A LOOK AT OLDER ADULTS. Cognitive Assessment in Aging Anne-Marie Kimbell, Ph.D. Pearson Clinical Assessment

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1 Cognitive Assessment in Aging National Training Consultant Pearson December 9, 2015 Agenda Older Adults Cognition Indications of need for cognitive assessment & benefits A look at Neurocognitive Disorder Assessment process and domains A LOOK AT OLDER ADULTS

2 The Number of Persons 65+ is Growing Aging In America 25% Age 65+ Age 85+ Percent of Total U.S. Population 20% 15% 10% 5% 12.5% 12.7% 1.2% 1.6% 13.2% 1.9% 16.5% 2.1% 20.0% 20.5% 2.5% 3.8% 0% (248.8 Million) (275.3 Million) 2000 (299.9 Million) Million) 2020 (351.1 Million) 2030 (377.4 Million) 2040 What do we know about today s older Americans? Although older adults are only 13% of our population 26% of physician office visits 35% of all hospital stays 34% of all prescriptions 38% of all emergency medical service responses 70% of home health services 90% of all nursing home use Have multiple chronic conditions and experience more mental health conditions 66% of older adults have multiple chronic conditions (versus 25% overall) 20% meet the criteria for a psychological disorder Institute of Medicine, Retooling for an Aging America: Building the Health Care Workforce, 2008, accessed at Centers for Disease Control and Prevention. The State of Aging and Health in America Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; PDF and interactive version available at

3 Older People Are Different Atypical presentation of illness Multiple concurrent problems Non-specific symptoms Hidden illness Under-reporting Multiple losses condensed into a short time span Expected physiologic aging changes Social roles Common Misperceptions Most older adults are depressed Older adults are lonely Cognitive decline is inevitable with age OLDER ADULTS AND COGNITION Copyright 2015 Pearson Education, Inc. or its affiliates. All rights reserved. 9

4 Cognition Cognitive Aging Cognitive Impairment means there is a change in how a person thinks, reacts to emotions, or behaves. Can range from mild memory problems to an inability to think independently. Copyright 2015 Pearson Education, Inc. or its affiliates. All rights reserved. Cognitive Aging Cognitive aging (Yu et al., 2014) 44% experience no decline 35% experience moderate decline 13% experience severe decline 8% fluctuate Influences on cognition Age and education Physical exercise and cognitive training Disease/injury (40% of variance) Cognitive Changes with Age INTACT Motor learning Priming Semantic memory (not word finding) Episodic Memory for welllearned life events Passive short-term storage of information Recognition memory Prospective memory in the real-world DECREASE Working Memory especially with interference Encoding new information in deep elaborative way (less strategic) Retrieval (particularly when effortful) Uncued recall, prospective memory, recovery of specific details, source memory

5 Dementia vs. Age-related changes Signs of Dementia Poor judgment and decision making Inability to manage a budget Losing track of the date or the season Difficulty having a conversation Misplacing things and being unable to retrace steps to find them Typical Age-Related Changes Making a bad decision once in a while Missing a monthly payment Forgetting which day it is and remembering later Sometimes forgetting which word to use Losing things from time to time 13 Causes of Cognitive Impairment Can be present at birth Can be caused by abuse of prescription medications, alcohol, street drugs or other chemicals Can be caused by a disease Can be a side effect of some medications Can be caused by a trauma WHY ASSESS? BENEFITS? Copyright 2015 Pearson Education, Inc. or its affiliates. All rights reserved. 15

6 Cognitive Concerns Normal Aging Worried well, age-associated memory changes Mild Cognitive Impairment earliest stage of detectible cognitive problems Dementia or Neurocognitive Disorder Routine screening is not recommended in asymptomatic patients (USPSTF & VA) Medicare now provides annual eval for detection of cognitive impairment. Copyright 2015 Pearson Education, Inc. or its affiliates. All rights reserved. 16 Functional Consequences of Cognitive Impairment Forgetting Things already learned, Appointments, Self-care (including medication) Getting Lost Following Commands/Instructions Mood Depression, Anxiety Unpleasant Interpersonal Behavior Anger, Paranoia, Inappropriate Sexual Remarks/Actions Capacity Limitations Decision-Making: Financial, Medical Communication Deficits Receptive, Expressive Red Flags for Possible Cognitive Impairment Consistently poor historian Inattentive to appearance or inappropriate attire for weather Missed appointments or comes at wrong time or on wrong day Repeatedly and apparently unintentionally fails to follow instructions Has unexplained weight loss or failure to thrive Unable to adapt or function in new settings Defers to caregiver family member answers questions directed at patient Alzheimer s Association, 2003; Adapted from Elizabeth Clark, MD 18 18

