Benjamin K. P. Woo

Unrecognized Medical Disorders in Older Psychiatric Inpatients in a Senior Behavioral Health Unit in a University Hospital

Medical disorders may cause psychiatric symptoms. This study investigated the frequency and nature of previously unrecognized medical disorders associated with behavioral disturbances in acute geriatric psychiatry inpatients. Data came from a chart review of 79 consecutive admissions to the University of California, San Diego, Senior Behavioral Health Unit from May 1999 to October 1999. The most common Axis I admission diagnoses were depression and psychosis. At admission, 27 of 79 cases (34%) had unrecognized medical disorders. Comparison of these cases with the cases that did not have unrecognized medical disorders found no differences in age, education, gender, or cognitive abilities. The group with unrecognized medical disorders had more medical disorders (mean 5.0 vs 3.6; P = .002). Unrecognized conditions (n) included constipation (7), urinary infection (7), and hypothyroidism (5). Elderly psychiatric patients are more likely to have physical comorbidity. A large number of medical disorders should alert clinicians to look carefully for unrecognized medical disorders. (J Geriatr Psychiatry Neurol 2003; 16:121-125)

Factors Associated With Frequent Admissions to an Acute Geriatric Psychiatric Inpatient Unit

As a first step toward developing strategies to reduce the frequency of psychiatric hospitalizations, the authors retrospectively collected and analyzed demographic and clinical variables from 424 consecutive admissions to a university-based geriatric psychiatry inpatient unit over a 20-month period. The study sample was dichotomized into patients who were admitted more than one time (35.6%) versus those with a single admission. Factors associated with rehospitalization were examined with multivariate logistic regression analysis. The great majority of readmissions (81%) occurred in the first 3 months after discharge. The logistic regression model indicated that significant predictors of rehospitalization were single relationship status, male gender, and bipolar disorder diagnosis. Our findings overlap with findings from previous similar studies and suggest that information readily obtainable on admission to an acute geriatric psychiatry inpatient unit may provide a useful indication of risk for frequent psychiatric hospitalizations and may contribute to readmission prevention strategies.

Substance misuse among older patients in psychiatric emergency service

OBJECTIVE To determine the prevalence of substance misuse among older patients presented to a psychiatric emergency service (PES) on involuntary bases. METHOD At the time of initial presentation to the PES, all patients received a comprehensive assessment that included a urine toxicology screening. The screening consisted of six substances: barbiturate, benzodiazepine, cocaine, opiate, phencyclidine and amphetamine. Charts of elderly patients (aged 65 and above) with positive urine toxicology were reviewed to ensure that the results were not due to (1) home medications and (2) medications given in the PES. RESULTS During the 2-year study period (2006-2007), there were 5914 patients under the age of 65 and 104 patients aged 65 and above. Our findings indicated that 471 (8.0%) and 14 (13.4%) urine toxicology screens were not collected during the PES visits in younger and older patients, respectively (P=.04). The positive urine toxicology rate was 31.5% (1716/5443) and 26.7% (24/90) for younger and older patients, respectively (P=.33). CONCLUSIONS Substance misuse in the older population presenting with psychiatric emergency is prevalent in the PES. Urine toxicology screens, as well as patient or collateral report of substance usages, should be obtained from this group of patients to ensure quality of care delivered at the PES.

Reduction of suboptimal prescribing and clinical outcome for dementia patients in a senior behavioral health inpatient unit

BACKGROUND Suboptimal prescribing in older psychiatric patients causes iatrogenic morbidity. The objectives of this study were to compare the prevalence of suboptimal prescribing before and after admission to a geropsychiatry inpatient unit and to evaluate a possible correlation between optimal medication use and functional improvement in patients with dementia. METHODS The study sample comprised 118 consecutively admitted patients to a 14-bed university hospital-based geropsychiatry inpatient unit over a period of 20 months who met the DSM-IVTR criteria for an Axis I psychiatric illness and co-morbid dementia. At admission demographic information, Mini-mental State Examination (MMSE) Score, Mattis Dementia Rating Scale Score (DRS), and number of active medical illnesses were recorded. At admission and discharge the number and type of medications, number of Revised Beers Criteria (RBC) medications (a published list of potentially inappropriate medications in older adults independent of diagnoses or conditions), Global Assessment of Functioning (GAF) scores, and Scale of Functioning (SOF) scores were tabulated. chi2 tests, paired t-tests and Pearson correlations were used to test the medication prevalence and associations between measures of clinical function and other variables. RESULTS The mean age (standard deviation) of the sample was 81.5 (6.2) years. The mean scores on the MMSE and DRS were 22.1 (6.2) and 116.6 (18.7), respectively. From admission to discharge, the mean number of RBC medications per patient decreased significantly from 0.8 (1.1) to 0.4 (0.6). There was also a significant correlation between reduction in Beers criteria medications and improved SOF score from time of admission to time of discharge. CONCLUSION Suboptimal medication use is a potential source of decreased function in older patients with dementia.

