Factors predicting referral acceptance of patients with chronic mental illness from adult to geriatric psychiatry services—a retrospective chart review

Abstract

Introduction: There is a dearth of evidence on indications for transfer of care from adult to geriatric mental health services for patients with adult-onset mental illness. In Vancouver, Canada, it is the responsibility of the Vancouver Coastal Health Authority Older Adult Mental Health Centralized Intake Service (OAMHCI) to triage referrals to older adult mental health teams (OAMHT). OAMHCI has seen increasing referrals from adult mental health teams (AMHT). This patient population is followed by adult psychiatrists for chronic mental illnesses such as Schizophrenia and Depression. Given changing demographics, anticipated growth in the geriatric population and limited resources, it is increasingly important to understand the reasons for these referrals and clarify indications for acceptance into geriatric psychiatry. This study is a retrospective chart review of referrals to OAMHCI of patients with chronic psychiatric diagnoses from AMHT. Its aim is to determine what factors predict acceptance to an OAMHT versus bounce-back to AMHT care. This information potentially serves to inform recommendations to adult psychiatrists regarding necessary screening prior to referral as well as characteristics of appropriate patients for geriatric psychiatry services. Older adult mental health resources are increasingly strained with the aging population. Optimizing the triage process is therefore a critical issue looming on the healthcare horizon with implications for empowering aging in those with chronic mental illness. Methods: A detailed, structured data form was used to abstract clinical and demographic information from the medical records of 81 patients (female1⁄451; male1⁄430) referred to OAMHCI in order to determine which factors contributed to acceptance into the program. Institutional ethics approval was in place. Results: Sixty patients (77%; mean age: 68.13 8.4 years) were accepted into an OAMHT while nineteen (23%; mean age: 67.16 9.9 years) were not. Chi-square analysis revealed that rejected patients were less likely to have a confirmed diagnosis of cognitive impairment or dementia (84% vs. 16%; X21⁄45.84, p<.05), more likely to have been assessed by an OAMHCI physician (85% vs. 15%; X21⁄48.04, p<.01) and have longer wait times from referral to final decision (acceptance vs. rejection; 30.8 days vs. 48.6 days, Z1⁄4 2.65, p<.01). Accepted patients were less likely to have delirium (95% vs. 5%; X21⁄44.84, p<.05), less likely to have an unconfirmed but suspected diagnosis of dementia or cognitive impairment (76% vs. 24%; X21⁄47.57, p<.01) and less likely to have facility placement transition issues (100% vs. 0%; X21⁄45.18, p<.05). In addition, accepted patients had more geriatric physical issues (61% vs. 39%; X21⁄43.52, p1⁄4.06), which approached significance. Binary logistic regression analysis showed aggression/agitation (OR: 5.67; 95% CI 1.02 31.48), facility placement transition issues (OR: 8.17; 95% CI 2.10 61.09), and absence of delirium (OR: 0.13; 95% CI 0.019 1.00) were the strongest predictors of acceptance to an OAMHT. Conclusions: While adult psychiatrists manage adult-onset psychiatric illnesses such as schizophrenia, geriatric issues may be less familiar. This study found that geriatric problems like confirmed cognitive decline and physical issues (e.g. falls) were common in patients accepted to OAMHT. Placement transition problems and aggression actually predicted acceptance (the latter likely represents a group with behavioural disturbance from dementia). Decision times may have been longer for rejected patients because intake clinicians were able to manage their issues with brief follow-up. This may also explain the higher number of rejected patients following physician assessment. Alternatively, it could represent added complexity of decisions around ambiguous cases. Findings around delirium and suspected cognitive problems are not surprising. Delirious patients would likely be better served by consultation to a medical specialist and may not require long-term psychiatric follow-up. Rejected patients with suspected cognitive problems may have tested as normal or as having static deficits secondary to underlying illnesses such as schizophrenia or bipolar disorder. This emphasizes the importance of consistent cognitive testing prior to referral. This study highlights the need to further clarify the scope of geriatric psychiatric services. Its findings suggest that advanced age and chronic mental illness alone are insufficient to warrant transfer to community geriatric mental health. It also suggests that issues such as progressing dementia, physical problems, aggression and nursing home placement are sufficient for acceptance by OAMHCI as it currently functions. Given the growing demands on geriatric services, further development of our criteria for acceptance to geriatric mental health care is needed as well as effective clinical assessment strategies in order to enhance efficiency and continuity of care.