• CAGE questionnaire (Box 16.12)

• FAST questionnaire (Box 16.13).

Putting it all together: clinical vignettes

Examples in practice are provided in Boxes 16.14–16.17.

as far as possible by visual corrections, hearing aids and

interpreters.

The central matters to be assessed are essentially cognitive:

can the patient make, understand, remember and communicate

decisions about medical treatment or other options before them?

Determining that a patient lacks capacity for a particular

decision leads to the next stage: making that decision on their

behalf. The key principles here are to ensure that any treatment

proposed must benefit the patient and be the least restrictive

option available; it should take account of any wishes the patient

has previously expressed, as well as the views of family members

and any other relevant others (such as nursing home staff).

The physical examination

Physical and mental disorders are associated, so always consider

the physical dimension in any patient presenting with a psychiatric

disorder, and vice versa. The setting and the patient’s age, health

and mode of presentation will determine the extent of physical

assessment required.

In psychiatric settings, general physical observation, coupled

with basic cardiovascular and neurological examination, will usually

suffice. Bear in mind that some physical disorders can present

with psychiatric symptoms (such as thyrotoxicosis manifesting

as anxiety – look for exophthalmos, lid lag, goitre, tachycardia

and so on). For older patients with multiple medical problems, or

those with alcohol dependence and associated physical harm,

a more detailed examination is clearly needed.

In primary care and acute hospital settings, patients will

usually undergo physical examination tailored to the presenting

problem, but it is important to be aware that some psychiatric

disorders can present with physical symptoms, such as chest

pain and transient neurological symptoms as manifestations of

panic attacks.

Collateral history

Collateral history is important whenever assessment is limited by:

• physical illness, acute confusional state or dementia

• severe learning disability or other mental disorder impairing

communication

• disturbed, aggressive or otherwise uncooperative

behaviour.

Sources of third-party information will usually include family and

other carers, as well as past and present general practitioners

and other health professionals. Previous psychiatric assessments

are particularly valuable when a diagnosis of personality disorder

is being considered, as this depends more on information about

behaviour patterns over time than the details of the current

presentation (Box 16.10).

16.10 Personality disorder: definition

Patterns of experience and behaviour that are:

• pathological (i.e. outside social norms)

• problematic (for the patient and/or others)

• pervasive (affecting most or all areas of a patient’s life)

• persistent (adolescent onset, enduring throughout adult life and

resistant to treatment)

From Hodkinson HM. Evaluation of a mental test score for assessment of mental

impairment in the elderly. Age and Ageing 1972; 1(4):233–238, by permission

of Oxford University Press.

16.11 The Abbreviated Mental Test

• Age

• Date of birth

• Time (to the nearest hour)

• Year

• Hospital name

• Recognition of two people, e.g. doctor, nurse

• Recall address

• Dates of First World War (or other significant event)

• Name of the monarch (or prime minister/president as appropriate)

• Count backwards 20–1

Each question scores 1 mark; a score of 8/10 or less indicates

confusion.

16.12 The CAGE questionnaire

• Cut down: Have you ever felt you should cut down on your drinking?

• Annoyed: Have people annoyed you by criticising your drinking?

• Guilty: Have you ever felt bad or guilty about your drinking?

• Ever: Do you ever have a drink first thing in the morning to steady

you or help a hangover (an ‘eye opener’)?

Positive answers to two or more questions suggest problem

drinking; confirm this by asking about the maximum taken.

326 • The patient with mental disorder

16.14 Clinical vignette: overdose

A 19-year-old woman attends the accident and emergency

department, having taken a medically minor overdose. She has

presented in this way three times in the last 2 years. She needs no

specific medical treatment.

Your assessment should concentrate first on the circumstances of

the overdose and her intentions at the time. Collateral information

should include assessments after previous presentations and any

continuing psychiatric follow-up. Mental state examination should

screen for any new signs of mental disorder emerging since her last

assessment, and in particular any mood problems or new psychotic

symptoms. She will clearly have undergone a detailed physical

assessment, but even if the overdose appears medically trivial, you

need to undertake a risk assessment to judge the chances of further

self-harm or completed suicide in the near future. She probably does

not need a detailed cognitive assessment or psychiatric rating scales.

