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A PRACTICAL GUIDE TO GERIATRIC NEUROPSYCHOLOGY

ii
OXFORD WORKSHOP SERIES

AMERICAN ACADEMY OF CLINICAL NEUROPSYCHOLOGY
Series Editors
Susan McPherson, Editor-in-C hief
Ida Sue Baron
Julie Bobholz
Richard Kaplan
Sandra Koffler
Greg Lamberty
Jerry Sweet
Volumes in the Series

Ethical Decision Making in Clinical Neuropsychology
Shane S. Bush
Mild Traumatic Brain Injury and Postconcussion Syndrome
Michael A. McCrea
Understanding Somatization in the Practice of Clinical Neuropsychology
Greg J. Lamberty
Board Certification in Clinical Neuropsychology
Kira E. Armstrong, Dean W. Beebe, Robin C. Hilsabeck,
and Michael W. Kirkwood
Adult Learning Disabilities and ADHD
Robert L. Mapou
The Business of Neuropsychology
Mark T. Barisa
Neuropsychology of Epilepsy and Epilepsy Surgery
Gregory P. Lee
Mild Cognitive Impairment and Dementia
Glenn E. Smith and Mark W. Bondi
Intellectual Disability: Civil and Criminal Forensic Issues
Michael Chafetz
Executive Functioning: A Comprehensive Guide for Clinical Practice
Yana Suchy
The Independent Neuropsychological Evaluation
Howard J. Oakes, David W. Lovejoy, and Shane S. Bush
A Practical Guide to Geriatric Neuropsychology
Susan McPherson and Deborah Koltai
iii
A PRACTICAL GUIDE
TO GERIATRIC NEUROPSYCHOLOGY
Susan McPherson, PhD, ABPP/CN

Deborah Koltai, PhD, ABPP/CN
■■■
OXFORD WORKSHOP SERIES
1
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1
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You must not circulate this work in any other form

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Library of Congress Cataloging-in-P ublication Data

Names: McPherson, Susan, 1958–author. | Koltai, Deborah, author. |
American Academy of Clinical Neuropsychology.
Title: A practical guide to geriatric neuropsychology /Susan McPherson,
Deborah Koltai.
Description: New York, NY : Oxford University Press, 2018. |
Series: Oxford workshop series | Includes bibliographical references and index. |
Identifiers: LCCN 2017038152 (print) | LCCN 2017038941 (ebook) |
ISBN 9780199988624 (UPDF) | ISBN 9780199988631 (EPUB) |
ISBN 9780199988617 (paperback : alk. paper)
Subjects: | MESH: Neuropsychological Tests | Aged | Geriatric Assessment |
Interview, Psychological | Mental Competency—psychology
Classification: LCC RA651 (ebook) | LCC RA651 (print) |
NLM WM 145.5.N4 | DDC 616.8/0 475—dc23
LC record available at https://lccn.loc.gov/2017038152
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Printed by WebCom, Inc., Canada
v
To James and Winifred McPherson, who taught me the value of persistence

and hard work.
To Asenath LaRue and Jeffrey Cummings, who inspired me.
To Mary Lynn, for her ever-present love and support.

SM
To my children, who are my joy and my light.
To my anchors, who bring me back to center.
To Susan, for sharing her venture with patience, determination, and cheer.
DK
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Contents
Acknowledgments ix
Chapter 1 The Aging Population in Clinical Practice 1
Chapter 2 Normal Aging 7
Chapter 3 Factors Affecting Clinical Interaction

and Performance 19
Chapter 4 The Clinical Interview 27
Chapter 5 Cognitive Screening 41
Chapter 6 Neuropsychological Assessment in Geriatric

Settings 53
Chapter 7 Psychiatric Disorders 67
Chapter 8 Capacity 87
Chapter 9 Feedback and Intervention 105
Chapter 10 Older Adults in the Workforce 123
Chapter 11 The Future of Health Care 131
Notes 141
References 143
Index 189
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Acknowledgments
Special thanks to Terry Barclay, PhD, for his unending patience in tracking
down articles, and to my co-author, Deborah, for her guidance and support.
SM
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A PRACTICAL GUIDE TO GERIATRIC NEUROPSYCHOLOGY

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■■■
The Aging Population in Clinical Practice
The landscape of the world population is changing, and over recent decades
in the United States the shifting demographics are manifest. Readiness, as
indicated by awareness, policy and systems is developing. We appreciate
that health care systems serving elders will be affected by these shifts, with
optimal systems anticipating and creating triage and care systems that are
responsive and effective. However, we are aware that much remains to be
done to prepare for changes in referral patterns and care needs that will
come. In this volume, we focus on dimensions of psychological aging asso-
ciated with risk, namely the aging central nervous system and mental health
of older adults. It is our hope to offer a general introduction to central mat-
ters of importance in the care of older adults at this point in the 21st century.
Census Indicators
According to the 2010 US Census, persons 65 years or older numbered
40.2 million, representing 13% of the US population, about one in every
eight Americans. In 2010, more people were older than 65 years than in
any prior Census, and this group represented the fastest growing segment
of the population between 2000 and 2010 (15.1% to 9.7%) (Werner, 2011).
By 2030, it is estimated that people 65 years and older will make up 19%
of the population, compared with 13% in 2010 (Ortman, Velkoff & Hoga,
2014). The ethnic and racial diversity of older adults in the United States will
also change, with older non-Hispanic whites accounting for only 6.9% of
1
2
the population older than 60 years, representing a decline of 9% from 2010

(Administration on Aging, 2016). Of the population older than 60 years, it
is expected that, between 2010 and 2030, the proportion of older Hispanics
will increase from 7% to 13%, the proportion of older Asian Americans will
increase from 3.5% to 5.6%, and the proportion of older African Americans
will increase from 8.6% to 10% (Administration on Aging, 2016).
It is well established that the leading cause of dementia in older adults is
Alzheimer’s disease (AD). Of the estimated 5.2 million Americans with AD,
the majority are older than 65 years (Hebert, Weuve, Scherr & Evans, 2013),
with an estimated 13% between the ages of 65 and 74 years, 44% between
ages 75 and 84 years, and 38% 85 years or older. The estimated incidence
(new cases per year) of AD increases significantly with age, rising to as high
as 231 new cases per 1,000 people 85 years and older (the “oldest old”)
(Hebert, Beckett, Scherr & Evans, 2001).
Older adults are also not immune to mental health disorders. In 1999, an
estimate one in four older adults had a significant mental health–related dis-
order. By the year 2030, the number of older adults with major psychiatric
illnesses is projected to reach 15 million (Jeste et al., 1999). Bartels (2003)
cited numerous studies indicating that older adults with mental illness are
at increased risk for receiving inadequate and inappropriate care resulting in
(1) impaired independent and community-based functioning, (2) compro-
mised quality of life, (3) cognitive impairment, (4) increased caregiver stress,
(5) significant disability, (6) increased mortality, (7) poor health outcomes,
and (8) higher utilization and costs of health care services.
The Impact of Older Adults on the Health Care System

Defined by the Census, the term older adults generally refers to individu-
als who are 65 years and older. Subsequent to the increase in the numbers
of older adults will be the increase in referrals for cognitive evaluation of
neurologic disorders common to older people, specifically dementia, as well
as referrals to psychologists for behavioral interventions to manage chronic
health conditions (e.g., diabetes, cardiac disease) and the concomitant con-
ditions that accompany many of those conditions (e.g., depression). Referrals
for mental health care will also increase in this population given the aging of
individuals with chronic psychiatric conditions.
Report of the impact of the aging population on Medicare and the
“Medicare Crisis” that will ensue as the baby boomers age permeates the
2 A Practical Guide to Geriatric Neuropsychology

3
news. These reports are not without some merit given the increased risk
for dementia as the population ages and the costs associated with care for
individuals with dementia. Individuals with AD incur about 60% higher
costs than non-A D patients in the Medicare program, and AD patients
impose a substantial cost on Medicaid programs through nursing home
use (Weimer & Sager, 2009). Individuals with dementia have a signifi-
cantly higher rate of hospital admissions for all causes and for ambulatory
care–sensitive conditions (ACSCs) for which proactive care may have pre-
vented hospitalizations than persons without dementia (Phelan, Borson,
Grothaus, Balch & Larson, 2012). Phelan et al. (2012) propose that pro-
actively monitoring dementia patients for ACSCs, such as urinary tract
infection or pneumonia, on an outpatient basis is likely to prevent the need
for a hospital stay and thus result in lower health care costs. Such preven-
tion requires the monitoring of mental status to detect dementia before the
individual is hospitalized, increasing the role of the neuropsychologist in
clinical care. As noted earlier, older adults with mental health disorders
have higher utilization and costs of health care services (Bartels, 2003).
Providing effective mental health services can result in cost offsets (Strain
et al., 1991).
The Need for Mental Health Services for Older Adults

Mental health disorders are particularly common in older adults who
are living in nursing homes. Data from 2005 indicated that among the
996,311 new admissions to nursing homes, 19% (n = 187,478) of patients
were admitted with mental illnesses other than dementia, whereas 12%
(n = 118,290) had dementia only (Fullerton, McGuire, Feng, Mor &
Grabowski, 2009). Conditions such as major depression, schizophrenia
and other psychotic disorders are becoming more common in the nurs-
ing home setting, yet access to psychiatric care is often not available or
is inadequate (Bartels, 2003). 30% to 56% of persons living in assisted
living facilities have a mental health diagnosis, but payment systems do
not allow for care within a residential living facility (Becker, Stiles &
Schonfeld, 2002). It has been estimated that approximately one-third of
older adults in primary care have significant mental health symptoms
(Lyness, Caine, King, Cox & Yoediono, 1999) and receive care from a
primary care physician instead of a mental health professional (USDHHS,
1999a).
The Aging Population in Clinical Practice3

4
The Role of Psychology and Neuropsychology in Care

The rapidly increasing aging population and subsequent rise in cases of
disorders such as dementia and chronic health conditions are producing
a demand for services that can be provided by clinical psychologists and
neuropsychologists. The need for cognitive evaluation and subsequent treat-
ment of behavioral disorders, caregiving issues, and mood disorders poses
an opportunity for neuropsychologists and psychologists to be on the “front
lines” of treatment. As will be discussed in detail in Chapter 5, one of the
potential roles for neuropsychology, whether in the institutional setting or
private sector, is in training other professionals in the appropriate use of
screening tools that might detect the earliest signs of cognitive change as
well as help determine which patients require additional evaluation. While
not diagnostic, the use of screening tools can assist all care providers in
determining changes in cognition that might trigger a dementia diagnosis.
Dementia caregivers, approximately 20% of whom are older adults,
report higher levels of stress and depression compared with the general pop-
ulation (Pinquart & Sorensen, 2007). Older individuals caring for a loved
one with dementia are also within the scope of practice of psychology as
well as neuropsychology. As will be discussed in Chapter 9, feedback and
intervention for individuals with dementia focus not only on the person
with the disease but also on the environment and persons caring for the
patient with dementia.
Scope of the Current Text

The increasing numbers of older adults in the population almost guar-
antees that practitioners who serve adult populations will begin to expe-
rience an increase in the number of older patients referred for services.
Unfortunately, across professions, the geriatric mental health care work-
force is not adequately trained to meet the health and mental health
needs of the aging population (Institute of Medicine, 2012). While this
text alone is not adequate in providing extensive training in geriatrics,
it will provide a basis for the practitioner in understanding the cogni-
tive changes that occur with normal aging (Chapter 2). We will focus
on factors that affect interaction with an older adult, such as vision and
hearing (Chapter 3) and the importance of gathering information from
a collateral source during the clinical interview (Chapter 4). The impor-
tance of screening for cognitive changes in primary care will be addressed

