Community management of acutely ill older people

Chapter 27 COMMUNITY MANAGEMENT OF ACUTELY ILL OLDER PEOPLE



INTRODUCTION


This brief chapter introduces some of the issues confronting mental health workers when dealing with acutely ill older people. Because older people have more general medical health problems than younger people, and are more prone to experience adverse effects when treated with psychotropic medication, the management of acute mental illness in the community can pose some challenges. Very little has been published on this topic, so this chapter is a distillation of the authors’ experience.



LEGAL ISSUES


All mental health workers need to be familiar with the operation of the local Mental Health Act (MHA). While every effort should be made to assess and treat people as voluntary patients, using the least restrictive means, use of the involuntary provisions of the MHA is inevitable in busy acute community mental health teams, including those caring for older people. In some situations, the mental health worker will need to request the assistance of the police. Most MHAs have specific provisions for calling on the assistance of the police. It is very useful for community mental health teams to have good working relationships with the local police service. Most police services value such links, as they enhance the work of both organisations and enable challenging clientele to be appropriately managed.



MEDICAL ISSUES


Although community mental health teams are not usually responsible for providing primary healthcare to older people with mental health problems, they nevertheless are often in a good position to identify acute deteriorations in their an older person’s physical health. Common acute problems encountered in older people during domiciliary visits include falls and confusion. When such problems are identified, and are an immediate risk to the person’s health, the community mental health team has an ethical obligation to take action. However, the management of general medical problems in older people with mental health problems will sometimes require the approval of a substitute decision maker, such as a statutory health attorney, an attorney for health matters under an enduring power, or the local guardianship authority.



WHAT CONSTITUTES AN EMERGENCY?


An emergency is any mental health problem that is immediately threatening the life of the older person or someone else, or has the potential to do so in the near future. Some clinical experience is needed to make this judgment, and inexperienced mental health workers are advised to consult with co-workers or clinical line managers if in any doubt. Other situations often treated as emergencies are those that put the person’s reputation, or their legal or financial status, at severe risk.



INDICATIONS FOR HOSPITAL ADMISSION


A frequent issue for community mental health teams caring for older people is when to arrange for a hospital admission. This issue is easier to negotiate when the team is operating as an integrated hospital and community service. However, in the situation where the community team is independent of the inpatient team, more work will often be needed to arrange a hospital admission.


Almost all older people who have attempted suicide should be admitted to hospital for further assessment and treatment. Many older people with major depression complicated by psychotic symptoms, inadequate oral intake, or suicidal thoughts, should be admitted to hospital. Most older people with mania and some with hypomania should be admitted to hospital. Some older people with psychotic disorders will need hospital admission, particularly if there are risk issues, including marked disorganisation and self-neglect, poor oral intake, or suicidal or homicidal thoughts. Although people with dementia do sometimes warrant hospital admission if their dementia is complicated by severe depression or severe psychotic symptoms, many inpatient mental health units are reluctant to admit them because of the difficulty of finding accommodation for the person after the need for acute hospitalisation resolves. For this reason, and the unsuitability of many inpatient mental health units for people with cognitive impairment, it is generally best to manage people with dementia in the community rather than in hospital.



ALTERNATIVES TO HOSPITAL ADMISSION


Mobile intensive-treatment teams are often utilised with younger clientele with serious mental health problems to avoid hospitalisation or to manage the person in the community until a hospital bed becomes available. However, most of these younger people are free of serious general medical problems and some are well known to the mental health service. The use of such an approach with older people with acute mental health problems and comorbid general medical problems would be possible if the staff of such teams were appropriately experienced with the care of older people. Unfortunately, this is rarely the case, and so inpatient care under a specialised older persons’ inpatient team is usually the preferred option.

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Aug 6, 2016 | Posted by in GERIATRICS | Comments Off on Community management of acutely ill older people

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