By Megan Carlos, PhD (Member, APA Committee on Disability Issues in Psychology) and Jennifer Moye, PhD (Chair, APA Committee on Aging)
On a Thursday at 3:30 pm, a psychologist received a request to evaluate the capacity of Mr. Mather, an 83 year old medical inpatient. He had previously agreed to a scheduled surgery, but was now refusing at the point of pre-surgical consent. He had trouble explaining why and seemed confused. Did he lack the capacity to make the decision? The psychologist found Mr. Mather in his room in a wheelchair.
Upon interviewing Mr. Mather, it became clear that the consent process had frightened him because he could not fully hear what was being said or read the consent document. The psychologist provided Mr. Mather with a pocket talker, and together she and the surgeon reviewed the consent with a magnifying glass. In the end, it was clear that Mr. Mather had capacity, and now, understanding the information, he provided informed consent for the surgery.
The U.S. population will be considerably older and more diverse by 2060. Healthcare providers need to prepare themselves. The age 65 and older population is expected to more than double between 2012 and 2060, from 43.1 to 92.0 million. By 2056, those over 65 are projected to outnumber those under 18 for the first time. Older adults are significant consumers of healthcare, accounting for about one-third of all primary care visits and one-third of all health expenditures combined.
As the population ages, and as psychologists venture further into integrated healthcare settings, the proportion of older adults in their client caseloads is likely to explode. Is the average healthcare setting designed to accommodate the special needs of older adults with sensory, mobility, cognitive, or other disabilities?
Here’s a checklist of 28 tips that professionals working in behavioral health and other health care settings should consider:
To address hearing loss:
- Minimize background noise (e.g., close the office door, forward incoming calls) as individuals with hearing loss have difficulty discriminating between sounds in the environment.
- Look at your client when speaking. Many individuals with hearing loss read lips to compensate.
- Speak slowly and distinctly. Older adults may process information more slowly than younger adults.
- Do not over-articulate or shout as this can distort speech and facial gestures.
- Use a lower pitch of voice because the ability to hear high frequency tones is the first and most severe impairment experienced by many older adults with compromised hearing.
- Arrange seating to be conducive to conversation. Sit close to your client, face-to-face, at a table rather than on the far side of a desk.
- Focus more on written communication to compensate for problems in oral communication. Provide written summaries and follow-up material.
- Have auditory amplifiers. Many companies sell hand-held amplifiers that connect to headphones for in-office use.
To address vision loss:
- Increase lighting.
- Reduce the impact of glare from windows and lighting as older adults have increased sensitivity to glare. Have clients face away from a bright window.
- Do not use glossy print materials as they are particularly vulnerable to glare.
- Format documents in large print (e.g., 14 or 16-point font) and double-spaced as presbyopia (blurred vision at normal reading distance) becomes more prevalent with age.
- Give your client adequate time to refocus his or her gaze when shifting between reading and viewing objects at a distance, as visual accommodation can be slowed.
- Be mindful of your client’s narrowing field of vision. A client may not be aware of your presence in the room until you are directly in front of him or her.
- Have reading glasses and magnifying glasses available on conference tables.
- Arrange furnishings so pathways are clear for those with visual or physical limitations.
To address mild cognitive changes:
- Conduct practice at a slower pace to allow your client to process and digest information, as information-processing speed may decline with age.
- Allow extra time for responses to questions, as “word-finding” can decline with age.
- Break information into smaller, manageable segments.
- Provide cues to assist recall rather than expecting spontaneous retrieval of information.
- Provide summary notes and information sheets to facilitate later recall. Include key points, decisions to be made, and instructions for at-home care.
- Confirm or reconfirm your client’s basic goal or problem to be solved.
To address changes in mobility:
- Be cognizant of the accessibility of your office for individuals using mobility aids (e.g., scooter, wheelchair). Be able provide guidance to clients about how to best access your office via ramps at building entrances and elevators.
- Ensure that your office is easy to navigate for a client who uses mobility aids.
- Ensure that there is an accessible restroom in close proximity to your office.
- When interacting with clients who use a scooter or wheelchair, sit at the same level as them.
- Do not push a wheelchair or touch mobility aids without asking.
- Do not assume that a client needs assistance with mobility issues – ask before you help.
APA Office on Disability Issues
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
Assessment of Older Adults with Diminished Capacity: A Handbook for Lawyers
Dr. Carlos received her MA in Child Psychology and her PhD in Child Clinical Psychology from the University of Minnesota at Twin Cities. Following the completion of her doctoral degree, she worked as a Post-Doctoral Fellow at Kaiser Permanente, where she provided individual, group, and family therapy to children and adolescents and taught parenting classes for caregivers of children with ADHD and autism. Before coming to the American School of Professional Psychology at Argosy University, San Francisco Bay Area, Dr. Carlos taught courses in child and adolescent psychology, human development, and cognitive assessment at University of the Pacific and Framingham State College. Her professional and research interests include attachment theory, developmental psychopathology, working with clients with disabilities, and empirically-based treatment of children and adolescents. Dr. Carlos is currently a member of the APA Committee on Disability Issues in Psychology.
Jennifer Moye, PhD, earned her doctorate in Clinical Psychology from the University of Minnesota. She completed her internship, and postdoctoral fellowship in Geropsychology. Dr. Moye is an Associate Professor of Psychology in the Department of Psychiatry at Harvard Medical School, and is the Director of the Geriatric Mental Health. Dr. Moye leads a geropsychology research laboratory with two broad areas of study. First, in the area of capacity assessment she has led a research team investigating the key neuropsychological and clinical markers of capacity loss within diagnostic groups, with the goal of improving direct, performance-based measurement of capacity. In addition, she has studied the quality of clinician assessment for guardianship and its impact on juridical practice. In addition to being the author of more than 60 publications, she is the editor of three handbooks produced by the American Bar Association and American Psychological Association on capacity assessment. In her second area of research, improving access to mental health care for patients with medical illness, she has investigated the clinical and cost effectiveness of specialized mental health treatment and care coordination for older adults with complex comorbid conditions. Current research focuses on the treatment needs and gaps for patients with dementia, and, in a second study, patients following cancer treatment. She has testified before the Senate Committee on Veterans Affairs regarding the outcomes of her research, and before the Joint Judiciary Committee of the Commonwealth of Massachusetts. Dr. Moye is currently chair of the APA Committee on Aging.
I think it is important to be patient and give time for your clients to adjust to their surroundings at their old age. I can see how it might be necessary to conduct practices at a slower pace so that they can keep up. Thank you so much for the helpful psychological testing information.