Missed diagnosis: The emerging crisis of borderline personality disorder in older people.

OBJECTIVE: Clinical experience suggests a growing prevalence of borderline personality disorder in aged residential care and psychiatric facilities with attendant difficulties in their management. This paper reviews the literature concerning the prevalence, phenomenology and diagnosis of borderline personality disorder in old age. The aim is to elucidate the phenomenological differences in old age and thus improve identification of the disorder. METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE and PsycINFO databases, employing the search terms including 'personality disorder', 'borderline personality disorder', 'aged care', 'gerontology', 'geriatric psychiatry' and 'life span'. The search included articles in English involving participants 65+ years. Long-term prospective studies of borderline personality disorder, long-term follow-up studies and studies involving older adults from 50+ years were also examined. RESULTS: There is a paucity of literature on borderline personality disorder in the elderly. No diagnostic or rating instruments have been developed for borderline personality disorder in the elderly. The phenomenology of borderline personality disorder in the aged population differs in several respects from that seen in younger adults, causing some of the difficulties in reaching a diagnosis. Escalations of symptoms and maladaptive behaviours usually occur when the diagnosis of borderline personality disorder is either not made or delayed. Improved identification of borderline personality disorder in older patients, together with staff education concerning the phenomenology, aetiology and management of these patients, is urgently needed. CONCLUSION: Diagnostic instruments for borderline personality disorder in the elderly need to be developed. In the interim, suggestions are offered concerning patient symptoms and behaviours that could trigger psychiatric assessment and advice concerning management. A screening tool is proposed to assist in the timely diagnosis of borderline personality disorder in older people. Timely identification of these patients is needed so that they can receive the skilled help, understanding and treatment needed to alleviate suffering in the twilight of their lives.

Experience from mental health clinics held during medical service camps in Fiji.

OBJECTIVE: We aim to describe the experience and findings of mental health clinics held during medical service camps in the rural settings of Fiji. METHOD: Descriptive data collated at the end of the medical camps across 2011-2014 are used to highlight the main findings. RESULTS: The exposure to mental health assessments and brief interventions at these camps was a validating experience for both individuals and medical students attending the clinics. The most common presentations can be categorised under symptoms of depression, anxiety and relationship problems. CONCLUSIONS: The accessibility of mental health support services is a challenge in Fiji. Medical service camps can form an important pathway in promoting mental health awareness, especially amongst the rural communities of Fiji, and a useful platform for medical students to acquire some clinical exposure.

Reducing restraint and seclusion in an acute aged person's mental health unit.

OBJECTIVE: This paper describes how a significant reduction in restraint and seclusion rates was achieved in an acute aged person's mental health unit. METHOD: We analysed seclusion and restraint data in 2009. This was supplemented with a random audit of patient files and qualitative data obtained from a survey of nursing staff. We also obtained management views on changes in management practice. RESULTS: Four major factors were found to reduce rates of restraints and seclusion. These included: (i) leadership and support from management in nursing practices, (ii) increased multidisciplinary team input, (iii) renovations to the inpatient setting, and (iv) changes in treatment-related factors such as collection of behaviour management history and improving documentation in patient files. CONCLUSION: Experiences such as this provide insights and practical strategies that can be applied in other aged inpatient units to reduce or eliminate rates of seclusion and restraints.