CHAPTER
5
The 15-Minute Older Adult Diagnostic Interview
PERFORMING a 15-minute interview with an older adult experiencing mental distress sounds impossible. Older adults have a lifetime of stories to tell, as well as accrued ailments and impediments of age and, often, an inability to name them succinctly. Gathering the crucial information in only 15 minutes requires a skilled interviewer. As you are developing this skill, remember the purpose of a brief interview. You cannot generate a complete differential diagnosis and a comprehensive treatment plan in 15 minutes, but you can seek the most likely diagnoses, identify a psychiatric emergency such as suicidality or elder neglect, and initiate treatment. Consider the following case:
Marcos, a 66-year-old man, presents to your primary care office to establish care. He tells your medical assistant that he “feels sad all the time.” She asks him to complete a Patient Health Questionnaire 9-item depression scale (PHQ-9), Generalized Anxiety Disorder 7-Item Scale (GAD-7), and the DSM-5 Level 1 Cross-Cutting Symptom Measure prior to your 15-minute visit (American Psychiatric Association 2013). His scores for the PHQ-9 and GAD-7 are 12 and 10, respectively. On his DSM-5 Level 1 Cross-Cutting Symptom Measure, he indicates some concern about depression, anxiety, and alcohol use. Reading over these results, you may find yourself feeling pressured because there are so many concerns to cover in 15 minutes.
When meeting a patient like Marcos for a 15-minute interview, we rely on three key strategies:
- Obtain as much background information as possible before the interview. Review any available records. Understand, if possible, why the patient is visiting today and with whom. Review any validated mental health screenings a patient and/or her caregiver completed prior to the visit. These screenings, particularly the DSM-5 Level 1 Cross-Cutting Symptom Measure, can give an idea of where to initially focus your diagnostic questions.
- Observe the patient’s functional status during the interview. If possible, walk your patient to an examination room. This simple courtesy gives you an opportunity to observe how the patient dresses, greets a stranger, ambulates, and navigates a space outside of her own dwelling.
- Determine whether the patient’s functional status matches her current level of social support and care. Learning how well a patient’s psychosocial needs and her currently available resources fit together is critical for deciding the first steps of your treatment plan. For example, a patient who is living independently without any significant social support but needs assistance with instrumental activities of daily living (IADLs) will have greater difficulty implementing your recommendations than one who is fully dependent on others for IADLs but benefits from a strong support network in an assisted living facility.
- Observe the patient’s functional status during the interview. If possible, walk your patient to an examination room. This simple courtesy gives you an opportunity to observe how the patient dresses, greets a stranger, ambulates, and navigates a space outside of her own dwelling.
Outline of 15-Minute Older Adult Diagnostic Interview
MINUTE 1
Review the screening responses before meeting the patient. Formulate in your mind what areas you want to focus on and how you intend to structure your interview.
MINUTE 2
Introduce yourself and explain the length and purpose of today’s interview.
MINUTES 3–6
Start with a general question (e.g., “Tell me, what brought you here?”) or a more specific comment tied to the screening materials (e.g., “Tell me more about the depressive symptoms you have had recently”). Instead of asking a list of closed-ended questions, allow a patient to narrate the history of her present illness. Get a sense of how well the patient can organize her history, how long she has been experiencing these symptoms, and how they affect her daily routine.
MINUTES 7–10
If possible, collect collateral information from the patient’s caregiver(s). If no caregiver is available, take these 3 minutes to do a psychiatric review of systems and a brief cognitive screening, which includes orientation and delayed recall.
MINUTES 11–12
Collect past psychiatric history and screen for red flags such as high risk for suicide, elder abuse, and heavy substance use, any of which will require you to refer your patient for further treatment, such as from mental health or social work practitioners. For the psychiatric history, determine whether or how long the person has been in mental health treatment; whether she has been hospitalized for psychiatric reasons; and whether there have been any suicide or homicide attempts and, if so, the lethality of those attempts. For the psychotropic history, you primarily need to know which antidepressants the patient has tried and whether she has ever taken a mood stabilizer and/or antipsychotic. You can speed up this process by having her review a list of psychotropic medications beforehand to check which ones have been previously prescribed.
MINUTES 13–15
By the end of the interview, you should know which of these actions is needed for your patient: 1) obtain further information and/or treat in primary care; 2) refer to mental health services for further treatment; or 3) in very rare circumstances, refer to emergency psychiatric services. Finally, you should share your initial treatment plan with the patient.
For example, the following is one way to structure a 15-minute interview with Marcos, the patient introduced at the beginning of this chapter.
Minute 1: Introduce yourself and the purpose of today’s conversation. “Hi, Mr. Pena. I’m Dr. Ryan, and today I’ll be spending about 15 minutes to talk to you about your mental health.”
Minute 2: Summarize the results of Marcos’s screening questionnaires, beginning with his depressive and anxiety symptoms, followed by the potentially more sensitive subject of his alcohol use.
Minutes 3–6: Tell Marcos something like, “I see you indicated you were feeling depressed recently. Please tell me more about that.” Because Marcos explains that he has been depressed and anxious for the past 3 months since being diagnosed with hepatitis C by his previous primary care practitioner, observe not just what he says but how he says it, listening for his emotional tone, cognitive ability, and character structure. Marcos tells you that he used heroin intravenously until about 30 years ago, when he enrolled in a methadone program; he has been abstinent ever since. He is embarrassed about his diagnosis and is anxious that his hepatologist will say he needs to go on a special regimen to treat his hepatitis C. He is also afraid to tell his family because he fears they will reject him.
Minutes 7–10: During the psychiatric review of systems, Marcos reports that he drinks 1–2 shots of tequila about 4–6 times per week after he gets home from work. Since his diagnosis of hepatitis C, he has also been drinking 1–2 beers per night to help him go to sleep. When you ask whether Marcos thinks he has a problem with drinking, he says he does not. However, he acknowledges that his hepatologist is concerned about his drinking.
Minutes 11–12: During your review of his history, Marcos denies any psychiatric history other than his treatment in the methadone clinic.
Minutes 13–15: During your final minutes, you begin by asking Marcos how interested he is in mental health treatment. He reports ambivalence about taking medication but agrees to discuss the stress of his new diagnosis of hepatitis C with the psychologist who is part of your clinic’s new primary care–mental health integration initiative. Hoping to spark Marcos’s interest in treatment, you use motivational interviewing techniques to prepare him for return visits and engagement in mental health treatment.
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