of everything from elective surgery to primary care consultations to certain medications may be an additional source of morbidity and mortality for older persons. This book will go to press as many of these situations in the world are evolving, and particularly impacting front-line clinicians. The best advice at this stage is to be guided by best-practice approaches for scientist–practitioners: Be aware of the clinical research (as described above and illustrated in the following chapters) as well as the major psychological theories of aging, which take into account critical factors such as cohort effects, coping and adaptive strategies, and resilience.

Important Overarching Psychological Theories of Aging

One of the most important theories of adaptation in later life is Paul Baltes’s selective optimization with compensation theory of successful aging (Baltes & Baltes, 1990). This theory suggests that individuals who age successfully actively use three strategies to make this transition into later life possible: selection, optimization, and compensation. Selection|7|includes identifying relevant goals, prioritizing them, and recognizing when they have been achieved. Optimization refers to the use of strategies to facilitate successful achievement of set goals. Compensation refers to the individual adapting to limitations (perhaps due to aging processes) that interfere with getting to their goal.

With regard to the example of COVID-19, how can older adults successfully adapt to these unprecedented circumstances? First, older adults might select the things that are most important to them; since isolation from family, particularly grandchildren, is viewed as a major source of distress, overcoming this isolation may be prioritized as a goal. This goal perhaps in the current circumstances takes precedence over lesser goals (meeting friends, going out for dinner). Optimization refers to a strategy to achieve the goal; potentially here it is setting up regular daily short sessions over the telephone or internet. Compensation involves problem solving about what might interfere with goal attainment, and here this might include buying the older adult (or the children!) a mobile device or computer to facilitate the maintenance of social contact.

Social support and social networks are increasingly recognized as having positive benefits for everything from brain health to positive aging (Pachana, 2016). The finding that older individuals report equal, if not greater, levels of social support than do younger age groups intrigued Stanford University researcher Laura Carstensen (Carstensen et al., 1999), who developed socioemotional selectivity theory to make sense of how growing older shifts how people view their friendship networks. The key lies in perception of time – as we age, we recognize that we have lived more of our lives than we have left to live, and this leads us to prioritize those relationships from which the greatest meaning and satisfaction are derived. In later life, the number of people in one’s social network declines, and this was thought to be due passive attrition due to death or incapacity. Carstensen demonstrated that older adults selectively prune their social networks to include those who offer the strongest social support, moving away from sources of unsatisfactory or unreliable support (English & Carstensen, 2014). The sense of having limited time left also drives people toward activities which are more meaningful, and leads to greater generativity, a feature of Gene Cohen’s complimentary theory of phases of human potential (Cohen, 2005). Cohen proposes a series of human potential phases, which “reflect evolving mental maturity, ongoing human development, and psychological growth as we age” (Cohen, 2005, p. 7).

In a period when many people, not just older adults, have a feeling of a potentially foreshortened future, Carstensen’s and Cohen’s theories are apt for those working with this population. Cartensen’s theory proposes that individuals cultivate networks that give maximal support; many older persons have found increased social supports online in response to COVID-19, but those left on the wrong side of the so-called digital divide require increased support and attention. The confines of various forms of lockdown can be reframed as time to focus on meaningful activities, and for many older adults this involves reaching out in terms of volunteering or otherwise making use of personal resources. Both theories underscore the drive for meaningful connection in later life, which is often associated with resilience.

Resilience, meaning broadly an individual’s adaptation to stress and adversity, is a construct which has been researched throughout the lifespan, including later life. Resilience is usually studied at the individual level, but it can also operate at a group level, and can be measured at the level of households, families, neighborhoods, communities, and societies. |8|In Figure 1.3, Wild and colleagues (2013) highlight not only these conceptualizations of resilience but also the differing scales of resilience that impact older adults’ ability to cope with adverse circumstances.

