Inpatient Geriatric Psychiatry: Optimum Care, Emerging Limitations, and Realistic Goals

424 Pages·2019·10.192 MB·English

by  Howard H. Fenn, Ana Hategan, James A. Bourgeois

Inpatient Geriatric
Psychiatry
Optimum Care,
Emerging Limitations,
and Realistic Goals
Howard H. Fenn
Ana Hategan
James A. Bourgeois
Editors
123
Inpatient Geriatric Psychiatry
HowardH.Fenn • Ana Hategan

JamesA. Bourgeois

Editors
Inpatient Geriatric
Psychiatry
Optimum Care, Emerging
Limitations, and Realistic Goals
Editors
Howard H. Fenn Ana Hategan
Department of Psychiatry and Stanford/ Department of Psychiatry
VA Alzheimer’s Center and Behavioural Neurosciences
VA Health Care System McMaster University
Palo Alto, CA Hamilton, ON
USA Canada
James A. Bourgeois
Department of Psychiatry
Baylor Scott and White Central Texas
Division College of Medicine
Texas A & M University
Health Science Center
Temple, TX
USA
ISBN 978-3-030-10400-9 ISBN 978-3-030-10401-6 (eBook)
https://doi.org/10.1007/978-3-030-10401-6
Library of Congress Control Number: 2019935522
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To our aging veterans
Foreword 1
Most people are aware of the rapidly changing demographics. In the USA,
10,000 Baby Boomers are turning 65 every single day, and this will continue
until 2030 [1]. What is not well appreciated is that the numbers of older
people with mental illnesses are rising even more rapidly [2, 3]. The number
of Americans with Alzheimer’s disease and other dementias is expected to
increase from 4 million today to 15 million by 2050 [4]. A large majority of
the persons with dementia have behavioral problems including psychosis,
depression, and severe agitation that are often multi-determined and difficult
to manage at home, especially in acute states. There are also problems in
diagnosing illnesses in older neuropsychiatric patients because of nearly
universal comorbidities. These patients need multidisciplinary evaluation
including psychiatric, neurological, general medical, neuropsychological,
nursing, and social assessments. A number of the patients also require con-
tinuous observation for several days. A common source of acute syndromes
such as delirium and dehydration is polypharmacy, which may warrant dis-
continuation of some medications, which often cannot be done safely in an
outpatient setting.
For all these reasons, geriatric inpatient units are a critical component of
geriatric psychiatry, and their value will increase even further in the near
future. A book on Inpatient Geriatric Psychiatry is, therefore, a very timely
addition to the literature. We are delighted and honored to write the Foreword
to this outstanding volume, edited with remarkable innovation and efficiency
by Howard H. Fenn, with Ana Hategan and James A. Bourgeois as coeditors,
and a superb cast of authors in various relevant areas. The comprehensive
approach to inpatient geriatric psychiatry makes this the first textbook spe-
cific to geriatric inpatient clinical operations. It would serve as a guide to the
best clinical practices in the evaluation and the treatment of psychiatric symp-
toms in older inpatients. The focus of the chapters is on inpatient settings
including inpatient psychiatry units, medical units, and postoperative units.
In clinical practice, it is often challenging to balance efficiency and thorough-
ness of evaluation with the constraints of time, length of stay, resources, and
cost, imposed by the healthcare system. Numerous medical and psychosocial
factors can interfere with the quality care that is needed for older adults with
neuropsychiatric disorders. We applaud the concept of “emerging limitations,
realistic goals” that is at the center of the approach presented in this book.
vii
viii Foreword 1
We are also pleased that, instead of having separate chapters on treatment
of psychosis, depression, and anxiety, which are well covered in many other
volumes, the editors have covered topics that are highly relevant to inpatient
settings but are typically not addressed together in one book, such as com-
munication barriers, sleep disorders, pain management, and legal issues. The
structure of the chapters is well designed, and a unique creative feature is a