7 Recognition of Cognitive Impairments - Importance Recognition allows: A framework for understanding symptoms Opportunity to build the right medical team Access to existing medications Opportunity to participate in research Access to programs and services Enhanced safety and security Opportunity to plan for the future Consideration of patient s ability to adhere to treatment recommendations 19 Recognition of Cognitive Impairments - Importance Increased risk for accidents, delirium, medical nonadherence, functional decline, falls, disability, and caregiver stress 4.9 million people >65 years old have AD currently Only 19% of people with AD have a diagnosis in their medical record. Studies show that only 25 to 40% of patients with moderate impairment are recognized in Primary Care Clinics Early and differential diagnosis is critical Effective treatments of depression or anxiety can improve cognitive functioning 20 Skills required for driving: Visual-perceptual skills Visual acuity Information processing Judgment Decision-making Performance of appropriate motor responses Sequencing Cognition Executive Functioning skills Memory Attention to detail

8 Cognitive Areas to Assess Mental Status/Orientation Sensory Skills Motor Skills/Balance Attention Processing Speed Memory Language Visual Spatial Reasoning Executive Functioning Reasoning/Judgement Diagnosis Diagnosis of Cognitive Impairment is made according to the type of impairment Diagnosis is made according to the Diagnostic and Statistical Manual-V criteria for the specific condition. NEUROCOGNITIVE DISORDER

9 DSM-5 Neurocognitive Disorders Dementia and amnestic disorder are now included under neurocognitive disorder (NCD). Dementia has been associated with the older population whereas NCD expands the category to also include etiologies occurring in younger adults. The term dementia is not excluded from use in etiological subtypes. Neurocognitive Disorders Neurocognitive Domains Complex Attention Executive Function Learning and Memory Language Perceptual-Motor Social Cognition 26 Neurocognitive Disorders Delirium Major and Mild Neurocognitive Disorders Major Neurocognitive Disorder Mild Neurocognitive Disorder Major or Mild Neurocognitive Disorder Due to Alzheimer s Disease Major or Mild Frontotemporal Neurocognitive Disorder Major or Mild Neurocognitive Disorder With Lewy Bodies Major or Mild Vascular Neurocognitive Disorder 27

10 Neurocognitive Disorders Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury Substance/Medication-Induced Major or Mild Neurocognitive Disorder Major or Mild Neurocognitive Disorder Due to HIV Disease Due to Prion Disease Due to Parkinson s Disease Due to Huntington s Disease Due to Another Medical Condition Due to Multiple Etiologies 28 Delirium Key Features: Rapid and Abrupt onset of: Impaired Attention Lack of Awareness of environment Change in at least ONE Cognitive Domain: Recent Memory Orientation Language (i.e. rambled speech, mumbling, difficult to understand) Perceptual Disturbance Associated Features Change in sleep-wake cycle Change in emotional states Worsening of behavioral problems in the evening Copyright 2015 Pearson Education, Inc. or its affiliates. All rights reserved. 29 Comparative Features of Dementia and Delirium 30

11 DSM-5 Criteria for Mild Neurocognitive Disorder Modest cognitive decline from previous levels in one or more domains based on both of the following: o Concerns of the patient, a knowledgeable other, or a clinician o modest impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. The cognitive deficits do not interfere with independence (i.e., tasks such as paying bills or managing medications), even though greater effort, compensatory strategies, or accommodation may be required to maintain independence. The cognitive deficits do not occur exclusively in the context of a delirium and are not due to another psychological disorder 31 DSM-5 Criteria for Major Neurocognitive Disorder Evidence of significant cognitive decline from previous levels in one or more domains based on both of the following: o Concerns of the patient, a knowledgeable other, or a clinician o Substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. The cognitive deficits interfere with independence The cognitive deficits do not occur exclusively in the context of a delirium and are not due to another psychological disorder (Rosen, A. Neurocognitive Disorders of the DSM-5. VA Palo Alto) 33

