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i
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
iv
1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press

198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2018
All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by license, or under terms agreed with the appropriate reproduction
rights organization. Inquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above.
You must not circulate this work in any other form

and you must impose this same condition on any acquirer.
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
9 8 7 6 5 4 3 2 1
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
vi
vi
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
vii
vi
ix
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
ix
x
xi
A PRACTICAL GUIDE TO GERIATRIC NEUROPSYCHOLOGY

xi
1
1
■■■
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
■■■
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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“Yes, but it takes such a pile of money to buy enough birthrights.
Nobody can vote without owning real estate, and property gives
people expensive notions. That’s why I am in favor of universal
suffrage. I should be willing even to give the ladies the vote—or
anything else the darlings desire.”
RoBards was hot enough to sneer:
“In a ladies’ election you would bribe them all with a smile.”
“Thanks!” said Chalender, destroying the insult by accepting it as a
compliment. “But let me have a look at your Bronx, won’t you? As an
engineer it fascinates me. It is the real reason for my visit to-day.”
This thin duplicity made even Patty blush. RoBards bowed:
“Our sacred Bandusian font is always open for inspection, but it’s
really not for sale.”
“Not even to save New York from depopulation?”
“That would be a questionable service to the world,” RoBards
grumbled. “The town is overgrown already past the island’s power to
support. Two hundred thousand is more than enough. Let the people
get out of the pest-hole into the country and till the farms.”
“You are merciless to us poor cits. No, my dear RoBards, what
New York wants she will take. She is the city of destiny. Some day
the whole island will be one swarm up to the Harlem, and it will have
a gigantic thirst. Doesn’t the Bible say something about the
blessedness of him who gives a cup of water to the least of these?
Think what blessings will fall on the head of him who brings gallons
of water to every man Jack in the greatest of American cities!
Quench New York’s thirst and you will check the plagues and the
fevers that hold her back from supremacy.”
“Her supremacy will do the world no good. It will only make her a
little more vicious; give crime and every evil a more comfortable
home.”
“Is there no wickedness up here in Arcadia?”
“None compared to the foulness of the Five Points.”
“Isn’t that because there is almost nobody up here to be wicked—
or to be wicked with?”
“Whatever the reason, we are not complaining of the dearth.”
“That’s fine! It’s a delight to find somebody content with something.
But show me your Bronx, and I may do you a service. You won’t
object if I find fault with the stream, because then I shall have
ammunition to fight with against your real enemies, who want to dam
the brook at Williams’s Bridge and pipe it into town. You and I should
be the best of friends; for I want the people to look to the Croton for
their help. It will enable New York to wash its face oftener, and drink
something soberer than brandy. And it will enrich me through the
sale of the miserable lands that have grown nothing for me but taxes
and mortgage interest.”
But RoBards was not content, and he was a whit churlish as he
led Chalender along the high ridges, and let him remark the silver
highway the river laid among the winding hills of Northcastle, down
into the balsam-snowed levels of the White Plains.
Little as RoBards approved his tenacious guest, he approved
himself less. He felt a fool for letting Chalender pink him so with his
clumsy sarcasms, but he could not find wit for retort or take refuge in
a lofty tolerance.
He suffered a boorish confusion when Chalender said at last, as
they returned to the house and the cocktails that Patty had waiting
for them on the porch:
“I agree with you, David. The Bronx is not our river. I can honestly
oppose its choice. But it’s a pretty country you have here. I love the
sea and the Sound and the big Hudson, but there is a peculiar grace
about these inland hills of Westchester. I shall hope to see much of
them in the coming years.”
“Yes?”
“Yes. I shall bid for a contract to build a section of the Croton
waterway. That may mean that I shall spend several years in your
neighborhood. My office will be the heights along the Hudson. That
is only a few miles away and a pleasant gallop. You won’t mind if I
drop in upon you now and then when I am lonely?”
Though Chalender ignored Patty’s existence in making this plea,
RoBards felt that it was meant for her. But what could he say except
a stupidly formal:
“It will be an honor to receive one of the captains of so great an
enterprise.”
“Thanks! And I can count upon always finding you here?”