summary algorithm/flowchart for each chapter, along with clinical vignettes
and take-away messages in the form of bullet points.
At the University of California San Diego, we have had a remarkably
patient- and family-friendly geriatric psychiatry inpatient unit for two
decades, developed and operationalized by our colleague Daniel Sewell,
MD. In addition to excellent multidisciplinary healthcare, the unit also offers
training in several relevant fields including geriatric psychiatry and medicine,
neuropsychology, social work, and family therapy, to name a few. We have
also published papers on topics such as unrecognized medical disorders (e.g.,
a new inpatient diagnosis of pancreatic cancer that had previously been mis-
diagnosed as major depression in outpatient setting) [5] and the use of iPads
to manage severe agitation among inpatients with advanced dementia as a
non-pharmacologic technology-based approach [6].
Other investigators too have used data from geriatric psychiatry inpatient
units for research publications in peer-reviewed journals. For example,
Weintraub and Mazour [7] compared demographic and clinical characteris-
tics of 198 admissions to a psychogeriatric inpatient unit in 1988 and 1998.
The recent cohort was more likely to have dementia with agitation or psycho-
sis, be older and taking more psychiatric medication on discharge, having a
shorter length of stay, and less likely to be discharged home. These changes
have implications for the delivery of treatment on inpatient units.
In another study of 424 consecutive admissions to a university-based geri-
atric psychiatry inpatient unit over a 20-month period, Woo et al. [8] exam-
ined factors associated with repeat hospitalizations, using multivariate logistic
regression analysis. Significant predictors of rehospitalization were single
relationship status, male gender, and a diagnosis of bipolar disorder. Such
information, which is readily obtainable on admission to an inpatient unit,
may provide a useful indication of the risk for frequent psychiatric hospital-
izations leading to use of readmission prevention strategies at the time of
discharge.
An important function of this book will be to document evidence for the
best practices in inpatient geriatric psychiatry, in order to work with regula-
tors of the hospitals such as The Joint Commission (TJC) to ensure that the
regulations are reasonable and pragmatic. An illustration of its value is the
recent announcement by TJC in 2017 that it is increasing scrutiny during
surveys on ligature, suicide, and self-harm risks in psychiatric hospitals and
inpatient psychiatric units of medical/surgical hospitals. Specifically, TJC
surveyors will determine if the hospital has already identified these risks and,
if so, what action plan has been developed and is being practiced to remove
or mitigate those risks [9, 10]. While the goal of this initiative is laudable,
there are several important practical issues in implementing it that need to be
Foreword 1 ix
considered with the input of key stakeholders. Also, it is necessary to realize
that the risk of suicide cannot be totally eliminated [11].
To conclude, we want to compliment the editors and authors of Inpatient
Geriatric Psychiatry for making an invaluable contribution to the literature
on a vital component of the practice of geriatric psychiatry. We believe that
the readers of the book will benefit from clinical, training, research, and pol-
icy perspectives, resulting in improved care and well-being of geriatric psy-
chiatry patients.
Funding Support
The work for this Foreword was, in part, by the National Institutes of Health
[NIH R01MH094151-01 (PI: Dilip V. Jeste, MD)], by the National Institute
of Mental Health [NIMH T32 Geriatric Mental Health Program MH019934
(PI: Dilip V. Jeste, MD)], and by the Stein Institute for Research on Aging at
the University of California San Diego.
San Diego, CA, USA Dilip V. Jeste, MD
San Diego, CA, USA Ellen E. Lee, MD
References
1. Pew Research Center. (2008). U.S. Population Projections: 2005–2050.
http://www.pewhispanic.org/2008/02/11/us-population-projections-
2005–2050/#fn-85-1. Accessed 12 Mar 2018.
2. Bartels SJ, Naslund JA. The underside of the silver tsunami--older adults
