Pathways to community living in practice: Local development and adaptation within an older peoples mental health service.

OBJECTIVE: To describe the local adaptation of the Pathways to Community Living (PCLI) program in an Older Peoples Mental Health (OPMH) service to guide other services. METHOD: A retrospective observational study was conducted. Data were obtained from service planning meetings and newly developed documents, Clinical Advisory Committee meetings, and OPMH PCLI database. RESULTS: The PCLI program was adapted for the local OPMH service through development of an assessment template, creating a Memorandum of Understanding with a partner Residential Aged Care Facility (RACF) and establishing processes for collaboration and regular review. Between 2019 and March 2023, 20 mental health consumers were referred to the OPMH PCLI program. Their demographic and clinical characteristics are described. CONCLUSIONS: Adaptation of the PCLI program for OPMH consumers required consideration of specific older adult needs to develop a bespoke plan for assessment and partnership with the PCLI-funded RACF. The development phase and ongoing processes for review facilitated engagement of key stakeholders across health and RACF sectors, highlighting issues with consumer engagement. Similar models could be used by other health services to implement the PCLI in their local context.

Falling into an identity crisis: Integrating identity into the assessment and management of falls in older adults.

OBJECTIVES: This article examines the psychological effects of falls for older adults through the lens of identity and suggests these may be integrated in the assessment and management of older patients within acute care and rehabilitation settings post-fall. An illustrative vignette is described to demonstrate this approach. CONCLUSION: Falls in older adults are complex phenomena which can lead to an identity threat, sometimes manifest as psychological symptoms and poor engagement in post-fall rehabilitation. A psychiatric formulation which incorporates an older person's self-identity and agency may inform interventions to address psychological and behavioural sequelae of falls.

A systematic review of evidence-based aftercare for older adults following self-harm.

OBJECTIVE: Self-harm is closely associated with suicide in older adults and may provide opportunity to intervene to prevent suicide. This study aimed to systematically review recent evidence for three components of aftercare for older adults: (1) referral pathways, (2) assessment tools and safety planning approaches and (3) engagement and intervention strategies. METHODS: Databases PubMed, Medline, PsychINFO, Embase and CINAHL were searched from January 2010 to 10 July 2021 by two reviewers. Empirical studies reporting aftercare interventions for older adults (aged 60+) following self-harm (including with suicidal intent) were included. Full text of articles with abstracts meeting inclusion criteria were obtained and independently reviewed by three authors to determine final studies for review. Two reviewers extracted data and assessed level of evidence (Oxford) and quality ratings (Alberta Heritage Foundation for Medical Research Standard Quality Assessment Criteria for quantitative and Attree and Milton checklist for qualitative studies), working independently. RESULTS: Twenty studies were reviewed (15 quantitative; 5 qualitative). Levels of evidence were low (3, 4), and quality ratings of quantitative studies variable, although qualitative studies rated highly. Most studies of referral pathways were observational and demonstrated marked variation with no clear guidelines or imperatives for community psychiatric follow-up. Of four screening tools evaluated, three were suicide-specific and one screened for depression. An evidence-informed approach to safety planning was described using cases. Strategies for aftercare engagement and intervention included two multifaceted approaches, psychotherapy and qualitative insights from older people who self-harmed, carers and clinicians. The qualitative studies identified targets for improved aftercare engagement, focused on individual context, experiences and needs. CONCLUSION: Dedicated older-adult aftercare interventions with a multifaceted, assertive follow-up approach accompanied by systemic change show promise but require further evaluation. Research is needed to explore the utility of needs assessment compared to screening and evaluate efficacy of safety planning and psychotherapeutic approaches.

Managing hoarding and squalor.

Hoarding and squalor are complex conditions with a range of physical and mental comorbidities GPs play a key role in identifying people who experience these conditions, screening for safety risks, referral to specialist services and encouraging people to accept treatment and ongoing monitoring. Treatment for contributing and comorbid conditions should be optimised, with the help of specialist services when required. Medicines should be reviewed and adherence confirmed For moderate to severe hoarding and squalor, referral to specialist psychiatry, geriatrics and allied health services is recommended for thorough assessment, treatment of underlying conditions and ongoing management.

A pilot study examining the profile of older people on clozapine.

