I am a forensic psychologist by training. One of the risks of my background is to focus on the notion of pathology and disease. I frequently offer that one of the causes of our seemingly endless uneasiness, our collective “disease,” is that our ecology, in the purest sense of the word, and our commerce with the world, is unnatural and unlike ever in our history. It should come as no surprise, that as I waited in line at the latest bank to be swallowed whole by another bank, the sky outside hardly seemed worth notice. My mind was on the Dow Jones Industrial average, the FDIC and the notion of a credit freeze, indeed, my sense of well-being was tied directly to them. The sky was ominous and purple with a stiff wind blowing two years of drought-dust horizontally across the ground. Inside, a tense, long line wound through the bank lobby. My chest was heavy. It was not long before an elderly man began to tease a little boy in line with his mother. The boy repeatedly retreated and cautiously approached, squealing in that oddest of human experiences, the combination of fear and excitement, every time the man growled at him, hands overhead reaching for the boy. I envied the little boy young enough to still be lost in play and the old man wise enough to be unfazed by life’s most recent crisis. Sometime around the third attack, I realized the elderly man had been one of “ours.” I remembered the first time I had seen him in Intake, broken and disconnected. In a business in which the numerator often feels so much smaller than the denominator, seeing him return to play was profound. When I went outside, I could smell the softly falling rain.
From a clinical perspective we may view life as a series of epigenetic challenges that are negotiated with more or less success. The failure to adequately negotiate a life stage may be rightfully seen as a crisis. I have noted, particularly with the elderly patients we treat, that regardless of whether this is their first treatment or they have long histories with multiple treatment episodes, their entry into treatment is frequently precipitated by loss or impending loss. Frequently, it is the death of a spouse, retirement, or diminished health, often manifested as anxiety, depression, loneliness and boredom. In treating these patients I have come to recognize the disintegrating effects of loss of attachment, identity and purpose.
There would be something comfortable about being able to quote the research and evidence-based practices. There is little data on the treatment of chemical dependency in the elderly. In spite of how “sensible” the trend toward evidence-based practices may be and how well advised we would be to be aware of the data, I urge you to return to being equally advised by your clinical judgment.
We have gleaned a number of recommendations from our experience treating elderly patients at Hemet Valley Recovery Center. The Center for Therapeutic Change promotes the theory that rapport is the single greatest factor in the successful treatment of any patient. With the elderly patients we’ve treated, generating a solid treatment alliance is the primary task. They often present as diminished and disintegrated. “How to Fail as a Therapist” offers the notion that a lack of disclosure or too much disclosure, and even the way in which the disclosure is presented, can be damaging to the therapeutic relationship. The elderly patients I have treated are warm and object-seeking. I would argue that they are more invested in the therapist and his or her personal life. With them I tend to disclose more and offer more casual interaction. Frequently, a patient’s “theory of change” is elicited by asking, “What would you do with you if you were me?” This simple question generates an approach to treatment. In my experience the elderly patient is more likely to respond with answers akin to: “you are doing a wonderful job” or “you are the experts, I can’t think of anything that you should do differently.” Whereas, a practical answer: “don’t let me get away with being evasive, help me understand my family, or just listen to me,” is golden and something to be mindful of during the patient’s treatment.
A thorough clinical interview is important but shouldn’t begin until adequate rapport is established. A non-threatening warm-up and simple gauge of recent and remote memory is to ask the patient “how long have you been in treatment? who is your case manager? who is your roommate? what was for dinner or lunch? what’s the most interesting thing you’ve learned? The responses to these questions and the quality of the response: rate and prosody of speech, confused, sparse, over-inclusive or odd, will begin to inform your understanding of the patient.
