Chapter 4. The Psychiatric Interview of Older Adults
© American Psychiatric Publishing
The foundation of the diagnostic workup of the older adult experiencing a psychiatric disorder is the diagnostic interview. Unfortunately, in this age of increasing technology in the laboratory and standardization of interview techniques, the art of the clinical interview has suffered. Also, time pressures limit the ability of clinicians to perform a thorough diagnostic workup. Nevertheless, such a workup will save valuable time over the course of an older adult’s illness. In this chapter, I review the core of the psychiatric interview, including history taking, assessment of the family, and the mental status examination; describe structured interview schedules and rating scales that are of value in the assessment of older adults; and outline techniques for communicating effectively with older adults.
History
The elements of a diagnostic workup of the elderly patient are presented in Table 4–1. To obtain historical information, the clinician should first interview the patient, if that is feasible, and then ask the patient’s permission to interview family members. Members from at least two generations, if available for interview, can expand the perspective on the older adult’s impairment. If the patient has difficulty providing an accurate or understandable history, the clinician should concentrate especially on eliciting the symptoms or problems that the patient perceives as being most disabling, then fill the historical gap with data from the family.
History Psychiatric interview of the elderly patient
History
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Present illness
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Past history
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Family history
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Context
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Medication history
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Medical history
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Family assessment
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Mental status examination
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Present Illness
DSM-5 (American Psychiatric Association 2013) provides the clinician with a useful catalog of symptoms and behaviors of psychiatric interest that are relevant to the diagnosis of the present illness. Symptoms are bits of data—the most visible part of the clinical picture and generally the part most easily agreed on among clinicians. Symptoms should be defined in such a way that if multiple clinicians independently obtain equivalent information, they would have minimal disagreement about the presence or absence of a symptom. The decision about whether those symptoms form a syndrome or derive from a particular etiology must be determined independently of the data collection on symptoms.
Even so, the clinical interaction may be confounded by bias when a clinician communicates with an older adult about psychiatric symptoms. As many insightful clinicians, such as Eisenberg (1977), have recognized, physicians diagnose and treat diseases—that is, abnormalities in the structure and function of body organs and systems. Patients have illnesses—experiences of disvalued changes in states of being and in social function. Disease and illness do not maintain a one-to-one relationship. Factors that determine who becomes a patient and who does not can be understood only by expanding horizons beyond symptoms. During the process of becoming a patient, the older adult, usually with the advice of others, forms a self-diagnosis of his or her problem and makes a judgment about the degree of ill-being perceived. For some, illness is perceived when a specific discomfort is experienced. For others, illness reflects a general perception of physical or social alienation and despair. Given that few uniform, satisfactory definitions of illness (or ill-being) exist, it is not surprising that terms for wellness (or well-being) also mean different things to different people. The historical background and the values of the older adult in a social class and culture contribute to the formation of constructs regarding the nature of the problem, the cause, and the possibility for recovery.
For these reasons, the clinician must take care to avoid accepting the patient’s explanation for a given problem or set of problems. Statements such as “I guess I’m just getting old and there’s nothing really to worry about” or “Most people slow down when they get to be my age” can lull the clinician into complacency about what may be a treatable psychiatric disorder. On the other hand, the advent of new and disturbing symptoms in an older adult between office visits can exhaust the clinician’s patience, thereby derailing pursuit of the problem. For example, the older adult with illness anxiety disorder whose awakenings during the night are increasing may insist that this symptom be treated with a sedative and plead with the clinician not to allow continual suffering. In the clinician’s view, however, the symptom is a normal accompaniment of old age and therefore should be accepted. Distress over changes in functioning, such as sexual functioning, may overwhelm the older adult patient and, especially if the clinician is perceived as unconcerned, may precipitate self-medication or even a suicide attempt.
To prevent attitudinal biases when eliciting reports by the older adult (which may result in missing the symptoms and signs of a treatable psychiatric disorder), the clinician must include in the initial interview a review of the more important psychiatric symptoms in a relatively structured format. Common symptoms that should be reviewed include excessive weakness or lethargy; depressed mood or “the blues”; memory problems; difficulty concentrating; feelings of helplessness, hopelessness, and uselessness; isolation; suspicion of others; anxiety and agitation; sleep problems; and appetite problems and weight loss. Less common yet critical symptoms that should be reviewed include the presence or absence of suicidal thoughts, profound anhedonia, impulsive behavior (“I can’t control myself”), confusion, delusions, and hallucinations.
