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Erith Community Mental Health Team, Oxleas Foundation Trust
St Martin’s Hospital, Canterbury
South London and Maudsley NHS Trust, Ladywell House, 330 Lewisham High Street, London SE13 6JZ, email: stephen.burton{at}slam.nhs.uk
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Introduction |
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 Top Introduction MethodResultsDiscussionReferences |
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The Lewisham Old Age Consultation and Liaison (LOACaL) psychiatry service was set up in November 2003 to serve four care of the elderly wards at University Hospital Lewisham. Elderly medical in-patients were seen prior to this as part of an ‘in-reach’ sector team-based service provided by two old age CMHTs. The new service comprised a consultant psychiatrist (5 sessions), a staff grade doctor (10 sessions), a psychologist (3 sessions) and a nurse (3 sessions). There are 124 care of the elderly beds out of a total of 550 at University Hospital Lewisham. In 2004-2005 there were 56 300 admissions to the hospital as a whole and the average length of stay on a care of the elderly ward at that time was 2 weeks.
Mujic et al (2004) found that capacity assessments represented a fifth of the workload of an old age liaison service. In an attempt to reduce the number of inappropriate referrals for simple capacity assessments, the new service’s referral form had guidelines for assessing capacity printed on the back.
The aims of this study were: to determine the quantity and type of referrals to the new old age liaison psychiatry service; to assess the quality of the referral information provided by the care of the elderly teams and their response to the recommendations made by the liaison team; to assess the response time of the liaison service and the outcomes of the patients seen; to assess the adequacy of the new service’s referral form and record the number of capacity referrals.
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Method |
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TopIntroductionMethodResultsDiscussionReferences |
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The second phase of the study was conducted prospectively and collected data on patients referred in the first year of the new LOACaL service (November 2003 to October 2004). At the inception of the new service a new referral form required the referrer to provide more clinical information, in particular relating to the patient’s capacity and consent to psychiatric referral and included a number of ‘tick boxes’ to obtain clinical information more systematically. This information was recorded in addition to phase 1 information. For both phases of the study all available clinical records were then examined from both the Mental Health of Older Adults Service and University Hospital Lewisham. Information was collected from both sets of clinical notes about diagnosis and outcome (discharge destination, onward referral to the CMHT and death). Phase 1 acted as a comparator with which the performance of the new service could be compared in the second phase of the study. Data were analysed using SPSS, version 12 for Windows.
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Results |
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TopIntroductionMethodResultsDiscussionReferences |
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Demographics
Age and gender were not significantly different between the two phases of
the study, with the ratio of female:male being 65:35 for phase 1 and 62.5:37.5
for phase 2. Mean age at referral was 84.25 (s.d.=63) years for phase 1 and
82.1 (s.d.=7.1) years for phase 2. The ethnicity profile
(Table 1) reflects that of the
hospital’s catchment area.
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Referral form
There was an improvement in the completion of some of the sections of the
referral form (Table 2):
demographic information, a named relative and provisional psychiatric
diagnosis. However, there was a reduction in the completion of others parts of
the form: purpose of the referral made clear, reason for medical admission and
past psychiatric history. The number of urgent referrals fell from 29.2 to
8.3% (Pearson 
2 P<0.001).
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Response of teams
The delay of the Mental Health of Older Adults team in seeing patients
(Table 1) was significantly
reduced from a median of 4.5 days (range 0-77) in phase 1 to 1 day (range 0-7)
in phase 2 (Mann-Whitney U-test P<0.001). In addition,
patients were seen on significantly more occasions: a median of 4 times (range
1-17) in phase 2 v. once (range 1-4) in phase 1 (Mann-Whitney
U-test P<0.001). More investigations were recommended in
phase 2 (26%) than in phase 1 (4.8%); and more medication (76 v. 47%)
but less psychological management was recommended (17.4 v. 19%) in
phase 1.
There was an improvement in completing the liaison service’s recommendations by the care of the elderly teams. For example, two-thirds of medical investigations recommended were acted upon in phase 1 compared with all in phase 2. However, the care of the elderly teams did not communicate information concerning patients’ discharges or deaths to the liaison team.
