Inpatient Geriatric Psychiatry 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.

Socio-demographic and Clinical Characteristics of Older Patients Transferred from a Consultation Psychiatry Service to Geriatric Psychiatry Inpatient Units

<h3>Introduction</h3> Consultation Psychiatry Services in general hospitals regularly encounter medical-surgical inpatients whose psychiatric co-morbidities necessitate transfer to psychiatric inpatient settings. To our knowledge, limited data exist on such transfers, with even less known about <i>geriatric psychiatry</i> transfers. <h3>Methods</h3> Billing record review determined the proportion of older (≥ 65 years) patients seen by Consultation Psychiatry from 1/1/21 - 8/30/21. Number of such patients transferred to a geropsychiatry inpatient unit were identified through the referral field in our EHR. Chart reviews abstracted sociodemographic and clinical characteristics of transfers. Patients were excluded if they had been transferred <i>from</i> psychiatry inpatient to medical-surgical inpatient and then back to psychiatry; or if they had been transferred from medical-surgical inpatient to psychiatry and then back to medical-surgical because of medical decompensation. Only patients who completed their geriatric psychiatry inpatient stay were included. A consensus assessment between two geropsychiatry evaluators (AV, BG) rated "active" versus "inactive" psychiatric treatment by consultation psychiatrists based on psychopharmacological management, efforts to facilitate ECT treatment where indicated, and re-evaluation prior to transfer. Relationships between key variables and geriatric psychiatry inpatient median lengths of stay (LOS) were evaluated by Mann-Whitney U tests with p-values determined. <h3>Results</h3> From 1/1/21 – 8/30/21, the Consultation Psychiatry service evaluated 1517 individuals, of whom 46% were over age 65 years. Sixty-seven (8.7%) of these patients were transferred to geriatric psychiatry units, which represented 32% of all admissions during that period. Descriptive analyses excluded patients meeting back-and-forth transfer criteria sequentially described above (n = 17 and n=12). Remaining patients (n = 38) comprised the final sample. Mean age of the transferred sample was 75.6 years (SD = 6.79; range = 65-92). 68.4% were women and 31.6% men. Two-thirds of the sample identified as White (68.4%), while 7.9% were Black, 10.5% Hispanic, and 10.5% Asian. 42.1% were married, 18.4% single, 18.4% divorced, and 13.2% widowed. Most patients (81.6%) had at least one child. Over two-thirds (71.1%) lived in a private home with a family member, 13.2% lived at home alone, and 13.2% resided in a nursing home or assisted living facility. The majority of patients (78.9%) were discharged to a private residence, with the remaining group (21.1%) discharged to a structured living facility. Of primary psychiatric diagnoses, 26.8% had a psychotic disorder, 41.8% had a major depressive disorder, 13.4% had bipolar disorder, and 17.9 % had a neurocognitive disorder with concomitant behavioral disturbances. "Active" psychiatric treatment (as defined above) by consultation psychiatrists during medical-surgical hospital stay occurred in approximately two-thirds (68.4%) of patients destined for transfer to geriatric psychiatry. Median length of stay (LOS) in geriatric psychiatry for the entire group was 22.0 (+/- SD 21.4) days. Relationships between median LOS and sociodemographic/clinical variables revealed the following statistically significant findings. Women had a median LOS of 25 (+/- 24.3) days whereas men had a median LOS of 16 (+/- 10.4) days (p < 0.0001). Patients living at home prior to medical-surgical admission had a median geriatric psychiatry unit LOS of 21.0 (+/- 20.1) days as compared to patients who were living in a nursing home or assisted living facility who had a median LOS of 35.0 (+/- 20.9) days (p < 0.0005). Patients discharged home had a median LOS of 20.0 (+/-11.1) days while patients discharged to any structured living facility for seniors had a median LOS of 38.0 (+/- 32.7) days (p < 0.0001). <h3>Conclusions</h3> Nearly half of consultation psychiatry patients were over age 65 years, suggesting geropsychiatric training/expertise in general hospital psychiatry is critical, especially since less than 10% of patients ended up transferred for specialty geropsychiatric inpatient care. Furthermore, that nearly a third of geropsychiatry inpatients emanated from consultation psychiatry and that a third of patients destined for transfer had ‘inactive' treatment during medical-surgical stays further supports closer interactions of consultation and geriatric psychiatry services. The diagnostic breakdown of transfers appeared representative of geropsychiatry inpatients not referred from medicine, however validation awaits comparisons. Gender differences in LOS may be explained by additional analysis of psychosocial/clinical profiles of men and women in this sample. The significantly longer LOS in patients coming from and being discharged to nursing homes or assisted living facilities suggests clinical complexity that should catalyze early disposition planning for such patients. <h3>This research was funded by</h3> N/A