Clinical psychologists also often conceptualize resilience as an individual trait, but the experience to date with COVID-19 shows the value of all levels of resilience, from household “bubbles” where people shelter in place, to societal and national levels of resilience, in everything from health care services to supply chains. For older adults, these ties have been severely tested, with everything from lack of family at the bedside while dying, to nursing home lockdowns causing huge distress to families and residents alike (Pachana et al., 2020). Research pre-dating COVID-19 demonstrates the range of factors associated with resilience in later life. In the large US Successful Aging Evaluation (SAGE) study, after adjusting for age, a higher self-rating for successful aging was associated with higher education levels, better cognitive functioning, better perceived physical and mental health, a reduced amount of depression, and greater optimism and resilience (Jeste et al., 2012). These same factors may be associated with resilience during the COVID-19 global pandemic, and clinical geropsychologists will have an important role to play in advocating for mental health services for older adults.

Figure 1.3 Model of resilience

Note. Reprinted with permission from “Resilience: Thoughts on the Value of the Concept for Critical Gerontology,” by K. Wild et al., 2013. Ageing & Society, 33, p. 137–158. © Ageing and Society, 2013.

|9|Lastly, immigration and acculturation are tied to mental health in older adults. Worldwide, the median age of international migrants is 38.4 years, almost a decade older than the median global age of 29.2 years, with international migrants in particular suffering increased mental health problems coupled with increased barriers to accessing mental health services (Pachana, 2016). This is particularly true in the US for recent older immigrants (Choi et al., 2016). Values and beliefs about aging, roles and responsibilities (often gendered) in later life, and what is a good death, are all shaped by one’s cultural values, and often thrown into turmoil for immigrants. In some studies, immigrants have been shown to have a higher prevalence of dementia compared with their US-born counterparts (Moon et al., 2019).

In the current COVID-19 crisis, ageism and xenophobia have both left older immigrants feeling rejected by their societies. Older immigrants may be more likely to experience both loneliness and social isolation, due to language barriers and lack of acculturation, especially among recent immigrants. First-generation immigrants also have lower rates of health service utilization for both mood and anxiety disorders (Bauldry & Szaflarski, 2017). Asian immigrants of all ages have experienced increased stigma globally due to the virus possibly originating in China. While communities and governments have sought to encourage support for immigrants and discourage stigma against older adults as well as Asian immigrants, older migrants will no doubt still be very vulnerable to psychological distress in the current crisis.

Globally, we are in a time of transition, one that includes a heightened awareness of the value of social contact, and the necessity of strong societal supports for all citizens. Older adults and their resilience as well as vulnerabilities have also been spotlighted. Those working to restore and maintain the wellbeing of the older members within our communities should be inspired to redouble efforts to ensure this group is well understood, and receives the highest standard of clinical care.

Suggested Resources for Clinical Gerontology

Bush, S., Allen, R., & Molinari, V. (2016). Ethical practice in geropsychology.American Psychological Association.

Fingerman, K., Berg, C., Antonucci, T., & Smith, J. (Eds.). (2011). Handbook of lifespan development. Springer.

Knight, B. (Ed.). (2020). Encyclopedia of clinical geropsychology. Oxford University Press.

Lichtenberg, P. A., & Mast, B. T. (Eds.). (2015). APA handbook of clinical geropsychology: Vol. 1. History and status of the field and perspectives on aging, and Vol. 2. Assessment, treatment, and issue of later life. American Psychological Association.

Mehrotra, C., & Wagner, L. S. (2019). Aging and diversity: An active learning experience (3rd ed.). Routledge.

O’Hara, R. (Ed.). (2020). Handbook on mental health and aging.Elsevier.

Pachana, N. A. (2016). Very short introduction to aging. Oxford University Press.

Pachana, N. A., & Laidlaw, K. (Eds.). (2014). Oxford handbook of clinical geropsychology: International perspectives.Oxford University Press.

Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2019). Counseling the culturally diverse: Theory and practice. Wiley.

