Sharon Reutens

Suicide attempts by jumping and psychotic illness

Background: Several recent studies have reported that serious violence towards self and others is more common in the first episode of psychosis than after treatment. Aim: To estimate the proportion of survivors of suicide attempts during psychotic illness by jumping from a height who had not previously received treatment with antipsychotic medication. Methods: An audit of the medical records of patients admitted to nine designated trauma centres in New South Wales, Australia, after surviving a jump of more than 3 m. Jumping was defined using routine hospital ascribed International Classification of Diseases (ICD) codes. The height of the jump and all clinical data were extracted from case notes. Results: The files of 160 survivors of jumps of more than 3 m were examined, which included 70 who were diagnosed with a psychotic illness (44%). Thirty-one of the 70 diagnosed with a psychotic illness (44%, 95% confidence interval [CI] 32–56%) had never received treatment for psychosis and hence were in the first episode of psychosis. One in five (19.4%) of all survivors of a suicide attempt by jumping had an undiagnosed and untreated psychosis that was often characterized by frightening delusional beliefs. Conclusion: A large proportion of the survivors of suicide attempts by jumping were diagnosed with a psychotic illness, which confirms an association between psychosis and suicide by jumping. Some suicides might not have been linked to psychosis had the patient not survived the suicide attempt, suggesting that the contribution of schizophrenia to suicide mortality might have been underestimated in psychological autopsy studies. The finding that nearly half of the survivors diagnosed to have a psychotic illness had never received treatment with antipsychotic medication indicates a greatly increased risk of suicide by jumping in the first episode of psychosis when compared to the annual risk after treatment.

Practical guidelines for the acute emergency sedation of the severely agitated older patient

The vulnerability of older people to serious underlying medical illness and adverse effects of psychotropics means that the safe and effective treatment of severe agitation can be lifesaving, the primary management goals being to create a safe environment for the patient and others, and to facilitate assessment and treatment. We review the literature on acute sedation and provide practical guidelines for the management of this problem addressing a range of issues, including aetiology, assessment, pharmacological and non‐pharmacological strategies, restraint and consent. The assessment of the agitated older patient must include concurrent assessment of the likely aetiology of, the risks posed by, and the risks/benefits of management options for, the agitation. A range of environmental modifications and non‐pharmacological strategies might be implemented to maximize the safety of the patient and others. Physical restraints should only be considered after appropriate assessment and trial of alternative management and if the risk of restraint is less than the risk of the behaviour. Limited evidence supports a range of pharmacological options from traditional antipsychotics to atypical antipsychotics and benzodiazepines. It is advised to start low and go slow, using small increments of dose increase. Medical staff are frequently called to sedate agitated older patients in hospital settings, often after hours, with limited access to relevant medical information and history. Safe and effective management necessitates adequate assessment of the aetiology of the agitation, exhausting all non‐pharmacological strategies, and resorting to pharmacological and/or physical restraint only when necessary, judiciously and for a short‐term period, with frequent review and the obtaining of consent as soon as possible.

Creative solutions for severe dementia with BPSD: a case of art therapy used in an inpatient and residential care setting

Behavioral and psychological symptoms of dementia (BPSD) are common, distressing and compromise care. Their diverse etiology necessitates targeted, individualized treatment. We present a case of an 82-year-old with severe dementia and BPSD, and with limited response to a range of pharmacological and non-pharmacological treatments. Individualized art therapy was developed in an inpatient setting using felt material cut into shapes and coloring with stencils and pre-drawn line drawings utilizing preserved skills of coloring, while supporting frontal-executive and language deficits. The activity was replicable and carried over to the residential care setting and supported by family and professional carers.

Management and outcomes of delirious patients with hyperactive symptoms in a secured behavioral unit jointly used by geriatricians and pyschogeriatricians

To compare the clinical outcomes and length of stay (LOS) between delirious patients with hyperactive symptoms admitted directly and those admitted indirectly from Emergency Department into a secured, behavioral unit jointly used by geriatricians and pyschogeriatricians (the Unit). A retrospective study analyzing data from the medical records of 122 patients with an admission diagnosis of delirium with hyperactive symptoms and subsequently discharged from the Unit, including restraint, one-to-one nursing care, falls, absconding, duration of delirium, recovery from delirium, destination and LOS. Significantly fewer patients with direct admission (n=68) required physical restraint or chemical restraint compared with those transferred (n=54). Patients admitted directly showed a higher discharge rate back home, shorter LOS, shorter duration of delirium and a higher rate of recovery from delirium than transferred patients. Of the transferred patients, more received one-to-one nursing care before transfer than after transfer. Three (5.6%) absconded before transfer, but none absconded from the Unit. The falls rate reduced from 14.2 to 6.7 falls/1000 patient delirium days after transfer. Delirious patients with hyperactive symptoms admitted directly to the Unit fared better in clinical outcomes and LOS. They also required less restraint, less intensive nursing and were unlikely to abscond compared to those transferred.

