Geriatric psychiatry liaison programme in a Singapore public hospital geriatric ward setting: descriptive and evaluation study on delirium and dementia

Abstract

Background:

Comprehensive geriatric psychiatry liaison services are in early and evolving stages in Singapore. A description and evaluation of a geriatric psychiatry liaison programme in geriatric wards was undertaken describing programme activity and clinical outcomes in patients with neurocognitive disorders. Dementia training and staff upskilling are also discussed.

Methods:

This study included all referred patients by the geriatric team in Changi General Hospital over a one-year period from 15 June 2017 to 14 June 2018. As measures of good clinical practice, diagnosis of delirium and new diagnosis of dementia made during the inpatient admission following liaison consultation were included in the study. Patient-related outcomes that included length of stay (LOS), institutionalisation rates and in-hospital mortality were evaluated.

Results:

Dementia (53%), delirium (49%) and depression (28%) were the commonest diagnoses in this study. Dementia was newly diagnosed in 30% of cases. The median LOS in those with delirium was 19 days; 19% with a delirium diagnosis had new institutionalisation rates. In-hospital mortality in this study was 2%.

Conclusions:

The geriatric psychiatry liaison programme in geriatric wards in Changi General Hospital improved detection rates of delirium and new diagnoses of dementia. It also reports increased LOS and new institutionalisation rates in those with a diagnosis of delirium. Nursing staff education in neurocognitive disorders is enhanced. This article has outlined the importance of team-based care, joint specialist care and staff training in recognition of delirium and dementia in an acute hospital setting to improve outcomes for older patients.

Keywords

Geriatric psychiatry liaison programme delirium dementia dementia training neurocognitive disorders

Introduction

Dementia, delirium and depression are common psychiatric conditions affecting hospitalised older people.^1,2 Comprehensive psychiatry liaison services, by a dedicated team with a special interest in older adult psychiatry, are in early and evolving stages in Singapore.

Notably, in the UK, the Five Year Forward View for Mental Health endorses that people with long-term physical illnesses have adverse outcomes if comorbid mental health problems exist.³ The liaison psychiatry, Rapid Assessment Interface and Discharge (RAID) service model in Birmingham, UK, achieved significant savings through reductions in length of stay (LOS) and avoiding readmissions.⁴ This service with a multi-skilled team provides a single point of contact for the acute hospital and emergency department 24 hours a day, 7 days of the week and has demonstrated an effective model of care with quality improvements in care of older adults and increased detection and diagnosis of dementia.⁵ Undoubtedly, these have been monumental drivers for good clinical practice and changes in delivery of psychiatry liaison care in the UK, which has prompted the current study on evaluation of the geriatric psychiatry liaison programme in geriatric wards at Changi General Hospital (CGH).

A literature review on geriatric psychiatry liaison service provision, evidence-based good practice measures and quality of care in geriatric wards in relation to delirium and dementia was undertaken to shape care delivery locally. A description and evaluation of the current programme was undertaken describing clinical programme activity, patient demographic characteristics, diagnoses and clinical outcomes in patients with neurocognitive disorders namely delirium and dementia. Training and staff upskilling, together with opportunities to reshape service delivery and patient care, are also discussed.

CGH is a 1000 bed public hospital catering to the needs of a population of more than one million people in the eastern part of Singapore. A geriatric psychiatry liaison programme has been operational since 2013 and this programme has metamorphosed since its origins with transformational changes in its organisational structure, team composition and care delivery.

Methods

This is a descriptive and evaluation study of the geriatric psychiatry liaison programme which included all referred patients over a one-year period from 15 June 2017 to 14 June 2018. This programme accepted referrals from all geriatric wards in CGH (five in number) with the exception of a private ward.

Programme description

In 2013, as part of the Ministry of Health directive, an inpatient dementia programme was commissioned to improve detection rates and management of dementia in geriatric wards at CGH. In addition, a consultation liaison programme to geriatric wards from the Department of Psychological Medicine (Geriatric Psychiatry Service) was formally embedded into the inpatient dementia programme.

