For better or for worse, I hail from New Jersey—from a terrifyingly loud, frenetic Italian family no less. At risk of propagating stereotypes about my people, I should pause to admit a few things: (1) I speak quickly, (2) talk frequently, and (3) gesticulate wildly. And if we’ve ever talked at length, please know that my tendency to interrupt (I’m sorry) comes from nothing more than my benign inability to control the thoughts a-bubbling at the tip of my tongue.
As a trainee of clinical psychology (working with older adults, no less) these tendencies sometimes present a few problems. Here’s why:
- Effective psychologists listen more than they speak. Also, interruptions frustrate people, compromise rapport, and contaminate process.
- Most clients, particularly older folks, struggle to process content delivered quickly or loudly.
- Indiscriminate gesturing distracts.
Thankfully, I noticed these patterns very early in my training while reviewing session tapes, humbly digesting lessons from each of the seemingly thousands of blunders I committed. These lessons, beyond providing humbling fodder, invited me to evaluate my interactions with older folks in the lab, too. To be sure, these tendencies have high costs both on the couch and in the lab, but may be uniquely expensive in experimental contexts where even small missteps can introduce error to the assessment situation. And few assessment situations rival the delicateness of those with older adults.
Classical test theory
Albeit obvious, the point must be made: psychology is a science of constructs, not of tangibles like biology or geology. And because psychologists cannot directly poke and prod the things they want to study—like anxiety, depression, dementia, intelligence—they attempt to tap these constructs psychometrically—using testing, measurement, and assessment.
This approach, admittedly, has its flaws. Classical test theory, sometimes known as true score theory (Allen et al., 2002), posits that a person’s observed score on any given assessment represents an additive composite of two components: a true score (error-free score) and an error score:
X = T(true) + E(error)
In more human terms, this means that the variability in measurement stems from the sum of variability due to true score and the variability due to error—or, error from the thing you’re actually measuring and how you are measuring it.
Systematic error and random error
Random and systematic errors characterize the two types of measurement errors. Random errors describe statistical fluctuations in the data due to precision limitations of the measurement, resulting from the researcher’s inability to take the same measurement in exactly the same way to yield identical results. Random errors, unlike their systematic counterparts, typically stem from individual differences at the time of test taking—like level of arousal (i.e., anxiety), preparedness, or even physical health.
Systematic errors, then, represent reproducible inaccuracies inherent to the system—divorced from the individual—due to problems persisting throughout measurement. In terms of psychological research, these errors might include poor wording of test items, the salience of stimuli, or even the validity of the constructs themselves.
Sources of error to consider when testing older adults
Sensory Impairments
Considering the sensory, physical, and cognitive changes accompanying aging, making thoughtful modifications to the testing environment can help not only to optimize older adults’ performance, but also to reduce measurement error.
“Typically, sensory acuity declines with age,” notes Sheila R. Black, Associate Professor of Psychology at the University of Alabama. “Keeping this in mind, researchers should anticipate that older adults will not be able to hear and see as well as younger adults,” she explains.
To ignore this as researchers would be only at our peril. Dual sensory impairment (DSI)— only anticipated to spike as the population ages— refers to the presence of both hearing and vision loss. According to the Centers for Disease Control and Prevention, at least 1.7 million people report DSI, with between 9% and 21% of adults over 70 having some degree of it (Saunders & Echt, 2007).
And presumably—if someone doesn’t have both visual and hearing impairments — (s)he likely has impairment in at least sight or hearing. Don’t buy it? Take that one out of six Americans over 70 has low vision due to common eye pathologies including macular degeneration and glaucoma (Elliott, McGwin, Kline, & Owsley, 2015) or that 59-76% have mid to high frequency clinical hearing loss, respectively (Helzner et al., 2005).
Why does it matter? Because you can’t encode what you can’t sense.
“Obviously, you want to make sure that your older participants can see and hear the stimuli,” says Kyle Kraemer, PhD student of cognitive psychology at the University of Alabama, “because otherwise, what are you really measuring?”