The review of symptoms is most valuable when considered in the context of symptom presentation: When did the symptoms begin? How long have they lasted? Has their severity changed over time? Are there physical or environmental events that precipitate the symptoms? What steps, if any, have been taken to try to correct the symptoms? Have any of these interventions proved successful? Do the symptoms vary during the day (diurnal variation)? Do they vary during the week or with seasons of the year? Do the symptoms form clusters—that is, are they associated with one another? Which symptoms appear ego-syntonic, and which appear ego-dystonic? As symptoms are reviewed, a specific time frame facilitates focus on the present illness. Having a 1-month or 6-month window enables the patient to review symptoms and events temporally—an approach not usually taken by distressed elders, who tend to concentrate on immediate sufferings.
Critical to the assessment of the present illness is an assessment of function and change in function. The two parameters that are most important (and not included in usual assessments of physical and psychiatric illness) are social functioning and activities of daily living. Questions should be asked about the social interaction of the older adult, such as the frequency of his or her visits outside the home, telephone calls, and visits from family and friends. Many scales have been developed to assess activities of daily living; however, in the interview, the clinician can simply ask about the patient’s ability to get around (e.g., walk inside and outside the house), to perform certain physical activities independently (e.g., bathe, dress, shave, brush teeth, select clothes), and to do instrumental activities (e.g., cook, maintain a bank account, shop, drive). It is also important to assess how often the elder actually engages in these activities; for example, the ability to walk outside does not always translate to outside exercise.
Past History
Next, the clinician must review the past history of symptoms and episodes. Has the individual had similar episodes in the past? How long did the episodes last? When did they occur? How many times in the patient’s lifetime have such episodes occurred? Unfortunately, the older adult may not equate present distress with past episodes that are symptomatically similar, so the perspective of the family is especially valuable in the attempt to link current and past episodes.
Other psychiatric and medical problems should be reviewed as well, especially medical illnesses that have led to hospitalization and the use of medication. Not infrequently, an older adult has experienced a major illness or trauma in childhood or as a younger adult but views this information as being of no relevance to the present episode and therefore dismisses it. Probes to elicit these data are essential. Older adults may ignore or even forget past psychiatric difficulties, especially if these difficulties were disguised. For example, mood swings in early or middle life may have occurred during periods of excessive and productive activity, episodes of excessive alcohol intake, or periods of vague, undiagnosed physical problems. Previous periods of overt disability in usual activities may flag those episodes. An older person sometimes becomes angry or irritated when the clinician continues to probe. Reassurance regarding the importance of obtaining this information will generally suffice, except when dealing with a patient who cannot tolerate the discomfort and distress, even for brief periods. Older persons who have chronic and moderately severe anxiety or a histrionic personality style, as well as distressed Alzheimer’s patients, tolerate their symptoms poorly.
Family History
The distribution of psychiatric symptoms and illnesses in the family should be determined next. The older person with symptoms consistent with major neurocognitive impairment may have a family history of a disorder such as major neurocognitive disorder due to Alzheimer’s disease. The genogram can be valuable for charting the distribution of mental illness and other relevant behaviors throughout the family tree. This genogram should include parents, blood-related aunts and uncles, brothers and sisters, spouse(s), children, grandchildren, and great-grandchildren (recognizing that data from many family members will not be complete). A history should be obtained about institutionalization, significant memory problems in family members, hospitalization for a nervous breakdown or depressive disorder, suicide, alcohol abuse and dependence, electroconvulsive therapy, long-term residence in a mental health facility (and possibly a diagnosis of schizophrenia), and use of mental health services by family members (Blazer 1984).
Of relevance to the pharmacological treatment of certain disorders—especially depression—in older adults is the tendency of individuals in a family to respond therapeutically to the same pharmacological agent. If the older adult has a depressive disorder and if biological relatives have been treated effectively for depression, the clinician should determine what pharmacological agent was used to treat the depression. For example, a positive response to sertraline in a family member of the depressed older patient could make sertraline the drug of choice in treating that patient, assuming side effects are not at issue (Ayd 1975).
Accurate genetic information can be better obtained when family members from more than one generation are interviewed. Many psychiatric disorders are characterized by a variety of symptoms, so asking the patient or one family member for a history of depression is insufficient. Research on the genetic expression of psychiatric disorders in families requires the psychiatric investigator to interview directly as many family members as possible to determine accurately the distribution of disorders throughout the family. Such detailed family assessment is not feasible for clinicians, yet a telephone call to a relative with permission from the patient may become a standard of clinical assessment as the genetics of psychiatric disorders are clarified.
Context
Psychiatric disorders occur in a biomedical and psychosocial context. Although the clinician will try to determine what medical problems the patient has experienced, it is possible to overlook a variation in the relative contribution of these medical disorders to psychopathology or to overlook the psychosocial contribution to the onset and continuance of the problem. Has the spouse of the older adult undergone a change? Are the middle-aged children managing high stress, such as simultaneously caring for an emotionally disturbed child and the loss of employment? Are the grandchildren placing emotional stress on the elderly patient, perhaps by requesting money? Has the economic status of the older adult deteriorated? Has the availability of medical care changed? Although many psychiatric disorders are biologically driven, they do not occur in a psychosocial vacuum. Environmental precipitants remain important in the web of causation leading to the onset of an episode of emotional distress and are critical to the assessment of the older adult.
