Psych Services Benefit Emergency Departments

TUCSON, ARIZ. – Dementia may be overdiagnosed and delirium overlooked when geriatric patients with vague symptoms are brought to emergency departments, Dr. Lesley Wiesenfeld suggested at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Wiesenfeld reviewed the first 22 patients screened by a small pilot program in which she provided a geriatric psychiatry consultation liaison service to emergency department physicians at Mt. Sinai Hospital in Toronto.

As a result of the consultations, she reported, patients were more likely to be admitted for medical reasons or discharged home. They were less likely to be placed in a psychiatric unit or discharged to long-term care.

“Emergency department doctors were disproportionately assuming cognitive problems in people who had medical and psychiatric problems and delirium,” Dr. Wiesenfeld, a staff psychiatrist and geriatric training program coordinator at the University of Toronto-affiliated hospital, said in a poster-side interview.

Most psychiatric departments offer consultation liaison services after patients are admitted to a hospital, according to Dr. Wiesenfeld.

The pilot program enabled emergency department physicians to seek help in evaluating whether difficult geriatric patients should be admitted.

Dr. Wiesenfeld described the population, which ranged from 66 to 95 years of age, as “quite a mix.” Some were depressed or had mental problems. Many “just seemed different and their family didn't know what to do with them, so they called 911 or brought them in.”

For emergency physicians, just taking a history could be difficult when patients had poor memories and did not know their medications. “They didn't look well, but they didn't look sick enough for admission to the hospital,” Dr. Wiesenfeld said. “[The emergency physicians] were in a kind of limbo about what they should do.”

Behavioral change was the most common reason for referrals to the service, cited by the emergency physicians in eight patients. Other reasons were delirium or dementia (six patients), safe to go home vs. emergency nursing home placement (five), and physical symptoms (three).

The final psychiatric diagnoses reported by Dr. Wiesenfeld were dementia/cognitive disorder (six patients), delirium (five), major mood disorder/episode (four), no disorder (four), and major psychotic disorder (three).

The emergency physicians anticipated that 10 patients would be admitted as psychiatric cases, 7 discharged to long-term care, 4 sent home, and 1 admitted to a medical unit. After the psychogeriatric consultations, the actual disposition was that eight patients went home with a prescription and/or outpatient appointment, seven were admitted for medical reasons, and five were admitted to the psychiatric service.

Only two were sent to long-term care.

Among the case descriptions posted by Dr. Wiesenfeld was a 75-year-old homeless man, presumed psychotic, who was found to have fever and delirium from a urinary tract infection for which he was admitted. Instead of being discharged to a nursing home, a developmentally delayed 66-year-old man was diagnosed with normal pressure hydrocephalus and referred to neurosurgery.

Dr. Wiesenfeld concluded that since the referrals doubled from 7 in the first year to 15 in the second year, this indicates that physicians found value in the service, even though it increased the length of time these patients spent in the emergency department.

Probable next steps, she said, will be more training to help the emergency staff distinguish dementia from delirium and better integration of social workers and psychiatrists into a psychogeriatric team. Also under consideration, she reported, is development of a geriatric crisis clinic.

TUCSON, ARIZ. – Dementia may be overdiagnosed and delirium overlooked when geriatric patients with vague symptoms are brought to emergency departments, Dr. Lesley Wiesenfeld suggested at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Wiesenfeld reviewed the first 22 patients screened by a small pilot program in which she provided a geriatric psychiatry consultation liaison service to emergency department physicians at Mt. Sinai Hospital in Toronto.

As a result of the consultations, she reported, patients were more likely to be admitted for medical reasons or discharged home. They were less likely to be placed in a psychiatric unit or discharged to long-term care.

“Emergency department doctors were disproportionately assuming cognitive problems in people who had medical and psychiatric problems and delirium,” Dr. Wiesenfeld, a staff psychiatrist and geriatric training program coordinator at the University of Toronto-affiliated hospital, said in a poster-side interview.

Most psychiatric departments offer consultation liaison services after patients are admitted to a hospital, according to Dr. Wiesenfeld.

The pilot program enabled emergency department physicians to seek help in evaluating whether difficult geriatric patients should be admitted.

Dr. Wiesenfeld described the population, which ranged from 66 to 95 years of age, as “quite a mix.” Some were depressed or had mental problems. Many “just seemed different and their family didn't know what to do with them, so they called 911 or brought them in.”

For emergency physicians, just taking a history could be difficult when patients had poor memories and did not know their medications. “They didn't look well, but they didn't look sick enough for admission to the hospital,” Dr. Wiesenfeld said. “[The emergency physicians] were in a kind of limbo about what they should do.”

