Geriatric Mental Health Disaster and Emergency Preparedness

Chapter 14 Geriatric Assessment for Differential Diagnosis 283
of emotion evident from the examination. It may be broad, labile, or constricted
to a narrow range. One also looks for congruence between the apparent
affect and the mood state. If the patient reports feeling fine yet shows
marked affective constriction, this is noteworthy and should be subject to
further exploration. The client’s ability to communicate coherently is noted.
Do the sentences and words used make sense? Are words used correctly?
This is the point in the examination to look for neurological deficits or disorders
such as aphasia or evidence of damage to the language areas of the
brain. Often associated with aphasia are significant depressive symptoms
since the client is embarrassed and frustrated that he cannot communicate
normally.
It is useful at this time to test the client’s ability to read, write, and draw
and copy simple diagrams such as the pentagon in the Mini Mental State
Examination, or MMSE (Folstein, Folstein, & McHugh, 1975). Another task
that provides a good deal of information is asking the client to draw the face
of a clock—that is, a circle in which they will place the clock numerals and
then draw the hands to a certain time. The quality of the drawing, the client’s
ability to comprehend the task, the positioning of the numbers and hands,
and the entire use of the space will give indications of spatial relational disturbances,
memory impairment, poor concentration, and attention.
Are there delusions present, false fixed beliefs that are not easily
changed? They may take the form of paranoid persecutory thoughts that
others are plotting against them or following them, setting traps, or coming
into the client’s home to harass them. This may also be a manifestation of
cognitive impairment or memory disturbance. Perceptual disturbances
such as auditory, visual, tactile, or olfactory hallucinations may be present.
These may be indicative of underlying neurological impairment, particularly
the presence of hallucinations; visual hallucinations should be considered
the result of an underlying medical illness or condition such as a
withdrawal state from alcohol or a benzodiazepine.
There are many similarities in the presentation of clinical syndromes
or disorders in the geriatric population. The three D s of geriatric mental
health—depression, delirium, and dementia—may all appear similar at
some point in time. They have considerable differences, however, in their
onset, time course, tendency to improve or relapse, prognosis, and treatment
implications. As a general rule, the examiner must have a high index
of suspicion that a medical illness is masquerading as a psychiatric disorder.
For example, pneumonia in older persons may present with the same
signs as a depressive disorder—depressed mood, slowed motor behavior,
mental dullness, and lethargy. The natural history of depression is that it