Cognitive and mood disorders in elderly populations

¶ … health issues present themselves during the elder years of any patient, there is a lot of attention paid to cognitive and mood issues in this age group. The disorders and maladies that are applicable when speaking of this subject include, among others, depression, dementia, mild cognitive impairment (MCI) and milder cases of Alzheimer's. Just as they could and should be handled and addressed for younger age groups, they should also be addressed for the elderly. This report shall endeavor to answer a series of questions relevant to the above including the demarcation between individual results and group trends, the ethics of diagnosing patients properly, the proper administration of tests, how to interpret the results of those tests and a few other important topics.

Introduction

The author of this report is offering a term paper relating to cognitive and depression issues with the elderly populations of the United States and the broader world. These disorders and maladies include dementia, depression and milder cases of Alzheimer's. The sections that will be included and well-covered in this report include a clear introduction, a discussion of the relevant subtopics, a review of the literature and an integration with the course text and materials. While depression and memory-related disorders are not entirely pervasive among the elderly population, they are certainly prominent enough so as to present some major challenges to both the patients as well as their providers and family members and thus there needs to be an in-depth review of the implications and facts as they exist and are currently known.

Preliminary Discussion

Regardless of the age of a given patient or person, the need for cognitive assessment often arises when it is clear that there is some sort of discord and problem with a person's mood, memory, emotions and so forth (Brown, 2014). For example, if an elderly person is all of a sudden sullen, extremely quiet and otherwise withdrawn, especially as compared to how they normally have been in recent weeks and months, this should be a cause for concern (Brown, 2014). Another example would be a person in their sixties or seventies that has been very sharp and on top of their daily affairs and they all of a sudden start forgetting very basic and obvious things like paying the credit card or phone bills (Brown, 2014). In short, when there is an obvious mental problem of any sort and/or there is a sharp departure from a person's normal behavior and mindset, this should precipitate a check of the person's cognitive faculties and abilities (Brown, 2014). Even better, there could also be a comparison to what has been measured and observed on prior occasions so that there is a reference point to draw against (Brown, 2014). Regardless, if it is clear that there is a depression-related or cognitive impairment such as dementia or even Alzheimer's, the protocol and norms for how that patient should be dealt with will obviously change. It could be as simple as therapy or pharmacology when it comes to depression (Long et al., 2015). When it comes to dementia and Alzheimer's, there is obviously going to be a focus on getting the patient into a care situation where they are safe and unable to hurt themselves, hurt others through negligence or go missing due to losing their bearings and point of reference (Brown, 2014).

Study Questions

What do you perceive are the primary strengths and limitations of cognitive assessment for the elderly?

How do you see a strong clinician balancing the tension between idiographic (individual) and nomothetic (generalized) perspectives on cognitive assessment?

In other words, how does the clinician effectively assess the individual while at the same time situating the individual within the larger understanding of human intelligence and achievement?

What are your opinions of clinicians making inferences about real-life performances form tests performed in a "test-taking" situation?

How credible do you believe this data is in evaluating a person's functioning?

What are some prominent ethical issues to consider in the evaluation of the individual?

The next two sections of this report are obviously the most important, those being the literature review and the discussion. The questions noted above will be answered as part of the discussion but only after the literature review is done in full. Indeed, the full literature review should be done so as to inform the answers that the author of this report comes to for the questions. The answers given will be from a combination of the literature review itself and the informed perspective of the author of this report.

Literature Review

The author of this report wishes to deeply study the cognitive and mood impairments mentioned above as they exist in the elderly. With that in mind, a thorough review of the scholarly literature will inform the author about the answers to come later in this report. One tactic that can be used to combat odd and incomplete results is the use of reexamination, reconceptualization and practical application of the data in question (Ridley, Li & Hill, 1998). This is but one way to ensure that any psychological assessment is as accurate, impartial and thorough as possible. Part and parcel of doing the assessments the right way is to ensure that the counselor or other clinician completing the test is qualified and adept at giving said test. As stated by Ridley, "this assertion, of course, rests on an incontrovertible presupposition: that clinicians are competent, especially in using reliable assessment procedures (Ridley, Li & Hill, 1998, p. 827). The assertion that Ridley et al. references is that "psychological assessment should be accurate, thorough and impartial (Ridley, Li & Hill, 1998, p. 827). This is further revealed to be important when taking into account that society and culture further muddy the waters when it comes to deciphering and interpreting what a patient is trying to say and project (Ridley, Li & Hill, 1998).