16.15 Clinical vignette: confusion, agitation and hostility

An 85-year-old man in a medical ward, where he is undergoing

intravenous antibiotic treatment for a chest infection, now appears

confused, agitated and hostile, in a way not previously evident to his

family.

You need to approach him carefully to establish rapport and to

interview him as much as he will allow, while anticipating that you may

have to rely heavily on collateral information, and a mental state

examination limited to observation of appearance and behaviour. It will

be crucial to talk to his family to establish his normal level of cognition

and independence, and to the nursing staff to establish the diurnal

pattern of his problems. If there is any history of previous episodes,

acquire the results of previous assessments. He will need a

neurological examination and assessment of his cognition via a

standard scale. Risk assessment should focus on the indirect risks to

his health if he tries to leave hospital against advice, generating a view

about his detainability under mental health legislation. A capacity

assessment of his ability to consent to continuing antibiotic treatment

is required, and may result in the issue of an incapacity certificate.

16.13 The fast alcohol screening test (FAST) questionnaire

For the following questions please circle the answer that best applies

1 drink = 1

2 pint of beer or 1 glass of wine or 1 single measure of spirits

1. Men: How often do you have eight or more drinks on one occasion?

Women: How often do you have six or more drinks on one occasion?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

2. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

3. How often during the last year have you failed to do what was normally expected of you because of drinking?

• Never (0)

• Less than monthly (1)

• Monthly (2)

• Weekly (3)

• Daily or almost daily (4)

4. In the last year, has a relative or friend, or a doctor or other health worker, been concerned about your drinking or suggested you cut down?

• Never (0)

• Yes, on one occasion (2)

• Yes, on more than one occasion (4)

Scoring FAST

First stage

• If the answer to question 1 is ‘Never’, then the patient is probably not misusing alcohol

• If the answer is ‘Weekly’ or ‘Daily or almost daily’, then the patient is a hazardous, harmful or dependent drinker

• 50% of people are classified using this one question

Second stage

• Only use questions 2–4 if the answer to question 1 is ‘Less than monthly’ or ‘Monthly’:

• Score questions 1–3: 0, 1, 2, 3, 4

• Score question 4: 0, 2, 4

• Minimum score is 0

• Maximum score is 16

• Score for hazardous drinking is 3 or more

Putting it all together: clinical vignettes • 327

16

16.16 Clinical vignette: fatigue

A 35-year-old woman attends her general practitioner, presenting with

fatigue.

Assessment of possible physical causes is required, via history,

examination and appropriate blood tests, but as these proceed, the

interview should also cover possible symptoms of depression, previous

episodes, family history and recent stressors. Mental state examination

should concentrate on objective evidence of lowered mood. Formal

assessment of cognition is probably not necessary, but a standard

rating scale for mood disorder may help establish a diagnosis and a

baseline against which to measure change. Risk assessment is not a

prominent requirement, unless a depressive illness is suspected and

she reports thoughts of self-harm, or is responsible for young children,

in which case the chance of direct or indirect harm to them needs to

be considered.

16.17 Clinical vignette: paranoid thoughts

A 42-year-old man attends a psychiatric outpatient clinic for the first

time, having been referred by his general practitioner for longstanding

paranoid thoughts.

It will be particularly important to establish rapport with a patient

who is likely to be very wary. The interview needs to cover the

psychiatric history in some detail, considering substance misuse, family

history of mental illness and a full personal history in particular. Mental

state examination should explore the paranoid thoughts in detail, to

establish whether they are preoccupations or overvalued ideas

(suggesting a personality disorder), or delusions (suggesting a

psychotic illness). Risk assessment should concentrate on the risk to

others about whom the patient has paranoid fears. Neither detailed

cognitive assessment nor a specific rating scale is likely to add much

to the initial assessment.

OSCE example 1: Assessing suicidal risk

Miss Gardiner, 27 years old, presented to the accident and emergency department the previous day after taking an overdose of paracetamol while

intoxicated with alcohol. She has undergone treatment with acetylcysteine overnight and is now medically fit for discharge.

Please assess her risk of self-harm and suicide

• Introduce yourself and clean your hands.

• Explain the purpose of your assessment; try to gain rapport.