This programme operates every Monday and Thursday morning with a multidisciplinary team comprising a Geriatric Psychiatrist, who spearheaded the programme, nursing staff from the inpatient dementia team and psychiatry resident staff.

The team provides psychiatric assessment, intervention and management plans for patients. The assessments included use of cognitive screening tools, such as Abbreviated Mental Test (AMT),⁶ Mini Mental Status Examination (MMSE),⁷ or Montreal Cognitive Assessment (MOCA),⁸ as needed. Diagnosis of psychiatric conditions was made using DSM-V diagnostic criteria.⁹ Consultations, assessments and interventions were also provided by Occupational Therapists and Psychologists from the liaison programme when required during the study period. There was close liaison with Consultant Geriatricians and geriatric teams to obtain history, and devise cogent management plans. The geriatric team were actively involved by the liaison team to facilitate joint discussions. Allied health professionals from the geriatric team, occupational therapists, physiotherapists and speech therapists, were involved by the liaison team when needed for assessments and provision of holistic care.

Database to capture activity, data collection and extraction

A team was formed in 2017 for study design, aims and measures of good practice. A database was set up to capture clinical programme activity, patient demographic profile, diagnosis, and management. The database was devised in December 2016 and trialled over a 6 month period, prior to full operationalisation in June 2017. Data entry was undertaken by the Geriatric Psychiatrist prospectively.

The focus of the study was on neurocognitive disorders namely dementia and delirium. As measures of good clinical practice, diagnosis of delirium and new diagnosis of dementia made during the inpatient admission following liaison consultation were included in the study. Patient outcomes that included LOS, institutionalisation rates, and discharge to another psychiatric hospital or transfer to a psychiatric ward and in-hospital mortality were evaluated. Subgroup analysis of those with delirium superimposed on dementia and delirium without dementia with relation to discharge destination was also undertaken.

The data was continually collected during the 12 month study period and captured in the database from 15 June 2017 to 14 June 2018. Additional information such as reasons for admission, and other relevant information including referral reasons were identified from electronic medical records and included into the extracted data.

SingHealth Centralised Institutional Review Board (CIRB), Singapore advised exemption from a formal application for ethical approval as this study was an evaluation of programme with a focus on improvement.

Staff training was embedded into the inpatient liaison programme with nursing staff in geriatric wards involved in case-based learning. Geriatric Psychiatrist and Psychologists from the programme were involved in conducting joint training sessions and facilitating group based learning. A combination of large (i.e. lecture based) and small group methodology was used.¹⁰ The large group was divided into smaller groups; the number was dependant on the attending participants. Case group activity was facilitated with case based learning approaches and active participation and critical thinking of learners was encouraged through case formulation. The face-face training provided opportunities for clarification of questions and learning points were highlighted at end of training by the facilitators. Staff training was not formally evaluated during the study period but informal positive verbal feedback was received.

Statistical analysis

Descriptive analysis was used in this study. Categorical data was presented as frequency (percentage). Numeric data was presented as mean (standard deviation) for parametric distribution and median (interquartile range) for non-parametric distribution.

To examine the associations between two categorical groups, Chi-square test or Fisher’s exact test were used. Two-sample t-test or Mann–Whitney test was used for between group comparisons, in case of two groups of continuous variables. For more than two group comparisons, one-way analysis of variance (ANOVA) or Wilcoxon signed rank test was used. In case of statistically significant difference in one-way ANOVA or Wilcoxon signed rank test, Bonferroni post hoc adjustment was used for multiple pairwise comparisons.

A two-tailed p-value of <0.05 was considered statistically significant. Statistical analysis was performed with SPSS statistical software, version 19.0 (IBM Corp, Armonk, NY).

Results

A total of 191 cases were assessed in total over the one year study period from 15 June 2017 to 14 June 2018. There were 186 unique patients with five readmissions.

136 cases (71%) had an initial single assessment and 55 cases (29%) required subsequent reviews, the number of which varied from 1 to 5. Table 1 shows the patient demographics. The majority of admissions were from home (91%) and the remainder from institutionalisation care which included nursing home (8%) and sheltered home (1%).

