Medical comorbidity in elderly psychiatric inpatients

Development and implementation of electronic medical handovers across psychiatric hospitals: quality improvement initiative

A lack of integration between internal processes and failure to use the full potential of information technology (IT) systems is common in psychiatric hospitals. We aimed to reduce the number of out-of-hours medical errors by ensuring that there is consistent and transparent weekend medical handover by creating an electronic handover system that is easy to use, robust and embedded into the existing trust IT systems. We employed quality improvement (QI) methodology to address this issue. After trialling in a single site followed by six cycles of improvement, the weekend medical handover system is now in use across four boroughs and has been integrated into trust policy. It has received qualitative and quantitative evidence of improvement, with 100% of doctors reporting the system improved patient care and a 64% (from 11 to 4 events/year) reduction in moderate, severe and catastrophic adverse incidents occurring out-of-hours within the older adult service (p=0.29, χ² 1.117). The increasing number of complex patients with comorbid medical illness in psychiatric inpatient services demands robust handover systems similar to that of an acute trust. This QI work offers a template for achieving this across other psychiatric trusts and demonstrates the positive change that can be achieved.

A retrospective study of medical comorbidities in psychogeriatric patients

BACKGROUND

This study contributes further research into the assessment and treatment of older psychiatric patients with medical comorbidities.

METHODS

A retrospective file audit was conducted at the acute inpatient psychogeriatric unit of St Vincent's Aged Mental Health Service, Melbourne, in order to determine the prevalence of certain medical comorbidities and the nature of medical interventions provided for psychogeriatric inpatients.

RESULTS

This study, investigating 165 admissions into an acute inpatient psychogeriatric unit, highlights that psychiatric and medical comorbidities are routine in this population: the vast majority (91.5%) of all inpatients had at least one medical comorbidity.

CONCLUSIONS

As the population ages, psychogeriatric wards are likely to see more of the oldest-olds, who are likely to have comorbid medical illnesses. Currently, appropriate detection, investigation, and management of these illnesses are often suboptimal and can affect quality of life, increase mortality, and complicate treatment. This paper adds to the literature about the need for integrating medical and psychiatric care to create a more comprehensive strategy for treating the older person with psychiatric illness.

Comorbidity in dementia: update of an ongoing autopsy study

OBJECTIVES

To examine systemic and central nervous system (CNS) comorbidities of individuals with dementia evaluated during general autopsy.

DESIGN

Retrospective cohort study.

SETTING

A large tertiary academic medical center in Los Angeles, California.

PARTICIPANTS

Individuals with clinically and neuropathologically diagnosed dementia who received complete autopsies (n = 86) and individuals with dementia who received partial (brain only) autopsies (n = 132).

MEASUREMENTS

Information on cause of death and systemic and CNS comorbidities was obtained from autopsy reports and clinical information as available from the medical records. Findings were tabulated with respect to type of dementia, semiquantitative assessment of the severity of cerebral amyloid angiopathy, semiquantitative assessment of the severity of cerebrovascular disease, and evidence of ischemic damage in the brain.

RESULTS

Of 218 subjects with dementia, 175 (80.3%) had Alzheimer's disease alone or in combination with other lesions that might contribute to cognitive impairment, such as cerebrovascular disease and diffuse Lewy body disease (DLBD), 14 (6.4%) had frontotemporal dementia, and seven (3.2%) had isolated DLBD. The most common cause of death in participants with dementia was pneumonia (n = 57, 66.3%), followed by cardiovascular disease (n = 14, 16.3%). Eighteen subjects (20.9%) had lung disease, and 16 (18.6%) had evidence of an old or recent myocardial infarction. Clinically undiagnosed neoplasms included colonic adenocarcinoma, metastatic pulmonary neuroendocrine carcinoma, meningioma, and Schwannoma.

CONCLUSION

Significant comorbidities were discovered at autopsy in individuals with dementia. Understanding the causes of death and associated comorbidities in individuals with various subtypes of dementia is important in the assessment of end-of-life care in these individuals.

