Category: Alzheimer's Disease

FAQ Regarding Psychological Practice in Geriatric Facilities

Over the last ten years, I have received multiple questions regarding psychological services in nursing homes and assisted living facilities.  Many of the questions are difficult to answer, due to the actual naming of a practice or individual.  What follows is a general fAQ for administrators and social workers to identify suspicious professional practice::

1)  They are marketed as appropriately trained psychologists when in fact most have no formal training in geriatrics, let alone dementia assessment and treatment. This is defined as “unethical” practice by the American Psychological Association.  Psychologists must have formal training in any population served or intervention offered.  My suggestion is to examine the psychologist’s vita for appropriate training.  Do not trust what marketing people have to say regarding qualifications.  See for yourself.

2)  The psychologist is working three to five days a week in your 120 bed facility. This is a recipe for ethical disaster, if not overt malpractice.  A 400 bed nursing home is not likely to offer more than 2 full days of work for most psychologists.  If the psychologist is not trained in neuropsychological assessment, one day should be plenty!  As the kids say-do the math.  Are there more than five or ten high functioning (mentally ill) residents that could profit from insight-oriented psychotherapy in your building?  Probably not.  Psychologists trained in outpatient work will fill their clinical time by treating demented residents.  It is imperative that they generate the numbers that please their respective corporations.  Medical necessity is reduced to a vague consideration.

3)  The psychologist treats dozens of residents, yet does not obtain written permission to treat any resident. A psychology corporation executive told me that an attending physician’s medical release covers psychologist’s liability as well.  This is not the historical position taken by the Florida Dept. of Health, Medicare, or the American Psychological Association.  Psychology is an independent profession that requires written permission to treat, and offers informed consent regarding the nature of the treatment.  As explained to the executive, I worked many years ago as a neuropsychologist for a company called Apogee.  A Medicare audit discovered that Apogee did not obtain written permission to treat their nursing home patients.  Medicare demanded a full refund for each patient that had not signed a release.  The company folded like a tent in a hurricane.

4)  The psychologist assigned to your facility changes every year or two. This reflects the fact that most psychologists hired by psychological corporations are young graduates.  Most have no experience in long-term care, have no formal training in dementia care, and have little desire to make a career in this area.  On the other hand, some older psychologists gravitate to geriatrics after failing in their primary area of interest.  This actually describes two owners of a local geriatric psychology corporation.  Both the young and old clinicians are similar in the sense of being inadequately trained.  They differ in that the young clinicians will move on to their chosen area of interest, and the older will cling to nursing homes as their last resort.  I do not believe either group adequately serves the interests of the residents.

5)  The psychologist/marketer offers to wave Medicare copays and treat managed care residents for free. An offer to wave Medicare copays is definitely not kosher.  Medicare rules for participating providers are clear that we must bill for our copays a total of three times!  I must admit that if I receive a letter refusing to pay, I let the matter drop at that point.  Technically, I may be in the wrong.  To tell others that I will not collect copays whatsoever is another matter.  As for free treatment of Medicaid and managed care residents, I’ll believe that when I see it.  I suspect that unpaid Medicaid patients are cured in two sessions, while all the paid residents require years of follow-up.

In summary, it is not difficult to identify unethical behavior or actual malpractice in your facility, but first you must be educated regarding the behavioral markers.  It is important to always keep in mind that psychological corporations are in your building to make money-period.  If your goal is to have all the Medicare residents billed as frequently as is allowable, I believe that you will not be disappointed with most psychology corporations.  If your goal is effective and ethical treatment of your residents, I fear you will have to look for individual experts and small dedicated group practices.  Lastly, I offer Holzmacher’s general rule of nursing home marketing as a helpful guide:

The potential for fraud and abuse increases in direct proportion to the slickness of the marketing, the frequency of the marketing efforts, and the reticence to supply the names and skills of those who actually perform the work.

Good luck!