OBJECTIVE:: The primary aim was to comprehensively describe the characteristics of a cohort of older people taking clozapine. METHOD:: Participants aged ⩾ 60 had a geriatric assessment including full medical, medication and social history. Standardized screening tools for cognition, function, comorbidity and antipsychotic side effects were administered and descriptive statistics utilized. RESULTS:: Thirteen patients were eligible to participate and 10 were assessed. The mean age was 69 years. The mean clozapine dose was 309 mg/day and mean duration of use was 10 years. All participants had executive dysfunction, and half had cognitive impairment. The mean number of co-morbid conditions was five. Seven people met the criteria for polypharmacy. Eight people experienced moderate-severe antipsychotic-related side-effects. The majority demonstrated impaired physical functioning. CONCLUSIONS:: This cohort of older people taking clozapine experienced considerable morbidity, functional and cognitive impairment. We suggest routine screening of cognition and function in clozapine patients aged ⩾ 60 years. Those screening positive should be considered for further assessment by Older Person's Mental Health Services and/or a Geriatric Medicine service.

How do general practitioners conceptualise self-harm in their older patients? A qualitative study

Background and objectives: Little is known about how general practitioners (GPs) conceptualise self-harm in older people. The aim of this study was to explore GPs' understanding of the reasons for recent self-harm in an older patient. Method: Short questionnaires were sent to the GPs of patients aged 80 years or older who had recently self-harmed and were participants in a qualitative study about self-harm. Questions evaluated GPs' understanding of the self-harm. Thematic analysis was used to identify and analyse themes. Results: Thirteen GP responses were analysed. GPs could identify multiple factors contributing to self-harm in their patients but did not see a role for themselves in addressing these issues. They feared repetition of self-harm if these underlying contributory factors, including depression, did not change. Discussion: Targeted education and practical options for GPs regarding management of the issues underlying self-harm in older people are needed. Families and carers may be underused allies in management. These strategies may serve to counter therapeutic nihilism and clinician isolation.

Development of an operational manual for a consultation-liaison psychiatry service.

OBJECTIVES: Consultation-liaison psychiatry (CLP) services sit between mental health and the general hospital, and risk being poorly understood by both systems. The aim of this study was to develop an operational manual for a CLP service, which defined functions and governance. METHODS: The CLP literature was reviewed with a focus on descriptions of CLP roles, organisational processes, quality measures and service development. The CLP team held service planning meetings and met with members of the mental health and hospital executives. Site visits and collaboration with other CLP services occurred in defining the roles of the CLP service and organisational governance. RESULTS: A CLP operational document was developed, including a description of the service, its functions, staff roles and governance. Procedural information such as the CLP timetable, referral process, triage and assessment, documentation, activity recording, quality assurance and relevant policies were outlined. CONCLUSIONS: The development of a dedicated operational manual for CLP clarified the roles, functions and governance of CLP within the general hospital and mental health systems. The development process facilitated the engagement of key clinicians and administrators of these systems, the determination of quality improvement targets and greater transparency and accountability.

Self-amputation of the hand: issues in diagnosis and general hospital management.

OBJECTIVES: To detail a diagnostic dilemma of intentional hand amputation in a man with a history of substance misuse and associated psychosis, depression and traumatic brain injury and to highlight issues in joint psychiatric and surgical management of such a complex patient in a general hospital setting. CONCLUSIONS: Deliberate limb self-amputation is a rare event with the majority of reported cases occurring during an episode of psychosis. This case illustrates the diagnostic utility of the literature supporting that a person who has self-inflicted amputation of a limb should be treated as psychotic until proven otherwise. The presence of a traumatic brain injury, with associated cognitive and psychosocial sequelae, affected diagnosis and management. Early and ongoing involvement of consultation-liaison psychiatry collaborating with a multidisciplinary general hospital team may improve mental and physical health outcomes for such patients.

Identification and rates of delirium in elderly medical inpatients from diverse language groups.

A linguistically diverse cohort of 126 medical inpatients 65 y and over was recruited to determine rates of delirium after admission, associated outcomes, and staff detection of delirium. A clinical interview and cognitive and functional questionnaires were completed with the patient and their carer, and files were reviewed. The incidence of delirium at comprehensive assessment early after admission was 10.3% and the overall incidence 19.1% over the whole admission. Cognitive impairment was common (n = 80, 63.5%), including 61 patients (48.4%) who had dementia. Most patients (83%) with delirium had dementia. Staff recognized less than 21% of patients with delirium, 33% of patients with dementia, and 36% of cognitively impaired patients. There was no difference in outcomes between English and non-English speaking patients. Given the high prevalence and poor recognition of cognitive disorders in older people, routine cognitive screening should occur. Staff education should focus upon improving delirium detection and addressing the needs of cognitively impaired older inpatients.