Perceptions of Giving Support and Depressive Symptoms in Late Life

PURPOSE OF THE STUDY

Research shows that parents benefit psychologically from generativity--giving and caring for the next generation--but older adults' perceptions on giving support to their children are rarely if ever explored in these studies. The current study examines the association between the support that aging parents give to one of their middle-aged offspring, their perception of this support as rewarding or stressful, and their levels of depressive symptoms.

DESIGN AND METHODS

The sample draws from The Family Exchanges Study and consisted of 337 older parents (mean age: 76) who were drawn from a larger study of middle-aged adults (i.e., target participants). Older parents reported tangible and nontangible forms of support given to the target middle-aged child and the extent to which they viewed providing such support as stressful and/or rewarding.

RESULTS

We found significant interactions between tangible support and feelings of reward and between nontangible support and feelings of stress in explaining parental depressive symptoms. Parents who found giving support to be highly rewarding had lower levels of depressive symptoms when giving high amounts of tangible support. Conversely, parents who view giving support to be highly stressful had higher levels of depressive symptoms when they gave low amounts of nontangible support.

IMPLICATIONS

Findings suggest older parents' perceptions of supporting their offspring may condition how generativity affects their mental health.

Characteristics of older adults hospitalized in acute psychiatric units in ontario: a population-based study

OBJECTIVE

As the numbers of older adults in Canada increases, there will be a growing need for mental health services for this population. Acute psychiatric units (APUs) provide inpatient psychiatric services for the management of serious mental illness. Understanding the characteristics of older adults in APUs is necessary to determine the range of inpatient services required for this population.

METHOD

We conducted a population-based study of all adults discharged from APUs in Ontario in a 2-year period, 2008-2010, using administrative databases. We compared the characteristics of older adults (aged 66 years and older) in APUs to those of younger adults (aged 18 to 65 years), including sociodemographics, psychiatric and medical diagnoses, and measures of cognition and functioning.

RESULTS

There were a total of 79 352 discharges from APUs, with older adults accounting for 8.8% of all discharges. Depressive disorder was the most common diagnosis, both in older and in younger populations (32.1% and 29.9%, respectively), while dementia accounted for 19.5% of discharges for older adults. Older adults, compared with younger adults, were more likely to have 2 or more chronic medical conditions (83.8% and 20.5%, respectively), significant cognitive impairment (47.0% and 14.5%, respectively), and moderate-to-severe functional impairment (21.8% and 3.3%, respectively).

CONCLUSIONS

Older adults in APUs are a complex group, with mental health and medical care needs that differ from younger adults. APUs must be able to provide adequate psychiatric, medical, and interprofessional services to achieve optimal outcomes. Future studies are required to understand the quality of care and outcomes for older adults in APUs.

Chronic physical conditions in older adults with mental illness and/ or substance use disorders

OBJECTIVES

To examine the association between mental illness and chronic physical conditions in older adults and investigate whether co-occurring substance use disorders (SUDs) are associated with greater risk of chronic physical conditions beyond mental illness alone.

DESIGN

A retrospective cross-sectional study.

SETTING

Medicare and Medicaid programs in Massachusetts.

PARTICIPANTS

Massachusetts Medicare and Medicaid members aged 65 and older as of January 1, 2005 (N = 679,182).

MEASUREMENTS

Diagnoses recorded on Medicare and Medicaid claims were used to identify mental illness, SUDs, and 15 selected chronic physical conditions.

RESULTS

Community-dwelling older adults with mental illness or SUDs had higher adjusted risk for 14 of the 15 selected chronic physical conditions than those without these disorders; the only exception was eye diseases. Moreover, those with co-occurring SUDs and mental illness had the highest adjusted risk for 11 of these chronic conditions. For residents of long-term care facilities, mental illness and SUDs were only moderately associated with the risk of chronic physical conditions.

CONCLUSION

Community-dwelling older adults with mental illness or SUDs, particularly when they co-occurred, had substantially greater medical comorbidity than those without these disorders. For residents of long-term care facilities, the generally uniformly high medical comorbidity may have moderated this relationship, although their high prevalence of mental illness and SUDs signified greater healthcare needs. These findings strongly suggest the imminent need for integrating general medical care, mental health services, and addiction health services for older adults with mental illness or SUDs.