Now RoBards amazed himself when he answered:
“I fear not. We came up only to escape the cholera. When that is
over, we shall return to New York. I have my law practice to
remember.”
He could feel, like hot irons in his cheek, the sharp eyes of Patty.
He knew what she was thinking. He had said that he wanted to dwell
here forever. And now he was pretending that he was only a brief
visitor.
Instead of gasping with the shock of her husband’s perversion,
she snickered a little. It was as if he heard a sleighbell tinkle in the
distance. But someone else was in that sleigh with his sweetheart.
He could not understand Patty. He seemed to please her most by
his most unworthy actions. He wondered if she had scented the
jealousy that had prompted his words, and had taken it once more
as an unwitting tribute to her.
He thought he detected a triumphant smile on Chalender’s face,
and he longed to erase it with the flat of his hand. Instead, he found
himself standing up to bow in answer to Chalender’s bow, like a
jointed zany.
The inscrutable Patty, when Chalender had driven out of sight of
the little lace handkerchief she waved at him, turned to her husband
with sudden anger in her face. He braced himself for a rebuke, but
again she confused him by saying:
“The impudence of Harry Chalender! Daring to crowd in on our
honeymoon! It was splendid how you made him understand that we
RoBardses don’t welcome him here.”
“Did I? Don’t we?” stammered RoBards, so pitifully rejoiced to find
her loyal to him and to their sacred union that he gathered her in his
arms, and almost sobbed, “Oh, my dear! my sweet! my darling!”
Though she was as soft and flexile as a shaft of weeping willow,
somehow she was like a stout spar upholding him in the deep waters
of fear, and he felt most ludicrously happy when she talked nursery
talk to him and cooed:
“Poor, little David baby wants its Patty to love it, doesn’t it?”
He could not answer in her language, but he felt a divinity in it, and
was miserably drenched in ecstasy. And she had used his first
name!
CHAPTER IV
BY and by the summer sifted from the trees and ebbed from the sky.
The honeymoon passed like a summer, in days and nights of hot
beauty, in thunder-salvos of battle, in passions of impatient rain.
For a while the autumn was a greater splendor, a transit from a
green earth starred with countless blossoms of scarlet, purple,
azure, to a vast realm of gold—red gold, yellow gold, green gold, but
always and everywhere gold. All Westchester was a treasure-temple
of glory. Then the grandeur dulled, the gold was gilt, was only
patches of gilt, was russet, was shoddy. The trees were bare. Sharp
outlines of unsuspected landscape came forth like hags whose robes
have dropped from their gaunt bones. The wind grew despondent.
Savor went with color; hope was memory; warmth, chill.
Something mournful in the air reminded RoBards of a poem that
Mr. Bryant, the editor of the Post, had written a few years before:
“The melancholy days have come, the saddest of the year,

Of wailing winds, and naked woods, and meadows brown
and sere;
Heaped in the hollows of the grove, the autumn leaves lie
dead;
They rustle to the eddying gust, and to the rabbit’s tread.”
When he quoted this to Patty, her practical little soul was moved,
as always, to the personal:
“Your Mr. Bryant writes better than he fights, Mist’ RoBards. Only
last year, almost in front of our house, I saw him attack Mr. Stone, of
the Commercial Advertiser, with a horsewhip. Mr. Stone carried off
the whip. It was disgusting, but it brightened Broadway. Oh, dear,
does nothing exciting ever happen up here? Wouldn’t it be wonderful
to stroll down to the Battery to watch the sunset and cross the bridge
to Castle Garden, and hear the band play, and talk to all our friends?
And go to a dance, perhaps, or a theatre? The Kembles are there
setting the town on fire! And am I never to dance again? I was just
learning to waltz when the cholera came. I sha’n’t be able to dance
at all unless we go at once.”
It shocked RoBards to think that marriage had not changed the
restless girl to a staid matron. That she should want to waltz was
peculiarly harrowing, for this new and hideously ungraceful way of
jigging and twisting was denounced by all respectable people as a
wanton frenzy, heinously immoral, indecently amorous, and lacking
in all the dignity that marked the good old dances.