But as others have pointed out, age related declines in sensory acuity may produce difficulties in performing cognitive tasks, even when visual or auditory stimuli presentation exceeds threshold levels that can be seen or heard (Baldwin & Ash, 2011).
“Psychologists, both clinical and experimental, must therefore be sensitive to these differences across the lifespan, making adjustments in the lab or clinic when necessary,” emphasizes Black. “They also need to consider these changes when discussing experimental results.”
Cognitive Impairments
Though sensory-acuity mediated performance provides another explanatory framework for age-related cognitive decline, another rests in widely accepted findings that prospective memory, episodic memory, and executive processing fade over time (Baldwin & Ash, 2011). Accordingly, some researchers have proposed that these age-related declines reflect impaired cognitive functions such as slowed information processing (Cerella, 1985; Salthouse, 1994) or decreased attentional capacity (Park et al., 2002, Salthouse, 1992).
“I find that many older adults don’t like to participate in cognitive studies because the procedures often involve some sort of cognitive testing,” observes En Fu, PhD candidate of cognitive psychology at the University of Alabama. “Participants tend to recall how their cognitive capacity has declined, developing negative attitudes and feelings toward themselves that they may or many not bring to the study.”
Tarek Amer, PhD student of psychology at the University of Toronto, echoes this: “I find it rewarding to work with older adults because they tend to be interested in my research questions,” he says, “but challenges include making sure that I am extremely careful with those who are concerned, sensitive, or anxious about their cognitive abilities,” he adds.
And anxiety matters.
Older adults, on average, harbor more negative beliefs and anxieties about their memory than younger adults. Most importantly, these anxieties actually appear to impair memory performance through the allocation of processing resources, strategy selection, motivation, or a combination of these factors (Chasteen et al., 2005). Concerns about being negatively stereotyped impact performance too. Per Steele’s (1997) notion of stereotype threat, older adults performing in a situation in which negative stereotypes about aging and memory are activated show impaired memory performance (Chasteen et al., 2005).
“Accordingly, I often reassure older adults that tasks are designed to challenge participants, and that it is very normal for participants of all age groups to find them difficult,” says Amer.
He adds, “That said, the cognitive literature tends to focus on cognitive decline and how brain changes with age contribute to that decline. But many older adults are, in fact, major contributors to society and fully capable of performing tasks encountered in daily settings. My research focuses on how these cognitive changes can actually be beneficial in certain contexts, and I often share that.”
Other health and physiological factors to consider: Circadian arousal & pain
To complicate matters, individual differences in chronobiology also appear to influence experimental outcomes. Variation in circadian arousal correlates with performance on a variety tasks (e.g. performing simple arithmetic), such that performance peaks at a certain level of arousal—a peak that occurs more or less regularly at a specific point in the day (Yoon, May, & Hasher, nd). Clear age differences appear to exist in circadian arousal patterns too, with older adults tending strongly toward morningness (vs. eveningness) than their younger counterparts—seemingly reaching their mental peak early in the day.
Pain’s another important—but often ignored— variable to consider, particularly because it represents one of the most widely cited symptoms underlying disability among older adults (Patel et al., 2013). Pain draws attention— draining valuable, scarce cognitive resources away from the individual (Seminowicz & Davis, 2006). In fact, several converging lines of evidence suggest that pain processing can interfere with cognitive processes and visa versa, with many studies demonstrating deficits in cognitive ability among older chronic pain suffers (Seminowicz & Davis, 2006). Medication side effects may exacerbate contributions of pain to performance, too.
“I remember when I was a student running older participants,” recalls Black, “I would have to adjust their seats in the lab so that they could be comfortable, not having to constantly tilt their heads to see the screens or sit for so long that their pain would start to distract them from the task.”
“I remind my students to make similar adjustments,” she adds.
So what?
Overarching the enterprise of science— psychological or otherwise— is the goal of reducing measurement error. Why? Simply put, error of any kind (random or systemic) reduces validity—our ability to measure what we claim, or purport, to be measuring. Even more importantly, it compromises our ability to detect true effects. Methodological flaws perpetuate Type I and Type II errors— false positives and false negatives respectively—that can transmit (dangerous) falsehoods throughout science and beyond.