Ease of screening for depression and delirium in patients enrolled in inpatient hospice care

BACKGROUND

Major depression and delirium are prevalent, underrecognized, and undertreated in hospice and palliative care settings. Furthermore, they are both associated with significant morbidity and mortality.

OBJECTIVE

A screening study of patients receiving inpatient hospice care was conducted in order to determine the ease of screening for depression and delirium in patients with advanced, life-threatening illnesses by hospice social workers and nurses, respectively.

METHODS

A two-question depression screening tool was administered to 20 consecutive patients on admission to a hospice general inpatient care center by social work staff during their initial assessment. A delirium-screening tool was administered daily to 22 consecutive patients admitted to the ICC daily by nursing staff. Screening results were collected, as were patient and staff feelings about the burden of the screening process.

RESULTS

Of the 20 patients screened on admission for depression by social work, 70% (14/20) screened positive. Of the 22 patients screened daily for delirium by nursing, 64% (14/22) screened positive at least once during their admission. Screening for both conditions was considered relatively easy to accomplish by the hospice staff. There were no significant associations between a positive screen of depression or delirium and patient gender, age, ethnicity, terminal diagnosis, or marital status.

DISCUSSION

These results support the notion that depression and delirium are very common in hospice inpatients, and that screening for both is relatively easy and practical for hospice clinicians to conduct.

Psychiatric issues in palliative care: recognition of depression in patients enrolled in hospice care

Major depression is prevalent, difficult to assess, underrecognized, and undertreated in hospice settings. Furthermore, it is associated with significant morbidity and mortality. A retrospective chart review of 2716 patients receiving hospice care was conducted in order to determine the baseline rate of recognition of depression in patients with advanced, life-threatening illnesses by frontline hospice clinicians. Documentation of "depression" as either a diagnosis or problem was used as an estimate of how often these disorders were considered significant issues by the treating interdisciplinary team. Of the patients receiving home/long-term care, 10.8% (234/2168) had depression documented as a diagnosis or significant problem. The presence of recognized depression in this setting was associated with significant differences in gender, marital status, and terminal diagnoses. Total length of hospice care was also significantly longer. Of patients receiving inpatient care, 13.7% (75/548) had depression documented as a diagnosis or significant problem. Recognized depression in this setting was associated with significant differences in marital status, length of inpatient stay, and total time in hospice care. If documentation is representative of the care that the interdisciplinary teams provide, depression of any kind appears to be underrecognized in this population. In fact, it is on the low end of prevalence estimates in the literature. Improved depression assessment is needed in order to minimize the impact of depression on patients living with advanced, life-threatening illnesses.

Reduced Age-Related Cataracts Among Elderly Persons Who Reach Age 90 With Preserved Cognition: A Biomarker of Successful Aging?

Tissue damage due to oxidative stress has been implicated in aging, memory loss, and cataract formation. We hypothesized that persons who achieved exceptional longevity with preserved cognition (successful aging [SAG]) would exhibit a lower rate of age-related cataract (ARC) than the general population. The age-specific rates of ARC for a group of 100 (50 male, 50 female) elderly persons who reached at least age 90 years with preserved cognition were compared to the corresponding rates of ARC reported in five population-based studies. The principal finding of this report was that the SAG group manifested a significant reduction in the age-specific rate and lifetime cumulative incidence of ARC compared to the general population. Steroid use, alcohol consumption, gout, and skin lesions resulting from excessive sun exposure emerged as risk factors. Our findings suggest that the progressive development of lens opacities may be reflective of degenerative events occurring more generally throughout the body.

Genome survey for loci that influence successful aging: results at 10-cM resolution

OBJECTIVE

A systematic genome survey was initiated to identify loci that affect the likelihood of reaching age 90 with preserved cognition (successful aging).

