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Assessment Procedures
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Diagnostic Procedures
These are of primary importance and include both psychiatric and medical history-taking together with physical examination and mental state assessment (including cognitive examination). Investigative procedures, e.g. EEG, blood tests, CT, MRI or SPECT scans are used as necessary.
There are now operationalized criteria or consensus statements for the diagnosis of the main types of dementia (e.g. Alzheimer's, Lewy body, vascular and fronto-temporal dementias), as well as for functional disorders. Many of the investigative procedures used in old age psychiatry are aimed at excluding other conditions in order to satisfy accepted international diagnostic criteria (e.g. the International Classification of Diseases, Tenth Edition, ICD-10).
Thus, the diagnosis of Alzheimer's disease requires that "other systemic or brain disease[s]" should be absent. This suggests the importance of blood tests (e.g. to exclude "amongst other things" vitamin B12 or folate deficiency) and brain scans (e.g. to rule out the possibility of tumours or haematomas). On the other hand, some diagnoses can be clinched by a particular finding on investigation (e.g. the finding on CT of multiple cerebral infarcts in a person whose history is in keeping with a diagnosis of vascular dementia). A functional scan, e.g. SPECT, might be a useful means to confirm a diagnosis of fronto-temporal dementia in someone where the anatomical scan (e.g. CT) only shows very mild frontal lobe atrophy. Such a scan might then be used to explain this bewildering and distressing condition to the family.
Illnesses in old age are commonly multiple, so that patients often suffer from several disorders simultaneously. Investigations become important, therefore, in functional illnesses too, not only because certain conditions need to be excluded (e.g. hypothyroidism in depression), but also because other physical conditions might make some psychiatric symptoms worse, or might preclude the use of certain medications. For example, chronic obstructive pulmonary disease, if not optimally treated, might exacerbate anxiety and panic; or a bleeding disorder or ulcer might limit the use of SSRIs.
Disorder of Function
Diagnosis alone does not tell you how severely disabled someone is. Two people with the same condition may behave very differently, e.g. dementia due to Alzheimer’s disease may render one person unsafe for independent living, but simply slow the other one down in the time taken to complete the daily crossword. It is important therefore to assess the functional disability that an old person suffers from and decide whether it can be relieved. Occupational Therapists and Physiotherapists play an important part here, but the doctor needs to be aware of this aspect of illness when he/she is taking a history. Not all functional disability is caused by illness - some is due to failure to learn (e.g. a widower who cannot cook and never could) or due to disuse atrophy, (e.g. taking to bed with an illness and then losing the ability to walk).
Quantifying Functional Disability
It is possible to quantify the changes referred to above and this assists not only in judging their severity but also watching their response to rehabilitation or observing any deteriorating with time or treatment. During your placements you will be shown standardised methods of measuring - cognitive performance, skills in activities of daily living and mood state.
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