Table 1.

Demographics.

Demographics	n = 186
Age
Mean ± SD	82.0 ± 7.0
Gender
Female	106 (57.0%)
Ethnicity
Chinese	148 (79.6%)
Malay	25 (13.4%)
Indian	6 (3.2%)
Eurasian	2 (1.1%)
Others	5 (2.7%)
Marital status
Widowed	98 (52.7%)
Married	66 (35.5%)
Single	16 (8.6%)
Divorced/separated	6 (3.2%)

The reasons for referral to the geriatric psychiatry liaison team are listed in Table 2. Other reasons for referral included hoarding, obsessive compulsive disorder, community support and personality difficulties. Some patients had more than one reason for referral.

Table 2.

Reasons for referral.

Reasons for referrals	n = 191 cases	%
Depressed mood	61	31.9
Verbal aggression/physical aggression/agitation	50	26.2
Medication review	32	16.8
Mental capacity	29	15.2
Cognitive evaluation	18	9.4
Psychotic symptoms	16	8.4
Sleep disturbance	14	7.3
Risk assessment	12	6.3
Food refusal/poor oral intake	11	5.8
Anxious mood	3	1.6
Disinhibited behaviour	1	0.5
Others	10	5.2

Table 3 details reasons for hospital admission. Other reasons for admission included pressure sores, toe gangrene, status epilepticus, dysuria, diarrhoea, palpitations, fluid overload and insomnia. Some patients had more than one reason for admission.

Table 3.

Reasons for admission.

Reasons for admission	n = 191 cases	%
Falls	64	33.5
Sepsis/infection	26	13.6
Behaviour issues	26	13.6
Poor oral intake/appetite	19	9.9
Confusion	15	7.9
Pain	13	6.8
Limb weakness	8	4.2
Giddiness	4	2.1
Stroke	4	2.1
Fracture	4	2.1
Drowsiness	3	1.6
Shortness of breath	3	1.6
Hypoglycaemia	3	1.6
Mood	3	1.6
Leg swelling	1	0.5
Anaemia	1	0.5
Others	29	15.2

The diagnoses identified by the geriatric psychiatry liaison team were delirium in 93 cases (49%), dementia in 102 cases (53%), mild cognitive impairment in 38 cases (20%), depression in 54 cases (28%), psychotic disorder in 21 cases (11%), adjustment disorder in 17 cases (9%), anxiety disorder in seven cases (4%), bipolar disorder in two cases (1%) and one case each in alcohol use disorder (0.5%), and benzodiazepine dependency (0.5%). No diagnosis of psychiatric disorder was given in five cases (3%). Other diagnoses included obsessive compulsive and related disorders, Charles Bonnet syndrome and acquired brain injury in six cases (3%). There was overlap of diagnoses with the commonest diagnosis being delirium superimposed on dementia.

In this study, mild cognitive impairment was newly diagnosed in 34 out of 38 cases (89%) and dementia was newly diagnosed in 31 out of 102 cases (30%). Total cases of delirium were 93 (49%). A breakdown of delirium and co-morbid diagnoses was undertaken and illustrated in Figure 1. Out of 93 delirious cases, 52 (56%) had delirium superimposed on dementia and 41(44%) had delirium without dementia. One case had co-morbid acquired brain injury which is grouped under other diagnosis.

Figure 1.

Delirium sole and co-morbid diagnoses (n = 93).

A subgroup analysis of cases with delirium superimposed on dementia and delirium without dementia in relation to discharge destinations was undertaken and is listed in Table 4. Twenty-four (26%) out of 93 cases of delirium went into institutional care at discharge. Eighteen (19%) out of 93 cases with a diagnosis of delirium were newly admitted into institutional care from home. Overall discharge destinations are depicted in Figure 2.

Table 4.

Discharge destinations of subgroups of delirium with various diagnoses.