Of course, we can’t ignore error—we’ve got to do the exact opposite: recognize that sucker and manage it.
Some errors, like those endogenous to individuals, are largely unpreventable. No matter what we do as researchers, we’ll probably never eliminate participants’ anxieties, reverse their hearing loss, or quell the knee pain that they inevitably bring to the testing situation. But we can make adjustments to accommodate those limitations. And of course, failure to consider sources of random error may eventually translate to systemic error, contaminating the study itself.
“I cannot emphasize enough the importance of making adjustments for your participants,” reminds Black.
“For example, if the goal of the study is to assess central rather than perceptual processing, you need to ensure that older adults will be able to process stimuli as well as a younger adult- otherwise you’re not really measuring what you’re trying to measure” she adds.
Error management strategies
Admittedly, attempting to manage these complexities may feel dizzying. So, where do you start and how can you do it?
General strategies
“First things first,” warns Black, “older adults are quite perceptive and don’t respond well to being patronized or infantilized. Always be patient, empathetic, and respectful.”
And before getting down to the whole business of testing, don’t hesitate to initiate conversation—it builds rapport and reinforces motivation.
“Older adults also tend to be more personal than college-aged students,” observes Kraemer. “They seem much more interested in the research than college aged students.”
Amer agrees: “Motivation can sometimes be an issue with younger adults who are participating for course credit—such typically isn’t the case for older adults,” he explains. “And because older adults generally tend to be more interested in learning about my research, I always make sure that I spend as much time as I can discussing any issues that interest them as well as answering any questions that they may have.”
The American Psychological Association’s (APA) working group on the older adult makes a similar suggestion, urging researchers to familiarize older adults with the purpose and procedures of testing. Older adults, especially those with little formal education, may be more cautious in responding otherwise.
“Older adults with a low level of education may also struggle with tasks that involve certain words as stimuli, instructions or informed consents written in language that is not easily understandable,” adds Kraemer. “For your sake and theirs, keep everything simple.”
Also do what you can to ensure optimal performance, like reminding older adults prior to their testing appointment to bring all necessary assistive devices with them, including hearing aids or eyeglasses. I’ve even known a few researchers who kept bifocals on site.
Strategies for managing sensory impairments
Computer-based protocols, like many in experimental psychology, can exacerbate visual symptoms commonly causing discomfort among older users (Ko et al., 2014).
“Some, but not all, adults also have limited experience with computers,” warns Kraemer. “A few express displeasure or apprehension toward even completing a study once they find out it involves a computer, others simply just require time to adjust to it,” he explains.
One option, of course, includes administering paper assessments—but that obviously isn’t always feasible and can quickly get messy. Another management option includes altering features of the interface itself.
Sound ophthalmological evidence suggests that because of their lower visual performance, older adults may be more susceptible to reduced visibility from glare than younger adults (Ko et al., 2014). Additional research indicates that they make take longer to perform visual tasks requiring repetitive transitions between brighter and dimmer areas than their younger counterparts (Ko et al., 2014).
Creating a well-lighted environment, aimed at reducing glare and uneven luminance includes one simple approach to accommodating the visual limitations common among older adult participants.
“Enlarging the font on documents and digital interfaces can also help ease eye strain due to presbyopia in this population,” adds Dr. Jack Parker, ophthalmologist at the Callahan Eye Hospital in Birmingham, Alabama.
“On the other hand,” shares Kraemer, “I know researchers who have personally used the mouse or keyboard for their participants, simply using verbal communication to respond to tasks” if and when these adjustments cannot be made or if participant discomfort persists.
“I just try to keep everything simple—using only two buttons for instance, and labeling them with brightly colored stickers so that they’re user friendly,” he adds.
Regarding managing hearing deficits, the National Institute on Aging (NIA) recommends talking slowly, clearly, and in a normal tone—particularly because speaking in a raised or high-pitched voice actually distorts language sounds and can give the impression of anger. Other suggestions include facing the person directly, at eye level, so that (s)he can lip-read or pick up visual clues.
