- Top of page
Aims: The purpose of this study was to examine the demographic and clinical characteristics that differentiate between elderly and non-elderly visitors in the psychiatric emergency room (ER), and to identify factors predicting transferal after psychiatric emergency management in the elderly.
Methods: Data were collected over four years for patients who visited the psychiatric ER. The elderly were defined as patients older than 65 years old. Demographic and clinical characteristics were analyzed using the χ2-test for categorical data and t-tests for continuous data. Multivariate logistic regressions were carried out to find predictive factors associated with being transferred to a general hospital for elderly visitors in the psychiatric ER.
Results: Elderly patients made up 3.4% of all included visitors (n = 243) during the four-year period. The mean number of visits for elderly visitors was 1.63 ± 1.18, ranging from 1 to 7. The χ2-test and the t-test indicated that the elderly visitors were different from controls in many demographic and clinical variables. Multivariate logistic regression analysis showed that being transferred to a general hospital for elderly visitors in the psychiatric ER was associated with age (odds ratio = 1.32) and a greater number of previous psychiatric hospitalizations (odds ratio = 1.42). Patients without a thought-form problem also required transferal to a general hospital more often in our study.
Conclusions: The study suggested that elderly visitors in the psychiatric ER were a unique group, and specific considerations should be included in the intervention for these patients.
EPIDEMIOLOGICAL RESEARCH INDICATES that the geropsychiatric population differs significantly from younger age cohorts.1 A consistent pattern of under-utilization by the elderly has been found in existing mental health services, including community mental health centers, psychiatric emergency services, and office practices of psychiatrists and mental health specialists.2–4 Herst has suggested that the more common geropsychiatric emergencies include depression, confusional states, and paranoid disorders.5 Perez and Blouin found that with increasing age, more patients were diagnosed as having organic brain syndromes and major affective disorders. Among the geriatric patients who were admitted after psychiatric consultation in the emergency room (ER), the three most common symptoms were depressive features, side-effects of psychotropic medication, and hallucinations and delusions.6
Waxman studied ER records and found that elderly patients were more frequently referred by family or friends than self-referred. Also, the elderly received a diagnosis of organic brain syndrome more often than middle-aged patients, and were less often diagnosed with substance abuse or schizophrenic disorders.2
Psychiatric emergency facilities must begin planning to meet the needs of the increasing number of elderly persons who will undoubtedly be seeking their attention.7 In circumstances with limited medical resources, hospitalization is a relatively expensive modality of medical intervention. To prevent elderly persons from being hospitalized, factors predicting transferal after psychiatric emergency management should be surveyed first. However, information about elderly persons who use psychiatric emergency services is insufficient. Better knowledge of the characteristics and needs of elderly persons can help these facilities plan and deliver services.8
This paper describes research aimed at determining the characteristics of elderly patients who sought help at a psychiatric ER and also factors predicting transferal after psychiatric emergency management.
- Top of page
Among all patients (n = 7143) in the psychiatric ER, 243 patients (3.4% of all included visitors) were defined as elderly visitors during the four-year period. The other 6900 visitors were defined as controls. A total of 50.6% were female (n = 123) and 49.4% were male (n = 120). The mean number of visits for elderly visitors was 1.63 ± 1.18, ranging from 1 to 7; and the mean number of visits for control visitors was 4.09 ± 3.04, ranging from 1 to 18.
Comparisons of demographic and clinical characteristics of elderly and control visitors are presented in Table 2. The χ2-tests indicated that the elderly visitors were more likely than the control visitors to have been identified by the clinician as married, as having appearance and behavior problems, as having thought-form and thought-content problems, as violent, as visiting the ER for medication refill, and as having hoarding behavior; and less likely to have been identified as having a previous psychiatric emergency visit, as male, as employed, as having insight and as having a substance-use or -dependence problem.
