Rethinking paradigms in geriatric ethics

This paper calls for a shift away from autonomy as the central value in geriatric ethics. In treatment and experimental settings, differences between older and younger adults are easily attributed to deficiencies on the part of the elderly when autonomy is the central value. Overemphasis on the concept of autonomy skews our understanding of human relationships toward excessively rational models, distracts attention from important physical and social characteristics of aged persons, and results in ethics by default. This paper describes several principles that would be more useful starting points than autonomy in developing a geriatric ethic.     

Cognitive-behavioral therapy for geriatric compulsive hoarding

This investigation examined response to a manualized cognitive-behavioral therapy (CBT) protocol for compulsive hoarding (Steketee & Frost, 2007) in a sample of 12 adults over age 65. All participants were cognitively intact, not engaging in any other psychotherapy, and had compulsive hoarding as their primary problem. All received 26 sessions of individual CBT over the course of 17 weeks. The primary outcome measures were the Savings Inventory-Revised and UCLA Hoarding Severity Scale, which were administered at baseline, mid-treatment, post-treatment, and 6-month follow-up. Other outcomes included Clinical Global Impression (CGI) scores, depression, anxiety, disability, and clutter image ratings. Results demonstrated statistically significant changes on hoarding severity and depression. However, only three of the twelve participants were classified as treatment responders at post-treatment, and their gains were not maintained at 6-month follow-up. CGI, anxiety, disability, and clutter ratings were unchanged at post-treatment and follow-up. No participants dropped out, but homework compliance was variable and correlated with decreases in hoarding severity. Findings suggest that older adults with compulsive hoarding may require an enhanced or alternative treatment.     

Utility of the MMPI in a geriatric population

Despite the popularity of the Minnesota Multiphasic Personality Inventory (MMPI), there exists a relative dearth of normative and validity research regarding its use with persons over the age of 60. Our investigation was designed to examine the MMPI performance of both a normal and a clinical sample of older men and women. Specifically, a nonpatient community sample of 204 subjects and an outpatient psychiatric sample of 30 subjects, between the ages of 60 and 90, were administered the MMPI as well as structured psychiatric interview, the Psychiatric Status Schedule (PSS). Results revealed that, on most of the MMPI scales, the mean scores were well above the norms (i.e., 5-10 t-score points). Through comparisons between the clinical and community subjects as well as between MMPI and PSS performance, the MMPI demonstrated substantial discriminative and concurrent criterion validity within this geriatric sample. The results of the study suggest that, with a few important exceptions, the MMPI, as generally utilized, is valid for use in the geriatric population.     

Psychosocial enhancement of immunocompetence in a geriatric population

This study assessed the enhancement of immunocompetence by relaxation and social contact in 45 geriatric residents of independent-living facilities. Subjects were randomly assigned to one of three protocols: relaxation training, social contact, or no contact. Subjects in the relaxation and social-contact conditions were seen individually three times a week for a month. Blood samples and self-report data were obtained at baseline, at the end of the intervention, and at a 1-month follow-up. At the end of the intervention, the relaxation group showed a significant increase in natural killer cell activity, and significant decreases in antibody titers to Herpes simplex virus and self-rated distress; the other two groups showed nonsignificant changes. There was a general increase in the T-lymphocyte response to phytohemagglutinin stimulation at the end of the intervention, with greater change at lower mitogen concentrations. These data suggest that cellular immunocompetence may be enhanced by psychosocial interventions.     

The effects of assertiveness training on the nontraditional role assumption of geriatric nurse practitioners

The Nurse Practitioner movement has been an important element in upgrading health care for the elderly, principally by reducing costs and increasing availability. One central concern in this movement is the ability of Nurse Practitioners [NPs] to break out of the restricted and repressed role of nurse. The teaching of assertive behavior has been an accepted method of assisting NPs in this role change. This study evaluates the effects of assertiveness training using a measure of role assumption in addition to the typical self-report attitude measures. Three cohorts of NP students (N=59) were evaluated with a pre-post administration of attitude measures of assertiveness and a six-month follow-up to measure role assumption. Although the training did have a significant impact on the attitude measures, the impact on nontraditional role assumption was minimal. Policy implications are discussed.     