Whitfield, K., & Baker, T. (Eds.). (2013). Handbook of minority aging. Springer. Crossref

|10|References

American Psychological Association. (2012). Guidelines for the evaluation of dementia and age-related cognitive change. American Psychologist,67(1),1–9. Crossref

Baltes, P. B., & Baltes, M. M. (1990). Psychological perspectives on successful aging: The model of selective optimization with compensation. In P. B.Baltes & M. M.Baltes (Eds.), Successful aging: Perspectives from the behavioral sciences (pp. 1–34). Cambridge University Press. Crossref

Bauldry, S., & Szaflarski, M. (2017). Immigrant-based disparities in mental health care utilization. Socius, 3. Crossref

Bennett, D. A. (2008). Cognitive health in indigenous peoples.Neurology,71, 1466–1467.Crossref

Browne, C. V., Ka’opua, L. S., Jervis, L. L., Alboroto, R., & Trockman, M. L. (2017). United States Indigenous populations and dementia: Is there a case for culture-based psychosocial interventions?The Gerontologist,57(6),1011–1019. Crossref

Carstensen, L. L., Isaacowitz, D. M., & Charles, S. T. (1999). Taking time seriously: A theory of socioemotional selectivity.American Psychologist,54(3),165–181. Crossref

Charlesworth, C. J., Smit, E., Lee, D. S., Alramadhan, F., & Odden, M. C. (2015). Polypharmacy among adults aged 65 years and older in the United States: 1988-2010. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences,70(8),989–995. Crossref

Choi, S., Kim, G., & Lee, S. (2016). Effects of nativity, length of residence, and county-level foreign-born density on mental health among older adults in the US. Psychiatric Quarterly,87(4),675-688. Crossref

Chopik, W. J., & Kitayama, S. (2018). Personality change across the life span: Insights from a cross-cultural, longitudinal study. Journal of Personality,86(3),508-521. Crossref

Cohen, G. D. (2005). The mature mind: The positive power of the aging brain.Basic Books.

English, T., & Carstensen, L. L. (2014). Selective narrowing of social networks across adulthood is associated with improved emotional experience in daily life. International journal of behavioral development,38(2),195–202.

Franceschi, C., Garagnani, P., Morsiani, C., Conte, M., Santoro, A., Grignolio, A., Monti, D., Capri, M., & Salvioli, S. (2018). The continuum of aging and age-related diseases: Common mechanisms but different rates. Frontiers in Medicine,5, 61. Crossref

Jeste, D. V., Savla, G. N., Thompson, W. K., Vahia, I. V., Glorioso, D. K., Martin, A. S., Palmer, B. W., Rock, D., Golshan, S., Kraemer, H. C. & Depp, C. A. (2012). Association between older age and more successful aging: Critical role of resilience and depression. American Journal of Psychiatry,170(2),188–96. Crossref

Karel, M. J., Holley, C. K., Whitbourne, S. K., Segal, D. L., Tazeau, Y. N., Emery, E. E., Molinari, V., Yang, J., & Zweig, R. A. (2012). Preliminary validation of a tool to assess knowledge and skills for professional geropsychology practice. Professional Psychology: Research and Practice,43(2),110–117. Crossref

Knight, B. G., Karel, M. J., Hinrichsen, G. A., Qualls, S. H., & Duffy, M. (2009). Pikes Peak model for training in professional geropsychology. American Psychologist,64(3),205–214. Crossref

Laidlaw, K., & Pachana, N. A.(2009)Aging, mental health, and demographic change. Professional Psychology: Research and Practice,40(6),601–608. Crossref

Lantrip, C., & Huang, J. H. (2017). Cognitive control of emotion in older adults: A review. Clinical psychiatry (Wilmington, Del.), 3(1),9. Crossref

León-Muñoz, L. M., Guallar-Castillón, P., García-Esquinas, E., Galán, I., & Rodríguez-Artalejo, F. (2017). Alcohol drinking patterns and risk of functional limitations in two cohorts of older adults. Clinical Nutrition,36(3),831–838. Crossref

|11|McGrath, R. P., Ottenbacher, K. J., Vincent, B. M., Kraemer, W. J., & Peterson, M. D. (2017). Muscle weakness and functional limitations in an ethnically diverse sample of older adults. Ethnicity & Health,1–12. Crossref

Moon, H., Badana, A. N., Hwang, S. Y., Sears, J. S., & Haley, W. E. (2019). Dementia prevalence in older adults: variation by race/ethnicity and immigrant status. American Journal of Geriatric Psychiatry,27(3),241–250. Crossref

O’Hara, R. (Ed.). (2020). Handbook on mental health and aging.Elsevier.

