Chapter 9 – The Home Assessment in Old Age Psychiatry

Abstract

The psychiatric assessment of older people can be carried out in many environments, including outpatient clinics, hospital wards, care facilities for the elderly and the individual’s own home. Each presents advantages, disadvantages and challenges. An initial assessment conducted in the patient’s home remains an important aspect of many old age psychiatric services in high-income countries. This chapter explores and discusses the clinical aspects of conducting an initial psychiatric assessment of an older person in their home. It aims to be neither prescriptive nor exhaustive, but hopes to increase the awareness of the reader to certain themes and considerations in such assessments.

Chapter 9 The Home Assessment in Old Age Psychiatry A Practical Guide

Bradley Ng and Martin Atkins

Introduction

The Advantages and Disadvantages of a Home Assessment

There are several potential advantages of a home assessment. One witnesses first-hand how the person mobilizes and operates in their environment, with less reliance on the patient’s or collateral accounts, which may be incomplete, biased or misleading.¹ The patient, their caregivers and family may be present and be more at ease and forthcoming in their own home.²^–⁴ Relevant environmental and psychosocial factors, family strengths and resources, and the role of other services may become more apparent.³^, ⁵ Home assessments have the potential to detect previously unnoticed or underappreciated problems, psychiatric or otherwise, as seen in Box 9.1.¹^, ⁶^–¹⁰ It may become apparent that the referred psychiatric issue may not be the most pressing matter.¹¹^–¹² Physical disabilities, deteriorating cognition, poor insight, immobility, no driver’s licence or driving ability, the lack of family to assist with travel, unfriendly public transport or a bewildering hospital system may be practical factors that favour a home assessment.¹³

Box 9.1 Potential problems identified by home assessments

Psychiatric/medical

Depression
Cognitive impairment or dementia
Behavioural and psychological symptoms of dementia (BPSD)
Psychosis
Alcohol misuse
Acute medical illness
Pain problems
Polypharmacy issues

Geriatric

Falls and other safety issues
Incontinence issues
Sensory impairment
Poor nutrition
Caregiver and family stress/conflict/burnout
Neglect and abuse
Medication errors
Need for ongoing placement or care

Environmental

Neglected household or squalor
Inadequate utilities/heating
Poor food availability
Mobility challenges

Scanameo A, Fillit H. A practical guide to seeing the patient at home. Geriatrics 1995; 50: 33–7. Levine SA, Barry PP. Home care. In Geriatric Medicine: An Evidence-Based Approach (eds. CK Cassel, RM Leipzig, HJ Cohen, EB Larson, DE Meier DE) 4th ed: 121–131. Springer, 2002.

There are disadvantages with home assessments as well. Some patients may be very uncomfortable with health personnel visiting their home. An explanation for the visit must, therefore, be given at initial contact, as well as the option of an outpatient appointment. The ability and equipment to conduct a physical examination are limited in a home visit. Finding a mutually convenient time for all involved may lead to delays. Home assessments do require more time for travel and potentially could be longer than outpatient assessments, because more issues may be uncovered. On clinical grounds, however, we believe this is an advantage and well worth any extra time spent.

Preparation

The Referral and Allocation

Although many old age psychiatric services accept and encourage referrals from a variety of sources, including patients and carers,¹⁴ we believe the involvement or approval of the patient’s general practitioner (GP) is essential. The GP is the primary healthcare provider and frequently has an intimate and long-standing relationship with the patient. There are occasions when a referral is received from a source other than the GP while the GP is already managing the situation well and views specialist input as unnecessary or inappropriate. The GP is the practitioner most likely to have an overall understanding of co-morbid physical illnesses, long-standing psychiatric disorders and current prescription medications. This information is invaluable in services where non-medical clinicians are required to triage or respond to the referral.

The reason for the referral and perceived urgency must be as clear as possible. Other information includes the details of involvement of other mental health services or practitioners, government or non-government agencies, and formal and informal social supports. Contact details for family and/or carers should be obtained as well as any known risk factors or dangers to the patient, family, carers or health and community personnel.