The Clock Drawing Test as a Measure of Executive Dysfunction in Elderly Depressed Patients

The aims of this research were to determine whether performance on the Clock Drawing Test (CDT) could accurately distinguish between older patients with depression and older patients with depression and previously undocumented executive dysfunction and to determine if there was a correlation between CDT and depression severity. The authors studied 52 patients consecutively admitted to a geriatric psychiatry inpatient unit of a university hospital who met DSM-IVcriteria for major depression or depression not otherwise specified but had no concurrent diagnosis of dementia. All the subjects completed the Mini-Mental State Examination (MMSE), Mattis Dementia Rating Scale (DRS), and the CDT, as well as the Geriatric Depression Scale (GDS). The patients were divided into 2 subgroups based on the DRS score: <129 (cognitive impairment) versus = 129. Results indicated that the depressed patients with a score of DRS <129 had significantly lower CDT scores than did patients with DRS = 129 and normal comparison subjects (P< .01). The results support the hypothesis that CDT score is lower in elderly depressed patients with executive dysfunction versus nondepressed seniors as well as depressed patients without executive dysfunction.

Improper eye care during inpatient psychiatric stay

Literature has shown that unrecognized physical illnessesmay exacerbate psychiatric symptoms leading to inpatient psychiatric hospitalization [1]. In the United States, there are approximately 257 per 100,000 population admissions to psychiatric hospitals and 480 per 100,000 population admissions to psychiatric beds in a general hospital in 2011 [2]. While medical clearance is often done in the emergency room before admittance, it is highly likely that investigation about the use of vision correction is often not asked in the emergency room (ER) or inpatient unit. Because emergency physicians need to determine if psychiatric presentation of a patient is due to a functional psychiatric condition versus an organic medical condition, it is imperative that a thorough history and physical are done [3]. Currently, there is a nonstandardized process of medical clearance, and while common causes of psychosis such as urinary tract infection and drug abuse are commonly screened for, little attention is paid to ophthalmic conditions that are often misdiagnosed or contribute to psychiatric conditions [3,4]. It has been shown thatmisperceptions in vision can lead to unique suspiciousness that is often interpreted as paranoid ideation or possibly misinterpreted as visual hallucinations [5]. Guidelines recommended by the American College of Emergency Physicians (ACEP) for the initial assessment of psychiatric patients, regarding review of systems of the eyes guide physicians to ask if there are “any visual changes,” but does not guide the physician to ask more in-depth questions [6]. The writers intended its use to identify patients with acute mental status changes that are at highest risk for mortality or serious morbidity. Therefore, since it is unlikely that use of glasses or contact lenses is asked in the ER, the admitting inpatient psychiatrist should ask these questions upon admittance. In the United States, more than 30 million people wear contact lenses [7]. Improper contact lens care and overnight wear can lead to noninfectious and infectious complications, with a variety of severity of clinical manifestations from insignificant to potential vision compromise and blindness. Overnight or extended contact lens wear may be associated with 6to 15-fold increase in the risk of infectious keratitis [8]. A growing number of psychiatric hospitals are able to provide medical care for their patient’s comorbid medical conditions such as diabetes and hypertension [3], yet inpatient physicians rarely ask about the use of contact lenses or provide care for them. This study examined the prevalence of patients with corrective vision use and the care for these during acute inpatient psychiatric hospitalization. During a 1-month study involving 54 involuntary-held psychiatric patients in a county hospital, with an average inpatient length of stay of 12 days, 34 (63%) of the 54 patients claimed to have corrected vision through the use of either contact lenses or glasses. Nine (26%) patients stated that they wore contacts lenses, and all of them on discharge