Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0129bThe Medical Psychiatry Inpatient UnitDavid G. Folks 1 and F. Cleveland Kinney 21 University of Nebraska College of Medicine, Omaha, NE, and2University of Alabama School of Medicine, Birmingham, AL, USAMedical psychiatry inpatient units primarily serving older adultshave increased in popularity and numbers in North America inrecent years. Several model programs have been described withrespect to structure and organization, clinical care and logisticaladvantages in the management of older psychiatric patients whosuffer from significant medical and surgical problems. Theliterature also suggests that medical psychiatry inpatient unitsoffer great advantages over traditional settings in the diagnosisand treatment of elderly patients with combined disorders. Olderpsychiatric patients with acute medical illness, chronic medicalconditions, the negative physiologic and psychologic concomitantsof ageing, the problems of polypharmacy, drug interactionand compliance, together with the need for a more comprehensiveand effective clinical approach, have culminated in a number ofrefinements in these units. The senior author’s own experience indeveloping, organizing, operating and continually evaluating adynamic geriatric medical psychiatry program lends support tothe importance and utility of this treatment modality. Thischapter will review in detail the structure, organization andclinical characteristics and financing of a medical psychiatryinpatient unit.STRUCTURE AND ORGANIZATION OF THEGERIATRIC MEDICAL PSYCHIATRY INPATIENTUNITThe medical psychiatry inpatient unit is generally orientatedtowards the admission and treatment of patients with combinedmedical and psychiatric illnesses. An attempt is made to integratemedical and psychiatric care, utilizing a biopsychosocial orsystems treatment approach. The unit itself may be influencedby the administrative structure of the facility, the orientation ofthe medical and psychiatric community, the priorities among theclinical and administrative leaders and/or the general resourcesand expectations of the population to be served. Young andHarsch 1 alluded to three guiding principles that must be met inorder for a medical psychiatry unit to succeed. These are thefollowing: (a) the provision of a distinct type of care; (b) animproved quality of care; and (c) more efficient care. Anotherprimary consideration in North America is the need to demonstratethat added costs to third-party payers and hospitals willyield greater benefits for both the patient population and themedical facility. The financing of these units with respect tochanges in the USA are to be addressed in this chapter.The medical psychiatry inpatient unit maintains a distinctivepatient population by virtue of admission criteria. Patientcharacteristics may also be determined by affiliation with variousgovernmental or community agencies, or perhaps by otherreferring psychiatric facilities that are unable to provide care formedically ill psychogeriatric patients. Of course, healthierpsychiatric patients may also benefit from the medical modeladopted in a medical psychiatry unit. However, these units trulyprovide a therapeutic edge and hold promise for the successfulclinical approach to a growing number of seriously medically ill orfunctionally compromised elderly psychiatric patients 2 . Furthermore,the work-up and treatment may potentially be performedwithout major increases in length of stay. Incidentally, these unitsare known to provide an excellent milieu for clinical training inpsychiatry and other disciplines.The ideal physical environment of a medical psychiatryinpatient unit ensures safety for delirious or behaviourallydisturbed elderly patients, facilitates the rendering of medicalservices, and provides a pleasant environment suitable forrelatively long hospital stays. The overall space requirements donot differ markedly, but do exceed the space ideal for generalhospital or free-standing psychiatric units. Presumably, thefacility contains essential equipment and structure that wouldnot otherwise be found on a psychiatric unit; the level of caredelivered could, therefore, not be provided, or provided as well,on the ‘‘typical’’ psychiatric unit. This inpatient approach is incontrast to the consultation–liaison model of managing medicallyill psychiatry patients on existing medical/surgical wards.Features of patient rooms in a medical psychiatry unit may varydepending on the individual characteristics of the patients.Essential safety features include shatterproof windows, breakawaycurtain rods, electrical outlets that disconnect in response totampering and lockable water taps, especially with semi-privatebaths. Certainly, for medically acute patients, lighting for bedsideexamination, outlets for oxygen and suction and adjustablehospital beds are necessary. A voice-call light system, a facilityfor glucose monitoring and availability of cardiac telemetry arehighly desirable. Medical psychiatry inpatient units are alsoexpected to provide care for patients requiring intravenous fluids/therapy or nasogastric suction, who need total care in a bedriddenor debilitated state, as well as oxygen support or clinicalmanagement of common medical conditions, e.g. diabetes,hypertension, angina, congestive heart failure, chronic pulmonarydisease, electrolyte or fluid balance disturbances, and urinary tractor pulmonary infections. Patients with great acuity may be toolabor-intensive, i.e. the ideal unit should be designed to strike abalance between the provision of basic medical care and theprovision of intensive psychotherapeutic care. The ideal unit willalso consist of patient rooms that are largely private, but somePrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd