The expanding population of older adults has created a need for all clinicians to participate in their care. Interviewing techniques require adaptation in older adults, such as accounting for hearing or vision impairment and speaking slowly and clearly. This podcast will cover additional factors to consider when evaluating older patients.
Published On: 8/29/2022
Duration: 18 minutes, 07 seconds
Referenced Article: “How to Interview the Older Patient,” The Carlat Geriatric Psychiatry Report, January 2022
Stephanie Collier, MD, MPH, and Rehan Aziz, MD have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Dr. Collier: The expanding population of older adults has created a need for all clinicians to participate in their care. Interviewing techniques require adaptation in older adults, such as accounting for hearing or vision impairment and speaking slowly and clearly. In this episode, we’ll cover additional factors to consider when evaluating older patients.
Welcome to The Carlat Psychiatry Podcast.
This is another episode from the geriatric psychiatry team.
I’m Dr. Stephanie Collier, The Editor-in-Chief of The Carlat Geriatric Psychiatry Report.
Dr. Aziz: And I’m Dr. Rehan Aziz, an associate professor of psychiatry and neurology at Hackensack-Meridian. I am also the associate program director for geriatric psychiatry at Jersey Shore University Medical Center.
Dr. Collier: We have some exciting news for you! You can now receive CME credit for listening to this episode and all new episodes going forward on this feed. Follow the Podcast CME Subscription link in the show notes to get access to the CME post-test for this episode and future episodes.
Dr. Aziz: Let's begin by determining how providers can assess an older patient’s functional status. This is something that makes working with older adults unique.
There are 2 different levels at which we access functional status. This can be done by asking about activities of daily living (ADLs) and instrumental activities of daily living (IADLs). IADLs are advanced skills, the first activities impacted by dementia. The IADLs are more advanced daily living skills and are often the first activities impacted by dementia. I recommend asking about them in the presence of a caregiver because patients may minimize their own deficits.
Dr. Collier: How do you remember the ADLs and IADLs?
Dr. Aziz: So I use a couple of mnemonics, they are a little bit morbid, but one of them is DEATH for ADLs and SHAFT for IADLs. Let's walk through each of these and talk about associated questions we can ask. For ADLs the mnemonic DEATH stands for dressing, eating, ambulating, toileting, and hygiene. To assess a patient’s ability to dress you can ask “Have you needed help getting dressed or buttoning your shirt? Have you put on things backwards or upside down?” For eating I will ask if they need any help cutting your food. Have you been choking on your food? For ambulating I will ask about falls and what situations have led to the falls. “Do you experience trouble getting out of bed or a chair? Or “How many falls have you had in the past few months?” For toileting I will ask about if there have been any accidents, like stool or urine. In recent times if they’re having to use any undergarments to help. And finally, for hygiene I will ask how often they shower or change your clothes. Do they need help in the shower, such as with hot and cold water? Taking their clothes off, getting dressed afterwards, and so on.
Dr. Collier: That's really helpful, so DEATH: dressing, eating, ambulating, toileting and hygiene. What about SHAFT?
Dr. Aziz: So SHAFT is the mnemonic for instrumental activities of daily living. So these are the more advanced daily activities that are usually impacted first when people are having memory issues. SHAFT stands for shopping, housekeeping, accounting, food preparation, and transportation. For shopping I'll ask how they are doing at the store, are they forgetting to get items that they need. Are they having trouble handling money at the cash register? Are they buying too many things they already have, or not buying what they came for? For housekeeping i'll ask about the condition of their residents. Are things more messy than they have been in the past? Are they having trouble using the washing machine, dishwasher, or vacuum cleaner? For accounting I'll ask if they've made any mistakes. We're checking if they're requiring more help balancing their checkbook or paying off bills. Have they incurred any late fees? For food prep, I'll ask, have they forgotten to turn off the stove or the oven? Have they burned any food? Are they forgetting old recipes? Is food tasting different than how it did in the past? And for transportation I will ask about driving. Mainly have they got lost on the roads? Have there been any motor vehicle accidents? Have they gotten any tickets?
Dr. Collier: All right, so SHAFT: shopping, housekeeping, accounting, food preparation and transportation.
How do you assess for the presence of caregiver support?
Dr. Aziz: So one thing that I've always required is that patients always come with a caregiver to their appointments. I find that the appointments aren't very helpful unless I have somebody else there who also can provide another perspective on the patient. So I'll be observing the way that the patient and their caregiver interact during the entire session and how queued in the caregiver is to the patient's needs. I will also ask the patient if you need help is somebody there for you? Are you able to reach out to them? Do you feel at times that you're struggling and there's no one there?
