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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. 1 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. 2 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. 3 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. 4 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? 5 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. 6 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 7 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. 8 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 9 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? 10