5
(Chapter 5), as will the purpose and utility of more extensive cognitive
evaluation (Chapter 6) and the evaluation and treatment of psychiatric
disorders (Chapter 7). This text will also provide an overview on issues
of capacity that can arise in the geriatric population and on how a variety
of capacities are determined (Chapter 8). The importance of providing
feedback and recommendations for treatment and intervention specific to
geriatrics will be discussed (Chapter 9). An increasing number of older
adults are remaining in the workforce past retirement, and we will focus
on some of the challenges specific to older workers (Chapter 10). Finally,
we will discuss the changes evolving in health care and the impact of
those changes on practice (Chapter 11). While not exhaustive, our intent
has been to provide an overview of the principles vital to the care of older
adults focusing on psychological and neuropsychological health. We
recognize the unique and overlapping expertise of neuropsychologists,
geropsychologists, geriatric psychiatrists, neurologists, geriatricians, and
behavioral-cognitive and behavioral health psychologists. We encourage
all to work collaboratively and are delighted to participate in the care of
our vital older adults.
The Aging Population in Clinical Practice5

6
7
2
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Normal Aging
Ms. Pickens is a 68-year-old, married woman who recently retired

from her nursing career. She has started to notice changes in her mem-
ory and states that she will “walk into a room and forget what it was
I went in there to get.” She has no difficulty remembering conver-
sations or remembering to takes medications and is not misplacing
items or repeating herself. She has no difficulty with navigating while
driving. She admits that she is “worried” because her mother devel-
oped Alzheimer’s disease at age 80. An interview with her husband
does not reveal any significant changes in memory or other cognitive
abilities. Testing does not reveal any significant deficits, and memory
scores were above average. Ms. Pickens is provided feedback regarding
the aging process and is reassured that her current test performance
does not reveal any signs of dementia or mild cognitive impairment.
Normal Aging: Physiological, Cognitive, and Psychological

Aging is a term used to describe advancement through the life cycle from
birth to death and is used by the general population to describe the process
of getting older (Pankow & Solotoroff, 2007). Normal aging encompasses
myriad changes involving physiological, psychological, cognitive, sociolog-
ical and economic aspects. While all of these areas are important in under-
standing the aging process, a comprehensive review is outside the scope of
this book. The present chapter will focus on the physiological, psychological
7
8
and cognitive aspects of normal aging given that those aspects of normal
aging are most likely to be encountered by the clinician.
Optimal Versus Typical Aging

One caveat to the study of normal aging involves whether the study popu-
lation of older adults includes individuals with “optimal” versus “typical”
aging. In studies of optimal aging (also referred to as “successful” aging),
individuals with common medical illnesses (e.g., diabetes, cardiac disease,
chronic obstructive pulmonary disease) or those taking numerous medica-
tions are excluded from the study. As will be discussed in later chapters,
the impact of medical illness needs to be considered when assessing mood,
cognition and quality of life. Optimal aging individuals have often been
described as “super normal” because they perform at the upper end of the
normal distribution of cognitive and physical test scores. Studies of “typical”
aging are motivated by the theory that diseases are to be expected as part
of normal physiological aging. Studies of typical aging include individuals
with common medical illnesses using the typical medications to treat those
illnesses (i.e., antihypertensive medication) and tend to provide a less opti-
mistic picture of normal aging than studies of optimal aging (Smith, Ivnik
& Lucas, 2008). In drawing conclusions about normal aging, it is important
to consider which group of individuals has been studied—those who are
typical of the aging process, or those who have in many aspects “succeeded”
in avoiding the typical process.
Physiological Aspects of Aging

Anatomical and imaging studies of the brain across the life span have
revealed differences in brain structure, particularly between men and
women. Cross-sectional studies of aging estimate the average rate of aging
from correlations with age but cannot directly determine rates of change and
individual differences, whereas many longitudinal studies have relied on
small sample sizes. A five-year longitudinal study of brain regions in healthy
adults revealed that longitudinal changes in brain volume are not uniform
and that the magnitude of change varies across regions and individuals (Raz
et al., 2005). In terms of brain regions, the greatest areas of shrinkage were
found in the caudate, cerebellum, hippocampus and tertiary association cor-
tices. Entorhinal cortex shrinkage was noted to be minimal, and stable vol-
umes were noted in the primary visual cortex. Age-related differences were
found for the hippocampus (memory) and prefrontal cortex (planning and

9
problems solving). Changes in brain volume varied during adulthood across

individuals, with reliable individual differences in change in a select group
of healthy volunteers in all measured regions except the inferior parietal
lobe. Significant differences in the entorhinal cortex were noted between the
oldest adults studied, with no shrinkage noted in younger and middle-aged
individuals (Raz et al., 2005).
Studies relying on larger sample sizes, such as the Framingham Heart
Study, have shown that age explained 50% of total cerebral volume age-
related differences after age 50 years (DeCarli et al., 2005). The greatest vol-
ume loss attribute to age was noted in the frontal lobe (12%), with smaller
difference found in the temporal lobe (9%) and “modest” occipital and pari-
etal lobe changes. Men had significantly smaller brain volume in the frontal
lobe compared with women, although other age-related gender differences
were noted to be small. The presence of infarction on magnetic resonance
imaging increased with age, was common after age 50 years and was associ-
ated with larger white-matter hyperintensity (WMH) volumes.
It is important for studies of anatomical aging to include individuals with
common health conditions so as to portray changes in “typical” versus “opti-
mal” aging. Using data from the Rotterdam Scan Study, Ikram et al. (2008)
investigated how age, sex, small vessel disease and cardiovascular risk fac-
tors affected cerebrospinal fluid, gray matter, white matter and white-matter
lesions. The study included 490 nondemented individuals between the ages
of 60 and 90 years who had a history of hypertension (51%), had a history
of diabetes mellitus (4.9%), were current smokers (17.8%) and were former
smokers (54%). Decreases in total brain, normal white matter and total
white matter decreased with increased age, whereas gray matter remained
unchanged. White-matter lesions increased in both men and women, even
when persons with evidence of infarctions (i.e., stroke) were excluded. Those
individuals with larger amounts of small vessel disease had smaller brain
volume and smaller normal white-matter volume. Other factors related to
smaller brain volume included diastolic blood pressure, diabetes mellitus
and current history of smoking.
Cognitive Aspects of Aging

While some cognitive decline due to aging is inevitable, not all older adults
develop degenerative conditions as they age. It is the task of the geriatric
clinician to determine whether the complaints and concerns of cognitive
Normal Aging9
10
change in the older adult reflect subjective worry or are indicative of a neu-
rodegenerative disorder. This chapter explores the factors related to stability
and decline in normal aging.
Cognitive Changes
It is well understood that along with normal age-related changes in brain
morphology, there exist incremental declines in cognition in multiple cog-
nitive domains (Drachman, 2006; Finch, 2009; Salthouse, 2009). These
declines begin early, in the third and fourth decades of life (Salthouse,
2009), but are often not noticeable until late life. Compared with young
adults, older adults show selective losses in functions related to speed and
efficiency of information processing. Vulnerable systems are those involved
with attention, memory recall, executive working memory and multitasking
skills (Salthouse, 1996; van Hooren et al., 2007). While delayed free recall is
less efficient, it is not the profound rapid forgetting deficit seen among those
with Alzheimer’s disease (AD) (Welsh Butters, Hughes, Mohs, & Heyman,
1991, 1992), and retrieval with cues is typically preserved. The profile of
amnestic disturbance in normal aging is primarily in the efficient access-
ing of stored information, rather than in the consolidation and storage of
information (Welsh-Bohmer & Koltai Attix, 2014). Performance on meas-
ures of executive efficiency (e.g., Trail Making) and language retrieval (e.g.,
verbal fluency) also tend to be lower in older groups compared with their
younger counterparts (Salthouse, 2010). Finally, normal older adults also
show less efficient performances than younger groups on tests of visuoper-
ceptual, visuospatial and constructional functions (Eslinger, Damasio,
Benton, & Van Allen, 1985; Howieson, Holm, Kaye, Oken & Howieson,
1993; Park & Schwarz, 2000).
Theories of Normal Cognitive Aging

Most cognitive science theories of normal age-related cognitive decline sup-
port the idea of a broad explanatory mechanism for age-related cognitive
change rather than unique and specific changes in specific domains and
structures. These explanations are not mutually exclusive, but rather use
difference vantage points to illustrate similar concepts. Perhaps the most
popular theory focuses on changes in the speed of central processing
(Finkel, Reynolds, McArdle & Pedersen, 2007; Salthouse, 2005). Another
explanation focuses on the “fluid versus crystallized” constructs of decades
past, with the novel problem-solving and flexible thought skills of fluid

1
intelligence being more susceptible than well-rehearsed verbal crystallized

skills (Botwinick, 1977; Horn, 1982). Support from neuroimaging and his-
topathological studies (Coffey et al., 1992; Gur, Gur, Obrist, Skolnick &
Reivich, 1987; Haug et al., 1983; Tisserand, 2003) have led to a conceptu-
alization of normal aging as a selective vulnerability in frontal-subcortical,
dysexecutive processes (Daigneault & Braun, 1993). Other theories have
focused more on failures in distributed brain networks across the age span
(Finkel et al., 2007; Reuter-Lorenz & Park, 2013; Salthouse 2010).
In considering the findings of studies involving normal aging, we offer
three basic cautions:
• Consider results in light of the definition for inclusion of “normal

older adults” in each study. There is substantial variability, with
some not screening objectively for nervous system disorders or
strictly operationalizing their criteria for normal aging.
• When considering differences in age-related test results, in
groups or individually, keep in mind that tests also have
different inclusion criteria for their standardization sample
(see test manuals) and that standard scores thus correct for age
differentially across measures.
• “Normal” aging is not a unitary state. Story and Koltai Attix
(2009) described the variability in normal, nonpathological aging
in three (albeit arbitrary) groups: (1) optimal aging, (2) normal
aging, and (3) suboptimal aging. Story and Koltai Attix proposed
that if one were to follow longitudinally a normal group of older
adults who have objectively met criteria indicating that they are
free from pathology (e.g., normal neurological examination and
neuroimaging, absence of major medical conditions and of history
of CNS trauma), the performance curves of aging in that group
of individuals would show normal variance, with some declining
less and some declining more than others, regardless of the group
(i.e., optimal, normal, suboptimal).
Identification of the Prodromal Stages of Neuropathological Aging

The ability to draw the line between normal and pathological aging is
indeed imperfect. Nonetheless, researchers have defined with increas-
ing accuracy the ability to detect the earliest signs of neurodegenerative
Normal Aging11
12
disease. Such efforts were launched to improve clinical treatment, care

planning, and management and to characterize cohorts for early interven-
tion in clinical trials.
In the early 1990s, researchers at Duke Medical Center character-
ized the neuropsychological hallmark of AD: the early amnestic pattern
of impaired consolidation and rapid forgetting (Welsh et al., 1991, 1992),
which remains the most affected area in most cases as other areas of cogni-
tion progressively become involved. Contemporaneously, the early selective
involvement of the medial temporal lobe, followed by progression through-
out the cortices, was illustrated in pathological stages by Braak and Braak
(1991). In 1995, the identification of the elevated risk for amnestic distur-
bance related to AD with the presence of one or two copies of the apolipo-
protein epsilon E4 allele (Roses et al., 1995) catalyzed AD research. More
recently, cerebrospinal fluid biomarkers of AB peptide and tau levels, along
with structural and functional neuroimaging studies, also have defined
uses in diagnostically ambiguous cases (Albert et al., 2011; McKhann et al.,
2011; Sperling et al., 2011).
Mild Cognitive Impairment

With the characterization of AD across stages with clinical, biologi-
cal, genetic, imaging and pathological correlates well defined, there was
also a new characterization of isolated memory disorders and the early
or prodromal phases of AD. The late 1990s and 2000s saw the clinical
characterization of mild cognitive impairment (MCI) and the subsequent
refinement of single-and multiple-domain, amnestic and nonamnestic
MCI definitions (Petersen et al., 1999; Petersen, 2004). Nomenclature
relevant to early identification includes MCI due to AD, prodromal AD
(used in Europe) and mild neurocognitive impairment due to Alzheimer’s
disease (used by the American Psychiatric Association Diagnostic and
Statistical Manual of Mental Disorders, fifth edition [DSM-5]) (Albert et al.,
2011; Dubois et al., 2010).
Incidence and prevalence rates for MCI have been established. In the
Chicago Health and Aging Project, 34% of a community sample was found
to have MCI, whereas 13% had AD. Not surprisingly, prevalence and inci-
dence rates of MCI and rates of conversion to dementia vary considerably
depending on the definition applied (Busse et al., 2003). Gomar et al. (2011)
investigated the utility of biomarkers and cognitive markers to predict con-
version from MCI to AD in the Alzheimer’s Disease Neuroimaging Initiative

