The fundamentals of psychiatric assessment for older people are the same as for younger people (thorough history, detailed mental state assessment, and a physical examination). However, the details and balance of each of these components varies considerably from the assessment in younger adults due to the high prevalence of physical morbidity and the crucial importance of proper cognitive assessment. In the same way, whilst the same kind of follow-up assessments, e.g. social work assessment and investigations, e.g. neuroimaging, are needed, the assessments themselves are quite different.
The Venue for the Initial Assessment
Assessment of the older person with a possible mental illness may take place in a range of settings, as considered below, and whilst each has its strengths and weaknesses, the evidence about the clinical and cost effectiveness of these different services is poor (Parker et al., 2000). In practice, the place where the initial assessment is conducted is constrained by the existing design of the local service, the manner of the referral and the urgency of the clinical problem. The assessing clinician needs to show flexibility to adapt his assessment to the advantages and disadvantages of the different locations.
Patients referred for old age psychiatry assessment should be seen initially at home. Such domiciliary assessment has several advantages over a hospital-based assessment for older people and is especially important for those with cognitive impairment. The patient is spared a time consuming, tiring, and perhaps expensive journey to clinic. Clinics, especially psychiatric ones, are too often unpleasant places to wait around and can be particularly distressing to frail, older, and cognitively impaired people. Unsurprisingly therefore, when patients were asked, they overwhelmingly opted for home-based assessment over clinic-based assessment or assessment at a primary care clinic (Jones et al., 1987). For the clinician, a home-based assessment provides a depth and quality of information that exposes the shallowness of what can be achieved in clinic, an aspect that frequently strikes medical students when visiting with consultants (Anderson and Aquilina, 2002). On arrival, the doctor is already aware of the local environment, whether it is large houses with spacious gardens or empty flats with boarded up windows, and the quality of the patient’s own house before knocking on the door. On entering, he is rapidly able to determine the state of the entrance area and main room and can observe any hazards, such as loose carpets or objects strewn on the floor, as well as the general level of cleanliness. After politely seeking permission, a quick inspection of the kitchen, looking for out of date food, an empty fridge, or burned pans can be revealing. Interestingly, it was this aspect of home-based assessments, the ability to understand the home environment, that one study reported as the main reason general practitioners asked for such assessments (Hardy-Thompson et al., 1992). It is much easier for a key relative or carer to be present at the patient’s home, and often several are present. As well as providing corroboration for the history, they can assist the patient to remember and clarify important elements of the history, and it may give an insight into family dynamics and the kind of relationships the patient enjoys. For those patients who have carers attending already, there should be a written care plan available and daily notes from the carer(s), giving useful additional information. An informative practice is to ask patients to produce their medication for checking, which, as well as confirming their current treatment, will often reveal evidence of erratic compliance. A domiciliary assessment also shows patients at their best, giving a more realistic assessment of their mood, cognition, and general behaviour. Although most of these advantages will be familiar to clinicians practising in the field, they are difficult to study, but one investigation reported a large reduction in nonattendance for home-based (1.7%) versus clinic-based (21.2%) assessments, leading to a more efficient use of valuable medical time (Anderson and Aquilina, 2002). This also results in patients being followed-up more effectively (Benbow, 1990). Nonattendance at clinics leads to important delays in assessment and on occasions assessment does not happen at all (Frankel et al., 1989).
When a referred patient is living in a residential care facility this is usually because of the development of some form of behavioural disturbance in someone with a pre-existing illness, in most cases dementia. They have often therefore been previously assessed and, providing their previous records are available, this enables the psychiatrist to concentrate on the current issue(s). Where there has been no formal psychiatric assessment previously it can be very difficult to complete a full history, because informants with a long-term knowledge of the patient are often not available. In some cases they may be available by telephone, but usually a pragmatic approach is necessary, making the best use of available sources of information. As well as that in the referral letter, documents from social services recording the admission process to the home and care records can be consulted. This can furnish valuable information about the previous history. Care staff are usually able to provide a reasonable account about the current problems, although it is prudent to enquire how well the carer-informant knows the patient and for how long.
For most patients referred to old age psychiatry services an initial assessment in their own home remains the choice for the reasons outlined above. Whilst some people with functional illnesses, especially those who are physically fit, may be adequately assessed in an outpatient clinic, in practice it is usually difficult to identify with confidence such people from the referral letter alone. The main group where outpatient clinic assessment can be advantageous is in people with a possible early dementia, and over the last 20 years memory clinics focusing on such patients have become an increasingly prominent feature in old age psychiatry services (Lindesay et al., 2002). Such clinics often deal with younger, less cognitively impaired patients and for those who have a dementia they are earlier in the course of their illness (Luce et al., 2001). More recently, memory clinics have expanded out of more academic settings and in England, following the publication of the 2009 National Dementia Strategy (NDS) (Health, 2009), there has been an increase in specialist memory assessment services. The NDS emphasized the importance of early and accurate diagnosis as one of its key objectives. Memory services are discussed in detail in Chapter 24.
