1. Understanding assessments, determinations, and diagnoses - and challenging doctors when needed
Carilyn Ellis, M.A. Clinical Psychology
(Psy.D. Clinical Psychology May, 2014)
Webinar for the Society for Certified Senior Advisors (CSA) January, 2014
Presentation title: Understanding assessments, determinations, and diagnoses – and challenging doctors when needed
Presentation Summary: We live in a highly clinical age, where aspects of everyday living are quantified, qualified and often given prescription medication to manage. We are screened and tested for a myriad of things when we enter the doctor’s office (cognitive functioning, orientation, health habits, depression, anxiety etc.). It can be difficult to understand what “normal aging” is or what constitutes “health” in this day and age. This presentation will focus on understanding some of the most common assessments used in elderly populations (E.g. Mini Mental Status Exam (MMSE), Montreal Cognitive Assessment (MoCA), Geriatric Depression Scale (GDS), Patient Health Questionaire-9 (PHQ-9) and more). Many of you work with patients who have been diagnosed based on screening tools, or deemed as having or not having capacity during a hospital admission in which they were medically fragile. Knowledge is power, and I hope to provide you with some knowledge of these tools, as well as methods of questioning determinations, asking for second opinions and aiding patients and their families in talking with (and sometimes challenging) their healthcare providers.

2. Goals:
To understand age-related (expected) vs. non-age-related decline (suggestive of dementia or other pathology)
To understand some of the basic assessments used in clinical settings (e.g. Montreal Cognitive Assessment (MoCA), Mini Mental Status Exam (MMSE), Mental Status Test of Older Adults (MiniCog), Short Blessed Test, Patient Health Questionnaire (PHQ-9) etc.
To understand the cognitive domains of these tests (what are they testing?)
To understand what they are (screeners) and what they are not (diagnostic truth) and how to help families and older adults advocate in the medical setting.

3. Age-related Decline Hedden & Gabrieli, 2004
Notice that the overarching term memory is not included on this one. We have verbal memory, which is your ability to verbalize things like words and directions, but memory is a whole lot bigger
Nat Rev Neurosci Feb;5(2):87-96.
Insights into the ageing mind: a view from cognitive neuroscience.
Hedden T, Gabrieli JD.
735112
Hedden & Gabrieli, 2004

4. Memory Loss Smith, Robinson & Segal, 2013
Does your memory loss affect your ability to function?
The primary difference between age-related memory loss and dementia is that the former isn’t disabling. The memory lapses have little impact on your daily performance and ability to do what you want to do.
Don’t get me wrong, they’re frustrating, and they’re often concerning to the people experiencing them, but they’re a natural part of life. You had tons of memory lapses when you were younger (think of all the times you forgot to get something at the store or lost your keys) but you weren’t older so you didn’t worry as much.
When memory loss becomes so pervasive and severe that it disrupts your work, hobbies, social activities, and family relationships, you may be experiencing the warning signs of Alzheimer’s disease, or another disorder that causes dementia, or a condition that mimics dementia.
Authors: Melinda Smith, M.A., Lawrence Robinson, and Robert Segal, M.A. Last updated: November 2013.
Smith, Robinson & Segal, 2013

5. When do we start to wonder…?
Look for impairment in activities of daily living. Are the person’s complaints or problems getting in the way of life?
Mark has noticed that as he gets older, he has greater difficulty finding his glasses, so he has made it a habit to place them on the table by the front door whenever he takes them off.
John has had increasing difficulty navigating his way around. He has been bumping into tables and having difficulty dressing himself. The eye doctor said his eyesight is fine.

6. The D’s (that aren’t Dementia!)
Delirium
Depression
Damaged Brain
Developmental Delay
Deficient Education
Delirium - Delirium is sudden severe confusion and rapid changes in brain function that occur with physical or mental illness.
Depression - While depression and sadness might seem to go hand and hand, many depressed seniors claim not to feel sad at all. They may complain, instead, of low motivation, a lack of energy, or physical problems. In fact, physical complaints, such as arthritis pain or worsening headaches, are often the predominant symptom of depression in the elderly.
Damaged Brain - Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. Also include multiple sclerosis (looks like hypochondria, often starts younger), Korsakoffs/alcohol/substance-related
Developmental delay – Is this someone who has had these problems most of his/her life? For example, A stutter interferes with language
Deficient Education – Half the tests we use require that people know what we are asking them. They often require reading, math and problem solving that is taught to us.

