It's not uncommon to encounter complex hospitalized medical/psychiatric patients who are also part of an aging population. The elderly can present with cognitive impairments that become a challenge to manage in a patient care unit. In an effort to address behavioral issues that can arise in a medical setting, MedStar Washington Hospital Center developed multi-disciplinary teams and protocols to better care for these patients.
Listen as Lourdes Desi Griffin, PhD, assistant vice president for medicine and psychiatry, shares best practices and lessons learned.
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Managing Med/Psych Patients in Aging Population
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Learn more about Lourdes “Desi” Griffin, PhD
Lourdes “Desi” Griffin, PhD
Lourdes “Desi” Griffin, PhD is an assistant vice president for medicine and psychiatry at Medstar Washington Hospital Center.Learn more about Lourdes “Desi” Griffin, PhD
Transcription:
Managing Med/Psych Patients in Aging Population
Melanie Cole (Host): Demographic trends globally point in the direction of increasing numbers of older people with serious and chronic mental disorders. My guest today, is Dr. Lourdes Griffin. She’s Assistant Vice President for Medicine and Psychiatry at MedStar Washington Hospital Center. Welcome to the show, Dr. Griffin. What are some of the most common mental health disorders you’re seeing in the aging population?
Dr. Lourdes Griffin (Guest): Good morning, Melanie. I am seeing an increase in the elderly population of depression, anxiety, confusion that may be linked to medication, or Alzheimer’s. As our population ages, these are becoming more prevalent in the patients that we see in our medicine locations as well as in our inpatient units.
Melanie: Some of the difficulties or complexities of managing med-psych patients in this aging population might have to do with comorbidities, Dr. Griffin. What are some of those that you see – and you mentioned medications, so blood pressure, diabetes – what are you seeing that makes it a little bit more difficult to diagnose what’s going on?
Dr. Griffin: We have to look at all aspects of the patient’s life. It may be that their medication needs to be calibrated differently for their age and span of their life. It also may be that their comorbid medical condition or their preexisting psychiatric and behavioral health issues that they may have had earlier in life continue to manifest and maybe change in their presentation, as they get older.
Our elderly patients are often times confused, they’re disoriented, and these are factors that we need to take a good look at in a healthcare setting to provide a safe environment for them to get the care that they need.
Melanie: While we’re speaking about bipolar disorder, and depression, and mental health issues in the aging population such as these, we’ve seen a growing sophistication in the treatment approaches. What are you doing with these people that will help them to manage these conditions?
Dr. Griffin: We’re beginning to look at integrated care more carefully, and the coordination of care between the behavioral health providers as well as their primary care providers in order to make sure that we’re treating the entire person. When it comes to the administration of medication and management, you need to look at their environment, their setting, what are the risks of their living situation? Are they alone? Do they have enough supervision, oversight, and assistance that they need? And also, one area that we’ve begun to pay attention to a little bit more is their substance use. A lot of the elderly population may have had substance use issues earlier in life, and these could continue to persist as they age and present a different and complicating set of factors.
Melanie: Are you seeing that some of these people had one of these mental issues as a younger person and then developed them more fully as they aged?
Dr. Griffin: More that they’ve continued, yes. Some of these are lifelong behavioral health issues that persist throughout their lifespan.
Melanie: And to help you with assessment and management, are you using neuroimaging? What are you doing to help assess the situation and the severity of it?
Dr. Griffin: Well, at the MedStar Washington Hospital Center, we have teams of trained clinicians, very good psychiatrists that are skilled in working with the elderly population, and looking at the effects of their medical treatments – their comorbidities, their medications, and how it might affect their mental status and the way that they function.
Melanie: So when we note that link between medical comorbidities and outcomes, what are you seeing as you look to assess these?
Dr. Griffin: We’re involving the support systems in the community, and looking for increased independence in the least restrictive environment as possible for these individuals.
Melanie: Does this depend on the type and number of conditions that are considered in this definition of comorbidities?
Dr. Griffin: Yes, it does, absolutely. The more conditions, the more complicated the case.
Melanie: And when medication intervention is involved, what are you looking to do when you’re trying to balance out these medications?
Dr. Griffin: I think that you need to work very closely with your specialist, whether it is that you’re working with their rheumatologist, their pulmonary specialist, whatever physicians are treating the medication condition, to make sure that the behavioral health treatment complements, does not interfere, or complicate the situation.
Melanie: Dr. Griffin, tells us about your Behavioral Emergency Response Team.
Dr. Griffin: Yes, a large number of the patients that are admitted to inpatient units in our facility, as well as in most facilities throughout the country, have a preexisting behavioral health issue or may be victims of dementia, Alzheimer’s, or some type of delirium due to their medical condition. What this does is the individuals tend to be often confused, agitated, and may not understand the reasons for being hospitalized and their care.