13
(ADNI) study. They found that cognition at baseline predicted conversion

over time better than most biomarkers. Here again, the utility of behavioral
data is underscored not only in its obvious use to characterize and educate
patients and families but also in its inclusion as a prognostic variable.
Studies have demonstrated conversion rates to dementia and risk fac-
tors for progression versus stability or improvement. Busse et al. (2006)
conducted a six-year study of a community of adults 75 years and older
who were dementia free. Based on their results they estimated that 60% to
65% of people with MCI will develop dementia during their life and that
the progression to AD from MCI was time dependent, occurring in the first
2 to 3 years. Fischer et al. (2007) likewise followed a group of community-
based adults older than 75 years over a period of 30 months. They showed
that conversion rates to AD were much higher for those who had amnestic
MCI (48.7%) than for those that had nonamnestic MCI (26.8%). A host of
studies characterized risk factors and probabilities for conversion to various
states of disease. All of these longitudinal studies likewise demonstrated
another important factor: that about 20% to 25% of those diagnosed with
MCI did not progress to dementia, but rather improved or remained stable
over time. This presumably is because cohorts with MCI include people
with cognitive impairment due to treatable factors (e.g., depression, meta-
bolic disorders) and potentially stable disorders (e.g., small vessel disease).
The varied longitudinal trajectories of these samples resulted in the apt
characterization of MCI as a “risk state” for dementia, rather than a preclini-
cal diagnosis.
More recently, the National Institute on Aging–A lzheimer’s Association
workgroups on diagnostic guidelines for AD detailed the diagnosis of MCI
due to AD (Albert et al., 2011) and characterized the preclinical stages of AD
(Sperling et al., 2011). Criteria for MCI due to AD include concern regard-
ing a change in cognition, impairment in one or more cognitive domains,
preservation of independence in functional skills, impairment of 1 to 1.5
standard deviations below age-and education-matched peers on culturally
appropriate measures of cognition and an absence of dementia. The incor-
poration of biomarkers into research criteria is discussed, and the value of
longitudinal cognitive evaluation is emphasized to establish the accuracy of
MCI due to AD.
In MCI due to AD, patients often show the characteristic memory dis-
order of more fully expressed disease, but they also may show other mild
deficits in executive function, language expression, visuoperception and
Normal Aging13
14
attention (Bäckman, Jones, Berger, Laukka & Small, 2005; Hayden et al.,
2005; Twamley, Ropacki & Bondi, 2006). Moving beyond normal aging
and MCI, as AD pathology spreads to include temporal, parietal and fron-
tal cortices, other areas of cognition become impaired (Small, Fratiglioni,
Viitanen, Winblad & Bäckman, 2000; Storandt, Grant, Miller & Morris,
2006; Welsh et al., 1992). With functional impairment resulting, a firm
diagnosis of AD dementia can be made (McKhann et al., 2011). At this
stage, the more fully expressed prototypical changes of AD appear, includ-
ing deficits in expressive language, higher executive control, semantic
knowledge and visuospatial function (for review, see Weintraub Wicklund
& Salmon, 2012). At later stages, semantic knowledge and naming are
effected, and conversational speech may be tangential and poorly organ
ized (Weintraub et al., 2012). Visuospatial problems may be evident, usu-
ally in late stages of the illness, and result in dressing apraxia, difficulty in
recognizing objects or people, and problems in performing familiar motor
acts (Cronin-G olomb & Amick, 2001). Alzheimer’s disease is by far the
most common disorder of aging that causes dementia. Affecting nearly
10% of the population older than 65 years, AD is estimated to have a prev-
alence of 25% to 40% in those 85 years or older (Hebert, Weuve, Scherr
& Evans, 2013).
Differentiating Normal Versus Pathological Aging

As is discussed in Chapter 6, neuropsychological evaluation provides
one of the most accurate methods of differentiating between normal
age-related changes and pathological cognitive decline. The strength of
neuropsychological evaluation rests on the absolute reliance on large nor-
mative standards that account for common confounding variables that
affect performance. The standard for specific age, education and gender
groups provides the reference point for the older adult’s individual perfor-
mance, with linguistic and cultural factors also being considered during
evaluation. These data establish pattern and magnitude of any weakness
in cognition, and then serve as a comparison point to follow the trajectory
over time.
Factors considered during objective evaluation include the patient’s
age, gender, formal education, race, language, and level of acculturation.
Occupation and past-times also are considered in reference to any bearing
on performance. Medical, psychiatric and family history also are considered
in interpretation.

15
Providing Feedback on Normal Aging Versus

Mild Cognitive Impairment
As discussed in Chapter 9, providing feedback from assessments conducted
to differentiate normal versus pathological aging can be a particularly
charged experience, wherein older adults and families await information to
better understand their current situation and prognosis. During the feed-
back session, older adults and family members are often approachable and
impressionable. They have trusted the provider to conduct a comprehensive
and quality evaluation and are looking to the provider to interpret, describe,
diagnose, characterize and prognosticate, as well as offer strategies, recom-
mendations, and, often, hope. A great deal of care can be delivered during
this vulnerable time through education, support, and normalization of the
experience whether it be normal aging, a risk state of MCI, or a disease state
of dementia. The provider can offer a rare understanding of the individ-
ual, highlighting the person’s unique strengths and areas of preservation.
Referrals to support groups and services should be offered. Critically, this is
an important time to clarify the impossibility of predicting any single case,
even when we can provide likely odds and group statistics, and to emphasize
the importance of focusing the person’s own story, so that it is not missed.
Psychological Aspects of Aging

A variety of qualitative and quantitative changes affect social roles in aging.
Changes in social and emotional life include the narrowing of social net-
works, a reduction in frequency of negative emotions, and an increase in
the investment in meaningful relationships (Charles & Carstensen, 2010).
Changes in physical ability and sensory loss make it difficult to complete
activities that were once easily completed, while sensory changes make con-
versation more effortful. Although much of the prior literature has focused
on models that view aging as a state of decline or deficiency, life span devel-
opmental models have focused on “specific processes and strategies that
facilitate adaptive aging” (Charles & Carstensen, 2010). This section consid-
ers some of the positive social and emotional changes that occur with age
(see Charles & Carstensen, 2010, for a more detailed review of the literature).
Social Networks and Relationships

Decreases in social networks in aging has been attributed to the death of
friends and family, decreases in social roles, and increases in functional lim-
itations that decrease mobility and lead to a reduction in social involvement
Normal Aging15
16
(Charles & Carstensen, 2010). In fact, the reduction in social network does
not happen later in life, but instead begins earlier in adulthood, in the 30s
and 40s when individuals begin to reduce social networks into smaller,
more intimate forms (Carstensen, 1992; Charles & Carstensen, 2010).
Changes in social networks in aging has been attributed to the reduction
of less meaningful, casual acquaintances while maintaining the number of
emotionally close relationships (Charles & Carstensen, 2010). When com-
pared with younger adults, older adults are more likely to prefer familiar and
emotionally close relationships, have more positive emotional experiences
with family members compared with friends, are more selective in choos-
ing social activities that are personally meaningful, are more satisfied with
their social networks and report higher levels of positive emotions (Charles
& Carstensen, 2010). Finally, older adults who report strong social networks
are at lower risk for morbidity and mortality (Berkman, Glass, Brissette, &
Seeman 2000; Ryff & Singer, 2001), experience lower levels of cognitive
decline (Barnes, Mendes de Leon, Wilson, Bienias, & Evans 2004; Wilson
et al., 2010; Zunzunegui, Alvarado, Del Ser & Otero, 2003) and may be
protected against the development of dementia (Fratiglioni, Wang, Ericsson,
Maytan & Winblad, 2000).
Emotions
Research has indicated that aging is associated with positive overall emo-
tional well-being and greater emotional stability with more complexity, as
noted by the presence of both positive and negative emotions (Carstensen
et al., 2011). Positive emotions have been related to longer survival rates,
health indicators such as blood pressure and immune response, and
physical morbidity and mortality (Charles & Carstensen, 2010). An 18-
year longitudinal study found that older adults with positive attitudes and
emotions regarding the aging process reported better functional health
over time than individuals with negative perceptions, even after control-
ling for baseline level of “functional health, self-r ated health, age, gender,
loneliness, race and socioeconomic status.” (Levy, Slade & Kasl, 2002).
Older adulthood is accompanied by more positive appraisals of a vari-
ety of situations. In laboratory studies, older adults report fewer regrets
in life than younger adults (Riediger & Freunk, 2008), have lower levels
of “buyer’s remorse” (Mather, Knight & McCaffrey, 2005), and are more
likely to infer positive rather than negative emotions when writing about
life experiences (Pennebaker & Stone, 2003). Studies that have focused

17
on how younger versus older adults process emotional information have

found that older adults tend to remember both positive and negative
information to equal degrees, compared with younger adults, who have
been found to have a negative bias when processing emotions (Charles &
Carstensen, 2010).
Positive interpersonal social exchanges have been related to higher lev-
els of well-being, whereas negative social exchanges have been related to
higher levels of depression, lower levels of emotional well-being,and worse
self-reported health (Newsom, Rook, Nishishiba, Sorkin & Mahan, 2008).
Older adults tend to limit exposure to negative experiences compared with
younger adults by controlling the way in which they navigate their environ-
ments, by engaging in behaviors that prevent escalations of tense social situ-
ations, and by striving for “harmony and goodwill” (Charles & Carstensen,
2010). As a potential result, older individuals in their 60s and 70s report
lower levels of negative emotions and higher levels of satisfaction compared
with individuals in their 20s and 30s (Charles, Reynolds & Gatz, 2001).
Mather et al. (2004) found that with advanced age there is a decrease in the
activity of the amygdala in response to negative information, while response
to positive information is maintained or increased. As such, neuroanatom-
ical changes may be responsible for the lower levels of negative emotions
found in prior research.
Summary
The aging process has historically been viewed as a state of continual decline
and deficit. Although changes in brain physiology and cognition occur as
a part of the aging process, changes do not necessarily denote a disease
process. Not all older adults will develop degenerative disorders such as
AD despite an increase in risk because of advancing age. In fact, neuroan-
atomical changes may have a positive effect on emotion in old age, as has
been shown by a lack of activity in the amygdala when exposed to negative
information. Factors such as social isolation, sensory deprivation and physi-
cal maladies are real and present among older adults. However, the presence
of these factors alone does not prevent an older adult from experiencing
meaningful social relationships and positive emotions.
Normal Aging17
18
19
3
■■■
Factors Affecting Clinical Interaction and Performance
Practitioners who work with the geriatric patients must consider a variety of
circumstances affecting delivery of care and services specific to this popu-
lation, such as changes in physiology, the effects of having multiple medical
conditions and medications, and pain and fatigue. Given the increasingly
diverse ethnic population of the United States, clinicians must also be pre-
pared to treat and intervene with individuals from different cultures. This
chapter addresses some common factors that may affect older adult patient
interactions and performance.
Vision
Individuals older than 60 years are at risk for numerous changes to vision,
including presbyopia, decreased contrast sensitivity, decreased dark/light
adaptation and delayed glare recovery. The four most prevalent age-related
ocular diseases are macular degeneration, glaucoma, cataracts and diabe-
tic retinopathy (Carter, 1994). Declines in vision have been shown to have
statistically significant negative effects on both instrumental activities of
daily living (IADLs) (e.g., driving, managing money and preparing meals),
activities of daily living (ADLs) (e.g., feeding and dressing), and increases
the probability of nursing home placement (Sloan, Ostermann, Brown, &
Lee, 2005). Impairments in visual acuity and contrast sensitivity have been
linked to difficulties with reading, dialing a telephone and ascending and
descending stairs (West et al., 2002). Reduced vision affects the validity
19
20
of cognitive screening and neuropsychological evaluation and potentially