7. Domains of Cognitive Functioning
Visual/spatial (often called “visuospatial”)
Executive functioning
Memory (Immediate, working, long term, recognition)
Attention
Abstraction
Orientation
Language (verbal fluency, confrontation naming)
Math/numeric ability
For every domain, we have an aspect of the brain as well as an appendage/tool used for that aspect of the brain.
We all know that sometimes the parts are more important than the sum. If we gave your body an overall score on a daily basis, we may miss important things like a broken arm or a heart problem.
The same is true of cognition. Often, you get an overall score for how the mind is doing, but as we saw before there are many different aspects of cognitive functioning. We’re really more concerned about a select few things.
Receptive vs. expressive aphasias
paraphasia
Ataxia (Uncoordinated movement)
Agraphia (inability to write)
Dyscalculia

8. Montreal Cognitive Assessment (MoCA)

9. MoCA continued

10. Mini Mental Status Exam (MMSE)

12. Mental Status Test of Older Adults (MiniCog)

13. Short Blessed Test

14. Short Blessed Test continued

15. Patient Health Questionnaire (PHQ-9)

16. PHQ-9 continued

17. Why do we use these? They’re short They’re easy They’re repeatable
They do have validity as screeners (they tap into domains that are affected by cognitive decline)

18. The Danger Visual/Hearing Impairments Improper administration
Diagnostic Rule Outs (The 6 D’s – alternatives to dementia)
Medication prescriptions and overuse
Because these are NOT diagnostic tools, they capture decline related to multiple diagnoses
Older adults are among those most vulnerable to medication misuse and abuse because they use more prescription and over-the-counter (OTC) medications than other age groups. They are likely to experience more problems with relatively small amounts of medications because of increased medication sensitivity as well as slower metabolism and elimination. Older adults are at high risk for medication misuse due to conditions like pain, sleep disorders/insomnia, and anxiety that commonly occur in this population. They are, therefore, more likely to receive prescriptions for psychoactive medications with misuse and abuse potential, such as opioid analgesics for pain and central nervous system depressants like benzodiazepines for sleep disorders and anxiety. Approximately 25 percent of older adults use prescription psychoactive medications that have a potential to be misused and abused.4 Older adults are more likely to use psychoactive medications for longer periods than younger adults. Longer periods of use increases the risk of misuse and abuse.3 In addition to concerns regarding misuse of medications alone, the combination of alcohol and medication misuse has been estimated to affect up to 19 percent of older Americans.8,9
SAMHSA
OLDER AMERICANS BEHAVIORAL HEALTH
Issue Brief 5: Prescription Medication Misuse and Abuse Among Older Adults

19. A note on medication
Currently in the United States, those 65 years of age and older make up 13 percent of the total population, but account for 30 percent of all prescriptions written. (Wegmann, 2013)
Nearly 3 in 10 people between ages 57 to 85 use at least five prescriptions, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).
Joe Wegmann, PD, LCSW, The PharmaTherapist Newsletter 12/31/13
All of the antidepressants that are routinely prescribed in younger age groups are applicable in the elderly. Older, cyclic antidepressants such as Elavil should be avoided, especially in those with memory and cognitive decline. For sleep problems, trazodone use at 50mg or less remains a safe option because of the general absence of anticholinergic effects such as dry mouth, blurred vision, constipation, and memory problems. 

Benzodiazepines should be used judiciously because of the risk of falls. 

Antipsychotics are currently the most significantly debated medication class when it comes to their use in the elderly. When to use them and in what particular setting has become a hot button issue. Many states vigorously enforce and even prohibit their use in nursing home patients, complicating the conundrum as to how to best pharmacologically manage very agitated older folks residing in these facilities. When utilized, the newer, second-generation agents are preferred.