But he was in a mood to grant her anything she wished. She had a
right to her wishes now, for she was granting him his greatest wish; a
son and heir was mystically enfolded in her sweet flower-flesh, as
hidden now as the promise of the tulip tree in a bud that hardly broke
the line of a bough in the early spring, but later slowly unsheathed
and published the great leaf and the bright flower.
So he bade the servants pack her things and his, and they set out
again for New York.
Now the tide flowed back with them as it had ebbed with them.
The exiles were flocking once more to the city, and new settlers were
bringing their hopes to market. A tide of lawyers and merchants was
setting strong from New England, and packs of farmers who had
harvested only failure from the stingy lands, counted on somehow
winnowing gold on the city streets, where sharpers and humbugs of
every kind would take from them even that which they had not.
The drive to New York was amazingly more than a mere return
along a traveled path. Though they had gone out in a panic, they had
been enveloped in a paradise of leaves and flowers and lush weeds,
as well as in a bridal glamor. Now they went back under boughs as
starkly bare as the fences of rail or stone; only the weeds bore
flowers, and those were crude of fabric as of hue. And the hearts of
the twain were already autumnal. Their April, June, and August of
love were gone and November was their mantle. Patty’s orange
blossoms were shed, and they had been artificial, too.
Below White Plains the road was a-throng with cattle that
frightened Patty and the horses. When they were clear of these
moving shoals, they came into the Post Road where the stages went
like elephants in a panic. But Patty found them beautiful. She
rejoiced in the increasing crowds, and as the houses congregated
about her, and the crowded streets accepted her, she clapped her
hands and cried:
“How good it is to be home!”
This sent a graveyard chill through RoBards’ heart, for it meant
that home to her was not in the solitude of his heart, but in the center
of the mob.
Home was to her more definitely the house in Park Place, her
father’s house to which he must take her till he found another
lodging. Her father and mother greeted her as a prodigal and him as
a mere body servant—which was what he felt himself to be.
The chief talk was of the cholera and its havoc. Three thousand
and five hundred dead made up its toll in the city, but the menace
was gone, and those who lived were doubly glad. The crowds in the
streets showed no gaps; there were no ruins visible. New houses
were going up, narrow streets being widened and the names
changed.
It was only when the Sabbath called them to church, or some
brilliant performance took them to see Fanny Kemble and her father
at the Park Theatre, and they inquired for one friend or another, that
they learned dreadfully how many good friends had been hurried feet
first to Washington Square, whence they would never return.
Dinners were few, since nearly every family wore mourning for
someone; but gradually the gayety returned in full sweep. The dead
were forgotten, and the plans for preventing a return of the plague
were dismissed as a tiresome matter of old-fashioned unimportance.
The pumps and cisterns were no longer blamed for the slaughter of
the innocents.
And now Patty must go into eclipse gradually. She grew more and
more peevish. When she complained that everybody worth while
was moving uptown, RoBards bought a house in St. John’s Park,
just south of Canal Street, and only a little distance from the Hudson
River. The house was new and modern, with a new cistern in the
rear. Only a few steps away was a pump supplied with water from
the new city water works in the salubrious region of Thirteenth Street
and Broadway. There was a key that admitted the family to the
umbrageous park, behind whose high fence there was seclusion.
There was something aristocratic and European, too, about the
long iron rail fence that framed the entire square, the same in front of
every house, and giving them all a formal uniform, a black court
dress.
But even aristocracy palled. Patty found but a brief pleasure in the
privilege of walking there at twilight, and she dared not venture out
before dusk. It was chill then and she shivered as she sat on a
bench and breathed in the gloom that drooped from the naked
branches like a shroud. She did not want to be a mother yet, and she
faced the ordeal with dread, knowing how many mothers die, how
few babies lived, for all the pain of their long preparation.
The winter was cold and she complained of the dark of nights,
though her husband multiplied the spermaceti candles and the astral
lamps till her room was as dazzling as an altar. He filled the bins in
the hall closet with the best Liverpool coal and kept the grates
roaring. But she wailed of mornings when he had to break the ice in
the water pitcher for her and she huddled all day by the red-hot iron
stove. She made her servants keep it charged with blazing wood,
until RoBards was sure that the house would be set on fire.