METHODS

The genome survey was conducted at 10-cM resolution for simple sequence tandem repeat polymorphisms (SSTRPs) that identify genes for Successful AGing (SAG loci) by virtue of linkage disequilibrium. Efficiency was enhanced by genotyping pools of DNA from 100 cognitively intact elders and 100 young (18-25 years) adults. The comparison groups included equal numbers of white men and women of similar ethnicity that were recruited from the southwestern Pennsylvania region.

RESULTS

Our genome survey identified nine SAG candidate loci that may influence the likelihood of reaching age 90 or more with preserved cognition. Two of the autosomal SAG loci revealed stronger allelic associations with successful aging in men than women (D1S1728, D8S264) and two were located on sex chromosomes (DXS9902, DYS390). DXS9902 resides within a predicted gene, whereas six of the SAG loci are located within regions previously reported to show linkage to other phenotypes.

CONCLUSIONS

The results of our study suggest that loci with differential effects on the successful aging of men and women may be common. The majority of the SAG candidate loci detected in this study overlap with regions previously reported to show linkage to susceptibility genes for cardiovascular disorders, psychiatric disorders, and the accumulation of tissue damage resulting from oxidative stress.

Characteristics of HCV positive patients in an Italian urban psychiatric unit

OBJECTIVES

1) to assess the prevalence of hepatitis C virus (HCV) infection in a population of acute psychiatric in-patients; 2) to find out relationships between HCV comorbidity and clinical features of psychiatric patients.

METHODS

Prospective observational study in a 6-year period.

RESULTS

2396 cases (1492 patients) were admitted in the considered period. Forty-two patients (2.8%) were affected by HCV infection. HCV infection was more frequent in patients with less years of education, lower social class, lower last year best Global Assessment of Functioning score, more hostile or violent behavior in hospital, with a lifetime history of previous suicide attempt, and with substance-related disorders.

CONCLUSION

HCV infection in psychiatric patients constitutes a major threat to the health of psychiatric patients and is related with unfavorable social background, worse global functioning, hostile or violent behavior, substance-related disorders. It appears also to be a significant risk of suicidal behavior.

Practice patterns and potential solutions to the shortage of providers of older adult mental health services

Little is known about the contribution of advanced practice nurses (APNs) to the mental health care of older adults. This study describes mental health services to older adults by APNs compared with primary care physicians, psychiatrists, psychologists, and social workers. The study uses a retrospective, cross-sectional design with a 5% national sample of 1999 Medicare outpatient claims. Bivariate statistics and multinomial logit models were used to determine differences among these mental health providers. A small proportion of the nationally available providers (10.4%) submitted claims for mental health services rendered to older adults. APNs, psychiatrists, and primary care physicians care for a disproportionate number of rural and poor older adults with complex medical/psychiatric needs compared with psychiatrists, psychologists, and social workers. APNs seem to be an untapped resource for providing mental health services to older adults. Health policy reform is needed to remove barriers to meet mental health care needs.

Medical comorbidity and health-related quality of life in bipolar disorder across the adult age span

BACKGROUND

Little is known about medical comorbidity or health-related quality of life (HRQOL) in bipolar disorder across the adult age span, especially in public sector patients.

METHODS

We obtained cross-sectional demographic, clinical, and functional ratings for 330 veterans hospitalized for bipolar disorder with Mini-Mental State score > or = 27 and without active alcohol/substance intoxication or withdrawal, who had had at least 2 prior psychiatric admissions in the last 5 years. Structured medical record review identified current/lifetime comorbid medical conditions. SF-36 Physical (PCS) and Mental (MCS) Component Scores, measured physical and mental HRQOL. Univariate and multivariate analyses addressed main hypotheses that physical and mental function decrease with age with decrements due to increasing medical comorbidity.

RESULTS

PCS decreased (worsened) with age; number of current comorbid medical diagnoses, but not age, explained the decline. Older individuals had higher (better) MCS, even without controlling for medical comorbidity. Multivariate analysis indicated association of MCS with age, current depressed/mixed episode, number of past-year depressive episodes, and current anxiety disorder, but not with medical comorbidity, number of past-year manic episodes, current substance disorder or lifetime comorbidities.

LIMITATIONS

This cross-sectional design studied a predominantly male hospitalized sample who qualified for and consented to subsequent randomized treatment.