Medication History
It is essential to evaluate the medication history of the older adult. A careful review of current and past medications by the clinician, a nurse, or a physician’s assistant is essential. The older person should be asked to bring to the appointment all pill bottles, a list of medications taken, and the dosage schedule. A comparison between the written schedule and the pill containers will frequently expose some discrepancy. Both prescription and over-the-counter drugs, such as laxatives and vitamins, should be recorded. The clinician can then identify the medications that potentially lead to drug-drug interactions and ask about them during subsequent patient visits.
Most elderly persons take a variety of medicines simultaneously, and the potential for drug-drug interaction is high. For example, concomitant use of fluoxetine and warfarin has been associated with an increase in the half-life of warfarin, which could lead to severe bruising (although this finding is not well documented). Some medications prescribed for older persons—such as the β-blocker propranolol and calcium channel blockers—can exacerbate or produce depressive symptoms.
Older persons are less likely than younger persons to have a substance use disorder, but a careful history of alcohol and drug intake (especially nonprescription use of prescription medications) is essential to the diagnostic workup. Although older persons do not usually volunteer information about their substance intake, they are generally forthcoming when asked about their drinking habits.
Medical History
Given the high likelihood of comorbid medical problems associated with psychiatric disorders in late life, a comprehensive medical history is essential. Most older persons see a primary care physician regularly (although decreasing payments from Medicare render this assumption less accurate each year). The geriatric psychiatrist should obtain medical records, if possible. Major illnesses should be recorded. A brief phone call to the primary care physician can be extremely useful.
Family Assessment
Clinicians working with older adults must be equipped to evaluate the family—both its functionality and its potential as a resource for the older adult. Geriatric psychiatry, almost by definition, is family psychiatry. The family assessment is best done, if possible, in conjunction with a social worker. Just as an elevated white blood cell count is not pathognomonic for a particular infectious agent yet is critical to the diagnosis, the complaint that “my family no longer loves me” does not reveal the specific problems in the family yet does highlight the need to assess the potential of that family for providing care and support for the older adult (Blazer 1984). The purpose of a comprehensive diagnostic family workup is to determine the nature of the family structure in interaction, the presence or absence of a crisis in the family, and the type and amount of support available to the older adult.
A primary goal of the clinician, as advocate for the older adult with psychiatric disturbance, is to facilitate family support for the elder during a time of disability. At least four parameters of support are important for the clinician to evaluate as the treatment plan evolves: 1) the availability of family members to the older person over time; 2) the tangible services provided by the family to the older person; 3) the perception of family support by the older patient (and therefore the willingness of the patient to cooperate and accept support); and 4) tolerance by the family of specific behaviors that derive from the psychiatric disorder.
The clinician should ask the older person, “If you become ill, is there a family member who will take care of you for a short period of time?” Next, the availability of family members who can care for the older adult over an extended period should be determined. If a particular member is designated as the primary caregiver, plans for respite care should be discussed. Given the increased focus on short hospital stays and the documented higher levels of impairment on discharge, the availability of family members becomes essential to the effective care of the older adult after hospitalization for a psychiatric disorder or a combined medical and psychiatric disorder.
What specific, tangible services can be provided to the older adult by family members? Even the most devoted spouse can be limited in the delivery of certain services because, for example, he or she does not drive a car, and therefore cannot provide transportation, or is not physically strong enough to provide certain types of nursing care. Generic services of special importance in at-home support of the older adult with psychiatric impairment include transportation; nursing services (e.g., administering medications at home); physical therapy; checking on or continuous supervision of the patient; homemaker and household services; meal preparation; administrative, legal, and protective services; financial assistance; living quarters; and coordination of the delivery of services. These services are considered generic because they can be defined in terms of their activities, regardless of who provides each service. Assessing the range and extent of service delivery by the family to the older person with functional impairment provides a convenient barometer of the economic, social, and emotional burdens placed on the family.
Regardless of the level and types of services provided by the family to the older person, if these services are to be effective, it is beneficial for the older individual to perceive that he or she lives in a supportive environment. Intangible supports include the perception of a dependable network, participation or interaction in the network, a sense of belonging to the network, intimacy with network members, and a sense of usefulness to the family (Blazer and Kaplan 1983). The sense of usefulness may be of less importance to some older adults who believe they have contributed to the family for many years and therefore deserve reciprocal services in their waning years. Unfortunately, family members, frequently stressed across generations, may not recognize this reciprocal responsibility.