Pachana, N. A. (2016). Very short introduction to aging. Oxford University Press.

Pachana, N. A., Beattie, E., Byrne, G., & Brodaty, H. (2020). COVID-19 and psychogeriatrics: The view from Australia. International Psychogeriatrics,32(10),1135–1141. Crossref

Pachana, N. A., Paton, H., & Squelch, N. (2010). The importance of feedback and communication strategies with older adults: Therapeutic and ethical considerations. In N. A.Pachana, K.Laidlaw, & B. G.Knight (Eds.), Casebook of clinical geropsychology: International perspectives on practice (pp. 155–177). Oxford University Press. Crossref

Patterson, C., Feightner, J., Garcia, A., & MacKnight, C. (2007). General risk factors for dementia: A systematic evidence review. Alzheimer’s & Dementia, 3(4), 341-347. Crossref

Reuter-Lorenz, P. A., & Park, D. C. (2014). How does it STAC up? Revisiting the scaffolding theory of aging and cognition. Neuropsychology review,24(3),355–370. Crossref

Schwaba, T., & Bleidorn, W. (2018). Individual differences in personality change across the adult life span. Journal of personality,86(3),450–464. Crossref

Shi, L., Chen, S. J., Ma, M. Y., Bao, Y. P., Han, Y., Wang, Y. M., . . . Lu, L. (2018). Sleep disturbances increase the risk of dementia: A systematic review and meta-analysis. Sleep Medicine Reviews,40, 4–16 Crossref

Stone, K. L., Blackwell, T., Ancoli-Israel, S., Ensrud, K. E., Kado, D. M., Wallace, M. L., Cawthon, P. M., & Buysse, D. J. (2018). Sleep health and functional limitations in older adults. Innovation in Aging,2(Suppl 1), 548. Crossref

United Nations, Department of Economic and Social Affairs, Population Division. (2019). World population prospects 2019: Volume 2: Demographic profiles.

United Nations, Department of Economic and Social Affairs, Population Division. (2004). World population prospects: The 2004 revision.

Wild, K., Wiles, J. L., & Allen, R. E. (2013). Resilience: Thoughts on the value of the concept for critical gerontology. Ageing & Society,33(1),137–158. Crossref

World Health Organization. (1948). Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June–22 July 1946; signed on 22 July 1946 by the representatives of 61 States and entered into force on 7 April 1948. Official Records of WHO,no. 2, p. 100.

|13|Chapter 2Assessment Approaches for Psychiatric and Cognitive Syndromes

Viktoriya Samarina, Madhuvanthi Suresh, Matthew Picchiello, Julie Lutz, Brian D. Carpenter, Sherry A. Beaudreau

Introduction

Competent assessment is an essential functional skill for working with older adults. The following chapter describes basic principles for assessing an older population and serves as a primer for students or clinicians with limited experience in assessing older adults. Moreover, experienced geropsychology specialists may find this chapter useful when reviewing cases and working with patients.

