'Auspicious liaisons'-evaluating the impact of a liaison geriatrician initiative on older adults psychiatric wards.

BACKGROUND: Although liaison services in acute hospitals are now the norm, the reverse is not usually available for patients in mental health trusts. Following the introduction of support from geriatricians to older people's mental health inpatient wards, we wanted to see if this intervention was effective and acceptable to clinicians. METHODS: We performed a retrospective cohort service evaluation on the impact of a liaison geriatrician, using routinely collected data, and assessed acceptability among medical staff by semi-structured interview. INTERVENTION: Our service introduced regular sessions from consultant community geriatricians across older adults psychiatric wards including a mixture of video conference and face-to-face input. RESULTS: There was no significant decrease in emergency transfers but there was a significant reduction in length of stay with an associated cost benefit for the service after the introduction of a liaison geriatrician. There was a significant increase in geriatrician consultations and a decrease in specialty consultations to other specialists. There was no change in discharge prescriptions or destination. There was a significant reduction in falls in the intervention arm but not in falls leading to emergency hospital admissions geriatricians gave confidence to psychiatrists of all grades to treat physical health care issues. CONCLUSIONS: A liaison geriatrician service may be a component in reducing length of stay (although there are many others) and improving continuity of care, although it confers no impact on emergency transfers. The intervention was highly acceptable to clinicians.

Case report: delayed response after electroconvulsive therapy in a patient with major depressive disorder.

BACKGROUND: Major depressive disorder and associated mood syndromes are amongst the most common psychiatric disorders. To date, electroconvulsive therapy (ECT) is considered the most effective short-term treatment for patients with severe or treatment-resistant depression. In clinical practice, there is considerable variation in the ECT dosing schedule, with the number of sessions typically ranging from 6 to 12, with early antidepressant effects being predictive of increased positive outcomes. We describe here an unusual case of a female patient with severe depression who did not respond to ECT until the 11th session, after which she had shown a drastic improvement in her mental state. CASE PRESENTATION: A 75-year-old female presented to the old age psychiatry inpatient unit with new onset dysphoric mood, anhedonia, and severe negativity. She scored 23 on the 17-item Hamilton Rating Scale for Depression (HAM-D), and was rated 6 on Clinical Global Impression severity (CGIS) by the responsible clinician. She suffered from post-natal depression fifty years ago and was successfully treated with ECT. She was therefore initiated on a course of ECT treatment. Her condition initially deteriorated, displaying features of catatonia and psychosis, unresponsive to ECT treatment or concurrent psychotropic medications. After 11th ECT session, she started to show signs of clinical improvement and returned close to her baseline mental state after a total of 17 ECT sessions. She remained well 3 months post-treatment, scoring 4 on HAM-D, Clinical Global Improvement or change (CGI-C) rated as 1 (very much improved). The diagnosis was ICD-10 F32.3 severe depressive episode with psychotic symptoms. CONCLUSIONS: we describe here an unusual case of delayed response to electroconvulsive therapy in the treatment of severe depressive disorder. Studies have shown the number of acute ECT treatments to be highly variable, affected by a number of factors including treatment frequency, condition treated and its severity, the ECT technical parameters, as well as concurrent use of pharmacological treatment. This may call for re-consideration of the current ECT treatment guidelines, requiring more research to help stratify and standardize the treatment regime.

Improving Conversations about Parkinson's Dementia.

BACKGROUND: People with Parkinson's disease (PD) have an increased risk of dementia, yet patients and clinicians frequently avoid talking about it due to associated stigma, and the perception that "nothing can be done about it". However, open conversations about PD dementia may allow people with the condition to access treatment and support, and may increase participation in research aimed at understanding PD dementia. OBJECTIVES: To co-produce information resources for patients and healthcare professionals to improve conversations about PD dementia. METHODS: We worked with people with PD, engagement experts, artists, and a PD charity to open up these conversations. 34 participants (16 PD; 6 PD dementia; 1 Parkinsonism, 11 caregivers) attended creative workshops to examine fears about PD dementia and develop information resources. 25 PD experts contributed to the resources. RESULTS: While most people with PD (70%) and caregivers (81%) shared worries about cognitive changes prior to the workshops, only 38% and 30%, respectively, had raised these concerns with a healthcare professional. 91% of people with PD and 73% of caregivers agreed that PD clinicians should ask about cognitive changes routinely through direct questions and perform cognitive tests at clinic appointments. We used insights from the creative workshops, and input from a network of PD experts to co-develop two open-access resources: one for people with PD and their families, and one for healthcare professionals. CONCLUSION: Using artistic and creative workshops, co-learning and striving for diverse voices, we co-produced relevant resources for a wider audience to improve conversations about PD dementia.

Managing the overlap between mental and physical health.

The interface between the Mental Capacity Act 2005 and the Mental Health Act 1983 can be complex, particularly in patients with co-existing mental and physical illnesses. The management of these patients requires the involvement of patients, relatives and multidisciplinary teams. This article presents four illustrative patient cases, all of whom suffered from co-existing mental and physical illnesses. In managing these cases, dilemmas had arisen in the provision of treatment encompassing both legal frameworks. These cases helped to emphasise the decision-specific and time-specific nature of assessment of mental capacity, requiring clinicians to assess on a case-by-case basis over a suitable period. Often, principles from both legal frameworks may be applied by the treatment team. These cases help to highlight the significant overlap between mental and physical health, which often cannot be managed independently. This may call for the need to better integrate the current legal frameworks, and the optimal involvement of specialists across both settings.