12 AGING VS DISEASE CONTINUUM Normal Aging Mild Neurocognitive Disorder Major Neurocognitive Disorder Primarily intact cognition, subtle processing speed slowing, & less efficient attention & executive reasoning Decline from lifelong abilities in 1 or more areas of thinking + inefficiency in daily activities Needs help with daily activities + substantial decline in 1 or more cognitive abilities (Adapted from Reynolds Institute on Aging, SR Cassidy) Alzheimer s Disease Described by Alois Alzheimer in 1906 Irreversible brain tissue deterioration Death usually occurs within 12 years Usually begins with Difficulty remembering recent events Learning new material Irritability As disease progresses Language problems intensify, including word-finding Disorientation Time, place, and identity confusion Agitation Depression 35 Alzheimer s Association s 10 Warning Signs Memory loss that affects job skills Difficulty performing familiar tasks Problems with language Disorientation to place and time Poor or decreased judgment Problems with abstract thinking Misplacing things Changes in mood or behavior Changes in personality Loss of initiative 36

13 MAJOR OR MILD VASCULAR NEUROCOGNITIVE DISORDER Criteria are met for major or mild NCD Clinical features are consistent with a vascular etiology, as suggested by the following: Onset of cognitive deficits is temporally related to 1 or more cerebrovascular events Evidence for decline is prominent in complex attention (including processing speed) and frontal-executive function. There is evidence of the presence of cerebrovascular disease from history, physical examination, and/or neuroimaging considered sufficient to account for the neurocognitive deficits. The symptoms are not better explained by another brain disease or systemic disorder. PROPORTIONAL RANGE OF DEMENTIA SUBTYPES Neurocognitive Disorders Domain Complex attention Executive abilities Learning/memory Language Visuoconstruction Visuoperception Social cognition Domains Tasks Major: diminished, multiple stimuli Mild: takes longer Major: abandon complex activities Mild: effort, multi-tasking Major: repeat self in conversation Mild: recent events, occasionally repeat Major: anomia, paraphasias Mild: Ø naming, word finding Major: not driving, Ø navigation Mild: maps, effort Major: insensitivity social contexts Mild: subtle personality, Ø empathy 39

14 ASSESSMENT PROCESS AND DOMAINS Domains of Comprehensive Geriatric Assessment Medical Functional (ADL & IADL) Mobility, Gait, Balance Vision and hearing Cognitive Mental status/orientation Memory Language Praxis Motor Speed / Psychomotor Processing Attention Executive Functioning Behavior Affective Social Support Environmental Economic Factors Quality of life Nutrition Factors that Influence Performance Poor vision or hearing Impaired gross- or fine-motor skills Medication Intellectual disability Severely impaired language functioning Severely impaired attention Significant Impulsivity Poor effort Lack of cooperation Fatigue Severely slowed psychomotor speed Psychological impairments Literacy, including to technology

15 Factors to consider when choosing tools 1. Tests need to be appropriate for age: a. Valid: does it measure what it claims to? b. Reliable: over time & between administrators c. Standardization sample/norms d. Developed specifically for older adults 2. Time to administer 3. Skill required & ease of administration 4. Appropriate for culture, language & education 5. Clinical utility vs. research 6. Stimulus materials Clinical Considerations in assessing the older adult Encourage maximal level of performance Establish rapport Use of appropriate corrective devices Environmental concerns (lighting, ventilation, temperature, free from distractions) Physical and sensory limitations Stimulus materials Literacy Process Factors It can be helpful to make some introductory conversation, talk about everyday things, maybe share a bit about yourself. Slow the pace where possible. Short testing sessions. Be aware of cultural factors. It is also very helpful to take time to discuss what a psychologist does with particular emphasis on providing information that will help them. More time taken to build rapport yields more accurate test results. Before testing, check for sensory deficits. Check medications.

16 Cognitive Screening: Goals To assess multiple areas of cognitive function quickly To identify areas of cognitive dysfunction To screen in such a way that the results are reliable, valid and clinically relevant for patient care, safety and selfesteem To be practical about what is possible in the setting and the patient population Instruments Brief Cognition Assessment/Screening Brief Cognitive Status Exam (BCSE) Mini-Cog Mini Mental State Examination (MMSE) Montreal Cognitive Assessment (MoCA) St. Louis University Mental Status Exam (SLUMS) Cognitive Assessment of Minnesota (CAM) Kokmen Test of Mental Status AD8 Comprehensive Cognitive Assessment Repeatable Battery for the Assessment of Neuropsychological Status Update (RBANS Update) 47 Instruments cont. Memory Wechsler Memory Scale Fourth Edition Wide Range Assessment of Memory and Learning Second Edition Rivermead Behavioral Memory Test Third Edition Rey Auditory Verbal Learning Test (RAVLT) California Verbal Learning Test Second Edition Language Boston Naming Test PPVT3 Controlled Oral Word Association Test (COWAT)