Family tolerance of specific behaviors may not correlate with overall support. Every person has a level of tolerance for specific behaviors that are especially difficult to manage. Sanford (1975) found that the following behaviors were tolerated by families of older persons with impairments (in decreasing percentages): incontinence of urine (81%), personality conflicts (54%), falls (52%), physically aggressive behavior (44%), inability to walk unaided (33%), daytime wandering (33%), and sleep disturbance (16%). These relative frequencies may appear counterintuitive, because incontinence is generally considered particularly aversive to family members; however, although the outcome of incontinence can be corrected easily enough, a few nights of no sleep can easily extend family members beyond their capabilities for serving a parent, sibling, or spouse.
Mental Status Examination
Physicians and other clinicians are at times hesitant to perform a structured mental status examination, fearing that the effort will insult or irritate the patient or that the patient will view the examination as a waste of time. Nevertheless, the mental status examination of the older psychiatric patient is central to the diagnostic workup. Many aspects of this examination can be assessed during the history-taking interview.
Appearance may be affected by the older patient’s psychiatric symptoms (e.g., the depressed patient may neglect grooming), cognitive status (e.g., the patient with dementia may be unable to match clothes or even put on clothes appropriately), and environment (e.g., a nursing home patient may not be groomed as well as a patient living at home with a spouse).
Affect and mood can usually be assessed by observing the patient during the interview. Affect is the feeling tone that accompanies the patient’s cognitive output (Linn 1980). Affect may fluctuate during the interview; however, the older person is more likely to demonstrate a constriction of affect. Mood, the state that underlies overt affect and is sustained over time, is usually apparent by the end of the interview. For example, the affect of a depressed older adult may not reach the degree of dysphoria seen in younger persons (as evidenced by crying spells or protestations of uncontrollable despair), yet the depressed mood is usually sustained and discernible from beginning to end.
Psychomotor activity may be agitated or retarded. Psychomotor retardation or underactivity is characteristic of major depression and severe schizophreniform symptoms, as well as of some variants of primary degenerative neurocognitive disorder. Psychiatrically impaired older persons, except some who have advanced neurocognitive disorder, are more likely to exhibit hyperactivity or agitation. Those who are depressed will appear uneasy, move their hands frequently, and have difficulty remaining seated through the interview. Patients with mild to moderate neurocognitive disorder, especially those with vascular neurocognitive disorder, will be easily distracted, rise from a seated position, and/or walk around the room or even out of the room. Pacing is often observed when the older adult is admitted to a hospital ward. Agitation can usually be distinguished from anxiety, for the agitated individual does not complain of a sense of impending doom or dread. In patients with psychomotor dysfunction, movement generally relieves the immediate discomfort, although it does not correct the underlying disturbance. Occasionally, the older adult with psychomotor retardation may actually be experiencing a disturbance in consciousness and may even reach an almost stuporous state. The patient may not be easily aroused, but when aroused, he or she will respond by grimacing or withdrawal.
Perception is the awareness of objects in relation to each other and follows stimulation of peripheral sense organs (Linn 1980). Disturbances of perception include hallucinations—that is, false sensory perceptions not associated with real or external stimuli. For example, a paranoid older person may perceive invasion of his or her house at night by individuals who disarrange belongings and abuse him or her sexually. Hallucinations often take the form of false auditory perceptions, false perceptions of movement or body sensation (e.g., palpitations), and false perceptions of smell, taste, and touch. The older patient who is severely depressed may have frank auditory hallucinations that condemn or encourage self-destructive behavior.
Disturbances in thought content are the most prominent disturbances of cognition noted in older patients with psychosis. The depressed patient often develops beliefs that are inconsistent with the objective information obtained from family members about the patient’s abilities and social resources. Meyers and Greenberg (1986) found delusional depression to be more prevalent among older depressed patients than among middle-aged adults. Of 161 patients with endogenous depression, 72 (45%) were found to be delusional. Delusions included beliefs such as “I’ve lost my mind,” “My body is disintegrating,” “I have an incurable illness,” and “I have caused some great harm.” Even after elderly persons recover from depression, they may still experience periodic recurrences of delusional thoughts, which can be most disturbing to otherwise rational older adults. Older patients appear less likely to experience delusional remorse, guilt, or persecution.
Even if delusions are not obvious, preoccupation with a particular thought or idea is common among depressed elderly persons. Such preoccupation is closely associated with obsessional thinking or irresistible intrusion of thoughts into the conscious mind. Although the older adult rarely acts on these thoughts compulsively, the guilt-provoking or self-accusing thoughts may occasionally become so difficult to bear that the person considers, attempts, or succeeds in committing suicide.
