III - The Influence of Health and Health Behaviors on the Rehabilitation of Cognitive Processes in Late Life
Editors: Backman, Lars; Hill, Robert D.; Neely, Anna Stigsdotter
Title: Cognitive Rehabilitation in Old Age, 1st Edition
Copyright 2000 Oxford University Press
> Table of Contents > Part III - The Influence of Health and Health Behaviors on the Rehabilitation of Cognitive Processes in Late Life > 10 - The Influence of Depression on Cognitive Rehabilitation in Older Adults
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10
The Influence of Depression on Cognitive Rehabilitation in Older Adults
Nancy A. Pachana
Bernice A. Marcopulos
Kellie A. Takagi
Depression is one of the most common mental disorders experienced by older adults (Alexopoulos, Young, Meyers, Abrams, & Shamoian, 1988) and remains a major health concern (National Institute of Health [NIH], 1992). Depressive symptoms have been estimated to occur in 10 25% of community-dwelling older adults aged 65 and over, and in 30% of older adults in residential care settings (Blazer, 1993). Depression and its symptoms are frequently underreported in the elderly (Lyness et al., 1995), and depression remains underdiagnosed and undertreated in this population (NIH, 1992). The distinctions between forms of depression in the elderly (early- vs. late-onset; clinical vs. subclinical manifestations of symptoms) is a focus of ongoing research. What has emerged from the research literature is a profile of depressive symptomatology among older adults that often includes complaints of cognitive dysfunction.
From both an assessment and a rehabilitation standpoint, depressed older adults present a particular challenge. Advancing age and comorbid medical conditions may affect cognitive and emotional presentation in this population. Assessment instruments and corresponding normative data must be chosen with care to ensure adequate reliability and validity for use with the elderly. The differentiation of cognitive decline secondary to depression from such declines resulting from progressive dementing disorders is a common but challenging assessment question. While treatment of depression with medication, psychotherapy, or some combination may have some positive effects on cognitive functioning (e.g., Siegfried, Jansen, & Pahnke, 1984), cognitive impairments may persist despite treatment (Fromm & Schopflocher, 1984). Rehabilitation efforts directed at improving cognitive function in depressed older adults must be designed with the particular complaints as well as the individual's cognitive
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strengths and weaknesses in mind. Although still a relatively recent area of research, techniques to improve cognitive functioning in older adults in general, and in particular subgroups such as those with mood or dementing disorders, are available.
The nature of depression and its effect on cognition in older adults, as well as issues of assessment and rehabilitation strategies aimed at this group, will be discussed in this chapter
Types and Etiologies of Depression in Old Age
Prevalence rates of depression in older adults vary in epidemiological studies due to differing methods used to diagnose psychiatric disorders. It has been estimated that the prevalence rate for major depression in older adult community residents is between 1% and 2%. (Blazer, Hughes, & George, 1987), and 2% for dysthymia (Blazer, 1989). However, it is not uncommon for older adults to present with a transient recurrence of depressive symptoms that do not meet current diagnostic criteria. Double depression, in which a major depressive disorder is superimposed on dysthymia or minor depression, has been described in several studies (Keller & Shapiro, 1982; Rounsaville, Sholomskas, & Prusoff, 1980) and may serve to further complicate the diagnostic picture.
Clinicians often distinguish between depressive disorders that develop either before (early-onset) or after (late-onset) the ages of 50 60. Distinguishable differences between late-onset and early-onset depression are in the areas of clinical manifestation and course of the disorder. Late-onset depression is associated with multiple medical disorders (Blazer et al., 1987), lower socioeconomic status, low social integration (Phifer & Murrel, 1986; Turner & Noh, 1988), and structural brain changes (Coffey, Figiel, Djang, & Saunders, 1989; Coffey, Figiel, Djang, & Weiner, 1990) including cerebrovascular disease (Steffens, Hays, George, Krishnan, & Blazer, 1996). Comparisons of early- and late-onset depressive symptomatology indicate that older adults tend to have decreased guilt feelings (Brown, Sweeney, Sweeney, Loutsch, & Kocsis, 1984) along with increases in loss of interest (Post, 1962), psychosis (Myers & Greenberg, 1989) and generalized anxiety (Brown et al., 1984; Myers & Greenberg, 1989). However, differences between early- and late-onset depression are far from clear-cut, with conflicting results reported in the literature (see Caine, Lyness, & King, 1993, for a review).
Both medical disorders and functional disabilities have been found to contribute substantially to the chronicity of depressive symptomatology in older adults (Kennedy, Kelman, & Thomas, 1991). Vulnerability to depression in older adults with a range of illnesses has been reported, including rheumatoid arthritis (Creed & Ash, 1992), stroke, cancer, hypothyroidism, and vitamin deficiencies (Finch, Ramsay, & Katona, 1992). (For an overview of functional impairment, physical disease, and depression in older adults, see Zeiss, Lewinsohn, & Rohde, 1996). However, King, Cox, Lyness, and Caine (1995) found that comorbid medical illness had minimal effect on test performance in same-age depressed and nondepressed elderly. Clearly, while age and medical conditions may impact depressive symptomatology in older adults, this is an area requiring further study.
Difficulties have been encountered in establishing clear boundaries between major
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depression and dysthymia as diagnostic categories, due to high rates of comorbidity and commonality of symptoms (Clark, Beck, & Beck, 1994; Kocsis & Frances, 1987; Murphy, 1991). Dysthymia is often comorbid with lifetime histories of major depression, anxiety disorders, bipolar disorders, personality disorders (particularly borderline and avoidant personality disorders), or substance abuse. The Epidemiologic Catchment Area (ECA) Study (Weissman, Bruce, Leaf, Florio, & Holzer, 1991) determined that while the onset of major depression and dysthymia was predominantly prior to age 45, a sizable subgroup of dysthymic patients developed the disorder somewhat later in life. Patients with dysthymia frequently lack neurovegetative symptoms but often complain of cognitive and behavioral dysfunction (Keller et al., 1997; Kocsis & Frances, 1987).
Grief reactions may also trigger depression in older adults (Gallagher, Breckenridge, Thompson, & Peterson, 1983); reactions may range from intense emotional symptoms to depression. Generally, while normal grief reactions may include depressive symptoms, feelings of worthlessness, pervasive guilt or hopelessness, and morbid thinking are absent (Gallagher, Breckenridge, Thompson, Dessonville, & Amaral, 1982). Especially after the death of a spouse, older adults are often faced with multiple challenges, including learning new skills. For this group, coping may be hindered by the presence of depressive symptomatology, particularly if cognitive dysfunction is present.