Dr. Collier: The next assessment to consider when evaluating older adults is the mental status assessment. The evaluation of mental status is similar to younger patients, but it involves a few additional observations. The first observation would be appearance.
Patients who experience depression or apathy might neglect hygiene. Those with cognitive disorders might be dressed inappropriately, such as wearing a few layers on a warm day. Appearance can also provide a clue regarding the adequacy of the patient’s support system. For example, overwhelmed caregivers may have less time or energy to help a compromised patient.
Dr. Aziz: The next observation to take note of is psychomotor activity. So this is the level of energy, motivation, and drive a patient has. Sometimes it can be elevated, sometimes it can be too slow. Often older adults who are feeling depressed have memory issues such as dementia or altered mental state may have slowed movements. Patients with advanced dementia might appear disengaged from the interview. Patients with moderate dementia might feel the opposite. They might be restless, they might be pacing, and patients with anxiety might fidget or wring their hands. Then there is affect. That's what we observe when we're talking to the patient and observing the patient in the exam room. A lot of older adults demonstrate reduced emotions, even in the absence of mental illness. In other words, a constricted affect, meaning reduced emotional expression, doesn't mean that a patient is depressed, but depression should remain on your differential. Other things to watch out for include if the patient is more withdrawn, if they seem irritable, if they're weary, or if they're apathetic.
Dr. Collier: We also want to be aware of behaviors such as paranoia, delusions, and hallucinations. Hearing or vision deficits can sometimes trigger hallucinations which can be fixable by correcting the deficits. Patients with Parkinson’s disease or dementia with Lewy bodies often experience complex visual hallucinations of people, animals, or shadows. Second-person auditory hallucinations are common in older adults with dementia. Severely depressed older patients may have auditory hallucinations that condemn them or encourage self-destructive behavior.
Dr. Aziz: Elders with moderate dementia can suffer from delusions. Delusions are fixed, false beliefs that are not in keeping with reality. Delusions can take many forms. Most often we see delusions of infidelity, paranoia, or theft in patients with dementia. They might be triggered by short term memory loss, for example, misplacing household items and thinking someone has stolen them. Delusional depression is also more prevalent in older adults who are depressed than in middle-aged adults. The most common delusions are frequently somatic, meaning body delusions, and often they're centered around the stomach. Delusions can also feature negative content, such as I'm losing my mind.
Dr. Aziz: Lastly, we want to take note of cognition, so this is something that I will be assessing for right from the first moments when I begin talking to the patient. I'll listen to how they tell me their story, what the recall is and what brought them to the appointment and at recent events as well as long term recall.
Especially on the initial interview, I will administer an office based cognitive assessment. The mini mental status exam has traditionally been the most popular one that's used, but it's fallen a little bit out of favor in recent years because it doesn't fully test the aspects of cognition that we're interested in.
I've started to use the Montreal Cognitive assessment more. Both of these, however, are copyrighted assessments and require some extra training, especially the MoCA. The scales in the public domain include the Saint Louis University mental state exam, also known as the SLUMS, which you can find easily online through a Google search as well as the Mini-Cog which has become very popular over the last few years. The mini-cog is just a three word recall, as well as a clock drawing. I would say overall the best assessment is the clock drawing if you can only do one test. For a clock drawing, you can ask the patient to draw the numbers on the face of a clock with the hands pointing to 10 past 11.
Dr. Collier: The last assessment providers should use when evaluating elderly patients is the safety assessment. This assessment has four main components including suicidal thoughts, driving, wandering, and elder abuse.
So how do you talk about sensitive topics with your older adult patients, like suicidal thoughts or elder abuse?
Dr. Aziz: So my experience in this area has been really good over the past several years. I find that my patients are much more willing and interested in talking about how they're feeling, especially during this pandemic and whether or not they've had thoughts about not living anymore. So my main advice would be don't be afraid to approach these topics with your older adults. Chances are they've heard about suicide, they've heard about depression, maybe they're experiencing it themselves and they're often very ready to talk about what their experiences are.
Dr. Collier: That's really different than in younger adults, right?
Dr. Aziz: I think that's true. Yeah, older adults are often thinking about death and dying, and so it's a topic that's on their mind. They might have experienced in their personal life with family and friends who have passed and they tend to have thoughts about those topics that they're willing to share, whereas younger adults may or may not be forthcoming with their suicidal intent.