	Cases with delirium superimposed on dementia	Cases with delirium without dementia diagnosis	Total cases with delirium diagnosis
n	52	41	93
Home	55.8% (29)	63.4% (26)	59.1% (55)
Institutional care	30.8% (16)	19.5% (8)	25.8% (24)
Step down and then home	5.8% (3)	12.2% (5)	8.6% (8)
Transfer to psychiatric ward in CGH	1.9% (1)	2.4% (1)	2.2% (2)
Died in hospital	1.9% (1)	0.0% (0)	1.1% (1)
Transfer to IMH	1.9% (1)	2.4% (1)	2.2% (2)
Others	1.9% (1)	0.0% (0)	1.1% (1)

Figure 2.

Discharge destination overall (n = 191).

Table 5 illustrates the overall change in destination at the time of admission versus discharge. Two cases (1%) were transferred to the psychiatric ward in CGH, both had delirium as a diagnosis in addition to other psychiatric diagnoses and three cases (2%) were transferred to tertiary psychiatry hospital (IMH) and two had resolved delirium as one of the diagnoses. Four cases (2%) died in hospital.

Table 5.

Home setting prior to geriatric ward admission versus discharge destination.

Discharge destination	Home setting prior to geriatric ward admission (n = 191)
	Living at home(n = 174)	Living in institutional care (n = 17)
Home	118 (67.8%)	0
Institutional care	31 (17.8%)	16 (94.1%)
Step down facility and then home	15 (8.6%)	0
Died in hospital	4 (2.3%)	0
Transfer to psychiatric ward in CGH	2 (1.1%)	0
Transfer to IMH¹	3 (1.7%)	0
Transfer to other RH²	1 (0.6%)	0
Others	0 (0.0%)	1 (5.9%)

LOS for those with delirium versus no delirium regardless of their dementia status was compared. Those with delirium had a longer LOS, median 19 (interquartile range (IQR) 11.0–31.5) days, as opposed to median 13.5 (IQR 9.0–29.3) days for non-delirious patients, which was statistically significant (p = 0.028).

Psychology referral rate was 6% (11/191) and occupational therapy referral rate was 57% (109/191). These referrals were made upon assessment by the geriatric psychiatry liaison team.

Nine sessions of dementia training to geriatric nurses were conducted during the study period with verbal positive feedback. The number of participants who attended during study period is listed in Table 6.

Table 6.

Participants who attended dementia training during the study period.

Training periods	Number of participants
June 2017	25
July 2017	38
August 2017	49
September 2017	36
October 2017	40
November 2017	41
December 2017	31
May 2018	41
June 2018	29
Total	330

Discussion

Dementia (53%), delirium (49%) and depression (28%), were the commonest diagnoses in this study, in keeping with the reported literature on common psychiatric conditions affecting hospitalised older patients.^1,2 The geriatric psychiatry liaison programme in CGH has played a pivotal role in identification and management of these conditions working in unison with the geriatric team. Depressed mood was the commonest reason for geriatric psychiatry liaison referral. However, it was not the commonest diagnosis after psychiatric evaluation. Delirium may be mistaken for depression in view of the considerable symptom overlap between the two and management of delirium takes precedence in view of the serious underlying pathology and morbidity.¹¹ In referrals to consultation liaison-psychiatry for assessment of suspected depression, delirium is the actual diagnosis with reported rates of misdiagnoses ranging from 6% to 52%.^11–15 Evidently, accurate diagnosis of delirium and its distinction from depression is paramount for targeted interventions and management.

Out of 61 referrals for depressed mood in this study, 54 cases were diagnosed as depression by the liaison team. The referral for depression by the geriatric team may have included other referral reasons such as food refusal, medication review or risk assessment. Misdiagnosis was not an outcome that we measured during this study and depression may manifest in many ways, i.e. food refusal.

