Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-027Non-computerized Assessment Procedures:Fundamental Assessment IssuesP. LogueDuke University Medical Center, Durham, NC, USABASIC ASSESSMENT ISSUESJust as individuals age, so do populations. The ‘‘graying ofAmerica’’ is a cliché that carries with it the inevitability of thenormal aging process combining with the advancement of medicalscience. The average age of all industrialized countries is going upsteadily. While, to some extent, these changes in basic demographicsrelate to improved infant mortality, there is also anincreasing ability and willingness on the part of the medicalprofession to treat the ailments that may come with aging andextend the lifespan of individuals within the society. Control ofischemia risk factors, dialysis and organ transplant are allcommonplace now but were much less advanced 30 years ago.In many ways this demographic change is a very positive trend.Individuals at 50 now are no longer considered to be as old as theyonce were. There are many physically vigorous and cognitivelyintact individuals who function effectively well into their 70s, 80sand 90s. However, extension of life is not necessarily the extensionof quality of life. With increasing age there is an increasingprobability of dementing processes. Dementia is not the inevitableoutcome of aging, but the diagnosis of dementing conditionsincreases significantly with each decade of life.There are multiple potential dementing conditions. Some ofthese conditions are the by-products of physical disease and othersof lifestyle choices made years earlier (see Table 27.1 for a partiallisting of the more common dementing processes from the familiarDSM). The clear majority of dementing processes, however, fallinto three general categories, Alzheimer’s dementia, vasculardisease-related dementia, and mixed dementias. While each has aprogressive course, the potential for treatment and the speed anduniformity of the progression varies significantly. Precision ofdiagnosis is critical in the appropriate treatment and managementin a geriatric dementia work-up.Depression in the old, in combination with the normal agingprocess, can produce a condition that is treatable but that mimicsthe effects of central nervous system-based dementias. Depressionin some cases may be the earlier preclinical precursor of dementia,but nevertheless, the accurate differential diagnosis of dementiaand depression is of extraordinary importance. The consequencesof a false-positive or false-negative diagnosis in dementia can bedevastating. If a patient is labeled as having early-stageAlzheimer’s syndrome, multiple negative consequences occurvery quickly. Driving privileges, financial and medical decisionmakingand the independence that is critical to any person are allrestricted and sometimes taken away. If the patient diagnosedwith dementia is not demented but is depressed, unnecessary andTable 27.1potentially irreversible changes occur in the quality of thepatient’s life, even if the diagnosis is later changed. Similarly, ifthe patient does have a progressive dementia and proceeds tomake decisions about finances, about health, or even about dayto-dayinstrumental activities of daily living, the consequences canbe equally negative.In summary, the geriatric population is growing. As people age,they become more susceptible to potentially treatable conditions.These conditions can radically alter the quality of life and theultimate prognosis and disposition for the successful managementof the case.ASSESSMENT PROCEDURESThe assessment of geriatric patients for dementing conditionsdemands considerable focus in assessment and knowledge of thescientific literature. These areas would include, at minimum, anunderstanding of the characteristics of the normal aging processand the salient behavioral/cognitive characteristics of the dementias.Necessary and desirable parameters of geriatric evaluationsare as follows.Necessary Characteristics of Any Assessment ProcedureNormsDSM-IV: common dementing processesDementia of the Alzheimer’s typeVascular dementiaDementia due to HIV diseaseDementia due to head traumaDementia due to Parkinson’s diseaseDementia due to Huntington’s diseaseDementia due to Pick’s diseaseDementia due to Creutzfeldt–Jakob diseaseDementia due to other general medical conditionsSubstance-induced persisting dementiaDementia due to multiple etiologiesDementia not otherwise specifiedDiagnostic and Statistical Manual of Mental Disorders, 4th edn, p. 133.Test results are significantly influenced by the age of the subjectand premorbid functioning levels; therefore, any assessmentPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd