Mental Disorders in Older Adults Admitted to General Hospitals: Review of Patient, Service Provision and Environmental Factors

Abstract

The prevalence of mental illnesses in older general hospital inpatients has been studied widely however data from the Irish population is lacking. Psychiatry of Old Age Liaison (`POA Liaison¿) services provide assessment and treatment to this population and accurate data on prevalence rates, contributing factors and service demands are needed to provide a proficient healthcare service to this cohort.

The aim of this thesis was to determine the rates of depression and anxiety in older hospitalised adults in an Irish acute general hospital setting, analysing for associated factors and outcomes at six-months. In addition to this we aimed to gather and review referral data pertaining to one POA Liaison team (St James¿s Hospital, Dublin) over two time periods and to collect data from clinicians providing POA Liaison services nationally. Data collection for our studies coincided with the outbreak of the SARS-CoV-2 virus (`COVID-19¿) pandemic in Ireland, we therefore incorporated assessing the impact of the pandemic on our studies.

The research contributing to this thesis is compiled of three separate studies. Study 1 was a prospective cohort study examining rates of depression and anxiety, associated factors, and their impact on six-month outcomes in a convenience sample of older adult inpatients. Study 2 included two retrospective audits and service evaluation of referrals to the POA Liaison service in St James¿s Hospital, initial data collection occurred in 2018 (`Routine period¿) and the subsequent data was collected in 2020 (`Pandemic period¿). The study was modelled on a previous audit of referrals to the POA Liaison service which was completed in 1998 (`Historic Period¿) and results were compared across the three time periods. Study 3 was a cross sectional survey of National Old Age Liaison Psychiatry service.

Our prospective cohort study included 69 patients. Due to infection control concerns following the outbreak of the COVID-19 pandemic outbreak our study was terminated prematurely, and our sample size was significantly smaller than planned, which also impacted our analysis. Following screening we found low rates of depressive symptoms (13%) and high rates of anxiety symptoms (42%). We also found moderate rates of loneliness symptoms (23.2%) when we screened this sample. Loneliness symptoms were associated with both depressive and anxiety symptoms. Qualitative data illustrated robust coping and resilience in the majority of our sample in spite of media coverage relentlessly labelling older adults with comorbidities as the most at risk from the virus. Patients with depressive, anxiety and loneliness symptoms had poorer outcomes at six-months, including higher rates of readmission, death during admission and death at six months. Lonely patients were also more likely to have a longer hospital admission and be discharged to a nursing home or convalescence. Older adults (¿85 years) and those with lower sMMSE scores (18-23) also had poorer outcomes including increased length of admission, increased frequency of discharge to a nursing home, increased rates of mortality during admission and at six months.

Our audit revealed that referrals over an 18-week period to POA Liaison services increased during the Routine period when compared with data from the Historic period (195 vs 100). During the Routine period referrals for assessment of anxiety increased (15% vs 0), and rates of diagnosis of anxiety (12% vs 7%) and adjustment disorders (7% vs 5%) also have increased. Rates of referral for assessment of depressive symptoms remained relatively stable (Routine 50% vs Historic 47%), however rates of diagnosis of depressive disorders decreased (Routine 27% vs Historic 27%). Compared to the Routine period, during the Pandemic period, rates of referral for behavioural disturbance increased (Routine 15% vs Pandemic 30%), rates of diagnosis of Behavioural and Psychological Symptoms of Dementia (BPSD) also increased (Routine 13% vs Pandemic 28%) however diagnosis of delirium remained stable (Routine 42% vs Pandemic 45%).

Results from the survey to POA consultants gathering information on liaison service provision in hospitals around Ireland highlighted the disparities in services available relative to hospital size and location. Our findings also illustrated that the POA Liaison service recommendations made by the Specialist Mental Health Services for Older People; National Clinical Programme for Older People: Part 2 report in 2019 are not being met.

To our knowledge this is the first body of research detailing patient, service and environmental factors related to mental illnesses in older hospitalised inpatients and Psychiatry of Older Adults Liaison services in Ireland. This research was conducted during the beginning of the initial wave of the COVID-19 pandemic, giving further insights into the impacts of the pandemic on this population and hospital services.