Associations of medical comorbidity, psychosis, pain, and capacity with psychiatric hospital length of stay in geriatric inpatients with and without dementia

Dementia in-patient units in psychiatric hospitals: research priority setting

AIMS AND METHOD

Dementia in-patient units (DIU) are mental health wards that care for people living with dementia (PLWD) whose symptoms are causing severe distress or potential risk. DIUs look after some of the most vulnerable and unwell people in society, yet they are environments that are underresearched: a recent systematic review revealed only 36 articles worldwide relating to DIUs. To better understand research priorities in DIUs, we undertook a two-round online Delphi survey of PLWD with experience of DIUs, their carers and professionals who work in DIUs.

RESULTS

Ten research priorities were described and ranked. The top three were how to use non-pharmacological techniques to manage non-cognitive symptoms of dementia, supporting families and better understanding of how to discharge PLWD safely and healthily.

CLINICAL IMPLICATIONS

This is the first Delphi consensus to describe DIU research priorities. This paper will help researchers focus on the areas that matter most to people who use DIUs.

Post-Disaster Community Transition of Psychiatric Inpatients: Lessons from the Fukushima Nuclear Accident

This study sought to explore factors related to community transition after the mandatory evacuation of psychiatric inpatients to other hospitals owing to the Fukushima Daiichi Nuclear Power Plant accident. A retrospective cohort design was adopted and 391 psychiatric patients were examined. Univariate and multivariate analyses were conducted to confirm the association between the achievement or non-achievement of discharge to community living and their backgrounds (age, gender, evacuation destination, psychiatric diagnoses, and physical complications). Multivariate analysis indicated that patients with psychiatric diagnoses of schizophrenia, schizotypal, and delusional disorders (International Statistical Classification of Diseases and Related Health Problems 10th revision, F20-29), and those with physical diagnoses of the circulatory (I00-95) and digestive (K00-93) systems showed a significant association with the non-attainment of community transition. From these results, we hypothesized that difficulties in the management of medication during and immediately after the extremely chaotic settings of evacuation could have negative effects on the community transitions. Furthermore, another possible concern was that individuals' persistent psychotic status before the accident had been carried over to the destination hospitals. Therefore, pre-disaster daily cooperation across hospitals and challenges for vulnerable psychiatric patients' future community lives are also essential.

What are the information needs of people with dementia and their family caregivers when they are admitted to a mental health ward and do current ward patient information leaflets meet their needs?

INTRODUCTION

An admission to a mental health ward is an uncertain and unexpected part of a person's journey with dementia and consequently, families require information about what to expect and how to prepare. This study aimed to establish the information needs of people with dementia and their families at the point of admission to a mental health ward and to collate existing ward information leaflets to explore if they meet these information needs.

METHODS

This research was conducted in two parts: (1) a qualitative study using focus groups, one with people with dementia and family carers with lived experience of such an admission (n = 6), and another with Admiral Nurses (n = 6) to explore information needs at the point of admission. (2) Each National Health Service (NHS) mental health trust (n = 67) was asked to provide a copy of their ward information shared at admission. A total of 30 leaflets were received from 15 NHS trusts; after removing duplicates, 22 were included. A content analysis was conducted to evaluate to what extent leaflets met the information needs identified by focus groups.

RESULTS

Two main categories 'honest, accurate and up-to-date information' and 'who is the information for' and four subcategories were derived from focus group data. Participants felt that people with dementia and their families were likely to have different information needs. Material for people with dementia needed to be in an accessible format. Information should cover the aim of the admission, a timeline of what to expect and details about how families will be involved in care. Practical information about what to pack and ward facilities was valued. Participants spoke about the need to consider the tone of the information, given that people are likely to be distressed. The information leaflets reviewed did not meet the information needs identified by focus group participants.

CONCLUSIONS

People with dementia and family carers have different information needs at the point of admission to a mental health ward. Information provided to people with dementia needs to be in an accessible format with content relevant to these needs. Wards should aim to co-create information to ensure that they meet people's information needs.