Disturbances of thought progression accompany disturbances of content. Evaluation of the content and process of cognition may uncover disturbances such as problems with the structure of associations, the speed of associations, and the content of thought. Thinking is a goal-directed flow of ideas, symbols, and associations initiated in response to environmental stimuli, a perceived problem, or a task that requires progression to a logical or reality-based conclusion (Linn 1980). The older adult who is compulsive or has schizophrenia may pathologically repeat the same word or idea in response to a variety of probes, as may the patient who has major neurocognitive disorder. Some older adults with a neurocognitive disorder exhibit circumstantiality—that is, the introduction of many apparently irrelevant details to cover a lack of clarity and memory problems. Interviews with patients who have this problem can be most frustrating because they proceed at a very slow pace. On other occasions, elderly patients may appear incoherent, with no logical connection to their thoughts, or they may produce irrelevant answers. The intrusion of thoughts from previous conversations into a current conversation is a prime example of the disturbance in association found in patients with major neurocognitive disorder associated with Alzheimer’s disease. This symptom is not typical of other neurocognitive disorders, such as that associated with Huntington’s disease. However, in the absence of a neurocognitive disorder, even paranoid older adults do not generally demonstrate a significant disturbance in the structure of associations.
Suicidal thoughts are critical to assess in the elderly patient with psychiatric impairment. Although thoughts of death are common in late life, spontaneous revelations of suicidal thoughts are rare. A stepwise probe is the best means of assessing the presence of suicidal ideation (Blazer 1982). First, the clinician should ask the patient if he or she has ever thought that life was not worth living. If so, has the patient considered acting on that thought? If so, how would the patient attempt to inflict such harm? If definite plans are revealed, the clinician should probe to determine whether the implements for a suicide attempt are available. For example, if a patient has considered shooting himself, the clinician should ask, “Do you have a gun available and loaded at home?” Suicidal ideation in an older adult is always of concern, but intervention is necessary when suicide has been considered seriously and the implements are available.
Assessment of memory and cognitive status is most accurately performed through neuropsychological testing. However, the psychiatric interview of the older adult must include a reasonable assessment. Although older adults may not complain of memory dysfunction, they are more likely than younger patients to have problems with memory, concentration, and intellect. There are brief, informal means of testing cognitive functioning that should be included in the diagnostic workup. The clinician proceeding through an evaluation of memory and intellect must also remember that poor performance may reflect psychic distress or a lack of education, as opposed to intellectual disability or neurocognitive disorder. In addition, to rule out the potential confounding of agitation and anxiety, testing can be performed on more than one occasion. More formal brief testing, such as with the Mini-Mental State Examination (Folstein et al. 1975), provides a baseline from which performance can be documented over time.
Testing of memory is based on three essential processes: 1) registration (the ability to record an experience in the central nervous system), 2) retention (the persistence and permanence of a registered experience), and 3) recall (the ability to summon consciously the registered experience and report it) (Linn 1980). Registration, apart from recall, is difficult to evaluate directly. Occasionally, events or information that the older adult denies remembering will appear spontaneously during other parts of the interview. Registration usually is not impaired except in patients with a major neurocognitive disorder.
Retention, on the other hand, can be blocked by both psychic distress and brain dysfunction. Lack of retention is especially relevant to the unimportant data often asked for on a mental status examination. For example, requesting the older adult to remember three objects for 5 minutes will frequently reveal a deficit if the older adult has little motivation to attempt the task.
Disturbances of recall can be tested directly in a number of ways. The most common are tests of orientation to time, place, person, and situation. Most persons continually orient themselves through radio, television, and reading material, as well as through conversations with others. Some elderly persons may be isolated through sensory impairment or lack of social contact; poor orientation in these patients may represent deficits in the physical and social environment rather than brain dysfunction. Immediate recall can be tested by asking the older person to repeat a word, phrase, or series of numbers, but it can also be tested in conjunction with cognitive skills by requesting that a word be spelled backward or that elements of a story be recalled.
During the mental status examination, intelligence can be assessed only superficially. Tests of simple arithmetic calculation and fund of knowledge, supplemented by portions of well-known psychiatric tests, are helpful. The classic test for calculation is to ask a patient to subtract 7 from 100 and to repeat this operation on the succession of remainders. Usually, five calculations are sufficient to determine the older adult’s ability to complete this task. If the older adult fails the task, a less exacting test is to request the patient to subtract 3 from 20 and to repeat this operation on the succession of remainders until 0 is reached. These examinations must not be rushed, because older persons may not perform as well when they perceive time pressure. A capacity for abstract thinking is often tested by asking the patient to interpret a well-known proverb, such as “A rolling stone gathers no moss.” A more accurate test of abstraction, however, is classifying objects in a common category. For example, the patient is asked to state the similarity between an apple and a pear. Whereas naming objects from a category, such as fruits, is retained despite moderate and sometimes marked declines in cognition, the opposite process of classifying two different objects in a common category is not retained as well.