When spring came again and released grass, birds, trees, souls,
flowers, the very air from the gyves of winter, she was so much more
a prisoner that she herself pleaded to be taken back to Tuliptree
Farm. If she could not meet people she did not want to see them
pass her windows, or hear them laugh as they went by in shadows of
evening time. On the farm she could wander about the yard
unterrified and, with increasing heaviness, devote herself to the
flowerbeds. She fled at the sight of any passerby and was altogether
as hidden and craven as only a properly bred American wife
undergoing the shameful glory of motherhood could be.
She was smitten at times with panics of fear. She knew that she
would perish and she called her husband to save her from dying so
young; yet when he got her in his arms to comfort her, she called him
her murderer. She accused him of dragging her into the hasty
marriage, and reminded him that if he had not inflicted his ring and
his name and his burden upon her she could have gone with her
father and mother this summer to Ballston Spa, where there was life
and music, where the waltz flourished in rivalry with the vivacious
polka just imported.
But even in her most insane onsets she did not taunt him now with
the name of Harry Chalender. That was a comfort.
One day Chalender drove up to the house, but she would not see
him. Which gave RoBards singular pleasure. Chalender lingered,
hoping no doubt that she would relent. He sat out an hour, drinking
too much brandy, and cursing New York because it laughed at his
insane talk of going forty miles into the country to fetch a river into
the city. Chalender wanted to pick up the far-off Croton and carry it
on a bridge across the Spuyten Duyvil!
When he had left, Patty, who had overheard his every sentence,
said: “He must be going mad.” She was absent in thought a while,
then murmured as if from far off:
“I wonder if he is drinking himself to death on purpose, and why?”
CHAPTER V
ALL summer the water-battle went on in town, but with flagging

interest. Colonel DeWitt Clinton threw his powerful influence into the
plan for an open canal from a dam in the Croton down to a reservoir
to be built on Murray’s Hill. Even Clinton’s fervor left the people cold.
When he pointed out that they were paying hundreds of thousands
of dollars every year for bad water hauled in hogsheads, they
retorted that the Croton insanity would cost millions. When he
pointed out that the Croton would pour twenty million gallons of pure
water every day into the city, and declared that New York water was
not fit to drink, the answer came gaily that it did not need to be, since
the plainest boarding house kept brandy bottles on the table.
One old gentleman raised a town laugh by boasting that he had
taken a whole tumblerful of Manhattan water every morning for years
and was still alive. And yet the dream of bringing a foreign river in
would not down, though the believers in the artesian wells were
ridiculed for “the idea of supplying a populous city with water from its
own bowels.”
The cholera had brought a number round to the Westchester
project, but the cholera passed in God’s good time. It would come
back when God willed. Plagues were part of the human weather like
floods and drouths, and not to be forefended.
In any case Patty was busied with her own concerns. Her baby
was born on Tuliptree Farm before her husband could get back from
White Plains with the doctor, though he had lashed his horses till the
carry-all flung to and fro like a broken rudder.
The son and heir was a girl, and in the hope that she would be an
heiress they named her after Patty’s Aunt Imogene, whose husband
had recently died and left her a fleet of vessels in the Chinese trade.
For a time instinct and pride in the flattery of people who cried that
the child was its mother’s own beautiful image gave the tiny replica a
fascination to Patty. She played with it as if it were a doll, and she a
little girl only pretending to motherhood.
But she tired of the bauble and turned the baby over to the
servants. Her Aunt Imogene cried out against her:
“Nowadays women don’t take care of their babies like they used to
when I was a girl. In the good old-fashioned days a mother was a
mother. She was proud to nurse her children and she knew all about
their ills and ailments. I had eleven children and raised all of them
but six, and I would no more have dreamed of hiring a nurse for
them than I would have I don’t know what. But these modern
mothers!”
Criticism had no power over Patty, however. She admitted all that
was charged against her and simply added it to the long list of
grievances she had against her fate. RoBards often felt that this was
cheating of the lowest kind. It left a man no means of either
comforting distress or rebuking misbehavior.