• Enquire how she is feeling physically (specifically asking about nausea, vomiting and abdominal pain).

• Tactfully introduce the subject of the overdose.

• Establish the number and type of tablets taken.

• Establish how much alcohol she drank, whether this was with the tablets (to ‘wash them down’) or whether she was already intoxicated at the time

of the overdose.

• Clarify the circumstances. Who else was present or expected? Did she write a note or otherwise communicate what she had done or was planning

to do?

• Clarify how she was found and either came or was brought to hospital.

• Explore recent or chronic stressors.

• Establish her intent at the time of the overdose. Did she expect to die? Is that what she wanted?

• Confirm her view now. Does she still wish to die? Does she have any thoughts about another overdose or other form of self-harm?

• Establish relevant past history. Are there any previous overdoses? Any previous or continuing psychiatric follow-up?

• Confirm whether she has parental or caring responsibilities for young children. Tactfully enquire about any thoughts of harming them.

• Establish who will be with her when she leaves hospital.

• Thank the patient and clean your hands.

Summarise your findings

The risk assessment should concentrate most on the short-term risk of suicide.

Advanced level comments

More advanced students would be expected to tabulate short- and long-term risk of both suicide and further self-harm, and to quote the risk of

completed suicide in the first year after an act of self-harm (1–2%).

328 • The patient with mental disorder

OSCE example 2: Assessing delirium

Mr Duncan, 82 years old, is admitted to an orthopaedic ward after falling and breaking his hip. Forty-eight hours after surgery he became restless and

agitated overnight, pulling out his intravenous line. He is now settled and cooperative.

Please assess the likely cause of this episode

• Introduce yourself and clean your hands.

• Explain the purpose of your assessment; try to establish rapport.

• Enquire how he is feeling physically (specifically asking about pain, fever, constipation, and urinary and respiratory symptoms).

• Establish his awareness of where he is, why he is there and how long he has been in hospital.

• Ask how much he remembers of the night’s events and enquire specifically about any recollection of hallucinations or persecutory fears.

• Enquire about any continuing hallucinations or fears.

• Ask about any previous similar episodes.

• Clarify how active he was before his fall, and whether there is any awareness of memory impairment leading up to it.

• Ask about alcohol intake.

• Administer simple tests of cognitive function, especially of attention and memory (advanced performers should know the Abbreviated Mental Test

questions).

• Undertake a basic physical examination, assessing for tremor, ophthalmoplegia and nystagmus.

• Gain the patient’s permission to speak to his next of kin, general practitioner and others.

• Thank the patient and clean your hands.

Summarise your findings

The diagnosis is delirium, with further enquiries needed to establish the likely cause (which may be alcohol withdrawal, given the timing), as well as

the possibility of pre-existing cognitive impairment as a vulnerability factor.

Integrated examination sequence for the psychiatric assessment

• Review the relevant information to clarify the reason for referral or mode of self-presentation.

• Establish rapport to reduce distress and assist assessment.

• Cover the key headings for the history (presenting symptoms, systematic review, past medical and psychiatric history, current medication, substance

misuse, family history, personal history).

• Cover the headings for the personal history (childhood development, losses and experiences, education, occupation, financial circumstances,

relationships, partner(s) and children, housing, leisure activities, hobbies and interests, forensic history).

• Make the extent, order and content of the assessment appropriate to the presentation and setting.

• Observe closely to gain objective evidence of mental state, especially non-verbal information.

• Cover the headings for the mental state examination systematically (appearance and behaviour, speech, mood, thought form and content,

perceptions, cognition and insight).

• Use brief formal tests to assess cognitive function (Abbreviated Mental Test, Mini-Mental State Examination, Montreal Cognitive Assessment).

• Consider your own emotional response to your patient.

• Consider standardised rating scales as a screening tool (and sometimes to monitor progress).

• Undertake physical examination as appropriate to the setting and the presentation.

• Gather further background information from other sources to the degree necessary (with permission).

• As well as a diagnosis and management plan, be sure to consider:

• assessment of risk to self or others

• capacity to take decisions

• need to use mental health or incapacity legislation.

