Dr. D. Dutta Roy, Ph.D.
Psychology Research Unit
Indian Statistical Institute,
Kolkata – 700108
Web:http://www.isical.ac.in/~ddroy
E-mail: ddroy@isical.ac.in

Other site: Principles of Geriatric Psychology

Present blog is based on today lecture at the Calcutta Metropolitan Institute of Gerontology, Kolkata.

Why Assessment ?

Assessment is meant for classification and identification of the elders who need more and less emergency care.
It provides insight about specific care plan and management.
It helps in changing existing or innovating specific care plan.

Case history taking and assessment

Identification: Age, sex, brought in by whom, chief complaint
Source of History (include reliability rating) : Patient, caregiver, family, friendsMedical records, Previsit questionnaire
History of Present Problems/Condition
Medications - old medication lists, herbal/alternative medications , Allergies/Adverse Drug Reactions: Name specific medications and characterize specific allergic/adverse drug reaction for each medication
Habits: tobacco, recreational drugs
Social History: Education, Marital Status/Children, Household members, Activities/Exercise, Travel, Occupational History/Toxin Exposures, Diet, Caffeine, Sexual Activity, Caregiver roles
Past Medical History: (ask about previous medical records, old lab/imaging/study reports)
Family History: Heart disease, cancer, diabetes, TB, HTN, mental health, Alzheimer's disease
Care Resources: past and present Home Health, Case Management, etc.
Personal History: Environment, Reverse developmental milestones


Review of Systems:
General: fevers, chills, malaise, fatiguability, night sweats, weight changes
Neurologic: syncope, seizures, weakness, paralysis, abnormal sensation/coordination, tremors, memory loss
Psychiatric: depression, mood changes, difficulty concentrating, nervousness, tension, suicidal ideation, irritability, sleep disturbances
Sensory Functions: visual changes, hearing changes, neuropathy, balance/coordination
Motor Functions: gait, falls, ataxia
Diet: preferences, restrictions (religious, allergic, disease), vitamins/supplements, caffeine, food/liquid intake diary, "look in fridge test", who prepares/obtains food
Skin: rash/eruption, itching, pigmentation, excessive sweating, nail/hair abnormalities
Head: Headaches, dizziness, syncope, severe head injuries, loss of consciousness
Eye: visual changes, blurring, diplopia, photophobia, pain, eye medication use, eye trauma, FH of eye disease
Ears: hearing loss, pain, discharge, tinnitus, vertigo
Nose: sense of smell, obstruction, epistaxis, postnasal drip, sinus pain, rhinorrhea
Oral: hoarseness, sore throat, gum bleeding/soreness, tooth abscess/extraction, ulcers, taste changes


Cardiac/Peripheral Vascular: Chest pain, palpitations, dyspnea, orthopnea, edema, claudication, HTN, previous MI, exercise tolerance, previous cardiac studies
Pulmonary: pleuritic pain, dypsnea, cyanosis, wheezing, cough/sputum, hemoptysis, TB exposure, previous CXR's
Gastrointestinal: appetite, digestion, dysphagia, heartburn, nausea, vomiting, hematemesis, diarrhea, constipation, stool changes, flatulence, hemorrhoids, hepatitis, jaundice, dark urine, history of ulcers/gallstones/polyps/tumors, previous X-rays
Renal/Urinary:dysuria, flank/suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, force of stream changes, STD's
Hematologic: anemia (dizziness/fatigue/dyspnea), easy bruising/bleeding, blood cell abnormalities, transfusions
Lymphatic: lymph node enlargement/tenderness
Endocrine/Metabolic: thyroid enlargement/pain, heat/cold intolerance, unexplained weight change, diabetes, polydipsia, polyuria, facial/body hair changes, increased hat/glove size, striae
Musculoskeletal: joint stiffness, pain, limited ROM, swelling, redness, heat, bone deformity
Sexual: libido, intercourse frequency, sexual difficulties, impotence
Gynecologic: itching, last Pap smear, menopause age
Breasts: pain, tenderness, discharge, lumps, mammograms, self-breast exams