Dementia, Pseudodementia, and Depression in Older Adults
The relationship between dementia, pseudodementia, and depression is also multi-faceted and continues to challenge clinicians and researchers in the area of evaluation and treatment. An epidemiological link has been found between depression and dementia, leading some clinicians and researchers to propose a possible etiological link. Some researchers have suggested that depression may predispose one to develop dementia and that normality, depression, pseudodementia, and dementia may lie on a progressive continuum, with depression being the first sign of dementia (Cassens, Wolfe, & Zola, 1990). The association between depression and dementia has been viewed from four vantage points: pseudodementia, dementia syndrome of depression, depression as an early symptom of dementia, and coexistence of dementia and depression.
Pseudodementia refers to unrecognized and untreated psychiatric disorders, especially depression, that may cause apparent cognitive deficits (Kiloh, 1961). Caine (1986) reviewed the literature and concluded that pseudodementia is most often associated with depression in elderly patients but can also occur in many other kinds of psychiatric diagnoses in younger patients. The assumption in pseudodementia is that the clinician must differentiate depression from dementia because if the depression is correctly identified and successfully treated, concomitant cognitive deficits may also abate. It is assumed that these two clinical entities are mutually exclusive and that pseudodementia is a reversible dementia.
Early follow-up studies lent support to the concept because in many cases, the diagnosis of presenile dementia eventually evolved into depression (Nott & Fleminger, 1975; Ron, Toone, Garralda, & Lishman, 1979). A more recent study found
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improvement on the Mattis Dementia Rating Scale on Initiation, Perseveration and Memory subtests following electroconvulsive treatment (Stoudemire, Hill, Morris, & Dalton, 1995).
In recent years, the concept of pseudodementia has been criticized, since it implies clinically dichotomous and mutually exclusive diagnostic entities when, in reality, patients can be both demented and depressed. Recent estimates of the prevalence of reversible dementias are less than 1% (Walstra, Teunisse, van Gool, & van Crevel, 1997; Weytingh, Bossuyt, & van Crevel, 1995). Patients with low intelligence, low education, physical illness, advanced age, or a history of mental illness are more likely to be diagnosed with pseudodementia, an outcome suggesting some problems with both the diagnostic criteria and the use of cognitive screening measures to aid diagnosis. Several authors have suggested that the term be abandoned (e.g., Bieliauskas, 1993; Lamberty & Bieliauskas, 1993; Marcopulos, 1989; Nussbaum, 1994; Poon, 1992; Reifler, 1982).
In their review, King and Caine (1996) concluded that neuropsychological deficits in depression are not an epiphenomenon but are due to depression-related changes in cerebral functioning, sometimes referred to as the Dementia syndrome of depression. Cognitive deficits found in depressed individuals, including inattention and declines in memory recall and spontaneous behavior, are similar to those found in patients with subcortical dementias, so some authors propose that depression be considered a form of subcortical dementia (Caine, 1981; Cummings & Benson, 1984; Folstein & McHugh, 1978; King & Caine, 1990).
Another way to look at this clinical dilemma is that normality, depression, pseudodementia, and dementia may lie on a progressive continuum, with depression being the first sign of dementia (Kral & Emery, 1989; Reding, Haycox, & Blass, 1985). Lishman (1987) warned that some cases of pseudodementia might turn out in fact to be a pseudopseudodementia. Nussbaum, Kaszniak, Allender, and Rapcsak (1991) found that 23% of their depressed patients showed cognitive decline over a 25-month period. These patients had more white-matter MRI, CAT, and EEG abnormalities than those who did not show decline (Reifler, 1982; Reifler, Larson, & Hanley, 1982).
Both retrospective and prospective community studies have found that depressed mood is associated with a moderately increased risk of developing dementia (Buntinx, Kester, Bergers, & Knottnerus, 1996; Devanand et al., 1996; Speck et al., 1995). For example, Alexopoulos, Meyers, Young, Mattis, and Kakuma, (1993) followed a group of patients who had reversible dementia for just over 2 years. Reversible dementia was defined as those depressed elderly inpatients who had diagnoses of dementia and depression on admission, but whose dementia and depression improved after treatment; improvement was defined as a Mini-Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975) score greater than 24. Alexopoulos et al. found that these patients had a 4.69 times greater risk of developing dementia than patients with a diagnosis of depression only.
It may be that depressed elders who show cognitive impairment may have subtle neurochemical or neurophysiological abnormalities that predispose them to show cognitive impairment in depression or to develop dementia. Zubenko, Henderson, Stiffler, Stabler, Rosen, and Kaplan (1996) found no relationship between depression and the apolipoprotein E (ApoE) and no relationship between MMSE score and ApoE in inpatient elders. However, depressed elders with psychotic features had a higher frequency
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of the ApoE alleles. Steffens et al. (1997) concluded in their twin study of depression and ApoE that depression may reflect prodromal symptoms rather than increase the risk of developing Alzheimer's disease.
Depressive symptomatology occurs in many forms of dementia; however, there are conflicting reports in the literature on prevalence rates for depression by type of dementia (Ballard, Bannister, Solis, Oyebode, & Wilcock, 1996; Bucht & Adolfsson, 1983; Fischer, Simanyi, & Danielczyk, 1990; Komahashi et al., 1994). In reviews of depression in mixed dementia patients, prevalence rates of coexistence varied between 0% and 87%, with modal rates above 30% (Reifler et al., 1982; Teri & Reifler, 1987; Wragg & Jeste, 1989; for a review, see Teri & Wagner, 1992). In comparisons with nondemented elderly, both AD and vascular dementia patients were more depressed than controls; the two demented groups did not differ in terms of depression (Fischer et al., 1990). Symptoms of depression were reported in the earlier stages of Alzheimer's disease in approximately 10 25% of patients (Rovner, Broadhead, Spencer, Carson, & Folstein, 1989). Clinical features that may signal depression in Alzheimer's patients include increased psychomotor retardation, ideas of worthlessness, recurrent thoughts of death, and early-morning awakening (Greenwald et al., 1989). Depressed Alzheimer's patients also have been found to demonstrate greater severity of cognitive impairment, greater dependency on others for activities of daily living, and higher prevalence of past psychiatric history than to nondepressed Alzheimer's patients (Rovner & Morris, 1989).
In one study (Sulzter, Levin, Mahler, High, & Cummings, 1993), Alzheimer's disease and vascular dementia patients were matched for severity of cognitive impairment, age, and educational background. It was determined that there was no significant relationship between severity of cognitive impairment and noncognitive symptoms such as depression. It was also determined that the vascular dementia patients had more severe behavioral retardation, depression, and anxiety than Alzheimer's disease patients.
In summary, the use of the term and concept of pseudodementia has been rejected by most researchers and clinicians. However, the prevalence of cognitive deficits in depressed older persons remains unknown. The dividing line between mild cognitive deficit in depression and mild depression in dementia is far from clear, although several authors have attempted clarification. For example, Emery and Oxman (1997) proposed that depressive dementia may be a transitional dementia. Much work remains to be done to clarify the relationship in older adults between cognitive deficits and depressive symptoms in both depression and dementia.
