• Understand the discrepancies of the quality of diagnosis between the older adult in comparison to younger adult cliental.



• Learn how and how often age-based biasness affect clinical practices and diagnostic guidelines.



• Learn how clinicians should effectively use clients age in assessing pathology and treatment planning.

Due to the burgeoning growth of the older adult population, clinicians soon may find significantly more older patients in their practices.
Unfortunately, previous research findings suggest that psychotherapists manifest typically negative, pessimistic attitudes in their dealings with older adult patients. When asked to evaluate older, as compared to younger, adult patients’, psychologists have regarded older adults’ depressive symptoms as significantly less severe, have rated their prognoses as poorer, and have provided them with fewer recommendations for psychotherapy and anti-depressant medication. These therapeutic biases are disturbing in light of recent metaanalytic findings suggesting that psychotherapy is an effective treatment for depression among older adults, and that treatment outcomes are similar for both younger and older depressed adults. Questions also may be raised regarding the ability or willingness of clinicians to make accurate dual diagnoses for older adults who may have personality disorders (PD). Estimates suggest that up to twothirds of depressed older adults have a comorbid personality disorder, and the accuracy of such dual diagnoses appears vital for effective, differential treatment planning.

To date (1997), no empirical studies have been designed to examine the extent to which psychologists possess the requisite knowledge to manage the complex diagnostic and treatment issues that often arise in work with older adults. Thus, in the present study, psychologists were presented with a narrative vignette in which patient age (middle-aged, 46 years; young-old, 66 years; and oldest-old 86 years) and patient pathology (major depression, and major depression with comorbid borderline PD) were varied directly in a 3X2 between subject factorial design in order to examine the extent to which clinicians exhibit age-related therapeutic biases, and ware aware of the sometimes special needs of older adult patients. Consistent with previous findings, we hypothesized that the psychologists would hold pessimistic, prejudicial attitudes toward the patient with borderline PD, and toward the two older, as compared to the middle-aged, adult patients. We also hypothesized that psychologists would display negative diagnostic and treatment biases toward the older adult patients, although clinicians who reported receiving gerospsychological training, versus those who did not, were expected
to demonstrate greater requisite knowledge.

One of the six different versions of the patient vignette was mailed to a total of 1000 Registrants in a randomized block design by the extent to which they reported targeting older adults in their practice. Of the 186 Registrants who responded, the 73 female and 113 male participants ranged in age from 31 to 76 years, and averaged 50 years of age. The Registrants were experienced clinicians, averaging more than 17.6 years in practice. In similar proportions the respondents described their primary theoretical orientation as cognitive- behavioral (26%), eclectic/integrative (38%), or psychodynamic (36%). Nearly half of the Registrants (47%) indicated that they did not target older adults specifically for their practice. Perhaps consistent with this proportion, the Registrants reported that, on average, only 13 percent of their patient experience was with older adults. Yet, the majority of the Registrants (56%) reported that they had additional training and course work in Gerontology.

Although only one of the 186 respondents indicated that she used patient age as a primary determinant for diagnostic decision making (for the 86 year old patient), it is noted that the Registrants displayed age-related diagnostic effects. Chi-Square tests showed that the clinicians were significantly more likely to diagnose or to rule out dementia and organicity in response to the oldest-old, as compared to the middle-aged, patient. Additionally, the Registrants appeared significantly more likely to respond to borderline pathology than to advanced patient age when assigning patient diagnoses. For example, the clinicians failed to display any age-related diagnostic bias against making a borderline (or any other) PD diagnosis for the older adult patients. The Registrants were just as likely to provide a PD diagnosis for the oldest-old patient as for the middle-aged patient.

Nearly one third of the clinicians reported that patient age was a factor in their treatment planning for the oldest- old, as compared to the young-old and middle-aged, patient. Consistent with this finding, a series of Chi- Square tests revealed that the clinicians made differential treatment recommendations in response to advanced patient age. Specifically, clinicians were more likely to recommend medical exams, age-related social support, and day programs for the oldest-old, as compared to the middle-aged, patient. It also is notable that the clinicians were no less likely to recommend individual psychotherapy or anti-depressant medication for older adult, as compared to the middle-aged, patients. Thus, the Registrants did appear to make specific judgments about treatment recommendations that were skewed positively in favor of addressing the sometimes special treatment needs of the oldest-old.

Analyses of variance (ANOVAs) or Chi-Square tests with patients age and pathology as independent factors were used to examine the dependent measures assessing the clinicians’ potentially negative attitudinal biases toward patients with advanced age and borderline PD. Findings revealed, as expected, that the clinicians displayed significant differences concerning the patients with borderline PD. Registrants regarded the patient with comorbid borderline PD, as compared to the patient with depressive disorder alone, as lower in overall functioning, as greater in symptom severity, as capable of less favorable outcomes in treatment, and as less ideal for their practice. The clinicians also showed greater aversion to the patient with borderline PD in that they were significantly less likely to volunteer their participation in a future study involving that patient. Contrary to expectation, however, no such difference was discovered among clinicians in their responses to both of the older adult, as compared to the middle-aged adult, patients. It is notable that an unobtrusive attitudinal measure (i.e., willingness to volunteer for a future study with that patient) revealed significant pathology related, but not age-related, preferences among the Registrants. The presence of borderline pathology may be a more decisive clinical feature than advanced patient age; the oldest-old patient with borderline pathology was viewed no more negatively than the middle aged patient with borderline pathology. This finding also suggests that the lesser rates of borderline PD observed among older adults in applied settings may be related to clinicians’ perceptions of lower base rates, or to age-related biases in DSM criteria; the clinicians in the present study showed no bias against diagnosing borderline PD among older adults when DSM criteria were met.

The extent to which the practitioners possessed requisite gerontological knowledge was examined with factorial analyses of variance. The results revealed that the Registrants appropriately viewed the oldest-old patient as at significantly higher risk for suicide and as a more likely candidate for ECT treatment. However, it is important to note that the clinicians appeared to display requisite knowledge primarily for the oldest-old patient; the increased suicide risk and potential benefits of ECT treatment were not noted for the young-old patient. This pattern of results, in which the age of the oldest-old patient appears to elicit significantly different responses than for the other younger patients also appears consistent with the finding that significantly more clinicians recalled patient age as a salient feature for the oldest-old patient than for either the young-old or middle-aged patient.

The potential relationships between clinicians’ personal (e.g., age) and professional (e.g., theoretical orientation, years in practice) characteristics, and their clinical and attitudinal judgments were examined. A series of significant relationships emerged in which gerontological training was associated with more informed diagnostic and treatment decisions. Specifically, Registrants who reported that they had gerontological training were significantly more likely to make or to rule out age-related diagnoses of dementia and organicity, and were more likely to make essential treatment recommendations for medical exams, than those without such training. No other interactive effects were discovered between the clinicians’ characteristics and clinical judgments.

Other findings involving the Registrants’ professional characteristics suggest that, even though the majority did not actively seek out older adult patients for their practice, the majority had appropriate gerontological training and expressed a willingness to work with older adult patients. Although it may be questioned whether the smaller number of practitioners without such gerontological training who chose not to target older adults for their practice were expressing an aversion to older adult patients, this does not appear likely. These Registrants were no more likely to manifest negative attitudes toward older adults than other Registrants, even though they were less likely to make age-appropriate diagnostic and treatment decisions. Rather, the practitioners without gerontological training responsibly chose not to prioritize their practice in terms of serving older adult patients.

These Registrants’ objective, neutral, and informed responses to older adult patients stand in marked contrast with more traditional findings in the literature, in which therapists have exhibited negatively biased and uninformed responses to older adult patients. In this case, not only did the Registrants show an absence of attitudinal and therapeutic prejudice toward the older adult patients, but they displayed certain appropriate, differential diagnostic and treatment judgments, particularly when the patient was from the oldest-old age group, and when the psychologist reported having sought out gerontological training or course work. The Registrants also appeared knowledgeable about increased risk factors associated with oldest-old patients, such as suicide. However, the clinicians also appeared to discriminate somewhat negatively toward the young-old patient, who was less likely to receive recommended, age-related treatment interventions. It is as thought the clinicians did not identify the 66 year old patient as “elderly.” It appears important that, while clinicians be encouraged to retain attitudinal neutrality toward older adult patients, they also be encouraged and trained to recognize advanced patient age as a relevant, salient factor in diagnosis and treatment planning.

Although these findings provide evidence for cautious optimism regarding psychologists’ objective and informed therapeutic attitudes toward older adult patients., it is important to discuss the limitations of our present study. The use of paper and pencil measures is least desirable in terms of observing practitioners’ naturalistic responses to older adult patients. (Yet, the findings that the practitioners did exhibit vigorous, prejudicial biases in response to borderline pathology suggest that our study’s age manipulations would have elicited similarly negative biases if they were inherent among the clinicians.) It also remains unknown whether such therapeutically neutral attitudes would be held toward older adult patients with severe neurological or organic disorders. Lastly, it is unclear whether Registrants are typical practicing psychologists; their voluntary self-inclusion in a professional organization with stringent qualifying criteria may indicate greater training, experience, and motivation.

References

James, J. W., & Haley, W. E. (1995). Age and health bias in practicing clinical psychologists. Psychology and Aging, 10, 610-616.

Molinari, V., Ames, A., & Essa, M. (1994). Prevalence of personality disorders in two geropsychiatric inpatient units. Journal of Geriatric Psychiatry and Neurology, 7, 209-215.

Niederehe, G., Cooley, S. G., & Teri, L. (1995). Research and training in clinical geropsychology: Advances and current opportunities. The Clinical Psychologist, 48, 37-44.

Pat-Hoerenczyk, R. (1988). Attitudes of psychotherapists toward diagnosis and treatment of depression in old age. Israeli Journal of Psychiatry and Related Sciences, 25, 24-37.

Perlick, D., & Atkins, A. (1984). Variations in the reported age of a patient: A source of bias in the diagnosis of depression and dementia. Journal of Consulting and Clinical Psychology, 52, 812- 520.

Scogin, F., & McElreath, L. (1994). Efficacy of psychosocial treatments for geriatric depression: A quantitative review. Journal of Consulting and Clinical Psychology, 62, 69-74.

Thompson, L. W., Gallagher, & Czirr, R. (1988). Personality disorder and outcome in the treatment of late-life depression. Journal of
Geriatric Psychiatry, 211, 133-146.

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May not be reproduced or reprinted without the publisher’s written permission.

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