Rating Scales and Standardized Interviews
Rating scales and standardized or structured interviews have progressively been incorporated into the diagnostic assessment of the elderly psychiatric patient. Such rating procedures have increased in popularity as the need has increased for systematic, reproducible diagnoses for third-party carriers (part of the impetus for the dramatic change in nomenclature evidenced in DSM-5) and for a standard means of assessing change in clinical status. A thorough review in this chapter of all instruments that are used is not possible. Therefore, selected instruments are presented and evaluated in this section, chosen either because they have special relevance to the geriatric patient or because they are widely used.
Screens for Neurocognitive Disorders
A number of standardized assessment methods for delirium have emerged. Perhaps the best and the most easily used is the Confusion Assessment Method (Inouye et al. 1990). The scale assesses nine characteristics of delirium, such as acute onset (evidence of such onset), fluctuating course (behavior change during the day), inattention (trouble in focusing), disorganized thinking (presence of rambling or irrelevant conversations and illogical flow of ideas), and altered level of consciousness (rated from alert to comatose). Diagnosis of delirium according to DSM-IV-TR criteria (American Psychiatric Association 2000) can be derived from the scale.
Two interviewer-administered cognitive screens for neurocognitive disorder have been popular in both clinical and community studies. The Montreal Cognitive Assessment (MoCA; Nasreddine et al. 2005), a one-page, 30-point assessment, is used to assess several cognitive domains relevant to neurocognitive disorders. The short-term memory recall task includes two learning trials of five nouns and delayed recall after approximately 5 minutes. Visuospatial abilities are assessed using a clock-drawing task and a three-dimensional cube copy. Multiple aspects of executive functions are assessed using an alternation task such as moving from numbers to letters in a systematic process, a phonemic fluency task, and a two-item verbal abstraction task. Attention, concentration, and working memory are evaluated using a sustained attention task, a serial subtraction task, and digits forward and backward. Language is assessed using a three-item confrontation naming task with low-familiarity animals (lion, camel, rhinoceros), repetition of two syntactically complex sentences, and the aforementioned fluency task. Finally, orientation to time and place is evaluated. The Mini-Mental State Examination (Folstein et al. 1975) is a 30-item screening instrument that assesses orientation, registration, attention and calculation, recall, and language. It requires 5–10 minutes to administer. Seven to 12 errors suggest mild to moderate cognitive impairment, and 13 or more errors indicate severe impairment. This instrument is perhaps the most frequently used standardized screening instrument in clinical practice.
A number of clinical assessment procedures for neurocognitive disorders have emerged. These are generally administered by neuropsychologists and accompanied by imaging studies and even explorations of biomarkers, such as scans for amyloid. For example, a scale assessing whether a neurocognitive disorder is due to vascular causes was suggested by Hachinski et al. (1975). In this study, cerebral blood flow in patients with primary degenerative dementia was compared with that in patients with vascular dementia. Certain clinical features were determined to be more associated with multi-infarct dementia, and each of these features was assigned a score of 1 or 2. The 2-point clinical features were abrupt onset, fluctuating course, history of strokes, focal neurological symptoms, and focal neurological signs. The 1-point features were stepwise deterioration, nocturnal confusion, relative preservation of personality, depression, somatic complaints, emotional incontinence, history of hypertension, and evidence of associated atherosclerosis. A score of 7 or greater was highly suggestive of multi-infarct dementia. However, given the frequent overlap of multiple small infarcts and primary degenerative dementia, as well as the difficulty of assessing these items effectively, most investigators have ceased to rely on the Hachinski scale for clinical use.
Depression Rating Scales
A number of self-rating depression scales have been used to screen for depression in patients at all stages of the life cycle; most of these scales have been studied in older populations. The most widely used of the current instruments in community studies is the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff 1977). The scale consists of 20 behaviors and feelings, and the patient indicates how frequently each was experienced over the past week (from no days to most days). In a factor-analytic study of the CES-D in a community population, four factors were identified: somatic symptoms, positive affect, negative affect, and interpersonal relationships (Ross and Mirowsky 1984). The disaggregation of these factors and the exploration of their interaction are significant steps forward in understanding the results derived from symptom scales such as the CES-D in older populations. For example, the somatic items (e.g., loss of interest, poor appetite) are more likely to be associated with a course of depressive episodes similar to that described for major depression with melancholia, and the positive-affect items are more likely to be associated with life satisfaction scores.
The Geriatric Depression Scale (GDS) was developed because the CES-D presents problems for older persons who have difficulty selecting one of four forced-response items (Yesavage et al. 1982–1983). The GDS is a 30-item scale that permits patients to rate items as either present or absent; it includes questions about symptoms such as cognitive complaints, self-image, and losses. Items selected were thought to have relevance to late-life depression. The GDS has not been used extensively in community populations and is not as well standardized as the CES-D, but many clinicians prefer its yes/no format to the CES-D’s frequency ratings.