PATIENT OR PUBLIC CONTRIBUTION

This research was supported by a patient and public involvement (PPI) group of people with dementia and carers who have experience in mental health wards. The idea for the study came from the group and was motivated by their experiences. The PPI group helped with the design of the study and took part in the focus groups. The information generated has been written up in this paper, and the knowledge generated has also been used to co-create a guide for wards on writing their information leaflets and to support the co-creation of a public information leaflet by Dementia UK about mental health admissions for people with dementia.

Family experiences of inpatient mental health care for people with dementia

Introduction

This study investigates family carers experiences of inpatient mental health care for people with dementia. A mental health inpatient admission for a person with dementia is usually considered when a person is distressed and this distress leads to behaviours that are assessed to be risky for the person or others.

Methods

Participants included seven family carers whose relative with dementia had been cared for within a mental health ward in the United Kingdom UK within the last 5 years. Interviews were used to explore the circumstances that led to the admission, expectations of mental health care, and perceptions of care during the admission and support received by family carers.

Results

Participants described their distress at the time of admission and how the process of admission sometimes added to their distress. Carers often felt excluded from their relatives care in hospital and many felt a loss of their rights. Participants felt that the mental health admission had a negative impact on their relative with dementia. Mental health law and legislation was difficult to navigate and carers were concerned about how much knowledge and understanding of dementia staff have.

Discussion

Findings suggest that family carers may benefit from targeted support during their relatives admission. Mental health wards could do more to recognise the expertise in care and knowledge of the person with dementia of family carers and involve them in planning care. More research is needed to explore the experiences and outcomes of people with dementia during such admissions.

The Characteristics and Outcomes of People with Dementia in Inpatient Mental Health Care: A Review

OBJECTIVES

Inpatient mental health beds for people with dementia are a limited resource. Practitioners need an understanding of this population to provide high-quality care and design services. This review examines the characteristics, care, and outcomes of people with dementia admitted to inpatient mental health services.

METHODS

Systematic searches of key databases were undertaken up to November 2021. Findings were grouped into categories and then synthesized into a narrative review.

RESULTS

The review identified 36 international papers, the majority of which were retrospective audits. The literature describes significant psychiatric and medical comorbidity and significant risk of change in residence and death associated with admission.

CONCLUSIONS

We found a limited literature describing the characteristics, care, and outcomes of people with dementia in inpatient mental health services. The lack of research is striking given the complexity and vulnerability of this client group. More research is needed to describe the needs of this group, current and best practice to optimize care.

CLINICAL IMPLICATIONS

Professionals working in inpatient mental health services need to be aware of the evidence base available, consider how they evaluate patient outcomes, review their staffing and skills mix, and seek the views of patients and relatives in improving services.

Factors for inhibition of early discharge from the psychiatric emergency ward for elderly patients

BACKGROUND

As society is aging, the number of elderly patients with psychiatric disorder, such as dementia, is increasing. The hospitalization period of elderly patients in psychiatric wards tends to be prolonged. In this study, we have determined the factors that inhibit early discharge from the psychiatric emergency ward for elderly patients in Japan.

METHODS

The information was collected from patients admitted to our hospital's emergency ward for elderly patients with psychiatric disorders between May 2015 and April 2016. We compared various factors between the early discharge group and the non-early discharge group. In addition, we used a multiple logistic regression model to clarify the risk factors for non-early discharge.

RESULTS

Of the 208 elderly patients, body mass index (BMI) and serum albumin level were significantly lower in the non-early discharge group. In addition, we also showed that higher serum C-reactive protein (CRP) (> 0.5 mg/dL) and use of seclusion or physical restraint significantly inhibited the early discharge of patients. The results of multiple logistic analysis showed that the BMI ≤ 17.5 kg/m² (OR, 2.41 [95% confidence interval (CI) 1.06-5.46]), serum albumin level ≤ 30 g/L (OR, 3.78 [95% CI 1.28-11.16]), and use of seclusion or physical restraint (OR 3.78 [95% CI 1.53-9.37]) are particularly important explanatory factors.

