Most of the literature describing inpatient geriatric psychiatric treatment does not specifically examine inpatient units in private psychiatric hospitals. However, a review of what we know about inpatient geriatric psychiatry treatment will help provide a useful background for more specific diagnosis and treatment trends in the private hospital setting. Research conducted in New Zealand has shown that treatment in an acute geriatric psychiatry inpatient unit is effective and beneficial. This outcome study found that those with ‘functional disorders’ showed improvement in behaviour and symptoms, while those with ‘organic disorders’ had improvement in functional impairment, behaviour and symptoms¹. Furthermore, there are clinical advantages to having a sub-specialized geriatric psychiatry unit. A retrospective chart review revealed that the specialized geriatric psychiatry unit offered more thorough and dedicated care to their geriatric patients compared to the general psychiatry unit². This study revealed that significantly greater percentages of older inpatients treated on the geriatric psychiatry unit received ‘complete organic medical workups, structured cognitive assessment, ageing-sensitive aftercare referral, and monitoring of psychopharmacological side effects and blood levels’ than patients on a general psychiatry unit.

Physical Structure of the Inpatient Unit

The physical structure of the geriatric unit is designed to accommodate both the emotional and physical needs of the patients. These units are designed to provide a therapeutic milieu that limits restrictions on the geriatric patient. Adaptations that may not be appropriate or considered safe for a general psychiatric unit (e.g. handrails and grab bars) are made for a specialized geriatric psychiatric unit. Other adaptations include: low beds and over-bed tables, walk out showers, whirlpool tubs, enlarged signs and posters, appropriate furniture (such as seating with arms that enhances independent standing), call lights, personal alarms, non-slip and cushioned flooring, large day rooms with space to wander safely, a designated area for those who yell to limit the disruption of the rest of the unit, wheelchair and walker accessibility, bright lighting, calendars in rooms, and large clocks in rooms. These units may even have fish tanks and other visually stimulating additions. Light and pet therapy, which has been shown to improve ‘psychopathological status’ and ‘perception of quality of life’ in cognitively unimpaired elderly subjects³, may be readily available.

Sub-specialized geriatric units might offer amenities that are specific to the unique needs of geriatric patients such as large signs, colour coordination and enlarged room numbers which aid patients in confronting problems with loss of orientation⁴. Private geriatric psychiatry units may create a home-like ambiance which is associated with ‘improved intellectual and emotional well-being, enhanced social interaction, reduced agitation, reduced trespassing and exit seeking and improved functionality of older adults with dementia and other mental illnesses’⁴.

Specialized Dementia Units

Private psychiatric hospitals that do offer designated dementia units are able to address needs specific to patients with dementia. For example, such units may utilize decreased auditory and visual stimulation, which has been shown to reduce agitation and aggression levels among demented patients⁵. A number of studies support the efficacy of environmental interventions to successfully manage the prevalent behavioural complications of dementia⁴. Factors to consider include providing patients with dementia-appropriate sensory stimulation and safety measures. Sensory overstimulation may exacerbate problems with distraction, agitation, concentration and confusion⁴. Alternatively, deprivation of sensory stimulation may have negative effects on patients with dementia⁴.

Designing a separate unit for patients with dementia may also afford the opportunity to create group treatment programming that is more specific to the needs of cognitively impaired individuals. Although some hospitals may offer a distinct dementia unit for those who are cognitively intact, many units include both those with cognitive disorders and primary affective or psychotic disorders. This requires that the treatment team be versatile in addressing the needs of the unit as the population mix changes.