CONCLUSIONS

Medical comorbidity is associated with lower (worse) physical HRQOL, independent of age. Surprisingly, younger rather than older subjects reported lower mental HRQOL. This appears due in part to more complex psychiatric presentations, and several mechanisms are discussed. Both results suggest that age-specific assessment and treatment may enhance HRQOL outcome.

Comorbidity in dementia: an autopsy study

CONTEXT

There is a paucity of accurate postmortem data pertinent to comorbid medical conditions in patients with dementia, including Alzheimer disease.

OBJECTIVES

The purposes of this study were (a) to examine general autopsy findings in patients with a dementia syndrome and (b) to establish patterns of central nervous system comorbidity in these patients.

DESIGN

Review of autopsy reports and selected case material from 202 demented patients who had "brain-only" autopsies during a 17-year period (1984-2000) and from 52 demented patients who had general autopsies during a 6-year period (1995-2000).

SETTING

Large academic medical center performing approximately 200 autopsies per year.

RESULTS

Among the 52 patients who underwent complete autopsy, the most common cause of death was bronchopneumonia, which was found in 24 cases (46.1%). Other respiratory problems included emphysema, found in 19 (36.5%) of 52 patients, and pulmonary thromboembolism, found in 9 (17.3%) of 52 patients. In 6 cases, pulmonary thromboembolism was the proximate cause of death. Twenty-one (40.3%) of the 52 patients had evidence of a myocardial infarct (varying ages) and 38 (73.1%) had atherosclerotic cardiovascular disease, 27 of a moderate to severe degree. Four clinically unsuspected malignancies were found: 1 each of glioblastoma multiforme, diffusely infiltrative central nervous system lymphoma, pancreatic adenocarcinoma, and adenocarcinoma of the lung. One patient with frontotemporal dementia and amyotrophic lateral sclerosis died of severe meningoencephalitis/ventriculitis, probably secondary to seeding of the central nervous system by an infected cardiac valve. Of the 202 demented patients who underwent brain-only autopsies, the following types of dementia were found: 129 (63.8%) cases showed changes of severe Alzheimer disease, 21 (10.4%) showed combined neuropathologic abnormalities (Alzheimer disease plus another type of lesion, such as significant ischemic infarcts or diffuse Lewy body disease), 12 (5.9%) cases of relatively pure ischemic vascular dementia, 13 (6.4%) cases of diffuse Lewy body disease, and 8 (4.0%) cases of frontotemporal dementia. The remaining 19 (9.4%) patients showed miscellaneous neuropathologic diagnoses, including normal pressure hydrocephalus and progressive supranuclear palsy. Among the demented patients, 92 (45.5%) had cerebral atherosclerosis, which was moderate to severe in 65 patients (32.2%).

CONCLUSIONS

Some of the conditions found at autopsy, had they been known antemortem, would likely have affected clinical management of the patients. Autopsy findings may be used as a quality-of-care measure in patients who have been hospitalized in chronic care facilities for a neurodegenerative disorder.

Rate of cognitive decline in preclinical Alzheimer's disease: the role of comorbidity

We investigated the influence of individual-difference variables implicated as risk factors for Alzheimer's disease (AD) or known to be related to cognitive performance in normal aging (e.g., age, sex, years of education, previous and recent diseases, apolipoprotein E status, social network, and substance use) on rate of cognitive change from preclinical to clinical AD. With the use of data from a population-based study, 230 persons who were nondemented at baseline and diagnosed with AD at a 3-year follow-up were examined with the Mini-Mental State Examination (MMSE). Of all predictor variables examined, only number of diseases resulting in hospital admission during the follow-up period made an independent contribution to rate of MMSE change. These results suggest that many variables affecting the onset of the degenerative process as well as cognitive functioning in normal aging exert little influence on rate of cognitive change in preclinical AD. This may reflect the fact that the emerging dementia disease overshadows the role of these variables for cognitive functioning. A possible exception to this pattern is that an increasing number of concomitant health conditions may exacerbate the rate of cognitive decline during the final portion of the preclinical phase in AD.