Dr. Collier: And do you ever feel like you offend your patients by asking these questions?
Dr. Aziz: I've never felt that way. I think a lot of asking these questions really is determined by how comfortable the patient is with you. So I'll usually ask these questions later in the interview after I've established rapport with the patient, so they already have a sense that I'm interested in them, I'm interested in their story, and I want to help. So when I start asking about suicidal thoughts they are usually right on board with that conversation.
Dr. Collier: And when do you jump in and do something?
Dr. Aziz: So if I think a patient is at high risk for hurting themselves or hurting others, then it's time to act and we have to keep the patient safe.
Dr. Collier: Can you talk about elder abuse and the kinds of forms that elder abuse can take?
Dr. Aziz: So as clinicians were mandated reporters for elder abuse, some states have Adult Protective Services, while others have Elderly Protective Services. Abuse can take many forms and I'm always listening for it as well as observing the patient to see if there are any obvious signs of abuse. Some of the forms include physical abuse, financial abuse, sexual abandonment, and neglect. If I suspect that an older adult has been the victim of abuse, I'll try to interview them alone and I'll ask how they feel at home. How do they feel with their family members or caregivers? How are they managing financially? Unfortunately, alot of older adults can become victims of financial abuse because they're dependent upon their caregivers for assistance, which can lead to a difficult situation for them. I will review the patient's advanced directives and pay attention to who has permission to communicate with the patient's clinicians.
Dr. Collier: And how do you assess for abandonment or neglect?
Dr. Aziz: So neglect, I think it is a little bit easier because I'll observe the patient, so if they seem disheveled, if they seem thin, if they're malodorous, if they have bruises or cuts or other unexplained injuries, then I'll become suspicious that maybe they're not being treated well, or they're being hurt in some way.
For abandonment, I might ask the patient if you need help is it available? Are you ever left alone? Are you struggling or feeling scared or lonely and is this happening often and for long periods of time?
Dr. Collier: And if you suspect, at what point would you call the adult Protective Services Agency?
Dr. Aziz: So what I always tell my trainees is it's not our job to do the investigation. Our job is to be suspicious. So as soon as I become suspicious that an older adult is being abused, that should trigger a phone call. It's the responsibility of these agencies to do the investigation to see whether or not the allegations are true.
Dr. Collier: Providers should also assess the ability of older adults to drive safely. Older adults are at higher risk for motor vehicle accidents due to decreased reaction times, impaired vision and hearing, and difficulty managing complex road situations. If cognitive impairment is suspected, a family member can be interviewed. Ask whether the patient has gotten lost driving in familiar neighborhoods or whether they have missed traffic signs in the past few months. Also ask about recent tickets and consider performing a Trail Making Test Part B in the office, since there is good evidence that it correlates with driving ability. If a patient is suspected to be unsafe driving, I request a driving evaluation or a retest. In the case of dangerous driving, clinicians may be obligated to alert the DMV.
Lastly, we should consider the issue of wandering. Wandering becomes an issue in moderate and severe dementia. Patients may become disoriented and unable to retrace their steps home. In some instances, patients wander outside in cold weather or onto highways. If a patient or caregiver reports concern about wandering, the patient can wear a medical ID bracelet or carry an item with embedded GPS tracking, such as a necklace, bracelet, or phone. Providers can also recommend installing deadbolts, doorway alarms, or even cameras, and alerting neighbors and the local police of a patient’s wandering risk.
Dr. Aziz: Overall, remember that older adults require an expanded assessment that takes into account functional capacity, social support, cognition, and safety. We discussed how providers can assess an older patient’s functional status by asking about activities of daily living (ADLs) and instrumental activities of daily living (IADLs) using the acronyms DEATH and SHAFT. We talked about how to conduct a mental health assessment by observing a patient's appearance, psychomotor activity, affect, and thought content including paranoia, delusions, and hallucinations. Finally, we covered the important components of a safety assessment including suicidal thoughts, driving, wandering, and elderly abuse.
Dr. Collier: The newsletter clinical update is available for subscribers to read in The Carlat Geriatric Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
Dr. Aziz: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry.
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Dr. Aziz: And don’t forget, you can now earn CME credits for listening to our podcasts. Just click the link in the description to access the CME post-test for this episode.
As always, thanks for listening and have a great day!