Mental Health Assessment of Older People

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Mental Health Assessment of Older People

• Information for referral to
• Psycho Geriatrician

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Acknowledgements

• I would like to thank Dr Adriana Lattanzio for
• her support and advice in preparing this
• presentation
• John Mansfield
• September 2008

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Assessing older people

• Aged Mental Health Care Services (AMHCS) have a
  country consultation and liaison service
• An assessment pack and key contact people are
  listed on their web site (www.mhsfopcls.com)
• Normally see clients over 65 ( 45 yrs for people
  of Aboriginal or Torres Strait Island descent)
  with a first presentation of a mental health
  issue
• Will see people under 65 if there is a mental
  illness and associated age related issues.
• Will see younger clients with a dementia,
  following acceptance in to AMHCS by a Consultant
  Psychiatrist

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Some differences in information needed

• Much of the information required is similar to
• a standard adult assessment
• The marked differences here are
• Physical illness and frailty
• Medications and adverse reactions
• The possibility of cognitive decline
• The complexity of support and care
• Needing to distinguish depression, delirium and
  dementia

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Key Information

• Referral
• Presenting Issue
• Collateral Information
• History
• Screens
• Medications
• MSE
• Risk

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Referral Identify and Describe

• Who referred? What are they seeking?
• Frequent requests include clarifying diagnosis,
  medication advice, advice on management
  (including behavioural management), support for
  carers
• What does the client see as the problem and what
  do they want?
• What does they carer see as problem?

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Presenting Issues

• What are the major presenting issues
• Describe symptoms and behaviour
• Onset, progress, frequency, intensity
• How do they impact on the persons life
• What makes them worse or better
• Note any precipitants

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Collateral Information

• Relatives
• Neighbours
• Community workers
• Residential care givers
• Other health professionals involved in care
• Previous notes and summaries

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History

• Medical history (identify GPs and specialists
  involved in care)
• Psychiatric history
• Alcohol or substance use (risky and dependant use
  is quite common in this age group)
• Personal and social history (include support and
  care agencies involved. Explore losses.)
• Activities of daily living
• Functional limitations sight, hearing,
  mobility, continence

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Picture may be complicated by physical conditions

• Common Medical Screens
• Biochemistry (check glucose, calcium and LFT)
• Routine haematology
• Vitamin B12 and folic acid concentrations
• Thyroid function
• MSSU (urine culture)
• Syphilis serology
• Medication serum levels (e.g. Digoxin, Warfarin,
  Lithium, Valproate)
• Chest X ray
• CT scan of head (if available)

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Medications Adverse reactions and interactions
are common in the elderly

• List of medications taken by client (including
  start dates if available)
• It is worth double checking with GP and carers
• List non prescription medications
• Consider compliance do they take the
  medications and do they take them as prescribed?
• How is medication given Webster packs, dosette,
  self, relative
• Note changes and variations to regimes
• Pay particular note of medications recently
  commenced or ceased

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Mental State Examination

• Appearance and Behaviour
• Conversation
• Mood and Affect
• Perception
• Thought processes
• Cognition
• Judgment
• Insight
• Rapport

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Cognitive functioning

• Levels of consciousness
• Memory - short term (registration and recall) and
  long term
• Orientation time, place, person
• Attention and concentration (serial 7s, months of
  the year backward)
• MMSE is widely accepted (but not specific)

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Some Useful Tools

• Mini Mental State Examination (MMSE)
• RUDAS for cognitive testing of CALD clients
• Glasgow Coma Scale
• Geriatric Depression Scale (short form)
• Delirium Assessment Scale
• Audit (Alcohol)
• ADL checklists

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Neuro-Vegetative Features

• Note changes to base line
• Levels of pleasure or interest
• Social activities and participation
• Sleep
• Appetite and weight
• Motivation, energy
• Concentration
• Psycho motor changes (agitation and retardation)
• Libido (enquire about interest rather than
  activity
• Diurnal mood variations

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Risk Use the usual risk assessment tools

• In addition
• Consider increased risk of exploitation (elder
  abuse is common)
• Vulnerability
• Risk of falls
• Risk of progression of physical illness
• The risk of delirium

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Delirium

• Depression, Dementia and Delirium can be
  difficult to differentiate
• Referral to a psycho geriatrician will help to
  clarify this issue
• However, as delirium is potentially a life
  threatening condition if is useful to be aware of
  the how this condition may present so that prompt
  medical attention can be sought

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Recognising Delirium This syndrome is
characterised by changes to baseline

• Rapid onset
• Impairment of recent memory
• Symptoms typically fluctuate through the day,
  with periods of relative calm and lucidity
  alternating with periods of florid delirium
  (often worse at night)
• Disruption of sleep wake cycle (often awake at
  night)
• Disorganised thoughts
• Fluctuating levels of attention and alertness
• Confusion and disorientation (especially time)
• Hyper-vigilance or reduced vigilance
• Hallucinations, illusions and misinterpreted
  stimuli

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Some differences in how depression in older
people may present

• Depression may present with somatic concerns as
  the main complaint
• Preoccupation with guilt, finances may reach
  delusional proportions
• Agitated depression is more common in older
  people.
• Depression with
• - Motor agitation
• - Psychic agitation or intense inner tension
• - Racing or crowded thoughts

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