LIAISON PSYCHIATRY FOR OLDER PEOPLE Fiona Thompson Consultant Psychiatrist Addenbrookes Hospital
US LP mid 18 th Century UK after WW2 Developmental History 1948 WHO defined health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity 1997 LP established in RCPsych RAID 2011
Increasing evidence of impact of mental health on physical health and wider health economy
Prevalence of Mental Illness in Older People in the Acute Hospital Two thirds of hospital beds occupied by older people Of these two thirds have a mental disorder so 40% 19% depression 13% delirium 20% dementia 5% anxiety, substance misuse, psychosis NDS 2009 Who cares wins 2005 NSF 2000
Impact on Care LOS Increased morbidity and mortality in CVA, MI, As, DM Reduced adherence to Rx Discharge to NH/RH Higher costs and work days lost Delirium costs US >$4 billion Sederer 2006 Who cares wins 2005 Rizzo 2001
RAID- Economic evaluation- why it was done US studies some positive proactive LP in hip# reduced LOS, modest benefit on outcome (only consultation model) Previous evidence suggested LP as part of wider system reduced LOS for older people Leeds 2006 2006-2008- LPOPP nationally funded review of evidence and survey of practice. Wide variation in models and resources. Little evidence base. RCTs methodologically weak, descriptive studies not well controlled for other factors. RAID = Rapid Assessment Interface and Discharge demonstrated cost savings in region 3:1 Strain 1991 Cole 1991 Holmes 2006
RAID Study Design 24/7 service to >16yo Consultation and liaison model Analysis of cost savings in local health economy: LOS, admission avoidance from short stay, reduced readmission Control group pre-raid Intervention groups referrals plus RAID influence Methodological weaknesses- confounding factors affected by passage of time, savings confined to local health economy without taking into account trim points and PbR, effect on other providers- LA, carers, third sector
RAID economic evaluation a no brainer? Combination intervention groups
Proactive consultation in US Proactive model of care in US all (mostly DME patients) screened for mental health issues that may impact on progress and LOS. Problems identified- addressed +/- f/up arranged. Reduced mean LOS and reduced %age of cases with LOS >4 days Favourable cost benefit ratio Desan 2011
So what do we actually do? Liaison enabling the whole hospital strategy, culture, training to safely (and legally) deliver high quality care for patients with mental health problems Ensure that the more complex patients are referred to us Consultation bio-psycho-social management
Psychological management Mr M 68 year old man referred with low mood and suicidal ideation post CVA Referred one month after admission with CVA right sided weakness and dysarthria. Low in mood a lot of the time, tearful, not engaging in rehab, wanting to leave hospital to kill himself Had had TIAs in past and had been thinking of choosing the right time to kill himself to avoid CVAs, permanent neurological problems which would make him dependent on others. Fearing the worst, hated not being in control care and uncertainty Appetite, sleep and concentration had been fine but not since this level of agitation
Past psych hx BPAD which was well controlled on Epilim, several episodes of mania and hypomania, sometimes very productive, often followed by severe depression. ADs ->mixed affective state and agitation. Harmful use of OH which sometimes correlated with previous relapses. Has not drunk OH recently and occ taken Disulfiram if he had the urge to drink. PMHx DVT, TIAs SHx Lives with wife, non-smoker, independent Personal hx retired education consultant, very successful, still working, semi-retired, travelling, reading, arts, fitness. Two children with whom he has a very close relationship PMP high achieving, high standards, gregarious, in control, high self esteem
Mental state In bed, crying++, agitated, angry, devastated. Very low, hopeless, looking at other patients who were bedbound and thinking that he may end up like them. Offloading made him calmer although continued to feel that he would like to get home and ask his children to help him to access means of suicide. Could challenge negative thoughts, not psychotic. Well oriented, recent memory, registration and recall and attention normal.
Plan Psychosocial Brief cognitive therapy Staff awareness and adaptation Timetable including prescribed time for rest Medical student every day! Pharmacological Kept Rx same but considered increasing Epilim if not improving
What is Cognitive behavioural therapy? Evidence base for Rx mood disorders in elderly Developed in 1970s Psychotherapist noticed that unhelpful thoughts often preceded unpleasant emotional states. These automatic thoughts could be brought to conscious attention. Previous experience Underlying assumptions and beliefs Distorted and dysfunctional cognitions 99%perfect is not good enough The world should be a safe place Bad things happen to bad people Emotions, behaviours and physiological changes
The therapy Identify dysfunctional thoughts that are maintaining mood and/or actions Examine evidence for and against, developing alternatives Behavioural experiments to test out predictions based on unhelpful thinking Graded exposure e.g. needle phobia Usually structured sessions, homework but in liaison, we tailor it to target the immediate behaviour and emotions related to their medical condition.
Cognitive therapy for older people Anyone over the age of 50 was uneducable and thus unsuitable for psychotherapy Freud 1905 (age 49) With current increasing evidence for effectiveness in depression and anxiety in the elderly The debate is not whether cognitive therapy is applicable to the elderly but rather how to modify existing CT programmes so that they incorporate differences in thinking styles in elderly people and age-related adjustment
Adapting to meet OP needs Individual and cohort cultural beliefs Tackle cognitive changes Tackle sensory impairment Allow for physical health Adjust setting and format Therapist views
How can DME get the most out of their psychiatrists? Consider proactive screening if new service Education menu Engage OPMH in governance, strategy development, especially for dementia and delirium, MH legislation Our nurses compliment DME nurses in Mx delirium and dementia Ensure that MHA is well managed As patient about mood and views, identify dysfunctional beliefs
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