A scale that has received considerable attention clinically, having been standardized in clinical but not community populations, is the Montgomery-Åsberg Rating Scale for Depression (Montgomery and Åsberg 1979). This scale concentrates on 10 symptoms of depression; the clinician rates each symptom on a scale of 0–6 (for a range of scores between 0 and 60). The symptoms include apparent sadness, reported sadness, inattention, reduced sleep, reduced appetite, concentration difficulties, lassitude, inability to feel, pessimistic thoughts, and suicidal thoughts.
General Assessment Scales
A number of general assessment scales of psychiatric status (occasionally combined with functioning in other areas) have been found to be useful in both community and clinical populations. DSM-5 has adopted the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) to assess disability in adults age 18 years and older (World Health Organization 2010; the scale is also available in DSM-5 Section III, “Emerging Measures and Models”). This 36-item self-assessment is divided into six areas of function: understanding and communicating, getting around, self-care, getting along with people, life activities (i.e., household, work, and/or school activities), and participation in society.
The Geriatric Mental State Schedule (Copeland et al. 1976), an adaptation of the Present State Exam (Wing et al. 1974) and the Psychiatric Status Schedule (Spitzer et al. 1968), is a semistructured interviewing guide that allows the rater to inventory symptoms associated with psychiatric disorders. More than 500 ratings are made on the basis of information obtained by a highly trained interviewer, who elicits reports of symptoms from the month preceding the evaluation. Data are computerized to derive psychiatric diagnoses (Copeland et al. 1986). The instrument measures depression, impaired memory, selected neurological symptoms such as aphasia, and disorientation.
The Older Americans Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire (Duke University Center for the Study of Aging and Human Development 1978), administered by a lay interviewer, produces functional impairment ratings in five dimensions: mental health, physical health, social functioning, economic functioning, and activities of daily living. In one community survey using OARS (Blazer 1978a), 13% of persons in the community were found to have mental health impairment. The OARS instrument was developed to integrate functional measures across a series of parameters relevant to older adults; it has been used widely in both community and clinical surveys. With the recent emphasis on discrete psychiatric disorders, however, the instrument has not been as widely used by mental health workers as it might otherwise have been.
Any discussion of clinical rating scales is not complete without a discussion of the Abnormal Involuntary Movement Scale (AIMS; National Institute of Mental Health 1975). There has been an increased incidence of tardive dyskinesia among older adults, coupled with the need for better documentation of this outcome due to prolonged use of antipsychotic agents. Regular ratings of patients on the AIMS by clinicians have therefore become essential to the practice of inpatient and outpatient geriatric psychiatry. The scale consists of seven movement disorders; the presence and severity of each is rated from none to severe. Three items require a global judgment: severity of abnormal movements, incapacitation due to abnormal movements, and the patient’s awareness of abnormal movements. Current problems with teeth or dentures are also assessed. Procedures are described to increase the reliability of this rating scale.
Structured Diagnostic Interviews
A number of structured interview schedules are available for both clinical and community diagnosis. These interview schedules have allowed increased reliability of the identification of particular symptoms and psychiatric diagnoses; however, if one adheres closely to the structured interview, the richness inherent in the unstructured interview tends to be lost. Comments made by the patient during the evaluation that could be used to trace relevant associations must be ignored to push through the interview schedule. Most of these interviews require more time than the traditional unstructured first session with the patient.
The most frequently used structured interview instrument in the United States is the Structured Clinical Interview for DSM-IV (SCID; First et al. 1997). This instrument is easily adaptable to DSM-IV (American Psychiatric Association 1994) and DSM-IV-TR; adaptation to DSM-5 is in progress. Although specific questions are suggested for probing most areas of interest, the interviewer using the SCID has the flexibility to ask additional questions and can use any available data to assign a diagnosis. The interviewer must have clinical training but does not have to be a psychiatrist. Many of the symptoms may not be relevant to older adults (especially the extensive probes for psychotic symptoms), and the interview frequently takes 2.5–3 hours to administer. Nevertheless, the experience gained by the clinician in using this instrument can contribute to a more effective clinical practice.
The Diagnostic Interview Schedule for DSM-IV (DIS-IV; Robins et al. 2000) is a highly structured, computer-scored interview that can be administered by a lay interviewer and allows psychiatric diagnoses to be made according to DSM-IV criteria and Feighner criteria (Feighner et al. 1972). The DIS-IV questions probe for the presence or absence of symptoms or behaviors relevant to a series of psychiatric disorders, the severity of the symptoms, and the putative cause of the symptoms. Diagnoses of cognitive impairment, schizophrenia or schizophreniform disorder, major depression, generalized anxiety disorder, panic disorder, agoraphobia, obsessive-compulsive disorder, dysthymic disorder, somatization disorder, alcohol abuse and/or dependence, and other substance abuse and/or dependence can be made from Axis I of DSM-IV. A diagnosis of antisocial personality disorder (Axis II) can also be made. The instrument has proved reasonably reliable in clinical populations for both current and lifetime diagnoses.
