Download Mental Health: Research Methods Teaching Module

Mental Health & Aging
Research Methods
California State University, Los Angeles, School of Social Work
This module is designed to introduce first year MSW students to research issues in the field of geriatric
mental health. Topics include dominant psychometric measures used in geropsychiatric field; strengths
and limitations of psychometric measures as they relate to older adults; evidence-based treatment
practices in the field of gero mental health; and areas requiring further research and understanding.
Objectives and Competencies:
1. Identify dominant psychometric measures used to detect normal versus morbid mental status
among the aging
2. Develop a basic understanding of the indications and administration of dominant psychometric
measures in gerontology
3. Develop and understanding of the strengths and limitations psychometric measures in detecting
mental illness among older adults
4. Understand the development and rationale behind the use of evidenced based practices in
geropsychiatry.
Introduction
Much of research in the field of geropsychiatry has focused on the development of appropriate detection
and diagnosis of varying types of mental illness among older adults. While progress in this area has been
achieved, there remains a lack of research data sufficient to support an understanding of the biological,
social, and cultural factors related to mental health in older adults. This module will focus on the
principal diagnostic tools used by clinicians to detect psychological morbidity among older adults; their
administration; strengths and limitations of these measures; and considerations for future research in the
field of aging and mental health.
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Dominant Psychometric Measures in Geropsychiatry
Geriatric Depression Scale (GDS)
Roughly five million older adults age 65 and older suffer from depression. The condition is generally
reversible however if left undetected and untreated depression can lead to more serious consequence for
older adults including: physical, cognitive and social impairment; delayed recovery from illness and/or
surgery; increased health care utilization and suicide. The Geriatric Depression Scale was developed by
for detect mild to major depressive symptoms in older adults and may be used with patients who are
healthy, medically ill and have mild to moderate cognitive impairment. The scale is reported to have 92%
sensitivity and 89% specificity when evaluated against diagnostic criteria for depression and has
demonstrated validity and reliability in clinical practice and research (Kurlowicz, 1999).
Administration
The patient is asked a series of 30 yes/no questions designed to evaluate their degree of depressive
symptoms. The Examiner assigns a numeric score of 1-30 based upon the patient’s answers. Numeric
indicators are interpreted as follows: a score between 0-9 normal; 10-19 mild depression; 20-30 severe
depression.
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Geriatric Depression Scale (Yesavage, et. al., 1983)
www.standford.edu/nyesavage/gds.html
Patient___________________________________ Examiner_____________________________
Date____________
Directions to Patient: Please choose the best answer for how you have felt over the past week.
Directions to Examiner: Present questions VERBALLY. Circle answer given by patient. Do not show to
patient.
1. Are you basically satisfied with your life? . . . . . . . …………..….……... . . . . yes no (1)
2. Have you dropped many of your activities and interests? ………………….. . . yes (1) no
3. Do you feel that your life is empty? …………... . …………….. . . . ….. . . . .. . yes (1) no
4. Do you often get bored? . . . . . . .. . . . . . . . . . . . . . . . . . . . ………….……..…. yes (1) no
5. Are you hopeful about the future? . . . . . …………………. . . . . . . . . … . . . .. . yes no (1)
6. Are you bothered by thoughts you can t get out of your head?.......................... yes (1) no
7. Are you in good spirits most of the time? . . . . . . . . . . . . . . . . . . . ……… . . . . yes no (1)
8. Are you afraid that something bad is going to happen to you? . . . . . . . . …. . . yes (1) no
9. Do you feel happy most of the time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . …. . yes no (1)
10. Do you often feel helpless? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. yes (1) no
11. Do you often get restless and fidgety? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes (1) no
12. Do you prefer to stay at home rather than go out and do things? . . . . . . . . . . yes (1) no
13. Do you frequently worry about the future? . . . . . . . . . . . . . . . . . . . . . . . . . …. yes (1) no
14. Do you feel you have more problems with memory than most? . . . . . . . . . . . yes (1) no
15. Do you think it is wonderful to be alive now? . . . . . . . . . . . . . . . . . . . . . . . ….yes no (1)
16. Do you feel downhearted and blue? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . …. yes (1) no
17. Do you feel pretty worthless the way you are now? . . . . . . . . . . . . . . . . . . . .. yes (1) no
18. Do you worry a lot about the past? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … yes (1) no
19. Do you find life very exciting? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ….. yes no (1)
20. Is it hard for you to get started on new projects? . . . . . . . . . . . . . . . . . . . . . … yes (1) no
21. Do you feel full of energy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . …. yes no (1)
22. Do you feel that your situation is hopeless? . . . . . . . . . . . . . . . . . . . . . . . . . . . yes (1) no
23. Do you think that most people are better off than you are? . . . . . . . . . . . . . .. yes (1) no
24. Do you frequently get upset over little things? . . . . . . . . . . . . . . . . . .. . . . . . . yes (1) no
25. Do you frequently feel like crying? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … yes (1) no
26. Do you have trouble concentrating? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … . yes (1) no
27. Do you enjoy getting up in the morning? . . . . . . . . . . . . . . . . . . . . . .. . . . .. ... yes no (1)
28. Do you prefer to avoid social occasions? . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . yes (1) no
29. Is it easy for you to make decisions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . yes no (1)
30. Is your mind as clear as it used to be? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . yes no (1)
TOTAL: Please sum all bolded answers (worth one point) for a total score. ______________
Scores: 0 - 9 Normal 10 - 19 Mild Depressive 20 - 30 Severe Depressive
Limitations
This instrument is limited in its ability to detect symptoms of depression which may be unique to cultural
expression. In Latino/Hispanic American, African American and Asian American/Pacific Islander
cultures for example, symptoms of depression and/or anxiety are more likely to be experienced and
presented as physical or somatoform disturbances versus overt feelings of hopelessness or lack of
pleasure.