Periodic limb movements and other movement disorders in sleep: Neuropsychiatric dimensions

Movement disorders such as Parkinsons disease and Tourettes syndrome, primarily manifest during wakefulness, intrude into sleep. There are some disorders, however, such as periodic limb movements in sleep, restless legs syndrome, paroxysmal nocturnal dystonia, bruxism, and somnambulism, which occur primarily during sleep. The diagnosis and management of these disorders pose a challenge to neuropsychiatric practice, not only because they may be difficult to distinguish from other neuropsychiatric disorders, but also because psychiatric disorders are often co-morbid with them. Study of these disorders is necessary for an understanding of the interaction of sleep and movement, and how disturbance in one may affect the other.

Workforce and Advanced Training Survey of the RANZCP Faculty of Psychiatry of Old Age: Issues and Challenges for the Field

Objectives: There is concern that there are insufficient old age psychiatrists in an ageing population. We aim to describe the work patterns of old age psychiatrists in Australia and New Zealand in order to identify barriers to training and practice. Methods: Members of the Faculty of Psychiatry of Old Age (FPOA) and other psychiatrists who have completed the Certificate of Psychiatry of Old Age were notified of the online survey by email in October 2008. Results: Two hundred and twenty FPOA members resident in Australia and New Zealand were surveyed and 87 responded (56% male, mean age 49.2 years). While 82% had a public appointment, 34% worked in private practice where barriers included the lack of a multidisciplinary team and remuneration. Only 18% of clinical time was in a rural or regional setting. High levels of job satisfaction (88%) were found, with the main factors being working with older people, working in a multidisciplinary team and the intellectual challenge. Advanced training was felt to be beneficial, though some weaknesses were identified. Conclusions: Old age psychiatry is a satisfying career with an advanced training program that is reported to be beneficial to practice. Because the old age psychiatry workforce will face mounting challenges over the next decades, it is imperative that planning for the future mental health needs of older Australians be commenced immediately.

Psychiatric Disorders in Ageing

The ageing of the population brings particular challenges to psychiatric practice. Although the clinical presentation of common psychiatric disorders such as mood and psychotic disorders is largely similar to those in younger adults, late life presentations tend to be more complex as co-morbidity with dementia and physical illness is common. Suicide tends to increase with age in most countries. In this chapter we argue that the aetiology of disorders may be best understood within a stress vulnerability model in which neurobiological and psychosocial factors interplay. We further present that management strategies need to be comprehensive, incorporating physical, social, pharmacological, and psychological treatments appropriate to each case. We close with a call for the use of specialised multi-disciplinary services to improve the overall quality of care.

When an elder is the abuser.

eparate paradigms and services for elder abuse and domestic violence raise the concern that S intimate partner violence in older couples is under-recognised (Box). These paradigms are associated with age-specific characteristics, with very different implications for management when compared with younger age groups. In addition, there is also a higher risk of death in older domestic violence victims compared with younger people and in incidents involving strangers.

Homicides by older offenders in New South Wales between 1993 and 2010

Objective: Homicides by older people are rare and might differ from those committed by younger people. To investigate the characteristics of older homicide offenders in New South Wales (NSW), Australia. Methods: A systematic search of legal, criminological and media databases for cases of homicide committed by people in NSW aged 55 and over, during the 18 years from 1993 to 2010. Results: Eighty-seven cases were identified through databases. Legal documents were obtained for 70 offenders, comprising about 5% of homicides committed in NSW in the period of the study. The proportions of male offenders and rates of firearm use were similar to other age groups. Twelve of the 14 homicides using guns occurred outside the metropolitan area. Older offenders were more likely to have cognitive impairment or psychotic illness. Victims were more likely to be female and in a domestic relationship with the offender. Conclusions: Homicide by an older person is rare, and more commonly involves a man killing a family member. Correctional facilities will increasingly have to consider the needs of older people serving long sentences.