reduces the efficacy of certain therapies (physical, occupational and speech).
A pocket eye chart is a helpful tool to identify individuals who may have
difficulty perceiving print and other visual stimuli. Interpretations of test
data must consider the presence and magnitude of any visual deficits. For
instance, poor visual acuity or search may negatively impact performance
on nonverbal memory tasks or naming tasks, necessitating the evaluation
of verbal memory or tactile naming. In addition to careful selection and
interpretation of tests considering known or suspected deficits, alternative
stimuli (e.g., enlarged pictures or print) may be used.
Hearing
Hearing loss is one of the most common sensory deficits affecting older
adults. Hearing loss affects approximately one-third of adults aged 61 to
70 years, and more than 80% of those older than 85 years (Walling &
Dickson, 2012). Men usually experience greater hearing loss and have ear-
lier onset compared with women. Age-related hearing loss, termed presbycu-
sis, is common among older adults. Other losses in hearing can occur from
less efficient transmission of sound through the eardrum and ossicles in the
middle ear (conductive hearing loss). Changes in the cochlea in the inner
ear, including loss of hair cells in the high-frequency region of the basilar
membrane, causes a loss of acuity for high-frequency sounds (sensorineu-
ral hearing loss), adversely affecting speech perception (Wingfield, Tun &
McCoy, 2005). Wingfield et al. (2005) suggested that aging produces deficits
in central auditory processing including the ability to detect and maintain
the ordering of rapidly arriving sounds, as well as the ability to isolate and
discriminate the frequency components of complex signals, both of which
as important for speech perception.
Hearing loss has been associated with increased cognitive impairment
in both demented and nondemented individuals (Uhlmann, Larson, Rees,
Koepsell & Duckert 1989). Individuals with moderate to severe hearing loss
reported greater difficulties in ADLs and IADLs, including shopping for per-
sonal items, taking care of personal finances, preparing meals and talking on
the telephone (Dalton et al., 2003). Poor hearing can affect a person’s ability
to converse, understand and follow instructions, and respond to telephone
calls, doorbells, and alarms. A study of women 69 years and older found that
vision and hearing loss combined resulted in greater cognitive and func-
tional impairments than either deficit individually (Lin et al., 2004).

21
Reduced auditory acuity and processing of auditory information have a

direct impact on the validity of cognitive screening, neuropsychological test
data and the ability of an older adult to follow directions in a therapeutic or
medical setting. Given the reduced ability to process information presented
rapidly, clinicians should speak slowly and clearly while making eye con-
tact. Some measures, such as the word list from the Consortium to Establish
a Registry for Alzheimer’s Disease (CERAD), battery allow the individual to
read the items to be recalled (Morris et al., 1993). Allowing individuals to
repeat items as they are being read, a technique known as “shadowing,” can
also help the clinician verify that information is being perceived correctly.
It is not uncommon for an individual with hearing loss to attend appoint-
ments without aids or with inadequate aids for communication, and remind-
ers to bring aids in preappointment letters or preappointment reminder calls
can be useful. Clinicians who work with older adults may invest in an audio-
amplified listening device or “pocket talker” and a set of headphones (avail-
able at most electronics stores and online retailers). These devices are used
in place of hearing aids and are very effective in improving auditory acuity.
Motor Functions
Changes in motor functions associated with age include slowed and variable
reaction time, impaired and imprecise reach and decreased postural stabil-
ity (Adamo, Martin & Brown, 2007). Conditions such as stroke, periph-
eral neuropathy and arthritis are common among older adults and result
in declines in motor dexterity and speed of motor performance. Motoric
decline will adversely affect the performance of older adults on cognitive or
functional tasks that depend on intact manual dexterity or hand strength,
such as measures requiring facile use of a pencil. Here, as with vision and
hearing, the selection of tasks and review of test data should involve careful
consideration of any primary deficits that could affect diagnostic interpreta-
tions, as well as appreciation of functional deficits that may be related.
Medical Conditions and Medications

Psychologists and neuropsychologists, in particular, need to be aware that
medical conditions and the medications used to treat those conditions
may adversely affect results of cognitive testing. Cardiovascular disease
(including atrial fibrillation hypertension, congestive heart failure), chronic
obstructive pulmonary disease, dementia, diabetes, eye diseases (cataracts,
glaucoma, macular degeneration), osteoarthritis and thyroid disorder are
Factors Affecting Clinical Interaction and Performance21

2
among the more common conditions encountered in older adults. It is essen-

tial that neuropsychologists remain abreast of the impact of such conditions
and their treatment on cognition.
The use of multiple medications, or the lack of use (i.e., forgetting to take
medications), may also compromise cognition, even in nondemented older
adults. As noted in Chapter 4, it is imperative for the clinician to have a
complete list of prescription and over-the-counter medications used by the
older adult. Houston and Bondi (2006) provide an excellent review of the
impact of medications on cognition in older adults. Use of older tricyclic
antidepressants, such as amitriptyline, has numerous cognitive side effects,
such as slowed reaction time, slowed information processing, decreased
attention and lowered verbal recall (Houston & Bondi, 2006). Sedatives and
hypnotics, such as opioid pain medications and the benzodiazepines used to
treat anxiety, can cause drowsiness and sedation. The first-generation anti-
convulsant medications, such as phenobarbital, valproate, phenytoin, car-
bamazepine and primidone, tend to have a greater side-effect profile, with
phenobarbital causing the most cognitive side effects. Sedating antihista-
mines, such as diphenhydramine, a common drug used in nonprescription
sleep aids, have been shown to be associated with impairments in atten-
tion, reaction time, vigilance, and short-term memory (Katz et al., 1998, Kay
et al., 1997), while newer antihistamines (loratadine, astemizole) cause less
sedation and cognitive side effects (Kay et al., 1997).
Sleep
Sleep disturbances and complaints of daytime sleepiness are common in
older adults and have been associated with decreases in quality of life,
poor daytime mental performance and decreased motor functions and
have been a predictor of nursing home placement (Stepanski, Rybarczyk,
Lopez, & Stevens, 2003). Sleep disorders in the older adult generally con-
sist of either difficulty in falling asleep or in staying asleep (i.e., insom-
nia) or excessive daytime sleepiness. A variety of medical conditions that
occur more often in older adults have been identified as precipitants to
sleep disorders, including pain, depression, medication effects, cardio-
pulmonary disorders such as chronic obstructive pulmonary disease
(COPD) and congestive heart failure (CHF), and neurodegenerative disor-
ders such as Alzheimer’s disease (AD) and Parkinson’s disease. Primary
sleep disorders in older adults include obstructive sleep apnea (OSA),

23
restless leg syndrome (RLS), periodic limb movement disorder (PLMD)

and rapid-eye-movement (REM) behavior disorder. As noted previously,
over-t he-counter sleep aids that contain antihistamines, such as diphen-
hydramine, have been shown to have an adverse impact on cognition, and
use of such agents for sleep should be discouraged. Referral to a physician
or health or rehabilitation psychologist is recommended for remediation
of sleep disorders.
Pain
Pain is common in the older adult population, with studies finding that 25%
to 50% of community-dwelling older adults experience significant pain at
least some of the time (American Geriatrics Society Panel on Chronic Pain
in Older Persons, 1998). Pain is more prevalent in nursing home popula-
tions, with estimates ranging from 49% to 83% (Fox, Raina & Jadad, 1999).
Older adults are more likely than younger adults to have multiple pain sites
(Andersson, Ejlertsson, Leden & Rosenberg, 1993), the most common of
which is musculoskeletal pain in the lower back, shoulder, upper arm, hand
or wrist and neck (Andersson et al., 1993; Khana, Khana, Namazi, Kercher
& Stange, 1997). Pain is associated with sleep disturbance, depression,
impaired physical functioning, and increased health care and utilization
costs and increases the likelihood of disability in the older adult (Yonan &
Wegener, 2003).
Neuropsychological impairments associated with chronic pain include
declines in attentional capacity, processing speed and psychomotor speed
(Hart, Martelli, & Zasler, 2000). Although some studies relate cognitive
changes to pain intensity, other studies suggest that concomitant factors
associated with pain, such as mood change, increased somatic awareness,
sleep disturbance and fatigue, may adversely affect testing as well.
Understanding pain intensity, impact on daily life, and factors that
ameliorate or intensify pain (e.g., sitting for long period of time) is
important for the clinician. While there are numerous methods used to
assess pain, studies of older adults have indicated that verbal descriptor
scales are preferred by elders because these are easy to use and accurate
in describing the pain (Herr & Mobily, 1993). Verbal descriptor scales
offer individuals labels such as no pain, slight pain, mild pain, moderate
pain, severe pain, extreme pain and pain as bad as it could be. Individuals
experiencing high levels of pain (moderate and above) may require more

24
frequent breaks, shorter testing and treatment sessions, appointments at a

different time of day, or they may need to have the appointment resched-
uled to maximize test validity.
Fatigue
Older adults may be at higher risk for test fatigue because of numerous
factors, including medications effects and impact of medical illnesses. Test
batteries for older adults should be driven by the referral question and
may be somewhat more focused so as to answer the question in a briefer
period of time. Breaks of 5 to 10 minutes can and should be orchestrated
into the evaluation. Several studies have suggested that older adults per-
form better on effortful cognitive tasks in the morning than in the after-
noon (Anderson, Campbell, Amer, Grady & Hasher, 2014; Hasher, Chung,
May & Foong, 2002; May, Hasher & Stolzfus, 1993). Anderson et al. dem-
onstrated that older adults were less able to filter out distractions in the
afternoon (1:00–5:00 p.m.) than in the morning hours. Thus, testing and
therapy may be more valid and effective when conducted in the morning.
Bereavement
As discussed in Chapter 7, the impact of bereavement on an older adult is
multifactorial and involves considering the presence of preexisting condi-
tions, such as depression. Scant research has been conducted on the topic
of the impact of bereavement on cognition, and conflicting findings exist
for the studies conducted. In a study of octogenarians, Xavier et al. (2002)
found that nondepressed, recently bereaved older adults performed lower
on measures of cognitive screening (Mini– Mental State Examination
[MMSE]), digit repetition and memory than did nonbereaved subjects
(Xavier, Ferraz, Trentini, Freitas & Moriguchi, 2002). Ward and cowork-
ers (2007) also studied a sample of bereaved versus nonbereaved subjects
and found that depression was related to slower information-processing
speed, anxiety was related to lower levels of attention, and stress was
related to attention and verbal fluency. The only difference between griev-
ing and nongrieving older adults, after controlling for mood, anxiety, and
stress, was the ability to switch attention between competing tasks (Ward,
Mathias, & Hitchings, 2007).
We suggest that the decision to test or not test an older adult who has
recently lost a loved one or spouse requires the consideration of several

25
factors, such as safety (e.g., Can the older adult live alone, reliably take medi-
cations, and remember to turn off the stove?) and the availability of clearly
identified support system to supervise and assist in day-to-day activities.
Literacy and Education

