Expert Led Session:
‘The Assessment of the Older Person’
Dr Gareth Thomas
Dr Mark Worthington
Consultant Psychiatrists for Older People
Lancashire Care NHS Foundation Trust
MRCPsych Examinations
• Features in both Paper A and B
• Old Age CASC Scenarios from this presentation
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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
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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
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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
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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
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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:
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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
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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
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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:
Biological
•Problem & assessment
•Differentials
•Aetiology
Predisposing
Perpetuating
Protective
•Further investigations
•Treatment / Management plan (MDT)
•Prognosis
Psychological
Social
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
FRONTAL
Problem solving,
judgement, emotion
regulation, & personality
PARIETAL
Visuospatial
abilities, praxis
OCCIPITAL:
Vision
TEMPORAL
Language, speech,
memory, naming
Temporal lobes
• Verbal memory
• Language
• Visual memory
– Naming
– Comprehension
– Repetition
• Reading
• Writing (dysgraphia)
• Prosopagnosia
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Parietal lobes
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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)
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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
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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
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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
ORIENTATION
REGISTRATION
ATTENTION
LANGUAGE
MEMORY (RECALL)
EXECUTIVE FUNCTION
DRAW
SHAPES
Orientation
Time: Please can you tell me…..
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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……
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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
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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