CONCLUSIONS

Hypoalbuminemia, low BMI, and the use of seclusion or physical restraint were identified as the factors that inhibit early discharge from the psychiatric emergency ward for elderly patients. These factors reflect malnutrition and extremely serious psychiatric symptoms.

Socio-demographic characteristics and factors associated with hospitalization in psychiatry of old age patients: an international comparison between Ireland and Turkey

BACKGROUND

Taking predictors of hospitalization characteristics into consideration internationally would broaden our understanding of this population on a local basis.

AIMS

We aimed to examine and compare socio-demographic profiles along with hospitalization characteristics including length of hospital stay (LOS), reasons for admission and diagnoses among older adult inpatients hospitalized in Ireland and Turkey, and to assess factors predicting these features.

METHODS

The admission charts of 356 psychiatric inpatients over 65 years of age who were admitted to two different acute psychiatric hospitals (Sligo/Ireland and Istanbul/Turkey) were analysed by means of descriptive modalities and logistic regression.

RESULTS

There were significant differences in several domains of socio-demographics, reasons of admission and diagnoses. LOS was significantly longer in Ireland. Living alone was the only significant predictor for longer LOS in both countries, whereas in addition to living alone, younger age was also a contributor for longer LOS in Turkey.

DISCUSSION

Given that the only factor predicting LOS both in Turkey and Ireland was living alone, helping to identify more acceptable ways of providing social support for living arrangements constitutes an important service to shorten LOS in old age psychiatric population.

CONCLUSIONS

It is possible to infer that independent from the cultural diversities, living arrangement is a consistent entity to influence length of hospital stay in older adult population.

Geographic Clustering of Admissions to Inpatient Psychiatry among Adults with Cognitive Disorders in Ontario, Canada: Does Distance to Hospital Matter?

OBJECTIVE

This study examined relationships among hospital accessibility, socio-economic context, and geographic clustering of inpatient psychiatry admissions for adults with cognitive disorders in Ontario, Canada.

METHOD

A retrospective cross-sectional analysis was conducted using admissions data from 71 hospitals with inpatient psychiatry beds in Ontario, Canada between 2011 and 2014. Data included 7,637 unique admissions for 4,550 adults with a DSM-IV diagnosis of Delirium, Dementia, Amnestic and other Cognitive Disorders. Bayesian spatial Poisson regression was employed to examine the relationship between accessibility of general hospitals with psychiatric beds and psychiatric hospitals, area-level marginalization, and hospitalization rate with the risk of admission to inpatient psychiatry among adults with cognitive disorders across 516 Forward Sortation Areas (FSA) in Ontario.

RESULTS

Residential instability and the overall hospitalization rate were significantly associated with an increase in the relative risk of admissions to inpatient psychiatry. Accessibility to general hospitals and psychiatric hospitals were marginally insignificant at the 95% credible interval in the final model. Significant geographic clustering of admissions was identified where individuals residing in FSA's with the highest relative risk were 2.0 to 7.1 times more likely to be admitted to inpatient psychiatry compared to the average.

CONCLUSIONS

Geographic clustering of inpatient psychiatry admissions for adults with cognitive disorders exists across the Province of Ontario, Canada. At the geographic level, the risk of admission was positively associated with residential instability and the overall hospitalization rate, but not distance to the closest general or psychiatric hospital.

Minimum Data Set Changes in Health, End-Stage Disease and Symptoms and Signs Scale: A Revised Measure to Predict Mortality in Nursing Home Residents

OBJECTIVES

To revise the Minimum Data Set (MDS) Changes in Health, End-stage disease and Symptoms and Signs (CHESS) scale, an MDS 2.0-based measure widely used to predict mortality in institutional settings, in response to the release of MDS 3.0.

DESIGN

Development of a predictive scale using observational data from the MDS and Medicare Master Beneficiary Summary File.