Studies of literacy indicate that 33% of adults 65 years and older tested
below average (Kirsch, Jungeblut, Jenkins & Kolstad, 2002). Results were
related in part to lower levels of education. Neuropsychologists practicing
with older adults must be aware of how literacy and education levels affect
interpretation of tests (Manly et al., 1999; Manly, Jacobs, Touradji, Small &
Stern, 2002). Low levels of literacy can adversely affect cognitive evaluations
from simple screening tools to more complex neuropsychological evalu-
ations, given the need to read instructions or provide written responses.
Older adults may be reluctant to admit to deficits in literacy. Simple meas
ures, such as the reading section of the Wide Range Achievement Test-4
(WRAT4) (Wilkinson & Robertson, 2012), can be used to assess reading
level and has norms for individuals up to 94 years of age.
Cultural Differences
According to the 2010 US Census, by 2050 the older population is pro-
jected to substantially increase in racial and ethnic diversity. The propor-
tion of the population older than 65 years is expected to be 77% white
alone, 20% Hispanic,1 12% black, and 9% Asian. As pointed out by Manly
(2006), there is a lack of scientific evidence and clear guidelines on how
best to assess and treat older adults from diverse ethnic backgrounds.
Briefly, clinicians need to be aware that issues that may seem clear-c ut,
such as years of education, can be particularly challenging when working
with older adults who come from minority groups, as defined by race, lan-
guage or ethnicity. Quality of education, literacy level, years of education
and acculturation level are all factors that need to be taken into consider-
ation when evaluating test results, including results of cognitive screen-
ing. Clinicians must be careful, for example, not to assume that testing an
individual born and raised in Mexico who has lived in the United States
for 20 years is the same as testing a Hispanic person who was born and
educated in the United States. Use of appropriate instruments for assess-
ment of nonwhite older adults is a key issue given that many tests, includ-
ing both screening tests and neuropsychological measures, have not been

26
validated in a wide variety of non–English-speaking populations, with

the exception of measures in Spanish. As noted by Manly (2006), the fact
that a test is administered in the native language of an individual does not
mean the test is valid or reliable for that population. We caution against
the attitude that a translated but unvalidated test is better than no test,
given that the test results will not be valid and could potentially lead to
misdiagnosis. It is important when using screening and testing measures
to find out if the test has been merely translated into the language or has
been validated (i.e., given to actual persons in that particular ethnic group
to create normative standards).
Summary
Numerous noncognitive factors can adversely affect the cognitive and func-
tional abilities of an older adult, as well as the assessment of abilities, and
can potentially result in erroneous conclusions regarding cognitive func-
tions. Practitioners must consider a variety of factors that can affect the eval-
uation of an older adult, including loss of hearing and vision, adverse impact
of medical conditions or multiple medications, pain, fatigue, literacy and
education and cultural differences.

27
4
■■■
The Clinical Interview
The initial clinical encounter with an older adult is the most common set-
ting in which essential medical, psychological, and social history will be
gathered. This information is the indispensible context within which objec-
tive cognitive and subjective rating scales will be considered to yield diag-
nostic and treatment recommendations. The importance of creating an
atmosphere that facilitates the acquisition of needed history should not be
underestimated. Of course, the method of gathering and source of history
will vary somewhat depending on the clinician and the reason for referral.
For instance, referral for neuropsychological evaluation will focus on issues
that differ from an evaluation for occupational therapy or physical therapy;
high-functioning patients may provide their own history, whereas patients
with significant cognitive compromise will often be accompanied by a
family informant to relate health and symptom history. As stated in other
chapters, dementia is common in older adults, but not universal. Guidelines
set by the American Psychological Association (2012) for the evaluation of
dementia and age-related cognitive changes provide excellent suggestions to
follow when interviewing an older adult, regardless of the condition being
evaluated. This chapter also provides a general outline of content to cover
in an initial interview, as well as suggestions related to initial encounter
interactions.
27
28
The Clinical Interview

Establishing rapport begins with demonstrating respect for the patient. This
is easily done by addressing the patient directly and first. Permission can
be obtained to gather information from other sources, including informant
perspectives (Blazer, 2004).
Asking patients to tell the clinician their understanding of why they have
been referred is one means of opening the clinical interview. Individuals
with cognitive compromise may have anosognosia, or lack of awareness of
deficits. This is rarely complete because patients are often aware of some
change in their cognition. Assessing the patient’s awareness of the degree
of compromise and impact on functioning can give insight into the patient’s
accuracy in awareness. Diminished accuracy is rarely psychologically moti-
vated; rather, it is often a neurologically based change in accurate monitor-
ing. Thus, interviewing a qualified informant (i.e., someone who has regular
contact with that individual) is important in cases in which dementia is
suspected.
The first part of the clinical interview should begin with the person pre-
senting for treatment or evaluation clearly being the focus of examination.
This is easily established through direct eye contact and questioning of the
patient. Whether to interview the older adult and family members together
or separately is a matter of preference of the older adult and/or clinician. The
interview can be prefaced by stating, “I am going to ask you some questions
about your mood, thinking, and health, and I would like to ask your fam-
ily the same questions. Would you prefer to be in the room while I gather
information from your family?” It is recommended that the clinician preface
the family interview with statements such as, “you may not agree with your
daughter’s viewpoint, but it is important that I gather all the information
necessary to help you,” and reminding the individual, “your son is not try-
ing to be hurtful, we just want to gather as much information as possible,”
or “it is quite unusual for family members to agree on all matters; usually if
I ask three family members to give me a rating on someone’s memory I get
three different ratings!” as one means of maintaining rapport. The clinician
should recognize that all family members may not feel comfortable talking
about their relative’s symptoms in front of them. In these cases, a clinician
might state, “sometimes members of a person’s family feel more comfortable
providing information without that person in the room. Would you be will-
ing to sit in the waiting area while I speak with your family?” Most patients

29
Box 4.1 Recommended Questions
Can you tell me how your memory has been?

Have you noticed a change in your ability to:
Remember conversations?
Remember to pay bills?
Remember to take medications?
Do you:
Misplace objects more frequently?
Repeat yourself?
Forget appointments or social events?
Forget to turn off the burners on the stove?
Have difficulty finding words when speaking?
Have trouble following conversations or understanding what
others are saying?
Get lost while driving?
Have difficulty multitasking?
Have any trouble with problem solving or reasoning through
matters?
Feel sad, hopeless, or depressed?
Feel you more irritable or emotional than you used to be?
will agree, but if they don’t the wishes of the patient should be respected.
Questions in Boxes 4.1 to 4.3 should be asked of any collateral source, if
available.
Presenting Symptoms
Questions should be asked about the symptoms for which the individual
is presenting, the date and character of onset (gradual versus sudden), and
their course over time (getting better, getting worse). Questions listed in
Box 4.1 should be asked of the individual presenting for treatment and the
informant with regard to the individual.
The Clinical Interview29

30
Box 4.2 Behavioral Issues to Review
Is the person:
More withdrawn?
Less likely to initiate activity?
Less interested in participating in activity?
More socially inappropriate (saying or doing things that are
outside of social norms)?
More disinhibited (saying things without first censoring what
they were going to say)?
Showing a lack of judgment (participating in lottery schemes
in which they are promised a big check if they send money
to “pay the taxes”)?
During the clinical interview, it is important to make observations

regarding language output. An individual with “empty” speech might have
the logopenia (difficulties with word finding) that accompanies Alzheimer’s
disease or may have a progressive fluent aphasia. Such observations will
inform not only the focus of the interview but also the types of referrals
that might be made. Changes in behavior should also be explored with the
individual as well as the family. Suggested issues to be addressed are listed
in Box 4.2.
Instrumental/Activities of Daily Living

Individuals should be asked about their ability to perform instrumental
activities of daily living (IADLs) and activities of daily living (ADLs). IADLs
include those “managerial” abilities listed in Box 4.3 that allow individuals
to maintain independence. Gathering information about IADLs allows the
clinician to determine the impact of cognitive impairment on routine activ-
ities in everyday life.
ADLs include the ability to shower, brush teeth, dress, and feed and toilet
oneself. While several scales exist to document IADLs and ADLs, most focus
on self-report or informant report. Individuals with dementia are not always
reliable historians when reporting abilities, and family members who do not
observe the person engaging in IADLs may not provide adequate history.

31
Box 4.3 Instrumental Activities of Daily Living
Cooking Ability to follow a recipe, keep track of

item while it is cooking
Paying bills Ability to write the correct amount on the
check, put it in the envelope, and mail it
Managing Ability to correctly add and subtract or
checkbook use a computer program to manage
checkbook.
Driving/using Ability to follow the rules of the road and
transportation navigate, use a bus or rail system, map
out the best route and follow the time
table
Shopping Ability to shop for items without assistance
Doing laundry Ability to run the washing machine and
dryer, follow the steps to load both
machines
Managing Ability to devise a method to remember to
medication take medications without reminder
(e.g., using a medication box or other
organized method)
Using the telephone Ability to find and dial a phone number,
take messages off a machine
The evaluation of IADLs and ADLs are either questionnaire- based

measures filled out by a family member or performance-based measures,
in which individuals are observed to enact the IADL (e.g., balancing a
checkbook or filling in a medication box). Performance-based measures
are generally conducted by an occupational therapist and can help to pro-
vide accurate information regarding the ability to perform IADLs in cases
in which reliable report cannot be obtained. However, performance-based
measures do not necessarily represent the best standard for assessing IADLs
(Strauss, Sherman & Spreen, 2006). Performance-based measures have been
The Clinical Interview31

32
criticized for (1) removing an individual from a chosen routine, (2) removing
environmental cues that facilitate the IADL, (3) representing only a single
evaluation data point compared with the multiple data points addressed in
questionnaire formats, and (4) being time-intensive and cost-prohibitive for
most clinical assessments performed by psychologists (Gold, 2012). Moore
et al. provide a review of the literature on performance-based IADLs (Moore,
Palmer, Patterson & Jeste, 2007).
The association between the cognitive abilities and questionnaire-based
assessment of functional abilities has been addressed in the literature. Gold
(2012) conducted a thorough review of the literature on the questionnaire-
based assessment of IADLs and concluded that individuals with multiple-
domain mild cognitive impairment (MCI) were more impaired on IADLs
than those with single-domain MCI and that declines in IADLs were predic-
tive of future cognitive decline. Ability to manage finances was among the
earliest IADL changes noted in MCI and was a strong predictor of conversion
from MCI to dementia.
Social History and Stressors

Social history is essential to appreciating the educational and cultural
background factors that might affect treatment or evaluation. If the indi-
vidual speaks English, but was not born and raised in the United States,
it is important to understand the age at which the person began speaking
English as well as the preferred spoken language in the current living situ-
ation. Understanding the individual’s present living situation (e.g., living
with spouse, living with children) can help to inform the professional of
potential support resources available for the patient. Years of formal educa-
tion should be obtained, as well as any history tutoring, special education,
diagnosis of learning disability or having repeated a grade. Occupational
history, including timing and circumstances of retirement if appropriate,
should be considered.
It is important to understand if current or ongoing stressors have precip-
itated the condition for which the individual is being evaluated. Stressors
may be recent, such as the death of a spouse or child, or ongoing, such as a
chronic medical condition. Older adults are working later in life, and loss of
a job may also be a significant stressor. Blazer (2004) stated that clinicians
must be prepared to evaluate the family in terms of the functionality of
the family and as a potential resource for the older adult. Family members
and dynamics can also be sources of stress. Blazer (2004) suggested that a