Differences in Burden Severity in Adult-Child Family Caregivers and Spousal Caregivers of Persons with Dementia

ABSTRACT Researchers are continuing to focus on the nature and sources of burden of family caregivers of persons living with dementia. Caregiving stress and burden are assessed and addressed by social workers, including at high-risk times such as hospitalization. This study tested whether adult-child family caregivers experience greater perceived burden than spousal caregivers, accounting for risks of acute stress which can accompany hospitalization for their care recipient, where social workers may be meeting with family caregivers for the first time. Family caregivers (N = 76; n = 42 adult-child; n = 34 spouse) were recruited during care-recipient clinical treatment. The settings of care included an outpatient memory care program and an inpatient geriatric psychiatry service. Results showed that adult-child caregivers reported greater burden as compared with spousal caregivers, but no differences regarding depressive symptoms, perceived stress, or grief. After controlling for demographics and location of care, being an adult-child caregiver remained a predictor of greater burden severity. Being an adult-child family caregiver may place an individual at increased risk for experiencing high burden. These findings suggest socials workers should consider how adult-child caregivers may benefit from strategies to address and reduce burden, beyond those typically offered to spousal caregivers.

Considerations for delirium screening in response to a case of COVID-19 on an inpatient geriatric psychiatric unit

IntroductionWhile the COVID-19 pandemic caused by the SARS-CoV2 virus has challenged healthcare systems across the country, inpatient psychiatric hospitals struggle with a unique challenge. Psychiatric patients participate in therapy groups and eat meals together on milieus. It is difficult to enforce mask use or self-isolation practices in the setting of psychosis or mania.Additionally, neuropsychiatric disorders such as new onset psychosis, delirium, and affective disorders have all been documented following a SARS-CoV2 infection. A surveillance study from the UK found that primary psychiatric diagnoses were most common in younger patients and encephalopathy was more common in older adults following a SARS-CoV2 infection. A multicenter cohort study looking specifically at older adults found that 226 (28%) of 817 geriatric patients with COVID-19 had delirium at ED presentation. Delirium was the sixth most common of all presenting symptoms of COVID-19. Of patients with delirium, 16% had delirium as a primary presenting complaint and 37% had no fever or shortness of breath.Our psychiatric hospital has a geriatric psychiatry service, which has generated further challenges during the pandemic. The hospital requires COVID-19 testing prior to admission, but false negatives are possible. We continue to adapt our procedures to best serve this vulnerable population as we learn more about COVID-19 and atypical presentations. We provide a case report of a geriatric psychiatry patient who presented with delirium secondary to COVID-19 and the subsequent consideration in our admission process.MethodsA case report of a patient who was admitted to the geriatric psychiatry inpatient service and was found to have delirium as a presenting COVID-19 symptom. A review of neuropsychiatric manifestations of COVID-19 will be presented.ResultsMs. A is an 80-year-old woman with history of major depressive disorder, recent non-ST-elevation myocardial infarction, aortic stenosis, ischemic cardiomyopathy, and hypertension. She was originally admitted to the inpatient psychiatry from the ED for suicidal ideation and worsening depression but was found to be inattentive and disoriented. She had multiple falls in the several days leading up to admission, but no respiratory symptoms or fever. The geriatric psychiatry service determined she was delirious and started medical work up for etiology. Her rapid COVID-19 test at an outside facility was negative. Her medical work up was remarkable for a leukocytosis of 11 ×109 per liter, and an acute kidney injury (AKI) with BUN 20 mg/dL and Creatinine 1.31 mg/dL increased acutely from baseline of 0.9. Urinalysis was negative for infection. She was transferred to the emergency room for encephalopathy and declining oral intake. There, she tested positive for COVID-19 by PCR and was admitted to medicine for delirium of likely