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 0-470-84641-021The Importance of Multidimensional Assessment inClinical PracticeM. Robin Eastwood* and Abhilash Desai(*Formerly at) St Louis University Medical School, St Louis, MD, USAIn many ways, geriatric psychiatry is a paradigm for contemporarymedicine. A multidisciplinary team is required to address thecomplex range of assessment and treatment issues. After all, olderpeople usually have more than one medical illness, are on severalmedications and may have considerable limitations (vision,hearing, mobility, cognition, finances).According to Eastwood and Corbin 1 , ‘‘the problems presented inthe assessment and treatment of geriatric psychiatry patients may bebest solved by a team composed of members with diverseprofessional training, meeting frequently to plan investigations,discuss findings and formulate coherent and comprehensivetreatment plans. Such a group must function with little overlap oftasks and few interdisciplinary jealousies, be problem-orientatedand exercise communication skills in order to be effective andefficient. Although the physician typically chairs team meetings andtakes medical and legal responsibility, each member of the teammust make a definite contribution, either in direct patient care, orwith technical and back-up services’’, and ‘‘Whatever the level ofsophistication, a geriatric psychiatry unit should be able to providean holistic and eclectic approach to assessment of the patient’’.For each patient there may be several assessments, each with adefinite purpose. Pre-admission assessment in the home isvaluable for evaluating functional level and the appropriatelevel of care. Admission assessment may be necessary to make adiagnosis and treatment plan. Follow-up assessment helpsmonitored treatment effects and overall outcome. The followinghealth care professionals are required in the therapeutic team:1. Psychiatry. Geriatric psychiatry is best practiced in a shortstay,10–15 bed unit. Ideally, the unit should be free-standingfor the elderly alone. Some would ague, because of the medicalrisks and need for specialist consultations, that the unit shouldbe in the general hospital. The psychiatrist brings together thepsychosocial and biological aspects of medicine and ispreferably a geriatric psychiatrist. The amount of trainingreceived in a general psychiatry residency is inadequate toqualify as a geriatric psychiatrist. Conversely, a full fellowshipis not necessary and a separate 6 month rotation is probablysufficient.2. Primary care physician. It is useful to have a primary carephysician on the team. This person can help identify medicalproblems, and suggest tests and medication to deal with these.They can help in the initial phases of assessment. The pace ofresearch makes it difficult for a psychiatrist to keep upsatisfactorily with new medications in other specialties andeven for common illnesses like hypertension and diabetes.3. Consultation team. It is useful for the geriatric psychiatrygroup to offer consultation services to other parts of thehospital. Looking for cases of delirium, dementia anddepression to treat or to transfer to the geriatric psychiatryward is a useful way of doing consultations and sharing goodrelations with other specialties.4. Nursing. Optimally, the same nurse should be responsible forinitial contact, inpatient care and follow-up. With thisfamiliarity, the nurse can be responsive to presenting problemsof safety and security, prostheses, fluctuations in daily activity,signs of therapeutic response and drug or other sensitivities.5. Social work. The social worker can assess the strengths andweaknesses of the patient’s current social network, andevaluate the potential for benefit from individual, family andgroup psychotherapy. The social worker should be able toprovide individual support to the patient and family members.6. Occupational therapy. The occupational therapist can evaluatethe patient’s response to social, physical and intellectualstimulation and self-care and instrumental activities of dailyliving. Occupational and leisure needs can be linked tocommunity agencies upon discharge. This therapist shouldbe able to help patients and their families with activities(music, storytelling, group activities, such as playing variousgames) that can be used to help cope with problem behaviorsand emotional distress.7. Psychology. The psychologist can critically determine globaland specific intellectual deficits and help manage certainbehaviors.8. Pharmacy. The pharmacist is vital in monitoring drug levels,interactions and reactions in order to avoid the problem ofdelirium.It is also advisable to have the consulting services of such specialtiesas internal medicine, cardiology, neurology, ophthalmology,otolaryngology, urology, physiotherapy and dietary science.The team faces a variety of diagnostic syndromes. These includedementia, affective disorder, delusional disorder, neurosis andpersonality disorder, alcohol or drug abuse, and delirium. Each ofthese requires a standardized diagnostic, treatment and managementprotocol, all subject to measures of efficiency and efficacy.REFERENCE1. Eastwood MR, Corbin SL. Multidimensional assessment in geriatricpsychiatry. In Bergener M, ed., Psychogeriatrics: An InternationalHandbook. New York: Springer, 1987; 136–7.Principles 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