Observation levels in acute psychiatric admissions

Suicide by mental health in-patients under observation

BACKGROUND

Observations in psychiatric in-patient settings are used to reduce suicide, self-harm, violence and absconding risk. The study aims were to describe the characteristics of in-patients who died by suicide under observation and examine their service-related antecedents.

METHOD

A national consecutive case series in England and Wales (2006-2012) was examined.

RESULTS

There were 113 suicides by in-patients under observation, an average of 16 per year. Most were under intermittent observation. Five deaths occurred while patients were under constant observation. Patient deaths were linked with the use of less experienced staff or staff unfamiliar with the patient, deviation from procedures and absconding.

CONCLUSIONS

We identified key elements of observation that could improve safety, including only using experienced and skilled staff for the intervention and using observation levels determined by clinical need not resources.

Integrating retrogenesis theory to Alzheimer's disease pathology: insight from DTI-TBSS investigation of the white matter microstructural integrity

Microstructural abnormalities in white matter (WM) are often reported in Alzheimer's disease (AD) and may reflect primary or secondary circuitry degeneration (i.e., due to cortical atrophy). The interpretation of diffusion tensor imaging (DTI) eigenvectors, known as multiple indices, may provide new insights into the main pathological models supporting primary or secondary patterns of WM disruption in AD, the retrogenesis, and Wallerian degeneration models, respectively. The aim of this review is to analyze the current literature on the contribution of DTI multiple indices to the understanding of AD neuropathology, taking the retrogenesis model as a reference for discussion. A systematic review using MEDLINE, EMBASE, and PUBMED was performed. Evidence suggests that AD evolves through distinct patterns of WM disruption, in which retrogenesis or, alternatively, the Wallerian degeneration may prevail. Distinct patterns of WM atrophy may be influenced by complex interactions which comprise disease status and progression, fiber localization, concurrent risk factors (i.e., vascular disease, gender), and cognitive reserve. The use of DTI multiple indices in addition to other standard multimodal methods in dementia research may help to determine the contribution of retrogenesis hypothesis to the understanding of neuropathological hallmarks that lead to AD.

Under the gaze of staff: special observation as surveillance

PURPOSE

This study explores the relationship of special observation (SO) to a range of patient, staff, and ward variables.

DESIGN AND METHODS

End-of-shift reports were completed by nurses on 136 acute mental health wards in England during 2004 and 2005.

FINDINGS

Intermittent SO (patient checked at specified intervals) was used five times more frequently than constant SO (patient kept within sight or reach). Significant relationships were found between SO and measures of ward surveillance, door locking, and the ease of observing patients on the wards. Both types of SO were more common when higher numbers of staff without a nursing qualification were on duty.

PRACTICE IMPLICATIONS

Improved ward design, less reliance on unqualified staff, and greater use of surveillance measures may reduce the need for SO.

Is confrontation naming performance in Alzheimer's disease the nominal linguistic retrogenesis of normal development?

We investigated confrontation naming performance of patients with Alzheimer's disease (AD) and normal children (NC) to see if the nature of naming performance of AD patients is the reversal of that in normal development. Sixty items of the Boston Naming Test were given to 78 AD patients (and 40 age- and education-matched normal elderly) and 1,080 NC (3- to 14-year-olds). The analyses revealed that, firstly, the naming abilities of the AD patients demonstrated an inverse relationship with those of the NC. Secondly, from the clinical point of view, AD patients tended to lose vocabulary acquired later first while maintaining those acquired in earlier stages of development. Based on the findings, we claimed that this phenomenon was 'a nominal retrogenesis' in which 'retrogenesis' is 'the process by which degenerative mechanisms reverse the order of acquisition in normal development' as defined by Reisberg and colleagues.

