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  • Dementia (Jan/Feb/March)
  • How to Interview the Older Patient

How to Interview the Older Patient

The Carlat Geriatric Psychiatry Report, Volume 1, Number 1&2, January 2022
https://www.thecarlatreport.com/newsletter-issue/cgprv1n12/

From The Carlat Geriatric Psychiatry Report, January 2022, Dementia

Issue Links: Learning Objectives | PDF of Issue

Topics: Free Articles

Print Friendly, PDF & Email

Rehan Aziz, MD. Inpatient geriatric psychiatry, Hackensack-Meridian Health, Perth Amboy, NJ. 

Dr. Aziz has disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

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 article will cover additional factors to consider when evaluating older patients.

Functional assessment

Appraising a patient’s functional status is critical. It’s 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. I recommend asking about them in the presence of a caregiver because patients may minimize their own deficits. See the table below for the unfortunate mnemonics DEATH and SHAFT along with sample questions to assess ADLs and IADLs.

Table: Death and SHAFT Mnemonics With Sample Questions

Click to view as full-size PDF.


For both ADLs and IADLs, I determine whether patients are independent, require assistance, or are fully dependent on others. To assess the presence of caregiver support, I ask patients, “During the past four weeks, was someone available to assist you if you wanted help?”

Mental status assessment

Evaluation of mental status is similar to younger patients, but involves a few additional observations, which we detail below.

Appearance 

Patients who experience depression or apathy might neglect hygiene. Those with cognitive disorders might be dressed inappropriately, such as wearing several layers on a warm day. Appearance can also provide a clue regarding the adequacy of the patient’s supports. Overwhelmed caregivers may have less time or energy to help a compromised patient.

Psychomotor activity

Older adults with depression, dementia, or altered mental status may have slowed movements. Patients with advanced dementia might appear disengaged from the interview. Patients with moderate dementia may pace. Patients with anxiety might fidget or wring their hands. 

Affect

Older adults may demonstrate reduced emotions even in the absence of mental illness—in other words, a constricted affect doesn’t mean a patient is depressed. Depressed elders might present as withdrawn, irritable, weary, or apathetic.

Paranoia, delusions, hallucinations

Hearing or vision deficits can sometimes trigger hallucinations (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.

Elders with moderate dementia often suffer from delusions. They can take various forms, such as delusions of infidelity or paranoia. Delusions may be triggered by short-term memory loss (eg, misplacing household items, then accusing a family member of theft). Delusional depression is more prevalent in older patients than in middle-aged adults (Blazer DG, FOCUS Spring 2004;11(2):224–235). The most common delusions are somatic or feature negative content, eg, “I’m losing my mind” (Gournellis R et al, Int J Geriatr Psychiatry 2001;16(11):1085–1091).

Cognition

A cognitive evaluation should be part of every initial assessment and then administered periodically. The most commonly used in-office standardized scales are the proprietary Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). Scales in the public domain include the Saint Louis University Mental Status exam (SLUMS) and the Mini-Cog (www.mini-cog.com). The single best assessment is the clock-drawing test: Ask the patient to draw the numbers on the face of a clock with the hands pointing to a specific time (often 10 minutes past 11 o’clock). 

Safety assessment

Suicidal thoughts 

I start by asking every patient if they have thought that life is not worth living. Keep in mind that older adults may have thoughts about death and dying even if they are not suicidal, which is starkly different from younger individuals. If a patient has had suicidal thoughts, I ask how they would attempt suicide and whether they have the means to do so. Contrary to popular belief, most older patients are not offended by these questions. Intervention is necessary when a patient has seriously considered suicide and has the tools available to carry it out, such as firearms (Blazer, 2004). Because men drive suicide rates in the older adult population, pay close attention to ensure protective factors are in place for these patients.