The Nature of Cognitive Loss in Depression
With increasing age, many spheres of cognitive functioning change. The impact of depression on cognition must be understood within the context of changes in cognition associated with normal or disease-free aging as well as cognitive changes associated with particular disease states, including physiological, neurological, and psychiatric disorders. As the topic of cognitive changes associated with normal aging is covered elsewhere in this book, what follows is a review of changes in cognitive functioning in depressed older adults.
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Although there is some neurobiological evidence that depression involves changes in brain structures and substances associated with memory (Bartus, Dean, Beer, & Lippa, 1982; McGaugh, 1983; Nussbaum, 1997), the research evidence as to the prevalence and extent of memory impairment in depressed elderly is equivocal. Many studies suggest various types and degrees of memory impairment in depressed subjects, in terms of learning and short-term memory (B ckman & Forsell, 1994; Caine, 1986; Gibson, 1981; Raskin, Friedman, & DiMascio, 1982); errors in recall (Henry, Weingartner, & Murphy, 1973; McAllister, 1981; Whitehead, 1973); and less effective coding and memory strategies (Breslow, Kocsis, & Belkin, 1981; Weingartner, Cohen, & Bunney, 1982). Other studies (Deny & Kuiper, 1981; Niederehe & Camp, 1985; Pearlson et al., 1989; Popkin, Gallagher, Thompson, & Moore, 1982) fail to demonstrate impairment in the overall memory performance of depressed subjects. In a study by Williams, Little, Scates, and Blockman (1987), while depressed and nondepressed adults were comparable on memory test performances, the depressed group complained of greater problems in memory than nondepressed adults. Subjective memory complaints are far more common among depressed older adults than among nondepressed controls (cf. Feehan, Knight, & Partridge, 1991); such negative evaluation of memory is congruent with depressed individuals' tendency to negatively evaluate many aspects of their self-worth and capacities.
Other cognitive processes that may impact performance on memory tasks, such as vigilance, attention, and reaction time (Breslow et al., 1981; Frith et al., 1983; Glass, Uhlenhuth, Hartel, Matuzas, & Fischman, 1981) and use of coding and memory strategies (Breslow et al., 1981; Cohen, Weingartner, Smallberg, Pickar, & Murphy, 1982), have also been found to be impaired in depressed patients. Hart, Kwentus, Taylor, and Hamer (1987a) found depressed patients less able than nondepressed elders to benefit from imagery to aid retention of items from a selective reminding task. In their study, Hart et al. (1987a) did find depressed patients able to make good use of cues (reminders).
The degree of cognitive impairment of depressed older adults may vary as a function of demographic variables, levels of care, or the presence of comorbid psychiatric conditions. In a review article, Poon (1992) stated that poor control of variables such as age and education may contribute to conflicting evidence on the impact of depression on cognitive function in late life. Differences in performance on memory tasks has been found between male and female depressed elderly (Cipolli, Neri, Andermarcher, Pinelli, & Lalla, 1990). Cultural differences are also often overlooked in studies of cognition and cognitive remediation, particularly among older adults (Altarriba, 1993; Gilinsky, Ehrlich, & Craik, 1993). Memory impairment has been found to be greater in psychiatric inpatients than in psychiatric outpatients, and greater in mixed unipolar and bipolar depression than in unipolar depression alone (Burt, Zembar, & Niederehe, 1995). King et al. (1995) compared elderly depressed inpatients with community-dwelling elders attending a senior center. They found deficits in attention, word generation, immediate and delayed verbal recall, and constructional praxis in the depressed group. No differences were found on verbal retention or nonverbal learning.
There are several different approaches to the study of memory in depression. Cognitive psychologists study aspects of the quality (content and process) of memory, while neuropsychologists often focus on the quantity (deficits) of memory functioning in depression and relate it to brain function. From a cognitive processing standpoint,
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depressed persons recall more negative information than positive, the so-called valence effect of recall (Blaney, 1986; Ingram & Reed, 1986). Hasher and Zacks (1979) proposed that depressed persons have more difficulty with cognitive processes that require effort (i.e., more attentional capacity than automatic processes). The reason may be that depressed persons are using attentional capacity to focus on depression-related thoughts (Hartlage, Alloy, Vazquez, & Dykman, 1993). Burt et al. (1995) found support for the valence effect theory that depressed persons find it easier to remember mood-congruent material (e.g., Blaney, 1986). However, in a study that included older adults, Rohling and Scogin (1993) did not find that depression was associated with effortful memory deficits. (See Hartlage and Clements, 1996, for a review of cognitive processes in depression.)
Although one might assume that the cognitive deficits associated with depression are more prominent in elderly persons, the literature does not support this assumption. Older depressed adults, like younger persons with depression, are able to remember more negative valence material and show mild decrements on memory testing and may demonstrate more problems with effortful memory processing. To date, the most comprehensive evaluation of the effect of depression on memory was completed by Burt et al. (1995) via meta-analyses. They found significant and consistent relationships between depression and memory impairment. What was surprising was that they found that this association was stronger in younger patients than in older patients. This finding agrees with that of Rohling and Scogin (1993), who found that depressed older adults were not more predisposed to memory loss. Kinderman and Brown (1997) conducted a meta-analysis of 40 studies looking at the effects of depression in older adults. They looked at patient characteristics and memory task factors and compared their results with those of Burt et al. (1995). Mixed unipolar and bipolar patient groups showed larger effect sizes than studies that included only unipolar patients. Also, like Burt et al., Kinderman and Brown found that studies that included younger subjects had larger effect sizes. Consistent with much of the neuropsychological literature, they found larger effect sizes for figural memory tasks than for verbal memory tasks, delayed memory versus immediate memory and recognition versus free recall.
Assessment Strategies for Cognitive Loss in Late-Life Depression
Assessment of older adults brings with it the usual clinical considerations of using appropriate instruments with adequate norms, being aware of patient fatigue or anxiety, possible sensory losses that may influence testing, and the existence of possible comorbid physical, psychiatric, or dementing conditions that may impact testing. Three primary purposes of assessment are diagnostic, descriptive, and longitudinal. It is important to complete a comprehensive enough assessment to determine the causes of cognitive declines while not straining either patient tolerance or clinical common sense. An assessment that provides a good description of the individual patient's strengths and weaknesses will be of enormous value when treatment and rehabilitation plans are devised. Assessments done over time can provide comparisons with baseline measurements in terms of rehabilitative progress or rate and degree of continued decline
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if dementia is present. Mood as well as cognitive dysfunction needs to be adequately assessed.