Special observations in forensic psychiatric practice: gender issues of the watchers and the watched

Special observations in psychiatric practice may create tensions for both the patient under surveillance and the staff undertaking the procedure. This study reports on special observations undertaken in forensic settings focusing specifically on the gender-sensitive issues. The aim of the study was to investigate the specific gender issues relating to special observations in relation to those under the procedure and those engaged in observing. Three medium secure units in the UK formed the sampling frame, and the population studied was eight female and seven male clinical Registered nurses. Semi-structured interviews were conducted, audio-tape-recorded and transcribed for analysis. The analysis involved a Grounded Theory approach to explicate categories and formulate two overarching themes: (1) the psychosocial fusion; and (2) the private as spectacle. There are implications for practice in relation to policy formulation and the implementation of special observations following risk assessment and individual skill identification. It is concluded that gender issues are extremely important for all concerned in this intrusive practice.

Constant special observation and self-harm on acute psychiatric wards: a longitudinal analysis

OBJECTIVE

Special observation (the allocation of nurses to watch over nominated patients) is a method of preventing patients harming themselves. This study assessed the relationship between constant special observation (keeping a patient within eyesight or reach) and rates of self-harm on acute psychiatric wards.

METHOD

A longitudinal analysis of officially collected data covering a period of 2 1/2 years from 16 acute wards at three Hospitals in London.

RESULTS

There was no statistically significant association between constant special observation and self-harm outcomes. Use of observation varied markedly between hospitals and wards, but overall, there was a significant decline over time. Self-harm incidents were rare (recorded in only 7% of ward weeks) and did not decline over time, but were correlated over consecutive weeks.

CONCLUSION

The lack of association with self-harm suggests that the use of constant special observation could be reduced without compromising patient safety.

Observation intervention: time for an overview

This paper aims to illustrate the nature and extent of research and development work related to observation practice over the last 28 years. It aims to show both local Scottish work and the National picture, how there is still a lack of research evidence despite all the work that has taken place and what needs to be performed to explore observation practice for the future. It is not intended to be a literature review in the traditional sense. Observation has not been studied enough to know the continuing ever-changing picture of what goes on in the reality of practice. There are now studies examining observation but none of these are 'gold standard' randomized controlled trials; some are quantitative and some are qualitative audit or guidelines all based at a lower level in research evidence terms. The time has come to take the evidence base to the next level through evaluative research.

Screening for Alzheimer's dementia at age 78 with short psychometric instruments

BACKGROUND

To date, no single instrument has proved to be adequate for screening for Alzheimer's dementia (AD). The aim of this study was to identify a combination of instruments which were highly sensitive for screening late onset AD.

METHODS

Subjects were drawn from the Vienna TransDanube Aging (VITA) study. This is an interdisciplinary, longitudinal community-based cohort study of the 21st and 22nd district of Vienna (Austria). Data refer to the cohort of 478 individuals at age 78 who took part in the first follow-up investigation of the VITA study. The psychometric instruments which were investigated were: the Ten-Point Clock Test, the Human-Figure Drawing Test, a Delayed Selective Reminding Test, Naming, the Trail Making Test-B, and Verbal Fluency. Further instruments were the Pocket Smell Test, and Subjective Memory Complaints. Data were analyzed using logistic regression analyses and cross validation.

RESULTS

A combination of the Delayed Selective Reminding Test and Verbal Fluency was best for screening AD (R2 = 0.38, main model). An area under the ROC curve of 0.829 was reached. This model discriminated between subjects with incident AD and subjects who did not have incident AD with a sensitivity of 91% and a specificity of 56%.

CONCLUSION

The combination of an episodic memory test and a test of verbal fluency was an effective way of screening for AD.

Diffusion tensor imaging of normal-appearing white matter in mild cognitive impairment and early Alzheimer disease: preliminary evidence of axonal degeneration in the temporal lobe

BACKGROUND AND PURPOSE

Diffusion tensor imaging (DTI) is a sensitive technique for studying cerebral white matter. We used DTI to characterize microstructural white matter changes and their associations with cognitive dysfunction in Alzheimer disease (AD) and mild cognitive impairment (MCI).

