Although it is important to reach a psychiatric and/or medical diagnosis, identification of the practical problems facing the patient may be the most urgent


requirement. Often the point at issue is whether he or she is able to cope at home. This may hinge on something as mundane as, for example, whether a neighbour who does the shopping is prepared to continue doing so.

An assessment in the patient's home surroundings is more meaningful than one carried out in hospital, and an interview with an informant is highly desirable, especially if there is any question of cognitive impairment. The timespan of the illness can be crucial in making a diagnosis; an acute confusional state will usually come on over hours or days, a mental illness such as depression over weeks, and dementia over months or years.

Psychiatric history and mental state are recorded in the usual way (see Chapter 3). Particular emphasis should be placed on medical factors and social circumstances, and it is essential to test cognitive function. Physical examination may well reveal undiagnosed pathology that needs attention.

Standardized instruments for interviewing elderly patients include the CAMDEX (Cambridge Examination for Mental Disorders of the Elderly) and the GMSS (Geriatric Mental State Schedule). Short questionnaires for assessing cognitive function include the Mini Mental State Examination.

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