Reducing “Road Rage” in Nursing Home Residents

So, maybe in seeing this title, what came to mind for you was the idea of nursing home residents crowding hallways and griping at each other about who gets to pass first (I work in a nursing home for veterans – a nearly all-male facility, so this actually happens fairly frequently). So, no, wheelchair “traffic jams” isn’t what I had in mind…. Although that might be a good topic for another post. I’ll make the connection in a few paragraphs here, below.

What I had in mind was the subject of the “call button,” something all residents of nursing homes (and pretty much anyone who’s ever spent any time as a patient in a hospital) knows about:

Hospital call bell

For residents in nursing homes, overwhelmingly older adults, many of whom who are completely dependent on nursing staff for their mobility, food, water, and other ADLs, the call button represents pretty much a lifeline. If you have a need to use the bathroom (and you’re able to use the toilet), but you need help from a staff member to get up from your bed safely, you hit the call button.

And you wait. And sometimes, you wait some more.

Although I haven’t run the numbers myself at the Community Living Center I work at (e.g., the nursing home care unit of the Palo Alto VA system), I would guess a significant proportion of both falls and behavioral issues such as yelling, verbal abusiveness, and agitation, are related to the interval between the time a call bell is answered (e.g., via intercom – a nurse usually answers and a disembodied voice speaks in the patients room, “how can I help you”), and the time it takes for a nurse to arrive in a residents’ room. There seems to be some consensus that extended wait times for call bells to be answered can be a contributor to fall risk (see here).

This makes intuitive sense, of course – the longer you wait (and the more urgent your need is), the more agitated and anxious you will be if you’re a resident / nursing home patient in need, correct? This seems to suggest a straightforward, technological or human-resources approach to fix to the problem – just increase staffing, or more intelligently balance staffing in order to minimize as much as possible the amount of time it takes for nursing staff to reach a patient who has depressed their call button.

Of course, there’s another take on this. While the above approach of increasing staffing obviously helps with the task of offering quality nursing care – it ignores the psychological dimension, and a possible psychological solution to the problem of the call button wait time intervals (as an aside, for a wonderful discussion of the value of paying homage to the psychological dimension in addressing human problems, I highly recommend viewing this “TED Talk” with UK advertising executive Rory Sutherland…. Goes to show you that sometimes the best psychologists are often people in the marketing field).

So what’s this possible solution? This brings us back to “road rage.” Imagine yourself at a red light (not hard to imagine for many of you – you may have had to wade through a dozen of them prior to getting to the office this morning). How many of you feel agitated, impatient, somewhat anxious when you’re at a red light and you’re on your way to an appointment, or to work? Most of us. Of course, studies have reportedly shown that longer, unjustified wait times for red lights increases driver frustration and can lead to increases in accidents – so again, the simple, technological approach, is to use advanced signaling technology, more intelligent use of sensors, etc., to minimize unjustified wait times at intersections, and to therefore decrease driver frustration and accidents. Of course, there’s a problem – drivers will still have to wait.

Enter the Eko Stoplight (mentioned in the TED Talk, referenced above):

Eko Stop Light

This stoplight, a really brilliant invention in my view, has as a feature a visual progress bar which gives immediate feedback to drivers at intersections how long they have to wait prior to the signal changing to green. Apparently there is data from Korea and also other data from the manufacturer that strongly suggests that this innovation significantly decreases red light running and accidents at intersections. Put simply – without even changing the wait time interval at traffic intersections, people are more able to be patient and wait, because they know how long they have to wait. And as you know, a minute at an intersection when you’re late for an appointment can sometimes feel like a hour!

So what if such an innovation could be applied to wait times for residents in nursing homes? As far as I can tell – although there is active work on improving call-bell technology in inpatient units (e.g., experimenting with wireless technology and IP-based call systems), as yet I have not seen this idea applied to the nursing home environment. But maybe it should! It would take some work – as my wife pointed out the other night, the Eko Stoplight idea doesn’t precisely map onto the nursing home situation – while the interval between when a stoplight goes from red to green is known precisely (thereby allowing the Eko to precisely calibrate the progress bar), the amount of time it takes for a nurse to reach your room after a call bell is activated tends to vary based on staffing, workload, and other factors. Still, one way of getting around that is allowing individual nurses to calibrate their assigned residents’ progress bars (their ‘Eko timers’) on-the-fly. As long as a nurse arrived before the progress bar elapsed in the patients’ room, I think this psychological, calming effect would still potentially hold. There could be other ways of implementing this idea.

What do you think?

Geropsychology as a Career? My unsolicited advice.

So I’m going to digress a bit here, and try and explain the long and winding path I took in my life to end up here – working in geriatric psychology. I wish I could tell you that I knew from a very young age that I wanted to work with older people, but I don’t have a neat story like that. Here’s what I can tell you – my parents (currently in their 70s, obviously at this point older adults themselves) told me they always thought from an early age I seemed more comfortable than most children speaking casually with adults, even as a toddler, at times I seemed to almost prefer the company of older people.

 

Aside from that, however, there wasn’t much about my life as a child that seemed to speak to a later career in geriatrics (defined as “of or relating to old people, esp. with regard to their health care”). I liked the company of adults, I felt comfortable with people a generation or two ahead of me, I was reasonably intelligent and curious about myself and others, and I was reasonably extraverted. That was about it – as a child, the idea of specific career aspirations was a confusing abstraction for the most part. I knew what I liked to do – reading nonfiction, writing stories, doing theatre camp, I remember at one point I did a summer camp where I worked in a local cable access TV production studio and made short films with other kids. I enjoyed myself, but through high school and into college, I was all over the map. Which I guess is typical.

When I got out of high school (which I was only too glad to do) and started undergraduate training I took some advice from adults and soft-pedaled my interests in television and entertainment. I was told that getting meaningfully employed in the entertainment world was something akin to winning the lottery – and the sacrifices in time and my personal life in order to be successful in such a field would be huge with a highly uncertain promise of reward. OK, fine. I wanted to be realistic, after all.

Fortunately, I found myself passionate about something else – psychology. While theatre and entertainment-related things scratched my itch for approval from others, one of my many hang-ups (applause after a good performance definitely scratches that itch), studying psychology scratched my own itch for self-reflection and self-knowledge. Or, at least, my yearning to “know thyself” at least provided some pretty strong motivation to move forward in it. While I don’t advise people to pursue psychology as a career because they’re curious about themselves, it’s undeniably a motivator for many, and potentially a powerful one.

I went to Reed College in the mid 90s. At the time, Reed was known in some circles as a place where students studied intensely hard, studied humanities, and where fraternities and sororities had no footprint, but at the time had a reputation that generally marked it as a school for the proverbial undergraduate “square pegs” who didn’t fit into the collegiate round holes of Stanford, Yale, etc. Since I left Reed, it’s reputation has only increased in prominence and respect, and now it’s considered one of the most academically challenging private colleges in the United States, at least by some metrics. I graduated in 1996 with a degree in psychology, with some emphasis on biology (I took biology courses at Reed, which I found incredibly daunting, and also did an honors thesis on neuropsychology).

After college, I did some traveling with my then-girlfriend and now-wife (Beth Trittipo, bio is here) worked as a research assistant for about year prior to attending graduate school at Pacific Graduate School of Psychology (now known as Palo Alto University, or PAU).

A brief, but I think important digression on graduate school in psychology. There may be any number of psychology students, or prospective graduate students in clinical psychology reading this blog who’ve considered the route of attending a professional doctoral program in clinical psychology, which overwhelming refers to unfunded doctoral programs. PAU is one of those programs. Granted, it tends to have a good reputation (arguably one of, if not the best) of unfunded professional programs. An overwhelming majority of its graduates (100% of its Psy.D. students as of last year) secure coveted internships accredited by the American Psychological Association, and tend to do well in terms of research productivity, licensure rates, and scoring high on the EPPP.