multiple etiologies including COVID-19. Her EEG showed generalized slowing and her head CT was negative for hemorrhage or infarction. The consult liaison psychiatry service continued to follow Mrs. A during her three-week hospitalization, during which she required Olanzapine 2.5 mg as needed for agitation related to her hyperactive delirium. Her AKI resolved with intravenous fluids and avoidance of nephrotoxic agents. She was discharged into the care of family on psychiatric medications fluoxetine 40 mg and mirtazapine 45 mg after her delirium gradually resolved with supportive care including physical and occupational therapy.ConclusionsThe diverse clinical presentation, often multifactorial etiology and the waxing and waning course of delirium makes it difficult to diagnose in an emergency room setting even for experienced physicians. Delirium can present with depressive, cognitive, and psychotic symptoms. It is not uncommon for delirious geriatric patients to be admitted to our inpatient unit for agitation, psychosis or depression, as was the case with Ms. A. Delirium can be a presenting symptom of COVID-19. Given this and our unique circumstances on a psychiatric milieu, we need to take greater consideration when assessing for delirium and other possible neuropsychiatric symptoms of SARS-CoV2 infection prior to admission. Grossman et al. developed a modified confusion assessment method for the emergency department (mCAM-ED) that requires 3 to 5 minutes to complete the whole instrument. However, despite having this and other tools, formal assessment tools for delirium are rarely used in the ED.It is important that geriatric patients are triaged to the appropriate level of care so proper medical treatment can be initiated without delay, as prolonged encephalopathy can lead to permanent decline in cognitive function, worse outcomes, and increased mortality. This case reinforces the clinical importance of including delirium on checklists of presenting symptoms of COVID-19, specifically for geriatric patients, that guide standardized screening, evaluation, and treatment.FundingThe authors received no financial support for the research, authorship, and/or publication of this article.

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.

“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

The Acute Psychiatric Impacts of the COVID-19 Pandemic on Older Adults

IntroductionThe COVID-19 pandemic has presented significant public health challenges worldwide, resulting in over a million deaths worldwide and major changes in social processes. Older adults are disproportionately represented among those experiencing severe illness and death. Older adults, particularly those with pre-existing psychiatric conditions, may also be more vulnerable to the psychiatric impacts of the pandemic and its resulting social sequelae. During peak months of the pandemic, our inpatient geriatric psychiatry service has cared for patients who presented with severe psychiatric states related to the pandemic. In this study, we examine four cases to illustrate differing mechanisms by which the pandemic causes acute psychiatric distress in older adults and describe targeted interventions to address each mechanism.MethodsCases seen in the Geriatric Psychiatry/Neuropsychiatry inpatient service at Johns Hopkins Hospital late in the first wave of the pandemic (June 2020) are analyzed to identify the psychological and social mechanisms for acute psychiatric distress, using a timeline representation approach.ResultsThe timeline analysis of the cases indicated four mechanisms for acute psychiatric distress during the pandemic: incitement of fear, social isolation, loss of routine and purpose, and disruption of medical services. These factors have been shown in other work to have adverse effects on the psychological well-being of older adults.ConclusionsWhile the older adult population as a whole may be heterogeneous in their psychological reactions to the COVID-19 pandemic, those with fewer social resources, lower resilience, or pre-existing mental illness are likely to experience disproportionate distress in the face of these changes. Interventions should be tailored to promote flourishing in individuals; including assistance in navigating changes in the healthcare system, developing technological skills, and leveraging connections and resources in the individual's social circle and community.FundingNone

Frailty in geriatric psychiatry inpatients: a retrospective cohort study.