One of the questions posed for this report focuses on intelligence. Building on the mention of culture and society covered in the prior paragraph, one has to understand that intelligence and knowledge have to be considered given the context of the culture and society that a person inhabits (Aklin & Turner, 2006). The full picture of intelligence is what a person knows and the cultural traits that feed and influence that knowledge and intelligence (Sternberg, 2004). Further, as society has changed, the aggregate IQ scores of the people within these societies has risen as well. This has been verified in multiple studies done by Flynn and others ranging from at least the 1980's to within the last decade. While technology and educational advances are seen as contributory to this increase in intelligence, the uniformity of the rise across all cultures and peoples cannot be explained by that alone. This has come to be known as the Flynn effect and would obviously have a bearing on what needs to happen with patients as they enter their elder years (Sternberg, 2010; McGrew, 2010).

When it comes to measuring things like cognitive impairment in the elderly, the number of instruments and how they are applied actually varies quite a bit. Indeed, there are about twenty brief cognitive instruments that are used for reasons such as efficacy, ease of administration and familiarity with the instrument (Velayudhan et al., 2014). Even with the litany of examinations and tests that exist, some methods have more staying power than others. For example, the mental status examination (MSE) has been around for half a century and is heavily used in psychiatry, clinical psychology and general social work (Polanski & Hinkle, 2000). At the same time, some realms and areas of mental health and cognitive disorders in general are less than settled. Just one example of this is the subject of what is known as Mild Cognitive Impairment (MCI). As recently as 2005, it was asserted that "MCI as an entity is evolving and somewhat controversial (Nasreddine et al., 2005, pp. 695). Beyond that, some people with MCI actually regain some of their cognitive function, which goes against the dementia/Alzheimer's grain that most people and clinicians tend to see and expect (Kang et al., 2014). Even with that being the case, it will be very important to find as much clarity and settle science/medicine as possible given that there will be 600 million of the world's population will be elderly (over the age of 65) by the year 2020, which is a scant five years from now (Morais, Rodrigues & Sousa, 2009). The efficacy and applicability of tests comes through things like validation. In other words, this would be proof that the test accurately measures what it proclaims to and intends to measure (Kaya et al., 2014).

Discussion

Question One

When it comes to the primary strengths and weaknesses when it comes to assessing the elderly, a strength would be the fact that the dimensions and definitions of the disorders in questions are fairly basic. Indeed, even if the patient is not completely participatory in the process of answering questions and agreeing to be measured, it is generally not all that difficult to observe and come to a general consensus of what is probably going on. This is obviously much truer when it comes to dementia and Alzheimer's. Further, dementia and Alzheimer's are much easier to monitor and keep an eye on given that the patients afflicted by the disorder are usually in a nursing home or some other controlled environment (Bokberg et al., 2015). A downside to measuring the mental acuity of the elderly comes more into play with depression but could really be applicable to any mental measurement paradigm. Indeed, truly getting to the bottom of what is wrong with a person from a mental standpoint requires their participation. This is especially true when speaking of disorders like depression, anxiety and so forth. Even if their mood and emotions are a little messy, they often know what is right and wrong and what is true or false. Given that, they can absolutely participate in the process and give full and complete answers to the questions stipulated and expected as part of using the DSM criteria (Goldstein et al., 2014).

Where things get a little messy and difficult is when the patient is not an honest and complete participant in the process. Indeed, if a patient is purposefully giving incomplete or false answers to the questions, not giving complete answers, not giving honest answers or just refuses to participate in the process altogether, this would obviously make it very difficult to get an accurate, timely and complete diagnosis. Indeed, validity of assessment outcomes is very important (Henry, 2010). Further, there are a great many elderly patients that are rather dejected and even hostile when it comes to being in a nursing home. Many people in nursing homes are in that situation because they have family members that are unable or unwilling to provide care and/or the patients have conditions that require a nursing home situation or something like it. Indeed, a dementia patient should not live in a standard home because their odds of wandering off are much higher. Further, they cannot be chained to their bed or chair when the other adults in the home are at work or shopping (Kaya et al., 2014).

Even so, it can be a very sobering and depressing experience to be in a nursing home. It can very much feel like a prison to someone that is present there and this can create depression and other mood/emotional issues to put it lightly. Rather than being a mental acuity issue, it is more an issue of hostility, rejection and a non-acceptance of one's eventual fate in said nursing home. Indeed, the nursing home is an end-of-life care situation. A person may be there for a short time or they may be there for a good number of years. As such, depression and other mood issues are almost to be expected. Further, the doors and windows are secured and monitored in these homes for good reason as some patients, whether they have their mental faculties in place or not, will tend to wander (Kaya et al., 2014).