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She drew Freda, who was shivering now, over on the couch, then turned
to Gregory.
“Good night, Gregory—again. You bring adventure with you.”
There was a smile in her eyes which he seemed to answer by a look in
his own. Then he looked past her to Freda.
“Good night, little wanderer. I’ll see you to-morrow.”
Freda saw him fully now. He was tall and thin and ugly. His dark eyes
seemed to flash from caverns above his high cheekbones. But he had a wide
Irish mouth and it smiled very tenderly at them both as he softly went out.
Freda would not take Margaret’s little couch bed for herself so Margaret
had to improvise a bed on the floor for her guest, a bed of blankets and
coats and Freda slept in Margaret’s warm bath robe. Oddly, she slept far
better than did Margaret, who, for a long while, held herself stiffly on one
side that her turning might not disturb Freda.
II
They both wakened early. Freda found the taste of stale adventure in her
mind a little flat and disagreeable. There were a number of things to be
done. Margaret telephoned briefly to the Brownley house, left word with a
servant that Miss Thorstad had spent the night with her.
“I’ll go up there after we have some breakfast,” she said to Freda, “and
get you some clothes. Then I think you’d better stay here with me. I’ll ask
the landlady to put an extra cot in here and we can be comfortable for a few
days. And please don’t talk of inconvenience”—she forestalled Freda’s
objections with her smile—“I’ll love to have company. If you stay in town
we’ll see if you can’t get a place of your own in the building here. Lots of
apartments have a vacant room to let.”
She was preparing breakfast with Freda’s help and the younger girl’s
spirits were rising steadily even though the thought of an interview with
Barbara remained dragging. It was great fun for Freda—the freedom of this
tiny apartment with its bed already made into a daytime couch, the eggs
cooking over a little electric grill on the table and the table set with a scanty
supply of dishes—two tall glasses of milk, rolls and marmalade.
“It’s so nice, living like this,” she exclaimed.
Margaret laughed.
“Then the Brownley luxury hasn’t quite seduced you?”
“I was excited by it. I’m afraid it did seduce me temporarily. But for the
last week something’s been wrong with me. And this was it. I wanted to get
out of the machinery. They leave you alone and all that—but it’s so ordered
—so planned. Everything’s planned from the menus to the social life. They
try to do novel things by standing on their heads sometimes in their own
grooves—at least the girls do—but really they get no freshness or freedom,
do they?”
“I should say that particular crowd didn’t. Of course you mustn’t
confound all wealthy people with them. They’re better than some but a
great deal less interesting than the best of the wealthy. And of course just
because their life doesn’t happen to appeal to your temperament—or mine
—”
“Are you always so perfectly balanced?” asked Freda, so admiringly as
to escape impertinence.
“I wish I were ever balanced,” answered Margaret. “And now suppose
you tell me a little more about what happened so I’ll be sure how I had
better take things up with the Brownley girls.”
Freda had been thinking.
“It really began with me,” she said. “Ted Smillie was Barbara’s man and
I was flattered when he noticed me. And of course I liked him—then—so I
let it go on and she hated me for that.”
“Stop me if I pry—but do you care for the young man now?”
“Oh—no!” cried Freda. “I’m just mortally ashamed of myself for letting
myself in as much as I did.”
“Everybody does.”
Margaret’s remark brought other ideas into Freda’s mind. She
remembered Gregory Macmillan and his apparent intimacy with Margaret.
But she asked nothing, going on, under Margaret’s questioning, with her
tale of the night before, and as they came to the part of Gregory’s
intervention, Margaret vouchsafed no information.
An hour later, she came back from the Brownley house, with Freda’s
suitcase beside her in a taxi.
“You did give them a bad night,” she said to Freda, “Bob Brownley
looks a wreck. It appears that later they went out to search the park—scared
stiff for you. And you had gone. They saw some men and were terrified.”
“Are they very angry?”
“Barbara tried to stay on her high horse. Said that although it was
possible she had misunderstood the situation it looked very compromising
and she thought it her duty in her mother’s absence—. Of course, she said,
she was sorry that matters had developed as they had. Poor Allie’d
evidently been thinking you’d been sewed up in a bag and dropped in the
river. They both want to let the thing drop quickly and I said they could say
that you were staying with me for the remainder of your visit. I also told
Barbara a few home truths about herself, and advised her to be very careful
what she said to her mother or I might take it up with her parents.”
“All this trouble for me!” cried Freda. “I am ashamed!”
“Nonsense. But I must go along quickly now. I’ve a meeting. Your trunk
will be along sometime this morning. Put it wherever you like and the
landlady will send the janitor up with a cot. And—by the way—if Gregory
Macmillan drops in, tell him I’m engaged for lunch, will you? You might
have lunch with him, if you don’t mind.”
“I feel aghast at meeting him.”
“Don’t let any lack of conventions bother you with Gregory. The lack of
them is the best recommendation in his eyes. He’s a wild Irish poet. I’ll tell
you about him to-night. I think you’ll like him, Freda. He’s the kindest
person I know—and as truthful as his imagination will let him be.”
“What is he in St. Pierre for?”
“Oh, ask him—” said Margaret, departing.
CHAPTER IX
WORK FOR FREDA
I T was on that morning that Gage Flandon made his last appeal to his wife
not to let herself be named as a candidate for Chicago at the State
Convention. He had been somewhat grim since the district convention.
As Margaret had realized would happen, certain men had approached him,
thinking to please him by sounding the rumor about sending his wife to the
National Convention. Many of them felt and Gage knew they felt that he
had started, or arranged to have started, a rumor that his wife would be a
candidate and that he meant to capitalize the entrance of women into
politics by placing his own wife at the head of the woman’s group in the
State. It was a natural enough conclusion and its very naturalness made
Gage burn with a slow, violent anger that was becoming an obsession. It
began of course with the revolt against that suspicion of baseness that he
could capitalize the position of his wife—that he could use a relation, which
was to him so sacred, to strengthen his own position. Yet, when these men
came with their flattery he could not cry down Helen without seeming to
insult her. There was only one way, he saw, and that was for Helen herself
to withdraw. If she did not, it was clear that she would be sent.
So he had besought and seemed to always beseech her with the wrong
arguments. He knew he had said trite things, things about women staying
out of politics, the unsuitability of her nature for such things, but he had felt
their triteness infused with such painful conviction in his own mind that it
continually amazed him to see how little response he awoke in her.
She had said to him, “You exaggerate it so, Gage. Why make such a
mountain out of a molehole? I’m not going to neglect you or the children.
I’ll probably not be elected anyhow. But why not regard it as a privilege and
an honor and let me try?”
“But why do you want to try?”
She looked as if she too were trying vainly to make him understand.
“I’d like to do something myself, Gage—something as myself.”
“You were content without politics two months ago.”
“I’ve changed—why begrudge me my enthusiasm?”
“Because I can’t bear to see you a waster like the rest of the women.
Because you’re so different. Everything about you is true and sound, dear,
and when you start deliberately using yourself for political effect, don’t you
see how you become untrue? There’s nothing in it, I tell you. The whole
thing’s cut and dried. There’s no big issue. If the women want to send some
one, let them choose some other figurehead!”
He had not meant it so but of course he seemed disparaging her.
“Perhaps,” she said rather frigidly, “perhaps I’ll not be such a figurehead
as you think.”
“But I didn’t mean to say that to hurt you.”
“I’m not sure what you do mean. It seems to me we’re actually childish.
You’ve chosen, quite deliberately, to be a reactionary in all this woman’s
progress movement. I’m sorry. But there is a loyalty one has to women,
Gage, beside the loyalty one has to a husband and I really cannot share your
prejudice against progress, as it applies to women.”
The unexpressed things in Gage’s mind fairly tore at him.
“If you really had one sensible objection, Gage—”
“There’s just one objection,” he said, doggedly, “you desecrate yourself.
Not by entering politics particularly. But by using yourself that way. You
mutilate your sex.”
She did not get angry. But she put one hand on his shoulder and they
looked at each other helplessly.
“Don’t you see,” said Helen, “that I want, like these other women, to
once in a while do something that’s clean of sex? That’s just me—without
sex?”
His eyes grew very hard. She struck almost mortally at the very thing he
loved most. And he moved away, as if to remove himself definitely.
“I’m sorry you feel so. It’s a pleasant remark for a man’s wife to fling at
him.”
Irony was so unusual in Gage that Helen stood looking after him after he
went out of the room. Her mind ached with the struggle, ached from the
assertion of this new determination of hers. Never had she wanted so to
give him comfort and be comforted herself. She saw the weeks ahead—
weeks of estrangement—possibly a permanent estrangement. Yet she knew
she would go on. It wasn’t just wanting to go on. She had to go on. There
was a principle involved even if he could not see it. Clearer and clearer she
had seen her necessity in these past two weeks. She had to waken her own
individuality. She had to live to herself alone for a little. She had to begin to
build defences against sex.
Gage was right. Margaret had sown the seed in his wife. Helen had not
watched her for nothing. She had seen the way that Margaret made no
concessions to herself as a woman, fiercely as she was working for the
establishment of woman’s position. It seemed paradoxical but there it was.
If you were truly to work for woman’s welfare you had to abandon all the
cushions of woman’s protected position, thought Helen—you couldn’t rest
back on either wifehood or motherhood. You couldn’t be lazy. You had to
make yourself fully yourself.
Here was her chance. She hadn’t wanted it but they had insisted. The
women wanted her to go to Chicago—not because she was Mrs. Flandon
but because she was Helen Flandon, herself. A little quiver of delight ran
through Helen as she thought of it. She would see it through. Gage would
surely not persist in his feeling. Surely he would change. He would be glad
when she proved more than just his wife.
She had a strange feeling of having doffed all the years which had
passed since she had left college, a feeling of youth and energy which had
often dominated her then but which had changed in the seven years of her
marriage. Since her marriage she had walked only with Gage and the
children—shared life with them very completely. Now it was not that she
cared less for them (she kept making that very clear to herself) but there
was none the less a new independence and new vigor about her. She felt
with them but she felt without them too.
It hurt her that Gage should feel so injured. But her exhilaration was
greater even than the hurt, because she could not sound the depths of her
husband’s suffering.
Gage went out of the house with no more words. He managed to focus
his mind on the work of the day which was before him but the basic feeling
of pain and anger persisted.
In the middle of the morning Helen called him, reminding him of his
promise to see if Freda Thorstad could be placed. She ignored, as she had a
way of doing, any difference between them.
“Are you going to drag that child in too?” he asked, ungraciously, and
then conscious of his unfairness for he knew quite well that the object was
to place Freda so she could earn her own living, he capitulated.
“Drummond gets back this afternoon. Send Miss Thorstad in about four
and I’ll take her to see him.”
“You’re a dear, Gage,” Helen rang off.
Gage tried to figure out whether something had been put over him or
not. There he let it go and sat in at the club with a chosen crowd before
lunch. It pleased him immensely to see Harry Harris stuck for the lunch. He
kidded him, his great laugh rising and falling.
II
At four Freda came and at her, “You’re sure I’m not too early, Mr.
Flandon?” Gage felt further ashamed of his ungraciousness. Freda was a
little pale, after her difficult night, and it made her rather more attractive
than ever to Gage. He thought she might be worrying over the chance of
getting the new work and was eager to make it easy for her.
“So you want to get into politics like all the rest?” he asked, but
smilingly.
“I want some work to do,” said Freda, “I’d just as soon do anything else.
But I really will have to work or go back to Mohawk and there isn’t
anything for me to do in Mohawk. I don’t much care what I do, to tell you
the truth, Mr. Flandon, so it is work. And I’ve a theory that I might be better
at washing windows than doing anything else.”
“This isn’t much of a job, you know.”
“Probably it’s all I could handle. I’m really a little nervous. Will they ask
for all kinds of qualifications?”
“There’s no ‘they’ There’s only one man and I think all he is looking for
is some one who is discreet and pleasant and can do ordinary secretarial
work.”
“I’m going to learn typewriting evenings,” said Freda.
It was so pleasant to be free from controversial conversation, or from
conversation which glossed over controversy that Gage found himself
feeling much warmer and more cheerful than he had for days. Together they
walked over to the office of the man who had the district chairmanship. Mr.
Drummond was embarrassed. Clearly he was embarrassed by the necessity
of refusing a favor Flandon asked. But he was put to it.
They left the office and at the street corner Freda stopped and held out
her hand.
“Pretty lucky for them that young Whitelaw got there first, I fancy.”
“Have you something else in mind?”
“I’ll try to find something. Maybe I can get a place as somebody’s
companion. Or maybe Miss Duffield will know—”
A tight little line came around Gage’s mouth. He didn’t want Margaret
Duffield running this girl. His dislike was becoming an obsession.
“I wonder,” he said slowly, “if you’d like to come into my office. I could
use another clerk, as a matter of fact. I’m away a great deal and I find that
since my assistant has been handling more law work he is too busy to do
things around the office—handling clients, sorting correspondence and such
things. The ordinary stenographer just messes up everything except a sheet
of carbon paper, and the last good one I had got married, of course. There
wouldn’t be much in it—maybe sixty a month, say—but if you’d like to try
—”
Freda looked at him straightly.
“If you’re just trying to find a job for me, I’d rather not, Mr. Flandon.”
He liked that, and gave her back honesty.
“Of course I would like to see you fixed. I thought this other thing would
work out better. But in all seriousness I could use another clerk in my office
and I’ve been wondering whom I could get. What do you say to trying it for
a month—”
“Let me try it for two weeks and then if I fail, fire me then. Only you’ll
surely fire me if I don’t earn my money?”
“Surely.”
III
Gage went home that night more cheerful than he had been for some
time. He had a mischievous sensation of having rescued a brand from
Margaret Duffield. At dinner Helen asked him if he had attended to Freda’s
case.
“Drummond had other arrangements already.”
“What a shame,” she said, “I wonder where we can place that girl. She is
too good to go back and do nothing in Mohawk. And she really wants to
earn money badly.”
“I placed her,” said Gage, hugging his mischief to himself.
“You did? Where?”
“I took her into my office.”
Helen looked at him in surprise.
“You know that she can’t typewrite?”
“I know. But I can use her. She has a good head and—a nice influence. I
think I’ll like to have her around. Since she has to work she’d be better
there than grubbing in politics.”
“As if your office wasn’t full of politics!”
“Well they’re not Duffield-politics.”
“Whatever you mean by that is obscure,” said Helen, “but don’t eat the
child’s head off, will you?”
CHAPTER X
THE CLEAN WIND
F REDA felt that night that all her dreams, all her vague anticipations of
doing were suddenly translated into activity and reality. In the strangest
way in the world, it seemed to her, so naïve was she about the obscure
ways of most things, she had a room of her own and a job in St. Pierre.
Margaret Duffield had smiled a little at the news of her job but at Freda’s
quick challenge as to whether she were really imposing on Mr. Flandon,
Margaret insisted that she merely found Gage himself humorous. She did
not say why that was so. Together she and Freda went to see the landlady
about a room for Freda. There was one, it appeared, in an apartment on the
third floor. Freda could have it, if she took it at once, and so it was
arranged.
It was a plain little room with one window, long and thin like the shape
of the room, furnished sparsely and without grace, but Freda stood in the
midst of it with her head high and a look of wondering delight in her eyes,
fingering her door key.
Later she went down to Margaret’s apartment to carry up her suitcase.
She found Gregory there. He had not come for lunch as Margaret had
warned her. Seeing him now more clearly than she had the night before,
Freda saw how cadaverous his face was, how little color there was in his
cheeks. She thought he looked almost ill.
They did not hear her come in. Gregory was sitting with his eyes on
Margaret, telling her something and she was listening in a protesting way. It
occurred to Freda that of course they were in love. She had suspected it
vaguely from their attitude. Now she was sure.
She coughed and they looked up.
“It’s my damsel in distress,” said Gregory, rising, “did everything clear
up? Is the ogress destroyed?”
“If she is, poor Miss Duffield had to do it.”
“She wouldn’t mind. She likes cruelties. She’s the most cruel person—”
“Hush, Gregory, don’t reveal all my soul on the spot.”
“Cruel—and over modest. As if a soul isn’t always better revealed—”
“You can go as far as you like later. Just now you might carry Freda’s
suitcase upstairs.”
He took the suitcase and followed them, entering Freda’s little room
which he seemed to fill and crowd.
“So this is where you take refuge from the ogress?”
“It’s more than a refuge—it’s a tower of independence.”
He looked at her appreciatively.
“We’ll agree on many things.”
Margaret asked Freda to come down with them and she went, a little
reluctantly wondering if she were not crowding their kindness. But Gregory
insisted as well as Margaret.
Margaret sat beside a vase of roses on her table and Gregory and Freda
faced her, sitting on the couch-bed. The roses were yellow, pink—delicate,
aloof, like Margaret herself and she made a lovely picture. Gregory’s eyes
rested on her a little wearily as if he had failed to find what he sought for in
the picture. He was silent at first—then, deftly, Margaret drew him out little
by little about the Irish Republic, and he became different, a man on fire
with an idea. Fascinated, stirred, Freda watched him, broke into eager
questioning here and there and was answered as eagerly. They were hot in
discussion when Walter Carpenter came.
There was a moment of embarrassment as if each of the men studied the
other to find out his purpose. Then Margaret spoke lightly.
“Do you want to hear about the Irish question from an expert, Walter?”
“Is Mr. Macmillan an expert?”
“He’s to lecture about it on Friday night.”
“It’s a dangerous subject for a lecture.”
“It’s a dangerous subject to live with,” answered Gregory a little
defiantly.
“Are you a Sinn Feiner, Macmillan?”
“I’m an Irish Republican.”
There was a dignity in his tone which made Walter feel his half-
bantering tone ill judged. He changed at once.
“We’re very ignorant of the whole question over here,” he said, “all we
have to judge from is partisan literature. We never get both sides.”
“There is only one side fit to be heard.”
Freda gave a little gasp of joy at that statement. It brushed away all the
conventions of polite discussion in its unequivocal clearness of conviction.
“I was sure of it,” she said.
Gregory turned and smiled at her. The four of them stood, as they had
stood to greet Walter, Margaret by the side of her last guest, looking
somehow fitting there, Gregory and Freda together as if in alliance against
the others. Then conversation, civilities enveloped them all again. But the
alliances remained. Freda made no secret of her admiration for Gregory.
The openness of his mind, the way his convictions flashed through the talk
seemed to her to demand an answer as fair. Her mind leapt to meet his.
Gregory Macmillan was Irish born, of a stock which was not pure Irish
for his mother was an Englishwoman. It had been her people who were
responsible for Gregory’s education, his public school and early Oxford
life. But in his later years at Oxford his restlessness and discontents had
become extreme. Ireland with its tangle of desires, its heating patriotism,
heating on the old altars already holy with martyrs, had captured his
imagination and ambition. He had gone to Ireland and interested himself
entirely in the study of Celtic literature and the Celtic language, living in
Connacht and helping edit a Gaelic Weekly. Then had come the war, and
conflict for Gregory. The fight for Irish freedom, try as he did to make it his
only end, had become smaller beside the great world confusion and,
conquering his revulsion at fighting with English forces he had enlisted.
Before the war Gregory’s verse had had much favorable comment. He
came out of the war to find himself notable among the younger poets,
acclaimed even in the United States. It seemed preposterous to him. The
machinations of the Irish Republican party absorbed him. Intrigue, plotting,
all the melodrama, all the tragedy of the Sinn Fein policy was known to
him, fostered by him. He had been in prison and after his release had fallen
ill. They had sent him to convalesce in Wales. It was while he was there that
there had come an offer from an American lecture bureau to go on tour in
the States telling of Irish literature and reading his own verse. He laughed at
the idea but others who heard the offer had not laughed. He was to come to
the States, lecture on poetry and incidentally see and talk to various
important Americans who might have Irish sympathies. The Republic
needed friends.
He came reluctantly and yet, once in New York, he had found so many
young literati to welcome him, to give him sympathy and hearing if not
counsel that his spirits had risen. And he had met Margaret Duffield and
drawn by her mental beauty, her curious cold virginity, he had fallen in love
with her and told her he loved her. For a few ardent weeks he wooed her,
she explaining away his love, denying it. Then she had come West and he
had sought his lecture bureau, making them include a lecture in this city
which held her. He had come and found her colder, more aloof than ever,
and now sitting in this room of hers he found a quiet, controlled, cultivated,
middle-aged man who seemed to be on terms of easy and intimate
friendship such as he had not attained.
After a little they divided their conversation. Margaret wanted to talk to
Walter about some complication in local politics—something affecting
Helen’s election. And Freda wanted to hear Gregory talk.
He told her about Ireland, of the men and women who plotted secretly
and constantly to throw off every yoke of sovereignty. He told of the beauty
of the Gaelic tongue, translating a phrase or two for her—talked of the Irish
poets and his friends and she responded, finding use now for all the
thoughts that had filled her mind, the poems she had read and loved. The
light in his deep set eyes grew brighter as he looked at the face turned to
his, meeting his own enthusiasm so unquestioningly. Once he looked at
Margaret curiously. She was deep in her discussion and with a glimmer of a
smile in his eyes he turned again to Freda.
At eleven he took her to her room. They went up the stairs to the door of
her apartment.
“Shall I see you between now and Friday night?”
“I’m going to work to-morrow.” Freda came back to that thought with a
jolt. “I don’t know.”
“To-morrow night? Just remember that I’m alone here—I don’t know
any one but you and Miss Duffield and I don’t want the people in charge of
my lecture to lay hands on me until it’s necessary. You’ve no idea what they
do to visiting lecturers in the provinces?”
“But hasn’t Miss Duffield plans for you?”
“I hoped she might have. But she’s busy, as you see.” His tone had many
implications. “So I really am lonely and you made me feel warm and
welcome to-night. You aren’t full of foolish ideas about friendships that
progress like flights of stairs—step by step, are you?”
“Friendships are—or they aren’t,” said Freda.
“And this one is, I hope?”
They heard a sigh within the apartment as if a weary soul on the other
side of the partition were at the end of its patience. Gregory held out his
hand and turned to go.
But Freda could not let him go. She was swept by a sense of the cruel
loneliness of this strange beautiful soul, in a country he did not know,
pursuing a woman he did not win. She felt unbearably pent up.
Catching his hand in both of hers, she held it against her breast, lifted her
face to his and suddenly surprisingly kissed him. And, turning, she marched
into her room with her cheeks aflame and her head held high. Groping for
the unfamiliar switch she turned on her light and began mechanically to
undress. It seemed to her that she was walking in one of her own storied
imaginings. So many things had happened in the last twenty-four hours
which she had often dreamed would happen to her. Adventures, romantic
moments, meetings of strange intimate congeniality like this with Gregory
Macmillan. She thought of him as Gregory.
Gregory went down the stairs quickly, pausing at Margaret’s door to say
good night. The other man was leaving too and they walked together as far
as Gregory’s hotel. They were a little constrained and kept their
conversation on the most general of subjects. Gregory was absent minded in
his comments but as he entered the hotel lobby he was smiling a little, the
immensely cheered smile of the person who has found what he thought was
lost.
Freda reported for work at the office of Sable and Flandon at half past
eight the next morning. She had not been sure at what time a lawyer’s office
began operations and thought it best to be early so she had to wait a full
hour before Mr. Flandon came in. The offices were a large, well-furnished
suite of rooms. There were three young lawyers in the office, associated
with Mr. Sable and Mr. Flandon, and three stenographers, in addition to a
young woman, with an air of attainment, who had a desk in Mr. Sable’s
office and was known as Mr. Sable’s personal secretary. Freda got some
idea of the organization, watching the girls come in and take up their work.
She became a little dubious as to where she could fit into this extremely
well-oiled machinery and wondering more and more as to the quixotic
whim which had made Mr. Flandon employ her, was almost ready to get up
and go out when Gage came in.
He saw her in a minute and showed no surprise. Instead he seemed to be
anxious to cover up any ambiguity in the position by making it very clear
what her duties were to be. He introduced her to the rest of the office force
as my “personal secretary” at which the Miss Brewster who held a like
position in Mr. Sable’s employ lifted her eyebrows a little. She was given a
desk in a little ante-room outside of Gage’s own office and Gage, with a
stenographer who had done most of his work, went over her duties. She was
to relieve the stenographer of all the sorting of his correspondence, take all
his telephone messages, familiarize herself with all of his affairs and
interests in so far as she could do so by consulting current files and be ready
to relieve him of any routine business she could, correcting and signing his
letters as soon as possible.
At five o’clock she hurried back to her little room to find a letter in her
mail box. It was from her father and at the sight of it she was saddened by
the sense of separation between them. Every word in it, counsel, affection,
humor breathed his love and thought for her. She was still poring over it
when Gregory came to take her to dinner, and forgot to be embarrassed
about the night before.
Gregory had never intended to be embarrassed evidently. He considered
that they were on a footing of delightful intimacy. His voice had more
exuberance in it to-night than she had previously heard. As they went past
Margaret’s door they looked up at her transom. It was dark.
“I hoped she was coming with us,” said Freda.
“She doesn’t want to come with me,” answered Gregory, “and that has
hurt me for a long time, it seems to me, although perhaps it is only weeks.
But it may be just as well. For I could never make her happy.”
“Would it be so hard?”
“I could never make any woman happy,” said Gregory with
extraordinary violence. “Happiness is a state of sloth. But I could live
through ecstasy and through pain with some one who was not afraid. For
this serene stagnancy which seems to be the end-all of most people, I’m no
good. I couldn’t do it, that’s all.”
His head was in the air and he looked, thought Freda, as if he would be
extremely likely to forget about any woman or anything else and go sailing
off in some fantasy of his own, at any time. She remembered him as he had
been, despondent, when she had first met him, last night full of blazing
enthusiasms, to-night blithely independent. It delighted her. She had never
before met a person who adjusted to no routine.
“Let’s walk in peace and watch the clouds and I’ll tell you what an old
Irish poet said of them.”
He could see her chin lift as she listened.
“To have in your mind such a wealth of beauty—what it must mean—to
feel that things do not starve within you for lack of utterance—” Her voice
was blurred into appreciations.
“Why let them starve?” asked Gregory.
“Perhaps because practical meat-and-drink body needs always claim the
nourishment the things of your mind need—and you let the mind go
hungry.”
“That’s it—that’s what people do—but you won’t. I hear it in your voice
—see it in your face. The things in you are too vital to be starved. You can
cripple them but you can’t kill them.”
“I do not know.”
“You must set yourself free.”
Freda smiled ruefully.
“That’s what women are always talking about and what they mean is a
washing machine.”
“That’s no freedom—that’s just being given the run of the prison. Don’t
you see that what I mean is to keep yourself free from all the petty desires
—the little peeping conventions—free for the great desires and pains that
will rush through you some day? You have to be strong to do that. You can
put up wind breaks for emotion so easily. And you don’t want them.”
“It means being very fearless.”
“I have never yet met anything worth fearing except cowardice.”
He stopped. They were in the middle of some sidewalk, neither of them
noticed where.
“Why did you kiss me last night?”
“I wanted to. I’ve not been sorry,” answered Freda. “By all the rules I’ve
learned I ought to be abashed, but you don’t live by rules, so why waste
them on you?”
Her smile was faintly tremulous. His strange, unfamiliar eyes looked
into hers and rested there.
“And we won’t have to spend time talking about love,” he said, half to
himself, “we shan’t wear it threadbare with trying to test its fabric. It comes
like the wind—like God.”
Again they breasted the wind and her hand was fast in his. It was a clean,
cool clasp. Freda felt oddly that she had saved her soul, that she had met an
ultimate.
CHAPTER XI
NEWSPAPER CUTS
T HE State Convention was imminent. In the vast barrenness of the