Diagnoses
Dementia, delirium and depression were the three most common psychiatric
diagnoses accounting for 81% of all diagnoses in phase 1 and 87% in phase 2.
More people were diagnosed with depression in phase 2 (23.9%) compared with
phase 1 (11.1%). The mean number of medical diagnoses at discharge in phase 1
was 3.2 and 2.2 in phase 2. The most common medical diagnostic categories were
cardiovascular disorders, infections, falls and cognitive impairment. There
was little or no reference to psychiatric diagnoses in medical discharge
letters.
Outcomes
Fewer people were referred on for CMHT follow-up in phase 2 (22%) than in
phase 1 (33%). More patients died who were assessed in phase 2 (27%) than
phase 1 (15.4%), but this was not statistically significant. In phase 2 29% of
referrals needed a psychogeriatric admission. Patients were discharged on a
variety of medications, with a mean of 5.5 drugs in phase 1 and 6.2 drugs in
phase 2.
Consent and capacity
Referrals for capacity assessments fell from 22.9% in 2003 to 6.2% in 2004.
A place to record the patient’s consent to referral was not available in
the phase 1 referral form but was in phase 2; however, only 27% of referral
forms in phase 2 recorded that the patient had consented to seeing a
psychiatrist. There were 42% of referrals documented to have capacity to
consent, and 13% recorded as lacking capacity, but, in 45% of cases, this
section of the referral form was left
blank.
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Discussion |
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TopIntroductionMethodResultsDiscussionReferences |
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The argument for specialist liaison input is strong but, despite this, 73% of services in the UK are provided according to a traditional sector-based model (Holmes et al, 2003).
In keeping with previous work (Scott et al, 1988; De Leo et al, 1989), the 3 ‘D’s (dementia, delirium and depression) of old age psychiatry represented the main diagnoses. However, referral rates in this population still did not reflect the prevalence rates of cognitive impairment (6-25%) and depression (33-66%) found in other studies (Goring et al, 2004). The new service diagnosed more people with depression and fewer with dementia. This change is interesting and reflects the difficulties of diagnosis in this population and highlights the issue of diagnostic overshadowing.
The introduction of a new referral form which requested more discrete items of clinical information (tick boxes) produced mixed results. There was less information gathered about the reason for referral, and the service has now revised the form to remedy this. However, a new ‘1-2 days’ category on the referral form may have contributed, along with increased confidence in a prompt assessment, to the reduction in urgent (<24 h) referrals. Including guidelines for assessing capacity on the form appeared to reduce referrals for this specific reason to 6%. However, this is an area the care of the elderly teams appeared to have difficulty with, as reflected by the poor documentation of consent/capacity on the referral forms. Finally, there may have been many reasons for the absence of records regarding informing the liaison team about patients’ discharge or death.
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References |
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TopIntroductionMethodResultsDiscussionReferences |
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GORING, H., BALDWIN, R., MARRIOTT, A., et al (2004) Validation of short screening tests for depression and cognitive impairment in older medically ill inpatients. International Journal of Geriatric Psychiatry, 19, 465 -471.[CrossRef][Medline]
HOLMES, J., BENTLEY, K. & CAMERON, I. (2003) A UK survey of psychiatric services for older people in general hospital. International Journal of Geriatric Psychiatry, 18, 716 -721.[CrossRef][Medline]
LIPOWSKI, Z. J. (1983) The need to integrate liaison
psychiatry and geropsychiatry. American Journal of
Psychiatry, 140, 1003
-1005.
MUJIC, F., HANLON, C., SULLIVAN, D., et al.
(2004) Comparison of liaison psychiatry service models for older
patients. Psychiatric Bulletin,
28, 171
-173.
SCOTT, J., FAIRBAIRN, A. & WOODHOUSE, K. (1988) Referrals to a psychogeriatric consultation-liaison service. International Journal of Geriatric Psychiatry, 3, 131-135.[CrossRef]
This article has been cited by other articles:
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  D. Anderson, H. Cattell, and E. Bentley Nurse-led liaison psychiatry service for older adults: service evaluation Psychiatr. Bull., August 1, 2008; 32(8): 298 - 302. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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