Donna Pinsker

Exploitation in Older Adults: Social Vulnerability and Personal Competence Factors

Clinicians are frequently called upon to determine whether an older adult is at undue risk of exploitation and, in particular, financial exploitation. However, there is currently no widely accepted clinical model for describing or explaining who will fall victim to exploitation in later life, and identification of vulnerable older people has been a somewhat onerous process. In this article, an overarching theoretical framework for conceptualizing such forms of vulnerability and its assessment in older adults is presented. Central to this framework are various personal competence factors (i.e., intelligence, cognitive functioning, social intelligence, social skill, personality traits, physical functioning) that purportedly contribute to, or protect against, exploitation. Recommendations and argument for a more holistic approach to assessing and educating potentially vulnerable older adults are presented, as well as directions for future research.

Financial Capacity in Older Adults: A Review of Clinical Assessment Approaches and Considerations

Financial capacity is a critical issue of autonomy for older people. However, determining the point at which a cognitively impaired older adult is no longer capable of independent financial management poses an onerous task for family members, and health and legal professionals. At present, there is no agreed-upon standard for evaluating financial capacity, and issues pertaining to the level of impairment that constitutes incapacity remain largely unresolved. In the absence of validated assessment guidelines, determinations of capacity are frequently based on neuropsychological measures and clinical judgment, although there is limited evidence to support the validity of these methods in capacity determinations. In this paper, various cognitive, psychiatric, social, and cultural factors that potentially contribute to financial incapacity in older adults are described. The strengths and weaknesses of clinical approaches and instruments currently used in capacity determinations are evaluated, and specific recommendations are made regarding broader assessment approaches. Finally, directions for future research and instrument development are offered.

Screening in delirium: A pilot study of two screening tools, the Simple Query for Easy Evaluation of Consciousness and Simple Question in Delirium

Delirium is poorly recognised and inadequately treated in medical settings. This research aimed to determine the psychometric properties of a newly developed tool, SQeeC against another emergent instrument, SQiD, in the screening of delirium.

Predictors of financial capacity performance in older adults using the Financial Competence Assessment Inventory

BACKGROUND Declines in financial capacity in later life may arise from both neurocognitive and/or psychiatric disorders. The influence of socio-demographic, cognitive, health, and psychiatric variables on financial capacity performance was explored. METHODS Seventy-six healthy community-dwelling adults and 25 older patients referred for assessment of financial capacity were assessed on pertinent cognitive, psychiatric, and financial capacity measures, including Addenbrookes Cognitive Examination - Revised (ACE-R), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), selected Neuropsychiatric Inventory (NPI) items, Financial Competence Assessment Inventory (FCAI), and Social Vulnerability Scale (SVS). RESULTS The internal consistency of the debt management subscale of the FCAI was relatively poor in our sample. Financial capacity performance differed between controls and patients. In our sample, performance on the FCAI was predicted by Mini-Mental State Examination, IQCODE, and GAI, but not by ACE-R, GDS, NPI items, or SVS (adjusted R(2) = 0.7059). CONCLUSIONS Anxiety but not depression predicted financial capacity performance, possibly reflecting relatively low variance of depressive symptoms in this sample. Current cognitive decline as measured by the informant-rated IQCODE was more highly correlated to financial capacity than either educational attainment or ACE-R scores. Lack of significance of ACE-R data may reflect the instruments decreased sensitivity to domains relevant to financial capacity, compared with more detailed neuropsychological assessment tools. The FCAI displayed fairly robust psychometric properties apart from the debt management subscale.

Propositional speech in unselected stroke: The effect of genre and external support

Distinguished from nominal language, propositional language generation refers to the spontaneous and voluntary aspect of language that introduces novel concepts to a specific context. Propositional language can be impaired in a range of neurological disorders, including stroke, despite well-preserved nominal language. Although external support can increase speech rate in patients with reduced propositional speech, no specific investigation of propositional speech has been carried out in unselected stroke patients. The current study investigated propositional language in an unselected post-acute stroke group (N = 18) with mild cognitive impairment and prominent executive dysfunction, but without significant aphasia. Specifically, we investigated whether genre or external support affected the number of words, sentences, and novel ideas produced, compared to healthy controls (N = 27). Results showed that discourse genre was not associated with differential performances. By contrast, speech quantity increased without external support although, for stroke patients, speech novelty decreased. Overall, the novelty deficit in unselected stroke patients highlights the importance of assessing cognition and propositional speech. Our findings suggest that for stroke patients with mild cognitive deficits, including executive dysfunction, introducing external support improved speech quality but not quantity. Implications for both assessment and rehabilitation of social communication are discussed.