What we’ve set up is a behavioral response team that will work with the nurses, and the physicians and the treatment providers on the acute care units to help explain was to de-escalate, manage, and help the patient who is having a behavioral health issue. It could be the demented patient who is confused and trying to leave to walk home who gets agitated. It could be patients that are withdrawing from substances or patients with pre-existing behavioral health conditions that need extra management. Most acute care nurses have had brief treatment in behavioral health or psychiatry, but not maybe the extent of treatment that would be required.
The goal is to provide integrated, comprehensive care for the patient, both inside, as well as outside our facility, so that they are able to stabilize and live a lift that is healthy and productive for them at whatever stage of life they’re in.
Melanie: And Dr. Griffin, tell us about some of the non-pharmacological approaches that may help individuals with serious mental illness, and comorbid conditions to better self-manage – or their loved ones – their complex comorbidity, as being relevant to improving both their symptomatic and functional outcomes.
Dr. Griffin: Understanding the root of the problem is the most important one. Finding out why the patient is upset. If there’s a patient who is having an acute episode and is either agitated or confused – understanding the source of that, working with the clinical team to see what that is. And then, there are very well-trained clinicians how are able to speak with the patient, calm the patient down. There are psychiatrists that are able to work with the attending if it is not a psychiatric provider, but a provider of another medicine -- some specialty, or some surgical specialty -- to prescribe the appropriate medication for that individual.
And then, caregivers are a very important piece. These patients will be discharged from an inpatient setting and the comprehensive approach to care in an outpatient setting involving the supports that they would need, counseling for the individual, as well as for the caregivers. Caregivers need to know how to identify when a patient is becoming agitated, and to try to address the situation before it becomes an issue. The same thing on the inpatient units, we’re working with the nurses to help them begin to identify when a patient is beginning to get agitated or experience difficulties. One of the goals of working with patients who have behavioral health concerns is learning to identify when there may be an issue that is arising. We are working with the nursing staff on the units -- and also, many outpatient providers work with caregivers to begin to identify situations that might trigger a problem – that might escalate a patient’s behavior. If you can address the situation before it develops into a behavioral health crisis, it would be much easier to manage.
Again, the goals are the treatment of the entire person, integrating the medical care with the behavioral health care both on inpatient settings and outpatient settings, and working with providers, whether we’re talking about nurses on an acute care unit, or family members who take care of a patient after discharge, increased awareness that behavioral health is a part of our society. Most individuals may have a behavioral health crisis at one point in their life or another, and addressing it and treating the entire patient in a caring, and compassionate way is our goal here at the MedStar Washington Hospital Center.
Melanie: Thank you, so much, Dr. Griffin, for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center, and for more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much, for listening.
Managing Med/Psych Patients in Aging Population
Melanie Cole (Host): Demographic trends globally point in the direction of increasing numbers of older people with serious and chronic mental disorders. My guest today, is Dr. Lourdes Griffin. She’s Assistant Vice President for Medicine and Psychiatry at MedStar Washington Hospital Center. Welcome to the show, Dr. Griffin. What are some of the most common mental health disorders you’re seeing in the aging population?
Dr. Lourdes Griffin (Guest): Good morning, Melanie. I am seeing an increase in the elderly population of depression, anxiety, confusion that may be linked to medication, or Alzheimer’s. As our population ages, these are becoming more prevalent in the patients that we see in our medicine locations as well as in our inpatient units.
Melanie: Some of the difficulties or complexities of managing med-psych patients in this aging population might have to do with comorbidities, Dr. Griffin. What are some of those that you see – and you mentioned medications, so blood pressure, diabetes – what are you seeing that makes it a little bit more difficult to diagnose what’s going on?
Dr. Griffin: We have to look at all aspects of the patient’s life. It may be that their medication needs to be calibrated differently for their age and span of their life. It also may be that their comorbid medical condition or their preexisting psychiatric and behavioral health issues that they may have had earlier in life continue to manifest and maybe change in their presentation, as they get older.
Our elderly patients are often times confused, they’re disoriented, and these are factors that we need to take a good look at in a healthcare setting to provide a safe environment for them to get the care that they need.
Melanie: While we’re speaking about bipolar disorder, and depression, and mental health issues in the aging population such as these, we’ve seen a growing sophistication in the treatment approaches. What are you doing with these people that will help them to manage these conditions?
Dr. Griffin: We’re beginning to look at integrated care more carefully, and the coordination of care between the behavioral health providers as well as their primary care providers in order to make sure that we’re treating the entire person. When it comes to the administration of medication and management, you need to look at their environment, their setting, what are the risks of their living situation? Are they alone? Do they have enough supervision, oversight, and assistance that they need? And also, one area that we’ve begun to pay attention to a little bit more is their substance use. A lot of the elderly population may have had substance use issues earlier in life, and these could continue to persist as they age and present a different and complicating set of factors.
