Inpatient Geriatric Psychiatry Unit Research Articles

Ethics Consult: Using Hospice as "Treatment" for Behavioral Problems of Dementia

Patients with Behavioral and Psychological Symptoms of Dementia (BPSD) are among the most challenging patients to treat; these behaviors are estimated to occur in up to 90% of patients with dementia (Aigbogun 2019); of these, one in 5 patients displays aggression (Eastley 1997). The usual treatments have only modest efficacy at best and at times are ineffective in some individuals. Some behaviors such as physical aggression make it difficult, if not impossible, to find placement for these patients. Placement in nursing homes on a hospice status have traditionally required evidence of a 6 month life expectancy; placement in an inpatient hospice setting is usually reserved for patients with even shorter life expectancies such as 2 weeks. Prognosticating life expectancy in patients with dementia is challenging and often inaccurate (Jayes 2004). Furthermore the use of terminal palliative sedation is supposed to be confined to the last 2 weeks of life and/or extreme physical suffering (Schuman-Oliver 2008, AMA Opinion 2013).This session will present 2 cases of individuals with advanced dementia who did not meet the traditional Medicare criteria for hospice, as both were ambulatory and did not have significant co-morbid medical issues. Both had significant aggressive behaviors that responded poorly to extensive trials of various medications during extended stays on a geriatric psychiatry inpatient unit. Both were referred to a local inpatient hospice where the staff use “suffering" as a hospice criteria and were “treated” with the usual hospice medications and expired in less than 3 weeks.This session will use the two clinical cases to address the following: review the issue of prognostication of advanced dementia and the challenges of defining the end of life; review efforts to define “suffering” in advanced dementia in both the medical and ethics literature; review issues concerning palliative sedation; define how this differs from medical aid in dying and euthanasia. The experience of Dutch geriatricians addressing these issues will be presented (Veldwijck-Rouenhorst 2021). A geriatric psychiatrist will present the 2 cases and set up the questions and ethical issues that these cases pose. An ethics professor-scholar from Emory University will review the ethics literature and teachings that address these issues and help lead a discussion with the audience. The overall goal is to provide a framework of steps the audience members can take if confronted with similar cases.

Impact of standardizing care for agitation in dementia using an integrated care pathway on an inpatient geriatric psychiatry unit.

This study examined the effectiveness of an integrated care pathway (ICP), including a medication algorithm, to treat agitation associated with dementia. Analyses of data (both prospective and retrospective) collected during routine clinical care. Geriatric Psychiatry Inpatient Unit. Patients with agitation associated with dementia (n = 28) who were treated as part of the implementation of the ICP and those who received treatment-as-usual (TAU) (n = 28) on the same inpatient unit before the implementation of the ICP. Two control groups of patients without dementia treated on the same unit contemporaneously to the TAU (n = 17) and ICP groups (n = 36) were included to account for any secular trends. ICP. Cohen Mansfield Agitation Inventory (CMAI), Neuropsychiatric Inventory Questionnaire (NPIQ), and assessment of motor symptoms were completed during the ICP implementation. Chart review was used to obtain length of inpatient stay and rates of psychotropic polypharmacy. Patients in the ICP group experienced a reduction in their scores on the CMAI and NPIQ and no changes in motor symptoms. Compared to the TAU group, the ICP group had a higher chance of an earlier discharge from hospital, a lower rate of psychotropic polypharmacy, and a lower chance of having a fall during hospital stay. In contrast, these outcomes did not differ between the two control groups. These preliminary results suggest that an ICP can be used effectively to treat agitation associated with dementia in inpatients. A larger randomized study is needed to confirm these results.