A third to a quarter of new referrals to old age psychiatry services come from wards in general hospitals, and assessment here is a very different experience from home-based assessments and brings its own difficulties. The growing recognition that inpatient assessments require a different approach has led to the increasing development in many places of specialist liaison old age psychiatry services. The UK NICE Clinical Guidelines for Dementia state that every acute hospital should have a dedicated specialist liaison team, planned by acute, mental health, and social services, able to holistically assess and manage older people in the acute hospital setting with dementia (NICE, 2006), and similarly one of the key objectives of the National Dementia Strategy is for a dedicated service with an identified lead clinician in the hospital (Health, 2009). Details about such services and the special approach and skills needed for inpatient old age psychiatry are discussed in Chapter 22.
The Psychiatric Assessment
Aims of the assessment
A psychiatric assessment aims to achieve much more than a diagnosis. A thorough assessment should enable the clinician to produce well-reasoned differential diagnoses and have some confidence in the most likely main diagnosis. But the initial assessment also aims to engage the patient and his or her family to facilitate further assessment as necessary and to foster cooperation in all aspects of future management. Thus the process of assessment should establish a good rapport with the patient and his/her family and carers, and achieving such a positive relationship improves the quality of information obtained. There is now a much greater tendency amongst old age psychiatrists to disclose the diagnosis of dementia, although other doctors in other specialities, e.g. neurology and geriatric medicine, remain reluctant to do so. This development has probably been largely driven by the availability of licensed treatments for Alzheimer’s disease, but the NDS and NICE Dementia Guidelines both encourage clinicians to discuss dementia diagnosis and its implications with patients and families because of the advantages it brings, e.g. facilitating advanced care planning (NICE, 2006; Health, 2009). Disclosing and discussing diagnosis is an important clinical skill and establishing a good rapport paves the way for dealing with this sensitive subject (Bamford et al., 2004).
As well as eliciting information to determine a diagnosis it is important to identify other relevant problems that need dealing with in their own right. The importance of noncognitive symptoms in dementia (commonly referred to as behavioural and psychological symptoms in dementia, BPSD) is now well recognized (Finkel and Burns, 2000), yet these usually play no role in the diagnosis that is based on cognitive symptoms, although new criteria include them as one element in diagnosis (McKhann et al., 2011). Clarifying functional difficulties, such as with mobility or personal care, and the presence of other relevant medical illnesses is essential as well. Thus, for example, a summary of a patient assessment should include, in addition to a diagnosis of dementia, reference to such issues as psychotic symptoms, mood disturbance, postural instability, difficulties using stairs, and bathing. The initial assessment should not, indeed cannot, aim to achieve a detailed understanding of all these matters, but should identify the range of issues that need further assessment. The initial assessment should therefore be holistic in aiming to achieve a clear overall understanding of the patient’s complete set of needs.
The initial assessment
Upon first meeting the patient, a good handshake, polite smile, and clear explanation of who you are and why you have come begins the process of forming a working relationship. The referral letter should have identified the key issues, but it is important at the outset to ensure they are correct, and where the letter is unclear to ask what the main problems are. It is common for patients to deny they have any problems, especially when they have cognitive impairment, and not infrequently the patient is found to have had no involvement in the referral process, which was initiated by concerned family members. Tact and sensitivity are needed to explain the concerns others have about the patient and to obtain patience and cooperation with the formal assessment itself. Seeking permission to speak with family or friends can be difficult in such circumstances, but it is still important to try to do so. Explaining to the patient that understanding the whole picture is important and that it is standard practice to ask other people for information achieves agreement in most cases.
A careful and detailed history remains the most important element in the whole assessment; physical and mental state examinations and special investigations only serve to clarify and confirm the history. It is therefore vital to establish a good rapport and give adequate time to cover all the necessary aspects in the clinical history.