SETTING

All Centers for Medicare and Medicaid Services (CMS)-certified nursing homes in the United States.

PARTICIPANTS

Development cohort of 1.3 million Medicare beneficiaries newly admitted to a CMS-certified nursing home during 2012. Primary validation cohort of 1.2 million Medicare recipients who were newly admitted to a CMS-certified nursing home during 2013.

MEASUREMENTS

Items from the MDS 3.0 assessments identified as likely to predict mortality. Death information was obtained from the Medicare Master Beneficiary Summary File.

RESULTS

MDS-CHESS 3.0 scores ranges from 0 (most stable) to 5 (least stable). Ninety-two percent of the primary validation sample with a CHESS scale score of 5 and 15% with a CHESS scale of 0 died within 1 year. The risk of dying was 1.63 times as great (95% CI=1.628-1.638) for each unit increase in CHESS scale score. The MDS-CHESS 3.0 is also strongly related to hospitalization within 30 days and successful discharge to the community. The scale predicted death in long-stay residents at 30 days (C=0.759, 95% confidence interval (CI)=0.756-0.761), 60 days (C=0.716, 95% CI=0.714-0.718) and 1 year (C=0.655, 95% CI=0.654-0.657).

CONCLUSION

The MDS-CHESS 3.0 predicts mortality in newly admitted and long-stay nursing home populations. The additional relationship to hospitalizations and successful discharges to community increases the utility of this scale as a potential risk adjustment tool.

Health-economic outcomes in hospital patients with medical-psychiatric comorbidity: A systematic review and meta-analysis

BACKGROUND

Hospital inpatients often experience medical and psychiatric problems simultaneously. Although this implies a certain relationship between healthcare utilization and costs, this relationship has never been systematically reviewed.

OBJECTIVE

The objective is to examine the extent to which medical-psychiatric comorbidities relate to health-economic outcomes in general and in different subgroups. If the relationship is significant, this would give additional reasons to facilitate the search for targeted and effective treatments for this complex population.

METHOD

A systematic review in Embase, Medline, Psycinfo, Cochrane, Web of Science and Google Scholar was performed up to August 2016 and included cross-references from included studies. Only peer-reviewed empirical studies examining the impact of inpatient medical-psychiatric comorbidities on three health-economic outcomes (length of stay (LOS), medical costs and rehospitalizations) were included. Study design was not an exclusion criterion, there were no restrictions on publication dates and patients included had to be over 18 years. The examined populations consisted of inpatients with medical-psychiatric comorbidities and controls. The controls were inpatients without a comorbid medical or psychiatric disorder. Non-English studies were excluded.

RESULTS

From electronic literature databases, 3165 extracted articles were scrutinized on the basis of title and abstract. This resulted in a full-text review of 86 articles: 52 unique studies were included. The review showed that the presence of medical-psychiatric comorbidity was related to increased LOS, higher medical costs and more rehospitalizations. The meta-analysis revealed that patients with comorbid depression had an increased mean LOS of 4.38 days compared to patients without comorbidity (95% CI: 3.07 to 5.68, I2 = 31%).

CONCLUSIONS

Medical-psychiatric comorbidity is related to increased LOS, medical costs and rehospitalization; this is also shown for specific subgroups. This study had some limitations; namely, that the studies were very heterogenetic and, in some cases, of poor quality in terms of risk of bias. Nevertheless, the findings remain valid and justify the search for targeted and effective interventions for this complex population.

Prevalence of mild behavioral impairment in mild cognitive impairment and subjective cognitive decline, and its association with caregiver burden

BACKGROUND

Mild behavioral impairment (MBI) describes later life acquired, sustained neuropsychiatric symptoms (NPS) in cognitively normal individuals or those with mild cognitive impairment (MCI), as an at-risk state for incident cognitive decline and dementia. We developed an operational definition of MBI and tested whether the presence of MBI was related to caregiver burden in patients with subjective cognitive decline (SCD) or MCI assessed at a memory clinic.