Assessment of late life depression

This article focuses on diagnostic and nosologic challenges intrinsic to geriatric depression, including characteristics interfering with symptom and syndrome ascertainment, the impact of medical and cognitive disorders, the usefulness of screening instruments, and barriers imposed by treatment settings. The article also identifies gaps in existing knowledge and outlines a research agenda. Nosologic characterization of depressives syndromes contributed by specific medical disorders may lead to effective strategies for prevention and treatment of depression. Studies need to examine whether treatment of depression can improve the outcome of medical illnesses requiring active patient involvement in treatment. Considering disability a distinct aspect of health status may add an important dimension to the assessment of depression and result in complementary interventions aimed at depression and disability concurrently. The provisional criteria for depression of Alzheimer's disease, if validated, may facilitate treatment research. Studies need to characterize cognitive dysfunctions associated with later development of dementia or poor treatment response in patients with depression. Care managers working together with primary care physicians can improve the recognition and treatment of depressed elderly patients by obtaining the training in using validated instruments and treatment algorithms.

Physical morbidity in elderly psychiatric inpatients: prevalence and possible relations between the major mental disorders and physical illness

BACKGROUND

This study examines the prevalence of physical morbidity in elderly psychiatric inpatients and the possible relationships between major psychiatric disorders (organic mental disorders, schizophrenic and mood disorders) and physical illnesses. The clinical implications of such relationships are discussed.

METHOD

Data were obtained from two old age psychiatry wards over a six month period. Seventy-nine subjects were studied and information was obtained from their medical files. Demographic characteristics, psychiatric diagnosis, number of physical illnesses and number of body systems affected were collected. Analysis of variance (ANOVA) was used to compare the psychiatric groups on continuous outcome data and chi(2) test to compare psychiatric groups on categorical data.

RESULTS

Seventy-five per cent of subjects had at least one physical illness. The number of medical illnesses was independent from the psychiatric disorder. Subjects with mood disorders, and especially depression, were more likely to suffer from hypertension, diabetes and cardiovascular illnesses than subjects with schizophrenic or organic disorders. Subjects with organic disorders had the lowest prevalence of endocrine disease and diabetes.

CONCLUSIONS

It was concluded the link between mood disorders (depression), cardiovascular diseases and hypertension could be of a 'cause/effect' type or are the results of a survivor effect. The high prevalence of physical morbidity has implications for training and continuing professional development of those in Old Age Psychiatry Services. It should also be taken into consideration when the location of services is being decided.

Depression in late life: psychiatric-medical comorbidity

The links between late-life depression and the medical comorbidities that are often associated with it can be divided into two paths. The path from medical illness to depression reflects general mechanisms related to stress, disability, and loss, as well as more specific physiological mechanisms, including those related to subclinical cerebrovascular disease, adverse drug effects, and endocrine/metabolic effects. Similarly the path from depression to medical illness includes general mechanisms related to self-neglect, decreased adherence to medical treatments, maladaptive health-related behaviors, and, possibly, more specific physiological mechanisms including those related to altered endocrine and autonomic functions, in the clinical context, these two paths can interact to constitute a vicious cycle. With further research, it should be possible to translate current understanding in these areas into advances in both basic knowledge and treatments that could initiate virtuous cycles with beneficial effects for both menial and physical health.

Novel role for the pontine micturition center, Barrington's nucleus: evidence for coordination of colonic and forebrain activity

This report provides evidence for a novel role of Barrington's nucleus, considered the pontine micturition center, in regulation of colonic function. Barrington's activation elicited increases in colonic intraluminal pressure that were eliminated by scopolamine and intrathecal lidocaine, suggesting an impact of Barrington's neurons on colonic activity via projections to lumbosacral parasympathetic neurons. Consistent with this, Barrington's neurons were transsynaptically labeled from the distal colon by pseudorabies virus and several of these were also retrogradely labeled from the locus coeruleus, which projects extensively to the forebrain. Thus, Barrington's nucleus is strategically positioned to coordinate colonic and forebrain activity. Dysfunctions within this divergent system may underlie the frequent comorbidity of colonic and psychiatric symptoms.