MENTAL STATUS
Most of this exam is observed through the interview conversation with patient
General Appearance/Behavior: Grooming and hygiene, unusual movements, attitude, psychomotor activity, eye contact
Affect: (external range of expression) flat, blunted, labile, full/wide range
Mood: (internal emotional tone) dysphoric, euphoric, angry, euthymic, anxious
Thought Processes: Language (quality/quantity of speech), tone, associations, speech fluencyNote presence of: pressured speech, poverty of speech, blocking, flight of ideas, loosening of associations, tangentiality,Circumstantiality, echolalia, neologisms, clanging, perseveration, ideas of reference
Thought Content: note hallucinations, delusions, illusions, derealization, depersonalization, suicidal or homicidal ideation
Cognitive: (mostly covered by psychometric tests)level of consciousness, orientation
Insight: the patient's understanding of his or her problems and implications of these problems
Judgment: based on history of patient's decision making abilities

Home Assessment

I) Social InformationII) Caregiver InformationIII) Patient's HealthIV) Head InjuryV) Activities of Daily LivingVI) History of FallsVII) VisionVIII) HearingIX) DentitionX) Bowel/BladderXI) SexualityXII) NutritionXIII) CommunicationXIV) Usual daily activities (with exercise)XV) Sleeping XVI) FinancesXVII) Home Safety ChecklistXVIII) Current MedicationsXIX) Care resources/agencies

Multiaxial System

Axis I: Clinical psychiatric disorders
Axis II: Personality disorders, mental retardation
Axis III: General medical conditions
Axis IV: Psychosocial and Environmental Stressors
Axis V: Global Assessment of Functioning

Care giver selection decisions

Faulty selection of care giver sometimes invites problems in the life style of elders. Therefore, before selection of care giver, think more about:a) Do they have phone ?b) car license ?c) Living close to you house ?d) Do they have adequate eldercare experience?e) Do they speak, read and write your language at a reasonable level?f) Do they have any objection to being fingerprinted?g) Have they ever been arrested or convicted?h) Are they reliable, punctual, what duties they have performed and if there were any problems.i) By visiting the care giver's own home, get idea about level of cleanliness

Care Plan for different categories of elder people

Physiological Care
Safety care
Social Care
Self esteem care
Self actualization care

Categories of elders: Anomic (who decay as soon as physical vitality is lost), adjusted (who can work in the protective surrounding), autonomous (who keep engaged himself in creative activity and are relatively immune to cultural changes).

Care plan :
Physiological and safety for Anomic elders
+ Social and esteem for adjusted elders
+ Self actualization for autonomous elders

How does Psychotherapy help the elders ?

It assists the old person to have minimal complaints to help him or her make and keep fresh of both sexes,

helps to relieve tension of biological and cultural origins

helps old persons work and play within the limits of their functional status and as determined by their past training activities and self concept in society.

Counselling & Psychotherapy (Where to apply)

Counselling
A brief treatment focusing on patient’s current problems. Helping people who have the capacity to cope in most circumstances, who are experiencing temporary difficulties or in a psychosocial transition.

Psychotherapy
Psychotherapy is more concerned with the resolution of longstanding personal issues and may be either brief or long term. When issues are more symptomatic of something deeper.


Counselling is meant for
Mild to moderate

Depression
Relationship difficulties
Anxiety
Bereavement
Emotional & Psychological difficulties
Response to physical illness
Life cycle developmental issues
Problems of adjustment
Response to trauma
Sexual difficulties

Psychotherapy is meant for

Moderate to severe disorder

Schizophrenia & related disorders
Mania/hypomania
Depressive disorders
Dementia
Risk of suicide
Hypochondriasis
OCD
Post traumatic stress disorder
Eating disorder
Personality and behaviour disorders
Severe anxiety

Psychodynamic Model

Psychodynamic therapists make genetic links between early childhood experiences and deal patient’s current character structure and symptomatology. The patient’s emotional response to the therapist (transference) and the therapist’s emotional response to the patients (counter transference) are also sources of learning. Key patterns of feeling and behaving from early childhood are repeated or ‘transferred’ on to the people in the patient’s adult life including the therapist.