Auditorium rows upon rows of ticketed chairs were filling up with
delegates, sectional banners waved in the various parts of the big hall,
flags made the background for the speakers, chairs and table.
“The machinery for creating a government is in progress,” said
Margaret, “what do you think of it?”
Helen shook her head.
“Inadequate. When you think why they have come, how they have come,
what destinies they hold in their hands. Would women do it better I wonder,
Margaret?”
“Women are more serious. Perhaps. Anyway we must try it. If we don’t
like that machinery we’ll have to invent another kind.”
“Funny male gathering. Think they all have their women—and their
feeling towards their own women must influence their feeling towards all of
us. Their own women to treat cruelly or kindly—or possessively.”
“They’re on the last lap of their possession,” answered Margaret.
The gallery was filling with women, reporters, spectators with one
interest or another. The men were taking their places, formality settling on
the assembly. The temporary chairman was on the platform, welcoming
them, bowing grandiloquently with a compliment that was inevitable to the
ladies in the gallery. Nominations for a chairman were in order. The
temporary chairman retained his place as he had expected. The committees
on credentials, resolutions, organization, retired and the delegation heard
with some restlessness further exhortation as to the duties which lay before
them and the splendor of opportunity awaiting the party in the immediate
future.
The platform was read. Cheers, a little too well organized and not too
freely spontaneous, punctuated it. The women listened to it attentively,
Margaret frowning now and then at some of its clauses.
It was a long task. On its consummation the convention adjourned for
lunch.
It was mid-afternoon before the business of electing the delegates at
large to the National Convention had been reached. Helen felt her face grow
hot and her heart go a little faster even while she mocked at herself for
those signs of nervousness. Margaret watched as if her finger was on the
pulse of a patient.
Hedley’s name went through nomination as every one had expected.
Then Jensen was on his feet.
He was good. The women admitted that after his first words. He dwelt
upon the fact of suffrage, on the practical differences it made in the
electorate. He spoke of the recognition of women as a privilege. Then with
a reference which Helen had feared must come he spoke of the one woman
whose name is “familiar to us through the fine party loyalty of her husband”
and who is herself “the unspoken choice of hundreds and thousands of
women of this State” as their delegate. Helen heard her name come forth
unfamiliarly, heard the burst of clapping, faced the barricade of glances
with a smile.
There was little doubt about it from the start. What opposition there was
must have decided it unsafe to show its teeth. An hour later a discomfited
man, pushed off the party slate by a woman, edged his way out of the back
of the gallery and the woman was surrounded by a group of men and
women, all anxious to be early in their congratulations, some from sheer
enthusiasm, others from motives more questionable.
“And where is Gage passing the cigars?” asked one man jocularly.
Helen looked around as if in surprise that he was not there.
“He isn’t here, is he?”
She knew he wasn’t. She had known he wouldn’t come, even while she
could not quite kill the hope that he would.
At the door were photographers, even a moving picture man waiting for
the new woman delegates. Margaret dropped Helen’s hand and Helen, on
Mrs. Brownley’s arm, moved past the range of picture-takers with an air of
complete composure. In a moment she was in her car and moving out of
sight. Margaret turned to walk back to her own apartment, complete
satisfaction on her face.
II
Helen entered the house quietly and leaving her gloves and wrap on the
hall bench, went into the kitchen to see how things were going there. There
was a pleasant air of competence about it. The maids were busy and the
dinner in active preparation. Upstairs the nurse had the children. She played
with them a little, a warm sense of satisfaction at her heart. It was so absurd
to choose—to fake a choice. This other work, this other business could be
done without sacrificing anything. Gage was absurd. She was no less a
mother, not a bit less good a housewife because she was a delegate to the
Republican Convention. It took a bit of management, that was all. If she
was treating Gage badly she would feel different.
But there was a guilty feeling which she could not control. He was
unhappy and she the cause. They had been too close for that not to hurt.
At seven o’clock, a little late for dinner, came Gage, a guarded courtesy
in his manner. He asked her pardon for not dressing and handed her a sheaf
of evening papers. She was thankful that they had been issued too early to
contain the news of her triumph. It postponed certain altercations. She
thought suddenly of her barrage of photographers and of what she had
completely forgotten, Gage’s tremendous dislike of having her picture in
the papers.
“I can’t bear the thought of your picture tossed about the country—
looked at casually for an hour and then used as old newspapers are used—to
wrap a package—line a stair-rug—heaven knows what!”
Of course it had appeared occasionally for all of that but Helen had made
the occasions infrequent. She had always liked that prejudice of his. As she
looked at him to-night she thought he looked tired. There were strained
lines around his eyes, and he was very silent.
She said several little things and then, because avoidance of the big topic
seemed impossible, joined him in his silence. He looked at her at last,
smiling a little. It was not the smile of a rancorous man but rather a hurt
smile, a forced smile of one who is going to go through pain wearing it.
“I have been congratulated all the way home on your account, Helen. It
seems to have been a landslide for you.”