We aimed to evaluate the prevalence, clinical determinants, and consequences (falls and hospitalization) of frailty in older adults with mental illness. Retrospective clinical cohort study. We collected the data in a specialized psychogeriatric ward, in Boston, USA, between July 2018 and June 2019. Two hundred and fourty-four inpatients aged 65 years old and over. Psychiatric diagnosis was based on a multi-professional consensus meeting according to DSM-5 criteria. Frailty was assessed according to two common instruments, that is, the FRAIL questionnaire and the deficit accumulation model (aka Frailty Index [FI]). Multiple linear regression analyses were conducted to evaluate the association between frailty and sample demographics (age, female sex, and non-Caucasian ethnicity) and clinical characteristics (dementia, number of clinical diseases, current infection, number of psychotropic, and non-psychotropic medications in use). Multiple regression between frailty assessments and either falls or number of hospital admissions in the last 6 and 12 months, respectively, were analyzed and adjusted for covariates. Prevalence of frailty was high, that is, 83.6% according to the FI and 55.3% according to the FRAIL questionnaire. Age, the number of clinical (somatic) diseases, and the number of non-psychotropic medications were independently associated with frailty identified by the FRAIL. Dementia, current infection, the number of clinical (somatic) diseases, and the number of non-psychotropic medications were independently associated with frailty according to the FI. Falls were significantly associated with both frailty instruments. However, we found only a significant association for the number of hospital admissions with the FI. Frailty is highly prevalent among geriatric psychiatry inpatients. The FRAIL questionnaire and the FI may capture different forms of frailty dimensions, being the former probably more associated with the phenotype model and the latter more associated with multimorbidity.

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.

Neuropsychological features of delusions in hospitalized older adults with neurocognitive disorders

ABSTRACT Individuals with neurocognitive disorders (NCD) frequently experience psychotic symptoms, such as delusions. Delusions can contribute to other behavior problems, create dangers for patients and caregivers, and contribute to inpatient hospitalization of individuals with NCD. The current study aimed to identify cognitive symptoms associated with the presence of delusions and to differentiate delusion types based on cognitive profiles among hospitalized older adults with NCD. A review of electronic medical records of hospitalized older adults from an inpatient geriatric psychiatry setting yielded 185 patients with a diagnosis of mild or major NCD who had a neuropsychological evaluation during their admission and whose documentation described a clear delusion. We identified a comparison group of 185 patients without delusions well matched for age, education, and sex, and similar in global cognitive status. Exclusion criteria included delirium and history of a psychotic disorder. We first compared the groups’ performances on a dementia battery. Then, cognitive performances of subgroups with specific delusion types (harm, theft, jealousy, and misidentification) were each compared to the remainder of the delusion-positive group. Exploratory analyses revealed that the delusion-positive group had a greater rate of discontinuation on Trails B and performed worse than the delusion-negative group on Trails A, Behavioral Dyscontrol Scale, Semantic Fluency, and Hopkins Verbal Learning Test-Revised (HVLT-R) initial registration. Theft delusions were associated with worse performance on HVLT-R recognition, misidentification delusions were associated with worse performance on Trails B, and harm delusions were associated with worse performance on a verbal generativity test. The presence of delusions in hospitalized older adults with NCD was associated with worse performance on several cognitive tasks with many being suggestive of associated with frontal-subcortical network integrity. Delusions of theft may be a consequence of reduced integrity of medial temporal lobe memory system.

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.

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

“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

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.

MEASUREMENT-BASED CARE: CAN TOOLS FROM PALLIATIVE CARE INFORM OUR PRACTICE IN GERIATRIC MENTAL HEALTH?