Table 2. Demographic and clinical characteristics of elderly and control visitors in the psychiatric emergency room
|Characteristics||Elderly visitors (n = 243)||Control visitors (n = 6900)||Test statistic||P|
|Previous psychiatric emergency visit||81||33.3||3867||56.0||χ2 = 49.08||<0.001|
|History of psychiatric hospitalization||85||35.0||2390||34.6||χ2 = 0.429||0.512|
|Gender, male||120||49.4||4251||61.6||χ2 = 14.87||<0.001|
|Married||163||67.1||2015||29.2||χ2 = 157.88||<0.001|
|Employed||12||4.9||1410||20.4||χ2 = 35.87||<0.001|
|Housing status|| || || || ||χ2 = 6.93||0.074|
| Homeless||1||0.4||56||0.8|| || |
| Living with somebody||208||85.6||6140||89.0|| || |
| Living alone||23||9.5||397||5.8|| || |
| Living at institution||8||3.3||167||2.4|| || |
|Appearance and behavior||200||82.3||5261||76.2||χ2 = 5.17||0.023|
|Thought form||60||24.7||1321||19.1||χ2 = 4.49||0.034|
|Thought content||196||80.7||4388||63.6||χ2 = 29.85||<0.001|
|Suicidality||22||9.1||900||13.0||χ2 = 3.43||0.064|
|Mood and affect||220||90.5||6135||88.9||χ2 = .52||0.469|
|Violence||92||37.9||2135||30.9||χ2 = 5.08||0.024|
|Insight, positive||61||25.1||2470||35.8||χ2 = 12.12||<0.001|
|Visiting ER for medication refill||44||18.1||926||13.4||χ2 = 4.31||0.038|
|Visiting ER for adverse drug effect||4||1.6||282||4.1||χ2 = 3.67||0.055|
|Hoarding behavior||3||1.2||22||0.3||χ2 = 5.62||0.018|
|Poor medical adherence||214||88.1||5820||84.3||χ2 = 2.30||0.129|
|Substance abuse or dependence||20||8.2||2395||34.7||χ2 = 74.15||<0.001|
|Physical restraint used||24||9.9||663||9.6||χ2 = .01||0.937|
|Brought by police or ambulance||63||25.9||1818||26.3||χ2 = .02||0.883|
|Axis I diagnosis|| || || || ||χ2 = 570.79||<0.001|
| Schizophrenia||38||15.6||2477||35.9|| || |
| Other psychotic disorder||44||18.1||394||5.7|| || |
| Mood disorder||63||25.9||1641||23.8|| || |
| Substance-related disorder||9||3.7||1639||23.8|| || |
| Neurotic disorder||12||4.9||334||4.8|| || |
| Dementia, delirium, organic brain syndrome||77||31.7||231||3.3|| || |
| Adjustment disorder||0||0||79||1.1|| || |
| Mental retardation||0||0||14||0.2|| || |
| Personality disorder||0||0||15||0.2|| || |
|Physical illness||12||4.9||201||2.9||χ2 = 3.33||0.068|
|Result of management at ER|| || || || ||χ2 = 48.89||<0.001|
| Voluntary hospitalization||129||53.1||3413||49.5|| || |
| Involuntary hospitalization||12||4.9||413||6.0|| || |
| Follow up at outpatient department||81||33.3||2655||38.5|| || |
| Transferal to a general hospital||12||4.9||108||1.6|| || |
|Number of previous ER visits (mean ± SD)||0.6 ± 1.1||2.9 ± 5.8||t = 6.163||<0.001|
|Number of previous psychiatric hospitalizations (mean ± SD)||1.7 ± 3.0||1.6 ± 3.1||t = −0.538||0.591|
|Age at onset (mean ± SD years)||61.6 ± 16.7||27.2 ± 10.0||t = −50.786||<0.001|
|Years of education (mean ± SD years)||5.0 ± 4.0||10.7 ± 3.1||t = 25.898||<0.001|
Among classifications of axis I diagnosis, elderly visitors were more likely to have been diagnosed as having another psychotic disorder, a mood disorder and dementia/delirium/organic brain syndrome; and less likely to have been diagnosed as having schizophrenia, a substance-related disorder, an adjustment disorder, mental retardation and a personality disorder. Considering the result of management at the psychiatric ER, elderly visitors were more likely to receive voluntary hospitalization and transferal to a general hospital, and less likely to receive involuntary hospitalization and follow up at the OPD. The t-test indicated that the elderly visitors had a greater age at onset, a lesser number of previous psychiatric emergency service visits and a lesser number of years of education.
