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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

Mental Health Assessment of Older People

Information for referral to

Psycho Geriatrician

acknowledgements
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
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
some differences in information needed
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

key information
Key Information

Referral

Presenting Issue

Collateral Information

History

Screens

Medications

MSE

Risk

referral identify and describe
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?
presenting issues
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
collateral information
Collateral Information
  • Relatives
  • Neighbours
  • Community workers
  • Residential care givers
  • Other health professionals involved in care
  • Previous notes and summaries
history
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
picture may be complicated by physical conditions
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)
medications adverse reactions and interactions are common in the elderly
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
mental state examination
Mental State Examination
  • Appearance and Behaviour
  • Conversation
  • Mood and Affect
  • Perception
  • Thought processes
  • Cognition
  • Judgment
  • Insight
  • Rapport
cognitive functioning
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)
some useful tools
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
neuro vegetative features
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
risk use the usual risk assessment tools
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
delirium
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
recognising delirium this syndrome is characterised by changes to baseline
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
some differences in how depression in older people may present
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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