Strategies for managing cognitive impairments
“If I sense that a participant appears to approach cognitive tasks with some apprehension or anxiety,” shares Black, “I often reassure them that they will perform fine. I also emphasize how much their participation contributes to science and our knowledge about cognitive aging generally.”
“Reassuring them that their results will remain confidential also eases some anxiety,” she adds.
Accordingly, many experts recommend using encouragement and verbal reinforcement liberally throughout testing with older adults, not only to quell uneasiness, but also to sustain motivation and rapport. And because older adults tend to tire more easily than youngsters, designing rest breaks into your protocol appears to help manage some the ‘brain drain’-associated fatigue participants may experience over the course of testing. You might also consider using multiple testing sessions to reduce participant burden.
Another strategy for optimizing performance includes scheduling testing appointments earlier (versus later) in the day, when cognitive arousal tends to be highest for older adults. Of course, asking what your participants would prefer never hurts either.
Finally, deemphasizing the assessment of memory during the instruction phase of the study may be another way of reducing anxiety. In a study of younger and older adults, researchers varied the instructions they gave to participants before completing a memory task, either emphasizing that memory was going to be assessed or deemphasizing the memory component of the task (Rahhal et al., 2001). Specifically, when older adults were told that the experiment was testing their ability to learn facts instead of remember them, they performed as well as young adults; the exact inverse, however, emerged when older participants were asked to remember (Chasteen, 2005). Thus, subtle but sensitive alternations in language may reduce the anticipatory anxieties that tend to subvert older adults’ cognitive performance. Of course, this strategy may require participant debriefing.
Strategies for managing physical and physiological impairments
“Finally, some older adults have limited mobility,” reminds Kraemer. “More than likely, you will encounter people with wheelchairs, assistive devices, or tremors.”
For this reason, whenever possible, the assessment space should be arranged to accommodate wheelchairs or other assistive devices for those with physical limitations. Accessibility of the space itself should also be considered: Are there ramps? Elevators? Is parking convenient, close, well-lit, and safe?
“Limited mobility can also mean that the older adults do not drive, in some cases,” Kraemer adds. “In order to get a large enough sample in a typical college town, it may be best to design an experiment that can travel and be conducted in a home, church, or another community that older adults have regular access to, rather than asking them to all come to an existing lab space.”
Assessing and reducing pain when possible, as well as considering the effects of medication on performance, include other effective management techniques.
Conclusion
Working with older adults is in equal measure rewarding and complex. The solution? KISS: Keep it simple, stupid.
Kisses,
C
References
Allen, M.J. & Yen, W.M. (2002). Introduction to Measurement Theory. Long Grove, IL: Waveland Press.
American Psychological Association (1998). What practitioners should know about working with older adults. Professional Psychology: Research and Practice, 29(5) 413- 427.
Baldwin, C. L., & Ash, I. K. (2011). Impact of sensory acuity on auditory working memory span in young and old adults. Psychology and Aging, 26(1), 85–91. http://doi.org/10.1037/a0020360
Cerella J. Information processing rates in the elderly. Psychological Bulletin. 1985;98(1):67–83.
Chasteen, A. L., Bhattacharyya, S., Horhota, M., Tam, R., & Hasher, L. (2005). How Feelings of Stereotype Threat Influence Older Adults’ Memory Performance. Experimental Aging Research, 31(3), 235–260. http://doi.org/10.1080/03610730590948177
Elliott, A. F., McGwin, G., Kline, L. B., & Owsley, C. (2015). Vision Impairment Among Older Adults Residing in Subsidized Housing Communities. The Gerontologist, 55(Suppl 1), S108–S117. http://doi.org/10.1093/geront/gnv028
Helzner EP, Cauley JA, Pratt SR, Wisniewski SR, Zmuda JM, Talbott EO, et al. Race and Sex Differences in Age-Related Hearing Loss: The Health, Aging and Body Composition Study. Journal of the American Geriatrics Society. 2005;53(12):2119–2127
Ko et al. (2014). Effect of font size and glare on computer tasks in young and old adults. Optometry and Vision Science, 91(6), 682-689.
