Whilst the referral process might be the same as for younger patients, it is more often different. In many cases the patient has no idea why, or indeed does not even know or has forgotten that she has been referred. (The feminine gender is used in this chapter because older women are more likely to develop a mental illness and to survive longer than men. However, what is written applies also to men.)

The process has most often been initiated by family members who might not have discussed it with the patient. Many old people live alone with no relatives nearby or even in the same country or state, so that referrals are frequently initiated by friends, neighbours, or other acquaintances, such as local shopkeepers, social services care workers, and people who run luncheon clubs.

In the case of a woman of 30 with a depressive illness, she is referred to a psychiatrist for treatment to effect a remission. However, an older woman of 80 with a similar condition may be referred for a variety of reasons including the following: the primary care doctor might be uncertain of the diagnosis, that is whether it could be dementia; the grown-up children might have removal from home to residential or nursing care as the first item on their agenda; the patient’s condition may not be the primary issue—there may be greater concern for her husband who is failing to cope, perhaps to the extent of physically abusing her.

A large number of older people seen by psychiatrists are unable to give complete or reliable information about themselves. Frequently, but not invariably, there is a spouse or adult offspring living with the patient. In other cases, however, it is necessary to track down someone less obvious. Neighbours are often helpful at relating recent history, but may know little of past personal or family history. Effort spent in telephoning relatives, even those on the other side of the world, can be invaluable in giving an account of such items as family history or premorbid personality. If an informant is not readily available, for example, because it is night-time in Australia, the psychiatrist should not shelve the task of phoning, but only defer it to the next available opportunity.

Where conflicting information is given by a variety of informants it might be necessary to weigh up the particular ‘hidden agenda’ of each one. For example, the husband of a demented woman may minimize his wife’s behaviour disturbance for fear that she would be ‘put away’; whereas the daughter may overstate it in order to support a case for her mother’s transfer to a nursing home because her father repeatedly phones her for assistance at all hours of the day and night. Each one of the two informants has cogent reasons for weighting the information, but the psychiatrist and his or her team cannot help to resolve the situation until they understand those reasons.

Psychogeriatrics is as dependent on multi-disciplinary working as any other branch of psychiatry. Many patients seen for the first time will already be well known to their primary care doctor who will be able to provide invaluable information. The same frequently applies to community psychiatric nurses who now take referrals directly from general practitioners and may themselves be making referrals to the old-age psychiatry service. The psychogeriatrician can save a great deal of time and effort by consulting community psychiatric nurses and general practitioners before seeing the patient or relatives.

The preferred place to assess older patients is in their own homes, although circumstances sometimes dictate that it will be elsewhere. At home patients feel less intimidated and can be seen within an environment which tells the psychiatrist a great deal that he cannot know in the clinic. If a house is filthy and cold and the patient in a similar state, and if there is reliable information that this is only a recent phenomenon, then it is a powerful descriptor of the patient’s inability to cope. However, the converse is not always true; a clean and tidy home may only reflect someone else’s willingness to support and care for the patient who could not otherwise do it herself (e.g. a daughter or neighbour). Another advantage of a home assessment is that cognitive disabilities, such as dyspraxia and agnosia, can be tested in an ecologically valid way (making tea, recognition of family members from photographs) that is more acceptable to a patient than being formally tested with the Mini-Mental State Examination.⁽¹⁾

Assessments at home require more preparation for the doctor than is necessary at outpatient clinics where equipment for physical examination and blood tests are available, for example. It is an obvious courtesy to the patient to let her know of the visit beforehand, but it is also wise to arrange for a suitable informant to be present. Furthermore, some older patients are incapable of letting visitors into their houses and the informant might well first have to facilitate the doctor’s access. Elderly patients are much more likely to be suffering from comorbid physical illness which may be the fundamental cause of the mental disorder, for example, pneumonia or a urinary tract infection manifesting delirium. The old-age psychiatrist does not therefore need to adhere rigidly to lines of specialty demarcation but rather be aware of the possibility of and prepared to search for physical illness. The basic equipment for a medical examination, such as a stethoscope, sphygmomanometer, and patellar hammer are items to be taken on home visits. Urine testing strips and a thermometer, especially a low-reading thermometer, are also sometimes useful.

