Psychogeriatric consultation services: effect and effectiveness.

OBJECTIVES: To determine the nature of referrals to a psychogeriatric consultation/outreach service, the types of interventions provided, and the effects and effectiveness of the service. METHOD: The study used a prospective approach in which 67 consecutive patients referred for psychogeriatric assessment were followed up 6 to 8 weeks after the initial assessment and then again 6 months after initial contact. Patients were rated at the time of referral and at follow-up on presence of psychiatric diagnosis, need for institutional care, and placement outcome. RESULTS: Of the 67 patients initially seen, 51 (76%) experienced memory problems and 46 (69%) had depressed mood. Consistent with this finding, 36 (54%) were diagnosed by consultants as having a dementia, and 15 (22%) received a diagnosis of depression. The most frequent recommendations included medication changes in 34 cases (50%) and further assessments in 37 cases (55%). Although information at 6-week follow-up was available for only 58% (n = 38) of the sample, 18 (46%) patients were generally improved. Interestingly, only 12 (31%) of referring physicians indicated that they had followed the advice of the consultants. Cognitive impairment and depressive symptoms were major concerns among referring physicians. The most common recommendation made involved pharmacotherapy. While compliance of family doctors to recommendations made was poor, patients improved over time. Patients requiring inpatient assessment were very old, living alone, experiencing behavioural problems, and not depressed. CONCLUSIONS: Psychogeriatric consultations appear most useful in cases where patients are more severely affected and/or are suffering from a greater range of symptoms.

Psychiatric illness and psychosocial concerns of patients with newly diagnosed lung cancer.

OBJECTIVE: To determine the nature and incidence of psychiatric illness, symptoms of potential psychiatric significance, substance abuse and psychosocial concerns among patients with newly diagnosed lung cancer. DESIGN: Case series. SETTING: Kingston Regional Cancer Centre, a tertiary care facility for ambulatory cancer patients. PATIENTS: Seventy-one consecutive English-speaking patients with recently diagnosed lung cancer undergoing radiotherapy or chemotherapy were asked to participate; 52 of the 57 patients who agreed were available for evaluation. OUTCOME MEASURES: Current and previous psychiatric diagnoses of affective, anxiety and adjustment disorders, and alcohol and tobacco abuse; symptoms of sadness, fear, shock, anger, denial, acceptance, guilt, suicidal ideation, thoughts of death, insomnia, loss of libido, impaired concentration and reduced level of work or interest; psychosocial concerns about family, work and finances; and an impression of coping. RESULTS: At the time of the interview two (4%) of the patients were found to have an affective disorder, none had an anxiety disorder, and six (12%) had an adjustment disorder. Previously, 16 patients (31%) had had an affective or anxiety disorder or both. Two (4%) had had an adjustment disorder following the diagnosis of their lung cancer that had resolved before the interview. At some point in their lives 24 patients (46%) had abused alcohol, and 7 (13%) were currently abusing alcohol. All had smoked, 33 (63%) having been tobacco dependent. Feelings of sadness were expressed by 23 (44%), fear by 15 (29%), anger by 2 (4%), shock by 9 (17%) and guilt by 4 (8%). Seven (13%) had considered suicide, and thoughts of death were reported by 16 (31%). Twenty (38%) were accepting of their diagnosis, and 5 (10%) expressed optimism. Twenty-seven (52%) had insomnia, which was reported to be severe by 15 (29%). Loss of libido was reported by 25 (48%) and was severe in 14 (27%). Difficulty concentrating was reported by 10 (19%) and a reduced ability to work or loss of interest by 17 (33%). Fifteen patients (29%) were concerned about their families and 4 (8%) about work or finances. Most (41 [79%]) had good family support, and 23 (44%) found support in religion. Seven patients (13%) seemed to be coping poorly. CONCLUSIONS: Although psychiatric illness was infrequent, symptoms of potential psychiatric significance and psychosocial concerns were common in this patient population. Attention to these symptoms and concerns should be addressed in a systematic and effective way by all health care professionals and agencies planning the care of patients with lung cancer.

Cognitive and behavioural impairment among elderly people in institutions providing different levels of care.

OBJECTIVE: To compare the prevalence and degree of cognitive and behavioural impairment in elderly patients in institutions providing different levels of care. DESIGN: Prevalence study. SETTING: A nursing home, a home for the aged and psychogeriatric wards in a provincial psychiatric hospital. PATIENTS: Only subjects 65 years of age or older were eligible for inclusion. A random sample was selected comprising 25% of the residents in the nursing home and the home for the aged; of the 119 asked to participate 95 agreed (44 in the nursing home and 51 in the home for the aged). All 50 on the psychogeriatric wards agreed to participate. MAIN OUTCOME MEASURES: The Mini-Mental State Examination (MMSE) and the Kingston Dementia Rating Scale (KDRS). RESULTS: An MMSE score of less than 24 (cognitive impairment) was given to 37 (84%) of the residents in the nursing home, 43 (84%) of those in the home for the aged and 48 (96%) of the patients in the psychiatric hospital; the corresponding numbers for a KDRS score of more than 0 (cognitive impairment) were 41 (93%), 48 (94%) and 50 (100%). The seven patients receiving the highest level of care at the home for the aged (special care) had more behavioural problems than those in the psychiatric hospital did (p less than 0.001). CONCLUSIONS: Cognitive and behavioural impairment was widespread in the three institutions regardless of the level of care. When planning services and allocating resources government funding agencies should consider the degree and prevalence of such impairment among elderly people in institutions.

An outbreak of pseudobacteremia caused by Enterobacter cloacae from a phlebotomist's vial of thrombin.

In a 15-day period, seven patients in a small hospital each had one blood culture positive for Enterobacter cloacae. None of the seven patients was septic. All seven positive culture specimens had been obtained by phlebotomist A, who also had obtained 13 negative culture specimens in the same period. Seven other phlebotomists had drawn 69 blood samples for culture during the same period; none had yielded any microorganism (p = 0.00001). Vials of thrombin, routinely used to coagulate blood specimens for chemical analysis, had been carried on the phlebotomy trays. We observed that phlebotomist A occasionally spilled drops of the viscous thrombin on her finger during the procedures. Culture of the thrombin on her tray yielded E. cloacae. No further cases of E. cloacae bacteremia occurred after she stopped drawing blood for culture and the thrombin on her tray was removed from use.