Reduced Activity in an Inpatient Liaison Psychiatry Service During the First Wave of the COVID-19 Pandemic: Comparison With 2019 Data and Characterization of the SARS-CoV-2 Positive Cohort.

Background: The COVID-19 pandemic led to changes in the way that healthcare was accessed and delivered in the United Kingdom (UK), particularly during the peak of the first lockdown period (the "first wave") beginning in March 2020. In some patients, COVID-19 is associated with acute neuropsychiatric manifestations, and there is suggestion that there may also be longer term neuropsychiatric complications. Despite this, at the time of writing there are only emerging data on the direct effects of the COVID-19 pandemic on psychiatric care. Methods: In this retrospective study we analyzed referrals to an inpatient liaison psychiatry department of a large acute teaching hospital during the first wave of covid-19 in the UK and compared this data to the same period in 2019. Results: We saw a 40% reduction in the number of referrals in 2020, with an increase in the proportion of referrals for both psychosis or mania and delirium. Almost one third (28%) of referred patients tested positive for COVID-19 at some point during their admission, with 40% of these presenting with delirium as a consequence of their COVID-19 illness. Save delirium, we did not find evidence for high prevalence of new-onset acute mental illness in COVID-19 positive patients. Conclusion: Our data indicate decreased clinical activity in our inpatient psychiatry liaison department during the first wave of the COVID-19 pandemic, although a relative increase in relative increase in referrals for psychosis or mania, suggesting less of a relative decrease in more severe cases of mental illness. The reasons for this are likely multifactorial, including structural changes in the NHS and patient reluctance to present to emergency departments (ED) due to infection fears and Government advice. Our data also supports the literature suggesting the high relative prevalence of delirium in COVID-19, and we support integration of psychiatry liaison teams in acute general hospital wards to optimize delirium management. Finally, consideration should be given to adequate staffing of community and crisis mental health teams to safely manage the mental health of people reluctant to visit EDs.

Time of referral to older adult liaison psychiatry service and other factors affecting length of stay in the general hospital.

OBJECTIVES: To explore the relationship between social and clinical factors with (1) Time to referral to an older adult liaison psychiatry service, and (2) Length of stay (LOS), in a sample of older adults admitted to an acute general medical hospital receiving liaison psychiatry intervention, in London, United Kingdom, over a 3-year period. METHODS: Information on patients referred to liaison psychiatry for older adults between January 2013 and December 2015 was collected using structured forms, with clinical diagnoses determined according to International Classification of Mental Disorders-10. The association of social and clinical factors with the time taken to refer to liaison psychiatry and LOS was assessed using Cox proportional hazards regression and zero-truncated Poisson regression, respectively. RESULTS: Compared with people who were diagnosed with depression, older adults with psychotic and alcohol use disorders had higher rates of referral to liaison psychiatry (adjusted hazard ratios [aHRs] 1.83 [95% CI: 1.30, 2.59] and aHR 1.69 [95% CI: 1.01, 2.83]) respectively. In adjusted models, LOS was increased in older adults with delusional disorders and shorter in people with alcohol use disorders, personality disorders and learning disabilities, compared to people with depressive diagnoses. Within this cohort, a new definite dementia diagnosis and longer time to refer to liaison psychiatry were both associated with a longer length of general hospital in-patient stay. CONCLUSIONS: In older adults admitted to general medical hospitals, and needing liaison psychiatry input, timely referral may be associated with a shorter LOS.

Liaison psychiatry for older adults in the general hospital: service activity, development and outcomes.

Aims and method This study used data collected to describe the activity, case-load characteristics and outcome measures for all patients seen during a 6-year period. RESULTS: The service reviewed 2153 patients over 6 years with referral rates and case-load characteristics comparable to those described in a previous study period. The team saw 82% of patients on the day they were referred. Data and outcome measures collected showed significant complexity in the cases seen and statistically significant improvement in Health of the Nation Outcome Scales (HoNOS) scores following service input. Clinical implications The outcome measures used were limited, but the study supports the need for specialist liaison psychiatry for older adults (LPOA) services in the general hospital. The Framework of Outcome Measures - Liaison Psychiatry has now been introduced, but it remains unclear how valid this is in LPOA. It is of note that cost-effectiveness secondary to service input and training activities are not adequately monitored. Declaration of interest None.

The Executive Interview (EXIT25) as a tool for assessing executive functioning in older medical and surgical inpatients referred to a psychiatry service: feasibility of creating a brief version.

BACKGROUND: Most neuropsychological tests of executive function are time-consuming and otherwise unsuitable for routine bedside assessment, particularly in older people admitted to a general hospital. After introducing the Executive Interview (EXIT25) in our routine clinical practice, we hypothesized that it would be possible to shorten it for easier administration in our group of patients while maintaining or improving properties of the scale. METHODS: The EXIT25 was applied in 122 clinically stable medical and surgical inpatients aged 65 years and over referred to the Liaison Psychiatry Service for Older People. Individual items were initially tested for floor and ceiling effects, inter-rater and test-retest reliability, and item-total correlations. Items were then selected for retention in the brief scale on the basis of adequate item-total correlation and inter-rater and test-retest reliability. The construct validity of the original and brief versions of the EXIT25 scale was assessed. RESULTS: The original EXIT25 scale was found to lack desirable scaling properties either as a classical or hierarchical scale. The study confirmed a possibility to reduce the number of items to nine out of the original 25 while improving internal consistency, test-retest and inter-rater reliability, and maintaining high correlation with the original EXIT25 score, and moderate inverse correlation with the Mini-Mental State Examination score. CONCLUSIONS: There is potential to abbreviate the original EXIT25, and improve internal consistency and hierarchical scaling properties. Future research is necessary to focus on piloting these brief measures of executive function in relevant clinical settings, when administered en bloc, rather than with items interspersed in the original longer version.

Mental capacity assessments among general hospital inpatients referred to a specialist liaison psychiatry service for older people.

BACKGROUND: Mental capacity has been little studied among older general hospital inpatients. METHODS: A retrospective analysis was undertaken of routinely collected data (age, gender, ethnicity, admission diagnosis, psychiatric diagnosis, Mini-mental State Examination score, whether capacity was assessed, the outcome of that assessment, and discharge destination) on referrals to a liaison psychiatry service for older people (2003-2006) from medical and surgical teams at a large London teaching hospital. RESULTS: 1267 patients were referred to the service, of whom 379 (30%) were assessed for capacity. The most common mental capacity issues were placement (303 assessed of whom 54% lacked capacity), treatment (86 assessed, 59% lacking capacity) and finances (70 assessed, 79% lacking capacity). Cognitive impairment, dementia and delirium, rather than mental disorders were associated with incapacity. Those assessed and deemed to lack capacity for placement decisions were twice as likely to be placed in a care home, and four times as likely to be placed in an elderly mentally ill (EMI) facility, independent of dementia diagnosis and cognitive functioning. CONCLUSION: Referrals to a liaison psychiatry service for older people for assessment of mental capacity are common. The main mental capacity issues in older people were those linked to discharge planning. The relatively high proportion of those found to have capacity when capacity had been queried by referring clinicians attests to the important role of specialist liaison teams, particularly in complex cases, in protecting the autonomy of vulnerable older people, and avoiding institutionalization.