Question Two

As for the second question, there does indeed need to be a balance between what manifests from an overall group when it comes to a given disorder or group of disorders (Zeiders, Umana-Taylor, Updegraff & Jahromi, 2015). However, a gifted clinician also needs to keep in mind that each person will manifest a bit differently than others and this is obviously possible even with the same disorder. Just as one example, bipolar disorder is a crippling and severe mental disorder that is typified by manic and depressive states. However, some people trend more towards the manic states rather than the depressive while others are on the other end of the spectrum. Others still are sort of in between and are not on either extreme at any given time (Janiri et al., 2015). Depression, dementia and Alzheimer's are no different. Some people are losing their mental acuity while some people are just generally forgetful. Any good clinician needs to understand that and diagnose accordingly (Babu-Sandiyan & Dening, 2015). Unfortunately, it not like diseases and viruses where it can often be verified with certitude whether a person has the virus or bacterial infection in question. For example, the detection of diseases like tuberculosis is pretty cut and dry. However, mental disorders are often manifested as differential diagnoses a lot of the time and there sometime has to be some troubleshooting or trial and error. Sometimes the first diagnosis works and sometimes other theories have to be tried. For example, attention issues could be an ADD/ADHD issue or could be an anxiety issue, among other possibilities. Given that, Ritalin could be the answer or it could be something like Zoloft or Xanax (Morais, Rodrigues & Sousa, 2009).

Question Three

Building on the response just offered for the second question, even with the varying nature of people, even when it comes to the same disorders, one has to keep in mind that the diagnoses and treatment arcs need to follow the broader treatment regimens and patterns of the broader medical practice for those disorders (Apostolo, Cardoso, Rosa & Paul, 2014). Obviously, things like human intelligence and achievement are certainly factors when it comes to mental health issues. Some people bend and shape their mental challenges in a way that allows them to do great things. They are able to pull this off through great coping skills. However, there is also probably a lot of medicine and other treatments involved as mental health and loss of mental faculties in general are not things that one just shrugs off. Indeed, it is ignorant to say that mental illness can just be "dealt with" and shrugged off. It is easy for a mentally balanced person to say "man up" but they would not be so bold (or obtuse) to say that if they know the slow hell that mental illness can be (McGinty, Goldman, Pescosolido & Barry, 2015). With that said, intelligence (or lack thereof) obviously changes the lens that needs to be used when diagnosing for a certain condition. Some people have great self-awareness and/or are well enough to know they are off-kilter. On the other hand, there are those that are a bit lost in their world of mental dysfunction and this is certainly not limited to those with dementia and Alzheimer's. One might think this is limited to true sociopaths and psychopaths but this is simply not the case. Some people can obtain perspectives that are skewed and out of phase and they just might not realize just where they are mentally. This would probably be rare but it certainly happens (Morais, Rodrigues & Sousa, 2009).

Question Four

When it comes to clinicians that are making "inferences" about real-world situations and dynamics based on the results from situations that are "test-taking" in nature, this is obviously unwise and improper. Indeed, the least of the issues involved would be what is called the Hawthorne Effect (Jung & Lee, 2015). This is when a person is being studied and they know they are being studied. As such, there is a much larger propensity to behave in a manner that is different than what would occur in a spontaneous and non-monitored situation. This is even truer when speaking of things that a person may be sensitive or more cautious about. Easy examples that come to mind are studies or questions about racism, sexism, sex and other things involving moral or religious values. For example, if someone is asked by a survey taker if they would ever cheat on their wife, they are probably (if not certainly) going to say no even if the answer to the question is really in the affirmative (Jung & Lee, 2015). There are ways to deal with that such as anonymous surveys and such. However, there is still the dichotomy that is posed by the question and that would be whether a person would think and react as they say they would in a survey or "test" when they are faced with the same issue in real life. True enough, there is a good chance that there would be a lot of correlation between the two environments. However, there would also tend to be a lot divergence. Sociologists and economists know this full well. Further, testing a sociological theory or economic theory in a controlled environment is something many scientists attempt to pull off but it can be extremely difficult to do so in a way that matches real-world conditions and how people react in a non-controlled environment (Espeland et al., 2014).

To come back to the subjects of this report, a person with dementia or Alzheimer's is not in the proper state of mind regardless of whether they are taking a test or not, so perhaps those tests would be more consistent. However, for someone that is depressed and knows they are "not right," how they act in their normal daily lives and how they act when they know they are being assessed would entirely depend on their state of mind, their willingness to truly participate in their treatment and how honest they want or intend to be. If someone truly knows they are in need of help and they really want to get better, the correlation between real-world experiences and what is gleaned from a test-taking session will probably match. However, for any clinician to presume or assume that is less than wise. There has to be a presumption that there will be some lies by omission and other resistance to treatment that has to be fettered out and dealt with. At the end of the day, that comes through dialog and discussion between patient and provider rather than a pre-planned test or survey. Further, even when someone is completely forthright and honest on the tests, translating that to treatment and real-life is not always fluid and easy (Heubrock & Petermann, 1998; Goldstein et al., 2014).