Assessment of Mood
A variety of instruments that assess depressed mood have normative data for, or have been developed specifically for use with, older patients (see Pachana, Gallagher, & Thompson, 1992, for a review). Despite its widespread use, the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) has limitations for use with older adults, although the reliability and validity of the instrument for this population are adequate (see Gallagher, 1986, for a review). The BDI does not sample depressive symptomatology characteristic of the elderly, such as emptiness and helplessness (Weiss, Nagel, & Aronson, 1986). The response format requires choosing from a variety of options the statement that best reflects the respondent's state of mind; cognitively compromised elders may find this task difficult. The number of questions assessing somatic symptoms limits the clinician's ability to distinguish distress due to medical illness from distress secondary to depression (Norris, Gallagher, Wilson, & Winograd, 1987). The Geriatric Depression Scale (GDS; Yesavage, Brink, & Rose, 1983), developed specifically for use with older depressed adults, addresses many of these limitations. Items on the GDS address symptoms commonly presented by older depressed adults and contain virtually no somatic complaints. The simplified yes/no response format of the GDS also reduces cognitive demands on patients. Several studies demonstrate the superiority of the GDS over the BDI and other self-report measures of depression in discriminating depressed and non-depressed elders (Brink et al., 1982; Hyer & Blount, 1984; Kiernan et al., 1986).
The Geriatric Depression Rating Scale (GDRS; Jamison & Scogin, 1992) is an interviewer-based rating scale that uses items from the GDS as topic areas in a structured interview format. Areas assessed include mood, hopefulness, cognitive function, and life satisfaction. This instrument, designed and normed specifically for older adults, includes detailed administration instructions by the authors. Another commonly used interviewer-based rating scale for depression, the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1967) and the more recent refinement of this scale, the Structured Interview Guide for the HRSD (SIGH-D; Williams, 1988) should both be used with caution in an elderly population. Item reliabilities for both instruments are only fair (Pachana et al., 1992); unsophisticated interviewers may fail to record the presence of depressive symptomatology in cognitively compromised frail elders and thus may underestimate depression (Lichtenberg, Marcopulos, Steiner, & Tabscott, 1992). As on the GDS, the fact that many items on the HRSD are somatic may lead to an overestimation of depression in medically compromised elders (Thompson, Futterman, & Gallagher, 1988).
When faced with assessment of depression with comorbid dementia, specialized instruments such as the Cornell Scale for Depression in Dementia (Alexopoulos, Abrams, Young, & Shamoian, 1988) or the Dementia Mood Assessment Scale (Sunderland et al., 1988) may be appropriate. The GDS appears to be a valid measure of depressive symptoms in patients with mild to moderate dementia (Feher, Larrabee, & Crook, 1992); however, in general, the greater the severity of dementia, the more limited the utility of the GDS (Burke, Houston, Boust, & Roccaforte, 1989).
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Assessment of Cognition
Neuropsychological tests used for assessment of older populations should have well-constructed age- and education-appropriate norms (e.g., Heaton, Grant, & Matthews, 1991; Ivnik et al., 1992; Spreen & Strauss, 1997). Also important is documentation of predictive and concurrent validity for assessing cognitive impairment in depression and identifying dementia, as well as adequate psychometric properties, including test-retest reliability for assessing change in future assessments (Christensen, Hadzi-Pavlovic, & Jacomb, 1991; LaRue, 1992). Knowledge of how normal cognitive changes differentially affect test scores is crucial. For instance, age effects are greater for memory, cognitive flexibility, and motor speed tasks than purely verbal tests (reviewed in Birren & Schaie, 1990). For this reason, it is better to use neuropsychological tests that have been adequately normed on older adults, rather than using cutoff scores (e.g., the Halstead-Reitan Battery), which tend to overestimate cognitive impairment in older adults (e.g., Moehle & Long, 1989). At a minimum, neuropsychological testing should encompass attention, language, memory, visuospatial skills, cognitive flexibility, and abstract reasoning (Thompson, Gong, Haskins, & Gallagher, 1987). While a discussion of neuropsychological testing of older adults is beyond the scope of this chapter, the reader is referred to several excellent texts and reviews of this subject (Albert, 1981; LaRue, 1992; Woodruff-Pak, 1997).
Assessment of the individual's current problems with cognition and the impact of everyday functioning cannot be overlooked if rehabilitation strategies are to be successfully implemented. As depression may result in the patient's being unable to realistically state current strengths and weaknesses, careful and thorough questioning is essential. Test scores should be used in conjunction with the clinical interview and assessment of prior or current cognitive strategies. A thorough assessment of the patient's developmental history may also be of help when designing rehabilitation strategies (Willis & Schaie, 1988). However, the clinician should be conscious not to tax the patient with too lengthy an assessment in one sitting, as one study (Hayslip, Kennelly, & Maloy, 1989) demonstrated that a lengthy, demanding test battery may exaggerate deficits observed in older depressed adults.
The distinction of dementia from depression on assessment is difficult but is essential for proper treatment recommendations. Behavioral features and qualitative aspects of cognitive performance may assist in such a differentiation (Kaszniak & Christenson, 1994); such features, along with differences on various formal testing measures, are discussed below. However, it is likely that in patients of advanced age, the distinction of the sequelae of depression and dementia may be impossible to make.
Generally, depressed older adults present as acutely aware of any cognitive deficits, which they may describe in great detail and which they report significantly interfere with normal functioning. While cognitive dysfunction is a prominent characteristic of depression in older adults, hopelessness, emptiness, feelings of envy, and a history of depressive feelings (Weiss et al., 1986) are also often present. The progression of these symptoms is often uneven, though their onset is often clear. In terms of test behavior, depressed patients in general display poor motivation and many I don't know responses and may display significantly improved performance with prompting and cuing.
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In contrast, older mild to moderately demented patients with depression are generally less aware of their degree of impairment and less articulate and forthcoming in their description of symptoms. Particularly in the case of Alzheimer's, the onset of symptoms is insidious, with a relatively steady decline in functioning. On testing, cooperation and motivation may be high, unlike those of depressed patients, but poor performance generally is not helped by prompting or cuing and indeed may be unrecognized as deficient by the patient. While behavior in the demented patient is often congruent with cognitive losses evident on testing, the same is not always true in depression alone (Strub & Black, 1988). However, whereas the social skills of dementia patients are often remarkably well preserved despite cognitive losses, the social skills of depressed elderly patients are often impaired (Mirchandani, 1988). Sun-downing, or the nocturnal worsening of cognitive and behavioral functioning, is often present in dementia patients but generally absent in depression (Mirchandani, 1988).
Depressed persons with and without comorbid dementia may also show differences in cognitive performance. Unlike demented patients, depressed older adults produce few intrusion errors (Marcopulos & Graves, 1990) and usually can benefit from cuing and encoding strategies. Depressed patients have normal serial position curve and normal rates of forgetting, whereas demented patients show rapid loss of information (Hart, Kwentus, Taylor, & Harkins, 1987b; Larrabee, Youngjohn, Sudilovsky, & Crook, 1993; DesRosiers, Hodges, & Berrios, 1995). Because the performance of depressed older adults varies greatly, even within a single testing session, several tests tapping the same cognitive domain may be useful in distinguishing depressed from demented patients, whose performance is much more stable. Naming and simple calculation skills are relatively unimpaired in depressed compared to demented patients (LaRue, 1992).
