Assessment pervades nearly every aspect of psychological or psychotherapeutic work with older adults. Thorough evaluation of the psychological status of an older person is an important but oftentimes complex and daunting process, even for experienced clinicians. In general, psychological assessment techniques are designed to evaluate a person's cognitive, emotional, social, and personality functioning. In clinical settings, the purposes of assessment are to find out what kinds of problems an older person is experiencing, to clarify personality features, to identify psychiatric disorders, to develop case conceptualization and intervention plans, and to evaluate effects of treatment. Traditional assessment strategies require some modification for older persons, given their often complex problems, unique socialization and life circumstances, and frequent comorbid health problems.
Overview of diagnosis and psychometric concepts in assessment
Diagnosis. The primary diagnostic guide for mental health professionals is the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; 1994), which includes specified criteria for several hundred mental disorders and encourages a full multiaxial diagnosis, including information on clinical disorders, personality disorders, medical conditions, psychosocial stressors, and a global assessment of functioning. However, whereas the DSM-IV has separate sections for childhood and adult disorders, there is no specific section on, or criteria for, mental disorders in later life.
Psychometric concepts. The primary psychometric concepts regarding psychological assessment of older adults include the topics of reliability, validity, standardization, and norms.
Reliability. Reliability refers to the degree to which measurement is consistent and stable over time. For example, a reliable psychological test yields consistent scores when a person retakes the test after an interval, usually several days to weeks. Internal consistency reliability is a measure of the extent to which items in a test are interrelated with each other. Test-retest reliability refers to the extent to which test scores are consistent from one administration to the next. Tests used with older persons should show ample evidence of reliability, since this is the first requirement for good measurement.
Validity. Validity refers to the extent to which a test measures what it purports to measure and the extent to which the test can be used to make accurate predictions. For example, does an anxiety test for older persons truly measure anxiety? Reliability and validity are closely inter-twined, as reliability is a necessary, but not sufficient, condition for validity. An unreliable test cannot possibly be valid, although it is possible for a test to have good reliability but poor validity if the test does not measure anything meaningful. The primary types of validity for psychological tests are content, construct, predictive, and concurrent validity. One should make sure that the tests one is using have been well validated in an elderly sample that is similar to the sample from which the respondent comes. Caution should be used in interpreting tests without proven validity among older persons.
Standardization and norms. Scores on most psychological tests rarely provide absolute measures of the construct being assessed (e.g., self-esteem). Rather, tests frequently indicate the relative performance of a respondent when compared to others. Thus, most popular psychological tests are standardized, which means that there are fixed procedures for administration and scoring and that the test has been given to many different people in order to establish statistical norms for age, sex, race, and so on. Norms provide standards for interpreting test scores, so that a person's responses can be compared to an appropriate reference group. Without standardization and norms, it would be impossible to determine if an older adult's score is typical, above average, or below average, making the assessment worthless.
Tests developed specifically for older adults (e.g., the Geriatric Depression Scale) have excellent norms. Likewise, standard intelligence tests have extensive age norms. Many other psychological tests did not initially furnish norms for older adults, but researchers have since provided good age-norms for some of them. Unfortunately, some tests still have missing or inadequate norms for older persons. Clinicians and researchers are encouraged to carefully review the technical manual of tests they use to determine if evidence for reliability, validity, and relevant norms for older persons are available. If not, they should be cautious in interpreting scores.
Assessment strategies and clinical conditions
Due to the complex nature of assessment with older persons, multiple strategies are often used in combination to elicit the most comprehensive and meaningful description of the older individual.
Clinical interview. The clinical interview is perhaps the most important and informative strategy during an evaluation of an older person. During the interview, the clinician gathers information about the person's current difficulties (the presenting problem), including a history of the problem. Other topics include an in-depth personal history, psychiatric treatment history, family history, mental status, and level of social functioning. It is important to develop rapport with the older person to allow him or her to disclose intensely personal information. Clinicians should explain clearly the purposes and procedures of the assessment and show respect for the older person. Any concerns the person may have about the evaluation should be addressed, since many older adults associate psychiatric services with tremendous shame and stigmatization.
It is imperative that clinicians fully assess concomitant medical conditions and medication use. This is important because many medical illnesses, and the medications used to treat them, can cause psychiatric conditions (e.g., delirium, depression, anxiety, psychosis). Diverse drug interactions can cause memory problems that mimic a dementing illness, such as Alzheimer's disease. Older adults are encouraged to bring a complete listing of medications to the testing session. Referral for a thorough medical work-up is always indicated if the person has not recently been medically evaluated.
Interviewers need to be flexible when engaging older persons. The environment should be adjusted to reduce the impact of any sensory or physical limitations (e.g., brightly lit and quiet testing room; use of large-print versions of tests). Traditional time constraints should be adjusted to not fatigue the older person. A final tenet in geriatric assessment is to involve close family members and/or caregivers in the assessment to gather corroborative or additional information about the person.
