CHAPTER
6
The 30-Minute Older Adult Diagnostic Interview
AS busy practitioners, we sometimes forget the importance of making (and taking) moments to get to know our older patients beyond their answers to diagnostic questions. Sometimes we need to comfort a crying widower or chat about hobbies with a bluff retiree before we ask any diagnostic questions. In moments such as these, we may feel that we do not know what we are accomplishing in a conversation. We may desire to refocus the conversation because we have other people to see and other tasks to complete. Good interviewers, however, understand that these seemingly wasted moments are as integral to the interview. These moments are valuable for providing clues about whether the patient’s distress is internal or external, what events bring him into and out of engagement with a practitioner, and how he formulates thoughts.
In an initial encounter, we start by getting to know the individual we are seeing. We use different strategies based on a person’s functional ability, the location in which we are meeting, our familiarity with the patient, the patient’s sense of humor, and any number of other variables. Before introducing ourselves to a patient, we like to know how long the patient has been waiting and with whom. The same patient will likely have different needs if he has sat calmly for 15 minutes in a waiting room than if he and his caregivers have been waiting hours in the emergency department. When we meet a person, we always prefer to open the conversation with a topic in which the person is already engaged. If he brings a book, we ask what it is about. If he is wearing the logo of a sports team, we ask about the team’s most recent season. The point is not to make an aesthetic judgment about the patient’s books or clothes but to understand how he thinks.
Asking about something that the patient is consciously (or unconsciously) presenting to you also builds the therapeutic alliance. Imagine if you walked into a medical encounter and your physician talked entirely about his interests while disregarding your attempts to discuss your own interests. You would most likely feel ignored and be reluctant to engage in treatment with the physician. Now imagine if you visited another physician and he knew your name, said it correctly, and then asked how you came by your name. You would likely be more responsive to this second physician and his treatment. You can (and should) extend the same engaging courtesy to the older adults you meet as patients.
We favor beginning every interview by introducing ourselves, asking an elder his name, assessing his expectations for the encounter, clarifying any misperceptions, and giving a sense of how long the encounter will last. We also like to know who arranged the visit: the person himself, his caregivers, or another practitioner. When someone else arranged for the evaluation, we acknowledge this immediately (e.g., “So your daughter wanted you to see me …”) to show an older adult we can see things through his eyes.
Even if the encounter is limited to 30 minutes, we believe that you can successfully develop a therapeutic alliance and perform a diagnostic interview. Before we explain how, we offer a few caveats.
- Any psychiatric examination in which all the information comes from a single source is incomplete. This is especially true when interviewing older adults, who often depend on others. Ask the patient whom he relies on and seek his permission to discuss his health with that person. See Chapter 11, “Selected DSM-5 Assessment Measures,” for tools to use in interviewing caregivers.
- A successful psychiatric examination ultimately provides access to the internal world of a person. The thoughts, impulses, and desires of an older person can be discovered in many ways. In what follows, we offer an interview that is best suited for a person who can tolerate direct questions. When interviewing someone who cannot do so because of age, impairment, or disinterest, we recommend focusing on the most essential portion of the examination and spending the remainder of your time developing a therapeutic alliance.
- A skilled psychiatric examination always includes an account of the relationships that constitute a person’s existence. During every interview we ask questions such as these: “Whom do you live with?” “How do you spend your days?” “Who cares for you?” and “Whom can you trust?” These naturally open onto other critical questions about the caregivers in an elder’s life.
With these caveats in mind, we offer the following as a guideline for a 30-minute diagnostic interview using DSM-5 criteria (American Psychiatric Association 2013). The interview does not include prompts for DSM-5 categories that are uncommon among older adults—namely, the neurodevelopmental, elimination, and paraphilic disorders. We have taught a version of this interview to students, residents, fellows, and faculty. Until you develop the habits of an experienced practitioner, it is useful to practice a structured interview. This practice helps in becoming comfortable asking about intimate concerns, remembering to screen all patients for the major categories of mental illness, and developing good interview habits.
Of course, using a structured interview has a downside. We have sometimes witnessed practitioners read one question after another, without stopping for the usual pauses that signify human speech or even looking at their patient. In the Pocket Guide to the DSM-5 Diagnostic Exam (Nussbaum 2013), these kinds of interviewers were called “psychiatric robots.” They push along their agenda, saying, “I hear you are suicidal,” but then before the patient can answer, they ask, “But do you really want to kill yourself now? And you don’t really want to hurt anyone else, right?” Such questions demonstrate a focus on using the structured interview as a checklist rather than as a guide to asking probing questions in pursuit of understanding the person. Although relying on a checklist is important to making sure you have covered important topics, you should not rely on checklist interviewing as the only skill in your interview toolbox. To help you learn how to do the diagnostic interview, we will share with you other skills you need in your toolbox to successfully interview older adults.
Providing the right amount of structure for the interview is challenging. An excitable person will need to be soothed, a sad person will need to be encouraged, and sometimes one person will need both in the same interview. Fortunately, you always have the best possible guide: the person before you. Follow his lead. Observe his body language. If he appears disinterested, it is time to alter your approach.
As you use this diagnostic interview, we recommend practicing a formal version until it becomes a habit and you develop a version that fits these questions to your own style and setting. The 30-minute diagnostic interview will seem forced at first, but gradually it provides the structure for a conversational interview.
Good interviewers always give a person a few minutes to speak his own mind. Then, after summarizing and clarifying his concern, they organize the examination as necessary, modulating the structure and language of the interview to fit the needs of the patient before them. They ask clear and succinct questions. If the patient is vague, they seek precision; if he remains vague, they explore why. They do not ask permission to change the subject but rather use transition statements, such as “I think I understand about [this], but how about [that]?” Developing a supply of stock questions is helpful, which is why we advise using this structured interview until it becomes a habit. These questions will help you develop a conversational interview in which a patient tells his story and you form an alliance with him, gain insight into his thought process, and gather the clinical data you need to make an accurate diagnosis. Developing a flow of exchange to the interview is important in building a therapeutic alliance.
Outline of the 30-Minute Older Adult Diagnostic Interview
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