One of the most important considerations in assessing late-life mental health is the ubiquity of co-occurring psychiatric and cognitive syndromes. On the one hand, older adults with psychiatric disorders often show signs of cognitive impairment, particularly executive dysfunction or memory deficits (Beaudreau & O’Hara, 2009; O’Hara, 2012). On the other hand, many older adults with cognitive syndromes have psychiatric symptoms or disorders, often termed “neuropsychiatric symptoms” based on the assumption that the mental health syndrome is part of a larger neurocognitive process (Taragano et al., 2008). Determining whether symptoms warrant a psychiatric diagnosis, cognitive diagnosis, or both is a common question for geropsychological assessment, as illustrated in the following case example referral:

|14|Mr. J. is a 75-year-old African-American man, recently widowed from his wife of 55 years, Jean, who died 9 months ago of cancer. Mr. J.’s oldest daughter, Janelle, lives in the nearby town and has been worried about her father’s health over the last couple months due to his difficulty with activities of daily living, managing his chronic medical issues (e.g., type 2 diabetes mellitus), memory problems, motivational issues, and his recent comments about death while denying any plan to harm himself. His family have been thinking about moving Mr. J. to an assisted living facility, but he refuses. Mr. J.’s primary care physician recommended further testing by a geropsychologist to assess for possible depression and dementia, and to advise the patient and his family’s in their decisions about his need for support services.

This referral includes several complex assessment issues regarding possible psychiatric and cognitive difficulties, interacting psychosocial and medical etiologies, and concerns about functional impairment and safety. Such complex issues are frequently encountered in assessing older adults.

The overarching goals of a competent geropsychology assessment are to

conduct clinical assessment leading to DSM diagnoses and other clinically relevant problems, formulation of treatment plans and, specifically, differential diagnosis (common problems and issues include but are not limited to depression, anxiety, grief, delirium, dementia; and medication and physical disorders and their effects on functioning). (American Board of Geropsychology [ABGERO], 2017, p. 32)

Also, clinicians need to demonstrate an ability to select and administer evidence-based measures and appropriate techniques for the evaluation of psychiatric, cognitive, decision-making, functional ability, and safety and risk issues in older adults (ABGERO, 2017). This chapter surveys information about basic geropsychological assessment methods as outlined in the Pikes Peak functional competencies for trainees and psychologists (Appendix 1; Knight et al., 2009). These competencies include knowledge of the theory and current conceptualizations that inform geropsychology assessment and the psychometric properties of tests used with older adults. Additionally, the Pikes Peak model requires familiarity with the importance of using a multimethod and interdisciplinary approach, and appropriate integration of collateral information from family, friends, or caregivers during the assessment.

After reviewing these general assessment issues, we review available evidence-based assessment measures, including how best to assess mental health and cognition in older adults with varying levels of cognitive functioning, from no impairment to dementia. Throughout the chapter, we also discuss diversity issues and how they may impact the overall assessment process. It is important to recognize that aging is a diversity variable and that many older adults also have unique backgrounds and identities that intersect with their status as an older adult. These intersecting identities include, but are not limited to, disability status, culture, race, ethnicity, sexual minority status and gender identity, religious background, native language, immigration status, and veteran status.

|15|Basic Assessment Principles in Older Adults

A good psychological assessment involves gathering information from multiple sources to respond to a referral question. Referrals come from a variety of sources and may differ depending on the setting in which the clinician practices. Common referral sources include neurologists, psychiatrists, primary care providers, neurosurgeons, nurse practitioners, social workers, or other psychologists. Family members or the older adult may also self-refer if they have concerns about the older patient’s cognitive functioning or mental health. In many cases, it is necessary to reach out to the referring provider to clarify the referral question and goals of the assessment, and to confirm that as a clinician you are able to address the question and concerns appropriately and competently (Hinrichsen, 2019).

Generally, the purpose of geropsychological assessments is to determine the presence or absence of psychiatric diagnoses and cognitive disorders. The clinician synthesizes the patient’s medical, cognitive, and psychiatric history to form hypotheses about the etiology of the presenting problem. This information guides recommendations for further treatment or services to address any psychiatric and cognitive syndromes and related concerns. Referrals are often triggered by concerns about an older adult’s safety, including, but not limited to, an ability to function independently while performing specific instrumental activities of daily living (IADLs; e.g., driving) or more general activities of daily living (ADLs; e.g., attending to basic hygiene). Other typical referral questions include differentiating between a mood disorder (e.g., depression) and dementia, or assessing capacity to make decisions. Unresolved diagnostic questions or issues raised during the evaluation often lead the clinician to recommend further specialized assessments from another professional.