Personality assessment. Personality tests strive to uncover the structure and features of one's personality, or one's characteristic way of thinking, feeling, and behaving. Objective personality tests are self-report pencil-and-paper tests based on standardized, specific items and questions. In contrast, projective tests present stimuli whose meanings are not immediately obvious and have an open-ended response format, such as a story from the respondent.
The most popular objective personality test is the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). The MMPI-2 has ten standard clinical scales (e.g., depression, schizophrenia, social introversion) and three validity scales to detect unusual test-taking attitudes. The MMPI-2 is widely utilized with older adults, although separate norms for older adults are not readily available and there is concern that some older adults may receive inaccurately elevated depression scores due to the high number of somatic items on the scale.
The Rorschach Inkblot Test and the Thematic Apperception Test (TAT) are popular projective tests. During the Rorschach Test, the respondent provides associations to ten bilaterally symmetrical inkblots. The TAT consists of thirty-one black and white pictures that tend to induce particular themes, such as sexuality and achievement. Typically, ten to twenty cards are administered and the respondent is asked to create a story about each picture. Though not developed specifically for older persons, both tests are used with older adults. Two projective measures designed for older adults include the Geriatric Sentence Completion Form (which provides provocative age-appropriate sentence "stems" that are completed by the respondent) and the Senior Apperception Test (which has age-relevant pictures and themes).
Symptom checklists. Self-report checklists have been developed for hundreds of psychological constructs. Fortunately, several elder-specific checklists are available and they have excellent psychometric properties. Some stellar examples include the Geriatric Depression Scale (GDS), the Geriatric Hopelessness Scale (GHS), and the Michigan Alcoholism Screening Test—Geriatric Version (MAST-G).
The GDS is one of the best screening measures for depression in older adults. It consists of thirty items presented in a simple Yes/No format. Items focus on cognitive and behavioral aspects of depression, and somatic items are excluded. The scale is in the public domain, and is available, with the scoring key, on the GDS website at http://www.stanford.edu/~yesavage/GDS.html. The GHS is a thirty-item Yes/No self-report scale that assesses pessimism and hopelessness in older adults, both of which are related to suicide. The MAST-G is used for substance abuse assessment, which is a significant problem among older persons and is linked to depression and suicide. The MAST-G contains twenty-four Yes/No items unique to older problem drinkers. In all cases, "yes" is the pathological response, and a cutoff of five positive responses indicates an alcohol problem.
Cognitive functioning. Assessment of cognitive functioning is an important part of any thorough geriatric assessment, since cognitive impairment (e.g., dementia) is an age-related problem (e.g., rates of dementia increase with age). Notably, other test results may not be valid if the respondent has significant cognitive impairment. Early detection of cognitive problems is crucial because many symptoms are reversible, especially for delirium. The primary DSM-IV cognitive disorders are delirium and dementia. Delirium refers to a clouding of consciousness with impaired concentration, disorientation, and perceptual disturbances that develop over a short period of time (hours to days). Since delirium is often obvious and acute, there are no specific tests for it. If delirium is suspected in an older person, they should be quickly referred for medical treatment, since delirium is typically reversible but can be deadly if the underlying cause (e.g., infections, malnutrition) is not corrected.
Dementia is a syndrome of multiple cognitive deficits that include memory impairment, but without impairment in consciousness. The most common type of dementia is Alzheimer's disease, which accounts for 50 to 60 percent of demented persons. It is important for clinicians to screen for dementia in all older clients during a psychological assessment. Several brief, standardized, and easily administered screening tools are available. The Folstein Mini-Mental State Examination takes five to ten minutes to administer and is well-validated. Items tap orientation, concentration, memory, language, and gross motor skills. Scores range from 0 to 30, with scores under 25 indicating a need for further testing and evaluation. The Dementia Rating Scale is a psychometrically sound, interviewer administered test designed for dementia evaluation. It consists of thirty-six tasks and takes about thirty minutes to complete.
Should concern about cognitive impairment result from a screening test, more thorough neuropsychological testing is warranted. Such testing assesses brain-behavior relationships in multiple domains and behavioral disturbances that are caused by brain dysfunction, and also helps to quantify and localize brain damage. One approach is for the examiner to use a standard and fixed battery (e.g., the Halstead-Reitan Battery), whereas another strategy is to carefully choose a variety of different tests to assess particular neuropsychological domains of interest. Finally, laboratory tests (e.g., electrolyte panel, urinalysis, electroencephalography) and high-tech brain-imaging procedures (e.g., CAT scan, MRI scan) are often used to complement neuropsychological assessment.
