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Psychological Assessment - Assessment Strategies And Clinical Conditions

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Due to the complex nature of assessment with older persons, multiple strategies are often used in combination to elicit the most comprehensive and meaningful description of the older individual.

Clinical interview. The clinical interview is perhaps the most important and informative strategy during an evaluation of an older person. During the interview, the clinician gathers information about the person's current difficulties (the presenting problem), including a history of the problem. Other topics include an in-depth personal history, psychiatric treatment history, family history, mental status, and level of social functioning. It is important to develop rapport with the older person to allow him or her to disclose intensely personal information. Clinicians should explain clearly the purposes and procedures of the assessment and show respect for the older person. Any concerns the person may have about the evaluation should be addressed, since many older adults associate psychiatric services with tremendous shame and stigmatization.

It is imperative that clinicians fully assess concomitant medical conditions and medication use. This is important because many medical illnesses, and the medications used to treat them, can cause psychiatric conditions (e.g., delirium, depression, anxiety, psychosis). Diverse drug interactions can cause memory problems that mimic a dementing illness, such as Alzheimer's disease. Older adults are encouraged to bring a complete listing of medications to the testing session. Referral for a thorough medical work-up is always indicated if the person has not recently been medically evaluated.

Interviewers need to be flexible when engaging older persons. The environment should be adjusted to reduce the impact of any sensory or physical limitations (e.g., brightly lit and quiet testing room; use of large-print versions of tests). Traditional time constraints should be adjusted to not fatigue the older person. A final tenet in geriatric assessment is to involve close family members and/or caregivers in the assessment to gather corroborative or additional information about the person.

Personality assessment. Personality tests strive to uncover the structure and features of one's personality, or one's characteristic way of thinking, feeling, and behaving. Objective personality tests are self-report pencil-and-paper tests based on standardized, specific items and questions. In contrast, projective tests present stimuli whose meanings are not immediately obvious and have an open-ended response format, such as a story from the respondent.

The most popular objective personality test is the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). The MMPI-2 has ten standard clinical scales (e.g., depression, schizophrenia, social introversion) and three validity scales to detect unusual test-taking attitudes. The MMPI-2 is widely utilized with older adults, although separate norms for older adults are not readily available and there is concern that some older adults may receive inaccurately elevated depression scores due to the high number of somatic items on the scale.

The Rorschach Inkblot Test and the Thematic Apperception Test (TAT) are popular projective tests. During the Rorschach Test, the respondent provides associations to ten bilaterally symmetrical inkblots. The TAT consists of thirty-one black and white pictures that tend to induce particular themes, such as sexuality and achievement. Typically, ten to twenty cards are administered and the respondent is asked to create a story about each picture. Though not developed specifically for older persons, both tests are used with older adults. Two projective measures designed for older adults include the Geriatric Sentence Completion Form (which provides provocative age-appropriate sentence "stems" that are completed by the respondent) and the Senior Apperception Test (which has age-relevant pictures and themes).

Symptom checklists. Self-report checklists have been developed for hundreds of psychological constructs. Fortunately, several elder-specific checklists are available and they have excellent psychometric properties. Some stellar examples include the Geriatric Depression Scale (GDS), the Geriatric Hopelessness Scale (GHS), and the Michigan Alcoholism Screening Test—Geriatric Version (MAST-G).

The GDS is one of the best screening measures for depression in older adults. It consists of thirty items presented in a simple Yes/No format. Items focus on cognitive and behavioral aspects of depression, and somatic items are excluded. The scale is in the public domain, and is available, with the scoring key, on the GDS website at http://www.stanford.edu/~yesavage/GDS.html. The GHS is a thirty-item Yes/No self-report scale that assesses pessimism and hopelessness in older adults, both of which are related to suicide. The MAST-G is used for substance abuse assessment, which is a significant problem among older persons and is linked to depression and suicide. The MAST-G contains twenty-four Yes/No items unique to older problem drinkers. In all cases, "yes" is the pathological response, and a cutoff of five positive responses indicates an alcohol problem.

