RECOMMENDATIONS AND INTERVENTIONS
The written report of a consultation focuses on data pertinent to the case and should be concise and easily understood by nonpsychiatric colleagues. The report can be in the form of a problem list that includes the questions asked, the major psychiatric syndromes detected along with a differential diagnosis, recommendations for further diagnostic evaluation, and suggestions for management, disposition, and follow-up. Recommendations should be specific (eg, specific drug doses and possible side effects) and should clearly state who will be responsible for the proposed interventions. Whenever possible, the consultant should provide answers to the questions asked, and other important issues and unstated questions should be addressed as well.
Direct communication with the referring physician, other team members, the patient, and family members is often as important as the written report. This interaction can clarify any remaining questions about the purpose of the consultation or the consultant’s recommendations and can improve compliance with proposed treatment.
The consulting psychiatrist may recommend and coordinate additional diagnostic evaluations to sort out a complicated differential diagnosis or to rule out organic causes of psychiatric symptoms. For example, agitation can result from underlying medical problems such as hypoxia, withdrawal states, and pain.
If psychoactive medications are warranted, a geriatric psychiatrist often can help with the complex task of properly prescribing these medications in the medically ill elderly. Altered pharmacokinetics in the elderly can be exaggerated by medical illness, which can further reduce lean body mass and renal or hepatic clearance, thus affecting drug dosing (see Ch. 21 and Pharmacotherapy in Ch. 94). The psychiatrist can help the referring physician follow target symptoms, monitor the patient for emergence of side effects, and recommend drug and dosage adjustments.
The psychiatrist may call attention to drugs that can cause or worsen psychiatric problems or have undesirable interactions with psychoactive medications. Of the 25 drugs most commonly prescribed for the elderly, 10 have anticholinergic side effects that could impair memory and attention span even in normal persons. Patients with organic mental syndromes may be particularly susceptible to cognitive impairment from benzodiazepines and anticholinergic drugs or to the extrapyramidal side effects of antipsychotics. A primary care physician has to weigh medical necessity against the probability that a drug may be affecting mental status.
As part of the consultation, the psychiatrist may recommend ongoing psychotherapy. This therapy may be provided by the psychiatric team or by other health professionals, including social workers. Literature on the effectiveness of psychotherapy in the elderly is limited, but most clinicians agree that it helps many hospitalized elderly patients. Supportive individual psychotherapy can minimize the patient’s distress and maximize a sense of autonomy, control, and self-esteem by building on remaining strengths and adaptive skills. The consultant addresses such issues, helping the patient to grieve and adjust to losses and to understand the psychologic meaning of the illness and the hospitalization. Consultants can teach patients about their illnesses and help them cope with intellectual deficits. At other times, psychotherapy may involve the family or staff, helping them deal with emotions such as anger, guilt, frustration, and helplessness. Techniques such as cognitive or interpersonal therapy can also be useful.
Treatment may include behavior management and environmental modification. Frequent reorientation and reassurance is provided by visits from family members or friends, by having familiar objects in the patient’s room, and by reducing noise, light, interruptions, and other disturbances in an intensive care setting. The consultant may direct the unit staff in generating a behavior management program for particularly difficult patients.
The psychiatric consultant should comment on plans for the patient’s ultimate disposition and follow-up. Disposition requires knowledge about the various services and placements available to the elderly such as retirement communities, nursing homes, Meals-on-Wheels programs, homemaker services, visiting nurses, outpatient and day-care programs, and supportive services for caregivers. Discharge planners and social workers are especially helpful. Patients and families may need help in negotiating the difficult task of placing a patient in a care setting outside the home.
Psychiatric follow-up during the patient’s hospitalization ensures maximum benefit from the consultation; postdischarge follow-up can also be an important predictor of the consultation’s long-term effectiveness. High relapse rates have been attributed to ineffective follow-up. Ideally, the consulting psychiatrist arranges for psychiatric follow-up on an outpatient basis or makes a home visit. If the psychiatric or behavioral symptoms are severe, a transfer to an inpatient psychiatric unit may be indicated for further evaluation and treatment.