One main problem may be given as the reason for referral, but typically several interrelated issues are present. These need to be identified and clarified individually, and their relationship, temporal and otherwise, established. At the outset it is appropriate to check that patients understand why they are being assessed and that the presenting problems are all those that need to be discussed. This may reveal important issues, such as that they resent having been referred and are angry with their wife for having brought this about. The development of each main symptom can then be covered, asking about key aspects such as duration, pattern of onset, change through time, and any known precipitants. The timing of the onset of amnesia and cognitive decline is frequently difficult to ascertain, but asking about this in relation to memorable dates can be useful, e.g. was the person his usual self last birthday or at Christmas or on holiday last summer? In old age psychiatry, people usually present with a history of insidious onset of amnesia, and whilst this is characteristic of Alzheimer’s disease, dementia with Lewy bodies (DLB) also presents this way and it is a common pattern in vascular dementia (VaD), especially of the subcortical type. The classic VaD presentation, a sudden onset of dementia and/or a stepwise deterioration, is unusual in old age psychiatry, probably because such patients usually present acutely to stroke services.
A more rapid (but not sudden) onset of cognitive impairment, over a few days or weeks, is consistent with a delirium or a depression and should lead to questions to identify these syndromes, e.g. for delirium the presence of an infection or fluctuating consciousness, and for depression of affective change and biological symptoms. In someone with an insidious onset of amnesia then questions to identify other cognitive symptoms may be appropriate, e.g. problems reading or writing, difficulties naming objects or recognizing objects or people, but such issues are usually identified more clearly during cognitive testing. Of more importance during history taking is covering the range of noncognitive symptoms that occur in dementia. It is essential to ask about problems in everyday function, in order to identify needs for which further assessment and help can be given and to assess the severity of the dementia. These are usually divided into basic activities of daily living (ability to maintain personal care) and instrumental activities of daily living (more complex everyday tasks) and the use of a structured assessment tool, e.g. the Bristol Activities of Daily Living (Bucks et al., 1996), may help here. Behavioural and psychological disturbances are common in dementia, and questions about social interaction, mood, paranoia, hallucinations, wandering, aggression, sleep, and eating (both appetite and eating behaviour) are usually appropriate. Identifying such symptoms is important because they are frequently troublesome and when present usually cause more distress than cognitive symptoms. Specific symptoms are also important in the differential diagnosis of dementia. Thus changes in social interaction and eating behaviour are characteristic of FTD (Neary et al., 1998) (Chapter 36), and visual hallucinations and sleep changes (especially REM sleep behaviour disorder; see Chapter 51) are diagnostic features of DLB (McKeith et al., 2005) (see Chapter 35).
Previous medical and psychiatric history
Often, a referral from primary care will come with a computer printout of the patient’s previous illnesses and medication. Whilst such records are helpful as a starting point, they often contain errors and omissions and it is prudent to confirm these illnesses, especially where there is apparent contradiction, e.g. a history of hypothyroidism but no prescription for thyroxine. Questions about previous psychiatric history should always be asked and any illnesses in the months before and since the onset of the presenting symptoms should be carefully assessed; cognitive decline and mood alterations after operations or major illnesses are not uncommon. If ‘vascular factors’ (stroke, transient ischaemic attacks, myocardial infarction, angina pectoris, peripheral vascular disease, diabetes, hypertension, and falls) were not covered in the presenting complaint they should be asked about here, as evidence in support of or against a diagnosis of VaD.
Whilst a good referral usually lists the currently prescribed treatments, it is prudent to check this information against the actual medication the patient is taking by asking the patient to produce his or her medication. As discussed earlier, this helps identify problems with compliance, but also enables one to check about nonprescribed, alternative treatments. The use of substances such as vitamins, ginseng, and gingko biloba is not uncommon in older people. Polite questioning about why these treatments, as well as the prescribed ones, are being taken can give useful insights into current concerns and may raise issues not identified elsewhere. Checking the treatment actually being taken may also reveal an important recent change of medication; it is not uncommon for medication to be altered in hospital and for the patient to be on different treatments from the referral letter. Treatments with adverse effects on cognition and behaviour may have been commenced, e.g. oxybutinin for urinary incontinence impairs cognition, and sometimes necessary treatments may have been stopped inadvertently, e.g. antihypertensives.
Obtaining a family history of mental illness can be helpful because the major mental illnesses, including dementia, have a definite genetic contribution. In practice, however, it can be very difficult to determine the validity of the information given for at least two reasons. First, younger informants may not be able to corroborate the information given by older patients, and where cognitive impairment is present this may not be accurate. Second, when informed that a parent had, for example, dementia it is not at all certain this term corresponds to the clinical diagnosis a psychiatrist would make. Thus the added diagnostic value of a family history of mental illness is unclear. Other family history about relationships with parents and siblings may be helpful in understanding certain behaviours or for ‘functional illnesses’, but again this information can be difficult to verify and is probably of less importance than in younger adults.