As soon as the baby could be weaned from her mother to a nurse,
Patty made a pretext of ill health and joined the hegira to Saratoga
Springs, which was winning the fashion hunters away from Ballston
Spa. She traveled with some friends from the South who brought
North a convoy of slaves and camped along the road, preferring that
gypsy gait to the luxury of a voyage up the river on the palatial
steamboats, in which America led the world.
During that summer RoBards was both mother and father to the
child, and Immy’s fingers grew into and around his heart like the ivy
that embraced the walls of the house. He was bitter against his wife,
whose fingers had let his heart slip with ease and indifference.
Yet, by the time Patty returned from taking the waters in the North,
he was so lonely for her that their reunion was another and a first
marriage. He found a fresh delight in her company and learned the
new dances to keep her in his sight and out of the arms of other
men.
By one of Nature’s mysterious dispensations, this girl with the soul
of a flirt and a gadabout had the bodily fertility of a great mother. To
her frank and hysterical disgust heaven sent her a second proof of
its bounty, which she received with an ingratitude that dazed her
husband—and frightened him, lest its influence be visited on the next
hostage to fortune. If the child should inherit the moods of its mother
it would come into the world like another Gloster, with hair and teeth
and a genius for wrath.
But the child arrived so placidly that the doctor could hardly wring
a first cry from him by slapping him and dipping him into a tub of cold
water. And he wept almost never. What he had he wanted. When it
was taken from him he wanted it no more. He chuckled and glowed
in his cradle like a little brook. He gave up his mother’s breast for a
bottle with such lack of peevishness that it was almost an act of
precocious gallantry. They named him Keith after an uncle.
Keithkins, as too often happens in a world of injustice, made it so
convenient to neglect him that his chivalry must be its own and only
reward. Patty left him in the country—“for his own good”—and went
earlier to New York than in the other autumns. There she plunged
into a whirlpool of recklessness.
She seemed to welcome every other beau but her husband. She
would not even flirt with him. She said he was too dangerous!
She laughed at his jealous protests against the worthless
company she affected. But when he courted her she fought him. Her
extravagance in the shops alarmed him, but when he quarreled with
her on that score, and demanded that she cease to smirch his credit
with debts upon the merchants’ books, she would run away from
home and stay until he sought her out in Park Place, where she was
wheedling her father into ruinous indulgence.
The old man’s business was prospering and his gifts to Patty were
hardly so much generosities as gestures of magnificence.
Harry Chalender was constantly seen with old Jessamine. They
talked the Croton project, but RoBards felt this to be only a tinsel
pretext of Chalender’s to keep close to Patty.
By the gods, he even infected her with his talk of water-power!
Everybody was talking it now. It had become politics.
For sixty years or so the town had dilly-dallied over a water supply
—ever since the Irishman Christopher Colles had persuaded the
British governor Tryon to his system of wells and reservoirs. Every
year a bill was put forward, and the Wars of the Roses were
mimicked in the Wars of the Rivers.
Bronx fought Croton incessantly but neither gained a victory. Wily
old Aaron Burr stole a march on both with his Manhattan Company
and sneaking a bank in under the charter of a waterworks sank a
well and purveyed liquid putridity at a high price.
It was a great relief to RoBards when the Crotonians gained the
upper hand in 1833, for it left his Bronx to purl along in leafy
solitudes undammed. But it took two years to bring the project to a
vote and then the majority was only seventeen thousand Ayes to six
thousand Nos.
Just after the skyrockets of the Fourth of July died down, the
engineers went out into Westchester to plant their stakes, outlining
the new lake that the dam would form, and the pathway of the
aqueduct from the Croton to the Harlem.
This row of posts billowing up hill and down alongside the Hudson
stretched like a vast serpent across the homes and farms and the
sacred graveyards of villages and towns and old families. It was the
signal for a new war.
The owners of the land fell into two classes: those who would not
let the water pass through their demesnes at any price, and those
who sought to rob the city by unwarranted demands.
The farmers seemed to RoBards to comport themselves with
dignity and love of their own soil, though Chalender denounced them
for outrageous selfishness in preferring the integrity of their estates
to the health of a vast metropolis.