Driving

Older adults are at higher risk for motor vehicle accidents (Cicchino JB, Accid Anal Prev 2015;83:67–73) due to decreased reaction times, impaired vision and hearing, and difficulty managing complex road situations. If I suspect cognitive impairment, I usually interview a family member. I ask whether the patient has gotten lost driving in familiar neighborhoods or whether they have missed traffic signs in the past few months. I also ask about recent tickets. I may perform a Trail Making Test Part B in the office, as there is good evidence that it correlates with driving ability. If I suspect a patient is unsafe driving, I request a driving evaluation or a retest. In the case of dangerous driving, clinicians may be obligated to alert the DMV.

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, I suggest a few interventions. The patient can wear a medical ID bracelet or carry an item with embedded GPS tracking, such as a necklace, bracelet, or phone. I also recommend installing deadbolts, doorway alarms, or even cameras, and alerting neighbors and the local police of a patient’s wandering risk.

Elder abuse

Elder abuse can take many forms: physical, financial, sexual, abandonment, and neglect. Clinicians are mandated reporters of suspected abuse. Generally, I will interview the patient alone about how they feel at home, or how they feel with their family members or caregivers. I ask how they are managing financially. I review the patient’s advance directives and pay attention to who has permission to communicate with the patient’s clinicians. I observe weight loss, the patient’s hygiene, and whether the patient has bruises or cuts (keeping in mind that older adults may bruise from blood thinners or medical illnesses). Depending on the circumstances, I may call the local adult protective services agency. Many local, state, and national social service agencies can also help with emotional, legal, and financial abuse. If I suspect the patient is in immediate danger, I call 911 or the local police ­immediately.

Carlat Verdict: Older adults require an expanded assessment, taking into account functional capacity, social support, cognition, and safety.

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Courses and Book CME
Medication Fact Book for Psychiatric Practice, Sixth Edition (2022)
2022 Carlat Psychiatry Report Self-Assessment Course
Prescribing Psychotropics: From Drug Interactions to Genetics
The Child Medication Fact Book for Psychiatric Practice (2018)
Issues Archives

2022

  • Anxiety (April/May/June)
  • Dementia (Jan/Feb/March)

2020

  • Esketamine (January)
  • Telepsychiatry (May)
  • Mind-Gut Connection (January)
  • Practical Psychotherapy (November/December)
  • Mood and Menopause (October)
  • When to Use Lithium (September)
  • Traumatic Brain Injury (August)
  • Borderline Personality Disorder (June/July)
  • Psychopharmacology Algorithms (April)
  • Bipolar II (March)
  • Inflammation and Depression (February)

2020

  • Mood Disorders in Children and Adolescents (Oct/Nov/Dec)
  • Identity & Culture in Children and Adolescents (July/August/September)
  • Psychosis in Children and Adolescents (April/May/June)
  • ADHD in Children and Adolescents (Jan/Feb/Mar)

2020

  • Harm Reduction (January/February)
  • Substance Use in Health Professionals (March/April)
  • Alternative Treatment in Addiction (November/December)
  • Social Aspects of Addiction (September/October)
  • Opioid Use Disorder Treatment (July/August)
  • Emerging Risks for Old Medications (May/June)

2019

  • Depression (May)
  • Adult ADHD (November/December)
  • Mental Health Apps (October)
  • How to Talk about Medication (September)
  • Side Effects Part II (August)
  • Side Effects Part I (June/July)
  • Sleep (April)
  • Parenting, Pregnancy, and Prevention (March)
  • Dark and Light Therapy (February)
  • Deprescribing (January)

2018

  • Drug Metabolism (November/December)
  • Working With Transgender Patients (October)
  • Emergency Psychiatry (September)
  • Treatment-Resistant Depression (July/August)
  • Neurobiology (June)
  • Anxiety (May)
  • Neurofeedback (April)
  • Antipsychotics Update (March)
  • Working With Families (February)
  • Bipolar Disorder (January)

2017

  • PTSD (December)
  • Retirement (November)
  • Intellectual Disability (September/October)
  • Antidepressants (July/August)
  • Personality Disorders (June)
  • Dementia (May)
  • Cognitive Behavior Therapy Techniques (April)
  • Pharmacogenetics (March)
  • Treating Psychosis (February)
  • Adult ADHD (January)