This naturally follows on from the family history and for early life often raises the same problems of corroborating information. For cognitively impaired patients it is usually helpful to move to the personal history near the beginning of the interview because patients can talk happily about their earlier life and are not distressed by difficulties in remembering recent events. Taking a detailed personal history serves two main functions in old age psychiatry: (1) it enables the psychiatrist to assess the severity of amnesia without the use of cognitive testing, which can be upsetting for patients who are anxious or in denial. Thus names, dates, and anecdotes from early in life may be easily remembered, but events later in working life and the names of children and especially grandchildren are forgotten; the approximate age at which memory fragments gives an indication of the severity of a dementia; and (2), as in general psychiatry, it helps understanding the patient as a person.
Obtaining a personal history in old age psychiatry follows the same chronological order as with younger adults but there is clearly more ground to cover. Generally, events earlier in life will be less important, but care should be taken to sensitively ask about the quality of relationships and experiences at all stages of the patient’s life. Unless issues emerge, questions about childhood can be restricted to those to do with happiness and friendships at school and contentedness with family life at home. Older people usually left full-time education at 14 or 15 and one should be careful about inferring intelligence levels from such information or from patients’ own comments about their educational attainments. The subsequent history of further training and their occupational record gives a surer indication of their ability. When eliciting this information it is important to try to clarify the degree of autonomy and responsibility the patient enjoyed. Being told someone worked in a factory is of limited value: was this packing boxes, as a clerk, or as a production manager? When, as is frequently the case, someone held many jobs over the decades of their working life, it is necessary to focus on their longest employments and any jobs that had special importance. Comments made about a marriage or relationships may raise this as a natural topic for discussion, but if not then it is important to elicit a marital history, again focusing on the nature of the relationship, enjoyed (or not), with the spouse and any children and grandchildren. Where there have been several marriages and sexual relationships, then matters may be very sensitive and it may be appropriate to obtain only the broad outline about these. Another area requiring tactful enquiry is the current sexual activity and degree of satisfaction with this and in the marital relationship in general. Some couples may find such questions inappropriate, but important information about the strength of the marriage may be revealed that impinge on the caregiving role. Bereavement and other loss events are obviously much more frequently experienced by older people. Most cope very well, recognizing this as an inescapable part of growing old, but the loss of children, even when they themselves may have become old, is a severe blow for many and such losses often precipitate a search for help when other bereavements have been borne well. Again, most cope well with serious illnesses, probably again because they are regarded as inevitable, but some disabling illnesses do cause depressive reactions. Some people, especially men, find adapting to retirement difficult and this can create stress at home and consequent marital difficulty, and discreet questions about adapting to this major change are appropriate in those close to retirement. Another event that frequently causes problems, and one that is familiar to old age psychiatrists, is placement in residential care. Services and residential homes are aware of the difficulty a patient may have in adapting to this new situation, but the spouse left behind has to adapt too and depression and alcohol abuse may result.
Clearly, in taking a personal history in old age psychiatry there is an immense amount of information that could be obtained. Clinicians need to adapt their questions to the nature of the problem at hand, e.g. questions about relationships in earlier life are more important for people presenting with a depressive or anxiety disorder than for those with probable dementia.
At the initial assessment the clinician can only begin to understand the personality of a new patient. There is limited value in asking either the patient or any informants directly about the patient’s personality; such questions provoke stereotyped answers lacking in depth. If a detailed personal and social history has been obtained, then the questions about relationships with family, at school, and at work, along with achievements and activities at school, work, and elsewhere, will have shed light on enduring personality traits that may have changed with illness and are important in managing the patient. A few extra questions to clarify matters as this history is taken may be all that is needed at this stage. For older people with long-term functional illnesses, the effects of their chronic illness may now be indistinguishable from their personality, but developing an awareness of personality traits is still important in understanding their behaviour and relationships. For those with a more recent illness, especially a dementia, the premorbid personality moulds the presentation of the illness. Someone who has lived independently all his life, has strong opinions, and has always had things his own way is unlikely to settle quietly into a nursing home! A referral from a ward or a residential home for ‘aggressive behaviour’ in such a person needs to be interpreted in this context of their personality, rather than lead to a prescription for antipsychotic medication.
The social history follows smoothly from the personal history, bringing it up to date. The pattern of the patient’s everyday life, his or her activities, and relationships with family members and others should be clarified and confirmed. The amount of care currently given to the patient, by family, friends, and formal carers, needs to be elicited and, in addition to information from the patient and informant(s), a written care plan may be available that can provide evidence of day-to-day issues as well as of the programme of care. Other health professionals may be involved, e.g. a district nurse, and the patient may attend day care or have a respite care programme. Enquiring about the pattern of daily activity can bring out problems such as apathy or resistiveness, as well as providing further evidence about the extent of current difficulties. Having established an understanding of the pattern of the patient’s living and current support, the social history may conclude with more direct questions about the use of alcohol and other substances. The abuse of alcohol and benzodiazepines remains the major foci of concern, but increasingly old age psychiatrists will see people abusing other substances and should be alert to this possibility.
