LIAISON PSYCHIATRY FOR OLDER PEOPLE Fiona Thompson Consultant Psychiatrist Addenbrookes Hospital

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Developmental History

• US LP mid 18th Century • UK after WW2 • 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

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Increasing evidence of impact of mental health on physical health and wider health economy

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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

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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 BGS S

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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 BGS S

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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

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RAID economic evaluation – a no brainer? Combination intervention groups

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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

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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

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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

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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

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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.

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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

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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

Emotions, behaviours and physiological changes

“99%perfect is not good enough”

“The world should be a safe place”

“Bad things happen to bad people”

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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.

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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”

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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

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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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