But RoBards saw through Chalender’s lofty patriotism. Chalender
could not unload his own land upon the city unless the whole
scheme were established, and Chalender’s price was scandalously
high.
The stakes were not yet nearly aligned when an almost unequaled
frost turned the buxom hills to granite overnight. It seemed that the
havoc which this high emprise was to forestall had been purposely
held in leash by the ironic fiends until the procrastinating city had
drawn this parallel of stakes, this cartoon of an aqueduct. For almost
immediately the cataclysm broke.
The idleness enforced upon the engineers by the evil weather
drove most of them back to town, Harry Chalender among them. And
now he dragged Patty into that vortex of dissipation for which the city
was notorious. Dancing, drinking, theatre-going, riotous sleigh-rides,
immodest costumes, and dinners of wild revel gave the moralists
reason to prophesy that God would send upon the wicked capital fire
from the skies—as indeed He did in terrible measure.
Harry Chalender began to follow Patty about and to encounter her
with a regularity that ceased to resemble coincidence. There was
gossip. One of the slimy scandal-mongering newspapers well-named
The Hawk and Buzzard printed a blind paragraph in which RoBards
recognized his own case.
But what could RoBards do? To horsewhip the editor or shoot the
lover would not only feed the newspapers but blacken the lives of the
babies, who were suffering enough now in the lack of a mother’s
devotion without being cursed for life with a mother of no reputation.
In a world governed by newspapers the old rules of conduct were
altered.
The winter of 1835 fell bitterer than any ever known before. The
cold was an excruciation. The sleighs rang along the street as if the
snow were white steel. The pumps froze; the cisterns froze; the
pipes of the water companies froze underground, and the fire-
hydrants froze at the curbs.
The main industry of the town seemed to be the building and
coaxing of fires, though coal and wood were almost impossible to
obtain, and the price rose to such heights that one must either go
bankrupt or freeze.
Everybody began to wonder what would happen if a house should
blaze up. The whole city would go. Who would come to the rescue of
a burning house in such weather? And with what water would the
flames be fought? Everybody listened for the new firebell that had
been hung in the City Hall cupola and had sent its brazen yelps
across the sky so often, but was ominously silent of late as if saving
its horrific throat for some Doomsday clangor.
Hitherto, membership in certain of the fire companies had been
cherished as a proof of social triumph. There were plebeian gangs
made up of mechanics and laborers, and the Bowery b’hoys were a
byword of uncouth deviltry.
But RoBards had been accepted into one of the most select fire
clubs with a silver plated engine. He kept his boots, trumpet, and
helmet in a basket under his bed, so that there was never any delay
in his response to the bell. He was so often the first to arrive that
they gave him the key, and in the longest run he always carried more
than his share of the weight in the footrace. But now he wished that
he had never joined the company.
Christmas drew near and Patty wore herself out in the shops and
spent her time at home in the manufacture of gifts with her own
hands. They were very apt hands at anything pretty and useless.
She was going to have a Christmas tree, too, a recent affectation
borrowed from the Hessian soldiers who had remained in the country
after the Revolution.
The evening of the sixteenth of December was unbearably chill.
The fire itself seemed to be freezing red. The thermometer outside
the house dropped down to ten below zero. The servants refused to
go to the corner for water and Patty was frightened into staying
home from a ball she was invited to.
That was the ultimate proof of terror. It was one of the times when
the outer world was so cruel that just to sit within doors by a warm
fire was a festival of luxury; just to have a fire to sit by was wealth
enough.
Patty was so nearly congealed that she climbed into her
husband’s lap and gathered his arms about her like the ends of a
shawl. It had been a long while since she had paid his bosom such a
visit and he was grateful for the cold.
And then the great bell spoke in the City Hall tower—spoke one
huge resounding awful word, “Fire!” before it broke into a baying as
of infernal hounds.
When RoBards started to evict Patty from his lap she gasped:
“You’re not going out on such a night?” RoBards groaned: “I’ve got
to!” He set her aside and ran upstairs for the basket of armor, and
Patty followed him wailing with pity.