In recent years, the question of driving motor vehicles has become a prominent issue as an increasing number of older people, including women who used rarely to drive, own and drive their own vehicles (Brown and Ott, 2004). If the patient is driving, the clinician may ask others about any concerns they may have or incidents that have occurred, and will need to consider whether to ask the patient to stop driving if it appears he or she cannot safely drive any longer. Assessment clinically is difficult because, whilst several neuropsychological measures, especially visuospatial and attentional tests, correlate well with driving performance (Adler et al., 2005), such measures are not easily available and also do not provide definitive evidence. Hence this review recommended a driving assessment for all patients with mini-mental state examination (MMSE) scores of less than 24 or where concern exists (Adler et al., 2005). These issues are discussed in detail in Chapter 62.
It is also important to ask some general questions about people’s property and financial arrangements, as these will influence whether theya are at risk of exploitation and also the choices that they may have in the future. For example, ask whether they manage their finances themselves or whether they have help and whether they own their house or rent it? Have they made any provisions for the future, such as making a Will or establishing a Lasting Power of Attorney? And are they in receipt of any benefits, such as Attendance Allowance?
Mental state examination
It is important to remember that the mental state examination is an assessment of the mental state of the patient at the time of the interview, and so symptoms identified in the history, e.g. hallucinations, may not be manifest for recording as part of the patient’s current mental state. The mental state assessment begins on arrival and continues throughout the interview and should be recorded in the standard way.
Appearance and behaviour
Generally speaking, older people have maintained more formal modes of dress and behaviour. Although this is changing, it means the clinician may be informed that an apparently well-groomed man has slipped in his standards. It is a delicate matter to enquire directly about issues of dress and hygiene, but it is appropriate to gently ask where there is an apparent discrepancy between the patient’s state of grooming and that of the spouse or the surroundings in the home. Another important element to consider in assessing older people is the presence of sensory impairment. The severity of any deafness and blindness should be noted because of both the influence it has on the assessment process, especially on cognitive testing, and the importance in ensuring that handicaps related to these are addressed during the management of the patient’s illness. A brief assessment of general health, including changes in weight and pallor, and the level of alertness are also important.
The clinician should be looking for the range of behavioural changes manifest in functional illnesses, e.g. poor eye contact in depression or suspiciousness in paranoid schizophrenia. In old age psychiatry, psychomotor changes can be especially prominent in the affective disorders, with agitation a common feature in depression. When a patient exhibits apparent psychomotor retardation it is important to consider whether this may be apathy or related to Parkinson’s disease (bradykinesia) rather than a depressive illness. The high prevalence of parkinsonism in older people and the diagnostic importance of this in dementia, as a hallmark feature of DLB, means it is good practice to assess for parkinsonism in every new patient. This can be done briefly in most settings by carefully observing the patient at rest for tremor and bradykinesia, examining the arms for rigidity, and asking the patient to take a short walk to watch for gait changes and postural instability. At the same time the examiner should look for focal neurological signs, especially those that may be due to stroke disease. Such an examination should not replace a more detailed physical examination (see Chapter 11) and is necessarily limited at an initial assessment in someone’s home, but it frequently adds important diagnostic information.
Apathy is highly prevalent even in early dementia (Mega et al., 1996) and often mistaken for depression (Levy et al., 1998). The listless and disengaged presentation of someone with apathy can usually be distinguished from the withdrawn and retarded picture in depression, although it can be difficult, especially in more severely impaired patients, and both may be present. At interview someone with apathy may appear uninterested and switched off when the clinician is discussing the situation with an informant, but then warm up and engage well when directly addressed and show a reactive mood. On questioning why he has given up certain activities the apathetic patient will intimate he no longer has the drive to do them and in fact still enjoys visits from friends and family, whereas someone with depression will explain he does not enjoy them any more, or at least not as he used to (anhedonia). Whilst ‘frontal dementias’ may be accompanied by an apathetic picture, a disinhibited presentation is also well recognized and much less likely to be due to a bipolar illness than in younger adults. Subtler aspects of disinhibited behaviour, such as overfamiliarity, may be difficult to distinguish from the normal range of social interaction, but more overt behaviours, such as coarse joking, sometimes occur, although even in such circumstances it is wise to consider whether this may be an aspect of the patient’s premorbid personality. In all cases it is prudent to observe the reaction of relatives and to gently enquire about whether such comments or interactions represent a change, before regarding them as pathological.