MATERIALS AND METHODS

We studied elderly subjects with mild AD (n = 6), MCI (n = 11), or normal cognition (n = 8). A standardized clinical and neuropsychological evaluation was conducted on each subject. DTI images were acquired, and fractional anisotropy (FA), axial diffusivity (DA), and radial diffusivity (DR) of normal-appearing white matter (NAWM) in frontal, temporal, parietal, and occipital lobes were determined. These diffusion measurements were compared across the 3 groups, and significant differences were further examined for correlations with tests of cognitive function.

RESULTS

Compared with normal controls, AD subjects demonstrated decreased FA and increased DR in the temporal, parietal, and frontal NAWM and decreased DA in temporal NAWM. MCI subjects also showed decreased FA and decreased DA in temporal NAWM, with decreased FA and increased DR in parietal NAWM. Diffusion measurements showed no differences in occipital NAWM. Across all subjects, temporal lobe FA and DR correlated with episodic memory, frontal FA and DR correlated with executive function, and parietal DR significantly correlated with visuospatial ability.

CONCLUSIONS

We found evidence for functionally relevant microstructural changes in the NAWM of patients with AD and MCI. These changes were present in brain regions serving higher cortical functions, but not in regions serving primary functions, and are consistent with a hypothesized loss of axonal processes in the temporal lobe.

Assessment of risk and special observations in mental health practice: a comparison of forensic and non-forensic settings

The use of special observations in psychiatric practice may be employed as an alternative to more restrictive methods such as the use of seclusion and restraint. From the literature, special observations are used for a complex array of signs and symptoms (and risk behaviours) which include suicidal intent, self-injurious behaviour, hallucinatory experiences, and absconding. This paper reports on research into the use of special observations in both forensic and non-forensic psychiatric settings. A comparative approach was adopted to establish if the perceived risk factors leading to the adoption of special observations were similar in both settings. Three groups of nursing staff were requested to assess 30 patients who were placed on special observations. Before this, nurses were requested to rate the risk factors in terms of their severity on a 7-point Likert scale. The rank-ordering analysis revealed a similarity of identified risk factors and anova (one-way, unrelated) and the Jonckheere Trend Test revealed that there were significant differences between the scores in the forensic and the non-forensic settings. The statistical differences existed for risk factors relating to harm to self and others but not for psychiatric symptomatology.

The use of special observations: an audit within a psychiatric unit

Observation is a fundamental skilled nursing intervention. Special observation is an intensified and often prolonged form of this intervention. Depending upon their nature, and the circumstances under which they are carried out, special observations may invoke varying degrees of stress in both the observer and the observed. They may also raise important ethical and significant financial questions. In psychiatry, special observations are usually imposed where a patient is assessed as representing some degree of risk to themselves or others because of their behaviours or potential behaviours. Special observations vary in their degree of intrusiveness and restrictiveness, and may arouse strong emotions in the patient and staff. Patients may be denied privacy for their most intimate needs, and staff may become a focus for patients' acting-out behaviours. Special observations may be medically imposed with minimal consultation with nursing staff, and where there is no nursing and medical staff agreement on their need, nursing staff may at times feel frustrated and powerless to reduce the patients' discomfort with their situation. This paper presents a study into the use of special observations on psychiatric inpatients across a range of clinical settings. The literature on special observations is reviewed, and the findings of an audit into the documentation of special observations is presented and discussed. The study sites comprised two open acute wards, one elderly functionally mentally ill assessment unit which also treats patients with eating disorders, and a secure high dependency unit, which provides rehabilitation within a secure environment for patients with severe and enduring mental illness.

Gremlins, glomeruli and diabetic nephropathy

There have been major advances in our understanding of the pathogenetic mechanisms of diabetic nephropathy in recent years. Of particular interest is the emerging paradigm of the role that developmentally important genes may play in this process, representing recapitulation of the ontogenic process. This review examines the potential pathophysiological involvement of one such developmental gene gremlin in diabetic nephropathy.