National Institute on Aging (2016). Talking with your older patient: A clinician’s handbook.
Patel, K. V., Guralnik, J. M., Dansie, E. J., & Turk, D. C. (2013). Prevalence and Impact of Pain among Older Adults in the United States: Findings from the 2011 National Health and Aging Trends Study. Pain, 154(12), 10.1016/j.pain.2013.07.029. http://doi.org/10.1016/j.pain.2013.07.029
Park DC, Lautenschlager G, Hedden T, Davidson NS, Smith AD, Smith PK. Models of visuospatial and verbal memory across the adult life span. Psychology and Aging. 2002;17(2):299–320
Rahhal TA, Hasher L, Colcombe SJ. Instructional manipulations and age differences in memory: Now you see them, now you don’t. Psychology and Aging. 2001;16:697–706.
Salthouse TA. Working-memory mediation of adult age differences in integrative reasoning. Memory & Cognition. 1992;20(4):413–423.
Salthouse TA. The nature of the influence of speed on adult age differences in cognition. Developmental Psychology. 1994;30(2):240–259.
Seminowicz, D.A., & Davis, K.D. (2007). Interactions of Pain Intensity and Cognitive Load: The Brain Stays on Task. Cereb Cortex 2007; 17 (6): 1412-1422. doi: 10.1093/cercor/bhl052
Saunders, G. H., & Echt, K. V. (2007). An Overview of Dual Sensory Impairment in Older Adults: Perspectives for Rehabilitation. Trends in Amplification, 11(4), 243–258. http://doi.org/10.1177/1084713807308365
Steele CM. A threat in the air: How stereotypes shape intellectual identity and performance. American Psychologist. 1997;52:613–629
Yoon, C., May, C.P., & Hasher, L. (nd). Aging, circadian arousal patterns, and cognition.
It is an amazing read. Research psychology can open many doors of improvement in providing health to seniors and taking the home care industry forward. You are spot on. Seniors do require daily care and support to live a happy life at an older age.
It’s a great read and speaks the core values in terms of senior care. Psychotherapy is one of the most incredible ways to help seniors live a better life. You have shared remarkably effective ways when
strategizing about providing the best care possible to seniors. Thanks for sharing.
Thanks Christina for sharing. Your blog is very thoughtful. In my opinion psychology is necessary for evaluating the best therapy methods for people. There is more number of seniors visiting psychologist because they have few friends left who can listen to their hardships. A psychologist does keep client privilege as his foremost rule. Anxiety in seniors is expected at an older age due to social isolation and existential crisis.
1. The conclusion that “Working with older adults is in equal measure rewarding and complex. The solution? KISS: Keep it simple, stupid.” is the epitome of condescension.
2. In terms of vision, many older adults, including me, have perfect vision as a result of cataract surgery some years ago.
3. Finally, how many older adults have limited experience using a computer these days? A few personal examples:
a. I ordered a new knife rack from Amazon a few days ago.It should be here tomorrow.
b. A month ago, I ordered some cooking equipment from Amazon and had it sent to my daughter in Albany for her birthday.
c. I checked the schedule of my Toastmasters meeting online to see whether I had a role at the next meeting.
d. I checked my email this morning, found this article, read it, and am posting this comment.
e. I pay certain recurring expenses, such as our mortgage, on line.
Thanks for chiming in Madeleine! I knew Christina’s latest post would be a little controversial and raised similar flags for me regarding condescension. The conclusion could have been written better, but this article reminded me of our experience redesigning emergency rooms for older adults. Many of the accommodations and changes Bill recommended for the “Senior ER” could be interpreted as patronizing when taken out of context. But when you compare them side-by-side to a standard ER, the reaction is universally “Why isn’t every ER designed this way???” In other words, researchers should be taking all these dimensions into consideration no matter the age or ability of the research subjects — it makes for better science.
Great article to remind all of us to slow down and be considerate of Elders needs emotionally when testing or even working with them.