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Cognition & Mental Health Assessment of Older Adults

Pavithra Nanayakkara

University of Ruhuna

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Objectives

To briefly understand age-related cognitive and emotional changes
To apply key Screening Tools for Cognitive Dysfunction; Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA) and for for Mental Health; Geriatric Depression Scale (GDS), Hamilton Depression Scale and Identifying signs of dementia, delirium, depression, loneliness, fear

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Importance of Cognitive & Mental Health Assessment in Older Adults

Early detection of dementia and Mild Cognitive Impairment

Improves care planning

Identifying reversible causes and treatable conditions like depression and delirium

Promote brain health

Improve health and safety outcomes

Reduce known health related disparities and in detection and cognitive care

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Normal Cognitive Aging vs Pathology

Feature	Normal Cognitive Aging	Pathological Cognitive Aging
Decline Rate	Gradual and mild	Rapid and severe
Cognitive Domains Affected	Primarily memory, executive function, processing speed	Multiple cognitive domains (memory, language, reasoning, etc.)
Functional Impact	Limited, may not affect daily life significantly	Substantial, interferes with daily activities
Brain Pathology	Mild functional changes, mostly in prefrontal cortex and basal ganglia	Accumulation of amyloid plaques and neurofibrillary tangles, affecting multiple brain regions
Risk Factors	Modifiable (hypertension, diabetes, etc.) and non-modifiable (age)	Primarily non-modifiable (age, genetics)

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Common Mental Health Issues in Older Adults

Depression:

Depression is not a normal part of aging and is often under-diagnosed and under-treated in older adults. Symptoms can mimic memory loss or other physical ailments, making it difficult to identify.

Anxiety:

Older adults may experience anxiety related to aging, fears about finances, ageism, or the loss of independence. Physical health changes can also trigger anxiety.

Dementia (including Alzheimer’s):

Dementia is an umbrella term for a decline in cognitive function that can impact memory, thinking, and problem-solving. Alzheimer's is a specific type of dementia.

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Common Mental Health Issues in Older Adults ctd….

Substance Abuse:

Older adults are also susceptible to substance abuse, including alcohol and drug addiction, often due to factors like loneliness, social isolation, or loss of loved ones.

Other Mental Health Issues:

While less common, other mental health issues like bipolar disorder and schizophrenia can also affect older adults, although their onset is often later in life.

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Alertness / Level of Consciousness
Attention
Comprehension
Construction
Emotional Status
Higher Memory Function
Insight
Intelligence

Judgment
Memory
Orientation to time, place, and person
Perception
Physical appearance
Psychomotor behavior
Speech and language
Thinking

Components of Mental Status Assessment

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Symptoms of Cognitive Impairment

Memory loss or forgetfulness, especially recent events or important details.
Difficulty concentrating or staying focused on tasks.
Confusion or disorientation, especially in familiar places or routines.
Trouble with problem solving or decision making.
Language problems (difficulty finding the right words or understanding conversations.)
Decreased ability to plan or organize tasks.
Impaired judgement or reasoning.
Changes in mood or personality, including increased irritability.
Difficulty learning new information or skills.
Challenges with spatial awareness or visual perception.

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Overview of tools used for cognitive assessment

Mini-Mental State Examination (MMSE):

This is a widely used, brief screening tool for cognitive impairment in older adults. It assesses orientation, memory, attention, language, and visuospatial skills. The MMSE has limitations, including potential cultural and educational biases and may not be sensitive to subtle cognitive changes.

Montreal Cognitive Assessment (MoCA):

The MoCA is another commonly used tool that provides a more comprehensive assessment of cognitive function. It evaluates visuospatial/executive function, naming, memory, attention, language, abstraction, and delayed recall. The MoCA is longer than the MMSE and may be more challenging to administer in primary care settings.

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Overview of tools used for Mental Health & Cognitive assessment ctd…

Mini-Cog:

This brief test combines a three-word recall task and a clock drawing test. The Mini-Cog is suitable for use with individuals of varying educational levels, age ranges, and language differences. It can be helpful in distinguishing between those with and without dementia.

Other tools:

In addition to the three mentioned above, other tools include the Abbreviated Mental Test Score (AMTS), the Six-Item Screener (SIS), and the Rowland Universal Dementia Assessment Scale (RUDAS).