2016

  • Complementary and Alternative Medicine in Psychiatry (November/December)
  • Side Effects (October)
  • Pain Management (September)
  • Medication in Pregnancy (July/August)
  • Psychoanalysis in Modern Psychiatry (June)
  • Correctional Psychiatry (May)
  • Antidepressant Roundup (April)
  • Burnout (March)
  • Private Practice (February)
  • Bipolar Disorder (January)

2015

  • Psychiatry and General Medicine (November/December)
  • Biomarkers in Psychiatry (May)
  • Telepsychiatry (October)
  • Sleep Disorders (September)
  • Interventional Psychiatry (July/August)
  • Eating Disorders (June)
  • Psychotherapy Updates (April)
  • Topics in Geriatric Psychiatry (March)
  • Antipsychotics Update (February)
  • Risk Management (January)

2014

  • Bipolar Disorder (November/December)
  • Pharmacogenetics (October)
  • Keeping up in Psychiatry (September)
  • Research in Psychiatry (July/August)
  • Marijuana (June)
  • Psychiatric Diagnosis (May)
  • Issues in Psychopharmacology (April)
  • Schizophrenia (March)
  • Women’s Psychiatry (February)
  • Ethics in Psychiatry (January)

2013

  • Military Psychiatry (December)
  • Depression (November)
  • Treatment of Dementia (October)
  • Anxiety Disorders (September)
  • Natural and Alternative Treatments in Psychiatry (July/August)
  • Autism Spectrum Disorder (June)
  • Practice Tips (May)
  • Substance Abuse (April)
  • Medicolegal Topics (March)
  • End of Life Care (February)
  • Antipsychotic Update (January)

2012

  • Screening Tools and Tips (December)
  • Medical Comorbidities (November)
  • Devices in Psychiatry (October)
  • Eating Disorders (September)
  • Bipolar Disorder (July/August)
  • Risk Management (June)
  • Antidepressant Roundup 2012 (May)
  • Gender and Sexuality (April)
  • Personality Disorders (March)
  • ADHD (February)
  • Natural Treatments in Psychiatry (January)

2011

  • Electronic Medical Records (December)
  • Insomnia (November)
  • Psychotherapy (October)
  • Alcoholism (September)
  • Anxiety Disorders (July/August)
  • Schizophrenia (June)
  • Managing Side Effects (May)
  • Antidepressant Roundup 2011 (April)
  • DSM-5 and Diagnostic Issues (March)
  • Drug-Drug Interactions (February)
  • Bipolar Disorder (January)

2010

  • Hospital Psychiatry (December)
  • Psychiatric Medication in Pregnancy (November)
  • Maintenance of Certification (October)
  • The Neuroscience of Psychotherapy (September)
  • Treatment of Depression (July/August)
  • Email and the Internet in Psychiatry (June)
  • Substance Abuse (May)
  • The Diagnosis and Treatment of Dementia (April)
  • Ethics in Psychiatry (March)
  • Natural Treatments in Psychiatry (February)
  • ADHD (January)

2009

  • Treating Schizophrenia (December)
  • Treatment for Anxiety Disorders (November)
  • The Latest on Antidepressants (October)
  • Topics in Neuropsychiatry (September)
  • The Interface of Medicine and Psychiatry (July/August)
  • Generic Medications in Psychiatry (June)
  • The Treatment of Eating Disorders (May)
  • Healthcare Policy and Psychiatry (April)
  • Antipsychotic Roundup 2009 (March)
  • Psychiatric Medication in Pregnancy and Lactation (February)
  • Transcranial Magnetic Stimulation (January)

2008

  • Treating Fibromyalgia and Pain in Psychiatry (December)
  • Issues in Child Psychiatry (November)
  • Improving Psychiatric Practice (October)
  • Treating Personality Disorders (September)
  • Bipolar Disorder (July/August)
  • Antipsychotic Roundup 2008 (June)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Neuropsychological Testing (May)
  • Psychiatric Medications: Effects and Side Effects (April)
  • Update on Substance Abuse (March)
  • Anticonvulsants in Psychiatry (February)
  • Brain Devices in Psychiatry (January)