A Practical Guide To Geriatric Neuropsychology Susan Mcpherson Full Chapter

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A Practical Guide to Geriatric

Neuropsychology Susan Mcpherson

A PRACTICAL GUIDE TO GERIATRIC NEUROPSYCHOLOGY

OXFORD WORKSHOP SERIES

Volumes in the Series

Susan McPherson, PhD, ABPP/CN

Published in the United States of America by Oxford University Press

© Oxford University Press 2018

All rights reserved. No part of this publication may be reproduced, stored in

You must not circulate this work in any other form

Library of Congress Cataloging-​in-​P ublication Data

To James and Winifred McPherson, who taught me the value of persistence

To Asenath LaRue and Jeffrey Cummings, who inspired me.

To Mary Lynn, for her ever-​present love and support.

To my children, who are my joy and my light.

To my anchors, who bring me back to center.

Chapter 1 The Aging Population in Clinical Practice 1

Chapter 2 Normal Aging 7

Chapter 3 Factors Affecting Clinical Interaction

Chapter 4 The Clinical Interview 27

Chapter 5 Cognitive Screening 41

Chapter 6 Neuropsychological Assessment in Geriatric

Chapter 7 Psychiatric Disorders 67

Chapter 9 Feedback and Intervention 105

Chapter 10 Older Adults in the Workforce 123

Chapter 11 The Future of Health Care 131

A PRACTICAL GUIDE TO GERIATRIC NEUROPSYCHOLOGY

the population older than 60 years, representing a decline of 9% from 2010

The Impact of Older Adults on the Health Care System

2 A Practical Guide to Geriatric Neuropsychology

The Need for Mental Health Services for Older Adults

The Aging Population in Clinical Practice3

The Role of Psychology and Neuropsychology in Care

Scope of the Current Text

4 A Practical Guide to Geriatric Neuropsychology

The Aging Population in Clinical Practice5

Ms. Pickens is a 68-​year-​old, married woman who recently retired

Normal Aging: Physiological, Cognitive, and Psychological

Optimal Versus Typical Aging

Physiological Aspects of Aging

8 A Practical Guide to Geriatric Neuropsychology

problems solving). Changes in brain volume varied during adulthood across

Cognitive Aspects of Aging

Theories of Normal Cognitive Aging

10 A Practical Guide to Geriatric Neuropsychology

intelligence being more susceptible than well-​rehearsed verbal crystallized

• Consider results in light of the definition for inclusion of “normal

Identification of the Prodromal Stages of Neuropathological Aging

disease. Such efforts were launched to improve clinical treatment, care

Mild Cognitive Impairment

12 A Practical Guide to Geriatric Neuropsychology

(ADNI) study. They found that cognition at baseline predicted conversion

Differentiating Normal Versus Pathological Aging

14 A Practical Guide to Geriatric Neuropsychology

Providing Feedback on Normal Aging Versus

Psychological Aspects of Aging

Social Networks and Relationships

16 A Practical Guide to Geriatric Neuropsychology

on how younger versus older adults process emotional information have

of cognitive screening and neuropsychological evaluation and potentially

20 A Practical Guide to Geriatric Neuropsychology

Reduced auditory acuity and processing of auditory information have a

Medical Conditions and Medications

Library of Congress Cataloging-in-P ublication Data

To Mary Lynn, for her ever-present love and support.

2 A Practical Guide to Geriatric Neuropsychology

The Aging Population in Clinical Practice3

4 A Practical Guide to Geriatric Neuropsychology

The Aging Population in Clinical Practice5

Ms. Pickens is a 68-year-old, married woman who recently retired

8 A Practical Guide to Geriatric Neuropsychology

10 A Practical Guide to Geriatric Neuropsychology

intelligence being more susceptible than well-rehearsed verbal crystallized

12 A Practical Guide to Geriatric Neuropsychology

14 A Practical Guide to Geriatric Neuropsychology

16 A Practical Guide to Geriatric Neuropsychology

20 A Practical Guide to Geriatric Neuropsychology

Factors Affecting Clinical Interaction and Performance21

22 A Practical Guide to Geriatric Neuropsychology

Factors Affecting Clinical Interaction and Performance23

24 A Practical Guide to Geriatric Neuropsychology

Factors Affecting Clinical Interaction and Performance25

validated in a wide variety of non–English-speaking populations, with

26 A Practical Guide to Geriatric Neuropsychology

28 A Practical Guide to Geriatric Neuropsychology

The Clinical Interview29

Instrumental/Activities of Daily Living

30 A Practical Guide to Geriatric Neuropsychology

The evaluation of IADLs and ADLs are either questionnaire- based

The Clinical Interview31

32 A Practical Guide to Geriatric Neuropsychology