expert led session: ‘the assessment of the older person’ dr gareth thomas dr mark worthington...

Expert Led Session:‘The Assessment of the

Older Person’

Dr Gareth ThomasDr Mark Worthington

Consultant Psychiatrists for Older PeopleLancashire Care NHS Foundation Trust

MRCPsych Examinations

• Features in both Paper A and B

• Old Age CASC Scenarios from this presentation– History taking from patient and informant– Cognitive Assessment – Physical Examination– ECG interpretation

Aims and Objectives

• Aim– Gain an overview of the assessment of an older person

• Objectives– Understand the principles of assessing the older person

which includes history taking, mental state examination, risk assessment and a holistic formulation

– Understand the basics of a cognitive assessment– Understand the importance of assessing for delirium in the

older person

Overall Process

• History

• Mental State Examination

• Focused Physical Examination

• Investigations

• Formulation

• Risk Assessment

• Multidisciplinary Management Plan

History Taking

Referral Information

• Who made the referral?• Is the patient already known to MH Services or is this

a new referral?• What has been their journey to this point?

• Has the patient come from home or are they in a care setting? (what type?)

• Detained under MHA (1983) or DOLS?

Presenting Complaint

• Why the patient has presented• What What is the patients perception of their

difficulties?• Most distressing symptom(s)

History of Presenting Complaint

• Onset and evolution of symptoms• Is this a new problem?• When did they last feel like their old self?• Has there been any recent trigger events– Changes in the social situation– Changes to physical health– Changes in care patterns– Medication changes

• Has the patient sought any help so far?• What interventions have occurred so far?

Relevant Psychiatric History

• Current or previous diagnoses?• Admissions to hospital - ?under MHA• Are there any specific relapse signs?• Interventions and their success… if not successful

then why not?• Does the patient engage with services?• Informant history/ review old notes / discuss with

relevant teams and GP

Physical Health

• Comorbidity common• Information from GP• May need general medical notes

• Are they under a specialist currently – who & where?• Any investigations ongoing?• Do we need to liaise with other specialties?

Medications• Polypharmacy is common• Find out any recent changes in medications

• Compliance – does patient know what and why they are taking medications?

• Don’t forget OTC medicines & allergies

• Who gives the medications?• Is this with the assistance of carers or does the patient self

medicate?

Family History

• Psychiatric illness• Neurological diseases• Dementia

Personal and Social History• Not always easy at the first interview• Overview from birth to now• Can help to put problems into context

• Level of education and occupational history indicates levels of expectation in formal cognitive assessments

• Current situation important– Living arrangements– Care packages and what they help with– Any deficits identified in care– Are there any Lasting Powers of Attorney for health or finances?

Alcohol And Drug History• Never assume the older person doesn’t drink or take drugs

• Every patient must be asked!

• Drinking pattern:– Estimate units consumed in average week– Frequency– Features of harmful use or dependence?– Duration – May be reflection of bereavement or isolation or may be a long

standing issues

Forensic History

• Explore previous criminal convictions

• Any pending cases?

• Difficulties in later life might be pointer to developing problem

(Lots of high profile celebrity cases involving the older person highlights the importance of asking about this)

Pre-Morbid Personality

• How would the patient describe themselves when well?• How would others describe them?• How do they usually cope with difficulties / stress?• How outgoing are they usually?

• Have social/life changes meant previous abnormal personality traits have surfaced now?

Mental State Assessment

Mental State Examination

• Appearance and Behaviour• Speech• Mood• Thoughts• Perceptions• Cognitions (we will focus on this aspect in a few

minutes)• Insight

The Assessment of Capacity

• This is a complex assessment and is decision specific

• It is important for complex decisions such as admission to hospital, treatment and placement decisions that a record of the patient’s capacity is documented and acted on accordingly

NB: There is an MRCPsych LEP specifically about the Legal aspects of OA Psychiatry in year 2 which covers Capacity

Physical Examination

Physical Health Review• Full systems review

• Focused examination (based on hx and presenting complaint)

• Bloods, urine studies and relevant imaging important

• Must act on findings

• Discuss with seniors and refer if appropriate

NB: There is an MRCPsych LEP specifically about Delirium

Risk Assessment‘The possibility of beneficial and harmful outcomes and the

likelihood of their occurrence in a stated timescale’

Risk Assessment (Safety Profile), An Introduction To The Arrangements For Risk Assessment In Lancashire Care NHS Trust

Risk Assessment• These are elements that should be thought about when

assessing patient and brought together in formulating the risk– Suicide/self harm risks– Neglect/history of neglect– Harm to others– Treatment/illness related risks– Substance misuse– Social circumstances

• Risk should be assessed regularly & be multidisciplinary

Formulation

• Description of:

• Problem & assessment

• Differentials

• Aetiology

• Further investigations

• Treatment / Management plan (MDT)

• Prognosis

Biological Psychological Social

Predisposing

Perpetuating

Protective

Cognitive Assessment

What is cognitive assessment?