Assumptions: Pathology of elderly people is due to conflict between structures of mind - Id, Ego and Super Ego. Study the pathology in terms of energy processing from Unconscious to conscious through Pre-conscious.

Psychosexual stages
Oral, Anal, Phallic,Genital and Latency

Ego-defense mechanisms – Regression, Repression, projection, rationalization, displacement, reaction formation etc.

Behaviour Therapy

Behavioural interventions include reinforcement, modelling, shaping, response cost ( the loss of positive reinforcement for certain behaviour ), time out, differential reinforcement of other behaviour, stimulus control, exposure, systematic desensitization, contingency contract, and assertion and social skills training.

Modelling
Through modeling, observation, and then imitation, elder develop new behaviors. Modeling should be as simple as possible for more elder persons. To use modeling effectively, you must determine whether an elder has the capacity to observe and then imitate the model.
modeling is influenced by three factors:
1) the characteristics of the model (competent, nurturing, supportive, fun, and interesting)
2) the characteristics of the observer
3) the positive or negative consequences associated with the behavior.
Elders are also more likely to imitate behavior that results in a positive consequence.

Shaping

Waiting for the appropriate target behavior or something close to that behavior to occur before reinforcing the behavior is referred to as shaping. Shaping can be used to establish behaviors that are not routinely exhibited.
Steps:
Select a target behavior and define it.
Observe how often the behavior is exhibited.
Select reinforcers.
Decide on close approximations and reinforce successive approximations to the target behavior each time it occurs.
Reinforce the newly established behavior.
Reinforce the old behavior on a variable schedule, and begin reinforcing the new behavior on an every-time or continuous schedule. The key to successful shaping is to reinforce closer
Any behavior that remotely resembles the target behavior should initially be reinforced. Prompts can be used and then faded. Shaping can be used for all kinds of behavior in the classroom, including academics. Steps toward successive approximation, however, must be carefully thought out; otherwise, behaviors that are not working toward the desired goal may inadvertently be reinforced.

Beck's Model

Dysfunctional behavior is dysfunctional thinking, and that thinking processes are shaped by underlying *beliefs*. Situations are interpreted according to basic beliefs and acted on accordingly. "If beliefs do not change," he said, "there is no improvement. If beliefs change, symptoms change. Beliefs function as little operational units".


Principles
Arbitrary Inference: Conclusions drawn without the absence of sufficient evidence.
Selective Abstraction: Conclusion drawn on the basis of but one of many elements in a situation.
Overgeneralization: Overall sweeping conclusion drawn on the basis of a single, perhaps trivial, event.
Magnification and Minimization: Exaggerations or feeling of self worthless

Social Learning Models

Abnormality is due to faulty modelling and self regulation.
Assumptions:

1. Reciprocal Determination: Environment causes behavior, true; but behavior causes environment as well.
2. Regarding self-observation -- know thyself! Make sure you have an accurate picture of your behavior.
2. Regarding standards -- make sure your standards aren’t set too high. Don’t set yourself up for failure! Standards that are too low, on the other hand, are meaningless.
3. Regarding self-response -- use self-rewards, not self-punishments. Celebrate your victories, don’t dwell on your failures.

Marital Counselling

Analyze and assess love pattern:

• Love as dependency,
• sadistic love,
• love as a rescue fantasy,
• compulsive love,
• love for the unattainable object,
• celibate love,
• critical love,
• loving for partner’s parents,
• revengeful love

As any of which lead to extramarital affairs and marital breakdown.

Probe the factors of the problem - ignorance about sex, cultural taboos, myths, poor communication, sexual failures, unrealistic concepts of success or undue performance pressure.

And finally give counselling.

Integral Psychology

Let individual allow to understand and harmonize his physical, vital, mental and psychic energies. Because abnormality is due to arrested and bewildered inner evolution in consciousness. It is the lack of harmonization of physical, vital, mental and psychic energies

Group Psychotherapy

Group psychotherapy, is intended to help people who would like to improve their ability to cope with difficulties and problems in their lives. But, while in individual therapy the patient meets with only one person (the therapist), in group therapy the meeting is with a whole group and one or two therapists. Group therapy focuses on interpersonal interactions, so relationship problems are addressed well in groups. The aim of group psychotherapy is to help with solving the emotional difficulties and to encourage the personal development of the participants in the group. The therapist (called conductor, leader or facilitator) chooses as candidates for the group people who can benefit from this kind of therapy and those who may have a useful influence on other members in the group.