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Mini-Mental State Examination (MMSE)

can be used to systematically and thoroughly assess mental status.
has 11 questions that tests five areas of cognitive function: orientation, registration, attention and calculation, recall, and language.
maximum score is 30.
A score of 23 or lower is indicative of cognitive impairment.
takes only 5-10 minutes to administer and is therefore practical to use repeatedly and routinely.

https://drive.google.com/file/d/1roOLg6gkcyzDG7TQuWgF2p_io9_0p10T/view?usp=sharing

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Administering MMSE

1. Creating a Supportive Environment:

Quiet, well-lit space
Building rapport

2. Informed Consent:

Explain the purpose and nature of the MMSE
Address any concerns

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STRENGTHS AND LIMITATIONS OF MMSE:

Effective as a screening instrument to separate patients with cognitive impairment from those without it.
When used repeatedly the instrument is able to measure changes in cognitive status that may benefit from intervention.
The tool is not able to diagnose the case for changes in cognitive function and should not replace a complete clinical assessment of mental status.
The instrument relies heavily on verbal response and reading and writing. Therefore, patients that are hearing and visually impaired, intubated, have low English literacy, or those with other communication disorders may perform poorly even when cognitively intact.

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Montreal Cognitive Assessment (MoCA)

A rapid screening instrument for mild cognitive dysfunction.
Assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation.
Time to administer the MoCA is approximately 10 minutes.
The total possible score is 30 points; a score of 26 or above is considered normal.

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Administration MoCA:

https://championsforhealth.org/wp-content/uploads/2018/12/MOCA-8.1.8.2-English.pdf

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MMSE vs MoCA

Feature	MMSE	MoCA
Primary Use	Screening and diagnosing cognitive impairment and dementia	Initial assessment of mild cognitive impairment (MCI)
Domains Assessed	Visuospatial orientation, registration, attention, calculation, short-term memory, language	Short-term memory, attention, concentration, working memory, orientation, language, executive functions, visuospatial abilities
Sensitivity	High for moderate-to-severe cognitive impairments, sensitivity ~81.1% for dementia	High for MCI (80.48%) and early Alzheimer's disease (100%)

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Feature	MMSE	MoCA
Specificity	~82.8% for dementia; lower for mild cognitive impairments	Specific for MCI (81.19%) and early Alzheimer's disease (87%)
Reliability	High test-retest reliability (Pearson correlation ~0.887)	Consistent and more reliable for MCI detection than MMSE
Limitations	Sensitive to education and intelligence; limited detection of executive function impairments	Less effective in schizophrenia and HIV-related cognitive impairment
Scoring Complexity	Simple scoring, max score of 30	Standard cutoff of 26 points; can adjust cutoffs based on specific conditions
Administration Time	Short, widely used in outpatient settings	Slightly longer than MMSE but more detailed

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Case Study: Cognitive Screening

Mr. Silva, 72, reports forgetfulness. Apply MMSE and interpret the score.

ROLE PLAY

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Depression in Older Adults

Depression in older adults is a significant issue, often underdiagnosed and undertreated.
It can manifest differently in older adults than in younger individuals, sometimes with symptoms like persistent physical complaints, fatigue, and apathy, which can be confused with other illnesses or cognitive decline.
Depression can have serious consequences for older adults, including increased risk of suicide, decreased physical and cognitive function, and increased self-neglect.

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Screening Tools of Depression

Geriatric Depression Scale (GDS)
Patient Health Questionnaire-9 (PHQ-9)
Depression in Old Age Scale (DIA-S)
Cornell Scale for Depression in Dementia (CSDD)
Beck Depression Inventory (BDI)

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Geriatric Depression Scale (GDS)

Instructions for the Administrator:

The GDS is a self-report or interviewer-administered questionnaire designed for older adults (typically 65+).
The respondent should answer "Yes" or "No" to each of the following 15 questions based on how they felt over the past week.
Emphasize that there are no right or wrong answers—encourage honest responses.

https://geriatrictoolkit.missouri.edu/cog/GDS_SHORT_FORM.PDF

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Patient Health Questionnaire-9 (PHQ-9)

The Patient Health Questionnaire (PHQ) is a tool used in primary care to screen for mental health disorders, particularly depression and anxiety.
Aligns with DSM criteria
Severity levels from mild to severe
Quick, validated

https://med.stanford.edu/fastlab/research/imapp/msrs/_jcr_content/main/accordion/accordion_content3/download_256324296/file.res/PHQ9%20id%20date%2008.03.pdf

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Beck Depression Inventory (BDI)

BDI is a 21-item, self-report rating inventory that measures characteristic attitudes and symptoms of depression.
The BDI takes approximately 10 minutes to complete, although clients require a fifth – sixth grade reading level to adequately understand the questions.

