Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-024History and Mental Status ExaminationHallie N. Richards 1 and Gabe J. Maletta 21 University of Minnesota Medical School and 2 VA Medical Center, Minneapolis, MN, USAA successful psychiatric evaluation in the elderly, including acomprehensive mental status examination, involves integratingcomponents of both medical and psychiatric clinical models. Theclassic medical model pursues symptoms and signs in a problemorientatedfashion, seeking to match them with a single unifyingdiagnosis and then designing an appropriate treatment strategyleading to a cure. This approach is less useful when dealing withgeriatric patients. With these patients, aspects of the psychiatricclinical model are emphasized, i.e. ongoing treatment rather thancure, and chronic rather than acute care given by an interdisciplinaryteam. This strategy leads toward maximizing andmaintaining individual function and behavior. Geriatric care isinvolved less with disease and more with disability. This is the casewhether the patient has a psychiatric or general medical problem;and treatment goals must address the situation of chronic careneeds, in contrast simply to the ‘‘fixing’’ of an isolated problem.Complicated presentations of disease in this age group createproblems most successfully approached from an interdisciplinaryperspective. Many syndromes manifest themselves with symptomscommon to psychiatry, internal medicine and neurology, illustratingthe overlap of these disciplines in geriatric care. The uniqueand challenging aspects of interviewing the elderly requiresdeveloping an individualized, functional clinical examination.With this goal in mind, the medical history will be examined andutilized to illustrate how the different medical specialties interactto integrate the art with the science of medicine. A successfulblending will result in obtaining the most clinically usefulexamination possible.PURPOSEObtaining a valid and reliable medical history continues to yield acorrect diagnosis in over 80% of clinical situations 1 . This remainstrue in elderly patients, but accomplishing the task in this agegroup is often difficult and time-consuming. Perfecting the skillsrequired to interview successfully an old, sick individual isinvaluable in understanding an unusual disease process oravoiding costly mistakes in evaluation and treatment 2 . Theworking, hands-on abilities necessary to effect a successful historyfall within two separate realms: fact-finding (science) and empathy(art) 3 . In the first realm, traditional medical training is replete withteaching and experiences. On the other hand, tutelage yieldingartful practitioners is much less universal; indeed, it is becoming arare and treasured experience in a medical residency.With a view in mind toward expanding the ‘‘art’’ realm, a newlook at interviewing elderly people is indicated. The interactionbetween patient and interviewer becomes much more than theprocess of collecting facts and related information to make adiagnosis. Gaining medical and social facts pertaining to theindividual’s problems is a primary but not exclusive goal. Olderadults often come to the physician with a complex agenda thatmay not be obvious by dwelling only on the chief complaint.Conducting the interview by this conventional fact-findingmethod may not be productive and actually may put one at riskfor generating too narrow a differential diagnosis.In addition to laying the foundation for a satisfying therapeuticrelationship, the initial gathering of information should guide thefirst steps in evaluation. Logical, stepwise investigation ofsymptoms and signs remains the practical approach to anymedical work-up. If this investigation yields nothing, the urge toperform more elaborate tests should be resisted and one shouldreturn to the history. Greater dependence on reviewing the historyagain with the patient is more likely to yield an appropriate plan.The ‘‘law of parsimony’’ is not as useful a guiding principle in thecare of geriatric patients as it is in general medicine 4 . A single,unifying diagnosis may not explain satisfactorily a symptomcomplex responsible for a precipitous functional decline in anelderly individual, and continuing investigation frequentlyuncovers multiple causes.An understood but often unstated purpose of the medicalinterview with old people is getting to know the patient. Thisrequires interviewer empathy (not sympathy or emotionalinvolvement), which may be of the highest importance in thepatient’s view. Using the initial interview to explore personalityand life experiences helps build rapport that is essential tosubsequent interactions. Whether a patient’s problem is psychiatricor medical, the initial interaction and relationship that growsfrom it are vital to achieving the goal of proper diagnosis andtreatment.ELEMENTSAlthough the components of the medical history in geriatrics donot differ from those in the practice of any other specialty, theorder in which they are pursued and their relative importance maybe unique. The classic approach of taking a symptom-directedchief complaint, history of present illness, past medical history,review of systems, social history and family history will produce adesired database from which to work. However, mechanically andswiftly following an unbending order or sequence of impersonalquestions may provoke successively less and less cooperation ifthe patient perceives that you are not really ‘‘listening’’. A moreeffective approach may require the physician to give up somecontrol over the process of the interview, allowing the patient toPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd