Mental Health Assessment of Older People

1. Mental Health Assessment of Older People Information for referral to Psycho Geriatrician

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

3. 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

4. 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

5. Key Information Referral Presenting Issue Collateral Information History Screens Medications MSE Risk

6. 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?

7. Presenting Issues • What are the major presenting issues • Describe symptoms and behaviour • Onset, progress, frequency, intensity • How do they impact on the person’s life • What makes them worse or better • Note any precipitants

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

9. History • Medical history (identify GP’s 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

10. 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)

11. 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

12. Mental State Examination • Appearance and Behaviour • Conversation • Mood and Affect • Perception • Thought processes • Cognition • Judgment • Insight • Rapport

13. 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)

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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