However, the biggest problem with professional programs in psychology, without a doubt, is the debt-to-income ratio that most students are left with. It’s a growing problem with all types of graduate and undergraduate degrees, but with students of professional (largely Psy.D.) programs, the problem has gotten out of control, with the average Psy.D. student leaving doctoral programs in psychology with 120K in student debt. At PAU, (which is in Palo Alto, after all) the average debt load is likely more than upwards of 250K at this point.

While 250K of student debt is manageable for a graduate of, say, a physician graduate of medical school who may begin earning six-figures or more immediately upon graduation, the median salary of a psychologist currently in the US is around 70,000 dollars per year according to the Bureau of Labor Statistics. That means if you have 200K-plus of debt as a graduate from a psychology professional program (very common these days), and you land a job paying around the median salary, even with the various repayment programs available to graduates these days (e.g., such as Income Contingent Repayment), the graduate could be sending out half a grand a month in loan repayments. If the graduate has private loans (which don’t qualify for these federal programs), this could drive up the costs further.

I graduated from PAU about a decade ago. While I have significant student loans from that adventure, they don’t approach the numbers I’m currently seeing with many clinical psychology graduate students, my interest rate is extremely low, and my payments, while annoying, are affordable with my VA salary. In short – I think I got lucky and I think I’m probably one of the last generation of professional student graduates from pricey schools like PGSP / PAU that can make the math even somewhat work. Even so, I pay several hundred dollars per month towards student loans, and that’s money that I definitely miss.

Anyways, off my soapbox.

So, I got into PGSP and began my studies. For me, getting into geropsychology was a matter of a bit of taking advantage of luck and propitious circumstance, and then capitalizing on the experiences gained even further, and then lather, rinse, and repeat. In graduate school, after languishing for a year or so doing generalist practicum experiences and toiling unproductively in a research group not related to geropsychology, I approached Larry Thompson and by extension, Dolores Gallagher-Thompson, both geropsychologists with stellar records of accomplishment and who were running a large-scale arm of the REACH-II (Resources for Enhancing Alzheimer Caregiver Health) research project on dementia caregiver interventions through the Older Adult and Family Center (OAFC) at the Menlo Park Department of Veterans Affairs.

Larry Thompson was very kind to me and offered to work with me on a dissertation project, and also found me a practicum training opportunity at the OAFC. This highly successful experience allowed me to attain an internship in geropsychology at the University of Medicine and Dentistry of New Jersey (UMDNJ), and then a fellowship in geropsychology at the University of Rochester Medical Center in Rochester, New York.

Since then, I’ve attained licensure as a psychologist, I’ve worked in community nursing homes, coordinated research projects, published articles, given talks, and have worked at the VA in Livermore as their staff Geropsychologist for approximately seven years now. I love my job, I enjoy what I do, and I think I’m very lucky.

So, what advice would I give to a student considering a career in geropsychology or geriatric mental health, in the future? I’ll break it down for you:

1) Don’t attend a doctoral program at a professional school in psychology, unless you’re independently wealthy or you receive some other form of funding. Just don’t. Make yourself competitive for funded programs. Get stellar grades in college. Get on publications, do research assisting for a year or two before you apply to graduate programs, and get a stellar GRE score, whatever you need to do. Moreover, short from a select number of professional programs like Rutgers, Baylor, perhaps PAU / PGSP, for the most part professional programs in psychology tend to struggle to match the reputations of funded programs, which is an extra cross to bear for professional school graduates. So, don’t do it.

2) Consider applying to nurse practitioner programs (medicine is OK too, but I see reimbursements declining, while tuition continues to rise). One side effect of Obamacare that I can see is that with all of the pressure being put on physicians due to what will supposedly be increased enrollment of the previously uninsured, demand for nurse practitioners will increase. And NPs command significantly greater salaries than psychologists. Consider masters-level programs in counseling or social work, with an emphasis in geriatric mental health as well (far less money and time for a degree that allows you to do many, if not most of the things professional clinical psychologists do).

3) If you’re bent on attending graduate programs in psychology, and you want to go into geropsychology, my advice is specialize, and specialize early. Make sure you get the specialty practicum, internship, and postdoctoral training opportunities where possible, and don’t forget to get elective coursework in geriatric mental health, geriatric neuropsychological assessment – as this will be critical in attaining later boarding as a Geropsychologist with the American Board of Professional Psychology (ABPP, something I talked about here). Geropsychology is a specialty, and in order to get specialized jobs, you’ll need specialized training.

4) Be prepared to not make a ton of money in geriatrics. This is not a glamorous field. Medicare continues to nickel-and-dime us to death. Don’t expect to get rich.

That’s it for now.

Functional Analysis and Noncontingent Reinforcement in Dementia Patients

There are a variety of ways to address behavior problems in dementia sufferers, which I’ve addressed in the past (such as here). A lot of what I do in my day-to-day life as a Geropsychologist at a VA Community Living Center (CLC, AKA skilled nursing facility) is trying to address some of the vexing and often mysterious behaviors exhibited by residents with dementia. I would like to focus on a specific type of patient, a specific type of problem, and a specific way (potentially) of addressing the behavior issue.

The kind of patient I’m referring to here is one who has slipped from mild to now, more moderate to severe dementia. A patient like that is as follows (this is a de-identified composite of patients I’ve had over the years). He’s in his 80s, he’s had some strokes, he’s at times been difficult with nursing staff due to his constant use of the call light for minor issues (e.g., requests to move a water glass, to chat with staff, to change a TV channel, et cetera, ad nauseam). He has had occasional falls due to poor safety awareness and impulsiveness. He has documented memory problems and issues with executive functioning (e.g., planning, judgment, reasoning, etc). He has had episodes of verbal assaultiveness at times in the past (e.g., cursing out nursing staff) but no physical assaults. However, with a recent hospitalization after a nursing staff noted alteration of consciousness, poor food intake, and nonresponsiveness, he returns to our facility and staff now report the patient regularly has episodes of trying to hit, bite, or kick staff when they attempt to render care to him (e.g., changing his incontinence briefs, bathing him, or changing his clothes, etc). Staff has responded to this patient’s assaultiveness by when he has an episode, they simply cease care and leave the room, what they think of as “giving him a break.” They try to take more time to explain what they are trying to do before they do it. They may try to bribe him with snacks, or soothe him with music before the care is rendered. Unfortunately, over the long term these interventions do not seem to yield any great results. He is also taking some psychotropic medications and pain medications, but given that he also refuses to take medications, these don’t help either (not that they probably would that much anyways).

So what is staff to do?

Of course, the traditional view of behavior problems in dementia is that these distressing, vexing, bizarre, and sometimes dangerous behaviors are simply the symptoms being emitted by a sick brain – they have no particular meaning and they simply are something that need to be treated with pharmacology, or nonpharmacological approaches to ‘calm the patient down’ (because it at least seems fair to suppose that this is connected to the patient being anxious or ‘agitated,’ to use the popular descriptor).

There’s a somewhat different viewpoint than the above. Imagine you’re the demented resident. Imagine that you’ve lost your ability to understand spoken language. Imagine you’ve forgotten why you’re in a hospital – or that you’ve even forgotten that you’re in a hospital. Imagine that you’re lying in bed, confused, with difficulty moving or ambulating, perhaps in some pain, and then one or two unfamiliar people come into your room and start talking. What they say doesn’t really make sense. Suddenly, without warning, their garbled verbalizations end and then they just start grabbing at you, in your most private places. When you yell in protest, they speak more excitedly and they begin to move faster at what they do, grabbing at you more. You try to swing at them to make them stop. They may hold one or both of your arms to prevent you from swinging, still talking quickly and excitedly. You start kicking, spitting, and yelling, wondering why they don’t stop. Finally, they stop and leave you alone. You’re left by yourself, relieved they’ve stopped, but anxious that they may return.

This, I think, is pretty much the experience of dementia patients when they start exhibiting this very familiar pattern of assaultiveness that I’ve been consulted on time and time again now. It’s very challenging for everyone to address. So, what is happening here?

First, obviously, the patient isn’t able to understand (or understands very little) the explanation that nursing staff give prior to rendering care, either due to decline in the patients receptive language abilities, language barrier (nursing staff may speak English as a second language), or both. So, the act of explaining what they are doing as nurses doesn’t really help. Not that they shouldn’t try!

