Transcript After - Society of Certified Senior Advisors

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
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.
Age-related Decline
Hedden & Gabrieli, 2004
Memory Loss
Smith, Robinson & Segal, 2013
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.
The D’s (that aren’t Dementia!)
• Delirium
• Depression
• Damaged Brain
• Developmental Delay
• Deficient Education
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
Montreal Cognitive Assessment (MoCA)
MoCA continued
Mini Mental Status Exam (MMSE)
Mental Status Test of Older Adults
(MiniCog)
Short Blessed Test
Short Blessed Test continued
Patient Health Questionnaire (PHQ-9)
PHQ-9 continued
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)
The Danger
• Visual/Hearing Impairments
• Improper administration
• Diagnostic Rule Outs (The 6 D’s – alternatives to
dementia)
• Medication prescriptions and overuse
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).
• 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)
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
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.
Advocacy
Knowledge is power
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
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 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
Age-related Decline
Hedden & Gabrieli, 2004
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?”