Introduction Measurement-based care, which encompasses the use of self-report scales for tracking patients’ responses to treatment, has been systematically reviewed in the context of primary care where it has been shown to enhance communication between providers and patients1. Among older adults with mood disorders, pain and somatic symptoms are common and often under-recognized2,3. Scales for monitoring mood, anxiety and physical symptoms have been well validated in older adults with psychiatric disorders within inpatient and outpatient settings. In the palliative care context, the Edmonton Symptom Assessment Scale (ESAS) and the Patient Dignity Inventory (PDI) are commonly used to track burden of symptoms and impact of illness on dignity. We explore the utility and relevance of using self-rating scales as part of a measurement-based care initiative in geriatric mental health at Baycrest, an academic health sciences centre in Toronto, Canada. We examine the relationship between depression, anxiety and somatic symptoms and introduce the use of the ESAS and PDI in a non-palliative care context. 1) Wray LO et al. Enhancing implementation of measurement-based mental health care in primary care: a mixed-methods randomized effectiveness evaluation of implementation facilitation. BMC Health Serv Res. 2018; 18: 753. 2) Chodosh J, Solomon DH, Roth CP et al. The quality of medical care provide to vulnerable older patients with chronic pain. J Am Geriatric Soc. 2004; 52:756-761. 3) Meeks TW, Dunn LB, Kim DS et al. Chronic Pain and Depression among geriatric psychiatry inpatients. Int J of Geriatr Psychiatry. 2008; 23:637-642. Methods Participants were recruited from an inpatient geriatric mental health unit and an outpatient day hospital for mood and related disorders. Self-report rating scales tracking mood, anxiety and somatic symptoms were completed, including the Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), the ESAS and the PDI. Demographic characteristics were gathered from a retrospective chart review. Inpatient and outpatient groups were compared using Fisher's exact test for categorical variables and Wilcoxon tests for continuous variables. Longitudinal cross-sectional models used generalized estimating equations and an exchangeable working correlation (WC) matrix to adjust for repeated measures within patient across time. Cross-sectional models including time-varying covariates measured concurrently with the outcome and were adjusted for baseline values for age, number of comorbidities and medications and level of cognition. Results Data were obtained for 33 English speaking patients (inpatients N=17, outpatients N=16) with a mean age of 76.5 (SD=6.1), 69.7 % female and 48.5% married. Inpatients had a significantly higher number of comorbidities than outpatients. Self-reported scales were measured from 1 to 17 weeks (mean number of weeks was 8.2, SD=4.7). At baseline, prevalence of moderate to severe ESAS symptoms (4 or higher score) ranged from 19% to 75% (Table 1). Higher GDS scores were significantly correlated with self-ratings for poor dignity and high anxiety (p GDS and PDI scores had a similar pattern to the mean ESAS pain item score across time (Figure 1). Mean scores for all the scores increased indicating worse scores for those remaining under follow up. Some example longitudinal modelling results are as follows: GDS scores decreased over time but less rapidly for patients reporting a higher degree of pain (p=0.02, WC=0.80). PDI scores decreased across time but higher PDI scores were associated with higher ESAS drowsiness (p=0.002, WC=0.82). Conclusions Self-report scales yielded relevant clinical information including the high physical symptom burden experienced by older adults in geriatric mental health inpatient and outpatient settings. This study suggests there is value in using self-report rating scales to track mood, anxiety, dignity, pain and other symptoms. Measurement-based care can create a dialogue between patient and clinician about symptom variability over time, and its usage in geriatric psychiatry warrants further exploration. In our study, there was an association between subjective distress experienced by participants and underlying pain. Over time, Geriatric Depression Scale scores tended to remain elevated for patients who simultaneously reported higher pain. As well, the Edmonton Symptom Assessment Scale was highly correlated across time with the GDS. Incorporating a palliative care lens may suggest new approaches to care and have relevance to inpatient and outpatient geriatric mental health settings where burden of symptoms is high. While our study is limited by its small sample size, the use of self-report scales commonly used in palliative care within a geriatric mental health context merits replication in other settings. This research was funded by A stipend was provided by Baycrest's Department of Psychiatry's Academic Development Fund.

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.