20. (Join Together Staff, Partnership for a Drug Free America, 2011)
Between 1997 and 2008, the rate of hospital admissions for conditions related to prescription medications and illicit drug use rose by 96 percent among people ages 65 and 84; for people 85 and older, admissions grew 87 percent.
SAMHSA notes medication misuse and abuse can cause a range of harmful side effects, including drug-induced delirium.
(Join Together Staff, Partnership for a Drug Free America, 2011)
Elderly at Risk for Prescription Drug Abuse
By Join Together Staff | September 12, 2011 | 3 Comments | Filed in Addiction, Drugs, Elderly & Prescription Drugs

21. Assumptions and Determinations
Number 1: Dementia
Number 2: Questionable decision-making capacity
Fundamentals of Decision-Making capacity
It is NOT global
Most hospitals are concerned only with medical decision making capacity.
Cognitive impairment and decline do not automatically mean impairment in medical decision-making capacity
Decision-making capacity has multiple parts
We see this a lot, and it freaks out and overwhelms families.
If you would like me to do a

22. Medical Decision Making Capacity
1) Does patient know his/her medical diagnoses?
Does patient know his/her medications, their purpose and how/when to take them?
Does patient understand:
- Current treatment options
- Risk/benefits of current treatment?
- Risk/benefit of no treatment?
- Risk/benefit of alternative treatment?
Is patient able to state/communicate a decision concerning his/her medical care? (Is it consistent?)
Based upon the above response, is the patient able to make an informed decision concerning his/her medical care at this time?
2) The ability to designate a durable power of attorney for medical decisions.
Is it consistent – remember that inductive reasoning component we talked about?

23. Advocacy
Knowledge is power

24. What you can do as a CSA: Before
Onset, Frequency, Intensity, Duration (OFID)
Prescription, over the counter and holistic med review.
Ask the doctors questions
Help your clients work through and establish when symptoms started, how often they appear, how bad they are and how long they’ve been going on
Help your clients get a list of all active Rx, expired Rx that clients are still taking, over the counter meds and holistic meds.
Vitamin B story
Delirium story
it helps to write them down before you go in.

25. What you can do as a CSA: After
Find out what screeners and/or diagnostic tools have been used.
Get a copy of screener/diagnostic results. Know your domains!
Check for tool/appendage impairment
What diagnosis are they going for?
How do they justify this diagnosis?
What symptoms does the diagnosis account for? What symptoms does it not account for?
If all they tell you is someone scored a 20 on the MoCA, what do you know? Where he/she is struggling?
did the person forget his/her hearing aid or glasses?

26. What you can do continued
Request records and read the notes
Make them explain any abbreviations or medical jargon in the notes
Example: 87yM with CAD, afib, MCI/AD, HTN, UI w/h/o MDD.
Get a second opinion
87 year old male with coronary artery disease, atrial fibrilation, mild cognitive impairment suggestive of Alzheimer’s dementia, hypertension, urinary incontinence and a history of major depressive disorder
Where did they get the Alzheimers? (from mild cognitive impairment? – turns out this guy had a MoCA of 21)

27. Age-related Decline Hedden & Gabrieli, 2004
Notice that the overarching term memory is not included on this one. We have verbal memory, which is your ability to verbalize things like words and directions, but memory is a whole lot bigger
Nat Rev Neurosci Feb;5(2):87-96.
Insights into the ageing mind: a view from cognitive neuroscience.
Hedden T, Gabrieli JD.
735112
Hedden & Gabrieli, 2004

28. Moral of the Story…
Words like dementia, Parkinson’s, Impairment…all of these induce shock. Don’t accept anything until you have definitive proof.
Knowledge is power. All patients have rights to ALL of their records. Encourage your clients to get copies.
Educate your clients on the basics and teach them the skill of questioning medical authority (in a respectful, collaborative way)
It is never wrong to ask questions of the doctors and make them prove to you what they believe. (Half the time it makes them go back and re-assess).
Ask, “Is there anything else it could be?”