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Mental Health Assessment of Older People Information for referral to Psycho Geriatrician Acknowledgements I would like to thank Dr Adriana Lattanzio for her support and advice in preparing this presentation John Mansfield September 2008 Assessing older people

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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 person’s 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 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


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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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