Second, when the patient begins to yell at strike out at the nursing staff, it’s a behavior that superficially looks inexplicable when seen from the eyes of us, as nominally cognitively intact people – but makes perfect sense from the perspective of a disoriented person with severe memory and receptive language problems. It’s “fight or flight” at base level. What would you do if random strangers walked into your room, spoke garbled nonsense for a few minutes, and then started grabbing at your private areas?

Third, what’s the natural response from nursing staff when they are faced with a patient who hits and yells when they attempt to render care? They do one or two things (or they do both) – they first try to speed up what they are doing, to get it done and over with. This, of course, just agitates the patient more. They could also simply just cease rendering care the moment the violence escalates significantly – they just stop. While in the short term, this halts the behavior, ironically over the long term this very response from nursing staff insures that the patient continues being assaultive, through a phenomenon known as escape / avoidance conditioning – which is a form of behavioral conditioning highly resistant to extinction. Once a patient has been “trained” to engage in this behavior, it’s very difficult to “untrain” them.

So what are we to do?

Well, what I’ve been talking about here is essentially the thinking behind functional analytics as they regard behavior problems in dementia. Functional analysis, which is most popularly used in managing problem behaviors in patients with developmental disabilities, has at its base level the assumption that all behavior has a purpose (in the operant-conditioning sense of the word). In the case of the above patient, there may be only a few different approaches that may make sense here.

What I’ve sketched out, above, is basically perform a descriptive functional analysis (DFA). I’ve done a pretty good job (if I do say so myself) narratively explaining the reinforcement contingencies (escape) that are encouraging this behavior (assaultiveness), which leads to a small set of ways of addressing it.

Now, I could have performed an experimental functional analysis (EFA), just to be sure. What makes an EFA different than DFA is that instead of just trusting the interventionists’ narrative description of what might be incentivizing a behavior problem, the interventionist goes ahead an directly manipulates the environment to see what might be pulling for this behavior. Unfortunately, in the case of the dementia patient it would require as part of the analysis for the staff to at times let themselves be hit (without withdrawing from the care situation) as a way to determine whether in fact a behavior was maintained by, say, escape conditioning or attention conditioning (here’s a great link to how EFA can be done outside of a situation where assault is an issue).

So, EFA is out, DFA is in, we’re pretty sure escape/avoidance is what maintains the behavior, and so what do we do? Well, like I said, there’s only a couple of different ways to go. Ideally we would want to engage in differential reinforcement of other behavior (or DRO) which means just what it sounds like – we would find another behavior (like smiling, cooperating, whatever) that we could reinforce with something a patient likes (praise, backrubs, cookies, whatever) and when the patient engages in the behavior we don’t like – we don’t respond to it. Again, since the behavior we don’t like is hitting – we can’t actually do that.

The only approach left that I’m aware of, from an operant conditioning perspective, is engaging in something called noncontingent reinforcement, or NCR. Unlike DRO, nursing staff could continue to withdraw (as they should) when the patient swings at them. However, what they would also be instructed to do is when they care for the patient is to provide him with escape / avoidance – but have it be provided irrespective of his physical aggression. The typical instruction I give to nursing staff is to stop every thirty seconds and simply pause for ten, and then resume. The idea there is that this breaks the link (eventually) between escape / avoidance and aggression.

The difficulty, of course, is that this intervention (NCR) is not a pill, and does not work immediately – it works over the medium to long term. Nursing staff would have to also apply this kind of intervention consistently and constantly over a period of days (or even weeks) across shifts to see positive effects. So, organizationally, this kind of intervention is extremely challenging to use. Ironically, it’s probably got the most solid body of logic and science behind it – much more so than using chemicals (e.g., antipsychotics) or blindly applying nonpharmacologic techniques to nonspecifically “calm” a patient.

What’s in a name: Senility, Dementia, or Neurocognitive Disorder – and Does it Matter?

It used to be called “senility” – which, according to the online etymology dictionary, comes from the French,  sénile, or “suited to old age,” from Latin senilis “of old age,” etc. Senility, or what we now generally call dementia, was initially considered to be simply part and parcel with the aging process. We no longer recognize that to be the case (as memory and cognitive loss is *not* a normal part of aging!), and generally the term “senility” has gone out of fashion to being outright discouraged (see here, and here), due to its ageist connotations.

Now, of course, even the term “dementia” is going out of fashion with the advent of the DSM-V (which I touched on previously in my last post)… and the preferred term is “major neurocognitive disorder” or MNCD. A couple of things to remember here – since we’re talking about etymologies (that is, the origin of words), the origin of the word “dementia” may even be a bit harsh as well, from the perspective of those who carry the diagnosis – according to the same etymology dictionary “dementia” originates from the latin term demens –  literally “mad, raving.”.

Around the time when psychiatrists were regularly referred to as “alienists” and Kraepelinian classification schemes for psychiatric disorders were all the rage (e.g., the early 1900s or so), schizophrenia was referred to as dementia praecox, as in “precocious” or “premature” dementia. While Emil Kraepelin, the physician who coined this term, didn’t actually intend to equate what we now call schizophrenia with the progressive cognitive decline noted in dementia and commonly seen in older adults, unfortunately – that’s what I think happened. Up until recently, Alzheimer’s disease (one of the most common forms of dementia) was commonly treated by relying on involuntary hospitalization in psychiatric institutions, and using physical and chemical restraints. In other words, dementia was considered (and maybe still is considered, see here) simply another form of chronic, incurable madness, as opposed to a neurological illness such as a stroke, or Parkinsons Disease. While dementia praecox is a term that is out of vogue now (replaced by the term “schizophrenia”), the use of the term “dementia” (for things like Alzheimers) persists, and perhaps with all the baggage of the madhouses and sanitariums of yesteryear carried along with it. This may be why the American Psychiatric Association (or “the big APA” as we psychologists call it) decided to push for a major semantic shift in referring to “dementia” instead as “neurocognitive disorder.”

Much like the science of psychology has for a long time suffered from what is often called “physics envy” (e.g., the idea that we should model psychological science on the precise methodology and measurement tools found in the science of physics), psychiatry has suffered from similar issues with “neurology envy.” While others more kind to psychiatry refer to it as being an ‘overlapping’ discipline, psychiatry has basically since its inception struggled to justify its standalone scientific basis, it’s raison d’être. It suffers from a very difficult, almost epistemological problem – if mental disorders are “disorders of the brain” (as the National Institutes of Mental Health, or NIMH, loves to regularly point out) – then why aren’t they the purview of neurologists? Often the rejoinder here is, “well, psychiatrists treat neurological disease when the cause isn’t completely understood.” If we don’t know that mental disorder is actually caused by discrete neurological illness, then why do we treat it as if it’s a disease at all? I should note that while I’m asking tough questions of institutional psychiatry – I say all of this as a practitioner, of course, who relies frequently and gratefully on the assistance of psychiatrists when I work with patients.

Enough of my neo-Szaszian digression.  The basic point is that clearly, Alzheimers Disease and the other so-called senile dementias (that is, dementias common to older adults) are in fact diseases of the brain, and we know this because we have increasingly reliable and valid histopathologic methods for identifying the sufferers (definitively via post-mortem as well as increasingly via the use of live biomarkers) and the disease has characteristic symptoms that professionals like me can readily and reliably identify. Will this gradual jettisoning of the term “dementia” be effective or useful in affecting de-stigmatization? Notably, the DSM-V does not proscribe providers from using the term “dementia,” they just suggest the new term, which I think they prefer because it sounds, well, more neurological.

But now I’ll turn the tables a bit – let’s go back to “dementia syndrome of depression” which I wrote about several months ago (and turns out to be one of my most popular posts!) remember that technically speaking, an older adult can be suffering from a (reversible) dementia caused entirely by the condition of being depressed, what they used to call “pseudo-dementia” or “pseudo-senility.” Does it change things to refer to a depressed older adult who may have problems with memory and concentration due to their depression as having a “neurocognitive disorder”? Is it less of a stigma to be referred to as having a dementia (that you’re ‘out of your mind’) or having a neurocognitive disorder (implying that you have a clearly, structurally sick brain – even if all you are is clinically depressed and in need of psychotherapy)? I honestly don’t have any idea – it’s worth noting that at one time, it was thought to be less stigmatizing to use the term “dementia” rather than “senility.” Two steps forward, one step backwards?  