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Confusion Assessment Method (CAM)
Approximately 15 - 60 % of older patients experience a delirium prior to or during a hospitalization but
the diagnosis is missed in up to 70% of cases. Delirium is associated with poor outcomes such as
prolonged hospitalization, functional decline, and increased use of chemical and physical restraints.
Delirium increases the risk of nursing home admission. Individuals at high risk for delirium should be
assessed daily using a standardized tool to facilitate prompt identification and management
Administration
The Confusion Assessment Method (CAM) includes two parts (Waszynski, C, 2001 and Inouye et. al.,
1990). Part one is an assessment instrument that screens for overall cognitive impairment. Part two
includes only those four features that were found to have the greatest ability to distinguish delirium or
reversible confusion from other types of cognitive impairment. The instrument is administered using
objective observations of the client’s behavior by the examiner. Assessment generally takes 5 minutes
with presence of delirium indicated by the algorithm. Concurrent validation with psychiatric diagnosis
revealed sensitivity of 94-100% and specificity of 90-95%. The CAM is significantly correlated with the
Mini-Mental Status Examination.
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The Confusion Assessment Method Instrument (Part 1):
1. [Acute Onset] Is there evidence of an acute change in mental status from
the patient’s baseline?
2A. [Inattention] Did the patient have difficulty focusing attention, for
example, being easily distractible, or having difficulty keeping track of what
was being said?
2B. (If present or abnormal) Did this behavior fluctuate during the interview,
that is, tend to come and go or increase and decrease in severity?
3. [Disorganized thinking] Was the patient’s thinking disorganized or
incoherent, such as rambling or irrelevant conversation, unclear or illogical
flow of ideas, or unpredictable switching from subject to subject?
4. [Altered level of consciousness]. Overall, how would you rate this
patient’s level of consciousness? (Alert [normal]; Vigilant [hyperalert, overly
sensitive to environmental stimuli, startled very easily], Lethargic [drowsy,
easily aroused]; Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain)
5. [Disorientation] Was the patient disoriented at any time during the
interview, such as thinking that he or she was somewhere other than the
hospital, using the wrong bed, or misjudging the time of day?
6. [Memory impairment] Did the patient demonstrate any memory problems
during the interview, such as inability to remember events in the hospital or
difficulty remembering instructions?
7. [Perceptual disturbances] Did the patient have any evidence of
perceptual disturbances, for example, hallucinations, illusions or
misinterpretations (such as thinking something was moving when it was
not)?
8A. [Psychomotor agitation] At any time during the interview did the patient
have an unusually increased level of motor activity such as restlessness,
picking at bedclothes, tapping fingers or making frequent sudden changes of
position?
8B. [Psychomotor retardation]. At any time during the interview did the
patient have an unusually decreased level of motor activity such as
sluggishness, staring into space, staying in one position for a long time or
moving very slowly?
9. [Altered sleep-wake cycle]. Did the patient have evidence of disturbance
of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia
at night?
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The Confusion Assessment Method (CAM) Diagnostic Algorithm (Part 2)
Feature 1: Acute Onset and Fluctuating Course
This feature is usually obtained from a family member or nurse and is shown by
positive responses to the following questions: Is there evidence of an acute change
in mental status from the patient’s baseline? Did the (abnormal) behavior fluctuate
during the day, that is, tend to come and go, or increase and decrease in severity?
