Assessing the Complex
Needs of Older Adults
Patrick Arbore, Ed.D.
Founder & Director, Center for Elderly Suicide
Prevention & Grief Related Services
Institute on Aging
3575 Geary Blvd, San Francisco, Ca 94118
Center for Elderly Suicide Prevention & Grief
Related Services (CESP)
24-hour Friendship Line for the Elderly –
(800) 971-0016
Grief Related Services – Individual Grief
Counseling and Traumatic Loss Grief
Groups
Medication Oversight Project
Contact: parbore@ioaging.org or (415) 7504180x230
Approach to the Elderly is Different
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Spectrum of complaints is different
Manifestations of distress subtle
Presentations frequently nonspecific
Symptoms difficult to interpret
Potential for functional loss
Improvements sometimes less dramatic
and slower to appear
• Advanced directives imperative
What is Comprehensive Geriatric
Assessment (CGA)?
• In-depth evaluations in multiple domains
• Interdisciplinary approach
• Addresses the multiple medical problems of the
elderly
• Catalogues the resources and strengths of the
older person
• Assessment of need for services
• May include development of team-coordinated
care plan
• Allows for tailored, focused interventions for
each specific older person
What is CGA?
• Requires not only physical data but also
an integration of the biologic,
psychosocial, and functional aspects of
the older person
• Inquiries into physiologic, and anatomic
function, growth and development, family
relationships, group involvement, and
religious and occupational pursuits are
essential
CGA and Care Regimens
• Primary Care – aimed at prevention of
disease and promotion and maintenance
of health
• Secondary Care – involves specific illness
or pathologic conditions and focuses its
efforts on the retardation or termination of
physical, mental, social or environmental
situations that have induced the conditions
Care Regimens Continued
• Tertiary Care – deals with restorative
measures that will enable the older person
to achieve an optimum level of function,
whatever that might be
Assessment Requirements
• Requires special abilities of the
professional – ability to listen patiently; to
allow for pauses; to ask questions that are
not often asked; to observe the minute
details; to obtain data from all available
sources; recognize normalities of late life
that would be abnormal in a younger
person
Assessment Requirements
• The quality and speed of the assessment
are an art born of experience
• A new person in the field should not be
expected to do an assessment; they
should observe seasoned professionals
Goals of CGA
• Coordinate interdisciplinary treatment
• Outreach and case finding
• Establishment of primary care of frail
elderly
• Eval for long term placement when
appropriate
• Improved health
• Diagnose and treat potentially reversible
problems
Goals of CGA
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Stabilization of multiple problems
Decreased acute admissions
Increased functional independence
Improved living situation
Increased quality and quantity of life
Limitations of CGA
• Expensive – often not cost effective
• Shortage of trained professionals
• Difficult to blend classical non consultative
interdisciplinary CGA model with primary
care physicians
• Time-consuming and exhausting for older
people
• May be perceived as cumbersome
Classic Interdisciplinary Team
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Physician
Nurse or NP
Social Worker
Additional Disciplines include Pt/Ot,
Mental Health, Audiology,
Dentistry/Podiatry, Pharmacy/Nutrition
Basic Categories of Assessment
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Medical Domain
Cognitive Function
Mood
Functional Status
Pain Assessment for Older Adults
Assessment of pain is important:
• Pain is the most common symptom of disease
• An accurate assessment will lead to an accurate
diagnosis
• Assessment facilitates evaluation of the effects
of therapy
• Assessment can help differentiate acute,
endangering pain from long-standing chronic
pain
Pain Assessment
• Successful pain management begins with
an accurate assessment
• Remember: That pain is whatever that
individual says it is
• Culture and gender are additional factors
that make pain assessment more difficult
and complex
A Pain Distress Scale
• On a 0 to 10 scale (0 = no pain; 10= worst
pain, what number would you give your
pain right now?
Content for Assessing Pain in the
Older Person
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Pain description
Observations of the person
Alleviating or aggravating factors
Impact
Social history
Assessment of Loneliness
• Loneliness is a passive, possessive, and
painful emotion – Is this person lonely or
does she/he like to be alone
• Loneliness is an affective state of longing,
emptiness, and feeling bereft
• Lonely people may be physically alone or
surrounded by others
• Self-growth comes from one’s ability to
recognize and cope with loneliness
Loneliness
• Factors of loneliness and aloneness
change as one moves up Maslow’s
hierarchy of needs
• Loneliness accompanies self-alienation
and self-rejection
• Loneliness is evidence of the capacity for
love
Substance Abuse in the Elderly
According to Atkinson & Blow (2009):
• Over 1 million older adults suffer from alcohol
dependence currently
• Because they regularly drink to excess they
experience serious adverse health and social
consequences
• With the increasing size of the aging population
the ranks of aging alcoholics will swell to 23
million over the next 25 years
Best Practices Guideline
Effective approaches to identifying,
assessing and treating older substance
abusing elderly were documented in a
federally sponsored treatment
improvement protocol published by the
Center for Substance Abuse Treatment
Substance abuse among older adults 26,
edited by Frederic Blow
Screening
Anyone who is concerned about an older
adult’s drinking practices can try asking
direct questions, such as:
• Do you ever drink alcohol?
• How much do you drink when you do
drink?
• Do you ever drink more than 4 drinks on
one occasion?