Technology will Save us All! (or, Cognitive Orthotics for Aging Baby Boomers)

Technology will either save us all, or be our undoing. Of course, at times, it seems like both is the case. What with internet addiction in all its forms (online gambling, shopping, porn, even illegal drugs being so easily available), the enabling of unconstitutional, mass dragnet spying by the National Security Agency, the supposed disconnection of society in favor of cold, disembodied online relationships – these are all real concerns. Perhaps they’re the price to pay for the disruptiveness of technological innovation brought to us by the Information Technology (IT) revolution, but they are real problems that need to be grappled with.

Anyways, even with all of these concerns, I tend to be of the type that sees technological innovation as a potentially liberating force. I tend to see technology as something that just may save us all.

Take, for example, the case what the DSM-V now calls mild neurocognitive disorder (MNCD), thought in many cases to be a precursor, an “upstream condition” from full-blown dementia (although in many cases it can resolve, or simply remain a chronic condition). Originally called mild cognitive impairment and developed and expounded on most notably by Ronald C. Peterson, M.D, Ph.D. of the Mayo Clinic, it’s a syndrome that’s designed to note abnormality of cognitive functioning but not necessarily to the level of significant impairment of functioning. The diagnostic criteria can be summarized as follows:

1) the patient must have concern about their cognitive functioning (or concern can be noted by a family member or physician); in other words, there’s some real worries about the patients memory or cognitive functioning.

2) Upon formal testing, they show significant, albeit modest deficits in one or more areas of cognitive functioning,

3) They remain independent in their basic activities of daily living (bathroom, bathing, etc.) and also more complex activities (e.g., meal preparation, paying bills, etc).They may be slowed in their performance of these activities and make more errors, but they remain independent. Finally,

4) They are not demented.

Enter the world of cognitive orthotics. A cognitive orthotic is merely a fancy term for the high-tech version of something that speech therapists, neuropsychologists, and geropsychologists have been making use of with their patients for years in low-tech forms: external memory aids. Think calendars, address books, memo pads, and post-it notes.

One big difference between simple external memory aids and cognitive orthotics is the limited flexibility of traditional ‘paper and pencil’ types of external memory aids. Paper calendars are bulky, and have to be carried with you separately, you have to remember to enter events individually and manually on it, and you have to remember to check it. If a family member, caregiver, or assistant wants to enter events on your calendar for you, they have to be in possession of your calendar book in order to do it. Using paper calendars for external memory aids is clunky, cumbersome, and labor-intensive.

I recall when I was in college in the early 90s and I first started using a “Palm Pilot” (remember those?) – it was like a revelation. As opposed to paper calendars, I could add repeating items, I could add alarms and reminders to events, it was astounding what I could do and it actually made my life far more functional, such as it was. What I was using was a rudimentary cognitive orthotic.

Since then, the PDA (or personal digital assistant) has been made obsolete by the widespread adaptation of smartphones such as iPhones and Droids, and the use of ‘apps.’ The great leap forward here is that a smartphone can remain constantly connected to the internet, or “the cloud” and interface directly with a vast array of databases. Calendaring, reminders, and use of address books become far more flexible as they are no longer tethered to data held on your phone, and the computing power now available in your tiny smartphone easily eclipses many times over the power of expensive desktop computers available just a few years ago.

So, I ran across this article the other day, which touts electronic “prostheses for the mind” as a fix for mild cognitive impairment in aging baby boomer attorneys. This article piqued my interest because I can’t help but imagine that the lion’s share of the newly-diagnosed MNCD patients that will be seen over the coming years will be baby boomers, many of whom will still be working in skilled and professional trades, may be doctors and lawyers with many years of experience and knowledge, and really enjoy their work and have no desire to stop doing what they do.

On the one hand, if your lawyer was developing MNCD and you knew about it, would you want to have them as your attorney? On the other hand, what if there were some simple things this lawyer could be doing to remediate their condition and allow them to continue working effectively?

There were a number of applications discussed in this article, but the main one I looked into is called Vitacare, which is an app created by a Canadian company. Apparently two of the principal founders of the company have been personally touched by Alzheimer’s disease and created this application to assist family caregivers in helping their care recipient family members remain maximally independent within the home. Since launching the app, the company that makes Vitacare (emAPPetizer) landed a major contract with a residential care facility in Canada that provides care to over 250 individuals, and has made use of the app as a way to provide medication and other reminders to their residents, who suffer from a variety of mental handicaps, and allow them to live semi-independently.

There are other apps, such as PEAT for Android, and It’s Done! for iOS all have similar ideas behind them – allowing caregivers to make use of technology to assist people with memory problems in remaining independent and safe in the home by making use of shared calendars, remote messaging and to-do lists, and a variety of other features that connect caregivers and their loved ones, typically within a stripped-down, simplified interface (which is something I liked about the Vitacare app).

Other apps that have potential applications for people with memory problems are apps such as Find Your Car with AR for iOS – which, as the name suggests, provides a simple way for users to retrace their steps and locate their cars in busy parking lots (I’ve actually had this problem before, so I may actually want to get this app!). Also, there are a number of other apps that may not necessarily be designed for people with memory issues that may have some very useful applications for them like text-to-speech apps (such as Dragon Dictation) or Google Calendar with the shared calendar and alarm functions – the latter of which I personally use and swear by.

So bottom line, although there’s currently relatively few market players in the ‘cognitive orthotics’ sector, I have no doubt this will in the near future be a booming business that’s ripe for innovation. If you’re a caregiver, or a person with memory problems who has an interest in making use of these kinds of apps, great! I think this a great thing to try. However, I would recommend the following before you try any of these apps:

1)     If you or your memory-impaired loved one were not a smartphone computer user previously, or are not comfortable with technology, this is not for you, obviously.

2)     These kinds of apps are appropriate for those with mild neurocognitive disorder (or mild cognitive impairment, as it used to be called), or perhaps some mild dementia with generally otherwise preserved functioning. Those with more advanced dementia probably won’t benefit from these kinds of technologies, and the downside of using them if a person is too impaired to benefit may be unnecessary frustration or disappointment, or perhaps even a false sense of security!

3)     Try to make use of a free trial for the app in question. If the developer isn’t offering a trial, email the company that makes the app and ask for one (they may be able to do one anyways).

4)     Realize that these apps will not be a panacea. In many cases, particularly in the case of older adults with newly-diagnosed dementia or mild neurocognitive disorder of the Alzheimer’s type, these types of memory problems will progress over time and these ‘cognitive orthotics’ will lose their effectiveness. Also, recognize there is currently not much formal research in the area of cognitive orthotics, particularly as regards these commercial available entities.

However,  in many cases, these kinds of technologies hold some exciting promise – much like using a walker can extend the independence of a person who suffers from ambulatory issues, using these ‘cognitive orthotics’ can extend the independence of a person who suffers from memory issues. And isn’t that a great thing?

Greek Grandfamilies (Kinship Caregivers)

Although this blog is called “Aging in America,” indulge me just for today. Although I’ll talk a bit about Greece and Europe, this isn’t unrelated to issues here in these United States.

Anyways, I have a habit of getting up particularly early in the mornings, usually a shade before 5am. I kind of enjoy it – everyone’s asleep, and I get to bustle around the kitchen, make coffee, do the dishes, and make sure a hot breakfast is ready for my kids when they wake up in the morning. While I do it, I also play a feed of “Russia Today” (RT) on my laptop while I do my thing. This is where I get plugged into the currently rather dismal world of international politics and finance (maybe it’s always been dismal).

A few mornings ago, I heard a fascinating spin on something that we all know has been going on for awhile, the so-called Greek “austerity crisis,” which refers to the steep economic decline being suffered in this country supposedly due to what are widely seen in the media as “draconian” or “savage” spending cuts.