The following case illustrates an assessment that revealed cognitive impairment associated with depression, but not dementia, which remitted with treatment.
Case I
Referral Question and Background Information: Mr. S, a 67-year-old, right-handed, college-educated, white male, was treated as an outpatient for I year for persistent depressive symptoms. Mr. S had had at least two previous episodes of major depression, which had been successfully treated. This recent episode was precipitated by several significant stressors, including forced retirement and marital stress. Testing was requested to further evaluate his recent cognitive decline.
Behavioral Observations and Clinical Interview: Mr. S presented as a well-groomed 67-year-old man, looking his stated age. He reported poor sleep and appetite and complained of anxiety and minor trouble with memory, mostly with remembering names. He had no history of cerebral trauma, although he did have a history of well-controlled non-insulin-dependent diabetes. Mild hearing difficulties and his required glasses for reading were noted. Mr. S showed some difficulty with distractibility and sustained concentration. He was very reluctant to guess at questions, answering many questions with I don't know. He made numerous self-deprecating comments and had very poor frustration tolerance. He frequently became anxious and overwhelmed by the tests, throwing up his arms and saying, I can't do this.
Test Results: On intelligence testing, Mr. S received an average IQ score; however, his performance on verbal subtests was significantly better than on performance subtests. He showed a steady decline in subtest performance across time, indicating difficulties with sustained effort. On memory tests, Mr. S achieved above-average scores for both immediate
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and delayed recall for stories, despite protestations upon hearing instructions for the test that I can't do that I'll just fail! His memory was poorer for learning a list of words, though cued recall was less impaired than free recall. While he showed little impairment on his copy and recall of simple designs, he had great difficulties in correctly drawing a more complex figure, particularly with respect to integrating proportions. A severe deficiency in recalling this figure after 30 minutes resulted in such frustration that testing was discontinued for a short time. Mr. S's naming of common objects was normal. Performance on a test of visual scanning and psychomotor speed was mildly impaired. When this test was made more difficult by requiring Mr. S to keep two concepts in mind simultaneously, his performance was moderately impaired in terms of both accuracy and speed. Motor speed was moderately impaired. Mr. S's score of 27 (out of 30) on the Geriatric Depression Scale indicated a severe level of depression.
Summary and Impression: Mr. S presented as a severely depressed man with neurovegetative symptoms who had mild to moderate cognitive impairment. The test results showed a mild decline in his overall intelligence from high average premorbid estimate to current average/low average. Because his performance declined on his Wechsler Adult Intelligence Scale-Revised (WAIS-R) subtests as the testing progressed, the lowest scores being on those tests administered last, this reduction was probably secondary to fatigue and inability to sustain cognitive effort due to depression rather than a dementia. He became overwhelmed and anxious, especially during performance tasks, and easily gave up his efforts. On concept formation tasks, he performed well. Memory and learning abilities were low average but essentially intact. His ability to learn and remember new material was mildly diminished, compared with that of other persons his age but more consistent with the deleterious effect of a mood disorder than with dementia. The fact that his delayed memory was superior to initial encoding argued against a primary degenerative dementia. He had mildly impaired verbal fluency, but naming was intact. The results were consistent with diminished cognitive efficiency characteristic of moderate to severe depression.
Discussion of Case 1
The typical presentation for a depressed person on neuropsychological testing is depressed mood or pervasive loss of interest coupled with a mild memory deficit (which may be exaggerated by the patient's self-report), a mild to moderate visuospatial impairment, and reduced abstraction and cognitive flexibility. Behavioral observations during testing often reveal considerable self-criticism, underestimations of actual ability, and rejection of positive or encouraging comments made by the examiner. The depressed patient often complains of fatigue or physical distress and complains of poor concentration. This patient's test results represent a classic profile for a depressed person. Memory, especially delayed memory, was intact, including a normal rate of forgetting. Depressed persons typically have a normal rate of forgetting, whereas demented patients show rapid loss (Hart et al., 1987b; Larrabee et al., 1993; DesRosiers et al., 1995). Mr. S's retention of information to be remembered was very good, probably the strongest argument against a diagnosis of primary degenerative dementia (Troster et al., 1993; Welsh, Butters, Hughes, Mohs, & Heyman, 1992). Language, reasoning, and abstraction were intact; these are typically impaired even in persons with mild dementia. Lower scores on Performance compared to Verbal subtests on the WAIS-R were displayed in this patient and are widely reported in depression (LaRue, 1992); dementia patients typically show declines on both Verbal and Performance subtests of the WAIS-R. An interesting observation about this patient's performance
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is its decline over the duration of testing, so that the tests administered last were the tests with lower scores. This outcome strongly suggests a fatigue or effort component, consistent with depression.
Qualitative aspects of his test performance were appropriate for his age and background; pathognomonic signs or other qualitative indicators of dementia such as intrusions, rotations, and confabulations were absent. Tasks that he did perform poorly on (visuospatial and motor speed) are not the most diagnostically significant for dementia and fit more with the most commonly found deficits in depression (Lyness, Eaton, & Schneider, 1994; Veiel, 1997). The onset of functional impairment and memory complaints coincided with the onset of the depressive episode. Although he had mild cognitive deficits that were probably related to his depression, it would be misleading to label his as pseudodementia or dementia syndrome of depression (depressive subcortical dementia).
This patient was briefly reassessed 4 months after he had experienced some remission of his depressive symptoms after treatment. Retest data demonstrated no further decline, and in fact, Mr. S showed improvement on nearly all tests readministered. Although one would expect some practice effects, especially on motor and memory tests (e.g., McCaffrey, Ortega, Orsillo, Nelles, & Haase, 1992), the improvements were quite large, and the test-retest interval was too long for the results to be entirely due to simple practice effects. The fact that his test performance improved was evidence that the mild deficits noted on the previous evaluation were related to his depression and not a dementing process.
Rehabilitation Strategies for Cognitive Loss in Late-Life Depression
As the above case illustrates, in older adults treatment of depression often brings about improvement of cognitive complaints. However, as in the course of treatment cognitive awareness and acceptance of improvement often occur after vegetative and mood symptoms remit, it may be necessary to give supportive rehabilitation until the patient's cognitive status improves. Rehabilitation is perhaps most important in depressed elderly patients when cognitive impairments persist despite treatment (Fromm & Schopflocher, 1984).
As the etiology, nature, and degree of cognitive complaints among elders are generally quite variable, an individualized approach to rehabilitation, coupled with a supportive environment, is most likely to achieve successful results (Poon, Fozard, & Treat, 1978). Research on the use of cognitive rehabilitation strategies in a variety of older populations, including depressed, stroke, and dementia patients, is burgeoning and reflects the growing body of research on older populations generally (Gouvier, Webster, & Blanton, 1986).