Consciousness, functional networks and delirium screening

BACKGROUND Consciousness, the medium of sentient thought, requires integrity of functional networks and their connectivity. In health, they function as a co-operative but mutually exclusive paradigm of introspection versus external awareness subserved via the Default Mode Network and Task Positive State, respectively. Higher thinking in the conscious state is then segregated according to need. There is research evidence to suggest that functional networks may be impacted in disorders of consciousness and conceptual support for a mechanistic role in delirium. This potentially central aspect of delirium manifestation is relatively unexplored. OBJECTIVE This article describes the role of disrupted functional networks in delirium. How this relates to current understanding of delirium neurobiology and the ramifications for clinical diagnosis is discussed. METHOD A review of the role of functional networks, particularly DMN and TPN, has been undertaken with respect to health and delirium. An exploration of how symptoms of delirium may be related to functional network aberrancy has been undertaken. Implications for research and clinical practice in delirium have been presented. RESULTS In delirium, a disturbance of consciousness, the DMN is pathologically co-activated and functional cortical connectivity is compromised. The clinical correlate is of an experiential singularity where internal and external drivers become indistinguishable, reality and delusion merge and the notion of self is effaced. Our group propose that functional network disruption in conjunction with cortical disconnectivity is central to the mechanism of delirium. Clinical tools may exploit the neurobiology of delirium to improve its diagnosis and an example of such a simple screening instrument (SQeeC) is provided. CONCLUSION Functional networks are critically disrupted in delirium and may be central to clinical features. A better understanding of the neurobiology of delirium will generate research opportunities with potential for therapeutic gains in detection, diagnosis, and management.

e-Screening revolution: a novel approach to developing a delirium screening tool in the intensive care unit

Delirium is common in the intensive care unit (ICU), often affecting older patients. A bedside electronic tool has the potential to revolutionise delirium screening. Our group describe a novel approach to the design and development of delirium screening questions for the express purpose of use within an electronic device. Preliminary results are presented.

The utility of the social vulnerability scale as a predictor of financial capacity in dementia patients

Abstract from the International Psychogeriatric Association Reinventing Aging through Innovation 15th International Congress, 6-9 September 2011, The Hague, Netherlands.Use of prescription medications for various conditions is highly prevalent in older adults, often leading to the use of multiple medications. The resulting polypharmacy is widely recognized as a risk factor for many negative outcomes, but less is known about the risks of specific types of medication upon cognitive functions. Benzodiazepines are commonly prescribed for the treatment of anxiety and insomnia, among other conditions. While dependency with continued use has been the subject of much concern over this type of medication, other literature has suggested an increased risk of cognitive impairment with chronic use of benzodiazepines. The nature of the cognitive changes and the domains of cognitive function most likely to be affected have differed across various studies. Here we describe the associations between measures of various domains of cognitive functioning and benzodiazepine use in 2879 older Canadian adults from the Canadian Study of Health and Aging (CSHA; 64.3% female, mean age 81.0 years, SD=7.44). These people underwent a comprehensive medical and psychosocial evaluation that included a record of medications used, in addition to a complete personal and medical history. The CSHA was a community-based epidemiological study of the prevalence of dementia and its associated risk factors in over 10,000 Canadians. Benzodiazepines were classified according to their half-life: short (under 12 hours), medium (12 to 40 hours) or long half-life (over 40 hours); 35 elderly people were excluded since they were taking more than one class of benzodiazepine. A comprehensive neuropsychological battery that assessed the major domains of cognitive functioning was administered to all participants who completed the CSHA clinical assessment. Neuropsychological test scores for the domains of short- and long-term memory, abstract reasoning, judgement, visuoconstruction, and language formed were the primary independent variables, while gender, age, and years of education were used as covariates in logistic regression models predicting use of each class of drug. Education was not a significant covariate for any analysis. Gender proved to be a significant covariate in the case of the medium-half life drugs, but not for the other two classes. Age was a significant covariate for the majority of test scores for the short and long half-life drugs. After controlling for the covariates, the results showed a broader range of cognitive impairments with the use of short half-life benzodiazepines than with the medium half-life or the long half-life benzodiazepine compounds. Six cognitive measures, assessing abstract reasoning and comprehension, verbal fluency, verbal memory, and visuoconstruction skills (BlockDesign), showed poorer performance among those who used short half-life benzodiazepines, two measures, those of abstract reasoning and comprehension, showed impaired performance by those using medium half-life benzodiazepines, and three measures, for abstract reasoning, verbal memory, and visuoconstruction skills, showed lower performance by those taking long halflife benzodiazepines. Wechsler Similarities, the measure of abstract reasoning, was the only showing significant differences common across all three drug class models. Results are discussed in terms of both the relative extent of lower neuropsychological test scores and the context of increasing evidence of impaired functioning associated with benzodiazepine use.

Instrumental and social competency assessment of older adults

This presentation covers the basics of neuropsychological testing in geriatric settings: instruments for a range of clinical settings (e.g. inpatient, outpatient, aged care assessment teams) as well as a broad spectrum of types of measures (screening tools, specialist batteries, informant instruments, tools to communicate in multidisciplinary teams). Examples of measures will be discussed in detail. Empirical literature as well as case studies will be presented.In older adults, instrumental competence involves the cognitive ability to cope with the requirements of independent living. Social competence involves the ability to interact with and make judgements about other people. Whether someone can correctly write a cheque, for example, depends on instrumental competence; whether someone has good judgement about when and to whom cheques should be written depends on social competence. This distinction, although intuitively obvious to most clinicians, has not been fully developed either in research or practice settings, despite having a sound basis in neuroscience. A clinically useful assessment of competence should include instrumental competence and social competence, as well as adequate and systematic exploration of individual issues of context. Assessment methods and preliminary data on new social competency measures for older adults will be presented.