To digress for a moment – the true picture of what is causing Greece’s problems are likely a bit more complicated. It appears that spending growth (which is different than spending cuts) seems to have flattened in Greece. Taxes, particularly those that affect the middle and bottom rungs of the economic ladder, such as the highly regressive, infamous Value Added Tax, or VAT – have skyrocketed. Finally, pension and wage guarantees for middle and lower-class public sector workers have been slashed. Overall government spending doesn’t seem to have been significantly affected in Greece. Getting on my soapbox for a moment – my guess is that the well-connected banker types continue to find ways to line their pockets in the Eurozone, as always, while the net affect is that the middle and lower classes in Greece have seen their incomes slashed, services cut, and taxes hiked, with predictable results.

Politics aside, regardless as to what the ultimate cause of Greece’s troubles are, the end result is it’s a country mired in deep recession, if not outright economic depression.

So what does this have to do with older adults, or “aging in America”? One of the things that piqued my interest about this story on RT was that they talked about the increasingly-observed phenomenon in Greece of grandparents caring for grandchildren. This is being driven by the phenomenon of Greek adults who are increasingly being forced to seek work abroad due to the slumping Greek economy. In the story (which I only briefly overheard), the somber-voiced RT newscaster spoke about viewing a Greek square in a small Greek town where children played in a fountain and socialized while their adult caregivers watched. Yet when you actually looked at the adults that were minding these children, they were all clearly overwhelmingly aged grandparents, with no younger adult faces to be found. Economic security is gone from Greece, a stark contrast from a decade ago.

This phenomenon of “grandfamilies” or “kinship caregivers” is certainly one of which I am familiar, having worked with this population as a postdoc in Rochester, New York. In the United States, where this phenomenon has been well-studied at this point, it’s mostly a phenomenon found in the social underclass of poor, African-American families where the parents have been decimated by the War on Drugs and mass imprisonment, drug addiction, or HIV/AIDS. Grandparents typically step in and are the ones that provide custodial care in lieu of their grandchildren ending up in the foster care system, which is a laudable goal – it definitely fits with cultural values in this case, families in the African American community “taking care of their own” and being self-sufficient within their own community.

However, taking on this role comes with some costs; as research tends to suggest, kinship care can be a stressful business.  Older adults in this role find themselves at higher risk for depression, anxiety, and stress-related illness than others. Some think this is because kinship carers are mourning the loss of their imagined lifestyle at retirement (e.g., being able to travel, relax, not work, see family at their own leisure, etc.), but they may also be mourning the loss of their children, especially if the event that caused them to take on this role in the first place was something tragic, like death. Also, family strains are frequently found – in the kinship caregivers I worked with in Rochester, often there were ongoing issues with parents who were peripherally still involved in the childrens’ lives, but due to drug addiction were only able to contribute dysfunction to the family and not much else. These grandparents may also be “double caregivers,” they may be caring for a relative or spouse of their own (perhaps with dementia or another chronic illness) at the same time they are caring for their grandchildren.

Finally, the children themselves are obviously a source of stress. Not only must these older people re-acclimate themselves to the physically and mentally taxing nature of child caregiving, they must do it within the context of an aging body and with their own health issues to contend with. It becomes even more challenging when you consider the possibility that many of these children may have some serious behavioral and emotional issues of their own to contend with, which may make them even more of a challenge to care for.

As I mentioned earlier, the issue of kinship caregiving and “grandfamilies” is still a fairly wide-open area for study and intervention. While there is some activity out there suggesting that comprehensive intervention programs may be being developed to address issues found in kinship carers, as of yet this area has not developed to the degree seen in (for example) the REACH-II program for dementia caregivers.

I’m glumly noting that the economic troubles of Europe seem to be continuing and not resolving, as are much of the economic troubles of the world (some would say that the recession has never really ended in the United States). Does this mean more parents will be uprooted from their children in industrialized countries due to the desperation of needing to find paid work? If other nations “go Greece,” will the phenomenon of kinship caregiving spread to other industrialized nations? It’s possible kinship caregiving will cease being just seen as a niche issue only affecting the urban underclass of the US and the world, and may soon be something hitting near you. The upside of this is that these particular older adult caregivers may finally get the attention they deserve, and maybe they’ll start getting the help they need.

CBT and Geriatric Anxiety Disorder – It Doesn’t Work?

A few weeks ago I sat through a series of very nice presentations on geriatric mental health by a series of distinguished Geropsychologists and scholars at the VA Palo Alto Healthcare system and elsewhere. Wanted to highlight this, of course, because last week I groused about the dearth of quality CEs in and for Geropsychologists out there. Occasionally good CE experiences do happen to me!

Anyways, one particular presentation that stood out in my mind was one by psychologist Julie Wetherell, professor “in residence” at the Department of Psychiatry at UCSD. Dr. Wetherell has carved out a niche for herself doing research on chronic pain and germane to the current discussion, geriatric anxiety disorders and cognitive behavioral therapy, or CBT.

CBT, of course, is one of several schools of thought in psychotherapy (e.g., as contrasted with psychodynamic, humanistic, and family systems schools of thought). CBT has many features that distinguishes it from other schools of thought. It tends to be focused on the here-and-now, tends to be specific and problem-focused, and tends to emphasize hypothesis-testing and active experimentation and use of ‘homework assignments’ as part of the work. Therapeutic dialogue often takes the form of ‘Socratic questioning’ in CBT, often with the aim of helping patients to find more accurate ways of viewing and interacting with the world.

In the case of CBT, it’s been found to be an approach that works exceptionally well with older adults in the case of major depression, as has been found time and time again. It also works exceptionally well with middle aged and younger adults with depression and anxiety disorders.

Curiously, and this is where Dr. Wetherell’s presentation got interesting for me – CBT does not seem to work particularly well for older adults with anxiety disorders, particularly as regards the entity of generalized anxiety disorder.

Briefly on different anxiety disorders. Generally clinicians tend to split anxiety disorders into a few different categories. It’s worth mentioning that the introduction of the new edition of the Diagnostic and Statistical Manual of Mental Disorders has changed things up somewhat (e.g.,  the DSM-V), for example, post-traumatic stress disorder, or PTSD is not longer considered an anxiety disorder anymore and now is in a category of it’s own.  However, generally anxiety disorders are still broadly categorizable into three groups, at least as I see them. First, there’s panic attacks, or Panic Disorder. This particular disorder is not-uncommonly seen in emergency rooms, and is frequently misdiagnosed as heart attacks or other medical disorders. The sufferer complains of all sorts of bodily symptoms such as sweating, shaking, pressure in the chest, racing thoughts, dizziness, etc., and is fearful that the symptoms are harbingers of serious health consequences or death. Panic disorder is frequently treated with anxiolytics and/or antidepressants, and psychotherapy.

Another category of anxiety disorder is phobias – the most classic one of which is fear of snakes (e.g., Indiana Jones). These phobias can take many forms, fear of heights, fear of open spaces (agoraphobia), fear of public speaking, et cetera. In this case, the treatment of choice is a specific form of psychotherapy called exposure and response prevention, or ERP.

Finally,  there is Generalized Anxiety Disorder, or GAD. This is the classic “free floating anxiety,” where the patient reports being worried and anxious about, well, just about everything, and it seems disproportionate to anything being worried about. The treatment of choice for GAD, at least for younger adults, is CBT, as we mentioned, and as a second-line treatment, antidepressant treatment (typically with SSRIs).

The mystery is that according to published research out there, unlike with treatments for depression, CBT does not seem to work for older adults with GAD (which seems to be the most common anxiety disorder in older adults). So, if you’re working with an older adult with an anxiety disorder, and particularly if GAD is noted, the responsible advice to give them is to make use of an antidepressant like paroxetine or citalopram, and supplement with relaxation techniques (which, although isn’t psychotherapy per se, can be effective as a supportive therapy).