and mental health care. N Engl J Med. 2013;368(6):493–6.
3. Jeste DV, Alexopoulos GS, Bartels SJ, et al. Consensus statement on the
upcoming crisis in geriatric mental health: research agenda for the next 2
decades. Arch Gen Psychiatry. 1999;56(9):848–53.
4. Alzheimer’s Association. 2017 Alzheimer’s disease facts and figures.
Chicago, IL: https://www.alz.org/documents_custom/2017-facts-and-
figures.pdf. Accessed 12 Mar 2018.
5. Woo BKP, Daly JW, Allen EC, Jeste DV, Sewell DD. Unrecognized
medical disorders in older psychiatric inpatients in a senior behavioral
health unit in a university hospital. J Geriatr Psychiatry Neurol.
2003;16(2):121–5.
6. Vahia IV, Kamat R, Vang C, et al. Use of tablet devices in the manage-
ment of agitation among inpatients with dementia: an open-label study.
Am J Geriatr Psychiatry. 2017;25(8):860–4.
7. Weintraub D, Mazour I. Clinical and demographic changes over ten
years on a psychogeriatric inpatient unit. Ann Clin Psychiatry.
2000;12(4):227–31.
x Foreword 1
8. Woo BK, Golshan S, Allen EC, Daly JW, Jeste DV, Sewell DD. Factors
associated with frequent admissions to an acute geriatric psychiatric
inpatient unit. J Geriatr Psychiatry Neurol. 2006;19(4):226–30.
9. The Joint Commission. 2017. Now effective: Surveying, scoring of liga-
ture, suicide, self-harm in inpatient psychiatric setting. https://www.
jointcommission.org/issues/article.aspx?Article=gyekSlHbR9Hi6%2FC
HXVKFw2XUfze5Q3AXldxy7eEkhZM%3D. Accessed 12 Mar, 2018.
10. The Joint Commission. (2018). Ligature Risks - Assessing and Mitigating
Risk for Suicide and Self-Harm. https://www.jointcommission.org/stan-
dards_information/jcfaqdetails.aspx?StandardsFAQId=1525. Accessed
12 Mar 2018.
11. Moran M.  Joint Commission Standards on Ligature Risks Cause
Concern. Psychiatric News. 29 Nov 2017. https://psychnews.psychiatry-
online.org/doi/full/10.1176/appi.pn.2017.12a26. Accessed 12 Mar 2018.
Foreword 2
If you’re a geriatric psychiatrist, this text will answer all your questions, and
you should keep it on your desk. It will be of interest not only to geriatric
psychiatrists and other specialists accustomed to providing care to the
elderly but also to internists, hospitalists, family medicine specialists, gen-
eral psychiatrists, neurologists, and trainees of all specialties who consult on
an inpatient unit. Due to the growing proportion of the aged among our inpa-
tient population, healthcare providers will be increasingly confronted with
the complex psychiatric and medical symptoms prevalent among geriatric
inpatients.
The editors have wisely focused on a range of topics which are often not
addressed in one volume yet are commonly seen in clinical care of aging
patients. Such issues include, for example, surreptitious or involuntary med-
ication interventions, psychotherapies within the inpatient setting, medica-
tion strategies such as tapering and withdrawal, identification of
discontinuation syndromes, and delivery of medical nursing care. The edi-
tors have chosen to include essential topics like pharmacological overview,
delirium, the medical workup, adverse medical events, and the management
of major neurocognitive disorder (MNCD) with behavioral disturbance.
They have not included, as separate topics, issues that are already well cov-
ered in many other fine texts, such as treatment of psychosis, anxiety, and
depression. Instead, they have woven these widely discussed subjects within
other chapters, such as when, for example, to use ECT and neuromodulation
for major depressive disorder or MNCD. Each chapter refers to other chap-
ters which may expand on a related topic, so that the book is as cohesive and
integrated as possible.
The text is supplemented by graphics which summarize the key points
simply and attractively. In addition, flowcharts at the beginning of each chap-
ter guide the reader through the topics which follow. These flowcharts offer
suggestions for clinical decision-making, but without the “and/or” format of
a decision tree, which often does not include the many nuanced choices avail-
able in actual clinical care. This is especially true in the geriatric patient,
wherein the research evidence may not be available to provide definitive
direction in each individual case.
xi