“Don’t go, darling!” she pleaded. “You can tell them to-morrow that
you were sick. You’ll die if you go out in this hideous cold, and then
what will become of me? Of us? Of our babies?”
Her solicitude heartened him. He was important to her after all! His
death would grieve her. That added a beauty to duty. But it took
away none of its authority.
While he struggled into his boots, she ran to a window looking
south and drew back the curtains. Through the thick lace of frost on
the panes a crimson radiance pierced, imbuing the air with a rosy
mist as if the town were seen through an upheld glass of Madeira.
“It looks like the end of the world!” Patty screamed. “What will
become of our beautiful city now? It will be nothing but ashes to-
morrow. Don’t go! You’ll be buried under a wall, or frozen to death in
the streets. If you’ll promise not to go down into that furnace, I’ll go
with you to-morrow to Tuliptree Farm, and never leave it again!”
His heart ached for her in her agitation, and it was not easy to tear
off the clinging hands for whose touch he had so often prayed. But
he broke free and dashed, helmeted and shod, into the icy world
between him and the advancing hell. The fire’s ancient enemy,
water, was not at hand for the battle, and the whole city lay helpless.
At the firehouse door RoBards met Harry Chalender. He was
dressed for the ball that Patty had planned to attend, and he wore
white gloves and dancing pumps.
CHAPTER VI
IT was like Harry Chalender to wear dancing pumps to a fire on a

midwinter night.
“Harry will have ’em on Judgment Day,” said one of the other
members of the fire company, and they laughed at him through
chattering teeth.
This did not amuse RoBards. He wanted to hate Chalender; but
justice was his foible, and he had to confess to his own prejudice
that, while it was Chalenderish to appear in pumps at a fire, it was
equally like him to be absent from no heroic occasion no matter what
his garb.
Harry played the fool, perhaps, but he was always at King Lear’s
side. And though he never forgot his bauble, it tinkled and grinned
wherever there was drama.
And there promised to be drama enough this night.
The gathering volunteers flung back the folding doors and
disclosed the engine, a monster asleep and gleaming as with
phosphorescent scales in the light of the brass and silver trimmings
polished often and piously. A light was struck with a tinder-box and
the signal lantern and torches brightened the room.
The Fire King Engine Company had been proud of its tamed
leviathan, though there had been some criticism because on one
side of the engine an allegorical figure of Hope had been painted
with almost no clothes on her. But New York was advancing
artistically with giant strides, and a painting of a semi-nude Adam
and Eve had been exhibited that summer without provoking anything
more violent than protest. Also, the Greek casts were displayed
nowadays without interference, though of course ladies did not visit
them at the same time with gentlemen.
But Heaven rebuked the ruthless allegory of Hope before this night
was over; and with the ruination of Hope went the beautiful scene on
the opposite flank of the engine, a painting of the recent burning of
the Roman Catholic Church in Nassau Street. The Fire Kings had
played a noble part there, and had almost saved the church.
Now, as they dashed into the street they were thrown into a tangle
to avoid the rush of the Naiad Hose Company swooping past with a
gaudy carriage, whose front panel presented the burning of Troy and
the death of Achilles, while the back panel showed an Indian maid
parting from her lover. The hosemen might have been Indians
themselves from the wild yell they gave.
There was no time for the usual gay dispute over the right of way,
and the cobblestones and brickbats with which the road would have
been normally challenged were frozen in the ice. Besides, the Fire
Kings were sparse in numbers.
Such Fire Kings as braved the elements would long tell of the
catastrophe. Getting to the neighborhood of the blaze was adventure
enough of itself. For the road was grooved with the tracks of sleigh
runners and chopped up with a confusion of hoof-marks impressed
in knife-edged ridges. The men inside the square of the draw-rope
alternately slipped, sliddered, fell, rose, stumbled, sprawled, and ran
on with wrenched joints and torn pantaloons. Their progress made a
sharp music as if they were trampling through a river of crackling
glass.
But they ran on because there was tonic in the community of
misery.
