Modifying the psychiatric evaluation for older adults: at tool for medical learners

Introduction The population of the United States is aging rapidly. The most recent estimate from 2019 data is that 16.3% of the US population is over 65, totaling over 52 million people. In parallel, cases of dementia are increasing, with an expected increase to 13.8 million US citizens affected by 2050. At the same time, there exists a serious shortage of geriatric psychiatrists, thus necessitating that non-psychiatrist physicians possess some basic skills in the assessment of their older patients’ mental health needs. Standard medical school curriculum includes limited training on mental health needs of older adults and those with cognitive disorders. A general psychiatric interview as taught to most medical learners may not be adequate for many older adults, particularly if there is an element of cognitive impairment. Also, the addition of family members or other collateral sources may be necessary when interviewing older adults which is distinctly different from the psychiatric interview of younger adults. Because of these needs, we set about to develop an educational tool for students and residents to use when performing a psychiatric evaluation on an older adult. Methods We contrasted the elements of the standard psychiatric interview of adult patients with that used by a panel of experienced geriatric psychiatrists to identify unique aspects of the interview that are age specific. Then, we developed an interview guide for older adults with the target audience being a learner, student or resident. While this would likely be used primarily in a psychiatry clerkship or residency, it has broader applicability to any provider addressing mental health needs in an older adult. Results After reviewing the interview elements that need to be emphasized when performing a psychiatric evaluation in a geriatric patient, we identified the following areas most likely needing to be adapted in this population. Introductions and identifying the chief complaint – Patients, especially if they have a cognitive concern, may lack insight about the purpose of the appointment. Clarifying roles and the purpose of the visit is appropriate to set the tone. Collaboration with collateral sources (CS) – Patients may present to clinic with a friend or family member who is eager to share their concerns about the patient. Setting ground rules for how these sources will be asked to contribute that information at the beginning of the interview is helpful, to allow for the addition of this vital information while respecting the dignity and autonomy of the patient. Screening for common psychiatric illness – Depression and anxiety, two of the most common psychiatric syndromes experienced by older patients, may present with a different symptom profile in the older adult, particularly in the presence of cognitive impairment. Focusing mood questions on dysphoria, sleep and appetite changes, feelings of guilt and suicidality may increase the depression screening specificity given that loss of interest, decreased attention and low energy are frequently seen in persons with dementia without depression. Likewise, symptoms of generalized anxiety disorder are much more common than OCD or panic disorder in this population. Psychotic symptom screening needs to occur with the recognition that specific delusions are common in dementia, and that visual hallucinations are a core symptom of dementia with Lewy bodies. Cognitive screening with a standardized test, such as the MOCA or MMSE, as well as assessing for functional impairment, is important to evaluate for dementia. Medication and medical history review – While this is an important part of any psychiatric interview, it takes on increased importance in older adults who are at greater risk for adverse events and are more likely to be prescribed inappropriate medications as outlined by the Beers Criteria. Social history – Because older adults are more likely to have significant medical co-morbidities and disabilities, clarification of sources of social support becomes more important. Physical exam – A focused neurologic exam can be exceptionally helpful in the differential diagnosis of dementia sub-types as well as medical etiologies of psychiatric syndromes. Wrap up discussion – Due to the breadth of the geriatric psychiatric evaluation, the effective interview concludes with an interim summary and plan that is shared with the patient and family members. Depending on the initial impression, laboratory testing and neuroimaging may be necessary to refine the differential diagnosis and provide a treatment plan. Conclusions The psychiatric evaluation in older adults, particularly those with cognitive disorders, needs to be modified to recognize the specific needs and common disorders of late life. Use of an interview guide that recognizes these differences can help students and residents focus on the specific issues which concern this patient population and better prepare them to assist their future older adult patients. Funding Not applicable.