• Cognition– Not just memory– Includes other higher cortical functions such as

orientation, perception, language, planning, judgement, & comprehension

• Cognitive assessment– Starts with history taking– It is useful to be aware of the relation of function to

different brain areas

Basic Neuropsychology

PARIETALVisuospatial

abilities, praxis

OCCIPITAL:Vision

FRONTALProblem solving,

judgement, emotion regulation, & personality

TEMPORALLanguage, speech, memory, naming

Temporal lobes

• Verbal memory• Language– Naming– Comprehension– Repetition

• Reading• Writing (dysgraphia)

• Visual memory

• Prosopagnosia – (parieto-temporal)

Parietal lobes

• Calculations*• R-L disorientation*• Finger agnosia*• Dyspraxia

• Receptive dysphasia• Naming / agnosia• Dysgraphia*

*=Gerstmann’s syndrome

• Constructional apraxia• Neglect / inattention• Topographical

disorientation• Anosognosia

Frontal lobes

• Luria (hand sequence)

• Go-no-go (inhibitory control)

• Similarities (conceptualisation)

• Cognitive estimates (abstraction)

• Letter / category fluency (initiation)

History taking & Assessment

• What problems have they / others noticed with their memory? (if any)

– Do they struggle to remember days / dates?– Have they forgotten recent events?– Do they forget appointments / medication ?– Do they tend to misplace things around the home?– Do they ask repetitive questions?– Do they ever get lost / struggle with route finding?

– When did the symptoms start? Was it sudden?– Have they progressed slowly & steadily or step-wise?

History taking continued…• Enquire about symptoms in other cognitive domains

– Attention and alertness (including fluctuations)– Language: Speech / Reading / Writing– Executive function (planning, multitasking etc.)– Spatial & perceptual functioning– Praxis

• Activities of daily living (ADLs)– Are they still able to do their domestic tasks– Any problems using household appliances / managing finances / driving?– Do they need assistance?

• Psychological and behavioural symptoms– Any changes in personality / out of character behaviours?– Features of depression or anxiety?– Delusions or hallucinations?– Changes in sleep / appetite?

General History• Past psychiatric history

– History of treatment for depression

• Past medical history– Vascular risk factors / CVA– Gait changes / falls– Bowel and bladder problems

• Family History – Psychiatric or neurological illness– Dementia

• Personal History– Age on leaving education; occupation– Drug & alcohol history

• Risks– E.g. Self-neglect, driving, wandering, falls, fire, medication, financial abuse,

aggression, carer stress, lack of insight

Cognitive Assessment: The Practical Aspects

Basic Screening Tests

• MMSE© / AMTS• Quick & easy to use• Limited range of abilities– Don’t measure executive functioning– Poor memory assessment– Poor sensitivity

• Other standard tools: e.g. MOCA / ACE-III

For an informal assessment you don’t have to, or can’t always use a standardised tool….

Sometimes you have to improvise

A simple mnemonic

ORIENTATIONREGISTRATIONATTENTIONLANGUAGE

MEMORY (RECALL)EXECUTIVE FUNCTIONDRAW SHAPES

Orientation

Time: Please can you tell me…..• What time of day it is? (approx.) • What day of the week it is today?• What is the date?• What month is it now?• What year is it?

Place: Could you tell me……• What is the name of this building?• What floor of the building are we on?• Which town / city are we in?• What is the name of the county?• What country are we in now?

Registration

• Tell the patient you are going to say three words which you would like them to repeat

• Can repeat the instruction up to five times

• Inform them you will be asking again later

Attention

Serial subtraction

OR

Month of the year in reverse

Language & Comprehension

• Naming– 2 objects

• Comprehension– Multi-stage instruction

• Repetition– Words and sentence

• Reading– Read and follow sentence

• Writing– Ask to write sentence of their

choice

Memory / Recall

• Anterograde– Ask them to repeat the items

learnt earlier

• Retrograde– What is the name of the current

prime minister?– What year did World War II end?

Executive Function

• Motor– 3 stage Luria task– Alternating hand movements

• Similarities– Apple and orange?– Table and chair?– Tennis & rugby?– Poem & statue?

Draw Shapes

• Copy wire diagram

• Draw clock face

Summary

• A structured approach is important• Have low threshold for cognitive assessment• Devise a way of remembering the areas to be

covered• A holistic approach to assessment / management is

important

• Cognitive assessment is easy if you’ve practiced!– With each other– But especially with real patients

Further Reading• Butler R., Pitt B. Seminars In Old Age Psychiatry. Royal College Of

Psychiatrists. Gaskell. 1993

• Risk Assessment (Safety Profile), An Introduction To The Arrangements For Risk Assessment In Lancashire Care NHS Trust

• Young J, Meagher D, & MacLullich A. Cognitive assessment of older people. BMJ 2011;343: d5042 www.bmj.com/content/343/bmj.d5042

• For more detailed information on cognitive assessment the following is a useful and succinct article:– C M Kipps, J R Hodges. Cognitive assessment for clinicians. Journal of

Neurology, Neurosurgery & Psychiatry 2005;76:i22-i30 http://jnnp.bmj.com/content/76/suppl_1/i22.full