Aging and Lifestyle

Business Logo for Psychological and Neuropsychological IssuesThere is an increasing amount of evidence that a person’s lifestyle is critical to successful aging.  It is hypothesized that ongoing participation in lifestyle activities may confer some resistance to cognitive decline in the older adult.  A longitudinal study was recently performed that appeared to consolidate this hypothesis.  Small et al. (2011) used data from the Victoria Longitudinal Study that followed approximately five hundred subjects for twelve years.  The study authors compared three lifestyle factors with three neuropsychological factors across this time period.  The three lifestyle factors were comprised of fitness, cognitive activities and social activities that require “complex cognitive functioning.”  The three neuropsychological factors were verbal speed and two types of verbal memory.  The study participants varied in age from fifty-five to ninety-four.  While the neuropsychological measures were administered by professionals, the lifestyle and health questionnaires depended on the subject’s self-report.  This is important to note, since the study lacked an objective assessment of lifestyle or health.  Ninety year old test subjects were asked to recall detailed aspects of their health and lifestyle, and the power of the study depended on the accuracy of their self-report.

The study found that preserved verbal speed was associated with preserved physical, cognitive and social activity.  The authors discovered that cognition and lifestyle activity were dual coupled.  This means that the factors worked both ways.  Verbal speed predicted lifestyle activities, and lifestyle activities predicted verbal speed.  The results of the memory measures were less coupled than verbal speed.  Memory for stories was dual coupled with physical activity, but not cognitive or social activity.  For example, increased cognitive activity predicted increased story recall, but the reverse did not hold true.  Conversely, better story recall predicted increased social activity, but increased social activity was not associated with better story recall.  Memory for word lists was not correlated with physical activity, whatsoever.  Increased cognitive activity was predictive of better word list recall, and proficient word recall was predictive of increased social activity, but the reverse did not hold true for either.  Generally, the study authors discovered that a decline in cognitive ability preceded a decrease in social activity.  This artifact is the opposite of many studies that have demonstrated increased levels of lifestyle activity improving overall cognitive performance.  The current authors suggest that impaired cognition causes decreased lifestyle activity, rather than decreased lifestyle activity producing the decline in mental functioning.

As mentioned, it is important to consider the affect of self-report in this study.  Both health and overall activity level were measured by self-report of the participants.  It is also important to consider that most older adults are not proficient at reciting their medical history, and very few can list their medications accurately.  Do not forget the natural tendency for people to please the examiner.  Questionnaires completed by test subjects invariably reveal the nature of the study; at the very least there are clues to the desired response.  Additionally, accurate self-appraisal declines over time.  The self-awareness of a fifty-five year old person is generally greater than an eighty year old.  For example, an eighty year old test subject is more apt to make temporal errors than a fifty-five year old subject.  Combined with the natural tendency to please the examiner, the eighty year old is likely to report more social and physical activity than they actually experience.  The current study may actually have measured the change in self-awareness with age, rather than the influence of lifestyle activity levels on cognitive performance.  Since the variable of self-awareness was not controlled in the study, the ability to draw a conclusion was tarnished.

The reader needs to be rather sophisticated and thorough when interpreting scientific articles.  The objections to the current study do not invalidate the results.   The reliance on self-report reduces the study’s power to predict whether lifestyle affects cognition or cognition influences lifestyle.  As with most psychological phenomenon, there is a dynamic interplay between overall lifestyle activity and cognitive functioning.  The early onset of Alzheimer’s Disease directly lowers the social interest of the afflicted.  Reducing environmental stimulation, at any age, will have negative affects on cognition.  It is not surprising that isolating one component of the interaction collapses the dynamic interplay.  Statistics is limited in this way, as one variable is examined while others are considered invariable, or held as invariable for purpose(s) of the study.  Lifestyle and cognition possess so many variables that an immense effort must be made to reduce the uncontrolled factors.  If the study authors used an informant to crosscheck health and lifestyle data, the predictive power of the study would be much greater.  Commonly, the cost in money and time becomes prohibitive.  The current study used data obtained over a twelve year period, such that informants had to be utilized at the inception of the research.  To add the use of informants later in the study would produce two studies, and the data cannot be compared once the methodology is changed.  Keep in mind that there is no such thing as the perfect study.  The most important part of a research article is not the results, but the limitations that influence the results.

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