RoBards was touched by the sight of Chalender’s lean face above
the satin stock and the frilled white shirt. The others were in red
flannel, and cold enough. Chalender’s great beaver hat was a further
trial to keep on, and finally the wind swirled it out of sight and
seeking. RoBards bared his own head and offered Chalender his
brass-bound helmet of glazed leather, but Chalender declined it with
a graceful gesture and a chill smile drawn painfully along the line of
his white mouth. The only color in his cheeks was imposed by the
ruddy flare of the sky.
The fire, wherever it was, seemed to retreat as the company
advanced. It grew in vastitude, too. The scarlet heavens were
tormented with yellow writhings, as if Niagara were falling upwards in
a mist of smoke and a spume of red spray.
Chalender’s patent leather pumps were soon cut through and his
nimble feet left bloody traces on the snow. This offended RoBards
somehow. Footprints on the snow were the sacred glory of the
patriot troops at Valley Forge. What right had a fop like Chalender to
such martyrdom?
When the puffing Fire Kings covered the long half-mile to City Hall
Park, the fire was just as far away as ever.
From here on the way was clogged with engines and hose carts
plunging south and fighting through a tide of flight to the north.
RoBards was reminded of the retreat from the cholera, until a
wrangle for priority with a rival company engaged his thoughts, his
fists, and his voice.
Wagons of every sort toppling over with goods of every sort locked
wheels while their drivers fought duels with whips and curses.
Merchants who had gone early to bed were scampering half-clad to
open their shops and rescue what they might. Everywhere they
haggled frantically for the hire or the purchase of carts. Two hundred
dollars was offered in vain for an hour’s use of a dray that would not
have brought so much outright that afternoon, with its team thrown
in.
The commercial heart of the city was spurting flames, and the
shop in Merchant Street where the volcano first erupted had spread
its lava in circles. Everything was burning but the frozen river, and
ice-imprisoned shipping was ablaze at the docks. Whole warehouses
were emptied and their stores carried to apparent safety as far as
Wall Street, where they were heaped up in the shadow of the cupola
of the new Merchants’ Exchange.
Certain shopkeepers of pious mind shifted their wealth into the
Dutch Reformed Church for safety. In the deeps of its gloom some
invisible musician was playing on the big pipe-organ. The merchants
lugging in their burdens felt that he interceded for them harmoniously
against the din of the fiends whose fires danced on the windows, as
if they reveled in the sacrilege of attacking the temples of both
Mammon and Jehovah. First the fiends made a joke of the costly
pretence that the Merchants’ Exchange was fireproof. Then they
leaped across a graveyard to seize the church and sent Maypole
ribbons twirling around and around its high spire. In half an hour the
steeple buckled and plunged through its own roof, and the roof
followed it, covering organ, pulpit, pews, and merchandise.
Pearl Street, whose luxurious shops had made lower Broadway a
second-rate bazaar, was sinking into rubble. Copper roofs were
melting and red icicles dripped ingots on the street.
The Fire Kings pushed on, with ardor dwindling as the
magnificence of their task was revealed to them. They were scant of
breath and footsore and cold, and their helmets rattled with flying
embers. Embers were streaming across the river to Brooklyn and the
people there sat on their roofs and wondered if their town must
follow New York to destruction. On all the roofs in New York, too,
shadowy bevies fought off the embers and flung them into the street.
The fire companies were driven back in all directions. They felt as
tiny and futile as apes fumbling and chittering against a forest blaze.
By and by the bells ceased to ring. The tollers were too cold to pull
the ropes—and what was the use of going on alarming those who
were already in a panic? Yet the silence had an awe of doom in it.
Merchants and their women cursed and wept, and tears smeared
smoky faces. It was maddening to be so useless; firemen sobbed
blasphemies as soldiers did when wet powder rendered them
ridiculous and mocked their heroism. Their nostrils smarted with the
acrid stench from bubbling paint and varnish, from mountains of
chewing tobacco, cigars, and snuff, from thousands of shoes and
boots and hats and household furnishings. Miles of silk and wool and
cotton, woven and prettily designed, were all rags now that
smoldered, or flew on the wind like singed birds, awkward ravens
frightened out of some old rookery.

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A Practical Guide to Geriatric

Neuropsychology Susan Mcpherson

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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

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