Feature 2: Inattention
This feature is shown by a positive response to the following question: Did the
patient have difficulty focusing
attention, for example, being easily distractible, or having difficulty keeping track
of what was being said?
Feature 3: Disorganized thinking
This feature is shown by a positive response to the following question: Was the
patient’s thinking disorganized or
incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of
ideas, or unpredictable switching
from subject to subject?
Feature 4: Altered Level of consciousness
This feature is shown by any answer other than “alert” to the following question:
Overall, how would you rate this patient’s level of consciousness? (alert [normal]),
vigilant [hyperalert], lethargic
[drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])
The diagnosis of delirium by CAM requires the presence of features 1 and 2 and
either 3 or 4.
http://www.bendigoheatlh.org.au/Regional-Dementia-Management/CAM.html
Limitations
The CAM identifies the presence or absence of delirium but does not assess the severity of the condition,
making it less useful to detect clinical improvement or deterioration.
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Mini Mental Status Examination
The Folstein Mini-mental Status Examination (Folstein et al, 1975) is used by gerontological clinicians to
assess for older adults level of cognitive function or decline. The exam is used extensively in
geropsychiatry and has demonstrated reliability and validity in clinical treatment and research settings.
Administration
Subjects are asked a series of 11 questions which involve verbal, written, and task oriented questions.
The Exam assesses patients’ orientation, attention, memory, verbal fluency, language, and visuospatial
ability. Each question has an assigned score which is known only to the examiner. Scores for each
question are tabulated to provide a cumulative value (maximum 30 points). A score of 24 or higher is
considered normal. Lower scores are indicative of cognitive impairment.
Mini Mental Status Examination
Folstein Mini Mental Status Examination
Task
Instructions
Scoring
Date
Orientation
"Tell me the date?" Ask for omitted items.
One point each for year, season,
5
date, day of week, and month
Place
Orientation
"Where are you?" Ask for omitted items.
One point each for state, county,
town, building, and floor or
5
room
Register 3
Objects
Name three objects slowly and clearly. Ask the patient
to repeat them.
One point for each item
correctly repeated
3
Ask the patient to count backwards from 100 by 7. Stop
One point for each correct
Serial Sevens after five answers. (Or ask them to spell "world"
answer (or letter)
backwards.)
5
Recall 3
Objects
Ask the patient to recall the objects mentioned above.
One point for each item
correctly remembered
3
Naming
Point to your watch and ask the patient "what is this?"
Repeat with a pencil.
One point for each correct
answer
2
Repeating a
Phrase
Ask the patient to say "no ifs, ands, or buts."
One point if successful on first
try
1
Verbal
Commands
Give the patient a plain piece of paper and say "Take
One point for each correct
this paper in your right hand, fold it in half, and put it on
action
the floor."
3
Written
Commands
Show the patient a piece of paper with "CLOSE YOUR
EYES" printed on it.
One point if the patient's eyes
close
1
Writing
Ask the patient to write a sentence.
One point if sentence has a
1
subject, a verb, and makes sense
Drawing
Scoring
Ask the patient to copy a pair of
One point if the figure has ten
intersecting pentagons onto a piece of corners and two intersecting
paper.
lines
A score of 24 or above is considered normal.
1
30
* Family Practice Notebook, LLC (2000). Mini Mental State Exam. Retrieved February 22, 2004 from
http://www.fpnotebook.com/nev70.htm
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Limitations
The MMSE has scoring limitations which lend themselves to cultural and/or class bias. Individuals who
have a higher level of education have a greater propensity to score false negative while those with lower
educational attainment may test false positive.
Interpretation of Mini-mental State Score (Maximum: 30)
A. Normal score: 24 or higher
B.
Educational and Age Norms
1.
Fourth Grade Education
a.
Ages 18 to 69: Median MMSE Score 22-25
b.
Ages 70 to 79: Median MMSE Score 21-22
c.
Age over 79: Median MMSE Score 19-20
2.
Eighth Grade Education
a.
Ages 18 to 69: Median MMSE Score 26-27
b.
Ages 70 to 79: Median MMSE Score 25
c.
Age over 79: Median MMSE Score 23-25
3.
High School Education
a.
Ages 18 to 69: Median MMSE Score 28-29
b.
Ages 70 to 79: Median MMSE Score 27
c.
Age over 79: Median MMSE Score 25-26
4.
College Education
a.
Ages 18 to 69: Median MMSE Score 29
b.
Ages 70 to 79: Median MMSE Score 28
c.