17

The frail elderly patient

Andrew Elder

Elizabeth MacDonald

Assessment of the frail elderly patient 330

Factors influencing presentation and history 330

The history 331

The presenting symptoms 331

Common presenting symptoms 331

Past medical history 331

Drug history 331

Family history 332

Social and functional history 332

Systematic enquiry 332

The physical examination 333

General examination 333

Systems examination 334

Functional assessment 335

Interpretation of the findings 337

OSCE example 1: History in a frail elderly patient with falls 337

OSCE example 2: Examination of an acutely confused frail

elderly patient 337

Integrated clinical examination for the frail elderly patient 338

330 • The frail elderly patient

Factors influencing presentation

and history

Classical patterns of symptoms and signs still occur in the frail

elderly, but modified or non-specific presentations are common

due to comorbidity, drug treatment and ageing itself. As the

combination of these factors is unique for each individual, their

presentations will be different. The first sign of new illness may

be a change in functional status: typically, reduced mobility,

altered cognition or impairment of balance leading to falls.

Common precipitants are infections, changes in medication and

metabolic derangements but almost any acute medical insult can

produce these non-specific presentations (Fig. 17.1). Each of

these presentations should be explored through careful history

taking, physical examination and functional assessment.

Disorders of cognition, communication and mood are so

common that they should always be considered at the start of

the assessment of a frail older adult.

Communication difficulties,

cognition and mood

Communication can be challenging (Box 17.2). The history

can be incomplete, difficult to interpret or misleading, and the

whole assessment, including physical examination, may be

time-consuming.

Whenever possible, assess the patient somewhere quiet with

few distractions. Make your patient comfortable and ensure they

understand the purpose of your contact. Provide any glasses,

hearing aids or dentures that they need and help them to switch

Assessment of the frail elderly patient

Comprehensive geriatric assessment is an evidence-based

process that improves outcomes. It involves taking the history

from the patient and, with the patient’s consent, from a carer

or relative, followed by a systematic assessment of:

• cognitive function and mood

• nutrition and hydration

• skin

• pain

• continence

• hearing and vision

• functional status.

The extent and focus of the assessment depend on the clinical

presentation. In non-acute settings such as the general practice

or outpatient clinic or day hospital, focus on establishing what

diseases are present, and also which functional impairments

and problems most affect the patient’s life.

In acute settings such as following acute hospital referral,

focus on what has changed or is new. Seek any new symptoms

or signs of illness and any changes from baseline physical or

cognitive function.

The complexity of the problems presented, and the need for

comprehensive and systematic analysis, mean that assessment

is divided into components undertaken at different times, by

different members of the multiprofessional team (Box 17.1).

There is no specific age at which a patient becomes

‘elderly’; although age over 65 years is commonly used as the

definition, this has no biological basis, and many patients who

are chronologically ‘elderly’ appear biologically and functionally

younger, and vice versa.

Frailty becomes more common with advancing age and is

likely to be a response to chronic disease and ageing itself. A frail

elderly person typically suffers multimorbidity (multiple illnesses)

and has associated polypharmacy (multiple medications). They

often have cognitive impairment, visual and hearing loss, low

bodyweight and poor mobility due to muscular weakness, unstable

balance and poor exercise tolerance. Their general functional

reserve and the capacity of individual organs and physiological

systems are impaired, making the individual vulnerable to the

effects of minor illness.

17.1 The multiprofessional team

Professional Key roles in assessment of

Physician Physical state, including diagnosis

and therapeutic intervention

Psychiatrist Cognition, mood and capacity

Physiotherapist Mobility, balance, gait and falls risk

Occupational therapist Practical functional activities

(self-care and domestic)

Nurse Skin health, nutrition and continence

Dietician Nutrition

Speech and language therapist Speech and swallowing

Social worker Social care needs

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Fig. 17.1 Functional decompensation in frail elderly people.

17.2 Communication difficulties: the seven Ds

Problem Comment/causes

Deafness Nerve or conductive

Dysphasia Most commonly due to stroke disease but sometimes

a feature of dementia

Dysarthria Cerebrovascular disease, motor neurone disease,

Parkinson’s disease

Dysphonia Parkinson’s disease

Dementia Global impairment of cognitive function

Delirium Impaired attention, disturbance of arousal and

perceptual disturbances

Depression May mimic dementia or delirium