Cognitive assessment and diagnosis in elderly patients with dementia

Cognitive Disorder in Elderly

Cognitive Disorders in Elderly

Sachiko Furuya

Cognitive Assessment & Lab

Kris Thomas, PhD

The research of this study is related to cognitive, dementia, Alzheimer disease, and depression issues with the elderly populations of the United States and in the world in general. Societies with a large number of elderly people such as the U.S.A. are increasingly focusing their efforts on improving the life standards of these people based on the types of services given to them. The well-being of those on palliative and hospice care is as important as the well-being of the family members of these patients. Although many 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 relevant to this population include, among others, depression, dementia, mild cognitive impairment (MCI) and milder cases of Alzheimer's. It is argued that this population should receive the same standards of care that their younger counterparts with the same conditions receive to improve their quality of life. 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 related topics.

Introduction

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. Hwang, Cha, and Cho (2015), "Alzheimer's disease (AD) is a common degenerative brain disease that causes dementia" (p. 2875). Depression and memory-related disorders are very serious problems with the elderly and their family. For example, an elderly person could begin to display symptoms of mental challenges all of sudden such as forgetting normal routines. These conditions are certainly prominent enough so as to present some major challenges to 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. The problem is exacerbated if an elderly person is all of a sudden sullen, extremely quiet and otherwise withdrawn when compared to how they normally have been in recent weeks and months.

Aims of the Report

The purpose of this project is to identify key issues in the aging process and determine to what degree cognitive assessments are important and how cognitive assessments can help counselors mitigate some of the psychological symptoms of aging. This report shall endeavor to answer a series of questions relevant to depression, dementia, mild cognitive impairment (MCI) and milder cases of Alzheimer's in elderly persons, 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. What do we perceive are the primary strengths and limitations of cognitive assessment for the elderly, and how does a strong clinician balance the tension between idiographic (individual) and nomothetic (generalized) perspectives on cognitive assessment? This identification of primary strengths and limitations of cognitive assessment for the elderly help the researcher to understand how important the cognitive assessment test actually is. Such identification can "....help gain an in-depth understanding of behaviors found in human beings. When the behavior is fully understood, a person therefore becomes better able to identify the reason why people behave the way they do" (Henwood & Pedgeon, 2003, p. 133). Mental health counselors need to understand the importance of their patient's trauma, stresses, and reasons for using these substances

Major Limitations and Strengths of Cognitive Evaluation for the Elderly

When it comes to the primary strengths and weaknesses of assessing the elderly, the strength would be the fact that the dimensions and definitions of the disorders in question are fairly basic. Indeed, even if the patient is not completely participatory in the process of answering questions and agreeing to be measured, it can be difficult to observe and come to a general consensus of what is probably going on in regards to human functioning. 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, interviewing a person from mental standpoint requires their active participation to gather insights related to their inner psychological state. This is especially true when speaking of disorders like depression, anxiety and so forth that are not always apparent on the surface. 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).

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. However, there are increased risks for a dementia patient and living in a standard elderly care facility may not be the best option. One common issue is that they may forget who they are or where they are at. They could also have problems performing daily activities such as cooking or cleaning as well as be a potential threat for others around them. For reasons such as these, dementia patients can often not be left unattended without restraint and some methods of restraint can be cruel and inhumane (Kaya et al., 2014). Thus a dementia patient can require special around the clock care by trained professionals.

Balancing the Tension between Idiographic (Individual) and Nomothetic (Generalized) Perspectives on Cognitive Assessment

The gifted clinician 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. Some people are losing their mental acuity while some people are just generally forgetful. Any good clinician needs to understand that and diagnose accordingly. 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 many times, 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.

Effectively Assessing the Individual while Positioning the Individual within the Larger Understanding of Human Intelligence and Achievement

Building on the response just offered, even with the varying natures 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 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. 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).

Clinicians Making Inferences about Real-Life Performance from Tests Taken in a Test-Taking Context

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. This effect causes a person to respond in the way that the tester wants or that is morally correct when a person is being studied and they know they are being studied. In other words, in test-taking situations, 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 more correct 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. 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).

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).

Credibility of Data in Assessing an Individual's Function.

When it comes to the data gleaned from the assessments mentioned in this report, a lot of it can be useful but it needs to be collected, observed and wielded in the right way. Just one example would be the reasons given for depression from a patient that is clearly out of sorts. Indeed, what they say is bothering them may not be the true story. Further, some assessments are simply not good at weeding out outliers and anomalies. A good assessment, at least in the eyes of the author of this report, will ask the same question in a number of different ways. If done well, it will be done in a way that is not easily noticed or detectable by the person taking the survey or assessment. If they catch on to the fact that there is repetition, they are much more able to game the survey's results if they are prone and intending to do so. While that may seem like an insane and silly thing to do, it happens and for a variety of reasons such as trying to get certain pills (e.g. benzos) through what is known as malingering, avoiding the real issue/disorder and/or trying to portend that nothing is really wrong with the patient to begin with. In short, the outcomes of assessments needs to be compared and contrasted to the other factors and facts that are known and observable (Heubrock & Petermann, 1998). If there is discord and disagreement between these data sets, the clinician has to figure out why this is the case.

Some of the Prominent Ethical Issues to Consider in the Individual Assessment

When it comes to the ethical issues that can arise when assessing a patient and interpreting their results, there are a few obvious ones to point to. First, there needs to be a dispassionate relationship between provider and patient. This will obviously not be an issue with most elderly patients, but the providers cannot allow themselves to get emotionally attached to their patients in any way. This includes any idealistic involvement as well as any connection outside of the clinician/patient relationship.

Second, there is the issue of maintaining and protecting client confidentiality which will present problems when there is a need to speak with relatives of the elderly patient. APA ethical principle 4. Privacy and confidentiality: 4.01 Maintaining Confidentiality (2010) states,

Psychologist have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium, recognizing that the extent an limit of confidentiality may be regulated by law or established by institutional rules or professional or scientific relationship. (p.7)

American Psychological Association (APA, 2010); 3.10 Inform Consent, stated

(a) When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understand-able to that person or persons expect when conducting such as activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code. (p.6)

Because of these rules, the clinician needs to get the consent of the elderly patient or the legal representative of the elderly patient if the patient is incapable of consenting before speaking with the patient's relatives.

Conclusion

Davis, Creavin, Yip, Noel-Storr, Brayne, and Cullum (2005) test key result is,

We found that MoCA was good at detecting dementia when using a recognized cut-off of less than 26. In the studies that used this cut-off, we found the test correctly detected over 94% of people with dementia in all settings. On the other hand, the test also produced a high proportion of false positives, that is people who did not have dementia but tested positive at the "less than 26" cut-off. In the studies we reviewed, over 40% of people without dementia would have been incorrectly diagnosed with dementia using the MoCA. (p. 2)

Davis et al. (2005) study is very useful when it comes to diagnosing and treating elderly patients with depressive or other cognitive dysfunction. There is the issue of diagnosing the patient in a reliable way even if the patient is less than cooperative or able to aid in their own care, and there is also the issue of taking the observations and test results and thus translating them to a viable treatment option. As noted above, even the best efforts can lead to some troubleshooting needing to be done, but there are usually telltale signs and patterns that lead one in the right direction. Even so, elderly patients present more of a challenge than non-elderly patients and there are a number of reasons for this including animosity about facing death/nursing home confinement and loss of cognitive function in general.

Any psychological assessment is as accurate, impartial and thorough as possible, part and parcel of doing the assessments the right way, 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).