THE PSYCHIATRIC EMERGENCY system in Japan is operated by individual local authorities, and most patients using this service are charged by the police because of behavioral problems. The police contact local mental and welfare centers to request that such patients visit a psychiatric emergency unit (police call). In the unit, if both of the two designated psychiatrists determine that the psychiatric state of a patient carries a high risk of self-injury or injury to others, the patient is hospitalized by administrative order (Obligatory Hospitalization). The psychiatric emergency system plays a significant role in psychiatric treatment in local areas and has to provide a flexible response in accordance with social situations. Early establishment of countermeasures is required for the increasing population of elderly patients in the psychiatric emergency field, but only a few studies1,2 have focused on elderly patients using these services. In this study, we investigated patients aged 65 years or older who visited our hospital as police-call cases, and here, we discuss the characteristics of these patients.
We investigated the differences between elderly and under-65-year-old patients using the psychiatric emergency system. The following characteristics were more common in elderly patients than in younger patients: organic mental disorder, mood disorder, dementia, disturbed consciousness, no excitation, physical complications, no history of visiting a psychiatrist and no history of hospitalization. In addition, significantly more elderly patients with mood disorder attempt suicide.
Data were obtained from a retrospective study of 291 patients who visited our hospital as police-call cases from April 2002 to March 2007. Age, sex, principal diagnosis, subdiagnosis, major symptoms, physical complications, and patient background were obtained from the ‘Medical Certificate for Obligatory Hospitalization’ and medical records. The 10th Revised Version of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) was used for diagnosis. Student t-tests and χ2-tests were used for comparison of average values and rates, respectively, with a significance level of P < 0.05. This study was approved by our university ethical committee.
Fourteen patients aged 65 years or older (elderly group) visited our hospital as police-call cases within 5 years. The average age of these patients was 76.0 ± 8.0 years old and they accounted for 4.8% of such cases. An increase in the percentage of elderly patients was apparent in 2006 and 2007 (13.1%).
A comparison of the elderly group and the patients who were younger than 65 (under-65 group) is shown in Table 1. Regarding the principal diagnosis, the percentage of patients with F0 (organic, including symptomatic, mental disorders) and F3 (mood disorders) diagnoses was significantly higher in elderly patients, whereas fewer elderly patients had F2 diagnoses (schizophrenia, schizotypal and delusional disorders). Among sub diagnoses and main symptoms, there was a significantly higher percentage of elderly patients with dementia and disturbed consciousness, whereas significantly fewer elderly patients showed excitation. In addition, a significantly higher percentage of elderly patients had physical complications. Regarding medical background, a history of visiting a psychiatrist and history of hospitalization were observed to be in fewer elderly patients than in under-65 patients. In addition, there was no significant difference in suicide attempts between the groups (data not shown), but a significantly higher percentage of patients who attempt suicide was found in those with mood disorder in the elderly group (5 patients; 100%) than in those with this disorder in the under-65 group (17 patients; 41.2%) (χ2 = 0.39; P = 0.020).
|Elderly (n = 14)||Under-65 (n = 277)||χ2|
|(1) Principal diagnosis (ICD-10)†|
|(2) Subdiagnosis and symptoms‡|
|(3) Physical complication||7||(50.0)||30||(10.8)||18.42***|
|No history of visiting a psychiatrist||7||(50.0)||60||(21.7)||6.04*|
|No history of hospitalization||11||(78.6)||105||(37.9)||9.19**|
The precise conditions of the 14 elderly patients were as follows. Regarding their circumstances, many of the elderly patients (10 patients; 71.4%) lived with limited care support such as living only with an elderly spouse. Regarding the duration of the untreated illness, seven patients (50%) had continuous problematic behaviors for over one year, and five patients (35.7%) had an episode for a few days with a background such as pain due to sickness, a recent death of a close relative, and drug-induced delirium. For seven patients (50%), treatment was required for physical complications during hospitalization, including severe diseases such as subendocardial myocardial infarction, aspiration pneumonia, and an elevated creatine phosphokinase level.
The percentage of elderly patients was only 4.8% of the total patient population, similar to the results found in studies carried out at the Tokyo Metropolitan Toshima Hospital3 (4.98%) and Cincinnati University Hospital2 (2.9%). However, the percentage of elderly patients has tended to increase since 2006. This trend corresponds to a report from Tokyo Matsuzawa Hospital1 and a further increase is anticipated.
A previous study of elderly patients seeking emergency psychiatric treatment showed a greater number of female patients,4 but there were more male patients in the elderly and under-65 groups in our patient population. This may be because the study was performed for cases associated with a police call, which indicated a more severe psychiatric problem. Thienhaus et al.2 reported that a large number of patients showed a principal diagnosis of dementia, organic brain disease or emotional disorder, and that major symptoms of disorientation and thoughts of suicide were shown among elderly patients who used psychiatric emergency services. These findings are consistent with our results. From these data, the initial clinical characteristics of elderly patients could be problematic behavior caused by organic brain diseases including cognitive deficit, and the second could be a suicide attempt caused by emotional disorder.
Thienhaus et al.2 also found that few elderly patients had used a psychiatric emergency service within the previous year, and our results showed similar trends. This suggests that the patients who exhibited continuous problematic behavior could not avail of primary psychiatric treatment because of the low level of support. Colenda et al.6 recommended a 24-hour hotline and out-reach nursing accessible to the elderly. Problematic behavior was also caused by drug-induced delirium in elderly patients, and physical complications were confirmed in many cases, which also correlates with previous reports.1,2 New complications that developed during hospitalization included severe complications caused by drugs, and thus careful physical management of elderly patients is also required. Buczek5 suggested that close cooperation between psychiatrists and physicians is required in psychiatric emergency services.
Finally, the statistical comparison of the elderly and under-65 patients is limited because of the small number of elderly patients in this study. Therefore, our findings should be considered as preliminary. Colenda et al.6 also suggested that psychiatric emergency for the elderly should include integrated medical, mental health, and social services. We agree with this point and hope to establish a sufficient psychiatric service system that integrates physical problems and social support.