The older adult you’re working with may understandably protest – many are not keen on taking yet another pill. So what do you do? While I would certainly be sympathetic (given how so many older adults are probably tired of taking pills), given the state of current understanding as regards treatment for GAD and anxiety disorders in older adults, I would make sure the older adult in question is informed that there are significant risks to refusing what is in this case the first-line treatment for older adult GAD. I would then offer this older adult CBT and relaxation techniques, and do my very darndest.

The real question is, why does it seem like older adult GAD and anxiety disorders seem to be qualitatively different entities than in their younger adult and middle-aged counterparts? No one’s quite sure yet. I’ll let you know if anyone finds out.

Geropsychology Continuing Education – A Rant

So, it’s that time that every psychologist in California looks forward to every couple of years, that time when one enjoys the distinct pleasure of paying the California Board of Psychology its annual fee of several hundred dollars ($445 this year) to…. Well, I’m not sure what they do for me every two years. But I need to do it or they don’t let me keep my license.

As a sidenote, there are only a few states (a half dozen or so, if this list is accurate) that don’t require psychologists to attend a requisite number of Continuing Education (CE) courses every year, and these are apparently Colorado, Connecticutt, Hawaii, Illinois, Michigan, New Jersey, and New York. I can imagine the reaction of many mental health consumers out there – “I will stay away from those states, they just let psychologists sit around and collect their fees and not update their skills at all!”

I’m more than sympathetic to that sentiment – any psychologist who simply gets their doctorate and doesn’t make any effort to read relevant literature, stay current, learn new techniques, etc., will eventually find themselves selling a highly inferior and arguably even dangerous product to the public (whether this is a danger that requires government force to correct for is another matter).

In California, psychologists are required to earn 36 hours of CEs every two years (70 percent of which can be earned online).  These courses must be accredited by the American Psychological Association, or APA – like most other states, California’s psychologist licensing standards (in terms of ethical standards) are borrowed heavily from the APA’s Ethical Guidelines, and generally, California marches to the APAs tune, for good or ill.

So one of the positives of having a CE requirement like in California, of course, is that psychologists are then required to seek out learning experiences on a regular basis (for fear of losing their ability to practice). Hopefully, these learning experiences are relevant and useful for the psychologist in practice, and make them a better practitioner in the end.

Let’s take a look at what I’ve amassed over the past two years:

1)     “The Role of Clinical Supervision in Facilitating Compassion for Self and Others” (daylong live course)

2)     “Sleep in the Veteran Population” (daylong, live)

3)     “Risk Management: Medical eRisk Considerations for Online Communication” (online)

4)     “Ethical Principles of Psychologists and Code of Conduct” (online)

5)     “Legal and Ethical Issues Related to Clinical Decision Support Systems” (online)

6)     “Suicide Risk Management Training for Clinicians” (online)

7)     “Cognitive Processing Therapy (CPT) Enhancement Course” (online)

8)     “An Introduction to Telehealth in VA” (online)

9)     “Mental Health Assessment and Interventions With Older Veterans” (daylong, live)

10)  “14th Annual Updates on Dementia: Translating Research into Practice.” (daylong, live)

A few things to note about this list. Number one on the list is a required course I needed to take in order to retain my right to supervise students. Was it a particularly practical course? I honestly don’t remember much of it, but I do remember getting generally warm fuzzies at the end of it (it focused a lot on self-care and self-reflection as a tool for improving one’s supervisory capacity), but I’m not sure it necessarily made me a better supervisor. Frankly, I think getting personal therapy has made me a better supervisor more than anything (along with getting CEs specifically in geropsychology related coursework – more on that later).

The second item on the list was worthy of note – in this case, I don’t precisely recall learning anything earth-shattering from this course (it reviewed common issues related to sleep in veterans, such as optimizing adherence to C-PAP treatment in veteran populations, common sleep issues in polytrauma patients, etc.) but it was particularly useful for me given the preponderance of sleep-related issues that seem to impact my population. Although not directly related to Geropsychology, it was a valuable course for me to take, it definitely helped me to stay current in some things I need to stay current with on a day-to-day basis.

Now, let’s focus on the rest of the list. Aside from the last two items on the list (which were generally outstanding presentations on the state-of-the-art in assessment and interventions for dementia patients and older adults with psychiatric issues), let’s be honest: the rest of these CEs listed here were “filler” courses. Sure, all psychologists need to know basic risk management techniques for managing suicidality, and need to be familiar with the APA’s Ethical Guidelines (I would say I was familiar with both just fine before I took those courses). And sure, telehealth is interesting, certainly a fine subject -and I must say, I completely forgot about what “clinical decision support systems” was even about. Finally, I will not be using cognitive processing therapy in my work with veterans (this was a good online course in that it netted me 2.5 hours of CEs – most of these were 1 or 1.5 hours in length), mainly because I haven’t had supervised training in it – but I now have earned CEs in it. In short, what do most of these classes really have to do with my job? I’ll be bluntly honest – aside from the class on sleep and the two geropsychology courses, I took all of my other CEs to fulfill my 36 hour requirement with the government. I would have taken CEs on aging-related or geriatrics issues if I could. They just weren’t available.

I know what most of you are thinking. This is just where Dr. Lane is being a grumpy, cynical provider. It’s good that I keep abreast of these things, even if they don’t necessarily relate to my day-to-day duties as a Geropsychologist primarily working in long-term-care psychology. So, it’s all good, right?

Here’s where I protest. I didn’t get into this field in order to just become a psychotherapist and learn a few assessment tools and then stop right there. Clinical psychologists with a Doctor of Philosophy (PhD degree) are scientist-practitioners by trade. Whether or not they are primarily researchers, they identify with the idea that truly competent practitioners are ones who maintain a firm footing in current science, utilize the hypothetico-deductive method (hypothesis testing) in the way they frame clinical questions, and have a strong basis in current scientific thinking when they practice their craft (whether it be testing, consultation, or psychotherapy). I take that very seriously.

I also take my identify as a Geropsychologist very seriously. I typically find myself browsing Google Scholar at least once or twice a week to search out interesting basic research papers, clinical guidelines, or what have you. When I run into a difficult patient issue, I often find myself going back into the literature to make sure I remain firmly grounded in current understanding. My recent obsession was with fronto-temporal dementia (FTD), as I seemed to have a couple of patients recently with this issue that I wanted to make sure I understood properly (see this recent article for a discussion). Of course, none of this tends to reward me with any CEs.

One of my biggest grouses are that there just aren’t that many CE courses out there being offered for psychologists on geriatrics-related issues. A very brief, unscientific Google search for “geropsychology CE courses” yields a couple of interesting links: first, the APA’s own online listing of approved CE courses lists a number of topic areas and a total of just over three hundred (303) online CE courses one can take to fulfill the requirements of one’s respective state. All told, there are only 14 courses offered in “Geriatrics” (4.6% of the total). Topic areas with more courses in them include “Professional Resources for Practice,” “Psychotherapy,” “Health Psychology,” “Ethics in Psychology,” “Clinical Psychology,” and “Death, Grief, and Suicidology.”

Now, I have nothing against psychologists learning about any of these topic areas, and in fact (particularly as regards health psychology and the topic area of death and dying) many of these areas overlap with Geropsychology in terms of focus. However, let’s be frank – the population of older adults in the United States will continue to explode over the coming years, as I continually find myself saying. The “demographic tsunami” is right on top of us. And the well-documented shortage of Geropsychologists, or even general practitioners (in psychology or medicine) well trained in aging-related issues doesn’t look as if it will be getting better any time soon at this rate.

What does this matter to me? Well, perhaps not much. I consider myself much better trained in geriatrics than a sweeping majority of psychologists and mental health practitioners out there (although don’t look to me to do sandbox play therapy with your three year old – I have enough trouble raising my own children to worry about treating yours). So what if it’s harder to find quality CE courses in geropsychology for someone like me? Again, maybe it doesn’t matter much. On the other hand, I don’t think it bodes well for our (rapidly aging) future when aging-related issues don’t seem particularly well-valued. For my money, geropsychology should be the hottest topic area in CE provision out there, given the numbers.