17 Instruments cont. Executive Functioning Delis-Kaplan Executive Functioning Scale (DKEFS) Behavioral Assessment of the Dysexecutive Syndrome Second Edition (BADS) The Executive Interview (EXIT-25) General Cognition Wechsler Adult Intelligence Scale Fourth Edition Woodcock Johnson-IV Stanford Binet IV Neuropsychological Assessment Battery Social Cognition ACS Social Cognition Social Perception Faces Names Interpretive Guidelines for Detecting and Characterizing Neurocognitive Impairment in the Elderly 1. Is there evidence for some type of acquired impairment? 2. What is the nature of the deficits? If deficits are detected, two additional questions become relevant: 3. What is the likely associated disease process? 4. What interventions are appropriate? 50 First Clarify the referral question Understand who the testing is for (who is the client or customer) Understand available history Medical Educational Occupational Family Copyright 2015 Pearson Education, Inc. or its affiliates. All rights reserved. 51

18 Evaluation Process Interview History Medical Record Review Observation Assessment Evaluation should be multidisciplinary Interview Current mental status Understanding of purpose of evaluation Prior psychiatric history Social aspects of client s situation History Can be most important part of evaluation Information gathered from patient and from collateral sources (family or other person with knowledge of patient) Description of behaviors, cognitive and memory functioning and problems and their effect on Activities of Daily Living (ADL) Onset time/course of illness/problems Looking for treatable causes

19 Medical Record Review Medical history not obtained from patient or collateral Medications Serum and Urine analysis Alcohol Specific Drug Levels Imaging (CT/MRI/PET) Behavioral Reports (compliance, changes) Observation Ability to learn and retain new information Handle complex tasks Reasoning ability Spatial ability and orientation Language Behavior Gait Vision and hearing Formal Assessment Testing is performed in a structured, controlled environment Patient is seen alone Test results are compared with scores from other patients the same age and education levels

20 Domains of Cognitive Testing Attention Executive Functioning Language/Verbal Ability Visuospatial and Visuoconstructional Function (Perceptual Motor) Memory Affect Psychological Functioning Attention Determines which information is perceived, processed, and remembered. Selective attention ability to choose task on which to attend. Focused attention ability to maintain focus on task in presence of distraction Divided attention ability to allocate mental resources between tasks performed together or at same time. Sustained attention ability to sustain mental resources on task over longer periods of time. Affects all ADLs Executive Functioning Ability to plan and carry out behavior consistent with cues and task requirements and to flexibly adjust behavior in response to changing task requirements. Development of task strategies, problem solving, conceptual inference, awareness of the quality of intellectual function and recognition and display of socially inappropriate behavior.

21 Executive Function impairment often leads to: Socially inappropriate behavior Inability to apply consequences from past actions Difficulty with abstract concepts (the inability to make the leap from the symbolic to the real world) Difficulty in planning and initiation (getting started) Difficulty with verbal fluency Language/Verbal Ability Speech Comprehension (Receptive Speech) Ability to respond to questions Ability to react appropriately to comments Ability to respond to instructions for simple tests Expressive speech Fluency Articulation Prosody Naming Repetition Perceptual Motor Involved in processing and manipulation of visual information from the environment. Maneuvering wheelchair down the hall Locating other people or items in busy environment Includes both written words and nonverbal stimuli such as picture, faces, and other images Impacts driving, food preparation, use of tools

22 Memory Most common referral concern Nature of complaint important: Recent vs. Remote Immediate vs. Delayed Verbal vs. Visual Recall, Recognition Testing evaluates ability to acquire, store, and retrieve information in memory Related to ability to self-medicate, manage finances, remember appointments, cook, drive Impacts all other areas Social Cognition Recognition of emotions Theory of Mind Copyright 2015 Pearson Education, Inc. or its affiliates. All rights reserved. 65 Affect Assessment also includes evaluation of depression and anxiety Information gathered during the interview Use of questionnaires to assess presence of depressive or anxious symptoms Findings from testing

23 INTEGRATING RESULTS AND MAKING REFERRALS 67 Integrate All Information Results from all measures should always be integrated with functional information such as that gathered from measures/techniques such as Texas Functional Living Scale (TFLS) linked with the WAIS-IV and WMS-IV used to assess activities of daily living (ADLs) Clinical Interviews Caregiver/family information Objective social-emotional/psychiatric Example = Beck Scales Thorough history Medical information Remember to check for vision, hearing, motor, medication contributions to performance. Recommendations for Attentional Impairments Evaluate for delirium Minimize presented information Keep instructions simple (one-step or two-steps at a time) Speak slowly, giving the person time to process each unit of information; speak in brief phrases or short sentences. Frequently orient the person (if appropriate for patient) Patient may need multiple chances to learn new information. Patient may have difficulty responding to rapidly changing task demands.