Melanie: Are you seeing that some of these people had one of these mental issues as a younger person and then developed them more fully as they aged?
Dr. Griffin: More that they’ve continued, yes. Some of these are lifelong behavioral health issues that persist throughout their lifespan.
Melanie: And to help you with assessment and management, are you using neuroimaging? What are you doing to help assess the situation and the severity of it?
Dr. Griffin: Well, at the MedStar Washington Hospital Center, we have teams of trained clinicians, very good psychiatrists that are skilled in working with the elderly population, and looking at the effects of their medical treatments – their comorbidities, their medications, and how it might affect their mental status and the way that they function.
Melanie: So when we note that link between medical comorbidities and outcomes, what are you seeing as you look to assess these?
Dr. Griffin: We’re involving the support systems in the community, and looking for increased independence in the least restrictive environment as possible for these individuals.
Melanie: Does this depend on the type and number of conditions that are considered in this definition of comorbidities?
Dr. Griffin: Yes, it does, absolutely. The more conditions, the more complicated the case.
Melanie: And when medication intervention is involved, what are you looking to do when you’re trying to balance out these medications?
Dr. Griffin: I think that you need to work very closely with your specialist, whether it is that you’re working with their rheumatologist, their pulmonary specialist, whatever physicians are treating the medication condition, to make sure that the behavioral health treatment complements, does not interfere, or complicate the situation.
Melanie: Dr. Griffin, tells us about your Behavioral Emergency Response Team.
Dr. Griffin: Yes, a large number of the patients that are admitted to inpatient units in our facility, as well as in most facilities throughout the country, have a preexisting behavioral health issue or may be victims of dementia, Alzheimer’s, or some type of delirium due to their medical condition. What this does is the individuals tend to be often confused, agitated, and may not understand the reasons for being hospitalized and their care.
What we’ve set up is a behavioral response team that will work with the nurses, and the physicians and the treatment providers on the acute care units to help explain was to de-escalate, manage, and help the patient who is having a behavioral health issue. It could be the demented patient who is confused and trying to leave to walk home who gets agitated. It could be patients that are withdrawing from substances or patients with pre-existing behavioral health conditions that need extra management. Most acute care nurses have had brief treatment in behavioral health or psychiatry, but not maybe the extent of treatment that would be required.
The goal is to provide integrated, comprehensive care for the patient, both inside, as well as outside our facility, so that they are able to stabilize and live a lift that is healthy and productive for them at whatever stage of life they’re in.
Melanie: And Dr. Griffin, tell us about some of the non-pharmacological approaches that may help individuals with serious mental illness, and comorbid conditions to better self-manage – or their loved ones – their complex comorbidity, as being relevant to improving both their symptomatic and functional outcomes.
Dr. Griffin: Understanding the root of the problem is the most important one. Finding out why the patient is upset. If there’s a patient who is having an acute episode and is either agitated or confused – understanding the source of that, working with the clinical team to see what that is. And then, there are very well-trained clinicians how are able to speak with the patient, calm the patient down. There are psychiatrists that are able to work with the attending if it is not a psychiatric provider, but a provider of another medicine -- some specialty, or some surgical specialty -- to prescribe the appropriate medication for that individual.
And then, caregivers are a very important piece. These patients will be discharged from an inpatient setting and the comprehensive approach to care in an outpatient setting involving the supports that they would need, counseling for the individual, as well as for the caregivers. Caregivers need to know how to identify when a patient is becoming agitated, and to try to address the situation before it becomes an issue. The same thing on the inpatient units, we’re working with the nurses to help them begin to identify when a patient is beginning to get agitated or experience difficulties. One of the goals of working with patients who have behavioral health concerns is learning to identify when there may be an issue that is arising. We are working with the nursing staff on the units -- and also, many outpatient providers work with caregivers to begin to identify situations that might trigger a problem – that might escalate a patient’s behavior. If you can address the situation before it develops into a behavioral health crisis, it would be much easier to manage.
Again, the goals are the treatment of the entire person, integrating the medical care with the behavioral health care both on inpatient settings and outpatient settings, and working with providers, whether we’re talking about nurses on an acute care unit, or family members who take care of a patient after discharge, increased awareness that behavioral health is a part of our society. Most individuals may have a behavioral health crisis at one point in their life or another, and addressing it and treating the entire patient in a caring, and compassionate way is our goal here at the MedStar Washington Hospital Center.
Melanie: Thank you, so much, Dr. Griffin, for being with us today. You’re listening to Medical Intel with MedStar Washington Hospital Center, and for more information, you can go to MedStarWashington.org, that’s MedStarWashington.org. This is Melanie Cole. Thanks, so much, for listening.