“I WILL STAY AT MCDONALD'S FOR THE NIGHT. IT'S MY RIGHT TO BE HOMELESS.”; CHALLENGES IN TREATING AN ELDERLY HOMELESS MALE WITH BIPOLAR DISORDER AND MILD INTELLECTUAL DISABILITY AND MULTIPLE MEDICAL ISSUES

Abstract

Introduction Frequent emergency department (ED) users make up nearly 30% of ED visits nationwide. Although there is no established definition of frequent ED utilization, the following classification was most commonly employed in recent literature: frequent users 4-9?visits/?year, super-users ≥ 10?visits/?year. Homelessness is strongly associated with frequent use of the emergency department services. According to the US department of Housing and Urban Development, the elderly homeless population has increased from 2.9 percent to 4.7 percent over the past 12?years. In addition to an increased risk of recidivism, homelessness is also associated with poor socioeconomic status, psychosocial issues, limited resources, and high incidences of mental health and substance abuse problems. However little research has been done towards identifying and characterizing subgroups within this population. Further classification of this vulnerable population might lead to the development of targeted interventions varying in intensity and composition with the goal of decreasing rates of recidivism. The objective of this case report is to discuss the challenges behind managing a homeless geriatric patient with complex comorbid medical and psychiatric conditions who qualifies as a super-utilizer with greater than 230 ED visits over 4?years who despite engagement is rejecting help and prefers to be homeless. This case also highlights the importance to continuously engage the patient and realizing that acceptance of “help” may not be instantaneous but requires a great deal of patience and trust acquisition. Methods This specific case was reviewed and compared to relevant literature for further discussion. Results Case Report Information: 62 year old Caucasian man, divorced and homeless, with a previous psychiatric history of Schizoaffective Disorder and mild Intellectual Disability and past medical history of hypertension, hyperlipidemia, coronary artery disease s/p stent placement, atrial fibrillation s/p ablation, AICD placement with pacemaker,heart failure, multiple strokes, and COPD presented to the emergency room under police custody after breaking a bus window with his cane and attempting to assault police officers. Review of records indicated approximately 40 inpatient medical admissions, the majority of which were exacerbations of existing chronic medical conditions due to non compliance and 4 psychiatric admissions over 4?years. On initial evaluation, the patient appeared disorganized and irritable with pressured and illogical speech, elevated mood, and paranoia associated with persecutory ideation. He displayed poor insight and judgement but consented to treatment with all prescribed medications and medical consultations. The patient began to improve with a regimen of Aripiprazole and Sodium Valproate over the course of his hospitalization. He became less disorganized and paranoid with speech that was more comprehensible. He was evaluated by the medical and cardiology consult service and recommended cardiology follow up and his pacemaker was interrogated ??? while on the unit. Pt was assisted in contacting his family in Mississippi from whom he was estranged. He was offered placement in supportive housing and case management services. He refused all shelter and housing services stating “I am a free man. I'm at the Mcdonald's nearby and I know the manager who allows me to sit there at night. I prefer to stay on the streets”. He displayed sufficient capacity to refuse offered resources. Although he agreed to follow up with both psychiatric and medical care once discharged, he did not show up for his scheduled appointments. Conclusions Frequent ED users are the focus of much research given the cost burden on healthcare systems. Moulin et al. analyzed the relationship between mental illness and frequent ED visits and found a strong association between homelessness and patients with Medicaid coverage with higher ED visit rates. homeless patients had higher rates of ED visits and hospitalizations and have higher morbidity and mortality when compared to non-homeless patients. Homeless patients with co-occurring medical problems have difficulty in keeping up with follow up and having adequate primary care follow up. Addressing barriers to outpatient care and providing supportive housing were among the most successful interventions found to positively improve healthcare utilization and expenditures. Other research corroborates intensive case management as the most successful intervention for recidivism prevention. Further research should focus on the need for collaborative care models targeting the complexities associated with geriatric psychiatric patients with co-occurring medical conditions as this could lead to improved care for this vulnerable patient population. It is important to analyze cases such as these to identify homelessness risk factors and associated characteristics that might indicate trends for the development of targeted prevention and early intervention strategies towards recidivism reduction and homelessness prevention. This research was funded by: Not applicable