Clinical assessment of elderly

NIMHANS, 22.04.2010

Ramkumar G S

Chairperson Prof Mathew Varghese.

Normative development and adaptive tasks of the elderly Ref. Handbook of Geriatric Assessment.Joseph J Gallo.2006

• Dealing with loss through death and relocation of family and friends.

• Adjusting to changes in living arrangements.• Retiring• Managing with less income• Changing social roles• Increasing leisure time.• Changing sexual and physical functioning.• Accepting the inevitability of death.

• The domains of multidimensional assessment, such as mental health, physical health, functioning, and social situation, set the field of geriatrics apart from other fields of medicine.

Purpose of psychiatric assessmentRef – Rutter and COX 1981

• Pose questions to obtain factual information on historical events, happenings and activities.

• It acts as a stimulus to ellicit emotions, feelings and attitudes.

• Begin to establish a therapeutic relationship with patients.

Should result in a comprehensive diagnostic formulation and importantly a proper assessment of need.

Locus

• Domiciliary assessment by hospital based psychiatrist/ GP/ community health worker.

• Assessment in residential homes.

• Outpatient assessment. [ memory clinics are becoming increasingly common- Wright

and Lindesay 1995 ]

• Inpatient assessment.

Geriatric assessment

• Not fundamentally different.• Some features that distinguish it.• If the goals are common the routes taken to reach

them are not necessarily so.• Outline of interview to be given at the beginning.• No assumption about relationships- ask who is who• Expect a more medical approach.• Talk slow, clear and loud. Face should not be

covered.

Geriatric assessment

• Many aspects of cognitive testing can be incorporated in interview.

• Some clinicians start with background history , others with HOPI.

• Patient to be interviewed first. Also give sometime alone

• Present with more physical rather than psychological complaints.( persistent themes)

• “Ageism” insomnia, fatigue as normal.• Social class, values,culture,• Biopsychosocial perspective.

Geriatric assessment

• Rapport, comfortable, privacy, confidentiality.• Visit to a doctor may induce fear, shame anxiety in the

patient.• Expect to be treated with respect.• Hand contact or namasthe• Medical approach is respected.• Accept the limitations and keep atmosphere as relaxed as

possible.• “ I will come to your main problem first let me know a little

about your background”• Inaccurate information from the patient can be as clinically

informative as that which is correct. But dementia or depression should not be concluded at this stage.

Geriatric assessment

• Open ended questions

• Involve family where ever feasible.• Details of medical illness• A feedback on diagnosis may be possible

on 2nd visit after the baseline investigation are available.

• Need to keep open mind as initial diagnosis may need to be revised

HOPI

Temporal sequence of symptoms development in relation to environmental events, physical health, functional ability and treatment interventions.

Disease vs Illness• onset, course• Common symptoms– excessive weakness,

depressed mood, memory problems, difficulty concentrating, hopelessness, helplessness, isolation, suspicion, anxiety and agitation, sleep problems, appetite problems.

• Other critical symptoms presence or absence of suicidal thoughts, profound anhedonia, impulsive behaviour, confusion, delusion and hallucination.

• Subsyndromal depression• Insomnia+anorexia+lack of interest.• Same occur in dementia• Sexual dysfunction, somatization• Variety of stresses

• Delirium.

• Cognitive decline

• Pain, visual and hearing impairment

• Psychiatric history……leading question for substance use

Past illness

• Similar illness in past– perspective of family is valuable.

• Other illnesses

• Not infrequently childhood trauma.

• Patient can sometimes get angry when we probe into the past.

Personal history

• Employment history.• Marital history.• Loss events.• Context of current problems.• Sexual history.• Personality- the physician should avoid the

stereotyphied notion of the old as either cantankerous or stuborn or else passive, sweet & dependent

coping stratergies. information from others.

Medication history

• Check both pill bottles and slips.

• Fluoxetine+ warfarin can cause bleeding.