Age over 79: Median MMSE Score 27
Evidenced based practice
The notion of evidenced based practice has become an area of emphasis in many practices settings in the
social science arena. Older adult mental health is no exception to this notion. Evidenced based practices
advance the field of geropsychiatry in the following ways:
 Establishes an understanding of what interventions are effective
 Distinguish which population(s) a particular intervention is (or is not) effective for
 Aides the practitioner in developing an understanding of how one appraises his/her situation
 Establishes what theoretical construct should be targeted for intervention
For example, it should be noted that various culture’s subjective view of distress is experienced and
expressed in different ways. In studies of care giver stress it was found that persons of various cultures
identified shame of requiring caregiver assistance and/or lack of knowledge as a significant source of
stress rather than the need for assistance alone. It is therefore indicated that interventions aimed at this
population should emphasis ways to decrease shame and increase knowledge associated with care giving
rather than provided traditional approaches to relieving stress such as relaxation and meditation
techniques.
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References
Council on Social Work Education (2002). Strengthening Aging and Gerontology Education for Social
Work (SAGE-SW) program. Teaching Resource Kit. Section 8: other Infusion materials and
Exercises. www.cswe.org/sage-sw
Kurlowicz, L. (1999). The Geriatric Depression Scale (GDS). Try this: Best Practices in Nursing Care to
Older Adults. The Hartford Institute for Geriatric Nursing. New York University. Issue Number 4,
May
Family Practice Notebook, LLC (2000). Mini Mental State Exam. Retrieved February 22, 2004 from
http://www.fpnotebook.com/NEU70.htm
Folstein, M. F., Folstein, S. E. & Mchugh, P.R. (1975) mini-mental state: A practical method for grading
the state of patients for clinician. Journal of Psychiatric Research, 12:189-198
Waszynski, C. (2001) Confusion Assessment Method (CAM) Try This: Best Practices in Nursing Care to
Older Adults from the Institute on Geriatric Nursing. New York University. Issue 13 November
2001
Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey MB, Leirer VO (1983). Development and
validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric
Research 17: 37-49
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Case Vignette: Aging & Mental Health
Mr. J. is a 76 year-old retired African-American widower who is referred to a mental health clinic after
his adult daughter Melissa reports that he has “…been behaving oddly in recent months.” Melissa states
that over the past year Mr. J has become more and more withdrawn frequently failing to show-up for
scheduled appointments with both friends and family. She also notes that he has been devoting far less
attention to his home and personal affairs. Melissa believes that the change in behavior may be in part
due to the death of her mother which occurred five years ago, but she does not feel that this is a likely
explanation. Melissa states that he was shaken at first, but for the past three years he seemed to be doing
well, involving himself in various church, community and volunteer activities. She reports that over the
past year he shows increasingly less interest in doing things with others, has become uncharacteristically
irritable, disorganized, and prefers to be home alone. She became very worried when her father’s phone
was recently disconnected because “he wouldn’t even leave the house to mail his bill payment; and he has
basically stopped going to church which is very unusual!” Although Mr. J. has always expressed a strong
opposition to help from anyone other than family or the church, he reluctantly agrees to an in-home
assessment for fear that his daughter might attempt to force him to move in with she, and her family if he
does not cooperate.
When Mr. J. answers the door he does not immediately remember the appointment, but after you remind
him of Melissa’s involvement he states that he does recall speaking with you. As you enter the home you
notice that Mr. J.’s residence seems a little unkempt but not dangerously so. There are stacks of unopened
mail on the counter in the entryway, newspapers & magazines clutter the living room floor and coffee
table, and the kitchen has a large stack of dirty dishes. As you begin to talk Mr. J. states that “…my
daughter is just a worrier I’m fine! I just have not been feeling very much like doing things lately…so
what!” He says that in recent months things have become a little overwhelming and he just prefers not to
be bothered.
As you inquire about his general health Mr. J. informs you that he has high blood pressure and chronic
arthritis in his knees. Both conditions are reported to be controlled with medication. He states that his last
appointment with his general physician was about a month ago and he received a new prescription for his
blood pressure medications at that time. When he retrieves the medicine to provide you with the name of
the drug you notice that the bottle is about ¾ full. In response to questions regarding self care Mr. J.
reports that he has minimal trouble with chores around the house such as cooking and bathing due to his
arthritis. Mr. J. repeatedly assures you that everything is fine and that he just needs some time in prayer.
Discussion Questions
1. What additional information would need to be obtained in order for the practitioner to formulate a
diagnosis?
2. Is there evidence for a differential diagnosis? If so what would the diagnosis be and factors should
be ruled out?
3. What cultural considerations might impact this case?
4. What community resources might be beneficial for Mr. J. or Melissa and her family?
5. What role might the macro practice social worker play in his/her relationship to Mr. J and his
family?
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