The Multidisciplinary Team

The inpatient geriatric psychiatry unit utilizes a multidisciplinary team that focuses on respecting the patient and their culture. This team includes the geriatric psychiatrist, the nurses, mental health workers or clinical nurse assistants, an internist preferably specialized in geriatric medicine, a clinical pharmacist, neuropsychologist, social worker, occupational and physical therapists and activity support staff. The geriatric psychiatrist is often the treatment team leader and the medical director, with administrative responsibilities that may include screening admission referrals, managing length of stay and handling personnel training and supervision. The geriatric psychiatrist initiates the appropriate neuropsychiatric work-up, including referral to subspecialists in neurology, geriatric medicine, neuropsychology, physical medicine and rehabilitation, and physical and occupational therapy. The geriatric psychiatry inpatient unit nurse must be comfortable with patients who may require total ADL (activity of daily living) care. The nurse needs to demonstrate flexible skills that enable her to assume the role of a medical nurse while providing traditional psychiatric nursing interventions, including supportive therapy for those who are cognitively intact. The neuropsychologist conducts neurocognitive testing to assist with differential diagnosis of cognitive disorders for patients referred by the geriatric psychiatrist. In addition, the neuropsychologist may assist in developing behavioural treatment recommendations, including implementation of individualized behavioural plans.

Managing Medical Co-morbidity in the Free-Standing, Private Psychiatric Hospital

Any inpatient unit in a private psychiatry hospital (and non-general medical hospital) setting is limited in the management of individuals who are severely medically compromised. Many of these units have a dedicated internal medicine specialist who is an integral member of the treatment team and will round daily and monitor individual medical issues including hydration status, treatment of co-morbid infectious disease (pneumonia, UTI, diarrhoea) and management of chronic medical issues such as diabetes and hypertension. Daily laboratory monitoring or the use of intravenous fluids or antibiotics may be required. The coordination of care with the medical team is essential to allow for a rapid and appropriate assessment of the patient with a suspected delirium. One of the most challenging aspects of this coordination of care is being able to differentiate the medical issues that can be effectively managed on-site and those that require a transfer-out to a local general medical hospital setting for diagnosis and management. In general, the development of a diagnosis of delirium in a hospitalized older adult is a medical emergency, and underlying causes need to be determined and treated in a timely manner. If the aetiology of the delirium is unknown or if there are changes in an individual’s vital signs or EKG, a referral to a general medical hospital setting is initiated for further acute medical work-up and treatment.

The Role of the Social Worker

The social worker on a geriatric psychiatry unit has an expanded, multilayered role, but primarily serves to educate families and coordinate post-discharge care with families and community referral sources. The social worker often provides supportive therapy directly to the patient or family. Focused interventions include helping families recognize and manage caregiver stress, feelings of grief related to illness in loved ones, and guilty preoccupation regarding decisions of long-term care placement. Some of the social worker’s responsibilities include: advocating for the family while planning for assisted living or nursing home placements, assisting families in arranging financial planning, and managing legal issues related to substituted decision making and guardianship. Social workers will also advocate for and coordinate hospice care after discharge when medically appropriate. The social worker must also be intimately familiar and liaise with community agencies, homecare and nursing agencies and protective services, as well as guardians and attorneys. Although the primary goal of the social worker on the geriatric psychiatry unit is to ascertain that each patient is placed at the appropriate level of care, this must be completed under increasingly time-pressured circumstances in which hospital administration goals and family wishes are often in direct conflict.

The Occupational Therapist

The occupational therapist works with patients on the unit to continuously assess physical and cognitive needs. The occupational therapist examines gait, mobility, motor skills, use of adaptive equipment, and independence with activities of daily living (ADLs), including transfers. These assessments are performed throughout the hospitalization, as medications and inactivity may adversely affect gait. Functional independence may be assessed with the structured Occupational Therapy Evaluation of Performance and Support (OTEPS)⁶ or the Kohlman Evaluation of Living Skills (KELS)⁷, which evaluate mobility, self-care, instrumental ADLs, safety, medication management, financial management, and meal planning and preparation. The occupational therapist functional assessment assists in providing an appropriate disposition for the patients based on their level of function. Furthermore, the occupational therapist will try to create an atmosphere on the inpatient unit that permits inclusiveness of all patients, adjusted for their cognitive level.

The Clinical Neuropsychologist