Imbedded in the usual clinical interview are questions that I find particularly rich. I am particularly interested in the stated motivation for entering treatment, the patients’ level of insight, theory of change and motivation in general. I always ask patients to characterize their childhood, in spite of their age; I rarely find them reluctant to discuss their childhoods. This question frequently begins them engaging in “life review” which is arguably “therapeutic.” Some patients generate a narrative about their lives that answers a number of interview questions without the usual battery of questions. I want to know their history of use: age of first use, nature and quality of use, including their history of abstinence or sobriety. If there were periods of sobriety, I ask what led to the lapse. The patients’ educational and occupational history, history of mental health treatment/hospitalization, history of self-injurious behaviors and their history of trauma, I believe offer additional insights. The patient’s perception of their health, evidence of distress (sleep and appetite disturbance), loss of interest in pleasurable activities, mood and current themes may hint at a disturbance in mood. Their relationship history, current level of relationship strain and level of perceived social support may illuminate personality issues. As early as possible, without straining rapport, I answer two fundamental questions that need to be asked in every intake/evaluation before letting the patient out of my sight. First, is the patient at risk of harming himself or others and second, is this patient experiencing psychotic symptoms? I have found that relatively few of our elderly patients endorse psychotic symptoms and virtually none endorse active suicidal ideation. Passive suicidal ideation is common. I also find that elderly patients are more sensitive to inquiries about suicidal thinking and thought disturbances than younger patients. The easy formulation is that they are more sensitive to the suggested stigma. I generally start with a question to determine if the patient is experiencing passive suicidal ideation: “Would you care if you didn’t wake up in the morning?” If you do a less than adequate examination and you are still simply writing SI, HI, please recognize that as woefully inadequate and examine one of the models like that offered by Resnick. If you are still engaging in “no-harm contracts” seek the advice of a risk management professional immediately.
With any patient and particularly with elderly patients, it is important to know their medical status and to be aware of how it may impact their treatment. At Hemet, the patients are evaluated daily by a medical doctor. Do not make the mistake of assuming that cognitive impairments are age-based, or be seduced by the notion that because of a report from home that they have been experiencing confusion or memory problems for a period of time. Also avoid noting they are “always confused” when they enter treatment at your facility or assuming there isn’t a medical cause. By now, we should have all discarded the idea that a patient cannot have their first psychotic break late in life. I advocate knowing these patients well. I am vastly better informed by simply discussing the patient with the nursing and case management staff and getting collateral information from the family via the family counselor.
To evaluate cognitive status Folsteins Mini Mental Status examination is a good start. The Folstein has serious limitations, it is a good measure of orientation, and yet, is very limited in regard to assessing problems with memory and language (often experienced by elderly patients). In the elderly patients we treat, problems with orientation are common (particularly early in treatment). I pay little attention to a patient being disoriented to time by a day or two and I consider it to be insignificant that most patients from outside of the area do not know the minute details of their location. Difficulty recalling three random words obviously suggests memory problems. It is difficult to ferret out problems with memory from problems with attention and concentration. If the patient experiences difficulty recalling the three random words, I test the limits by offering contextual cues or phonemic cues and make note of whether the failure appears to be a difficulty with encoding or retrieval. I follow O’Briens’ advice and offer a couple of additional measures of attention, an additional calculation, and the number of quarters in a particular sum. To further screen for problems with language, I use a test of verbal fluency. I ask the patient to name as many items in a category in one minute. Most patients often start shifting somewhere during the minute. If their responses are sparse and only cover one venue, I hypothesize a language problem and perhaps, a problem with cognitive flexibility (the cut-off for dementia is theorized to be 10). Difficulty with naming (anomia) can be assessed with the Boston Naming Test or the NIS Stroke Scale. There are additional measures of language offered by NIS. One of the great things about the NIS program is they offer tutoring in the appropriate use of their instruments. I don’t focus much on assessing visuo-spatial reasoning and I have found little value in the intersecting pentagons at the end of the MMSE. I am frequently surprised by seeing a reasonable rendition of the intersecting pentagons followed by a highly dysmorphic or confused drawing of a clock face. It is not wholly uncommon to have the patient solve the problem of indicating the time on the clock by drawing it in digitally. The digital depiction of the time is consistent with a high level of confusion in my experience. I briefly examine abstract reasoning with proverbs and similarities. I like “spilt milk, glass houses and monkeys falling from trees. Beyond being a measure of abstract reasoning, these proverbs offer clinical material, in that the patient will often offer their world view. Through the entire assessment make note of intrusion errors, perseveration and cognitive slippage.