Occasionally when dealing with older people the clinician will encounter someone who is loud and garrulous, consistent with FTD or mania, but quiet and impoverished speech is much more common, being a feature of the major degenerative dementias and depression. Dysphasia is another key feature of early dementing illnesses and one that does not occur in depression. Thus whilst poverty of speech does not in itself help to distinguish depression from dementia, the presence or absence of dysphasia does. However, deafness is a frequent problem and at interview it can be very difficult to distinguish whether an apparent failure to understand is because of receptive dysphasia or deafness. In milder dementia, subtle difficulties in speech structure occur, especially in finding names, but these can be difficult to detect at interview because patients can be adept at covering up these problems through the use of circumlocutions. Whilst instruments exist for formally assessing dysphasia (see Chapter 10 on cognitive assessment) these are not well suited to regular clinical practice.
Abnormalities of mood follow the same pattern as in disorders of younger adults. Lowering of mood in a depressive illness is often accompanied by a more prominent anxiety than in earlier life, with other associated anxiety symptoms, and this can be misleading; an anxiety presentation in later life, especially in someone with previous psychiatric history, should make one enquire carefully for a depression. The reluctance of many older people to express their feelings is better recognized and, although probably changing in the young-old compared with the old-old, the clinician still needs to be aware of this phenomenon. Elevation of mood in a manic illness tends to be attenuated, like the rest of the illness, in later life and also occurs in frontal dementias, and where present in dementia it may be indicative of a more severe illness, especially when associated with agitation. A feature of mood disturbance more specific to old age psychiatry is the mood lability that occurs with cerebrovascular disease (Morris et al., 1993). Stroke disease, but also less obvious cerebrovascular disease, is frequently accompanied by mood abnormalities and, whether the prevailing change is an elevation or a depression of mood, it is often highly labile. Apparently spontaneous, but typically short-lived, episodes of weeping without any sustained lowering of mood should alert the clinician to the possibility that this may be emotional lability related to stroke disease rather than a mood disorder as such (House et al., 1989).
With increasing age, people are more likely to spend time reviewing their past life and thinking about its end, and this seems to be a normal phenomenon. If someone is depressed, they may well start to feel that life is no longer worth living or that the future holds little for them. They may even wish that their life would come to end or that they might not wake up from their sleep one morning. Among people in their 90s it is not uncommon to hear them say that they feel they have lived too long. More active suicidal thoughts, e.g. I wish that I was dead, or thinking about how one might kill oneself, are less common and are more likely to occur in more severe depression. In the most extreme cases, a person will be actively seeking to harm or kill him- or herself. In the interview, therefore, it is important to assess this range of thoughts in a sensitive but thorough manner. A sequence of questions starting with ‘How depressed do you get?’ is a useful approach. ‘Do you cry a lot?’ ‘Are there times when you feel hopeless or that life is not worth living?’ ‘Are there ever times when you want your life to come to an end?’ ‘Do you ever think of harming yourself or doing away with yourself?’ ‘Do you have any plans to kill yourself?’ It is useful to note that in depressed older people, thoughts of wanting their life to end are common but active suicidal ideation is much less so. However, when it is present it is extremely serious and should be responded to.
Abnormalities in the form of thought occur in schizophrenia, depression, and bipolar disorder as in younger people, but it is rare to encounter formal thought disorder in late-onset schizophrenia. Incoherence of thought is, of course, common in dementing illnesses, and can occur early on but is more common in advanced disease.
Paranoid delusions, especially of theft, are extremely common in dementia and can be difficult to distinguish from the effects of amnesia and from related confabulation (Burns et al., 1990). Misidentification delusions are characteristic of dementia, and whilst the Capgras syndrome (more accurately a symptom) is the most well-known, there are several variants (Harwood et al., 1999). All appear to be related to a failure to recognize or correctly identify an image. In the Capgras syndrome the patient believes a close relative has been substituted by an exact double. The ‘mirror sign’ occurs when patients fail to recognize their image in the mirror, leading to them engaging this stranger in conversation or becoming angry at their presence. People seen on television are believed to be really present in the room with the patient in the ‘TV sign’, and in the phantom boarder syndrome the patient believes extra people are living in the house (perhaps after failing to recognize relatives). More sophisticated and complex delusions are unusual in dementia but remain typical of schizophrenia in either its early or late onset forms.