Social interaction patterns of geriatric home and community residents

Thirty elderly nursing home residents and ten community residing older adults were observed in group settings. Their behavior was assessed for dependent personal maintenance, independent personal maintenance, and appropriate and inappropriate behaviors. Responses by staff and peers to these behaviors were classified as positive, negative, or ignore. The frequency of occurrence of these behaviors as well as the relationship of resident to peer or staff behaviors were analyzed. Results indicate that community-residing elders' behaviors differ from nursing home residents' in quantity rather than quality of interactions. There was a lower frequency of behaviors in the nursing home residents. Though older adults respond differentially to various behaviors of other nursing home residents, staff responses were consistent regardless of residents' behavior. These results suggest that geriatric home residents' behavior can be characterized as withdrawn rather than dependent.     

Trends in geriatric psychiatry relevant to pastoral counselors

This article is a general overview of mental disorders in the aged that stresses the complementary roles that religious and mental health professionals can play in meeting the psychological and spiritual needs of elders. Chaplains and pastoral counselors should be competent in recognizing serious psychiatric disorders in older adults and able to differentiate them from the more common and benign emotional disturbances. Both counseling and biological treatments have distinct but often overlapping roles in the treatment of mental disorders in the aged. When treating emotionally disturbed elders, religious professionals should be aware of new trends in psychotherapy and biological psychiatry that are now making the integration of secular and religious techniques more and more feasible.Funding for this study was provided by the Center for the Study of Aging and Human Development at Duke University Medical Center and by the Geriatric Research, Education, and Clinical Center of the Veterans Administration Medical Center in Durham, North Carolina.     

Use of the Beck Depression Inventory-II with depressed geriatric inpatients

To provide information about the clinical utility of the Beck Depression Inventory-II (BDI-II) [Beck, A.T., Steer, R.A., & Brown, G.K. (1996b). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation] with geriatric inpatients, the BDI-II was administered to 130 psychiatric inpatients who were 55 years old or above and who were diagnosed with principal DSM-IV major depressive disorders (MDD) (N = 85, 65%) or adjustment disorders with depressed mood (N = 45, 35%). The internal consistency of the BDI-II was high (coefficient alpha = 0.90), and its total score was not significantly related to sex, age, or ethnicity. An iterated maximum-likelihood factor analysis found the Cognitive and Noncognitive dimensions which have been reported for the BDI-II by Steer and co-workers (Steer R.A., Ball R., Ranieri W.F., & Beck A.T. (1999). Dimensions of the Beck Depression Inventory-II in clinically depressed outpatients. Journal of Psychopathology and Behavioral Assessment, 55, 117-128) in a younger sample of clinically depressed psychiatric outpatients. The mean BDI-II total score of the 85 geriatric inpatients with MDD was also comparable to that of 42 younger (< or = 54 years old) inpatients with MDD. The results were discussed as supporting the use of the BDI-II with clinically depressed geriatric inpatients.     

Efficacy of two behavioral treatment programs for comorbid geriatric insomnia

Older adults with comorbid insomnia and medical illness have been excluded from behavioral treatment research, but recent evidence suggested that such treatments would be effective with this population. In this study, 38 older adults with comorbid insomnia were randomized to 1 of 3 conditions: classroom cognitive-behavioral treatment (CBT), home-based audio relaxation treatment (HART), or delayed-treatment control. Compared to the control group, the CBT group had significant changes in 5 of 7 self-report measures of sleep at the 4-month follow-up. The HART group obtained significant outcomes on 3 of 7 measures. Wrist actigraphy measures and secondary-outcome measures did not yield significant findings for either treatment. Clinically significant changes at follow-up were obtained for 54% of patients in CBT, 35% in HART, and 6% in the control group when treatment dropouts were included. Although not as effective as in-person CBT, home interventions may have utility as a first-line, low-cost treatment.     