Patients who are assessed after admission to psychiatric beds lack the advantages of being in their own environment, although the opportunity for physical examination is much easier. Another advantage for hospital inpatients is that the assessment can be carried out over a longer period of time, since older people tire more easily and cooperation varies from day-to-day. For example, some demented patients will object to undergoing full cognitive assessment in one go, especially because they are often aware that they are failing. If a few questions are asked in the course of several short sessions, a more accurate and complete picture of the patient’s abilities eventually emerges. If the Mini-Mental State Examination is administered in this way, a higher total can be achieved than if an attempt to administer it all at once meets with sullen refusal after the first few questions, with all subsequent ones having to be scored zero.

Information from other informants is as crucial for hospital inpatients as it is for those seen at home. It is usually the responsibility of the house officer or resident to collect the history, and they may be required to telephone several informants in distant and local parts to obtain a full picture which the patient is incapable of providing.

Liaison visits to patients in general hospitals make up a considerable part of the old-age psychiatrist’s work because comorbid mental and physical illnesses are very common. In spite of the fact that the host nurse’s instinct is to lead the visiting psychiatrist straightaway to the patient’s bedside, the latter should insist on first reading the case notes (charts) and speaking to the nursing staff who know her best. From the case notes and the prescription cards (medication orders) invaluable information on current and past drug therapy as well as details of the patient’s medical history are obtained. Clues as to the patient’s mental state are often best gleaned from the records written by the nurses. Nevertheless, non-psychiatrist doctors, surgeons, and nurses are not accustomed to assessment of the mental state and statements such as ‘confused’ should not be taken at face value, since they stand for anything from slight difficulty in answering complex questions due to anxiety at being in a strange environment to major mental disturbance. As in most other settings, time spent telephoning informants from the general hospital ward is well invested and may permit the visiting old-age psychiatrist to express an opinion on the patient’s condition more firmly than would otherwise have been possible.

A useful final step before going to talk to the patient is, if possible, to observe her from a suitable distance. In this way signs of delirium, disruptive behaviour, social interaction, and other phenomena such as dyskinesias may be seen.

When seeing the patient herself, wherever possible she should be taken to a separate room and not examined in an open ward where there are other patients. If it is impossible for the patient to leave her bed, then it is usually feasible to move the bed to a more private place.

Much of that which is required for liaison visits to general hospitals applies to assessment in residential or nursing homes, most notably trying to see the patient in a private room away from other residents. Since abuse of elderly people is sometimes an issue in these
settings, it is preferable to have at least some time completely alone with the patient first, and if indicated, to check for bruises or other injuries, and secondly to allow the patient to tell the doctor things which she might be frightened to do in front of the staff of the home. Another problem in some nursing and residential homes is that the psychiatrist finds that an untrained or unqualified member of staff accompanies him, the quality of whose information may not be at the level of trained nurses. Careful questioning of several members of staff, attention to written records, and telephone calls to appropriate informants should all improve the quality of the assessment.

As has already been made clear, for many older patients a complete history may have to be obtained from a variety of informants. With the patients themselves a more flexible approach than is taken with younger ones is often needed. Whether intellectual failure is obvious and global or there is only relatively mild cognitive impairment (MCI), for some to give a history that is fully chronologically correct can be too great an effort. The examiner must accept these limitations and try to keep the atmosphere as relaxed as possible. Much more than the young, elderly psychiatric patients perceive the psychiatric interview as an ordeal or a form of trial in which it is easy for them to acquire a sense of failure. This in turn induces anxiety and a vicious spiral of ever worsening performance. One way in which the patient can be put at ease is to reassure her that you will come to her main problem in due course but that it would be good to hear something of her background first. For most older patients the family and personal histories are easier to recall than the confusing events which have led up to the referral. This is not simply good for the patient but for the examiner as well. Amongst the most profitable of pleasures in old-age psychiatry are the life stories of people who have lived during some momentous periods of world history. Furthermore, these stories put patients into a context which makes it much easier to understand why and how they have reacted to the mental illness with which they have presented.