• Propranolol + alpha methyldopa depression

• Bnz cause confusion

• TCA + clonidine hypertension.

Family history

• Genogram.

• Information about medication which has benefited a similarly will be handy in pharmacological management.

Functional assessment (HOPI)

• Social functioning

• Activities Of Daily Living( ADL)

Social assessment

• Quality and quantity of social contact.

• Current level of contact may also be indicative of past contacts.

• Social network- marital status, living arrangement, who can bring to the emergency when required.

• Informal support- neighborhood, congregate housing setting, church, social & ethnic group.

Career's needs.

• Independent interview of career• Objective assessment of caretaker burden• How much time they spend, effect on their

family, social and employment.• Subjective burden.• Clinical depression in caregiver.• Physician should take realistic perspective.• Careers have rights ( Career’s Act)

Family assessment

• Geriatric psychiatry almost by definition is family psychiatry.

• To advocate for the psychiatrically disturbed older adult.

• Availability, tangible services, perception of family support by the patient, tolerance by family of disturbance in patient.

MSE

• Serial mse may be needed• General observation. Attention and conc.• Psychomotor activity-Agitation. retardation • Guarded and suspicious– paranoia• Apathetic and withdrawn• bradykinesia with slow gait is common in the 8th

to 10th decade.• Short shuffling gait, mask like facies.• Impulsive disinhibited behavior with minimal

cognitive impairment may be the first signs of frontotemporal dementia.

Talk and thought

• Dysphasia vs retardation.

• Mutism. Paucity of speech

• Circum locution.

• Slow flight of ideas

• Content of thought – somatic obscessions, hypocondriacal delusions………

mood

• Depression can be missed

• Masked depression.

• Somatization.

• Suicidal ideation.

Cognitive function

• MMSE24 out of 30

• HMSE

• Neuropsychological testing.

Schema for testing cognitive function based on extented MMSERef: OTP, 2nd edition 2009

Function Sub function Examples

orientation Time

Place

person

Year, month,date, season

Own address, hosp, city,country

Own name, recognise others

memory Immediate recall

Delayed recall

Long term recall

General information

Immediate recognition of 3 objects or address

Repetition as above after a distracter task

Give historical or personal events

Names of politicians or other VIPs

concentration Month of tear in reverse, count from 20 back,

praxis Construction

Ideomotor

dressing

Copy diagram of interlocking pentagons

Draw a clock and indicate time

Put on a jacket, refasten buttons

Sensory recognition Visual

Auditory

Tactile

Reading

olfactory

Recognize photographs from unusual angles

Regognise the door bell

Recognise objects placed in palm

Any sample with large print

Recognise something from the kitchen

language Expressive

Understanding

naming

Repaet “no ifs ands or buts”

Carry out three stage command

Naming objects of increasing complexity

Verbal fluency List as many items from a category

writing Write an ordinary english sentence

calculation Not too complex, a simple sum

Left right orientation Face hand test

Abstract thinking ‘In what way an aplle and banana alike?’

‘In what way are a boat and car similar?’

Interpretation of simple proverbs

Daily functioning

• ADLs basic, instrumental, and more complex social and cog functions.

• Informant opinion more valuable

• Instruments not widely used.

• Insight and judgement

Physical examination

• General physical examination focal neurological signs, abdominal mass, hernia , breast carcinima.

Motor and sensory fn, reflexes,coordination and evaluatuon of vision, hearing

SCALES ( used in Geriatric clinic , NIMHANS)

• Hindi Mental Status Examination (HMSE)

• Everyday Abilities Scale for India (EASI)

• Geriatric Depression Scale (GDS)

• Hachinski Ischemic Score

References

• Oxford textbook of psychiatry 2nd edition

• Comprehensive textbook psy 9th edition

• Textbook of geriatric psy Am psy pub. 2004.

• Handbook of geriatric assessment 4th edition, joseph j Gallo.Jones and Bartlett publishers 2006.

• And others……………..