Assessment of intelligence is another important area. Intelligence tests are standardized tests designed to measure a person's mental ability. The two prominent tests are the Stanford-Binet Intelligence Test, fourth edition and the Wechsler Adult Intelligence Scale, third edition (WAIS-III). The WAIS-III consists of fourteen separate subtests: seven verbal and seven performance. Raw scores for each subtest are converted into scaled scores, and score sums are converted into a verbal intelligence quotient, a performance intelligence quotient, and a full-scale intelligence quotient. Both tests have extensive age-norms and are the leading measures of intelligence assessment across much of the life span.
Daniel L. Segal
See also Delirium; Dementia; Diagnostic and Statistical Movement of Mental Disorders—IV; Emotion; Imtelligence; Memory; Mental Status Examination; Neuropsychology; Personality.
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Butcher, J. N.; Dahlstrom, W. G.; Graham, J. R.; Tellegen, A.; and Kaemmer, B. MMPI-2: Manual for Administration and Scoring. Minneapolis: University of Minnesota Press, 1989.
Folstein, M. F.; Folstein, S. E.; and McHugh, P. R. "Mini Mental State: A Practical Method for Grading the Cognitive State of Patients for the Clinician." Journal of Psychiatric Research 12 (1975): 189–198.
Fry, P. S. "Assessment of Pessimism and Despair in the Elderly: A Geriatric Scale of Hopelessness." Clinical Gerontologist 5 (1986): 193–201.
Mattis, S. Dementia Rating Scale. Odessa, Fla.: Psychological Assessment Resources, Inc., 1988.
Murray, H. A. Thematic Apperception Test. Cambridge, Mass.: Harvard University Press, 1943.
Rorschach, H. Psychodiagnostik. Bern: Hans Huber, 1921; 1946.
Yesavage, J. A.; Brink, T. L.; Rose, T. L.; Lum, O.; Huang, V.; Adey, M. B.; and Leirer, V. O. "Development and Validation of a Geriatric Depression Screening Scale: A Preliminary Report." Journal of Psychiatric Research 17 (1983): 37–49.
The assessment of personality variables.
Psychological assessment is used for a variety of purposes, ranging from screening job applicants to providing data for research projects. Most assessment methods fall into one of three categories: observational methods, personality inventories, or projective techniques .
Observational assessment is performed by a trained professional either in the subject's natural setting (such as a classroom), an experimental setting, or during an interview. Interviews may be either structured with a standard agenda, or unstructured, allowing the subject to determine much of what is discussed and in what order. Impressions gained from interviews are often recorded using rating scales listing different personality traits . Expectations of the observer, conveyed directly or through body language and other subtle cues, may influence how the interviewee performs and how the observer records and interprets his or her observations.
Personality inventories consist of questionnaires on which people report their feelings or reactions in certain situations. They may assess a particular trait, such as anxiety, or a group of traits. One of the oldest and best known personality inventories is the Minnesota Multiphasic Personality Inventory (MMPI), a series of 550 questions used to assess a number of personality traits and psychological disturbances for people over age 16. The MMPI is scored by comparing the subject's answers to those of people known to have the traits or disturbances in question. While initially designed to aid in the diagnosis of serious personality disorders , the MMPI is now widely used for persons with less severe problems, as enough data has been collected from this population to allow for reliable interpretation of test results. One problem with personality inventories is that people may try to skew their answers in the direction they think will help them obtain their objective in taking the test, whether it is being hired for a job or being admitted to a therapy program. Validity scales and other methods are commonly used to help determine whether an individual has answered the test items carefully and honestly.
A projective test gives the subject a greater opportunity for imaginative freedom of expression than does a personality inventory , where the questions are fixed beforehand. Projective tests present individuals with ambiguous situations which they must interpret, thus projecting their own personalities onto those situations. The best known projective test is the Rorschach Psychodiagnostic Test, or inkblot, test first devised by the Swiss psychologist Hermann Rorschach in the 1920s. The test subject describes his or her reactions to elaborate inkblots presented on a series of ten cards. Responses are interpreted with attention to three factors: what parts or parts of each inkblot the subject responds to; what aspects of the inkblot are stressed (color, shape, etc.); and content (what the inkblot represents to the subject). Another widely used projective test is the Thematic Apperception Test (TAT), developed at Harvard University in the 1930s. In this test, the subject is shown a series of pictures, each of which can be interpreted in a variety of ways, and asked to construct a story based on each one. Responses tend to reflect a person's problems, motives, preoccupations, and interpersonal skills. Projective tests require skilled, trained examiners, and the reliability of these tests is difficult to establish due to their subjective nature. Assessments may vary widely among different examiners. Scoring systems for particular traits have been fairly reliable when used with the Thematic Apperception Test.
See also Personality inventory; Rorschach technique
Personality and Ability: The Personality Assessment System. Lanham, MD: University Press of America, 1994.