Psychiatrists working with older people encounter patients with auditory hallucinations, and sometimes olfactory hallucinations, typical of schizophrenia, but more frequently they encounter prominent and persistent hallucinations in other sensory modalities. This is a well-recognized consequence of the ‘organic’ nature of the illnesses that present to old age psychiatry. Visual and tactile hallucinations are frequently seen in patients with delirium in the general hospital but also in less overt delirium during home assessments. Complex and enduring visual hallucinations, characteristically of people and animals, are a core feature of DLB (McKeith et al., 2005; Mosimann et al., 2006) (see Chapter 35), but it is always important to consider whether they may be due to a delirium. Often it can be difficult to be sure whether the visual hallucination is truly occurring in the absence of a real stimulus or whether it is a misperception resulting from poor eyesight or some other defect in visual processing. However, since such problems in visual processing commonly occur in DLB, the presence of such phenomena suggests such a diagnosis, even if frank hallucinations cannot be confirmed. Sometimes, persistent, complex visual hallucinations are the only phenomenological feature confirmed during assessment; in particular, there may be no significant cognitive impairment or alteration in consciousness. Such patients are said to have Charles Bonnet syndrome and although many will proceed to decline cognitively and develop a dementia and other features of DLB, this does not appear to happen to everyone presenting in this way. Most old age psychiatrists are familiar with a similar phenomenon of persistent auditory hallucinations in clear consciousness and in the absence of cognitive decline (an auditory hallucinosis, sometimes called auditory Charles Bonnet syndrome). Typically such patients experience musical hallucinations for hours on end, hearing choirs singing hymns or bands playing old songs, and show good insight, often giving detailed descriptions of their hallucinations. Musical hallucinations are often association with sensorineural deafness, which suggests that the phenomenon may arise as a form of tinnitus that is organized into a more complex perception by the cerebral cortex. Neither the visual nor auditory variants of Charles Bonnet syndrome do well with antipsychotic treatment (Batra et al., 1997).
Formal cognitive assessment is dealt with in detail in Chapter 10. However, the clinician should have been gleaning cognitive information throughout the assessment. A structured brief instrument for assessing cognition should be used as part of the cognitive assessment, and although many are available, the MMSE (Folstein et al., 1975) appears to remain the favourite of most clinicians. Such instruments can provide an estimate of the extent of cognitive impairment and through repeated use over time enable the clinician to monitor illness progression or response to antidementia treatment; patients ‘typically’ decline at 2–3 points per year on the MMSE (Salmon et al., 1990), but in clinical practice immense variability between patients is observed. Whilst dysphasia can be difficult to assess formally during a standard clinical assessment it can frequently be observed during the process of history and mental state assessment. More obviously, inconsistencies and gaps in the patient’s account provide evidence of both the presence and the severity of amnesia. Other information on orientation, cognition, and perhaps spatial or executive dysfunction may also be detected. Whilst this information does not replace proper cognitive testing, it provides important additional evidence.
Insight is a complex, variable, and multidimensional phenomenon (Howorth and Saper, 2003). In patients with ‘functional’ disorders the degree of insight varies in much the same way as in younger adults. It is good practice to record a brief description of the extent of insight, rather than a summary phrase; for example, to say ‘she understands she has a depressive illness, of which her anxiety and tremor are manifestations, and is willing to take antidepressant medication for this’ rather than simply ‘full insight’. In people with moderate to severe dementia there is usually very little insight, just an awareness perhaps that one is not right and an acceptance that help is needed. However, patients may have more awareness of their illness than they are able to express verbally, perhaps due to better preservation of implicit memory (Howorth and Saper, 2003). Such insight appears to be greater for the amnesia than for the impact of the cognitive decline on their function and perhaps least for the impact of their illness on other people. In those with milder dementia there is typically more insight into the illness but the extent to which this is acknowledged varies considerably. Often the clinician suspects the patient and family are colluding in denying the severity of problems because they are aware of the implications. There has been a trend recently towards disclosure of the diagnosis of dementia and whilst such openness is usually appropriate this may not always be the case, especially when the family appears to prefer denial. When prescription of antidementia treatment is indicated the issue of diagnosis is especially acute and difficult to avoid and sensitive handling of the issue is needed.
Assessment of capacity
Capacity and decision-making have become increasingly prominent features of old age psychiatry practice and capacity assessment and the relevant legislation is dealt with in detail in Chapter 63. Key principles of the Mental Capacity Act 2005 (for England and Wales) are that capacity is specific to the time of the assessment and that it is functional in nature (capacity varies by the function being assessed). A formal assessment of capacity is not part of routine clinical assessment and indeed, for these reasons, strictly speaking, it cannot be made unless it is requested because the clinician needs to know what the patient is being assessed for at any point in time. When making an assessment the clinician needs to determine whether the four aspects of capacity (sufficient information has been conveyed; this information can be retained for long enough to make a decision; an ability to weigh matters up is present; a decision can be communicated to others) are fulfilled for each particular decision-making issue.