There should be a “gold rush” on for providers to get trained in the latest and best methods for working with older adults – because by the numbers, every clinical practitioner will likely find themselves with older adult clients regularly at their doors in the near future – even those who ostensibly work with child populations (ever heard of kinship caregivers? I have).

If such a “gold rush” were ever to occur, there is at least one organization that stands to benefit. I’d like to introduce you to a relatively early-mover in the area of providing CEs for mental health providers in geriatrics: Concept Healthcare, Inc. Founded by Joe Casciani, Ph.D., the principal founder of the nursing home consulting firm, VeriCare, Concept Health bills itself as a company devoted to providing quality training to providers in mental health care services for older adults (although to be fair, I note they also manage a long-term-care psychology group practice as well). While this firm definitely looks promising and knowing Dr. Casciani, they likely offer quality products and services – I note that I do not have access to any of their products as a VA employee (although I could, theoretically, pay for some of their classes myself).

Soapbox rant over. Hopefully I’ll return to more interesting clinical issues in the next week or so.

Some General Thoughts on Geropsychological Assessment

Even prior to my entrée into Geropsychology practice, I have long regarded psychological assessment as a critical area for me to attain expertise – I consider assessment to be an indispensable aspect of psychology professional practice.  I think the context of practicing assessment in a research context served me very, well later in my career when it came to learning psychological test administration.

My internship year (University Behavioral Healthcare at the University of Medicine and Dentistry of New Jersey – UBHC at UMDNJ) was when my training and experience in psychological assessment was taken to another level, particularly as regards applications of neuropsychological testing to Geropsychological practice. In my year at the UBHC Dementia Diagnostic Clinic (DDC) in Piscataway, New Jersey, I performed easily 60-70 neuropsychological screening batteries on older adult patients with memory complaints in my year as Geropsychology intern. Typically, clinic patients were seen for suspected primary progressive dementia issues (e.g., Alzheimer’s disease, cerebrovascular dementia), however, on occasion we saw other, more challenging diagnostic issues present, such as cognitive deficits secondary to chronic alcoholism, dementia syndrome of depression, and reversible dementias due to medication issues (one issue I recall was due to probable lithium toxicity in a bipolar patient we assessed).

I performed at least an additional 30 or so batteries on adult and older adult clientele in my year at the UBHC Psychological Assessment clinic – it was there that I became competent on more involved neuropsychological assessment batteries, and doing more complex referral questions (e.g., ruling out various forms of dementia), capacity and disability assessments, and doing integrated assessment batteries as a means of assisting in treatment planning. In both cases (e.g., working for the DDC and the Assessment Clinic) I was able to learn valuable initial skills in that I continue to take with me today – in terms of test selection, report writing, and most importantly, in terms of providing feedback to clientele, caregivers, and other providers. This is where I really began to learn the value of Geropsychological assessment practice; the value is difficult to overestimate in terms of how it informs the work of paid and unpaid caregivers with our patients, and how it informs intervention approaches. Speaking of which, as I later progressed in my work and my practice began to coalesce around working in long term care Geropsychological practice, I feel that my approach to providing psychological assessment for primarily geriatric clientele within an integrated healthcare setting has gone from competent / proficient (as a practicum student and intern) to expert-level. I am extremely comfortable in performing a seamless blend of assessment with a therapeutic / consultative approach in my LTC practice where necessary. It is my practice identity, as it were.

As a geropsychologist, assessments are no good as isolated, academic exercises. My colleagues (nursing, medicine, social work) need specific questions efficiently answered on issues such as cognitive functioning (both as a snapshot and across time), personality functioning, psychiatric status, and capacity status. They need to know these things as they are critical to insuring patient safety, physical, psychological, and financial well-being, and in optimizing medications, and in finding the best way to approach patients in general. Assessment can be critical in alerting staff how they should approach patients. For example, personality testing may indicate whether the patient tends to prefer direction and structure from their caregivers, or whether they prefer nondirective approaches and more emphasis of independence and choice (e.g., whether trait resistance is an issue). Does a patient have memory problems? If so, how can we best assist the patient compensate and optimize for their deficits? If they have short-term memory loss, is cueing helpful? If so, do they have strengths and weaknesses in receptive language that would guide nursing approaches (e.g., written, spoken, pictorial and/or gestural cueing / reminders, etc.)? And so on.

A special category of geropsychological assessment are capacity assessments. A particularly valuable resource which I acquired in 2008 is the “Assessment of Older Adults with Diminished Capacity,” which I acquired around the same time. I made careful use of this resource, which covers areas I was previously barely familiar with as an early-career geropsychologist (e.g., such as undue influence, sexual consent capacity, etc). Since I have been licensed in 2006, I have performed scores of capacity assessments on my geriatric patients for the VA system – primarily regarding issues regarding medical decisionmaking capacity and capacity to live independently. In other roles (such as assessment consultant with the Institute on Aging), I have performed assessments of testamentary and fiduciary capacity as well (e.g., capacity to manage funds, finances, change wills, name durable power of attorney, etc). I tend to use a fixed-flexible battery approach where I combine standardized neuropsychological screening batteries (e.g., Cognitive Testing Battery, RBANS, etc.) with additional instruments added to do some limits-testing, and also to assess function (e.g., Independent Living Scales, etc). I also have several forms of semi-structured capacity assessment instruments which I have made use of over the years which supplement my interviews (e.g., the Hopemont Capacity Assessment Inventory, the Hopkins, etc).

I have found that a competent capacity assessment on my part is often written in a qualitatively different form than my other reports. The level of subjective detail is often much denser and my conclusions are based often on considerably more painstaking justification. In part this is due to the fact that in many areas of capacity that I am asked to assess that are rather murky in terms of relevant standards (such as sexual consent capacity) or where there is simply just not much relevant research and guidelines to light the way (such as undue influence).  This may also have to do with attention paid to my audience – frequently capacity assessment reports are more often consumed by case managers and lawyers as opposed to medical professionals, and really – a patients liberty often hinges on my assessment in this case. I take that responsibility very seriously.

I find psychological assessment with my geriatric patients to be one of the most professionally satisfying activities I engage in as a Geropsychologist. It’s for several reasons – I thoroughly enjoy the intellectual exercise of crafting a well-written report with concise conclusions based on systematic data. I also find the intellectual exercise of differential diagnosis (particularly as regards different types of dementia syndromes) to be quite engaging and satisfying as well. Finally, there is the personal gratification I receive when a paid or family caregiver or medical professional gains a new and useful understanding of the patient based on my report, sometimes with profound consequences.

Geropsychology, Specialization, and Boarding (hopefully not too boring)

I’d like to talk about the importance of Geropsychology as a bona-fide specialty area in clinical psychology. In my years of practice as a Geropsychologist, I have found that families and patients are in a lot of pain, turmoil, and confusion about where to turn when it comes to receiving competent services. An example comes to mind – recently, I had occasion to review the case of an older adult man who had received a diagnosis of “mild cognitive impairment” from a neuropsychologist (not a geriatrician) who had done what was otherwise a very detailed assessment of this gentleman’s cognitive functioning.

In reviewing this case, I noted that this gentleman (who was married and was the sole breadwinner, and also tended to be the primary financial decisionmaker) had a house that was now in foreclosure, and had several lawsuits against him for legal malpractice, and seemed to be making an increasing number of poor financial decisions over the last several years. He had recently gotten lost in his car in his hometown (greatly distressing his wife) and also had recently had an MVA with a parked vehicle. This and other issues led me to note a fairly clear pattern of occupational, financial, and physical dysfunction and risk of harm to this patient which had been escalating over the years. Subjective memory complaints were present and memory deficits were noted (along with other deficits) on neuropsychological testing.

After reviewing the testing report, I concluded that the “mild cognitive impairment” diagnosis had been improperly offered in this case. The report itself was carefully crafted, the data systematically reported, and the writing was clear. However, the conclusion, I believe, rested on what I consider to be somewhat of a basic mistake that I often see committed by non-geriatric specialists (and students in training) – basically, that it was concluded that a somewhat “softer” diagnosis to offer, less stigmatizing, possibly defensible, and therefore appropriate.