“Social security is a scam”: the Ethical Dilemmas in Treating Overvalued Beliefs

<h3>Introduction</h3> In the 19^th century, Carl Wernicke introduced the term ueberwertige idee (overvalued idea), a rigidly held belief that influences behavior and is shared by others. Delusions, on the other hand, are defined as fixed, false beliefs, not accepted by others of that culture. Through the internet and social media, information is ever more readily accessed, leading to rapid transmission of ideas, including those considered fringe or extreme. Here, we present the case of a man with major neurocognitive disorder complicated by an ueberwertige idee that undermined his care. We consider the diagnosis of delusional disorder versus an overvalued belief, and the ethical implications inherent in the distinction. <h3>Methods</h3> Case report: The patient was assessed and treated on the inpatient geriatric psychiatry unit. This case was reviewed and compared with relevant literature. <h3>Results</h3> This is a case report of an elderly homeless man with a history of major neurocognitive disorder, lower extremity deep venous thromboses, chronic venous stasis, and blindness secondary to glaucoma. He was hospitalized for treatment of cellulitis, then involuntarily transferred to the inpatient geriatric psychiatry unit for grave disability. He had a long-standing suspicion of the American social security system, believing it to be a means of covert government control. He expressed a consistent preference to live on the streets, while his health conditions required a higher level of care. Unfortunately, his fixed beliefs were a barrier to supported housing, health insurance, and disability benefits. During his prolonged psychiatric hospitalization, he did not exhibit other psychotic symptoms and he refused to take psychotropic medication. We were unable to secure a Lanterman Petris Short conservatorship for him; themes of the difference between delusion and extreme belief dominated the legal hearing. The patient was discharged to the streets, per his preference. <h3>Conclusions</h3> Distinguishing between delusions and overvalued beliefs can be a significant challenge. With the internet and the global growth of subcultures, encountering patients with extreme beliefs will become increasingly common. Examining the diagnosis and ethical considerations carefully is essential to providing the care most aligned with an individual's interests and values. <h3>Funding</h3> No funding sources to report

Geriatric Psychiatry In-Patient Perspectives on the Diagnosis of Dementia/Major Neurocognitive Disorder (MNCD)

<h3>Introduction</h3> According to recent estimates, there are approximately 5.8 million Americans age 65 and older living with the most prevalent type of MNCD, Alzheimer's dementia (Hebert 2013). The number of new and existing cases of Alzheimer's dementia and other MNCDs is expected to increase in the next decades as the older population in the United States grows (Alzheimer's Association 2020; US Census Report 2016). Despite the increasing prevalence of MNCDs, there is significant variability in clinical practice regarding the communication of this diagnosis to patients and families. This has significant ethical and practical implications in the care provided to individual patients, as well as on the public perception of these conditions. Published literature worldwide recommends disclosure of dementia/MNCD, based on evidence that patients want to know their diagnosis (Abe, Michiko, et al. 2019) and clinical considerations regarding respect of patient autonomy, improved adherence to treatment and the ability to provide support to patients and families (Carpenter, Brian, et al. 2004). However, a systematic review found that only 34% of general practitioners reported disclosing the diagnosis to patients (Low, Lee-Fay, et al. 2018). Reasons why providers chose not to disclose the diagnosis included diagnostic uncertainty, perceived futility given limited treatment options, concern for the patient's ability to comprehend or remember the diagnosis and concerns for the psychological impact of disclosure (Carpenter, Brian, et al. 2004). Studies have suggested that disclosing the diagnosis of MNCD is associated with an increased risk of suicide (Erlangsen et. al. 2008; Annor et. al. 2019). Clinicians' fear of provoking or worsening depression symptoms and/or increasing suicide risk in patients may be a potential reason behind decisions to withhold the diagnosis of MNCD. The aim of this study is to assess the beliefs and attitudes regarding the diagnosis of MNCD of patients in an urban inpatient geriatric psychiatry unit, and specifically, to ascertain whether these patients believed that such disclosure would cause them to feel depressed or suicidal. Such information potentially can aid clinicians, patients and their caregivers to develop additional strategies to manage the disclosure of MNCD. <h3>Methods</h3> Retrospective chart review. <h3>Results</h3> Preliminary results from this ongoing study revealed the following: The sample consisted of 7 males and 8 females, with an average age of 72.5+/-8.71 years and with 60% self-identifying as Caucasian. 66.67% of patients reported completing high school. Montreal Cognitive Assessment (MoCA) scores were available for 8 participants and ranged from 6 to 26, with an average of 17.25+/-8.24, suggesting a range of mild to severe cognitive impairment in the sample. Geriatric Depression Screening (GDS) scores ranged from 0-14, with an average of 4.08 +/-3.95, suggesting that the sample as a whole was not depressed. The average number of comorbid mental and physical conditions was 2.2+/-1.15 and 10.87+/-7.03, respectively, and 53.33% of the patients carried a diagnosis of MNCD prior to admission. 60% (n=9) of patients in the study reported having memory problems. Only one patient reported receiving a diagnosis of dementia/MNCD by a physician, while another patient reported that the diagnosis had been shared with a family member, but not with the patient directly. Of the patients interviewed, 53.33% (n=8) reported that it would be helpful for them to receive the diagnosis if they had it. They cited validation of their symptoms and prompt access to treatment as the main reasons for this. Regarding the psychological impact of disclosure, participants described potential feelings of disbelief, frustration, hopelessness, acceptance and determination to overcome. 20% (n=3) of patients indicated that seeking non-pharmacologic help for MNCD would be most helpful to them. Of interest, only 20% (n=3) of the patients reported that they would feel depressed if the diagnosis of MNCD was revealed to them. Only 13.33% (n=2) of the patients interviewed stated they may feel suicidal, and of these two, one provided a history of having been diagnosed previously with dementia/MNCD. <h3>Conclusions</h3> We found that the beliefs and attitudes regarding the diagnosis of MNCD of patients in an urban inpatient geriatric psychiatry unit ranged from hopelessness to acceptance of memory impairments. Of note, 20% (n=3) of the patients interviewed believed that disclosure of a diagnosis of MNCD would cause them to feel depressed and 13.33% (n=2) believed that it would make them feel suicidal. Limitations of this preliminary study include the small sample size and subjective nature of the interview which relied on patients' impressions at one point in time. Further research is being conducted to expand on these findings in hopes that such information can aid clinicians, patients and their caregivers to develop additional strategies to manage the disclosure of MNCD. <h3>Funding</h3> Not applicable.