In our study, falls in the community was the commonest reason for hospital admission followed by sepsis and behavioural disturbances. Systematic review and meta-analysis of the Hospital Elder life Programme, by Hshieh et al.,¹⁶ concluded that multicomponent non pharmacological delirium interventions were effective in reducing incident delirium and rate of falls with a trend towards reducing LOS and preventing institutionalisation. Geriatric inpatient stay is an opportunity to identify, address and manage multifactorial causes for falls in hospitalised older adults. Additionally, preventative strategies for in patient falls could be undertaken through increased detection rates of dementia.⁵

In our study, 30% (31 out of 102) of new diagnoses of dementia were made and 89% (34 out of 38) of new diagnoses of mild cognitive impairment. Case finding of dementia in a general hospital setting is exemplified in the state-of-the-art review by Livingston et al.,¹⁷ which endorses that clinicians need to consider case finding for dementia in hospitalised older adults to improve management and clinical outcomes. The Irish national audit study findings on acute hospital dementia care highlighted several deficiencies,¹⁸ notably poor cognitive assessments and paucity of dementia care pathways in hospitalised older adults and confers that dementia friendly care needs to be provided in acute hospitals. In addition, the audit recommends access to provision of daily liaison psychiatrists, in particular old age psychiatry liaison service for referral and treatment of dementia in acute hospitals.

Overall mortality at discharge in this study was low at 2% (4 cases). Delirium is consistently associated with an accelerated mortality rate across all non-surgical patients.¹⁹ A prospective cohort study with 2 year follow up revealed that delirium without dementia has a higher earlier risk of mortality during the 6 months following admission and again after 1 year.²⁰ The findings of the cohort study highlights that those with delirium without dementia are more seriously unwell, than those with underlying dementia. Undoubtedly these findings have implications for early recognition and treatment of both delirium and dementia.

Of those with a delirium diagnosis in this study, 19% had a change of discharge destination from home into institutional care. These findings are well described in the literature, with delirium being associated with increased institutionalisation rates,^19,21 and higher healthcare costs and increased LOS.^19,22. Incident delirium (new onset), but not prevalent delirium (present on admission),¹⁹ is an important predictor of longer hospital stays in aged medical inpatients.²²

Mental capacity assessments were undertaken in 15% of cases which is indicative of the role of geriatric psychiatry liaison programme in supporting the geriatric team. Training in relation to mental capacity assessment, is one of core functions of the geriatric psychiatry liaison programme.

The rates of occupational therapy referral from inpatient dementia programme was 57% but psychology referral rate was low at 6% in the study and this has since been addressed through better psychology integration in joint assessments with the study psychiatrist. Work is in progress to further develop our team’s psychology services in relation to care of patients with delirium and dementia.

Nursing training in dementia care is an integral component of the geriatric psychiatry liaison programme and was achieved through nine sessions of learning during the study period. Training was embedded into existing arrangements with nursing managers involved in organising the sessions. Training accessibility was thus ensured and case based learning provided opportunities for group learning. The unified classroom training approach involving psychologist and psychiatrist equipped and enriched nursing staff with case formulation and case-based learning approaches rooted in person centred care principles.²³ Translation of learning into practice together with knowledge-based content underpinned the training delivery methodology. Training was consequently relevant and applicable to clinical practice.²⁴ The training discussed embeds some of the core features highlighted by Surr and Gates,²⁵ in a literature review, and critical synthesis of evidence in delivering dementia education.

The geriatric psychiatry liaison programme does not replace the existing blue letter liaison referral pathway which is prevalent in the hospital. It offers an enhancement to the service and ensures continuity of care for the patients referred. The model provided in this Geriatric Psychiatry Liaison programme achieves better integration of the physical and mental health needs of older patients through a joint nursing and psychiatric assessment. It is noteworthy that during the study period the number of blue letter referrals from participating wards reduced to 24 in contrast to 191 referrals to the geriatric psychiatry liaison programme over the same period.

Limitations

This is the first study to the best of our knowledge that formally evaluates and describes a geriatric psychiatry liaison programme in a public hospital in Singapore. The data was collected by the study Geriatric Psychiatrist prospectively. Data integrity and accuracy was ensured with no missing data. This study indicates measures of good practice with new diagnosis of dementia and high rates of delirium detection.