Which, and how many, staff respond to a referral will depend on several factors, including service policy, staffing levels, the patient’s history with the service and transport availability. If a patient was previously known to a service or has accepted the referral and has no identifiable risk factors, it may be appropriate for only one staff member to respond. If there are potential risks and complexity, two clinicians have the advantages of mitigating safety concerns, gathering more information and developing an initial multidisciplinary formulation. Whether or not a doctor needs to go on every home assessment is debatable¹⁵ and often dictated by availability. Studies have shown non-medical staff to be equally skilled at providing initial assessments in old age psychiatry.¹⁶ Depending on availability, allocation by profession may have benefits in an initial assessment. For example, a referral indicating significant social stresses might be allocated to a social worker in the multidisciplinary team, while cognitive impairment or falls might prompt an occupational therapy perspective.

Initial Contact

Telephone contact with the patient should be made beforehand to obtain consent for a home assessment, to obtain permission to gather collateral history and to facilitate participation in the assessment, if appropriate, of family, carers or other parties involved.¹⁷ Alternative approaches will need to be considered when the patient cannot be contacted by phone, including writing to the patient or visiting unannounced. Culturally and linguistically diverse populations may require a clinician who speaks the patient’s language, interpreter services or, as a last resort, a family member to assist with the assessment.

Issues of informed consent are influenced by the referrer’s assessment of the patient’s presentation. If the patient has significant cognitive impairment, it may be considered appropriate to contact family or carers without consent, or to visit without prior notification. Sometimes the patient is unaware of the referral, or even the referrer. How much is disclosed to the patient may depend on the referrer, their relationship with the patient and the apparent willingness of the patient to engage in assessment. It may prove necessary to go back to the referrer for clarification of some issues following initial telephone contact with the patient.

The clinician should try to find out whether there are family members who may be able to assist the assessment, to clarify the patient’s own perceptions of their circumstances and to identify the patient’s own priorities and concerns. An appointment date can be confirmed, necessary directions elicited and any problems regarding access discussed (e.g. bad roads, access to gated communities, building security controls).

Identified Risks and Safety Issues

Potential risks to staff should be identified prior to any home assessment with strategies implemented to reduce or minimize them. These factors will dictate the arrangements and timing of the assessment, including the number and mix (professional background, gender) of staff and the potential role of any emergency services and police.

Morning appointments may be preferable in neighbourhoods that are violent or have illicit drug problems. Any vehicles should not be ostentatious or contain valuables and be parked to ensure rapid egress if this proves necessary. A ‘doctor’s bag’ may also attract the attention of individuals with drug-seeking behaviour, and a nondescript bag or rucksack may be preferable in such areas. Mobile telephone reception needs to be monitored.

Owners should be asked to restrain or isolate potentially aggressive animals. This can be done by telephone from the front gate, if necessary. The general layout of the property should be considered, including routes of egress, alternative exits and barriers such as secured doors or excessive household items and refuse. Consideration of the situation of stairwells and functionality of lifts (elevators) is necessary in multi-storey residential blocks. This may be necessary owing to issues with the patient’s partner or family, including hostility, violence and drug and alcohol issues.

Safety issues include the availability of mobile phones or other telecommunications, ready access to relevant phone numbers (home base, crisis response team, ambulance and police) and sufficient fuel (a major issue in more rural areas). Visits should be planned in accordance with service safety policies, including staff working alone and with an effective system in place for tracking where staff have gone and their expected return time.¹⁹ Equipment that might be taken on home assessments is detailed in Box 9.2.

Box 9.2 Home assessment equipment

Patient records and stationery
Medical equipment such as blood pressure cuff, stethoscope and thermometer
Blood test request forms, radiological request forms and prescription pad
Medication samples
Antipsychotic depots and syringes (e.g. if a previously known patient is known to have defaulted on a depot antipsychotic)
Relevant mental health legislation paperwork
Spare clothing, especially trousers, are always worth consideration if squalid home circumstances are anticipated
Patient education materials and brochures introducing the service
Dictaphone
Introduction/business card

Scanameo A, Fillit H. A practical guide to seeing the patient at home. Geriatrics 1995; 50: 33–7. Unwin BK, Jerant AF. The home visit. Am Fam Physician 1999; 60: 1481–8.

Awareness and re-evaluation of such risk issues should be ongoing throughout a home visit. Any signs of aggression, anger or intoxication from substances in the patient or others should be monitored closely and note taken of any potential weapons in the environment. While de-escalating confrontational situations is an option, assessments should be politely terminated if there is evidence of escalation that poses a threat to staff, or indeed to the patient or any other people in the household. If it proves necessary to terminate the home visit, the degree and urgency of the situation, as well as risks to the person and healthcare staff, will dictate what subsequent response is required.

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