Even if assessing someone at home, a brief physical assessment is appropriate. In those who are found to be physically unwell, perhaps delirious, this will need to include hydration status and cardiovascular, respiratory, and abdominal assessments prior to referral to colleagues at the general hospital. In routine practice the need is for a neurological examination, especially to look for features of stroke disease and parkinsonism. Power, tone, coordination, basic sensation, gait, and most cranial nerves can all be examined without the need for special equipment. Such an examination does not replace the need for a full assessment with related physical investigations later but does provide valuable evidence to clarify the potential causes of a dementia.
The informant interview
Obtaining a history from a family member, friend, or carer who knows the patient helps fill out the history and ensure that all problems have been identified and understood. In those with cognitive impairment it is essential because the patient is unable to provide reliable information. A decision about how much useful information can be garnered from the patient can usually be made early in the interview. Those with early dementia or other cognitive impairment can typically give a reasonable account of their personal history until the recent past, and some information on major medical or psychiatric illnesses as well, but for the more impaired an informant is needed for this as well and the interview with the patient focuses on the mental state, especially the cognitive assessment.
Whilst most informants are reliable historians who desire appropriate treatment and help for the patient, this is not always the case and the assessing clinician should be alert to other possibilities. In some cases the informant is cognitively impaired themselves and on other occasions does not have sufficient knowledge of the patient. Occasionally conflict within the family is revealed by different opinions being offered and an informant may not be a disinterested party but one with his or her own views about what should be done, e.g. a patient kept inappropriately at home so benefits and allowances continue to be available.
Following the initial assessment, the psychiatrist is usually in a position to make a differential diagnosis and plan further assessments to clarify or confirm this and to deal with other important issues that have arisen. Inpatient admission and assessment is only necessary in a small minority of cases, usually where there are severe behavioural disturbances or significant immediate risks. Such admission provides for a thorough assessment but one that is limited by it not taking place in the home environment. More frequent is further assessment through attendance at a day unit. This is a suitable setting for coordinating a full physical assessment and associated physical investigations and one that allows nursing staff to provide longer-term assessment of the patient’s interaction with other people and to observe for significant psychopathology. In most cases, further assessment can be satisfactorily carried out at home, with visits from other relevant professionals as required. For example, in patients with borderline or mild cognitive impairments, suggesting they may have an early dementia, a more detailed neuropsychological assessment by a psychologist is helpful to clarify the pattern and extent of any deficits. Where difficulties in everyday functioning have been identified or are likely to be present, it is appropriate to refer to an occupational therapist for a detailed functional assessment. In such circumstances, and where financial issues arise and care plans may need adjustment, the involvement of a social worker specializing in dealing with older people with mental illness is also necessary. Community psychiatric nurses are able to monitor changes in mental state in response to treatment and to deal with carer stress issues and related problems that may be present in their relationship with the patient.
Principles of Management
Management in old age psychiatry settings should develop seamlessly out of the assessment process. The initial clinical assessment by the old age psychiatrist leads to the identification of the main needs of the patient and key carers. The psychiatrist will initiate, titrate, and monitor drug treatments targeted at key symptoms. When the initial assessment leads to a diagnosis of a functional illness, the appropriate pharmacological treatment can be initiated immediately and consideration given to the need for any additional psychosocial intervention. These treatments are broadly the same as for younger adults and their application to older people is discussed in later chapters (see Chapters 16–21).
When dementia is diagnosed, cholinesterase inhibitors or memantine may be commenced and, for both ‘functional’ and dementia illnesses, the psychiatrist will engage other members of the multidisciplinary team to conduct more detailed assessments in specific areas. These assessments in turn clarify needs and lead to focused interventions. The psychiatrist has a coordinating and consultative role in managing the overall strategy. In more straightforward cases the different individuals involved gradually withdraw as problems are solved, symptoms improve, and the patient settles in to a stable existence again. In people with dementia, such a meeting is usually followed by a period in which the agreed management plan is enacted and, if successful, all settles down again. In those who have severe functional illnesses, long-term follow-up by the psychiatrist and/or community nurse is usually the outcome, rather than discharge from the service. In the most resistant and severe illnesses, closer long-term follow-up may be needed by regular attendance at a day unit, e.g. to monitor psychosis in people on clozapine or mood in those on combinations of antidepressants and mood stabilizers. Throughout the assessment and management process the psychiatrist has an essential leading role using his or her expertise to make key decisions, supervise other team members, and ensure the patient’s care is optimally and ethically delivered. Management of dementia is discussed in more detail in Chapter 39, and for other conditions in the specific relevant chapters.
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