Cognitive functioning. Assessment of cognitive functioning is an important part of any thorough geriatric assessment, since cognitive impairment (e.g., dementia) is an age-related problem (e.g., rates of dementia increase with age). Notably, other test results may not be valid if the respondent has significant cognitive impairment. Early detection of cognitive problems is crucial because many symptoms are reversible, especially for delirium. The primary DSM-IV cognitive disorders are delirium and dementia. Delirium refers to a clouding of consciousness with impaired concentration, disorientation, and perceptual disturbances that develop over a short period of time (hours to days). Since delirium is often obvious and acute, there are no specific tests for it. If delirium is suspected in an older person, they should be quickly referred for medical treatment, since delirium is typically reversible but can be deadly if the underlying cause (e.g., infections, malnutrition) is not corrected.

Dementia is a syndrome of multiple cognitive deficits that include memory impairment, but without impairment in consciousness. The most common type of dementia is Alzheimer's disease, which accounts for 50 to 60 percent of demented persons. It is important for clinicians to screen for dementia in all older clients during a psychological assessment. Several brief, standardized, and easily administered screening tools are available. The Folstein Mini-Mental State Examination takes five to ten minutes to administer and is well-validated. Items tap orientation, concentration, memory, language, and gross motor skills. Scores range from 0 to 30, with scores under 25 indicating a need for further testing and evaluation. The Dementia Rating Scale is a psychometrically sound, interviewer administered test designed for dementia evaluation. It consists of thirty-six tasks and takes about thirty minutes to complete.

Should concern about cognitive impairment result from a screening test, more thorough neuropsychological testing is warranted. Such testing assesses brain-behavior relationships in multiple domains and behavioral disturbances that are caused by brain dysfunction, and also helps to quantify and localize brain damage. One approach is for the examiner to use a standard and fixed battery (e.g., the Halstead-Reitan Battery), whereas another strategy is to carefully choose a variety of different tests to assess particular neuropsychological domains of interest. Finally, laboratory tests (e.g., electrolyte panel, urinalysis, electroencephalography) and high-tech brain-imaging procedures (e.g., CAT scan, MRI scan) are often used to complement neuropsychological assessment.

Assessment of intelligence is another important area. Intelligence tests are standardized tests designed to measure a person's mental ability. The two prominent tests are the Stanford-Binet Intelligence Test, fourth edition and the Wechsler Adult Intelligence Scale, third edition (WAIS-III). The WAIS-III consists of fourteen separate subtests: seven verbal and seven performance. Raw scores for each subtest are converted into scaled scores, and score sums are converted into a verbal intelligence quotient, a performance intelligence quotient, and a full-scale intelligence quotient. Both tests have extensive age-norms and are the leading measures of intelligence assessment across much of the life span.

DANIEL L. SEGAL

BIBLIOGRAPHY

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, D.C.: APA, 1994.

BLOW, F. C.; BROWER, K. J.; SCHULENBERG, J. E.; DEMO-DANANBERG, L. M.; YOUNG, J. P.; and BERESFORD, T. P. "The Michigan Alcoholism Screening Test—Geriatric Version (MAST-G): A New Elderly-Specific Screening Instrument." Alcoholism 16 (1992): 372.

BUTCHER, J. N.; DAHLSTROM, W. G.; GRAHAM, J. R.; TELLEGEN, A.; and KAEMMER, B. MMPI-2: Manual for Administration and Scoring. Minneapolis: University of Minnesota Press, 1989.

FOLSTEIN, M. F.; FOLSTEIN, S. E.; and MCHUGH, P. R. "Mini Mental State: A Practical Method for Grading the Cognitive State of Patients for the Clinician." Journal of Psychiatric Research 12 (1975): 189–198.

FRY, P. S. "Assessment of Pessimism and Despair in the Elderly: A Geriatric Scale of Hopelessness." Clinical Gerontologist 5 (1986): 193–201.

MATTIS, S. Dementia Rating Scale. Odessa, Fla.: Psychological Assessment Resources, Inc., 1988.

MURRAY, H. A. Thematic Apperception Test. Cambridge, Mass.: Harvard University Press, 1943.

RORSCHACH, H. Psychodiagnostik. Bern: Hans Huber, 1921; 1946.

YESAVAGE, J. A.; BRINK, T. L.; ROSE, T. L.; LUM, O.; HUANG, V.; ADEY, M. B.; and LEIRER, V. O. "Development and Validation of a Geriatric Depression Screening Scale: A Preliminary Report." Journal of Psychiatric Research 17 (1983): 37–49.

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