METHODS

MBI was assessed in 282 consecutive memory clinic patients with SCD (n = 119) or MCI (n = 163) in accordance with the International Society to Advance Alzheimer's Research and Treatment - Alzheimer's Association (ISTAART-AA) research diagnostic criteria. We operationalized a definition of MBI using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Caregiver burden was assessed using the Zarit caregiver burden scale. Generalized linear regression was used to model the effect of MBI domains on caregiver burden.

RESULTS

While MBI was more prevalent in MCI (85.3%) than in SCD (76.5%), this difference was not statistically significant (p = 0.06). Prevalence estimates across MBI domains were affective dysregulation (77.8%); impulse control (64.4%); decreased motivation (51.7%); social inappropriateness (27.8%); and abnormal perception or thought content (8.7%). Affective dysregulation (p = 0.03) and decreased motivation (p=0.01) were more prevalent in MCI than SCD patients. Caregiver burden was 3.35 times higher when MBI was present after controlling for age, education, sex, and MCI (p < 0.0001).

CONCLUSIONS

MBI was common in memory clinic patients without dementia and was associated with greater caregiver burden. These data show that MBI is a common and clinically relevant syndrome.

Post-fall reporting in aged acute inpatient mental health units: an 18-month observational cohort study

BACKGROUND

Despite the high risk of falling for people with severe mental illness, there is limited falls research in mental health settings. Therefore, the objective of this observational cohort study was to conduct a focused post-fall review of fall episodes within aged acute inpatient mental health units at one of Australia's largest publicly funded mental health organizations.

METHODS

A post-fall reporting tool was developed to collect intrinsic and extrinsic fall risk factors among three aged acute mental health inpatient units over an 18-month period. Descriptive and inferential analyses were conducted to describe fall risk factors and predictors of fall risk.

RESULTS

There were a total of 115 falls, of which the tool was used for 93 (80.9%) episodes. Falls occurred most often in consumer's bedroom/bathroom and were unwitnessed. Intrinsic risk factors were most often attributed to postural drop and losing balance during walking. However, that was in contrast to consumer's who self-reported feeling dizzy as the reason of the fall.

CONCLUSIONS

Based on the cohort, future falls could be reduced by targeting those aged above 82 years, or with a diagnosis of dementia. Recurrent falls during admission could be reduced by targeting those with psychotic illness and males with a diagnosis of dementia. A clearer dialogue among consumers and clinical staff reporting about fall episodes may support future remedial interventions and inform programs to reduce fall risk and assist the challenge of describing unwitnessed falls in aged acute inpatient mental health settings.

Predictors of length of stay in psychiatry: analyses of electronic medical records

BACKGROUND

Length of stay is a straightforward measure of hospital costs and retrospective data are widely available. However, a prospective idea of a patient's length of stay would be required to predetermine hospital reimbursement per case based on patient classifications. The aim of this study was to analyse the predictive power of patient characteristics in terms of length of stay in a psychiatric hospital setting. A further aim was to use patient characteristics to predict episodes with extreme length of stay.

METHODS

The study included all inpatient episodes admitted in 2013 to a psychiatric hospital. Zero-truncated negative binomial regression was carried out to predict length of stay. Penalized maximum likelihood logistic regressions were carried out to predict episodes experiencing extreme length of stay. Independent variables were chosen on the basis of prior research and model fit was cross-validated.

RESULTS

A total of 738 inpatient episodes were included. Seven patient characteristics showed significant effects on length of stay. The strongest increasing effects were found in the presence of affective disorders as main diagnosis, followed by severity of disease and chronicity of disease. The strongest decreasing effects were found in danger to others, followed by the presence of substance-related disorders as main diagnosis, the daily requirement of somatic care and male gender. The squared correlation between out-of-sample predictions and observed values was 0.14. The root-mean-square-error was 40 days.

CONCLUSION

Prospectively defining reimbursement per case might not be feasible in mental health because length of stay cannot be predicted by patient characteristics. Per diem systems should be used.