2007

  • The Treatment of Insomnia (December)
  • Avoiding Malpractice in Psychiatry (November)
  • Update on Eating Disorders (October)
  • Complex Psychopharmacology (September)
  • Laboratory Testing in Psychiatry (August)
  • Psychotherapy in Psychiatry (July)
  • Posttraumatic Stress Disorder (June)
  • Topics in Geriatric Psychiatry 2007 (May)
  • Pregnancy and Menopause in Psychiatry (Apil)
  • Antipsychotic Roundup 2007 (March)
  • Understanding Psychiatric Research (February)
  • Antidepressant Round-up 2007 (January)

2006

  • Technology and Psychiatric Practice (December)
  • The Use of MAOIs (November)
  • Medication Treatment of Depression (January)
  • Seasonal Affective Disorder (October)
  • Treatment of ADHD (September)
  • Topics in Bipolar Disorder (August)
  • Neurotransmitters in Psychiatry (July)
  • Treating Substance Abuse (June)
  • The STAR*D Antidepressant Trial (May)
  • Natural Treatments in Psychiatry (April)
  • Medication Treatment of Anxiety (March)
  • Panic Disorder: Making Treatment Work (March)
  • Antipsychotic Roundup 2006 (February)
  • Antidepressant Roundup 2006 (January)

2005

  • Self-Help Books and Psychiatry (December)
  • Genetics and Psychiatry (November)
  • Pregnancy and Psychiatric Treatment (October)
  • Benzodiazepines and Hypnotics in Psychiatry (September)
  • Geriatric Psychiatry Update (August)
  • Chart Documentation in Psychiatry (July)
  • The Treatment of Bipolar Disorder (June)
  • Weight Loss and Smoking Cessation in Psychiatry (May)
  • Treating ADHD (April)
  • Drug Industry Influence in Psychiatry (March)
  • Atypical Antipsychotics 2005 (February)
  • Antidepressant Roundup 2005 (January)

2004

  • Sexual Dysfunction (December)
  • Suicide Prevention (November)
  • To Sleep, To Awake (October)
  • Women’s Issues in Psychiatry (September)
  • OCD: An Update (August)
  • Chronic Pain and Psychiatry (July)
  • Neuroimaging in Psychiatry (June)
  • Natural Medications in Psychiatry (May)
  • Posttraumatic Stress Disorder (April)
  • Treatment of Alcoholism (March)
  • Battle of the Atypicals (February)
  • Antidepressant Roundup, 2004 (January)

2003

  • Research Methods in Psychiatry (December)
  • Antidepressants in Children (November)
  • The Treatment of Dementia (October)
  • Bipolar Disorder, Part II: The Novel Anticonvulsants (September)
  • Bipolar Disorder: The Basics (August)
  • Drug-Drug Interactions in Psychiatry (July)
  • Managing Antidepressant Side Effects (June)
  • Antidepressants in Pregnancy and Lactation (May)
  • ADHD: Medication Options (April)
  • Panic Disorder: Making Treatment Work (March)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Medication Treatment of Depression (January)

2019

  • Autism in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (May/June/July/August)
  • Substance Use in Children and Adolescents (September/October)
  • Trauma in Children and Adolescents (March/April)
  • Anxiety in Children and Adolescents (January/February)

2018

  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Stephanie Collier, MD, MPH

Dr. Collier is the director of education in the Division of Geriatric Psychiatry at McLean Hospital and an instructor in psychiatry at Harvard Medical School. Dr. Collier completed her psychiatry residency at Duke University Medical Center and fellowship in consultation-liaison psychiatry at Brigham and Women’s Hospital. Dr. Collier teaches and supervises medical students, residents, and fellows in geriatric psychiatry, and she works on projects training non-specialist clinicians in resource-limited settings.

Full Editorial Information

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