Research on clinical or practical cognitive training in older adults has identified both inter- and intraindividual variables that may impact the success of such rehabilitation efforts. Several studies (e.g., Schaie & Willis, 1986) have shown differences in cognitive performance after training between young-old and old-old adults, suggesting that more intensive and lengthy training procedures are needed to remediate declines in older cohorts. These group differences may be due in part to differences in arousal
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levels (Faucheux, Lillie, Baulon, Dupuis, & Bourliere, 1985) and attentional functioning (Kinsbourne, 1980) between young-old and old-old adults. Ability-specific cognitive training approaches are also superior to simple repeated exposure or practice effects, as demonstrated by several extensive studies on test-retest effects in the elderly (Baltes, Dittmann-Kohli, & Kliegl, 1986; Hofland, Willis, & Baltes, 1981). Such approaches appear particularly effective for old-old groups; whereas simple practice was enough to facilitate performance on a wide range of cognitive tasks in young-old cohorts, for older individuals targeted cognitive training was required for remediation (Willis, 1989).
As a consequence of the generally high levels of heterogeneity in the experiences, functioning, and goals of older adults, optimum conditions and strategies for cognitive retraining may need to be highly tailored, so group approaches may be less effective in improving performance in specific individuals (Poon, Walsh-Sweeney, & Fozard, 1980; Robertson-Tchabo, 1980; Winograd & Simon, 1980). Barbara Wilson's research on group memory training at Rivermead Hospital has found that group memory training is as yet underresearched, and that both the therapy process itself and the sensitivity of outcome measures require improvement (Wilson & Moffat, 1992). The most useful individualized approaches require a thorough assessment of an individual's cognitive strengths and weaknesses, including preserved abilities that may be recruited to assist those in decline, as well as determination of that individual's responsiveness to aids such as visualization, organizational aids, rehearsal, and retrieval cues. When combined with self-reports of the cognitive problems causing distress in everyday life, such individualized approaches will allow for target abilities to be trained and reasonable individual goals to be achieved (B ckman, 1989).
For rehabilitation to be most effective, the strategies employed should be easy to use, should address current complaints, and should be taught with an eye to generalization (rather than teaching the test ) and to how learning can be incorporated and used in the patient's daily activities. Ideally, strategies will have feedback mechanisms built in, to increase both motivation and maintenance of gains. Older patients should also be warned that gaining mastery over new strategies to aid cognition may take much time and effort, particularly initially. Such forewarning, coupled with a supportive learning environment, should bolster both compliance and performance.
Available strategies for treatment of specific cognitive complaints in depressed older adults are discussed later, along with interventions for depressed elderly with comorbid dementia.
Attention/Orientation
Intact attentional skills are important for successful completion of most cognitive operations, including learning, encoding, and scanning of information. Older adults may benefit from increased focus on attention, particularly with regard to sustained attention to tasks over time, as some research suggests that older adults may discontinue learning tasks prematurely (Murphy, Sanders, Gabriesheski, & Schmitt, 1981).
In the case of dementia patients, orientation to their environment may be a critical part of any rehabilitation or coping intervention. The use of clocks, calendars, large notes, signs, and the assistance of relatives and staff in orientation for cognitively impaired patients may also increase functioning. Environmental adaptations such as
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signs on doors not only assist with orientation but also decrease the demands on a patient's cognitive system by reducing the need to remember. Such modifications to the environment, in conjunction with active orientation training, have been shown to be effective both immediately and at follow-up (Gilleard, Mitchell, & Riordan, 1981; Hanley, 1981).
Memory
In order to improve performance of practical, everyday tasks for older depressed adults, techniques should include internal strategies such as organization, visualization, and verbal elaboration, as well as external strategies such as writing notes as reminders, making lists, and using calendars (West, 1989). In a study of strategies used by older and younger adults, Cavanaugh, Grady, and Perlmutter (1983) found that external memory aids are used more frequently than internal aids, and that older adults make use of memory aids more often than younger adults for prospective tasks such as appointments. External strategies such as selected memory places for objects, specific object cues in the environment (such as leaving out in full view an item to be taken to the cleaners), and general reminders such as timers or pill boxes may be successfully used with older adults (West, 1985). Lovelace (1984) reported mental retracing as a common internal aid to remembering used by older adults. Imagery techniques (i.e., pairing objects to be remembered with their location) and the method of loci (pairing items to be recalled with landmarks on a mental walk ) are examples of other internal strategies that have been used successfully with elders (see Treat, Poon, Fozard, & Popkin, 1978, for full descriptions of these and other techniques; see also the chapter by Stigsdotter Neely in this text). Memory strategies may be thought of as being high or low in their familiarity and discriminability (or distinctiveness). More familiar strategies and more distinctive cues and mnemonics have increased success in enhancing older adults' performance (Kotler-Cope & Camp, 1990).
Empirically, whether it is better to utilize familiar, successful strategies or to teach unfamiliar and possibly more powerful memory strategies to older adults remains an open question (West, 1989). A study on older adults' use of the method of loci (Anschutz, Camp, Markley, & Kramer, 1987) suggests that issues of compliance must be addressed if results of training are to be used beyond the rehabilitation setting. Rehabilitation therapists may need to be guided as much by the specific needs, goals, and existing skills and deficits of the depressed older patient as by the extant literature.
However, research with practical memory skills in older adults may suggest fruitful paths for rehabilitation. As older adults often do not spontaneously develop or engage in organizational strategies, techniques promoting their use are a valuable training technique (Craik, 1984). For example, older adults may more easily remember organized than unorganized arrays (Waddell & Rogoff, 1981). Similarly, older adults were as good as younger adults at locating specific items in an unfamiliar supermarket (Kirasic & Allen, 1985). Thus, increasing organization or giving instruction in comparing familiar and unfamiliar organizational plans may increase memory for the location of objects as well as memory for large-scale spaces such as the layout of shops in a street, landmarks, or neighborhood locations (West, 1989). Improving visual scanning and simply encouraging increased interaction with new environments can also be of great assistance.
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Organization may also facilitate recall of planned or completed activities, such as hierarchical organization of activities according to goals (Meacham, 1982). While familiar activities are often better recalled than unfamiliar activities (West, 1989), distinctive encoding of tasks, through verbal elaboration or imaginal strategies, for example, may enhance activity memory (Kausler & Hakami, 1983; West, 1985). An improved organizational approach may assist in more fruitful utilization of external memory aids (for example, organizing where notes and lists are to be kept).
The use of imagery techniques as mnemonics may have some limitations with elders, as some studies suggest that older adults find it difficult to produce and remember visual images (Poon et al., 1980; Winograd & Simon, 1980). Several studies (Camp, Markley, & Kramer, 1983; Wood & Pratt, 1987) suggest that older adults tend not to use visual imagery and develop verbal strategies more spontaneously. Cermak (1980) suggested that verbal techniques may be more effective than visualization for this population.
