Geriatric Patients

Mental health treatment of older adults is challenging under the best of circumstances. It requires an understanding of the expected medical and psychological changes with aging, effects of life transitions, nuances of psychiatric presentations in the elderly, and ability to tailor treatments to be safe and effective in older adults. Understanding the social and family dynamics of older adults and families is always essential, but more poignant amid the COVID-19 pandemic. Our goal at Michigan Medicine is to continue to provide effective care for these vulnerable patients in an ever-changing model of practice with increased reliance on technology to facilitate patient interactions.

The information contained on this website is meant to serve as a guide for primary care clinicians in assessing and treating common psychiatric conditions in older adults, with attention to delivering care in a virtual setting. Sections on psychiatric conditions are organized around common presentations in older adults, screening methods, and initial treatment recommendations. Consultation and Geriatric Psychiatry referral is appropriate in instances of diagnostic uncertainty or cases with complicated conditions, management, and family dynamics. Additional references and resources are cited for the curious reader.

Geriatric Psychiatric Assessment and Use of Video Visits

What are the elements of a geriatric assessment?

As with any patient, you should assess past medical history, family history, medications, and a social history. The functional assessment is central to a geriatric interview. This includes asking the patient and caregiver about the patient’s ability to perform Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs). Clinicians should also inquire about vision and hearing, nutrition and weight, balance and gait, cognition, mood, and social supports. (This information need not be obtained in one meeting.) A geriatric assessment should also screen for geriatric syndromes, including falls, memory changes, incontinence, frailty, and polypharmacy.

What are ways to conduct or modify these assessments in a virtual visit?

Fortunately, much valuable information can be gathered from patient report, family information, and review of the medical record. Many aspects of a cognitive assessment can be easily incorporated into a video visit along with the psychiatric mental status examination. Geriatric psychiatry is often family psychiatry. Involving trusted caregivers in these video assessments is invaluable whenever possible.

Setting up video visits for geriatric patients:

  1. Do not assume that older adults are not adept at using technology for communication and video calling. Many are already doing this with family.

  2. Offer multiple options for video conferencing platforms to see if they have particular comfort or familiarity.

  3. Be persistent! Do not be quick to settle for a phone call. Remind them that video options help you provide the best care for them.

  4. Involve family members to help them set up video sessions. Often a supportive child or spouse is happy to help and even participate in the visit.

General suggestions for communicating via video:

  1. Speak clearly and slowly, but not in a patronizing way.

  2. Repeat yourself if needed.

  3. Be sure that the patient is using glasses and hearing aids during the appointment.

  4. Have a family member or caregiver present for the evaluation if possible.

 Physical examination findings that can be readily obtained in the home or by video:

  1. Heart rate and blood pressure (if a home cuff is available)

  2. Finger stick glucose

  3. Weight

  4. Attention to facial and involuntary oromandibular movements.

  5. Is the patient able to sit still? Are they restless/pacing?

Mental status examination:

Assessment of appearance, behavior, speech and language, emotional state, thought content and process, cognition, and insight are no different when performed via video visit and in the clinic.

In speaking with a patient by telephone, the clinician is often able to garner sufficient information to comment accurately on a patient’s cognition, speech and language, mood state, and thoughts. Without observing the patient, information is lost with regard to appearance and affect, which can be valuable clinical clues to gauging a patient’s mood and anxiety. 

Physical examination findings that can be modified:

  1. Ask the patient/family about changes in gait.
  2. Any slowing down, shuffling, or falls?

  3. Hold hands up to screen at rest to monitor for tremor.

  4. With assistance from a family member, it is possible to record the patient walking if gait changes are of clinical concern.

Screening tools in geriatric psychiatry:

Screening tools can also be readily used in a virtual visit or easily modified. These include the Montreal Cognitive Assessment (MoCA) and Geriatric Depression Scale (GDS). 

The GDS has a clinician-administered version that is read to the patient and scored with yes/no answers.

The MoCA-blind is a version of the same screening instrument without sections that require an individual to see the test. It omits sections on following a sequence of trails, copying a cube, drawing a clock, and naming pictures of animals. The remainder of the test is administered orally by the tester, and ideal for use in phone or video sessions. A dedicated tester can ask a patient to draw a clock and hold it to the camera for interpretation.

 

Other assessments can be administered in a similar oral manner or shared with the patient or caregiver through the medical chart.

 

Additional resources

  1. Montreal Cognitive Assessment https://www.mocatest.org
  2. Geriatric Depression Scale https://consultgeri.org/try-this/general-assessment/issue-4.pdf

  3. University of Michigan patient and clinician information for video visits https://www.uofmhealth.org/virtualcare/virtual-care-video-visits

  4. University of Michigan geriatric psychiatry recommendations for managing anxiety amid COVID-19 https://psych.med.umich.edu/pdf/covid-older-adults.pdf

  5. If you are a Michigan Medicine provider, and would like access to our lists of behavioral health resources, you may contact Michele Brown at resoho@med.umich.edu

Select references

Blazer DG. Techniques for communicating with your elderly patient. Geriatrics. 1978;33:79-84.

Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA:  brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695-9.