Table 3 shows the results of multivariate logistic regression analysis. Predictive factors of being transferred to a general hospital for elderly visitors in the psychiatric ER were age (odds ratio [OR] = 1.32) and a greater number of previous psychiatric hospitalizations (OR = 1.42); and a thought-form problem (OR = 0.42) was negatively associated with being transferred to a general hospital.
Table 3. Results of multivariate logistic regression analysis of independent predictive factors associated with being transferred to a general hospital for elderly visitors in the psychiatric emergency room (forward conditional)
|Number of previous psychiatric hospitalizations||1.42||1.08–1.87||0.012|
- Top of page
The study found that elderly visitors made up a small percentage of individuals who visited the psychiatric ER (3.4%), and that the elderly were relatively infrequent visitors. The percentage of elderly visitors in the psychiatric ER was similar to other studies (5–6%).10 The elderly visitors were different from control visitors in many demographic and clinical characteristics as presented in Table 2. According to our definitions of the psychopathological variables, appearance and behavior problem included uncooperativeness and agitation. A thought-form problem included disorientation; and a thought-content problem included somatic concern and helplessness/hopelessness. The above psychopathological symptoms and signs were compatible with those seen in dementia, delirium or depressive disorder patients in the elderly. There was inconsistency about violence in previous studies. Some studies revealed no difference of violence between different age groups;11,12 however, some studies revealed that younger patients were more likely to be violent.13 Our study found that elderly visitors were more likely to have been identified as violent than control visitors. The possible explanation was that impaired memory functioning frequently found in elderly also predicted object aggression.14 Hoarding behavior is often seen in obsessive–compulsive disorder. One study reported a prevalence of hoarding behavior in patients with dementia (22.6%).15 Hoarding behavior had also been reported in Diogenes syndrome in elderly patients.9 However, a comprehensive survey of hoarding behavior in the elderly is lacking. There were more women among the elderly visitors than men. This was possibly due to the longer life span of women.
Logistic regression indicated that the predictive factors of being transferred to a general hospital for elderly visitors in the psychiatric ER were age, a greater number of previous psychiatric hospitalizations and being without a thought-form problem. The elderly with greater age had more physical illnesses. A greater number of previous psychiatric hospitalizations often meant a longer duration of illness and treatment, which may result in more complications and adverse drug effects. According to our raw data, only two patients with thought-form problems (disorganization, distractibility, disorientation) had physical illnesses that were both hypertension. On the contrary, patients without thought-form problems had more moderate to severe physical illnesses including asthma and epilepsy, which may require transferal to a general hospital. This might explain why being without a thought-form problem was one of the factors predicting transferal to a general hospital.
This study has some methodological limitations that should be addressed. First, it was retrospective and the patient population was selected from a single catchment area, although covering a relatively large city. When interpreting the results of this study one should bear in mind that not all of the patients coded as ‘no previous psychiatric emergency visit or hospitalization’ were really new patients without previous psychiatric contacts. Second, the inter-rater reliability was not proved. In addition, we used information not verified by laboratory findings.
Despite these limitations, the novel aspect of our study is to compare demographic and clinical characteristics of elderly visitors with other visitors in the psychiatric ER, and to find predictive factors of being transferred to a general hospital for elderly visitors in the psychiatric ER. Furthermore, the large sample size and analysis of data collected over a four-year period were also rarely seen in previous studies. The findings mentioned above reinforce the necessity to address the needs of elderly visitors, particularly aiming at factors associated with being transferred to a general hospital.