Language
A majority of stroke patients, regardless of age, suffer from depression (Robinson, Starr, Kubos, & Price, 1983). Poststroke depression can present a major impediment to rehabilitation and to maximizing quality of life (Hibbard, Grober, Stein, & Gordon, 1992). With elderly stroke patients, age-related physiological changes combined with the presence of depression may seriously impede rehabilitation efforts. A complete discussion of specialized language and cognitive rehabilitation in older stroke patients is beyond the scope of this chapter; the reader is referred to Skilbeck (1996) for an excellent review of the subject.
Executive Abilities
Executive cognitive skills may include problem solving, planning, task initiation and completion, and self-monitoring. Problem-solving abilities have been shown to be amenable to training by researchers using a variety of strategies, including modeling and verbal self-regulation (Denney, Jones, & Krigel, 1979; Meichenbaum, 1974). Training in use of appropriate strategies combined with anxiety reduction training was successful in increasing inductive reasoning performance of older adults (Labouvie-Vief & Gonda, 1976). Practice with prototypical tasks and feedback regarding correctness of responses also appears useful in terms of improved performance (Willis, 1989).
Self-instructional training to improve self-monitoring and metacognition have met with some success in older adults (Adams, Rebok, & King, 1981; Labouvie-Vief & Gonda, 1976). Age-related deficits in metamemory (Cavanaugh, 1989) and failure to initiate newly learned strategies as well as to self-correct strategies if they are not working properly (Poon et al., 1980) suggest that neglect of self-monitoring may inhibit rehabilitation gains. Teaching on-task monitoring of performance may both increase performance and increase utilization and practical application of strategies mastered (West, 1989).
Case 2
Background Information: Mr. W, a 64-year-old, right-handed, high-school-educated, white male, was seen for follow-up testing and possible rehabilitation recommendations following
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treatment for depression. The patient had suffered a severe corneal injury and diplopia secondary to an eye injury at his place of work 3 years previously. Since the time of the accident, he had had to leave work and had been suffering from symptoms of depression, including apathy, mild dysphoria, poor sleep, and decreased cognitive functioning. After trials on a variety of medications to treat his mood disorder, he had appeared stable on a regime of fluoxetine for the past 6 months. His history was significant for a head injury sustained when he was a teenager; otherwise, he had no prior psychiatric or substance abuse history and had functioned well both occupationally and socially prior to his accident
Test Results: Mr. W was given a range of neuropsychological tests, the results of which were essentially unchanged from testing I year before, despite slight improvement and stabilization of mood. Namely, attention was variable, with poor concentration, especially for more complex tasks, and significant memory impairment was evident for both verbal and nonverbal information. As on previous testing and as noted in the interview, language skills and social behaviors were intact. Mr. W's performance on attentional and memory tasks was very frustrating for him and caused him much distress. He also tended to underestimate his ability to complete tasks and to belittle his performance. Despite its being pointed out to him that his memory was better when he was given cues, he merely repeated that his memory was not what it used to be, and it used to be perfect.
Rehabilitation Assessment: Mr. W was interviewed at length as to his current difficulties with attention memory. He admitted that his poor memory was having an adverse affect on his relationship with his wife and their friends. For example, in order to keep busy at home, Mr. W had embarked on several small home improvement projects at his wife's urging. These always seemed to turn out badly and resulted in fierce arguments between the pair. Upon further questioning, Mr. W revealed that he never wrote down dimensions or specifications before going to the hardware store to purchase supplies and never measured materials before cutting or joining. Socially, Mr. W enjoyed bowling with friends and was often asked to keep score (his traditional role before his accident). However, he often failed to record scores or made mathematical errors, which irritated his teammates and which had caused several to refuse to play on Mr. W's team.
Summary and Impression: Mr. W continued to complain of mild depressive symptoms, which had improved but not completely resolved with pharmacological treatment. Attention and memory complaints continued to significantly impair his daily functioning and might well inhibit further improvement in mood. Individual therapy as well as the institution of cognitive rehabilitation training was recommended.
Discussion of Case 2
This presentation of cognitive deficits is typical of the cognitive dysfunction accompanying moderate depression. Mr. W's elevated scores on a self-report measure of depressed mood supported this diagnosis, as did his overall presentation and history. The patient's wife concurred that changes in his behavior since the accident had included decreased attention, memory, energy, and self-confidence and increased depression, guilt, and irritability. Short-term (20-session) cognitive behavioral therapy was initiated, along with a program to teach strategies aimed at cognitive rehabilitation.
Internal strategies such as visualization were unappealing to Mr. W, who claimed to have little imagination. External strategies such as use of calendars and extensive note taking were at first rejected on grounds that they would become a crutch. Slowly, as therapy progressed, strategies for improving memory were combined with homework assignments to bolster therapeutic gains. Strategies such as buying and using a large, simple calculator to assist with scorekeeping, organizing tools and other
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commonly used materials, and use of a special home improvement notebook to record details of ongoing projects helped not only increase memory but also to increase the pleasure derived from participating in these activities. Fostering a supportive environment, particularly in terms of eliciting his wife's support in encouraging active use of memory strategies, was invaluable in increasing both motivation and compliance in this patient.
It should be stressed that not all older adults show improvement in cognition with rehabilitation. In his review of the literature, Poon (1985) stated that memory retraining helps only a portion of elders, and improvements are often not maintained after training. Poon also stated that strategies learned in training are often not applied in daily life, and that issues of motivation and generalization need to be addressed when implementing rehabilitation. In the case of Mr. W, learning to monitor his own cognitions, and to implement appropriate strategies when information needed to be encoded or recalled, was an immense help in reinforcing the use of strategies learned in rehabilitation.
The effect of improvement in mood on cognitive performance, regardless of intervention, may be significant. Zarit, Gallagher, and Kramer (1981) found that subjects receiving memory training and subjects participating in growth sessions such as relaxation or social skills training showed increased memory performance and decreased subjective memory complaints. Decreases in depressive mood, rather than improved memory performance, were related to decreases in memory complaints. The current level of depressive symptomatology experienced by the patient is an important and potentially fluctuating variable to be conscious of throughout the course of assessment and rehabilitation.
While the ability to learn new information may be denied by the depressed patient, the potential for learning is often overlooked by professionals when dealing with older adults with a dementing disorder. Although learning in dementia patients is unquestionably impaired, some limited and potentially valuable learning opportunities may be fruitfully identified and used by clinicians (see Miller & Morris, 1993, pp. 113 115). Many studies suggest that demented elderly are less able to benefit from manipulations on the processing of information, such as deep processing (Corkin, 1982; Wilson, Kazniak, Bacon, Fox, & Kelly, 1982), organizational instructions (Diesfeldt, 1984; Weingartner et al., 1982), or copy cues (Miller, 1975). Thus, for depressed patients with comorbid dementia, the key is to focus on select targets of high utility, to have realistic expectations of what may be gained, and to elicit the aid of family and staff wherever practical. External supports to cognitive functioning, such as message boards, large signs, name tags, printed directional arrows, and warning signs may be immediately useful for the patient. Such an approach also redirects the patient's family and other caregivers away from attempts to restore prior ability levels and instead focuses energy on working with the person's own cognitive strengths and weaknesses to maximize current functioning.