https://www.ismanet.org/doctoryourspirit/pdfs/Beck-Depression-Inventory-BDI.pdf

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Comparison: GDS vs PHQ-9 vs BDI

Feature	GDS	PHQ-9	BDI
Primary Use	Screening depression in older adults	Screening, diagnosing, and monitoring depression severity	Assessing presence and severity of depression
Population	Older adults	General population, including older adults	Adolescents and adults
Number of Items	15 (short form) or 30 (long form)	9 items	21 items
Response Format	Yes/No	4-point Likert scale (0–3)	4-point Likert scale (0–3)
Time to Administer	~5–7 minutes	~5 minutes	~10 minutes

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Feature	GDS	PHQ-9	BDI
Scoring Range	0–15 (short form)	0–27	0–63
Cutoff Scores	0–4: Normal5–8: Mild9–11: Moderate12–15: Severe	5–9: Mild10–14: Moderate15–19: Moderately Severe20–27: Severe	0–13: Minimal14–19: Mild20–28: Moderate29–63: Severe
Strengths	Simple, Less somatic focus, Suitable for cognitive impairment	DSM aligned, Free and widely used, Validated across populations	Comprehensive, Good psychometric properties
Limitations	Not useful for younger adults, Binary response limits nuance	May over-identify depression in medically ill	Time-consuming, Copyrighted, Not freely available

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Anxiety in Older Adults

Anxiety disorders are common in older adults, affecting up to 20% of the population.
Generalized anxiety disorder (GAD) and specific phobias are particularly prevalent.
Anxiety can manifest in various ways, including physical symptoms like racing heart, shortness of breath, and nausea, as well as emotional and behavioral changes like excessive worry, avoidance of social situations, and difficulty concentrating.

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Tools to screen anxiety in older adults

Generalized Anxiety Disorder-7 (GAD-7): A brief, 7-item questionnaire designed to screen for GAD. https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf
Beck Anxiety Inventory (BAI): A 21-item questionnaire that measures the severity of anxiety symptoms. It is commonly used in both outpatient and inpatient settings. https://res.cloudinary.com/dpmykpsih/image/upload/great-plains-health-site-358/media/1087/anxiety.pdf
Depression Anxiety Stress Scales (DASS): A multi-dimensional scale that assesses depression, anxiety, and stress. chrome-extension://efaihttps://maic.qld.gov.au/wp-content/uploads/2016/07/DASS-21.pdf
Hamilton Anxiety Scale (HAM-A): A rating scale used to quantify the severity of anxiety symptoms. https://dcf.psychiatry.ufl.edu/files/2011/05/HAMILTON-ANXIETY.pdf�

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Tools to screen anxiety in older adults ctd…

Yale-Brown Obsessive Compulsive Scale (Y-BOCS): Used to assess the severity of symptoms related to obsessive-compulsive disorder. https://pandasnetwork.org/wp-content/uploads/2018/11/y-bocs-w-checklist.pdf
Social Phobia Inventory (SPIN): A tool for screening social anxiety disorder. https://psychology-tools.com/test/spin
Overall Anxiety Severity and Impairment Scale (OASIS): Useful for measuring symptoms across a broad range of anxiety disorders. https://greenspacehealth.com/en-us/anxiety-oasis/
Hopkins Symptom Checklist-25 (HSCL-25): A checklist used to assess symptoms related to anxiety and depression.
Hospital Anxiety and Depression Scale (HADS): A scale used to assess anxiety and depression symptoms in a hospital setting. https://www.svri.org/sites/default/files/attachments/2016-01-13/HADS.pdf

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Delirium among older adults

A sudden and severe disturbance in thinking, is a significant concern among older adults, particularly those with dementia or those hospitalized.
It's characterized by changes in attention, awareness, and cognition, often leading to disorientation, confusion, and difficulty speaking or remembering.
Delirium is often triggered by underlying medical conditions, infections, or medication side effects, and can have serious consequences, including increased hospital stays, functional decline, and death.

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Confusion Assessment Method (CAM)

CAM is a standardized evidence-based tool that enables non-psychiatrically trained clinicians to identify and recognize delirium quickly and accurately in both clinical and research settings.
The CAM includes four features found to have the greatest ability to distinguish delirium from other types of cognitive impairment.
There is also a CAM-ICU version for use with non-verbal mechanically ventilated patients.
The CAM-S is a companion tool to the CAM that can be used to assess the severity of delirium.

https://www.va.gov/covidtraining/docs/The_Confusion_Assessment_Method.pdf

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Case Study: Delirium Detection

Mrs. Nirmala, 80, becomes confused post-surgery. CAM positive. Diagnosis: Delirium.