The range of disorders probed by the DIS-IV questions, coupled with the instrument’s relative ease of administration (it generally takes 45–90 minutes to administer to an older adult), has made it popular for use in clinical studies. In addition, community-based comparative data are available on a large sample from the Epidemiologic Catchment Area study (Myers et al. 1984; Regier et al. 1984). The DIS-IV can be supplemented with additional questions to probe for specific symptoms, such as melancholic symptoms, and additional data on sleep disorders for depressed older adults. No problems have arisen when the instrument is used among older adults in the community. In general, the memory decay that occurs in elderly persons causes no more of a performance problem on this instrument than on others. Nevertheless, the DIS-IV is of less value in the study of institutional populations and in reconstruction of lifetime history regardless of setting, because memory problems cannot be circumvented by clinical judgment. Supplementary data can be added to the instrument for developing a standardized diagnosis. A shortened version of the DIS-IV that has been used in more recent epidemiological surveys is the World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview (CIDI) (Kessler and Ustün 2004; Kessler et al. 2005).
Effective Communication With the Older Adult
The clinician who works with the older adult should be cognizant of factors relating to both the patient and the clinician that may produce barriers to effective communication (Blazer 1978b). Many older persons experience a relatively high level of anxiety yet do not complain of this symptom. Stress deriving from a new situation, such as visiting a clinician’s office or being interviewed in a hospital, may intensify such anxiety and subsequently impair effective communication. Perceptual problems, such as hearing and visual impairment, may exacerbate disorientation and complicate the communication of problems to the clinician. Elderly persons are more likely to withhold information than to hazard answers that may be incorrect—in other words, older persons tend to be more cautious. Elderly persons frequently take longer to respond to inquiries and resist the clinician who attempts to rush through the history-taking interview.
The elderly patient may perceive the physician unrealistically, on the basis of previous life experiences (i.e., transference may occur). Although the older patient will sometimes accept the role of child, viewing the physician as parent, the patient is initially more likely to view the clinician as the idealized child who can provide reciprocal care to the previously capable but now impaired parent. Splitting between the physician (idealized) and the child of the patient (devalued) may subsequently occur. Also, the clinician may perceive the older adult patient incorrectly because of fears of aging and death or because of previous negative experiences with his or her own parents. For a clinician to work effectively with older adults, these personal feelings should be discussed during training—and afterward.
Once physician and patient attitudes have been recognized and acknowledged, certain techniques have generally proved to be valuable in communicating with the elderly patient. These techniques should not be implemented indiscriminately, however, for the variation in the population of older adults is significant. First, the older person should be approached with respect. The clinician should knock before entering a patient’s room and should greet the patient by surname (e.g., Mr. Jones, Mrs. Smith) rather than by a given name, unless the clinician also wishes to be addressed by a given name.
After taking a position near the older person—near enough to reach out and touch the patient—the clinician should speak clearly and slowly and use simple sentences in case the person’s hearing is impaired. Because of hearing problems, older patients may understand conversation better over the telephone than in person. By placing the receiver against the mastoid bone, the patient with otosclerosis can take advantage of preserved bone conduction.
The interview should be paced so that the older individual has enough time to respond to questions. Most older individuals are not uncomfortable with silence, because it gives them a welcome opportunity to formulate their answers to questions and elaborate certain points they may wish to emphasize. Nonverbal communication is frequently a key to effective communication with elderly individuals, because they may be reticent about revealing affect verbally. The patient’s facial expressions, gestures, postures, and long silences may provide clues to the clinician about issues that are unspoken.
One key to successful communication with an older adult is a willingness to continue working as a professional with that person. Older adults—possibly unlike some of their children and grandchildren—place a great deal of stress on loyalty and continuity. Most elderly patients do not require large amounts of time from clinicians, and those who are more demanding can usually be controlled through structure in the interview.
Key Points
- The diagnostic interview is the cornerstone of assessment and treatment assignment for the older adult with psychiatric impairment.
- A thorough medication history, although it takes time to obtain, saves valuable time and complications in the treatment of psychiatric disorders in older adults.
- Functional status (i.e., the ability to perform usual activities of daily living) is often as important as diagnosis in tracking the progress of treatment of psychiatric disorders in older adults.
- Geriatric psychiatry is family psychiatry.
- What is gained in reliability by using a structured diagnostic interview is offset by the loss of valuable information about the subjective feelings of the older adult and the context of the emergence of symptoms.
- Speak clearly and slowly but not in a patronizing way to the older adult, who might have a hearing impairment.
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