I often test the limits at the end of the MMSEand ask the patient to recall the three random words one more time. If questions remain as to the patient’s memory functioning, I may choose additional tests of memory. I use digit span forward to test immediate memory and digit span backward to assess working memory. The Rey Auditory Verbal Learning Test (RAVLT) can be used to further assess memory and to gauge their ability to learn and retain verbal material. I compare the performance on digit span forward with their first trial of the Rey and note any significant difference. If the performance on the last trial of digit span is significantly better than the first trial of the RAVLT, I usually attribute it to the “shock” many patients experience at their first exposure to the length of the Rey.
If there is any uncertainty, screen for mood disturbance. The
research suggests that depression and anxiety are common in substance
abusing patients and my estimate is that approximately 80% of the
elderly patients we treat are depressed. Do not forget the
pseudodementing effects of depression or better said when discussing
older adults the dementia syndrome of depression (usually reversible). I
have used the Yesavage Geriatric Depression Scale (short form) to
assess for depression. The Yesavage offers the
opportunity for the patient to generate a narrative and hints at the “depressogenic” thinking that may underlie any depression.
Returning to your clinical judgment, the intention of this work is not to diagnose dementia, or identify cortical versus sub-cortical patterns. The intention is to inform the clinical team of your process, while gaining rapport and identifying difficulties that may interfere with the care of your patient. This includes discovering previously unappreciated cognitive difficulties, mood disturbance, hearing and vision impairment, psychotic symptoms, sequelae of trauma or existential crisis and to generate a treatment plan. I do not encourage exhausting the patient or making him even more aware of cognitive deficits. Use your judgment to tailor the battery to your patient and gather the data you need. I don’t make the patient endure any more testing than necessary. Be prepared to discuss the results. I find these patients are frequently concerned about their cognitive status, indeed, when they seem unconcerned with memory loss, generally the impairment is severe. I always attempt to offer hope and attempt to follow-up. As always, the work is to educate, recognize antecedents, offer alternative strategies, increase mindfulness and build resilience through enhanced coping and emotional processing skills. I still adhere to the notion that any successful treatment requires a “corrective emotional experience” and our job is to facilitate that experience.
The take-home message is simple, generate a sturdy alliance. Collect enough data to know how to treat the patient, with formal data collection get in and get out. Be flexible and tailor treatment to the needs of the patient.
To my view of cognitive-behavioral therapy, one of the interventions is to change the individual’s view of their circumstances. I attempt to find success in the patient’s history and bring it back to their attention. I will point out the success of their children, their work or military service. When I was a post-doc with the Department of Veterans Affairs, I became accustomed to saying “welcome home” to veterans and thanking them for their service. I was astounded by how many men told me that I was the first person to welcome them home. I am always touched by veterans of the “forgotten” Korean War and those caught up in the controversy surrounding the war in Viet Nam. I am particularly touched by the veterans of the Second World War. These men are always humble about their service. I always say, I don’t know how often you think about it but – “You and your generation, saved the world.” Without fail they would reply “I didn’t see that much combat” or “I only flew in the B-29’s, it wasn’t that scary.” My reply is always the same, “I always try to tell the truth…you saved the world….it’s just a (expletive) fact.” I get choked up sometimes…I’m alright with it… for me, our work is deeply personal and only works when we feel it. One of our jobs is to build resilience in our patients and part of our professional survival is to build it within ourselves. This comes from finding meaning in our work. We must remember that long droughts will end with rain and old men will play the boogey man for little boys; they always have.