Chapter 12 PSYCHIATRIC HISTORY TAKING
INTRODUCTION
Comprehensive psychiatric evaluation includes history taking, mental state examination, physical examination, laboratory investigations, neuroimaging, neuropsychological assessment, diagnostic formulation and treatment planning. This chapter is devoted to history taking from an older person in the community setting. In most clinical situations, the history provides more diagnostically useful information than the mental state examination and its value should not be underestimated. This chapter should be read in conjunction with the chapters on specific mental health problems.
SOURCES OF INFORMATION
History needs to be assembled from all available sources, taking into account the issues of consent and privacy. Likely sources of information include the older person, health workers such as doctors and community nurses, health records (hospitals, general practitioners, specialists, other health workers), family members, friends and neighbours, and police and other community agencies including pharmacies.
PREPARATION FOR THE INITIAL HOME VISIT
Prior to a domiciliary assessment visit, it is customary to telephone the person to discuss the referral and to ascertain their agreement to a home visit. If all goes well during this telephone call, a date and time can be made for the visit. If cognitive impairment is suspected, then a follow-up letter confirming the visit arrangements is likely to be well worth the extra effort. However, if the older person declines consent for a domiciliary visit, they should be offered a clinic visit. Some older people with persecutory ideation feel more comfortable seeing the mental health worker in a hospital or clinic setting. Some are embarrassed to receive visitors at home due to the presence of hoarded material or some other feature of their dwelling. If the older person declines contact with the older persons’ mental health service (OPMHS), the referring person or agency should be recontacted to establish whether there are grounds to suggest that the older person is at immediate risk. If this is not the case, then the OPMHS might have to recontact the older person at a later date or decline the referral.
Prior to setting out for the home visit, the mental health worker needs to check that they have everything they will need. They should check that they have a fully charged mobile telephone and that their vehicle has sufficient fuel for the round trip, which in rural or remote settings could be several hundred kilometres. They need to let their administrative officer or supervisor know what their plans are so that an emergency plan can be instituted if they do not return to base within the expected timeframe. They need to check that they have the necessary assessment paperwork, including any forms that might be required for involuntary assessment or treatment under the local Mental Health Act. They need to check that they have a physical examination kit if that is to be part of their assessment.
ENGAGEMENT OF THE PERSON’S GENERAL PRACTITIONER
In many OPMHS, it is an operational requirement that the person’s general practitioner (GP) agrees to the referral if the referral has not come from the GP in the first place. Although there may be occasional situations where this is not feasible or not appropriate, this is generally a sound principle. It encourages the OPMHS to liaise with the GP and is likely to assist the OPMHS to obtain a summary of the person’s clinical history and other useful information about the person. It is likely also to make it much easier for the OPMHS to ask the GP to do the physical examination, arrange the blood tests, electrocardiogram (ECG) and neuroimaging (computed tomography (CT) or magnetic resonance imaging (MRI) brain scan). Sometimes, the GP will prefer to be present during the OPMHS domiciliary visit. Where this is possible, it is worthwhile scheduling the visit to fit in with the GP’s availability. However, in recent years this has become less likely in many places and the person is more likely to be seen alone or seen with one or more family members, friends, neighbours or supporters. Nevertheless, engagement of the person’s GP is an important aspect of the work of the OPMHS, and one that usually pays dividends for the person and the OPMHS in the long run.
THE HOME VISIT
Upon arriving at the person’s home (or other residential accommodation), it is important to ensure that the person is aware of the names and roles of the personnel undertaking the home visit. There are several advantages to having two workers on initial assessment domiciliary visits. One important advantage is that there is safety in numbers. Another is that one worker can act as a chaperone for the other doing a physical examination. A third is that two workers can often interview the person and an informant simultaneously, thus reducing the total duration of the visit and preserving the confidentiality of both the person and the informant. Alternatively, the second worker can inspect the environment. When the person is highly distressed, one worker can comfort the person, while the other concentrates on obtaining what history can be reasonably attained under such circumstances.
Some OPMHS take the view that one of these two workers should be a medical practitioner, whereas other OPMHS take the view that two non-medical mental health workers can do a similar job. Of course, in some rural and remote regions, the OPMHS team will consist of a solo mental health worker and the luxury of having two workers present on initial assessment visits is simply not feasible.
Many older people living at home have a spouse, adult child, neighbour or other supporter present during the visit. Further information can often be obtained from that person, particularly where the person being assessed is cognitively impaired or lacking insight in the context of psychosis. Older people seen on domiciliary visits will sometimes want to give their history in the presence of a supporter, but sometimes will want to give it in private. The mental health worker should respect the person’s wishes in this regard, if it is safe to do so. If there are two mental health workers on a home visit, one can take informants into another part of the house, enabling the older person to be seen alone.
The state of the home (or the environment if the person is homeless) will often tell much about the likely mental state of the person, even if they are unable or unwilling to divulge their history. It may also reveal risks or dangers to which the person is exposed.
VISITING A RESIDENTIAL AGED CARE FACILITY
When a domiciliary visit is being undertaken at a residential aged care facility (RACF), the dynamics are rather different from those that apply during a visit to the person’s own home. Although residents in aged care facilities are entitled to visits from outside health workers, where possible such visits should be organised with both the older person and the facility’s care manager. In many instances, it will be appropriate also to invite the older person’s spouse or substitute decision maker to attend.
Assessment visits to RACFs will often be prompted by staff of the facility following an episode of abnormal behaviour by the resident. This commonly occurs in the context of dementia, but also in older people with mood disorders, psychotic disorders and personality disorders. In this situation, it is particularly important to establish who has the problem. Is the identified person psychologically distressed or mentally ill, or does the problem lie more with the staff’s ability to manage or cope with the person’s behaviour? This is an important distinction for it may be necessary to intervene with the staff rather than with the person.
Formal psychiatric history taking (as described below) with people with moderate or severe dementia will usually be limited to obtaining information from collateral sources such as staff, family members, GP records and hospital records. However, in such cases challenging behaviours often prompt the referral. There are various synonyms for these challenging behaviours, including disruptive behaviour, behaviours of concern, and behavioural and psychological symptoms of dementia (BPSD). Although an approach to the assessment of challenging behaviours is discussed separately (see Ch 28), it is important not to neglect those aspects of the standard psychiatric history that can still be obtained from informants other than the older person.
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