Containment of a COVID-19 Outbreak in an Inpatient Geriatric Psychiatry Unit.

OBJECTIVES: The first known COVID-19 outbreak in a long-term care facility in the United States was identified on February 28, 2020, in King County, Washington. That facility became the initial U.S. epicenter of the COVID-19 pandemic when they discovered 129 cases associated with the outbreak (81 residents, 34 staff members, and 14 visitors) and 23 persons died. The vulnerability of the elderly population, shared living and social spaces, suboptimal infection control practices, and prolonged contact between residents were identified as contributing factors to the rapid spread of the disease. The first known case of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak in a U.S. inpatient geriatric psychiatry unit was also in King County, Washington, and occurred soon afterward on March 11th, 2020. Between March 11 and March 18, nine inpatients and seven staff members were confirmed to have SARS-CoV-2 infection. This article examines how the swift identification and isolation of confirmed patients, an enhanced infection prevention protocol, and engagement of frontline psychiatric care staff prevented a catastrophic outcome in a vulnerable population. METHODS: Here we describe infection control and nursing-led interventions that were quickly enacted in response to this SARS-CoV-2 outbreak in an inpatient geriatric psychiatry unit. RESULTS: The interventions effectively contained the outbreak, with no further patients and only one staff member testing positive for SARS-CoV-2 over the subsequent 2-month time period. CONCLUSIONS: We share our learnings and preventative infection control measures that can be adapted to a variety of settings to prevent or contain future outbreaks of COVID-19.

Prolonged persistence of PCR-detectable virus during an outbreak of SARS-CoV-2 in an inpatient geriatric psychiatry unit in King County, Washington

BackgroundWe describe key characteristics, interventions, and outcomes of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak within an inpatient geriatric psychiatry unit at the University of Washington Medical Center – Northwest.MethodsAfter identifying 2 patients with SARS-CoV-2 infection on March 11, 2020, we conducted an outbreak investigation and employed targeted interventions including: screening of patients and staff; isolation and cohorting of confirmed cases; serial testing; and enhanced infection prevention measures.ResultsWe identified 10 patients and 7 staff members with SARS-CoV-2 infection. Thirty percent of patients (n = 3) remained asymptomatic over the course of infection. Among SARS-CoV-2 positive patients, fever (n = 5, 50%) and cough (n = 4, 40%) were the most common symptoms. Median duration of reverse transcription polymerase chain reaction (RT-PCR) positivity was 25.5 days (interquartile range [IQR] 22.8-41.8) among symptomatic patients and 22.0 days (IQR 19.5-25.5) among asymptomatic patients. Median initial (19.0, IQR 18.7-25.7 vs 21.7, IQR 20.7-25.6) and nadir (18.9, IQR 18.2-20.3 vs 19.8, IQR 17.0-20.7) cycle threshold values were similar across symptomatic and asymptomatic patients, respectively.ConclusionsAsymptomatic infection was common in this cohort of hospitalized, elderly individuals despite similar duration of SARS-CoV-2 RT-PCR positivity and cycle threshold values among symptomatic and asymptomatic patients.

“IT'S NOT ME, IT'S YOU” PERSONALITY DISORDERS IN GERIATRIC PATIENTS

Introduction Personality refers to the unique characteristics and qualities that define an individual's ability to form relationships, cope with life stressors, and approach the tasks of daily living. However, when these patterns become debilitating or interfere with interpersonal relationships or overall functioning, the result is referred to as a disorder. Personality disorders persist into late life and pose complex challenges in patients across various medical and psychiatric settings. Many older adults with personality disorders can easily become overwhelmed by age-associated losses and stresses, largely because they lack appropriate coping skills and the personal, social, or financial resources to buffer their losses. Personality disorders persist into late life and pose complex challenges in patients across various medical and psychiatric settings. Most studies estimate that 10% of older adults have personality symptoms that rise to the level of a clear disorder, the most common include Borderline, Narcissistic and Dependent traits. Methods 3 case studies from patient population at Mount Sinai Beth Israel Psychiatric Department, which is full service teaching hospital which has been serving New York City for the past century. Beth Israel has an academic affiliation which Ichan School of Medicine at Mount Sinai and is a major clinical campus. The psychiatric department serves a multicultural, varied socio-economic patient population. One case was chosen from outpatient geriatric clinic, comprehensive psychiatric emergency program (CPEP) and inpatient geriatric psychiatry unit from 2017 to 2019. The cases presented illustrates symptoms on of the three categories of personality disorders as listed in DSM 5, and the barrier it presented to treatment. A personalized treatment planning approach was utilized in each case. Results Case Studies: 1) Mr. RG an elderly male with overwhelming Dependent Personality Disorder has exhausted many clinicians before arriving to the outpatient clinic of an academic medical center. He utilized high levels of services, often visiting the Emergency Department and Clinic in the same day, several times per week. A safety net intervention was created for the patient, with frequent check ins and calls to help reduce excess service utilization and prevent unnecessary hospitalizations. 2) Ms. MZ an older woman with many Borderline and narcissistic traits was dissatisfied with every clinician who cared for her in the past. She wrote, called and came to the institution demanding different providers, medications and care plans without following up on any. A behavioral contract with utilized to maintain support but prevent overt acting out. 3) Ms. AS has been with the program for decades, with frequent periods of absences due to moving in with friends and relatives over suspiciousness towards landlords and neighbors. She has been highly functional in isolative jobs but has difficulty relating to others as her suspicious thoughts become overwhelming. She has difficulty trusting health care professionals and is reluctant to seek care for medical problems. While supportive therapy proved limited, low doses of a second generation antipsychotic agent allowed her to feel less anxious in some settings. Conclusions The limited literature on the prevalence and longitudinal course of older adults with personality disorders makes treatment strategies difficult and challenges the clinician to adapt therapies on a case by case basis. These clinical vignettes illustrate how therapeutic strategies may be adjusted to meet the needs of older adults who are dissatisfied with care, utilize services at high rates but reject care repeatedly and often show limited benefits. Plans include setting up a data base of personality disorder symptoms in late life and the interventions found to be most successful. Matched with up to date clinical practice information on late life personality disorders frequently encountered by practicing clinicians designed to offer practice guideline for psychotherapeutic and psychopharmacologic strategies. This research was funded by: n/a

THE APPLICATION OF HEALTH SYSTEMS SCIENCE CURRICULUM ON A GERIATRIC PSYCHIATRY INPATIENT UNIT

Introduction Health Systems Science is one of the central tenets of undergraduate medical education at Penn State College of Medicine. While there is a clearly defined course in the first two years of the undergraduate curriculum, application of and more formal education of this in the clinical arena is variable. Geriatric patients, particularly those with underlying psychiatric illness, have unique needs including complex medical co-morbidities, cognitive impairment, and difficulty accessing community resources due to psychosocial, financial and insurance limitations, making them a more vulnerable population in terms of comprehensive health maintenance and stability within the community. When these individuals require admission to the inpatient psychiatric service, their hospital admissions are longer, and a systems level approach is necessary in their treatment and subsequent transition to the community in an effort to maximize stability and minimize risk of rehospitalization. Health systems science includes 12 curricular domains: 6 core domains (health care structures and processes; health care policy, economics, and management; clinical informatics/ health information technology; population health; value based care; health system improvement); 5 cross-cutting domains (leadership and change agency; teamwork and interprofessional education; evidence-based medicine and practice; professionalism and ethics; scholarship); and the linking domain of systems thinking. The inpatient geriatric psychiatry unit provides an environment in which these curricular domains coalesce in the overarching management of these individuals with complicated psychiatric, medical and social determinants. The scholarly question this project aims to address is how health systems science competencies can be taught within the sphere of geriatric mental health care, with the anticipated outcome being the creation of an elective for medical students during which time the 12 principles of health systems science are addressed, utilizing the backdrop of the geropsychiatry inpatient unit at Pennsylvania Psychiatric Institute. Methods This project aims to create a medical student elective in which the domains of health systems science are explicitly addressed in the geriatric psychiatric inpatient population at Pennsylvania Psychiatric Institute. This is an innovative approach in that it requires the application of health systems science to a population which is complex and underserved, both due to the “geriatric” and the “psychiatric” descriptors that fall upon it, and one that is not typically utilized in the teaching of health systems science. Potential educational strategies in this elective include the identification of social determinants of health for a patient facing discharge soon, rounding with the inpatient team with an emphasis placed on understanding the multidimensional factors that affect discharge planning, and the co-leading of a discharge meeting. Results The primary result of this project is the development of an elective in which health systems science is the primary focus, while geriatric psychiatry serves as the backdrop. We will plan to review the components of the elective created and how each component ties in with either the central or core cutting domain of health systems science. We will also review the steps necessary to consider in the development of this unique elective. Conclusions Health systems science is an emerging and evolving component of medical education. The geriatric mental health sphere is a unique and novel environment to allow for teaching of these principles. This research was funded by: not applicable

READINGS IN GERIATRIC PSYCHIATRY: A QUALITATIVE RETROSPECTIVE ANALYSIS OF A STRUCTURED LITERATURE REVIEW COURSE

READINGS IN GERIATRIC PSYCHIATRY: A QUALITATIVE RETROSPECTIVE ANALYSIS OF A STRUCTURED LITERATURE REVIEW COURSE

Engaging Social Interest and Creating Awareness for the Behavioural and Psychological Symptoms of Dementia.

Novel multimodal sensing study that has been installed and tested in a geriatric psychiatry inpatient unit is reviewed. Perspectives and experiences of behavioural and psychological symptoms of dementia are also examined. Further, the Spare a Thought for Dementia Through the Your Story My Story campaign, a project that seeks to amplify empowering stories from persons living with dementia and their friends and family carers in order to combat stigma and show carers that they are not alone in their journeys, is also discussed.

Exploring the Relationship Between Timed Up and Go Test Times and Fall History in an Inpatient Geriatric Psychiatry Unit: A Retrospective Case-Control Study.

Inpatient geriatric psychiatry units have the highest fall rates in the acute care setting and most falls in this population occur during the mobility tasks of transfers and ambulation. The Timed Up and Go (TUG) test includes these 2 specific functional tasks and has been used to predict falls in other geriatric populations but has never been tested in an inpatient geriatric psychiatry unit. The purpose of this study was to determine whether the TUG time measurements of inpatient geriatric psychiatry patients were associated with falling. The study was a retrospective chart review using a case-control design. The sample was obtained from patients admitted to 1 inpatient geriatric psychiatry unit during the 4-month study period. The total sample size was N = 62 and included older adults with (N = 29; "fallers") and without (N = 33; "nonfallers") a history of falls in the 6 months prior to admission. The mean age of fallers (M = 75.8, SD = 9.6) was not significantly different from the age of nonfallers (M = 74.0, SD = 7.6), P = .424. Both groups had higher proportions of female subjects; nonfallers were 75.8% (n = 25) female and fallers were 69.0% (n = 20) female. Most nonfallers (84.8%) completed the TUG testing without an assistive device, while most fallers (48.3%) used a walker. A significant difference was found between the TUG times of nonfallers and fallers, U = 737.00, z = 3.65, P < .001, r = 0.46. Fallers took longer to complete the TUG test (median = 26.5) than nonfallers (median = 13.6). The TUG time explanatory variable was statistically significant, P = .002. Increasing TUG times were associated with an increased likelihood of patient falls (odds ratio = 1.10). The optimal TUG cutoff score was 16.5 seconds, with 79.3% sensitivity and 72.7% specificity. The TUG time measurement was found to be associated with falling. A cutoff time of 16.5 seconds is recommended to identify nonfallers from fallers in the inpatient geriatric psychiatry setting.

CHALLENGES IN 21ST CENTURY INPATIENT GERIATRIC PSYCHIATRY AND LONG TERM CARE PRACTICE.: Session 112

With the increase in life span, there has been a rise in the number of older adults. In 2010, approximately 40 million persons aged 65 years and older lived in the United States and this statistic is projected to increase to 88.5 million by 2050, accounting for 20.2% of the population. The number of older adults with psychiatric disorders is also expected to increase to 15 million by 2030. A significant proportion of these older adults will also have co-morbid medical issues, which may pose challenges. In this session, we will provide an overview of how nursing home facilities and inpatient geriatric psychiatry units are adapting to changes and challenges to provide care for this vulnerable population. In the last 20 years, the number of elderly patients cared for in nursing homes has increased, with facilities expanding to include more beds to respond to this need. The average resident age has also increased, with a corresponding increase in functional limitations, disabilities, cognitive and mental disorders requiring advanced care. Additionally, policy and industry changes over the years have affected the way we provide care for these residents. There has been rapid growth in assisted living facilities in order to provide an alternative care setting for these individuals who require more assistance with activities of daily living. This has led to the development of specialized units that will meet the needs of these residents. Since the implementation of the minimum data set (MDS) system, many prevalence reports have relied on either recorded diagnoses or scales derived from MDS to identify residents with psychiatric conditions. These have also been used as screening tools to identify residents in need of treatment. Available data indicates that there are an inadequate number of geriatric psychiatrists in the USA to care for these older adults with mental illness. The unfortunate consequence has been providers without specialist training or oversight attempting to provide care for residents. This often includes prescribing multiple psychotropic medications that are inappropriate for their symptoms and their age, which can ultimately lead to substantial psychological and functional morbidity. Additionally, these medication side effects and undertreated psychiatric disorders have a significantly negative impact on the residents’ quality of life, disability, and cost of care. Approximately 75-80% of residents in long- term care have a neurocognitive disorder. Although most major neurocognitive disorders are incurable, appropriate comprehensive treatment can substantially improve the quality of life of a resident, their family, and their caregivers. Routine provision of evidence-based care by a mental health care team with expertise in long-term care is essential for maintaining dignity and reducing suffering for these patients. This includes ongoing staff education, discontinuation of inappropriate medications, optimal use of appropriate psychotropic medications and other behavioral interventions. We will review how the geriatric psychiatrist, along with other allied health care professionals, can work as a team in today's highly regulated environment of long term care to improve patient outcomes. With the projection that the older adult population will swell over the next several decades, inpatient geriatric psychiatry facilities have arisen to address the need to provide acute services for these patients. These units appear to have distinct clinically relevant assessment and treatment advantages. They are more comprehensive in their diagnostic assessment of patients, are more likely to provide cognitive assessments and are more cognizant of potential side effects of psychotropic medications. They are also more likely to provide more age-specific aftercare recommendations, which is important in maintaining success after the hospitalization. However these specialized units are limited, expensive, and may encounter a unique set of challenges as the landscape changes for healthcare delivery, reimbursement and managed care. In this session, we will describe key characteristics of a typical geriatric psychiatry unit, discuss advantages of such a unit over a general psychiatry unit, discuss different models of geriatric psychiatry facilities, outline standard admission screening criteria for appropriate patient selection, address treatment challenges associated with the need for rapid improvement in patient psychopathologies and discuss the increased pressures in providing high quality care in the context of reduced length of stays with scarce resources for aftercare. At the end of our presentation, we will briefly showcase the unique characteristics of our inpatient geriatric psychiatry unit.

Use of Actigraphy to Measure Symptoms of Agitation in Dementia

To evaluate the feasibility and validity of actigraphy as a measurement of agitation in dementia. Participants aged 65 and older, diagnosed with dementia, residing in a geriatric psychiatry inpatient unit or long-term care facility were included in a cross-sectional study. Agitation was assessed using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory (NPI). Actigraphy was measured over seven days and compared across groups categorized as low or high agitation based on a CMAI cutoff score of 50. Twenty participants were enrolled (mean age = 74.3 years, standard deviation [SD] = 8.69). The 24-hour mean motor activity as measured with actigraphy was significantly different between the low and high agitation groups (180.23, SD = 86.34 versus 81.51, SD = 30.29, Z = 2.29; p = 0.02). Most actigraph variables had significant correlations with CMAI and NPI scores. Actigraphy was highly correlated with informant-based methods for measuring agitation in individuals with dementia and actigraphy may be useful tool for measuring agitation.

An Innovative Approach to Adequate Oral Hydration in an Inpatient Geriatric Psychiatry Unit.

Suboptimal hydration status and dehydration are problems that often exacerbate comorbid conditions in geriatric patients. At a Veterans Administration Hospital, it was observed that suboptimal hydration status in Veterans hospitalized in the geriatric psychiatry unit was a contributing factor in the worsening of their psychiatric and medical conditions. A quality improvement project was chartered to improve hydration in this group of patients. Using a three-pronged intervention approach (i.e., providing flavored water, providing larger cups, and increasing the prompting by nurses for patients to drink more), the project was successful. The goal was to increase average daily fluid intake by 125 mL; the result was an increase of 700 mL. This project has been sustained and the interventions have also benefitted non-geriatric psychiatry in-patients. [Journal of Psychosocial Nursing and Mental Health Services, 57(4), 15-20.].

Characteristics of Hospice Referrals From an Inpatient Geriatric Psychiatry Unit

Geriatric psychiatrists who treat neuropsychiatric symptoms of dementia are in the unique position of offering palliation to people with terminal illness in whom neuropsychiatric symptoms may be indicators of the illness's end stage (e.g., feeding problems). Little is known, however, about the characteristics of hospice referrals from inpatient geriatric psychiatry units. This was a retrospective chart review of patients with dementia admitted to an inpatient geriatric psychiatry unit and referred to hospice on discharge. Patients were referred to hospice because of feeding problems, with oral intake insufficient to sustain life. Most patients (78%) died within 31 days of discharge, and all patients (100%) died within 6 months of discharge. The results from this study support a symptom-based approach to hospice referral for people with dementia, as opposed to prognostic estimation, where certain symptom clusters may indicate a more rapidly progressing course.

Patient Location and Mobility Factors Associated with Falls on an Inpatient Geriatric Psychiatry Unit

ABSTRACTObjective: The purpose of this study is to describe the location and patient activity factors associated with falls on one inpatient geriatric psychiatry unit. Methods: This was a descriptive retrospective analysis of 61 patient fall events during a 3-year review period. Results: Most falls, 67.8% (n = 40), occurred in the patients’ personal areas as compared to the communal areas, 32.2% (n = 19). The most common locations of patient falls were the patient room (44.1%, n = 26), bathroom (23.7%, n = 14), hallway (18.6%, n = 11), and living room (11.9%, n = 7). The most common patient activities at the time of a fall were ambulating (49.1%; n = 28) and transferring (36.8%, n = 21). More than half (57.1%, n = 12) of all transfer-related falls occurred during a bed transfer. Conclusions: The findings suggest that clinical fall risk assessments and interventions in inpatient geriatric psychiatry units should emphasize patient personal space areas and include mobility factors, particularly ambulation and transfers.