Case 3
Background Information: Mrs. L, an 80-year old, right-handed, widowed, Caucasian female with 16 years of education, was seen for neuropsychological testing to diagnose possible dementia. She reported insidious onset and progressive memory impairment over the last 4 years, which were followed by social isolation, fatigue, irritability, and feelings of sadness.
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Interviews with family members confirmed the presence of significant and progressive memory impairments, which had resulted in the hiring of a full-time professional caretaker to assist Mrs. L with activities of daily living. MR] and PET scan results showed some diffuse atrophy with mild bilateral frontal hypometabolism; other laboratory results were normal. No psychiatric history, chronic medical problems, personal or family history of suicide, or history of substance abuse was reported. The patient's three children lived at some distance but had traveled to the clinic to participate in the clinical evaluation. Significant losses in the patient's recent history included the death of a much-loved family pet and her youngest daughter's recent move out of the state.
Behavioral Observations: Upon her arrival at the clinic, Mrs. L appeared somewhat disheveled and was vague when asked the purpose of her evaluation. She was generally cooperative during the testing until the examiner asked her to draw the same figure a second time without the benefit of the model. She quickly drew the figure, then erased it, and finally threw both pencil and paper at the examiner in frustration. Mood ranged from anxious to depressed, and affect was restricted. Her speech was loud, rapid, and generally content-appropriate, although occasionally perseverative. She tended to sacrifice accuracy in tasks due to her carelessness. There was no evidence of hallucinations, but there was evidence of delusions, such as other people moving her furniture without her consent.
Test Results: Mrs. L scored 19/30 on the MMSE, a score suggesting impaired cognitive functioning. While her performance on tests of simple attention was within normal limits, sustained concentration was poor. Mrs. L had no difficulty rapidly counting backward and reciting the alphabet but demonstrated difficulty counting by 3s. On a test of concentration, visual scanning, psychomotor speed, and sequencing abilities (Trials A), she was within the low average range. During Trials B, a more demanding task, she utilized verbal mediation in order to complete the task but still scored in the impaired range. Naming was poor, with phonemic cues of only limited value in eliciting additional responses. Verbal fluency was also in the borderline range. The Fuld Object Memory Evaluation, a test of verbal learning and retrieval by categories, was used to assess memory functioning. In the categories of female names, Mrs. L scored in the low average range; with the categories of food and vegetables, she was in the severely impaired range. She did not show a learning curve, and recognition memory was borderline impaired. Both immediate and delayed recall of short stories, word pairs, and drawings from the Wechsler Memory Scale-Revised (WMS-R) were impaired. Performance on a complex figure was discontinued due to increasing patient agitation. Psychomotor speed was in the low average range across several tasks. The patient demonstrated a tendency toward concrete thinking, impaired judgment, and perseveration. Other evidence of frontal impairment came from impulsivity and carelessness shown on many tests. Mrs. L endorsed 12 of 30 items on the Geriatric Depression Scale. She stated that she felt sad and depressed but that she had not experienced a change in sleep, appetite, or weight. Suicidal ideation was denied.
Summary and Impression: The major finding of this assessment was of impairments in short-term memory, visual and verbal learning, judgment and reasoning, and complex attention. Neuroimaging studies, psychiatric findings such as paranoid ideations, and impaired cognitive functioning pointed to the probable presence of a primary degenerative dementia syndrome. Mrs. L had several areas of relatively intact cognitive functioning, including intact simple attention and good motivation despite moderate dysphoria. It is important to note that her performance on tests and current deficits were compounded by her rapid performance on all tasks, her lack of care on tasks, and her lack of questions for clarification regarding instructions.
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Discussion of Case 3
This patient had experienced profound losses that all agreed had accelerated her cognitive declines, particularly her lack of care with regard to herself or any tasks she undertook. The patient was started on a low dose of Zoloft, with the aim of decreasing dysphoria and agitation. Cognitive rehabilitation was aimed at establishing routines and behavioural patterns that would increase Mrs. L's level of functioning. A number of external cognitive aids, such as large calendars, prominent wall clocks, and a wrist-watch with a beeper to remind her to take her medication, were successfully introduced. The combination of increased daily structure, external memory aids to decrease cognitive load, and pharmacotherapy combined to allow for a decrease in caregiving required while increasing quality of life for this patient.
Studies examining the maintenance of training effects unfortunately often only look at gains maintained over relatively short periods, although a few studies (e.g., Anschutz et al., 1987; Baltes & Willis, 1982; Sheikh, Hill, & Yesavage, 1986) have examined gains after 6 months or more. Since retest studies have shown that repeated testing often results in a significant increase in items attempted, which thus can increase number of correct responses over time, error analyses should be conducted to examine more closely what behaviors have been affected and what gains have accrued from training (Willis, 1989). Unfortunately, a variety of studies have shown that continued use of cognitive strategies after completion of formal rehabilitation is low in older adults (Kotler-Cope & Camp, 1990). Older adults have a sizable developmental reserve capacity, which current rehabilitation strategies may not yet be fully utilizing (Kliegl, Smith, & Baltes, 1989). Kotler-Cope and Camp (1990) suggested that particularly with older depressed adults, use of creative and research-grounded cognitive interventions be linked with strategies aimed at increasing confidence and decreasing anxiety concerns about levels of functioning.
Finally, and perhaps most significantly, research on lifestyle antecedents of cognitive change indicates that in the natural environment, active lifestyles involving high levels of stimulation are associated with maintenance of previous performance levels in older adults, whereas a restrictive lifestyle, associated with low activity levels and loss of family supports, is associated with decline of performance (Gribbin, Schaie, & Parham, 1980; Stone, 1980). Thus, the environment to which an individual returns will have an important effect on the maintenance of rehabilitation gains (Willis, 1989).
Conclusion
In order both to study the true efficacy of cognitive rehabilitation strategies and to be able to effectively provide such treatment to older adults with depression, many issues must be considered. A good understanding of the biological and psychosocial factors influencing normal and abnormal cognition and psychiatric function in older adults is critical. Careful diagnostic workup of patients, especially those with pronounced cognitive deficits or suspicion of dementia, will guide all phases of assessment and treatment. A clear delineation of individuals' strengths and weaknesses, as well as their particular goals in rehabilitation, will maximize therapeutic gains.
Cognitive rehabilitation of older adults with a diagnosis of depression is an area of
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growing research interest. Problems with cognitive functioning can significantly impair daily functioning and quality of life for these patients. Despite adequate diagnostic workup and treatment for depression, residual cognitive effects may remain; this is especially true for those who may suffer from depression with comorbid dementia. The implementation of rehabilitation strategies to improve functioning, enhance quality of life, and preserve independence is possible with careful consideration of an individual's unique presentation, a good working knowledge of rehabilitation strategies, and an understanding of the cognitive and psychiatric considerations involved in working with older adults.
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