The geriatric psychiatry liaison programme receives referrals from geriatricians and is therefore a referred population. However, it reflects everyday practice and is aimed at enhancing care of older adults working collaboratively with the geriatric team.

Economic evaluation of this programme was not undertaken and this could be addressed in future evaluation programmes. The Birmingham RAID service model has shown that a single point of contact for acute hospital and emergency department 24 hours a day, 7 days a week has been effective in reducing LOS and readmissions. A similar 24 hours a day, 7 days a week Geriatric Psychiatry Liaison programme and service provision will be needed in order to evaluate and demonstrate its impact on LOS. At the current time, as part of our aim to continually improve, some of the core principles of good practice from the RAID model could no doubt be weaved into liaison service provision.

In-hospital mortality rate was low in this study. Future studies using research methodology should address long-term, clinical outcomes in relation to mortality, readmissions and institutionalisation post discharge.

Lastly nursing training was not formally evaluated during the study period. Formal evaluation took place through a study questionnaire during the early part of 2017 with positive feedback, improved knowledge and confidence levels with suggestions for future training. Formal and informal verbal feedback continues to shape the training programme to ensure applicability. It is beyond the scope of this article to discuss the training programme in any further detail. An appendix outlining the training programme is attached.

Conclusions

This descriptive and evaluation study of the collaborative geriatric psychiatry liaison programme in geriatric wards in CGH improved detection rates of delirium, new diagnoses of dementia and mild cognitive impairment. It also reports increased LOS and new institutionalisation rates in those with a diagnosis of delirium. Nursing staff education in neurocognitive disorders is enhanced through unified psychiatrist and psychologist classroom training using case-based learning and formulation approaches. The geriatric psychiatric liaison programme described in this study further complements provision of care of older adults with delirium and dementia in geriatric wards and complements improved care delivery.

Early and accurate detection of mental health issues is the foundation for healthy ageing and this article has outlined the importance of team-based care, joint specialist care and staff training in recognition of delirium and dementia in an acute hospital setting to improve outcomes for older patients. Providing holistic mental health and cognitive assessments, early detection and management of unrecognised psychiatric conditions, as well as proactive and coordinated discharge planning, form the backbone of a comprehensive care pathway for delirium and dementia. For effective outcomes for older patients with physical and mental health needs, the integrated multidisciplinary collaborative model highlighted above is paramount. This descriptive study reports findings, measures of good practice and discharge outcomes in relation to delirium and dementia, which hopefully will rekindle audits and research to further improve outcomes in neurocognitive disorders.

Footnotes

Appendix

Acknowledgements

The authors would like to thank Josephine Lee Sze Ching, formerly Associate Executive, Inpatient Dementia, Department of Geriatric Medicine and Nurfarhana Sa’idah Binte Abdul Manap, Associate Executive, Memory clinic, Department of Geriatric Medicine for administrative support in data collection, and Dr Alisson Ching Ching Sim, Senior Resident Physician, Department of Psychological Medicine for setting up the database.

Authors’ contributions

BB was the lead author involved in study design, data collection, writing the first draft and subsequent revisions. PSY was the second author who was involved in study design with contributions to write up and revisions. BHR was the third author who was involved in study design with contributions to write up and revisions. JWK was the fourth author involved in study design, data analysis with contributions to write up and revisions. TMYL was the fifth author involved in study design, data analysis with contributions to write up and revisions. SV author involved in study design, data analysis with contributions to write up and revisions. All authors reviewed and edited the manuscript and approved the final version.

Availability of data and materials

The data set generalised and analysed are available from the corresponding author.

Conflict of interest

The authors declare that there is no conflict of interest.

Ethical approval

SingHealth Centralised Institutional Review Board, Singapore advised exemption from a formal application for ethical approval as this study was an evaluation of programme with a focus on improvement.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Informed consent

Anonymised patient data was used in line with the evaluation initiative of this project and therefore informed consent was not applicable.

ORCID iD

Bharathi Balasundaram

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