Direct assessment of quality of care in a geriatric nursing home

Direct observation was used to examine multiple aspects of care provided in a proprietary nursing home. The samples were taken at random intervals, 7 days per week for 5 weeks, across several categories of environmental and resident conditions as well as staff and resident activity. Results showed a high degee of compliance with predefined standards (based on current federal regulations) for environmental and resident conditions. Overall distributions of resident and staff activity showed results similar to those found in previous studies, with residents spending most of their time engaged in nonsocial activity and staff spending the majority of their time engaged in nonresident work. When data were analyzed across areas of the facility, times of day, and weekdays versus weekends, some differences were noted. Weekend versus weekday comparisons showed higher resident:staff ratios on weekends and more resident inactivity, but no significant differences in environmental or resident conditions. In addition, more frequent resident care, resident interaction, and resident activity were observed in Medicare units than in non-Medicare units. Results are discussed in terms of federal requirements for monitoring the quality of care in nursing homes and the potential use of time sampling expressly for this purpose.     

Plasma anticholinergic activity and cognitive function in geriatric patients

This study evaluated the putative impact of circulating anticholinergic equivalents on cognitive functional performance in non-demented geropsychiatric inpatients. Standard rating instruments were administered to measure memory functions, concentration and overall functional competency. Anticholinergic plasma activity was assayed, using a radioreceptor technique with tritiated quinuclidinyl benzilate as the active reagent. None of the cognitive tests employed indicated a statistically significant change in the subjects' quantifiable level of cognitive performance. All changes in anticholinergic activities were related to adjustments in psychotherapeutic medications. The possible role of reversal of pseudodementing features is discussed as well as the potential for monitoring anticholinergic activity when treating elderly individuals with more than one centrally active medication having anticholinergic properties.     

Physical therapists' nonverbal communication predicts geriatric patients' health outcomes

Two studies explored the link between health care providers' patterns of nonverbal communication and therapeutic efficacy. In Study 1, physical therapists were videotaped during a session with a client. Brief samples of therapists' nonverbal behavior were rated by naive judges. Judges' ratings were then correlated with clients' physical, cognitive, and psychological functioning at admission, at discharge, and at 3 months following discharge. Therapists' distancing behavior was strongly correlated with short- and long-term decreases in their clients' physical and cognitive functioning. Distancing was expressed through a pattern of not smiling and looking away from the client. In contrast, facial expressiveness, as revealed through smiling, nodding, and frowning, was associated with short- and long-term improvements in functioning. In Study 2, elderly subjects perceived distancing behaviors of therapists more negatively than positive behaviors.     

Psychometric properties of attitudinal measures of behavioral treatment in geriatric settings

Internal consistency of two forms of the Geriatric Treatment Acceptability Survey (GTAS) and the Attitudes toward Behavior Analysis Scale (ABAS), a global measure of attitudes toward behavior modification, was evaluated. Alpha coefficients regarding treatment acceptability ratings for GTAS Form H were: (a) wandering 0.94; (b) hoarding 0.96; (c) disruptive behavior 0.92; (d) property destruction 0.95; and (e) aggression 0.94. Internal consistency for Form NH was: (a) wandering 0.96; (b) hoarding 0.97; (c) disruptive behavior 0.96; (d) property destruction 0.97; and (e) aggression 0.76. Internal consistency of the ABAS resulted in alpha coefficients of 0.90 (total score); 0.87 (ethics and humaneness); and 0.76 (use). These measures appear useful in assessing older adults, nursing home patients' and geriatric nursing staffs' global and specific attitudes regarding the use of behavioral treatments with older adults. Further research is needed to establish psychometric constructs assessed by the instruments and sensitivity to detecting change in attitudes based on educational or clinical interventions.