Group characteristics

Usually, there are between 8 to 12 members in the group. Above 15 members, it is impossible to create a therapeutic atmosphere and have enough time for each member to work personally. The length of every session can be from an hour and a half to three hours (this does not include workshops and marathon groups). The frequency can be once to twice a week. The duration of the group depends on many components such as the severity of the problems and the targets sought. It can be from a few months to a few years. You should allow 4 to 6 months to pass in order to feel the effect of the group.

Role of Participants
The participant in the group is expected to be present each week and come on time. It is required that the information brought up by members of the group and their names be kept confidential by all the group members. In some groups, the participant is asked to commit for a specified length of time at the beginning of the group. The usual commitment is between 3 to 6 months. This facilitates getting a sense of how the group works. When participating in a group, you will not be required to talk, or reveal intimate issues when you do not want to. However, it is clear that the more you can participate, be open and talk about yourself, your feelings and thoughts - the more you can gain from this experience.

Effectiveness

1. It helps to understand one another's behavior and symbolic productions successfully;
2. the learning of new behavioral patterns or modification of old behavior is best achieved for some patients in group therapy;
3. group therapy facilitates the transition and adjustment of the patient to the hospital, and to discharge from the hospital;
4. group psychotherapy greatly facilitates the patient's ultimate adjustment to society.

References & Link Sites

Principles of Geriatric Psychology

Behaviour Therapy based on operant conditioning

OPERANT CONDITIONING
Operant therapies are based on Skinner's assumption that people learn behaviours through reinforcement or rewards and punishment. e.g. we reward and punish our children in order to increase certain behaviours and stop others.
TREATMENTS:
Aversive Therapy
Aversive therapy aims to rid the client of the undesirable behaviour by pairing the behaviour with aversive consequences. e..g. If alcohol is paired with a nausea-inducing drug, or a sexually deviant impulse is paired with electric shock, the expected results is that the client will avoid the undesired behaviour. Merely thinking about alcohol makes the person feel nauseated. However, this method does not always last as upon withdrawing the drug or electric shock the old behaviour may returns.
Systematic Desensitisation
Systematic desensitisation introduced by Joseph Wolpe in 1958, is used mainly to treat phobias and specific anxieties. The client is fgradually exposed to the feared object or situation. Over time the panic induced by the feared object will disappear.
Flooding
Flooding treats anxiety in quite the opposite manner. The phobic patient is immersed in the phobic situation and are encouraged to experience the full force of the anxiety storm. For example, someone who is agoraphobic and afraid to leave home would be encouraged to spend an hour in the park and thus be flooded with anxiety. Gradually the anxiety would disappear.

Behaviour Therapy

Delirium

Delirium is a change in mental state, which comes on suddenly, fluctuates over 24 hours, alters consciousness, disturbs thinking and attention, and results in changed behaviour. Symptoms include problems with attention, thinking, memory, psychomotor changes and the sleep-wake cycle (Lipowski, 1989; Ignatavicious, 1999, Bater, 2006, DSM-IV-TR, 2000).
If Delirium is not recognized, it can lead to permanent disability or death.
Delirium is considered a “medical emergency”.
Delirium affects older persons in all areas of health care. All staff must be skillful in recognizing and responding to it.
Shocking Delirium Statistics
Despite the fact that Delirium is treatable,
In Acute Care:
15% of older persons admitted to hospital have delirium
56% of older persons may develop delirium in hospital
30-40% of older persons become delirious after hip surgery
In Residential Care:
40-60% of residents experience delirium
http://www.viha.ca/ppo/learning/delirium/


References:

Link sites

National Institute of Mental Health

National Institute of Aging

Healthy Aging: Preventing Disease and Improving Qualityof Life Among Older Americans

Pocket Guide

Consumer’s Tool Kit for Health Care Advance Planning

Elder abuse victims

Calculator

Senior Health