Use of Tablet Devices in the Management of Agitation Among Inpatients with Dementia: An Open-Label Study

To investigate the feasibility, safety, and utility of tablet devices as novel nonpharmacologic tools in managing older psychiatric inpatients with agitation and dementia. Thirty-six patients at a geriatric psychiatry inpatient unit were provided with tablets when agitated and used various apps on the tablet related to communication, games, music, web browser, and photography during their stay. Study staff documented the frequency, duration, and app usage history and rated the extent to which agitation improved after tablet use. All participants, regardless of dementia severity, were able to use apps and were rated by staff to have clinical benefit. Dementia severity was negatively associated with app complexity. Age was negatively associated with frequency and duration of tablet use. Tablet use as a nonpharmacologic intervention for agitation in older adults, including those with severe dementia, appears to be feasible, safe, and of potential utility.

Psychotropic Risks Heightened in Patients With Dementia

Psychotropic Risks Heightened in Patients With Dementia

Tamoxifen and Depression: Drug Interactions in Breast Cancer

This case describes a 76-year-old African-American female with a history of depression, breast cancer, and hypothyroidism admitted to the inpatient geriatric psychiatry unit for an electroconvulsive therapy (ECT) evaluation. She had one previous episode of depression, which began after a lumpectomy in 2007. Her home medication regimen included tamoxifen 20 mg daily. This case highlights the incidence of depression in persons with breast cancer, examines the controversy of tamoxifen-induced depression, and evaluates antidepressant considerations regarding potentially efficacy-reducing cytochrome P450 2D6 drug interactions with tamoxifen. The pharmacy team played an active role in educating the medical team regarding tamoxifen drug interactions. After many discussions, the patient was ultimately treated with mirtazapine 15 mg at bedtime, in addition to ECT.

A 74-Year-Old Woman with Anxiety and Paranoid Delusions

Healio.com/Psychiatry | 471 A 74-year-old single, retired, white female was admitted to the inpatient geriatric psychiatry unit for evaluation and treatment of increasing anxiety and agitation over the previous 5 months. She had recently moved out of her own apartment to an assisted living facility due to difficulty with activities of daily living. Since then, frequent anxiety episodes and panic-like attacks had resulted in repeated emergency department visits. At other times, the patient experienced variable combinations of paranoid delusions and perceptual disturbances. Her delusions involved beliefs that her apartment was occupied by witches; her perceptual disturbances included visual hallucinations of bugs and illusions of distorted forms and shadows. A sense of overwhelming dread often accompanied her symptoms. Between episodes, she was described as lucid and insightful. Recently, her nocturnal fearfulness and agitation had become so severe that she required 24-hour supervision. The patient’s medical history was significant for Parkinson’s disease (PD), major depressive disorder, breast cancer (in remission following a mastectomy 25 years prior), hyperlipidemia, and osteoporosis. She had a history of alcohol abuse that at the time of presentation had been in full sustained remission for over 10 years. Family medical history was significant for bipolar disorder in her mother. Medications on admission included carbidopalevodopa (25/100 mg x 2,6 times daily), nortriptyline (10 mg at bedtime), and rivastigmine patch (4.6 mg/24 hours). The carbidopa-levodopa dose recently had been increased due to frequent on-off episodes, which are dramatic changes in motor function due to dopaminergic fluctuations. The patient was initially diagnosed with Parkinson’s 8 years prior when she presented with a left-sided resting tremor. Although she had a clear history of syndromal depression antedating her Parkinson’s diagnosis, her psychiatric symptoms were noted to have worsened in the previous 7 months, coincident with the advancement of her Parkinson’s disease. Her only other psychiatric hospitalization occurred approximately 5 months ago, in the context of hallucinations and agitation. Neuropsychological testing performed at that time revealed deficits in executive function and visuospatial processing. During the year prior to admission, her behavioral dysfunction had progressed to a point requiring formal designation of a relative for decision-making regarding personal finances, living arrangements, A 74-Year-Old Woman with Anxiety and Paranoid Delusions