Screening
• Do you ever drink when you are upset or
lonely?
• Does drinking help you feel better?
• Have you ever wondered whether your
drinking interferes with your health or any
other aspects of your life in any way?
• Where and with whom do you typically
drink?
Screening
• How do you typically feel just before your
first drink on a drinking day?
• What is it that you expect when you think
about having a drink?
Assessment
For older people with positive screens, an
assessment is needed to confirm the
problem
For purposes of insurance or other funding
resources, the assessment should follow
the guidelines in the Diagnostic and
Statistical Manual of Mental Disorders
(DSM-IV TR)
Assessment
For some older adults it may be impossible
to understand the true impact of their
alcohol and drug use or to recommend
appropriate treatment services without a
full assessment of their physical, mental,
and functional health
Depression
• The most common mental health problem
of late life – affecting up to 15% of people
>65
• Remains under-diagnosed and undertreated among this population
• Estimates of the prevalence of depression
in homebound elderly adults is between
26% and 44% (Loughlin, 2004)
Depression
• Assessment of depression in racial/cultural
older populations may be affected by
attitudes on the part of the professional or
the consumer and by the lack of culturally
appropriate assessment tools
• Estimates are that minor depression may
affect as many as: 10% of older AfricanAmericans; 15% of older Latinos; and 12%
of older Asian Americans
Assessment Tools
The Geriatric Depression Scale (GDS)
• Created by Yesavage, et al – this tool has
been tested and used extensively with
older people
• There is both a 30 item form and a 15 item
short form
Assessment Tools
The Patient Health Questionnaire (PHQ-9)
• A 9-item patient self-report depression
assessment – the 9 items come directly
from the DSM IV TR signs and symptoms
of depression
Dementia
Assessment for Mild Cognitive Dysfunction:
• Montreal Cognitive Assessment (MoCA)
• It assesses different cognitive domains:
attention and concentration, executive
functions, memory, language,
visuoconstructional skills, conceptual
thinking, calculations, and orientation
• www.mocatest.org
Dementia
Alzheimer’s disease is the most common
cause of dementia in people aged 65 and
older
• 4 million people in the U.S. are currently
living with the disease; one in ten people
>65 and nearly half of those >85 have AD
• At least 360,000 Americans are diagnosed
with AD each year and about 50,000 are
reported to die from it annually
AD
• Nearly all brain functions, including
memory, movement, language, judgment,
behavior, and abstract thinking, are
eventually affected
Dementia Alzheimer’s Type
• The only accurate method of diagnosing
AD is to perform a brain biopsy or autopsy
• Rule out treatable conditions
• Patient history
• Physical examination
• Neurological evaluation
• Cognitive and neuropsych tests
• Brain scans
Dementia Alzheimer’s Type
Lab Tests:
• Complete blood count
• Blood glucose test
• Urinalysis
• Drug and alcohol tests
• Cerebrospinal fluid analysis
• Analysis of thyroid and thyroid-stimulating
hormone levels
• A doctor will order only the tests that he/she
feels are necessary and/or likely to improve the
accuracy of a diagnosis
Suicide and the Elderly Risk
Assessment
• White males >85 commit suicide at a rate
estimated to be six times the national rate
(NIMH, 2007)
• Up to 75% of older adults who die by
suicide visited a physician with 1 month of
their suicidal death; 40% within 1 week;
and 20% on the same day (NIMH, 2007)
• The above statistics implies opportunities
for intervention
Suicide and the Elderly
Assessment
According to Jacobs et al (1999) “There is no
psychological test, clinical technique, or
biological marker sufficiently sensitive and
specific to support accurate short-term prediction
of suicide in an individual person.”
• The goal of a suicide assessment is not to
predict suicide, but rather to place a person
along a putative risk continuum to appreciate the
bases for the suicidality, and to allow for a more
informed intervention
Suicide and the Elderly
Assessment
Geriatric suicide Ideation Scale (GSIS)
• The first multidimensional measure of
suicide ideation developed among seniors
• A 31-item, 5 point Likert-scored measure
with impressive psychometric
characteristics (Heisel, Flett, & Bresser,
2002)
Suicide Risk Assessment
• Cooper-Patrick et al (1994) developed a
four-item screen for identification of
suicidal ideation among general medical
patients – items included (1) Have you
ever felt life is not worth living; (2) Have
you ever thought of hurting or harming
yourself; (3) Have you considered specific
methods for harming yourself; and (4)
Have you ever made a suicide attempt
References
Office of Communications and Public
Liaison, National Institute of Neurological
Disorders and Stroke, National Institutes
of Health, Bethesda, MD, 20892
American Psychological Association,
Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. DSM-IV-TR.
Arlington, VA
References
Heisel, M., Flett, G., & Bresser, A. (2002).
Cognitive functioning and geriatric suicide
ideation. Am J Geriatr Psychiatry 10:4,
428-436.
Upadbyaya, A., Conwell, Y., Duberstein, P.,
Denning, D., and Cox, C. (1999).
Attempted suicide in older depressed
patients: effect of cognitive functioning.
Am J Geriatr Psychiatry, 7:4.
References
Blow, F., and Bartels, S., et al. Evidence
based practices for preventing substance
abuse and mental health problems in older
adults.
Blow, F., (ed.) (1998). Substance abuse
among older adults. US Dept of Health
and Human Services.