In my case, I felt the risk of harm to the patient by soft-pedaling the diagnosis (which clearly pointed to mild dementia, likely of the Alzheimer’s type, as far as I was concerned) was that treatment would  be unnecessarily delayed, as would be withdrawal from sensitive occupational responsibilities, and finally, measures that might need to be taken for the patients safety and health (and the health and safety of those around him) would also be needlessly put off – and the only upside of proffering the “softer” diagnosis of MCI in this case would be that the eventual difficulty of coming to terms with a dementia diagnosis would simply be pushed off until a later date, which, in this particular case, is exactly what happened.

So, how do you know how to choose a competent geriatric psychologist, or Geropsychologist? It’s a tough one. While most clinical psychologists (69%) report that they work with older adults in their practices, at least some of the time, less than a third of them report they have had any specialized graduate coursework in geriatrics. An even smaller percentage of that (20%) report they have any supervised experience providing services to older adult clientele, according to APA’s 2004 Guidelines for Psychological Practice with Older Adults.

So, let’s say you wish to hire a competent clinical psychologist in the area of, let’s say, late-life depression or dementia care. In other words, you want to hire a geriatric psychologist, or Geropsychologist. So, you’ll want to make sure they have three things – relevant education, training, and experience (and hopefully plenty of all three) in this particular area. Let’s start from first principles.

For clinical psychology per se, the very basic set of qualifications to assure a minimum level of competence is that they received training from a doctoral program in clinical psychology that was accredited by the American Psychological Association (APA) at the time of their graduation. While there are certainly a number of quality graduate programs in clinical psychology that do not have this nationally-recognized standard of accreditation for whatever reason, it should be pointed out that arguably, APA accreditation is not a particularly high bar for a program to attain, and as far as national standards are concerned, it’s really the only bar out there that’s universally recognized.

Moreover, even if a clinical psychologist has earned a doctoral degree from an otherwise quality, unaccredited program, the fact they have not achieved a degree from an APA-accredited program basically means that attaining quality internship and post-doctoral residency training programs are typically near to impossible, which further hampers their ability to attain quality training experiences. Basically, if your psychologist has not gotten their degree from an APA-accredited program, that would be a big red flag to me.

So, we’ve assured ourselves that our psychologist has graduated from a program that assures at least a basic standard of quality (APA accreditation) in the training it delivers to its graduates.  But we want to know – how can I find a good Geropsychologist?

We could ask ourselves whether a psychologist has received classwork that relates to Geropsychological practice, such as Adult Development and Aging (a course I took in graduate school), or Geri-Neuropsychological Assessment, or what have you. If a psychologist has received this kind of coursework in graduate school, I think this can be a potentially important. Again, a fairly small percentage of psychologists have had any formal classwork in gerontology-related topics at all.

However, one of the most important markers of specialty competence, that is, what makes a person a Geropsychologist, in my view, would be whether this person has received supervised experience delivering psychological services to substantial numbers of older adult clientele either as a predoctoral intern, a postdoctoral fellow, or ideally, both. Where a clinical psychologist receives their internship training is probably *the* single most important factor in terms of determining what area  a particular clinical psychologist will practice in after they become licensed (presuming they do not enter into a career as a researcher).

One reason why this is is that when employers first review résumés of freshly-licensed clinical psychologists, one of the first things they look at is where the person received their internship and postdoc training. In my case, both my internship and postdoc training programs were exclusively Geropsych-focused, which led me to a series of employment opportunities and most recently, to my last five years as staff Geropsychologist at the VA Palo Alto Healthcare System’s Livermore Division.

So, let’s talk about board certification. In the world of physicians, board-certification is basically de rigueur – it’s nearly mandatory. According to 2008 figures, approximately nine in ten US-licensed physicians possess board certification in a given specialty – for example, at my place of work, the physicians I work with (MDs) typically have board certification from organizations like the American Board of Medical Specialties or the American Board of Physician Specialists, in specialties such as geriatric medicine or hospice and palliative care.

What is board certification? It basically means that if a physician has attained this certification, you can be assured of a basic standard of competency in a given specialty area. A geriatric-boarded physician, in other words, you know has specialized knowledge in the care and treatment of older people and their particular issues.

What about psychologists? In contrast to medicine, where there are a small handful of nationally-recognized boarding agencies, for psychology there is only one, the American Board of Professional Psychology, or as most psychologists refer to it, “ABPP” (“ay-bepp”) which has, as of last year, 14 separate specialties that it recognizes as part of it’s boarding process. (It should be noted that there are other organizations that offer competing specialty certifications for psychologists, such as the International College of Professional Psychologists, or ICPP, but this organization and probably any of the others you might encounter, are not reputable). It should also be mentioned that there are definitely other ways that psychologists can attain formal, national recognition for their work as psychologists, such as being an APA or APS fellow, but ABPP is the only organization that recognizes clinical psychologists for reaching a standard of proficiency in specialty practice.

In contrast to physicians, where 90% or more of them are boarded, it’s worth noting that less than 4% of all eligible clinical psychologists are board certified. Personally, I find this a curious development, considering how clearly specialized (and competitive) the world of mental health practice has become. Might this be one of the reasons that reimbursement rates and salaries for psychologists have been dropping over the years?

One of the things that I have always found makes good career sense for professional psychologists (and something that I always advise my students) is to aim for specialization in your training as early as possible in your career, and to avoid where possible being tarred with the brush of being a “generalist” practitioner. Although there’s probably nothing wrong with aiming to be the “jack of all trades” in your practice (does that make you the master of none?), for a professional psychologist, not having carved out a career niche basically makes one, in my opinion, highly uncompetitive against all of the other (many of them quite newer) licensed mental health disciplines out there, such as MFTs, LPCs, etc…. that “generalist” psychologist will get their lunch promptly eaten.

So, obviously I’m making the case for psychologists achieving board certification status here. While it’s possible that a psychologist can distinguish themselves from the generalists by virtue of their education, training, and experience (as I talk about above), let’s be frank – I believe it’s a rarity that psychologists will post or make available their entire vita to prospective clients. Moreover, I would imagine that an even smaller percentage of clients will think to ask for a résumé from their prospective psychologist. Although I’m not exactly sure why, I think plenty of prospective clients feel it may be, well, unseemly to request a complete résumé or curriculum vita of a psychologist prior to hiring them. Moreover, even if a prospective client did acquire the work history of the psychologist they were considering working with – not many would know how to evaluate it. What do clients have to go on? Typically it’s a one-paragraph, pleasant-sounding blurb (e.g., “I work to help clients attain personal satisfaction in their lives, heal from trauma,” etc.), and sometimes information as to where they went to school, statements about what populations they work with (older adults, addictions, etc.), and that’s about it. If you’re lucky, someone might have rated them on Yelp.com.

As I have written about elsewhere, the “demographic tsunami” (e.g., the aging of the Baby Boom generation) is upon us. Demands for competent geriatric specialists are rising rapidly, and while there seems to be somewhat of a (growing) oversupply of clinical psychologists in the United States (thanks in part to the proliferation of large-scale professional psychology programs run by companies like the Apollo Group and University of Phoenix), there seems to be a rather distressing shortage of appropriately trained Geropsychologists in the United States that will only continue to grow.  It seems an extremely difficult situation for consumers who wish to find competent Geropsychological services – at the same time the supply of (in many cases, poorly trained) psychologists continues to grow, the supply of Geropsychologists relative to demand continues to shrink over time.

And this is where it gets exciting for Geropsychology. As of this year, ABPP has announced (after a multiple years of buildup) that they will begin the initial process of examining candidates to attain board-certification in the specialty area of Geropsychology! I consider this a critical step for consumers and organizations to begin to easily be able to sort the “wheat from the chaff” when it comes to the confusing world of clinical psychology. Specialty boarding in Geropsychology will be, without a doubt, a career goal for me. I consider it not only a smart career move (lets be honest), but it’s also a critical service to the community. As I showed in the example above (where I discussed the case of the older adult gentleman who was misdiagnosed with mild cognitive impairment as opposed to dementia), psychological, physical, and financial well-being can be at stake.