Regarding the case example of Mr. J., it will be important to determine which diagnoses should be ruled out (e.g., dementia or depression), assess for suicide risk, and choose which measures can be used to assess these areas of concern. This information will help guide Mr. J. and his family’s decision about his future living situation and potential need for additional care. Thus, the assessment recommendations often inform critical decisions of the older adults and their family members regarding housing, issues with autonomy, and the need for an additional evaluation of competency. These recommendations can include the need for further testing of medical or neurological issues through referral to a primary care or specialty provider, or an occupational or physical therapist, or a referral for a driving evaluation.

Mr. J.’s referral source is concerned that he might not be fit to live on his own. An older adult’s safety and well-being should be routinely assessed, including any signs of elder abuse. Elder abuse includes not only physical and sexual abuse, in which there may be physical or other interpersonal warning signs observed with family members or caregivers, but also self-neglect and financial abuse which may not be as readily identified (for information about signs of elder abuse, see Acierno et al., 2010). If Mr. J. is unable to meet his basic needs – for instance, he does not meet general dietary guidelines and has poor hygiene – this could be an instance of self-neglect. Observations regarding whether Mr. J. behaves differently when his family is present (e.g., fearful, nervous, and quiet) compared with when he is alone with the clinician, can indicate the potential for other physical or emotional abuse by family. The concerns Mr. J. has about missing money from bank accounts or potential mismanagement by family should be assessed for potential financial |16|abuse. In some cases, older adults with significant memory concerns will report that their checkbook, money, or purse was stolen in the absence of financial abuse – either because they have forgotten that someone else is managing their money or due to confusion if they have been misplacing important financial items. The source of any such financial concerns should be clarified and reported as required for licensed professionals in the state in which the geropsychologist practices.

Sources of Information

Prior to the in-person assessment, a medical chart review is often conducted. This review can alert the clinicians to diagnoses or issues that will need to be considered in addressing referral questions. Medical chart reviews can provide crucial information about the older adult’s past psychiatric diagnoses and history of treatment, medical history, current medications and hospitalizations, previous cognitive and neuropsychological testing results, previous psychiatric or psychosocial assessments, and previous family involvement in their treatment. For Mr. J., the following information was gathered during a medical chart review to inform his assessment:

According to his medical record, at his last appointment with his primary care physician, Mr. J. had lost 10 pounds (4.5 kg), explaining, “There’s just me, and my wife did all the cooking. Sometimes I don’t feel like eating so I have a bowl of cereal.” He also acknowledges that he has not been checking his blood glucose levels for his type 2 diabetes, though he reports taking his diabetes medication as directed. His physician has known Mr. J. for many years and has been treating his hypertension and high cholesterol with several medications. In total, Mr. J. takes four medications and a daily multivitamin. Mr. J. also has sleep apnea, though he doesn’t use his continuous positive airway pressure (CPAP) regularly, despite his physician’s urging that he is depriving his brain of oxygen and that he may feel more rested and alert after using it. Early signs of a cataract have reduced Mr. J.’s visual acuity, making it harder for him to see clearly at night because of the increased glare. This has made him reluctant to drive at night.

The clinician follows up on this information during a clinical interview. This additional preparation can increase the focus of a clinical interview on pertinent questions about the patient’s history. In this case example of Mr. J., questions about the management of his health conditions, such as his diabetes, which can affect mood and cognition, should be discussed during the clinical interview. The astute clinician will further consider the potential for malnourishment and any gross mismanagement of his medical conditions and thus the need to rule out self-neglect.

The Clinical Interview

A flexible, semistructured clinical interview lasting 30–90 minutes is used to gather information about the older adult’s background such as social, educational, developmental, familial, medical, psychiatric, and psychological history, and available brain neuroimaging or |17|