24 Recommendations for Executive Impairments Persons with executive impairment may need help with anything from dressing themselves to medical decisionmaking and financial planning and management The worse the impairment, the more structured and controlled environment is needed (but provide least restrictive support) Don t take inappropriate behavior personally! Avoid assuming an impaired person can really do something when he or she can t! Recommendations for Executive Impairments cont. Maintain a familiar environment Keep everything orderly Avoid use of dangerous appliances, tools, machinery No driving Maintain a familiar routine Maintain consistent caregiver behavior Redirect; don t argue or scold Recommendations for Language Impairments Refer for speech evaluation Use one- or two-step commands if comprehension is a problem Avoid long sentences Ask Yes-No questions Use alternative communication devices Pointing and gesturing may be helpful Emphasize visual communication Consider evaluation with speech therapist

25 Recommendations for Visual-Spatial Impairments Rule out vision problems For neglect, place objects to one side Emphasize verbal communication Establish strong, simple environmental cues Provide safety measures if person wanders or gets lost Patient may have difficulty locating objects in L or R visual field. Patient may need assistance with tasks involving visuospatial skills. Patient should not operate a motor vehicle or machinery. Recommendations for Memory Impairments (visual) include use of calendars, notes, pictures, other cues (verbal) include repeating directions over and over, use of strategies to remember names or other information, such as saying information out loud, repeating it, making associations, restating, use of audio recorder to cue. Emphasize remote memories, and de-emphasize recent memories Simplify the environmental demands Establish routines and structured environments Recommendations for Memory Impairments cont. Be patient! Keep incoming information simple Have the person repeat information Give the person multiple trials of learning Provide clues when asking questions Use memory assistance: e.g., notes, visual cues, alarms, calendars, pictures

26 Recommendations Need For Further Assessment Administer additional neuropsychological testing Recommend medical or neurological evaluation including neuroimaging where appropriate Recommend a psychiatric evaluation Recommend an assessment of specific functional capacities and in-home safety Consider evaluation by social worker, visiting nurse, or case manager of the patient s living situation and family, community, and fiscal resources. Substance use/abuse Suicide Firearm presence/safety Mood Nutrition Capacity SLP 76 Recomendations cont. Need For Further Treatment Medications or other agents may be indicated to treat the cognitive symptoms of dementia. Psychoactive medications may be indicated to manage other symptoms associated with dementia (psychosis, agitation, depression, anxiety, sleep disturbance) Psychosocial interventions may be helpful, including Behavior-oriented treatments Stimulation-oriented treatments Emotion-oriented treatments Cognition-oriented treatments focused on specific deficits may be warranted in patients with sufficiently preserved cognition. Environmental changes such as making adjustments in the residential environment 77 78

27 Resources APA Office on Aging: apa.org/pi/aging American Psychological Association: Assessment of Older Adults, American Psychological Association: Guidelines for Psychological Practice with Older Adults American Psychologist, 59 (1) American Psychological Association, Section 12, Division II; American Society on Aging; Alzheimer s Association Clinical Geropsychology: gerocentral.org Center for Disease Control: cdc.gov/aging Gerontological Society of America; Lichtenberg, PA (Ed.) (1999). Handbook of Assessment in Clinical Gerontology. NY: John Wiley & Sons.

28 Resources (cont.) Mental Health: A report of the Surgeon General. Chapter 5: Older Adults and Mental Health. 1.html National Council on Aging; National Institute on Aging at NIH: Psychotherapy and Older Adults Resource Guide: An extensive list of resources relevant to assessment and treatment of older adults. Substance Abuse and Mental Health Services Administration (SAMHSA); U.S. Census Bureau, P23-212, 65+ in the United States: 2010, U.S. Government Printing Office, Washington, DC, U.S. Census Bureau (2012). Projections of the Population by Age and Sex for the United States: 2015 to 2060 (NP2012-T12). Zarit, SH, Zarit JM, (2007). Mental Disorders in Older Adults: Fundamentals of Assessment and Treatment (2nd ed.). New York Customer Service (USA) (Canada) Questions Anne-Marie.Kimbell@Pearson.com