Behavioral change was the most common reason for referrals to the service, cited by the emergency physicians in eight patients. Other reasons were delirium or dementia (six patients), safe to go home vs. emergency nursing home placement (five), and physical symptoms (three).

The final psychiatric diagnoses reported by Dr. Wiesenfeld were dementia/cognitive disorder (six patients), delirium (five), major mood disorder/episode (four), no disorder (four), and major psychotic disorder (three).

The emergency physicians anticipated that 10 patients would be admitted as psychiatric cases, 7 discharged to long-term care, 4 sent home, and 1 admitted to a medical unit. After the psychogeriatric consultations, the actual disposition was that eight patients went home with a prescription and/or outpatient appointment, seven were admitted for medical reasons, and five were admitted to the psychiatric service.

Only two were sent to long-term care.

Among the case descriptions posted by Dr. Wiesenfeld was a 75-year-old homeless man, presumed psychotic, who was found to have fever and delirium from a urinary tract infection for which he was admitted. Instead of being discharged to a nursing home, a developmentally delayed 66-year-old man was diagnosed with normal pressure hydrocephalus and referred to neurosurgery.

Dr. Wiesenfeld concluded that since the referrals doubled from 7 in the first year to 15 in the second year, this indicates that physicians found value in the service, even though it increased the length of time these patients spent in the emergency department.

Probable next steps, she said, will be more training to help the emergency staff distinguish dementia from delirium and better integration of social workers and psychiatrists into a psychogeriatric team. Also under consideration, she reported, is development of a geriatric crisis clinic.

TUCSON, ARIZ. – Dementia may be overdiagnosed and delirium overlooked when geriatric patients with vague symptoms are brought to emergency departments, Dr. Lesley Wiesenfeld suggested at the annual meeting of the Academy of Psychosomatic Medicine.

Dr. Wiesenfeld reviewed the first 22 patients screened by a small pilot program in which she provided a geriatric psychiatry consultation liaison service to emergency department physicians at Mt. Sinai Hospital in Toronto.

As a result of the consultations, she reported, patients were more likely to be admitted for medical reasons or discharged home. They were less likely to be placed in a psychiatric unit or discharged to long-term care.

“Emergency department doctors were disproportionately assuming cognitive problems in people who had medical and psychiatric problems and delirium,” Dr. Wiesenfeld, a staff psychiatrist and geriatric training program coordinator at the University of Toronto-affiliated hospital, said in a poster-side interview.

Most psychiatric departments offer consultation liaison services after patients are admitted to a hospital, according to Dr. Wiesenfeld.

The pilot program enabled emergency department physicians to seek help in evaluating whether difficult geriatric patients should be admitted.

Dr. Wiesenfeld described the population, which ranged from 66 to 95 years of age, as “quite a mix.” Some were depressed or had mental problems. Many “just seemed different and their family didn't know what to do with them, so they called 911 or brought them in.”

For emergency physicians, just taking a history could be difficult when patients had poor memories and did not know their medications. “They didn't look well, but they didn't look sick enough for admission to the hospital,” Dr. Wiesenfeld said. “[The emergency physicians] were in a kind of limbo about what they should do.”

Behavioral change was the most common reason for referrals to the service, cited by the emergency physicians in eight patients. Other reasons were delirium or dementia (six patients), safe to go home vs. emergency nursing home placement (five), and physical symptoms (three).

The final psychiatric diagnoses reported by Dr. Wiesenfeld were dementia/cognitive disorder (six patients), delirium (five), major mood disorder/episode (four), no disorder (four), and major psychotic disorder (three).

The emergency physicians anticipated that 10 patients would be admitted as psychiatric cases, 7 discharged to long-term care, 4 sent home, and 1 admitted to a medical unit. After the psychogeriatric consultations, the actual disposition was that eight patients went home with a prescription and/or outpatient appointment, seven were admitted for medical reasons, and five were admitted to the psychiatric service.

Only two were sent to long-term care.

Among the case descriptions posted by Dr. Wiesenfeld was a 75-year-old homeless man, presumed psychotic, who was found to have fever and delirium from a urinary tract infection for which he was admitted. Instead of being discharged to a nursing home, a developmentally delayed 66-year-old man was diagnosed with normal pressure hydrocephalus and referred to neurosurgery.

Dr. Wiesenfeld concluded that since the referrals doubled from 7 in the first year to 15 in the second year, this indicates that physicians found value in the service, even though it increased the length of time these patients spent in the emergency department.

Probable next steps, she said, will be more training to help the emergency staff distinguish dementia from delirium and better integration of social workers and psychiatrists into a psychogeriatric team. Also under consideration, she reported, is development of a geriatric crisis clinic.